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REVISED SYLLABUS – NURSING FOUNDATION – II NOTES

(PART – 1)
(FIRST YEAR, SECOND SEMESTER) 2021)
CONTENTS
 Health Assessment
 The Nursing Process
 Nutritional Needs
 Hygiene
 Elimination Needs
 Diagnostic Testing
 Oxygenation Needs
 Fluid, Electrolyte and Acid-Base Balances
 Administration of Medications
 Sensory Needs
 Psychosocial Needs – (a). self-concept
 (b). sexuality
 (c). Stress and Adaptation
 (d). Concepts of Cultural Diversity and Spirituality
 Nursing Theories: Introduction
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UNIT – 1 HEALTH ASSESSMENT

HEALTH ASSESSMENT
Health observation and assessment is a systematic process to
collect data about a patient. This data provides information about
the patient's condition, and is used to inform the care which is
appropriate for that patient. Nurses undertake health observation
and assessment constantly, in all clinical settings.

Health observation and assessment is the first step in the nursing

care cycle, illustrated in the diagram to the right:

Health assessment involves three concurrent steps:

 Health History: collecting subjective data - data about a

patient's symptoms. Data is collected via an interview with
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the patient and / or significant others. Data collected may

be primary or secondary.

 Physical Examination: collecting objective data - data about a

patient's signs. Data is collected via a physical examination of
the patient, using techniques such as inspection, palpation,
percussion and auscultation, and measurement of the vital
signs and other key physical indicators.

Symptoms are what the patient subjectively experiences. Signs are

what a nurse objectively observes, feels, hears or measures. In
some cases, data collected during health observation and
assessment may be both a symptom and a sign. For example, a
client may say that she "feels sweaty" (a symptom), and the nurse
observes diaphoresis (a sign).

 Documentation of Data: data collected during health

observation and assessment must be documented so that it
can be used to: (1) assess the patient's condition, and (2)
inform the care which is appropriate for that patient. There
are a variety of ways that data can be recorded. Regardless
of the manner, documentation must be complete, accurate,
concise, legible and free from bias.

There are a number of different types of health assessment which

a nurse may undertake:

 Comprehensive health assessment: taking a detailed health

history and physical examination of a client, to identify all of
the person's health care issues and needs. Usually performed
on admission.
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 Problem-based / focused health assessment: collecting data

related to a specific complaint. Common in outpatient
settings.

 Rapid assessment: collecting data to provide immediate, life-

sustaining intervention to a patient. Often performed in
emergency care.

 Episodic / follow-up assessment: a nurse following up with a

patient to collect data on a previously-identified problem.
The goal is to determine how the patient has responded to
care, by identifying changes in the patient's condition.

 Screening assessment: collecting data with the aim of

detecting the presence of a specific disease.

The type of assessment used depends on: (1) the context, and (2)
the health care issues and needs of the patient. In an acute care
setting with a new client, a comprehensive health assessment is
usually appropriate. However, in an emergency care setting where
a patient presents with a clear, significant problem, a rapid
assessment is typically more suitable.

INTERVIEW TECHNIQUES
INTERVIEWING

Obtaining a valid nursing health history requires professional,

interpersonal, and interviewing skills. The nursing interview is a
communication process that has two focuses:
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1. Establishing rapport and a trusting relationship with the client to

elicit accurate and meaningful information and

2. Gathering information on the client’s developmental, psychological,

physiologic, sociocultural, and spiritual statuses to identify deviations
that can be treated with nursing and collaborative interventions or
strengths that can be enhanced through nurse– client collaboration

Phases of the Interview

The nursing interview has three basic phases: introductory, working,

and summary and closing phases. These phases are briefly explained by
describing the roles of the nurse and client during each one.

Introductory Phase

After introducing himself to the client, the nurse explains the purpose
of the interview, discusses the types of questions that will be asked,
explains the reason for taking notes, and assures the client that
confidential information will remain confidential. The nurse also makes
sure that the client is comfortable (physically and emotionally) and has
privacy. It is also essential for the nurse to develop trust and rapport at
this point in the interview. This can begin by conveying a sense of
priority and interest in the client. Developing rapport depends heavily
on verbal and nonverbal communication on the part of the nurse.

Working Phase

During this phase, the nurse elicits the client’s comments about major
biographic data, reasons for seeking care, history of present health
concern, past health history, family history, review of body systems for
current health problems, lifestyle and health practices, and
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developmental level. The nurse then listens, observes cues, and uses
critical thinking skills to interpret and validate information received
from the client. The nurse and client collaborate to identify the client’s
problems and goals. The facilitating approach may be free-flowing or
more structured with specific questions, depending on the time
available and the type of data needed.

Summary and Closing Phase

During the summary and closing, the nurse summarizes information

obtained during the working phase and validates problems and goals
with the client. She also identifies and discusses possible plans to
resolve the problem (nursing diagnoses and collaborative problems)
with the client. Finally, the nurse makes sure to ask if anything else
concerns the client and if there are any further questions.

OBSERVATION TECHNIQUES
Nursing observation is the purposeful gathering of information from
people receiving care to inform clinical decision making.

It involves a person-centred approach to actively engage with people

receiving care and their families and carers.

The goal of nursing observation is to develop rapport, and contribute to

assessment and recovery.

Engaging with people during purposeful observation contributes to

nurses fulfilling their duty of care.
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There are several principles that underlie the practice of nursing

observation:

 observation is multifaceted
 observation and assessment are interrelated
 observation is grounded in therapeutic engagement with the
person
 nurses appreciate how inpatient environments influence
behaviour
 observations are communicated between colleagues
 There is a clear process of documentation that is timely and
descriptive.
 Observation can be initiated for several reasons, including when
people:
 may benefit from periods of concentrated therapeutic
engagement
 have physical health issues that need to be managed
 Pose a risk to themselves or others.

PURPOSES OF HEALTH ASSESSMENT

Health assessment is important and often first step in identifying the
patient’s problem. Health assessment helps to identify the medical
need of patients. Patient’s health is assessed by conducting physical
examination of patient.

A health assessment is a plan of care that identifies the specific needs

of a person and how those needs will be addressed by the healthcare
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system or skilled nursing facility. Health assessment is the evaluation of

the health status by performing a physical exam after taking a health
history. There are different from diagnostic tests which are done when
someone is already showing signs and/or symptoms of a disease. The
major health assessments are Initial Assessment in which determine
the nature of the problem and prepares the way for the ensuing
assessment stages. Focused Assessment, which expose and treats the
problem. Time-Lapsed Assessment, which ensure that the patient is
recovering from his malady and his condition has stabilized. Emergency
Assessments focus on rapidly identifying the root causes of concern for
the patient and assessing the airway, breathing and circulation (ABCs)
of the patient.

PROCESS OF HEALTH ASSESSMENT

Health assessment involves three concurrent steps:

 Health History: collecting subjective data - data about a

patient's symptoms. Data is collected via an interview with the
patient and / or significant others. Data collected may
be primary or secondary.
 Physical Examination: collecting objective data - data about a
patient's signs. Data is collected via a physical examination of the
patient, using techniques such as inspection, palpation,
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percussion and auscultation, and measurement of the vital signs

and other key physical indicators.

Symptoms are what the patient subjectively experiences. Signs are

what a nurse objectively observes, feels, hears or measures. In some
cases, data collected during health observation and assessment may
be both a symptom and a sign. For example, a client may say that she
"feels sweaty" (a symptom), and the nurse observes diaphoresis (a
sign).

 Documentation of Data: data collected during health observation

and assessment must be documented so that it can be used to: (1)
assess the patient's condition, and (2) inform the care which is
appropriate for that patient. There are a variety of ways that data
can be recorded. Regardless of the manner, documentation must
be complete, accurate, concise, legible and free from bias.

There are a number of different types of health assessment which a

nurse may undertake:

 Comprehensive health assessment: taking a detailed health

history and physical examination of a client, to identify all of the
person's health care issues and needs. Usually performed on
admission.

 Problem-based / focused health assessment: collecting data

related to a specific complaint. Common in outpatient settings.

 Rapid assessment: collecting data to provide immediate, life-

sustaining intervention to a patient. Often performed in
emergency care.

 Episodic / follow-up assessment: a nurse following up with a

patient to collect data on a previously-identified problem. The
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goal is to determine how the patient has responded to care, by

identifying changes in the patient's condition.

 Screening assessment: collecting data with the aim of detecting

the presence of a specific disease.

The type of assessment used depends on: (1) the context, and (2) the
health care issues and needs of the patient. In an acute care setting
with a new client, a comprehensive health assessment is usually
appropriate. However, in an emergency care setting where a patient
presents with a clear, significant problem, a rapid assessment is
typically more suitable.

HEALTH HISTORY
The collection of a health history from a patient - that is, subjective
data which focuses on the patient's symptoms - is the first step in
health observation and assessment, and is a fundamental skill for
nurses working in all clinical areas.

This involves collecting subjective data - that is, data about a

patient's symptoms (i.e. what the patient experiences). A variety of
other important information is also collected during the interview -
including, for example, information about a person's health-related
values, beliefs and attitudes, their current health-related practices, the
socioeconomic, cultural and other factors impacting on their health,
and their willingness and capacity to make health-related changes, etc.
Data is collected via an interview with the patient and / or significant
others. Data collected at this stage may be primary (i.e. obtained from
the patient themselves) or secondary (i.e. obtained from another
person, such as the patient's family member or carer, etc.). In acute
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situations, the patient's health history may be communicated by

another health care provider - for example, an emergency paramedic.

Health history is obtained through an interview between a nurse, the

patient and significant others (where appropriate). The nurse's role in
the interview process is to: (1) facilitate discussion to collect health-
related data, and (2) record this data. Data collected during a health
history interview informs both the subsequent physical examination of
the patient, and also the health care which is provided to that patient.

In many clinical settings, patients are asked to complete a

questionnaire as part of the process of collecting their health history.
Health history questionnaires typically consist of a series of simple yes /
no questions, often related to the specific symptoms and risk factors
associated with common disease (e.g. cardiovascular disease,
respiratory disease, diabetes, etc.). It is important for nurses to realise
that health history questionnaires do not replace or preclude the need
for the health history interview. Although these questionnaires can be
useful tools for collecting data related to a person's health history, and
can prompt a patient to think deeply about their past medical problems
and symptoms, they only collect superficial information which should
then be further investigated by a nurse in a conversation with a patient.

Types of health histories

It is important for nurses to note that there are a number of different

types of health histories which may be collected from a patient:

 A comprehensive health history. This collects detailed information

about a patient - including their biographical data, present health
status, past medical history, family history, personal situation and
a review of all body systems. It is usually completed on admission
to a health care facility and during a general health check-up.
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 A rapid or focused health history. This collects specific information

about a clear health-related issue or need with which a patient
presents. The information gathered is used to inform the
immediate care of the patient.

The type of health history collected from a patient depends on: (1) the
context in which the patient has presented, and (2) the patient's health
care issues and needs. This module will focus on teaching the
knowledge and skills required to collect a comprehensive health history
from a patient, as it is this knowledge and these skills which also
underpin the collection of a rapid or focused health assessment.

Components of a health history

A health history interview typically consists of three distinct sections:

(1) introduction, (2) discussion, and (3) summary. Each of these sections
is described following:

Introduction Section Discussion Section Summary Section

 Nurse introduces  Nurse facilitates  Nurse
self and role to discussion to collect summarises the
patient. health-related data. key data
 Nurse explains  Discussion is patient- collected.
the purpose of centred - that is,  Nurse allows the
the interview. focused on the person patient to clarify
 Nurse explains and their issues / data, where
the process of needs. required.
the interview  Nurse uses various  Nurse explains
(e.g. what the communication, inter- how this data will
patient should personal techniques. be used to
expect). inform the health
care provided.
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All health history interviews begin with the nurse introducing

themselves to the patient (and others present in the interview, if
relevant), and explaining their role in the provision of the patient's
health care. Adult patients should be addressed by their title and
surname, until they inform the nurse of their preferred name and
provide the nurse with permission to use it. It is usually acceptable, and
preferable, to address adolescents and children by their first name.
Nurses explain why the interview is being conducted, and also the
processes involved. The aim of this explanation is to prepare the
patient and to enhance their comfort in sharing health-related
information.

The next section of the interview, the discussion section, is where the
nurse focuses on facilitating discussion with the patient to collect
health-related data. The nurse uses a range of questioning and other
communication techniques - discussed in detail in the following section
of this chapter - to collect the information required to inform the
physical examination and the subsequent provision of the patient's
health care. This discussion is patient-centred - that is, it focuses on the
person and their unique issues and needs. Patients are encouraged to
share their perceptions and experiences in their own words, without
interruption, judgement or interpretation from others (including the
nurse).
The nurse focuses on collecting the following information:

Component Examples of Data Included

Biographical  Name, gender, date of birth.
information  Address, contact telephone number.
 Details of contact person / next of kin.
 Other appropriate information to inform care - for example, the patient's
religion, ethnicity, occupation, marital status, etc.

Reason for  The patient's chief complaint or presenting problem.

seeking  This should be recorded in the patient's own words.
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health care  If the patient has more than one complaint / problem, record all of them.
 If a patient's problem is urgent (e.g. pain, dyspnoea, injury, etc.), the
interview should be suspended and care provided.

History of This is best achieved by assessing the patient's symptoms; this can be done using a
presenting strategy remembered by the mnemonic 'OLD CARTS':
illness
O = onset  When did the symptoms begin?
 Did they develop suddenly or over time?
 Where was the patient / what were they doing when
the symptoms started?

L = location  Are the symptoms located in a specific area?

 Is this area specific or generalised?
 Does the symptom radiate to another location?

D = duration  How long do the symptoms last?

 Are they changing over time?
 Are they constant? If so, does their severity fluctuate?
(Describe).
 Are they intermittent? If so, how often do they occur,
and what happens in between episodes?

C = characteristics  Describe what the symptom feels like (i.e. the

sensation - stabbing, dull, aching, throbbing, itching,
tingling, etc.).
 Describe what the symptom looks like (i.e. colour,
texture, composition, etc.)

A = aggravating /  What makes the symptoms worse?

alleviating factors  What makes the symptoms better?

(E.g. physical factors [activity, position, etc.], psychological

factors [anxiety, etc.], environmental factors, etc.).
R = related symptoms  Do other symptoms occur at the same time (e.g. pain,
nausea, fever, etc.).

T = treatment  What treatments have you tried?

 How effective have these treatments been?

S = severity  Describe the size, extent or amount.

 Rate the symptom on a scale of 0 to 10.
 Does the symptom interrupt the person's activities of
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daily living?

Present  The patient's pre-existing health conditions.

health status  The patient's current medications (prescription, over-the-counter).
 The patient's allergies.
 The patients' current health-related practices.

Past health  Significant childhood illnesses.

history  Previous hospitalisations for surgery, accidents, illnesses, etc.
 Immunisation status.
 Most recent physical examinations, and findings.
 Obstetric history, if relevant (gravidity, parity, etc.).

Family  Diseases affecting biological relatives - parents, grandparents, aunts /

history uncles, siblings and children.
 Genetic conditions known to be present in the family.

Personal and  Personal status (e.g. education, occupation, etc.).

psychosocial  The patient's important family / social relationships.
history  The patient's diet / nutrition and exercise status.
 The patient's functional ability and mental health.
 The environment in which the patient lives / works / learns.
 The patient's health-related values, beliefs and attitudes.
 The socioeconomic, cultural and other factors impacting on health.
 The patient's willingness / capacity to make health-related changes.

A review of The patient should be questioned about abnormalities or concerns in each of their
the patient's body systems: the integumentary system, the cardiovascular system, the immune /
body lymphatic system, the endocrine system, the nervous system, the reproductive
systems system, the respiratory system, the musculoskeletal system, the digestive system
and the urinary system. The patient should also be asked about any general or
systematic symptoms they experience (e.g. fatigue, etc.).

PHYSICAL EXAMINATION
Assessment of physical findings should confirm data obtained in nursing
history. Baseline information is obtained on admission. The proper
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examination proceeds logically from head to be starting with general

appearance, blood pressure, pulse, hands and neck, heart, lungs,
abdomen, feet and legs

DEFINITION

Physical examination is defined as a complete assessment of patient’s

physical and mental status

PURPOSE

 To understand the physical and mental well being of the patient

 To detect disease in its early stage
 To determine the cause and the extent of disease
 To understand any changes in the condition of diseases, any
improvement or regression
 To determine the nature of the treatment or nursing care needed
for the patient
 To safeguard the patient and his family by noting the early signs
especially in case of a communicable disease
 To contribute to the medical research
 To find out whether the person is medically fit or not for a
particular task

METHODS OF EXAMINATION

Inspection

Visual examination of the body is called inspection. It is the observation

with the naked eyes to determine the structure and functions of the
body. It means looking with eyes. It reveals any rash, scar, color, size,
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shape, contour or symmetry of body parts. The quality of inspection

depends on the time spent by the nurse to be thorough and systematic.
In a hurry, we may overlook significant findings and make an incorrect
conclusion. The following principles should be kept in mind for making
accurate inspections.

 Good lighting and exposure are essential

 Inspect each area for size, shape, color, symmetry and proposition
and find out any deviations from normal
 Use additional lights for examining body cavities, e.g. oral
 Use sense of olfaction along with visual to detect abnormalities
e.g. bad breath indicates unhygienic mouth conditions. Acidic
smell is significant of diabetic acidosis

PALPATION

It is feeling of the body or a part with the hands to note the size and
positions of the organs. In palpation, the finger pads and not the
fingertips are used. Palpation is an assessment technique in which the
examiner feels with his/her fingers and one or both hands. Skill and
gentleness are important. The degree of pressure applied during
palpation varies, depending on, e.g. tenderness of the area and the
depth of palpation required. It reveals may swelling, coldness, hotness,
stiffness, hardness, smoothness, roughness, pain, vibration, firmness
and flaccidity

The following points are to be kept in mind while doing palpation:

 The client should be relaxed and comfortable. Observe non-verbal

signs of discomfort during palpation
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 Palpation to be done with warm hands, short fingernails and a

gentle approach
 Palpation to be done slowly and gently
 For light palpation the hand is depressed about 1 cm (1/2 inch)
and for deeper palpation it should be approximately 2.5 cm ( 1
inch)
 Use appropriate parts of the hands for doing various palpations

PERCUSSION

It is the examination by tapping with the fingers on the body to

determine the condition of the internal organs by the sounds that are
produced. It is done by placing a finger of the left hand firmly against a
part to be examined and tapping with the fingertips of the right hand. It
means striking/tapping with fingers. It elicits sounds, which indicate
whether the underlying tissues are solid or filled with air or fluid. The
sounds may be:

Resonance: a low pitched and loud sound heard over the normal lung
tissues

Hyperresonance: very loud, very low pitch sound longer than resonance
and is of booming quality signifies emphysema

Tympany: a drum-like sound heard over the air-filled tissues such as

gastric air bubble

Dull: a medium-pitched sound with a medium duration without

resonance heard over solid tissues such as heart and liver
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Flat: a high-pitched sound with a short duration without resonance

heard over complete solid tissues such as hand, thigh

Method of percussion: the percussion can be done by two methods.

These are:

 Direct percussion: striking the body surface directly with one or

two finger, e.g. ascitic thrill
 Indirect percussion: placing the middle finger of the non-
dominant hand firmly against the body surface and striking the
distal joint of now-dominant finger with the middle fingers of the
dominant hand

AUSCULTATION

It means listening with stethoscope/placing ear against the body. It

reveals sounds produced within the body and the blood vessels such as
heart beats, bowel sounds, while auscultation frequency loudness,
quality and duration of the sound to be noted

MANIPULATIONS

It is the moving of a part of the body to note its flexibility. Limitation of

movements is discovered by this method

Testing of reflexes: the response of the tissues to external stimuli is

tested by: means of percussion hammer, safety pin, wisp of cotton, hot
and cold water, etc

Assessment using the sense of smell (olfaction)

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A well-developed sense of smell enables a nurse to detect odours that

are characteristic of certain conditions. Some alterations in body
function and certain bacteria create characteristic odours, for example:

• The ‘fishy’ smell of infected urine

• The ammonia odour associated with concentrated or decomposed

urine

• The musty or offensive odour of an infected wound

• The offensive rotting odour associated with gangrene (tissue necrosis)

• The smell of ketones on the breath in ketoacidosis (accumulation of

ketones in the body)

• The smell of alcohol on the breath — due to ingestion of alcohol

• Halitosis (offensive breath) accompanying mouth infections; for

example, gingivitis or certain disorders of the digestive system; for
example, appendicitis

• The foul odour associated with steatorrhoea (abnormal amount of fat

in the faeces)

• The characteristic odour associated with melaena (abnormal black

tarry stool containing blood)

• The faecal odour of vomitus associated with a bowel obstruction

• Bromhidrosis (offensive smelling perspiration) caused by bacterial

decomposition of perspiration on the skin.
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PREPARATION FOR EXAMINATION: PATIENT AND UNIT

GENERAL ASSESSMENT
PREPARTION OF THE ENVIRONMENT

 Maintenance of privacy
 A separate examination room is needed
 Keep the doors closed. The relatives are not allowed
 Drape the patient according to the parts that are exposed
 Lighting: as far as possible natural light should be available in the
examination room, because if a patient is jaundiced, it may not be
detected in the artificial light. There should be adequate lighting
 Comfortable bed or examination table: the patient should be
placed comfortably throughout the examination. There should be
provision for the maintenance of a suitable person, e.g. a
lithotomy position may be maintained when examining the
genitalia. To maintain this position, a special examination table
with stirrup rods is needed
 The room should be warm and without draughts

PREPARATION OF THE EQUIPMENT

All the articles needed for the physical examination are kept ready for
the examination at hand.

 Sphygmomanometer
 Stethoscope
 Fetoscope
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 TPR tray
 Tongue depressor
 Pharyngeal retractor
 Laryngoscope
 Tape measure
 Flash light
 Weighing machine
 Ophthalmoscope
 Otoscope
 Tuning fork
 Nasal speculum
 Percussion hammer, safety pins
 Cotton wool, cold and hot water
 Test tubes
 Vaginal speculum
 Proctoscope
 Gloves
 Sterile specimen bottles, slides
 Cotton applicators

GENERAL ASSESSMENT
PREPARATION OF THE PATIENT

Physical Preparation

 Keep the patient clean

 Shave the part if necessary
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 Keep the patient in a comfortable position which is convenient for

the doctor to examine the patient
 Empty the bladder prior to the examination. Empty the bowels by
an enema if required
 Loosen the garments and change into the hospital dress, if it is the
custom
 Drape the patient with extra sheets and expose only the need
areas
 Avoid unnecessary exposure

Mental Preparation

 The patient may be quite new to the hospital situation and he

may be anxious about his illness
 He may have false ideas about the medical examination
 It is the duty of the nurse to allay his anxieties and fears by proper
explanations
 Explain the sequence of the procedure to gain his confidence and
cooperation
 As far as possible a nurse should remain with a female patient
during the physical examination

ASSISTANCE IN THE EXAMINATION

To take Height and Weight

 To measure the length of the baby who cannot stand, place the
baby on a hard surface, with the soles of the feet supported in an
upright position
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 The knees are extended and the measurement is taken from the
soles of the feet to the vertex of the head
 The head should be in such a position that the eyes are facing the
ceiling
 After a child can stand, the height can be measured, if the child
with the heels back and head against a wall
 A small flat board held from the top of the head to the wall, will
give an accurate measure of the height that is the distance from
the floor to the board
 The weight of a person who can stand is generally measured by a
standing scale
 The patient stands on the platform and the weight is noted on the
dial
 Usually the weight is taken without shoes
 To take the weight of the baby, a baby weighing scale is used, in
which there is a container, where the baby can be laid
 It is important to weigh a baby unclothed weigh the clothes
separately and subtract this weight

To Measure the Skull Circumference

The skull is measured at its greatest diameter from above the eyes to
the occipital protuberance

Examination of the Eyes

 The examination is done in a lying or sitting position

 The examiner frequently uses a head mirror that reflects light to
the patient’s face
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 The first examination is one of inspection to determine the

movements of the eyes, reaction to light, accommodation to near
and far objects
 For detailed examination of the internal parts of the eye an
ophthalmoscope is used

Examination of the Ears

 The patient may be placed either in a lying or sitting position with

the ear to be examined turned towards the examiner
 Articles used for the examination are a head mirror, ear speculum
of various sizes, cotton tipped applicators and autoscope
 Tuning fork is used to test the hearing
 A child needs to be carefully restrained
 Young children sit on their mother’s lap with their legs restrained
between the mother’s knees and their arms held against their
back
 The mother them holds the child’s head against the chest
 Very small infants can be laid on the examination table

Examination of the Nose, Throat and Mouth

 The patient is usually seated with the head resting against the
back of the chair
 For the examination of the throat, a tongue depressor and a good
light are needed
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 For examination of the nose, a nasal speculum and a head mirror

are used. Sometimes the autoscope is also used

Examination of the Neck

The neck need to be palpated for lymph nodes. In order to assess the
thyroid glands, the patient is asked to swallow saliva.

Examination of the Chest

 While examining the anterior chest, the patient is placed in a

horizontal recumbent position
 The chest is examined in several ways
 It is percussed to determine the presence of fluid or congested
areas
 The physician listens to the sound within the chest by means of a
stethoscope
 To examine the posterior chest, the patient is placed in a sitting
position
 The heart and lungs are examined by percussion and auscultation
 The breasts are examined by palpation for the presence of lumps
or growths
 The axillae are palpated for enlarged lymph nodes
 During the examination, the patient’s face is turned away from
the doctor

Examination of the Abdomen

 Extremities are inspected, palpated and moved

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 A fine tremor suggestive of hyperthyroidism can be observed, if

the patient is asked to hold the arms out in front of him for a few
minutes

Admission Assessment

Aspect Normal Deviations from normal

General physical Normal weight for Overweight, underweight

appearance age, sex, height,
body build

Personal hygiene Appears to be neglected

and grooming
satisfactory

Skin Normal colour for Pallor, cyanosis, jaundice

race
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Neither dry nor Excessively dry or moist

moist

Normal temperature Elevated temperature, localised

warmth or coldness

Smooth Rough, or localised changes or

irregularities

Elastic Diminished by dehydration or

oedema

No lesions Rashes, bruises, scars, abrasions,

ulcers, nodules

Hair Normal texture for Brittle, dry, coarse

age, race

Normal distribution Areas of hair loss

Scalp clean and Dandruff, lesions, lice

healthy
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Shiny and clean Dull, neglected

Nails Transparent Streaks (red or white)

Smooth Ridged

Convex Concave curves

Pink nail beds Cyanosed, pale

Eyes Sclerae and corneas Pale, inflamed, jaundiced

clear

Eyelashes turn out Rubbing on eyeball

and away

Open eyelids do not Ptosis (drooping)

fall over pupils

Pupils equal and Dilated, pinpoint, unequal, non-

reacting to light reactive
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No discharge Watery or purulent discharge

Tolerance to light Photophobia (intolerance to light)

Normal visual acuity Visual impairment

Ears Normal hearing Hearing impairment

acuity

Ear canal clean Inflamed, presence of excessive

wax

No discharge Watery or purulent discharge

Itching, pain, tinnitus

Mouth Lips pink, moist, Pale, cyanosed, dry, cracked

smooth

Mucosa pink, moist, Pale, cyanosed, dry, ulcers, cracks

glistening
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Gums pink, moist, Inflamed, swollen, bleeding,

smooth lesions

Teeth white, Discoloured, chalky, decayed

straight, smooth

Tongue pinky red, Coated, cracked

moist

Breath fresh Halitosis (bad breath), ketone

odour

Thorax and lungs Normal-shaped Barrel-shaped chest

chest

Normal breath Wheezing, rales, gurgles, dry or

sounds moist cough

Abdomen Slightly convex, Excessively concave,

symmetrical asymmetrical, distended

Posture and gait Able to sit, stand Postural abnormalities, e.g.

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and walk normally kyphosis, scoliosis; abnormal gait

Mobility Full range of joint Stiffness or instability of a joint,

motion unusual joint movement, swelling
of a joint, pain on movement

Muscle tone and Normal tone and Increased or decreased tone,

strength strength decreased strength

Speech Ability to speak Speech impairment, e.g. lisp or

clearly stammer

Mental and Appropriate Responses inappropriate,

emotional status emotional responses apprehension, anxiety,
depression, hostility

Level of Alert, responsive, Disoriented, unresponsive to

consciousness and oriented to time, stimuli, shortened attention span
orientation place, person

Presence of None, although aids Spectacles, contact lenses,

prosthesis or aids to sight and hearing artificial eye, hearing aids,
are common walking sticks, frames,
wheelchairs, artificial limb,
dentures
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CARE OF AFTER EXAMINATION

 Assist him to dress and help him to remain in a comfortable

position in the bed
 After-care of equipment: wash the equipment with soap and
water, rinse, dry and sterilize, as needed
 Replace the equipments in their usual places
 Label specimens properly and send them to the laboratory
immediately

NURSE’S RESPONSIBILITIES DURING PHYSICAL EXAMINATION

 A separate examination room is needed. Keep the doors closed,

screen the patient and provide privacy if he is not in a separate
room. Relatives are not allowed
 Drape the patient according to the parts that are to be examined.
Natural light should be available in the examination room
 There should be adequate lighting in the room. The patient should
be comfortable throughout the examination
 There must be provision for the maintenance of a suitable
position, e.g. lithotomy position. The room should be warm
 The nurse must stay in the room at all times while the doctor
examines a female patient
 During the examination of a male patient’s genitals, the nurse
must leave the room. Take the patient’s temperature, pulse,
respiration and blood pressure, if recent readings are not
available
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 Give health teaching to the patient as need arises

ASSESSMENT OF EACH BODY SYSTEM

The nurse should assess:

Body Region Examples of Health Observation and Assessment

The head and face  The contour, intactness and tenderness of the skull.
 The colour and distribution of the hair.
 The symmetry and intactness of the facial features and bony
structures.
 The texture and tenderness of the skin and sinuses.
 The condition of the skin.

The eyes  The near and peripheral vision.

 The symmetry, position, closure, blinking and colour of the
eyes.
 The symmetry of the eye movements.
 The colour and clarity of the sclera.
 The transparency of the cornea.
 The pupillary response to light.

The ears  The alignment, position, size, shape, symmetry, intactness of

the ears.
 The external auditory canal.
 The superficial lymph nodes.
 The internal auditory canal.

The nose, mouth and  The symmetry of the nose.

oropharynx  The nasal canal.
 The lips, mucosa and gums.
 The teeth.
 The floor of the mouth and palates.
 The oropharynx, uvula, tonsils, pharynx, etc.
 The tongue.
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The neck  The symmetry of the neck, trachea and thyroid.

 The range of motion of the neck.
 The carotid pulses.
 The jugular vein.
 The lymph nodes.

The upper extremities  The skin, temperature, moisture of the hands.

 The symmetry of the hands.
 The shape, colour, thickness, cleanliness of the nails.
 The arms, elbows, wrists.
 The brachial / radial pulses.
 The range of motion, muscle strength and sensation of the
arms.
 The deep tendon reflexes.

The posterior chest  The respirations.

 The shoulders, spine alignment, posture, etc.
 The skin.
 The vertebrae.
 The breath sounds.

The anterior chest  The respirations.

 The skin.
 The heart sounds.
 If indicated, the breasts.
 The lymph nodes.

The abdomen  The skin.

 The abdomen itself, for contour and movement.
 The bowel sounds.
 The abdominal quadrants.

The lower extremities  The legs, ankles and feet.

 The temperature, pulses, pressure, deformities, etc.
 The range of motion, motor strength and sensation.

The neurologic system  The use of muscles, ease of movement, coordination.

 The person's alertness, orientation, thought process.
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The genitalia and rectum  The skin and mucosa.

 The urethra and other openings.
(if indicated)

It is important that nurses comply with their organisation's policies and procedures. In
order to perform an assessment using a particular technique, it is also important that
nurses are appropriately trained in the correct use of that technique, and in the data it
returns.

There are a range of other focused assessments which may also be completed - for
example:

 Blood glucose levels.

 Blood laboratory studies.
 Comprehensive neurological evaluation.
 Diagnostic imaging studies.
 Electrocardiogram (ECG) monitoring.
 Height, weight and Body Mass Index (BMI).
 Mental health assessment.
 Neurovascular function.
 Pain assessment.
 Sensory perception.
 Skin assessment.
 Urinalysis.

It is important that nurses are familiar with any pieces of equipment which may be used
in the assessment of a patient. This equipment may include (but is not limited to):

 Scale.  Thermometer.  Watch with a second

hand.

 Sphygmomanometer.  Stethoscope.  Drape sheet.

 Examination table.  Otoscope.  Opthalmoscope.

 Speculum.  Tongue blade.  Penlight.

 Examination gloves.  Ruler, tape  Marking pen.

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measure.

 Percussion hammer.  Gauze.  Speculum.

When assessing a patient, it is important that you are organised and prepared with the
equipment you need. It is important that you develop a routine, and that you practice
this so you develop confidence.

DOCUMENTATING HEALTH ASSESSMENT FINDINGS

Documenting health observation and assessment findings

At each stage of the assessment, it is important that nurses

document, or record in written format, the data they collect. This
allows data to be: (1) used to determine the patient's clinical
condition and make decisions about appropriate care, and (2)
communicated between different professionals involved in the
care of the patient.

There are a variety of different ways that data can be recorded,

and this differs between clinical settings and organisations.
Regardless of how data is recorded, however, documentation
must:

 Be complete, accurate, concise, legible and free from bias.

 Record facts, without the use of non-committal language.
 Be written contemporaneously, or as close to the time of
collection as possible.
 Include the name, signature and designation of the nurse
who created it.
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 Be unaltered; if errors are made, these must be struck

through with one line and initialled.
 Be kept securely, an in a way which protects the patient's
right to confidentiality.
 Avoid using acronyms, abbreviations, jargon and archaic
terms.
 Use short sentences and simple words.
 Involve the patient and their significant others, and use
language they understand.

As stated by the National Health Service's (NHS, 2010: p. 2) CG2 -

Record Keeping Guidelines, "[r]ecords must demonstrate a full
account of the assessment made, the care planned and provided
and actions taken, including information shared with other health
professionals."

Creating and maintaining appropriate documentation is a legal,

ethical and professional requirement for nurses. Health records
provide evidence about the type of assessment and care patients
receive. They are also important clinical tools, enabling continuity
of care and effective decision-making.
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UNIT – 2 THE NURSING PROCESS

CRITICAL THINKING COMPETENCIES, ATTITUDES FOR
CRITICAL THINKING, LEVELS OF CRITICAL THINKING IN
NURSING
As a nurse, you will face many clinical situations involving patients,
family members, health care staff, and peers. In each situation it is
important to try to see the big picture and think smart. To think smart
you have to develop critical thinking skills to face each new experience
and problem involving a patient’s care with open-mindedness,
creativity, confidence, and continual inquiry. When a patient develops a
new set of symptoms, asks you to offer comfort, or requires a
procedure, it is important to think critically and make sensible
judgments so the patient receives the best nursing care possible.
Critical thinking is not a simple step-by-step, linear process that you
learn overnight. It is a process acquired only through experience,
commitment, and an active curiosity toward learning.

Clinical Decisions in Nursing Practice

Nurses are responsible for making accurate and appropriate clinical

decisions. Clinical decision making separates professional nurses from
technical personnel. For example, a professional nurse observes for
changes in patients, recognizes potential problems, identifies new
problems as they arise, and takes immediate action when a patient’s
clinical condition worsens. Technical personnel simply follow direction
in completing aspects of care that the professional nurse has identified
as necessary. A professional nurse relies on knowledge and experience
when deciding if a patient is having complications that call for
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notification of a health care provider or decides if a teaching plan for a

patient is ineffective and needs revision. Benner (1984) describes
clinical decision making as judgment that includes critical and reflective
thinking and action and application of scientific and practical logic.
Most patients have health care problems for which there are no clear
textbook solutions. Each patient’s problems are unique, a product of
the patient’s physical health, lifestyle, culture, relationship with family
and friends, living environment, and experiences. Thus as a nurse you
do not always have a clear picture of a patient’s needs and the
appropriate actions to take when first meeting a patient. Instead you
must learn to question, wonder, and explore different perspectives and
interpretations to find a solution that benefits the patient.

Because no two patients’ health problems are the same, you always
apply critical thinking differently. Observe patients closely, gather
information about them, examine ideas and inferences about patient
problems, recognize the problems, consider scientific principles relating
to the problems, and develop an approach to nursing care. With
experience you learn to creatively seek new knowledge, act quickly
when events change, and make quality decisions for patients’ well-
being. You will find nursing to be rewarding and fulfilling through the
clinical decisions you make.

Critical Thinking Defined

Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy for

prostate cancer yesterday. His nurse, Tonya, finds the patient lying
supine in bed with arms extended along his sides but tensed. When
Tonya checks the patient’s surgical wound and drainage device, she
notes that the patient winces when she gently places her hands to
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palpate around the surgical incision. She asks Mr. Jacobs when he last
turned onto his side, and he responds, “Not since last night some time.”
Tonya asks Mr. Jacobs if he is having incisional pain, and he nods yes,
saying, “It hurts too much to move.” Tonya considers the information
she has observed and learned from the patient to determine that he is
in pain and has reduced mobility because of it. She decides that she
needs to take action to relieve Mr. Jacobs’ pain so she can turn him
more frequently and begin to get him out of bed for his recovery.

In the case example the nurse observes the clinical situation, asks
questions, considers what she knows about postoperative pain and risk
for immobility, and takes action. The nurse applies critical thinking, a
continuous process characterized by open-mindedness, continual
inquiry, and perseverance, combined with a willingness to look at each
unique patient situation and determine which identified assumptions
are true and relevant (Heffner and Rudy, 2008). Critical thinking
involves recognizing that an issue (e.g., patient problem) exists,
analyzing information about the issue (e.g., clinical data about a
patient), evaluating information (reviewing assumptions and evidence)
and making conclusions (Settersten and Lauver, 2004). A critical thinker
considers what is important in each clinical situation, imagines and
explores alternatives, considers ethical principles, and makes informed
decisions about the care of patients.

Critical thinking is a way of thinking about a situation that always asks

“Why?”, “What am I missing?”, “What do I really know about this
patient’s situation?”, and “What are my options?” (Heffner and Rudy,
2008; Paul and Heaslip, 1995). Tonya knew that pain was likely going to
be a problem because the patient had extensive surgery. Her review of
her observations and the patient’s report of pain confirmed her
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knowledge that pain was a problem. Her options include giving Mr.
Jacobs an analgesic and waiting until it takes effect so she is able to
reposition and make him more comfortable. Once he has less acute
pain, Tonya offers to teach Mr. Jacobs some relaxation exercises.

You begin to learn critical thinking early in your practice. For example,
as you learn about administering baths and other hygiene measures,
take time to read your textbook and the nursing literature about the
concept of comfort. What are the criteria for comfort? How do patients
from other cultures perceive comfort? What are the many factors that
promote comfort? The use of evidence-based knowledge, or knowledge
based on research or clinical expertise, makes you an informed critical
thinker. Thinking critically and learning about the concept of comfort
prepares you to better anticipate your patients’ needs, identify comfort
problems more quickly, and offer appropriate care. Critical thinking
requires cognitive skills and the habit of asking questions, remaining
well informed, being honest in facing personal biases, and always being
willing to reconsider and think clearly about issues (Facione, 1990).
When core critical thinking skills are applied to nursing, they show the
complex nature of clinical decision making (Table 1). Being able to apply
all of these skills takes practice. You also need to have a sound
knowledge base and thoughtfully consider what you learn when caring
for patients.
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TABLE 1

Critical Thinking Skills

SKILL NURSING PRACTICE APPLICATIONS

Interpretation Be orderly in data collection. Look for patterns to

categorize data (e.g., nursing diagnoses). Clarify any
data you are uncertain about.

Analysis Be open-minded as you look at information about a

patient. Do not make careless assumptions. Do the
data reveal what you believe is true, or are there
other options?

Inference Look at the meaning and significance of findings.

Are there relationships between findings? Do the
data about the patient help you see that a problem
exists?

Evaluation Look at all situations objectively. Use criteria (e.g.,

expected outcomes, pain characteristics, learning
objectives) to determine results of nursing actions.
Reflect on your own behavior.

Explanation Support your findings and conclusions. Use

knowledge and experience to choose strategies to
use in the care of patients.

Self- Reflect on your experiences. Identify the ways you

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SKILL NURSING PRACTICE APPLICATIONS

regulation can improve your own performance. What will

make you believe that you have been successful?

Nurses who apply critical thinking in their work are able to see the big
picture from all possible perspectives. They focus clearly on options for
solving problems and making decisions rather than quickly and
carelessly forming quick solutions (Kataoka-Yahiro and Saylor, 1994).
Nurses who work in crisis situations such as the emergency department
often act quickly when patient problems develop. However, even these
nurses exercise discipline in decision making to avoid premature and
inappropriate decisions. Learning to think critically helps you care for
patients as their advocate, or supporter, and make better-informed
choices about their care. Facione and Facione (1996) identified
concepts for thinking critically (Table 2). Critical thinking is more than
just problem solving. It is a continuous attempt to improve how to
apply yourself when faced with problems in patient care.

TABLE 2

Concepts for a Critical Thinker

CONCEPT CRITICAL THINKING BEHAVIOR

Truth seeking Seek the true meaning of a situation. Be

courageous, honest, and objective about asking
questions.
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CONCEPT CRITICAL THINKING BEHAVIOR

Open- Be tolerant of different views; be sensitive to the

mindedness possibility of your own prejudices; respect the
right of others to have different opinions.

Analyticity Analyze potentially problematic situations;

anticipate possible results or consequences; value
reason; use evidence-based knowledge.

Systematicity Be organized, focused; work hard in any inquiry.

Self-confidence Trust in your own reasoning processes.

Inquisitiveness Be eager to acquire knowledge and learn

explanations even when applications of the
knowledge are not immediately clear. Value
learning for learning’s sake.

Maturity Multiple solutions are acceptable. Reflect on your

own judgments; have cognitive maturity.

Thinking and Learning

Learning is a lifelong process. Your intellectual and emotional growth

involves learning new knowledge and refining your ability to think,
problem solve, and make judgments. To learn, you have to be flexible
and always open to new information. The science of nursing is growing
rapidly, and there will always be new information for you to apply in
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practice. As you have more clinical experiences and apply the

knowledge you learn, you will become better at forming assumptions,
presenting ideas, and making valid conclusions.

When you care for a patient, always think ahead and ask these
questions: What is the patient’s status now? How might it change and
why? Which physiological and emotional responses do I anticipate?
What do I know to improve the patient’s condition? In which way will
specific therapies affect the patient? What should be my first action?
Do not let your thinking become routine or standardized. Instead, learn
to look beyond the obvious in any clinical situation, explore the
patient’s unique responses to health alterations, and recognize which
actions are needed to benefit the patient. With experience you are able
to recognize patterns of behavior, see commonalities in signs and
symptoms, and anticipate reactions to therapies. Thinking about these
experiences allows you to better anticipate each new patient’s needs
and recognize problems when they develop.

Levels of Critical Thinking in Nursing

Your ability to think critically grows as you gain new knowledge in

nursing practice. Kataoka-Yahiro and Saylor (1994) developed a critical
thinking model (Fig. 1) that includes three levels: basic, complex, and
commitment. An expert nurse thinks critically almost automatically. As
a beginning student you make a more conscious effort to apply critical
thinking because initially you are more task oriented and trying to learn
how to organize nursing care activities. At first you apply the critical
thinking model at the basic level. As you advance in practice, you adopt
complex critical thinking and commitment.
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FIG. 1 Critical thinking model for nursing judgment

Basic Critical Thinking

At the basic level of critical thinking a learner trusts that experts have
the right answers for every problem. Thinking is concrete and based on
a set of rules or principles. For example, as a nursing student you use a
hospital procedure manual to confirm how to insert a Foley catheter.
You likely follow the procedure step by step without adjusting it to
meet a patient’s unique needs (e.g., positioning to minimize the
patient’s pain or mobility restrictions). You do not have enough
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experience to anticipate how to individualize the procedure. At this

level answers to complex problems are either right or wrong (e.g.,
when no urine drains from the catheter, the catheter tip must not be in
the bladder), and one right answer usually exists for each problem.
Basic critical thinking is an early step in developing reasoning (Kataoka-
Yahiro and Saylor, 1994). A basic critical thinker learns to accept the
diverse opinions and values of experts (e.g., instructors and staff nurse
role models). However, inexperience, weak competencies, and
inflexible attitudes can restrict a person’s ability to move to the next
level of critical thinking.

Complex Critical Thinking

Complex critical thinkers begin to separate themselves from experts.

They analyze and examine choices more independently. The person’s
thinking abilities and initiative to look beyond expert opinion begin to
change. A nurse learns that alternative and perhaps conflicting
solutions exist.

Consider the case of Mr. Rosen, a 36-year-old man who had hip
surgery. The patient is having pain but is refusing his ordered analgesic.
His health care provider is concerned that the patient will not progress
as planned, delaying rehabilitation. While discussing the importance of
rehabilitation with Mr. Rosen, the nurse, Edwin, realizes the patient’s
reason for not taking pain medication. Edwin learns that the patient
practices meditation at home. As a complex critical thinker, Edwin
recognizes that Mr. Rosen has options for pain relief. Edwin decides to
discuss meditation and other nonpharmacological interventions with
the patient as pain control options and how, when combined with
analgesics, these interventions can potentially enhance pain relief.
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In complex critical thinking each solution has benefits and risks that you
weigh before making a final decision. There are options. Thinking
becomes more creative and innovative. The complex critical thinker is
willing to consider different options from routine procedures when
complex situations develop. You learn a variety of different approaches
for the same therapy.

Commitment

The third level of critical thinking is commitment (Kataoka-Yahiro and

Saylor, 1994). At this level a person anticipates when to make choices
without assistance from others and accepts accountability for decisions
made. As a nurse you do more than just consider the complex
alternatives that a problem poses. At the commitment level you choose
an action or belief based on the available alternatives and supports it.
Sometimes an action is to not act or to delay an action until a later
time. You choose to delay as a result of your experience and
knowledge. Because you take accountability for the decision, you
consider the results of the decision and determine whether it was
appropriate.

Critical Thinking Competencies

Kataoka-Yahiro and Saylor (1994) describe critical thinking

competencies as the cognitive processes a nurse uses to make
judgments about the clinical care of patients. These include general
critical thinking, specific critical thinking in clinical situations, and
specific critical thinking in nursing. General critical thinking processes
are not unique to nursing. They include the scientific method, problem
solving, and decision making. Specific critical thinking competencies in
clinical health care situations include diagnostic reasoning, clinical
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inference, and clinical decision making. The specific critical thinking

competency in nursing involves use of the nursing process. Each of the
competencies is discussed in the following paragraphs.

General Critical Thinking

Scientific Method

The scientific method is a way to solve problems using reasoning. It is a

systematic, ordered approach to gathering data and solving problems
used by nurses, physicians, and a variety of other health care
professionals. This approach looks for the truth or verifies that a set of
facts agrees with reality. Nurse researchers use the scientific
method when testing research questions in nursing practice situations.
The scientific method has five steps:

1 Identifying the problem

2 Collecting data

3 Formulating a question or hypothesis

4 Testing the question or hypothesis

5 Evaluating results of the test or study

Consider the following example of the scientific method in nursing

practice.

A nurse caring for patients who receive large doses of chemotherapy

for ovarian cancer sees a pattern of patients developing severe
inflammation in the mouth (mucositis) (identifies problem). The nurse
reads research articles (collects data) about mucositis and learns that
there is evidence to show that having patients keep ice in their mouths
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(cryotherapy) during the chemotherapy infusion reduces severity of

mucositis after treatment. He or she asks (forms question), “Do
patients with ovarian cancer who receive chemotherapy have less
severe mucositis when given cryotherapy versus standard mouth rinse
in the oral cavity?” The nurse then collaborates with colleagues to
develop a nursing protocol for using ice with certain chemotherapy
infusions. The nurses on the oncology unit collect information that
allows them to compare the incidence and severity of mucositis for a
group of patients who use cryotherapy versus those who use standard-
practice mouth rinse (tests the question). They analyze the results of
their project and find that the use of cryotherapy reduced the
frequency and severity of mucositis in their patients (evaluating the
results). They decide to continue the protocol for all patients with
ovarian cancer.

Problem Solving

You face problems every day such as a computer program that doesn’t
function properly or a close friend who has lost a favorite pet. When a
problem arises, you obtain information and use it, plus what you
already know, to find a solution. Patients routinely present problems in
practice. For example, a home care nurse learns that a patient has
difficulty taking her medications regularly. The patient is unable to
describe what medications she has taken for the last 3 days. The
medication bottles are labeled and filled. The nurse has to solve the
problem of why the patient is not adhering to or following her
medication schedule. The nurse knows that the patient was discharged
from the hospital and had five medications ordered. The patient tells
the nurse that she also takes two over-the-counter medications
regularly. When the nurse asks her to show the medications that she
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takes in the morning, the nurse notices that she has difficulty reading
the medication labels. The patient is able to describe the medications
that she is to take but is uncertain about the times of administration.
The nurse recommends having the patient’s pharmacy relabel the
medications in larger lettering. In addition, the nurse shows the patient
examples of pill organizers that will help her sort her medications by
time of day for a period of 7 days.

Effective problem solving also involves evaluating the solution over

time to make sure that it is effective. It becomes necessary to try
different options if a problem recurs. From the previous example,
during a follow-up visit the nurse finds that the patient has organized
her medications correctly and is able to read the labels without
difficulty. The nurse obtained information that correctly clarified the
cause of the patient’s problem and tested a solution that proved
successful. Having solved a problem in one situation adds to a nurse’s
experience in practice, and this allows the nurse to apply that
knowledge in future patient situations.

Decision Making

When you face a problem or situation and need to choose a course of

action from several options, you are making a decision. Decision
making is a product of critical thinking that focuses on problem
resolution. Following a set of criteria helps to make a thorough and
thoughtful decision. The criteria may be personal; based on an
organizational policy; or, frequently in the case of nursing, a
professional standard. For example, decision making occurs when a
person decides on the choice of a health care provider. To make a
decision, an individual has to recognize and define the problem or
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situation (need for a certain type of health care provider to provide

medical care) and assess all options (consider recommended health
care providers or choose one whose office is close to home). The
person has to weigh each option against a set of personal criteria
(experience, friendliness, and reputation), test possible options (talk
directly with the different health care providers), consider the
consequences of the decision (examine pros and cons of selecting one
health care provider over another), and make a final decision. Although
the set of criteria follows a sequence of steps, decision making involves
moving back and forth when considering all criteria. It leads to
informed conclusions that are supported by evidence and reason.
Examples of decision making in the clinical area include determining
which patient care priority requires the first response, choosing a type
of dressing for a patient with a surgical wound, or selecting the best
teaching approach for a family caregiver who will assist a patient who is
returning home after a stroke.

Specific Critical Thinking

Diagnostic Reasoning and Inference

Once you receive information about a patient in a clinical

situation, diagnostic reasoning begins. It is the analytical process for
determining a patient’s health problems (Harjai and Tiwari, 2009).
Accurate recognition of a patient’s problems is necessary before you
decide on solutions and implement action. It requires you to assign
meaning to the behaviors and physical signs and symptoms presented
by a patient. Diagnostic reasoning begins when you interact with a
patient or make physical or behavioral observations. An expert nurse
sees the context of a patient situation (e.g., a patient who is feeling
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light-headed with blurred vision and who has a history of diabetes is

possibly experiencing a problem with blood glucose levels), observes
patterns and themes (e.g., symptoms that include weakness, hunger,
and visual disturbances suggest hypoglycemia), and makes decisions
quickly (e.g., offers a food source containing glucose). The information
a nurse collects and analyzes leads to a diagnosis of a patient’s
condition. Nurses do not make medical diagnoses, but they do assess
and monitor patients closely and compare the patients’ signs and
symptoms with those that are common to a medical diagnosis. This
type of diagnostic reasoning helps health care providers pinpoint the
nature of a problem more quickly and select proper therapies.

Part of diagnostic reasoning is clinical inference, the process of drawing

conclusions from related pieces of evidence and previous experience
with the evidence. An inference involves forming patterns of
information from data before making a diagnosis. Seeing that a patient
has lost appetite and experienced weight loss over the last month, the
nurse infers that there is a nutritional problem. An example of
diagnostic reasoning is forming a nursing diagnosis such as imbalanced
nutrition: less than body requirements (see Chapter 17).

In diagnostic reasoning use patient data that you gather or collect to

logically recognize the problem. For example, after turning a patient
you see an area of redness on the right hip. You palpate the area and
note that it is warm to the touch and the patient complains of
tenderness. You press over the area with your finger; after you release
pressure, the area does not blanch or turn white. After thinking about
what you know about normal skin integrity and the effects of pressure,
you form the diagnostic conclusion that the patient has a pressure
ulcer. As a student, confirm your judgments with experienced nurses.
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At times you possibly will be wrong, but consulting with nurse experts
gives you feedback to build on future clinical situations.

Often you cannot make a precise diagnosis during your first meeting
with a patient. Sometimes you sense that a problem exists but do not
have enough data to make a specific diagnosis. Some patients’ physical
conditions limit their ability to tell you about symptoms. Some choose
to not share sensitive and important information during your initial
assessment. Some patients’ behaviors and physical responses become
observable only under conditions not present during your initial
assessment. When uncertain of a diagnosis, continue data collection.
You have to critically analyze changing clinical situations until you are
able to determine the patient’s unique situation. Diagnostic reasoning
is a continuous behavior in nursing practice. Any diagnostic conclusions
that you make will help the health care provider identify the nature of a
problem more quickly and select appropriate medical therapies.

Clinical Decision Making

As in the case of general decision making, clinical decision making is a

problem-solving activity that focuses on defining a problem and
selecting an appropriate action. In clinical decision making a nurse
identifies a patient’s problem and selects a nursing intervention. When
you approach a clinical problem such as a patient who is less mobile
and develops an area of redness over the hip, you make a decision that
identifies the problem (impaired skin integrity in the form of a pressure
ulcer) and choose the best nursing interventions (skin care and a
turning schedule). Nurses make clinical decisions all the time to
improve a patient’s health or maintain wellness. This means reducing
the severity of the problem or resolving the problem
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completely. Clinical decision making requires careful reasoning (i.e.,

choosing the options for the best patient outcomes on the basis of the
patient’s condition and the priority of the problem).

Improve your clinical decision making by knowing your patients. Nurse

researchers found that expert nurses develop a level of knowing that
leads to pattern recognition of patient symptoms and responses
(White, 2003). For example, an expert nurse who has worked on a
general surgery unit for many years is more likely able to detect signs of
internal hemorrhage (e.g., fall in blood pressure, rapid pulse, change in
consciousness) than a new nurse. Over time a combination of
experience, time spent in a specific clinical area, and the quality of
relationships formed with patients allow expert nurses to know clinical
situations and quickly anticipate and select the right course of action.
Spending more time during initial patient assessments to observe
patient behavior and measure physical findings is a way to improve
knowledge of your patients. In addition, consistently assessing and
monitoring patients as problems occur help you to see how clinical
changes develop over time. The selection of nursing therapies is built
on both clinical knowledge and specific patient data, including:

• The identified status and situation you assessed about the patient,
including data collected by actively listening to the patient regarding his
or her health care needs.

• Knowledge about the clinical variables (e.g., age, seriousness of the

problem, pathology of the problem, patient’s preexisting disease
conditions) involved in the situation, and how the variables are linked
together.
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• A judgment about the likely course of events and outcome of the

diagnosed problem, considering any health risks the patient has;
includes knowledge about usual patterns of any diagnosed problem or
prognosis.

• Any additional relevant data about requirements in the patient’s daily

living, functional capacity, and social resources.

• Knowledge about the nursing therapy options available and the way
in which specific interventions will predictably affect the patient’s
situation.

NURSING PROCESS OVERVIEW

Nursing process is referred to as the basic framework for the practice of
nursing, which allows the nurse to provide care in a systematic,
organized fashion. Because nursing is an evolving profession, this
framework is constantly being modified and adapted to current
practice.

The Nursing Process is a problem solving approach used by nurses to

meet the needs of the patient. It is a deliberative method that relies on
the use of cognitive, interpersonal and psychomotor skills. The nursing
process is the systematic and rational method of planning and
providing nursing care.

Its goal is to identify a client’s health status, actual or potential health

care problems, to establish plans to meet the individual needs and to
deliver specific nursing interventions to meet those needs. The nursing
process is a cyclical process that is the component of the nursing
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process follows a logical sequence, but more than one component may
be involved at any given time. The nursing process provides a
framework for accountability in nursing

Nurses and clients as partners to

 Promote health
 Prevent disease/illness
 Restore health
 Facilitate coping with altered functioning

DEFINITION

 The Nursing Process is a cyclical process that is the component of

the nursing process follows a logical sequence, but more than one
component may be involved at any given time. The nursing
process provides a framework for accountability in nursing
 The Nursing Process can be defined as an orderly, systematic way
of identifying the clients (patients) problems, making plans to
solve them, initiating the plans or assigning others to implement it
and evaluating the extent to which the plan was effective in
resolving the problems identified

STEPS IN THE NURSING PROCESS

The nursing process consists of five steps or components. These five

steps of the nursing process are: assessment, nursing diagnosis,
planning, implementation and evaluation. The scientific nursing
activities and responsibilities are associated with each steps of the
nursing process.
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Assignment

It is collecting, verifying and organizing data about the client’s health

status. Data about physical, emotional, developmental, social, cultural,
intellectual and spiritual aspects of the client’s are obtained from a
variety of sources and are the basis for actions and decisions taken at a
subsequent phases.

Nursing Diagnosis

It is a process of making a clinical judgment about a client’s potential or

actual health problem. Nursing diagnosis is the statement of the
judgment. In this phase, the nurse sorts, clusters the data and analyzes,
what are the actual and potential health problems for which the client
needs nursing assistance and what may be the contributing factors to
this problem.

Planning

It involves a series of steps in which the nurse and client set priorities,
formulate goals or expected outcomes and establish a written care plan
for nursing interventions. The plan to resolve or minimize the identified
problems of the client and to coordinate the care provided by all the
health team members

Implementation

It is putting the nursing care plan into action. During the

implementation phase, the nurse continues to collect data and carries
out the prescribed nursing activities or delegates the care to an
appropriate person who validates the nursing care plan.

Evaluation
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It is assessing the client’s response to nursing interventions and then

comparing the response to predetermined standards. These standards
are often referred to as ‘outcome criteria’. The nurse determines the
extent to which the goals are predetermined and the outcomes of care
that have been achieved, partially achieved or not met.

BENEFITS OF NURSING PROCESS

Benefits for the Client

Quality client care: The nursing care is planned to meet the unique
needs of the individual, family or community. Continuous evaluation
and reassessment of the client’s changing needs ensure an appropriate
level of care

Continuity of care: the written care plan is accessible to all the persons
involved in the client’s care and it prevents the client from repeating
information and preferences to each caretakers

Participation by the client in their health care: the process can help the
clients to develop skills related to their health care and to become
more committed to the goals of care.

Benefits for the Nurse

Consistent and systematic nursing education: the agency which

accredits nursing education programs requires all graduates to be
competent in using the nursing process

Job satisfaction: well written care plans has given the nurses to be
confident about that nursing interventions which are based on correct
identification of the client’s problems, thus preventing the
uncoordinated, trail- and – error nursing
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For professional growth: by elevating the effectiveness of the nursing

interventions, the nurse learns which interventions are most effective,
and which ones can be adapted to meet the needs of other clients.

Meet professional standards: learning and implementing the nursing

process while providing client care is a basic requirement for
professional nursing competence

A Framework for Accountability

 Accountability is the condition of being answerable and

responsible to someone for specific behaviors that are part of the
nurse’s professional role
 The nursing process provides a framework for accountability and
responsibility in nursing and maximizes accountability and
responsibility for standards of care
 Nurses are accountable to the client (public), to their professional
statuary nursing body, to colleagues, to the employing agency and
to themselves
 The nursing process provides a framework for accountability in all
areas. A professional nurse is accountable for activities in all five
phases of the nursing process

NURSING ASSESSMENT

The first step of nursing process is assessment. Assessment is the

collection of data about the client from a variety of sources.
Assessment is the continuous process carried out during all phases of
the nursing process. It may be used during the diagnosis phase to
validate a diagnosis.

Pre-requisites to Assessment
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Beliefs: The nurse’s belief encompasses a caring philosophy about the

client’s responsibilities and health and illness and the role of nursing in
health care. These philosophies do not blossom overnight but are
molded during the course of nursing education by nurses, other
students, instructors, and clients

Knowledge: the knowledge base for nurses is extensive and nurses are
required to use information from sciences such as nursing, anatomy,
physiology, microbiology, pharmacology, chemistry, and nutrition using
all of these sciences is guidelines, the nurse can analyze data collected
about the client

Skill: a variety of skills are required to perform a complete assessment

of the client. They include psychomotor and interpersonal

Psychomotor skills are the technical skills required in many phases and
nursing process. During the assessment phase, the most common skills
are those of physical assessment such as inspection, palpation and
auscultation

Interpersonal skills are important in all phases of nursing process but

are a critical component of the assessment phase. The term therapeutic
relationship is often used to describe the communication techniques
that allow the client and family to share views and telling openly

Data Collection

Data collected from a patient includes both objective and subjective

data. Objective data are detectable by an observer. Examples of
objective data are blood pressure recording, checking body
temperature, detecting cyanosis in a patient. Subjective data are
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apparent only to the patient concerned. Examples of subjective data

are feeling of pain, itching, etc

Sources of Data

Client: The chief source of data is usually the client unless the client is
too ill, young or confused to communicate clearly. The client can
provide subjective data that no one else can offer

Significant others: significant others are supporting person who knows

the client well and often provide data. They might convey information
about the stress the client was experiencing before the illness, family
attitudes to illness and health and the client’s home environment

Health personnel: health personnel are often the sources of

information about a client’s health. Nurses, physicians, social workers
and physiotherapist are involved. Physician who knows the client’s
home setting may provide valuable data about the family and
environmental stress

Medical records: Medical records are often a source of a client’s

present and past health and illness patterns. This record can provide
nurses with information about a client’s coping behaviors, health
practices, previous illness and allergies

Other records and reports: Other records and reports can also provide
information pertinent to health, laboratory, and tests are frequently
ordered as part of the physician’s initial examination to aid in a medical
diagnosis
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Literature: the review of nursing and related literature, such as

professional journals and reference texts, can provide additional
information for the database

Methods of Data Collection

Observation: The nurse observes mainly through sight, all of the senses
are engaged during careful observations. Observation has two aspects:
(a) noticing the stimuli and (b) selecting, organizing and interpreting the
data, i.e. perceiving them. Observation is a conscious, deliberate skill
that is developed only through effort and with an organized approach

Interviewing: The nurse interviews the patient and his significant others
obtain data by asking relevant questions. Interview is a planned
communication or conversation with a purpose. Interviewing can be
viewed as a process in the nursing health history, which is the primary
tool for data collection during the assessment phase of the nursing
process

Examination: Nurses perform physical assessment to obtain the

objective data needed to complete the assessment phase of the
nursing process. A complete database of both subjective and objective
data allows the nurse to formulate nursing diagnosis, to develop client
goals and intervene to promote health and prevent disease

Guidelines for Data Collection

The Initial history: The data collected in this step usually include the
historical data (past illness), current data (the current complaint) and
demographic data (data of birth, address). It is helpful to address the
client’s chief complaint early in the interview process
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Symptom analysis: When a client expresses a problem the nurse

conducts a complete analysis of a symptom. This process begins with
symptoms analysis which is the collection of subjective data about the
problem. Symptoms analysis requires the client to identify the location
of the symptoms, describe the symptoms, severity of the pain, and
timing of the symptoms (including onset, duration and frequency)

Aggravating and relieving symptoms and any associated symptoms. It is

crucial that the nurse be able to perform a complete symptoms
analysis. The data obtained can guide the nurse in detecting what the
problem is and what degree of priority is should be given

Approaches to history taking: These are various approaches that can be

used to provide a systematic guide to assessment. Gordon has devised
functional health patterns and the North American Nursing Diagnosis
Association (NANDA) has devised human response patterns based on
patterns of unitary persons

Physical examination: Physical examination of the client is the second

portion of assessment. Examination allows the nurse to gain objective
data through the use of inspection, percussion, palpation and
auscultation. These data further define the client’s response to the
disorder, provide a baseline of data for further comparison, and
elaborate on the subjective data provided in the client’s history

STEPS OF ASSESSMENT

 Collection of data
 Subjective data collection
 Objective data collection
 Validation of data
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 Organization of data
 Recording/documentation of data

Data collection

Data collection is an important task in the assessment. Nurses

collect data, cluster cues, Make inferences and identify emerging
patterns and potential problem areas.

Types of data

Mainly two types of data collected in the assessment. Those are

Subjective data and objective data.

Subjective data

Only the patient provides subjective data about their health

problems. It usually includes feelings, perceptions and self-report
of symptoms.

Objective data

Objective data around generation or measurement of a patient’s

health status. For example, inspecting the condition of a surgical
incision or on, describing object behaviour and measuring blood
pressure.

Sources of data

Nurses obtain data from variety of sources that provide

information about the patient’s current level of wellness and
functional status, anticipated prognosis, risk factors, health Health
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practices and goals, responses to previous treatment, and

patterns of health and illness.

Data validation

Validation is comparing data with another source to check its

accuracy. Meditation opens the door to gathering more
assessment data because it involves clarifying vague or unclear
data. Occasionally nurses need to reassess previously covered
areas of nursing history or gather further physical examination
data. Continually analyse and think about a patient’s database to
make concise, accurate and meaningful interpretations.

For example, nurses say that a patient who has been scheduled
for surgery looks anxious, so the nurse asks the question,” you
look tensed and anxious whether you are uncertain about your
surgery result?” Here the patient will explain the causes of his
anxiety, this is the validation process.

Data organization

Collected data must be organised so as to be useful to the

healthcare professional collecting the data and to others involved
in the clients care. After being organised into categories, the data
clustered into groups of related pieces. Data clustering is the
process of putting data together in order to identify areas of the
client’s problems and strengths. Many healthcare agencies use an
admission assessment format, which assists the nurse in collecting
and organising data.

Data can be organised in following ways:

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Hierarchy of Needs: Maslow’s hierarchy of needs proposes that

an individual’s basic needs must be met before higher-level needs
can be met. An initial assessment of all psychological needs
followed by an assessment of higher-level need Is necessary when
using this model.

Body systems model: the body systems model organises data

collection according to tissue and organ function in the various
body systems. Physicians frequently use this model, so it is
sometimes called the “medical model”.

Interpreting the data

After the data is collected, the nurse can begin developing

impressions or inferences about the meaning of the data.
Organising data in clusters helps the nurse recognise patterns of
response or behaviour. When data are placed in clusters, and the
nurse can:

 Distinguish between relevant and irrelevant data.

 Determine whether and where there are gaps in the data.
 Identify patterns of cause and effect.

Data Documentation

Data documentation is the last part of a complete assessment.

The timely, thorough, and accurate documentation of facts is
required in recording patient data. If you do not record an
assessment finding or problem interpretation, it is lost and
unavailable to anyone else caring for the patient. If information is
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not specific, the reader is left with only general impressions.

Observing and recording patient status is legal and professional
responsibilities.

The basic rule is to record all observations succinctly. When

recording data, pay attention to facts and be as descriptive as
possible. Anything heard, seen, felt, or smelled should be reported
exactly. Record objective information in accurate terminology
(e.g., weighs 170 kg, the abdomen is soft and non-tender to
palpation). Record subjective information from a patient in
quotation marks.

NURSING DIAGNOSIS

Since 1973, a group of nurse researchers and educators formulated

plans to standardize communication and categories of nursing care.
Before this standardization, descriptions of nursing care differed both
between hospitals and also within one hospital because nurses literally
invented their own descriptions of nursing-related concerns for clients.
In 1982, with members from Canada and the United States, the group
became known as the organization North American Nursing Diagnosis
Association (NANDA). In 2002, the organization was revised and
became NANDA – I International (NANDA – I) using an updated model
of health called Taxonomy II.

 Nursing diagnosis is actual or potential problems that are

amenable to resolution by nursing actions are identified as
nursing diagnosis.
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 The five national conferences on the classification of nursing

diagnosis held in 1970’s and the clearly 1980’s have provided an
impetus for the identification and classification of nursing
diagnosis according to symptom
 When developing the nursing diagnosis for a particular patient,
the nurse must first identify the commonalities among the
assessment data-collected. These common features lead to the
categorization of related data that reveal the existence of a
problem and the need for nursing intervention. The patient’s
nursing problem is then defined as the nursing diagnosis
 It must be remembered that nursing diagnosis are not medical
diagnosis, they are not medical treatments prescribed by the
physician; they are not diagnostic studies; they are not the
equipment utilized to implement medical therapy
 They are not the patient’s actual or potential health problems
that are amenable to resolution by nursing actions. Nursing
diagnoses that are succinctly stated in terms of the specific
problems of the patient will guide the nurse in the development
of the nursing care plan

Identifying Health Problems, Risks, and Strengths

In this decision-making step after data analysis, the nurse together with
the client identifies problems that support tentative actual, risk, and
possible diagnoses. It involves determining whether a problem is a
nursing diagnosis, medical diagnosis, or a collaborative problem. Also at
this stage is wherein the nurse and the client identify the client’s
strengths, resources, and abilities to cope.
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Components of nursing diagnosis

The nursing diagnosis may be stated as a two-part statement or a
three-part statement. The two-part statement is NANDA- International
approved and used by most nurses because it is brief and precise.

The three-part statement is often required of nursing students and is

preferred by nurses who desire the diagnostic statement to include
specific manifestations.

Two-Part Statement: The first part, the actual nursing diagnosis, is a

problem statement or diagnostic label describing the client’s response
to an actual or risk health problem or a wellness condition.

The second part is the aetiology, the related cause or contributor to the
problem, which is identified in the complete NANDA-International
diagnosis description. The diagnostic label and aetiology are linked by
the term related to (R/T). Because the NANDA-International list of
nursing diagnoses is constantly evolving, there may be times when no
aetiology is provided.

In such cases, the nurse attempts to describe likely contributing factors

to the client’s condition. Examples of a two-part nursing diagnosis
statement are Disturbed Body Image R/T loss of left lower extremity
and Activity Intolerance R/T decreased oxygen-carrying capacity of
cells.

Three-Part Statement: In a three-part statement, the first two parts are

the diagnostic label and the etiology. The third part consists of defining
characteristics (collected data, also known as signs and symptoms,
subjective and objective data, or clinical manifestations). The third part
is joined to the first two parts with the connecting phrase as evidenced
by (AEB).
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Formulating Diagnostic Statements

Formulation of diagnostic statement is the last step of the diagnostic
process wherein the nurse creates diagnostic statements. The process
is detailed below.

In writing nursing diagnostic statements, describe the health status of

an individual and the factors that have contributed to the status. You
do not need to include all types of diagnostic indicators. Writing
diagnostic statements vary per type of nursing diagnosis

PES Format

Another way of writing nursing diagnostic statements is by using

the PES format which stands for Problem (diagnostic label), Etiology
(related factors), and Signs/Symptoms (defining characteristics). Using
the PES format, diagnostic statements can be one-part, two-part, or
three-part statements.

One-Part Nursing Diagnosis Statement

Health promotion nursing diagnoses are usually written as one-part

statements because related factors are always the same: motivated to
achieve a higher level of wellness though related factors may be used
to improve the of the chosen diagnosis. Syndrome diagnoses also have
no related factors. Examples of one-part nursing diagnosis statement
include:

 Readiness for Enhance Breastfeeding

 Readiness for Enhanced Coping
 Rape Trauma Syndrome
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Two-Part Nursing Diagnosis Statement

Risk and possible nursing diagnoses have two-part statements: the first
part is the diagnostic label and the second is the validation for a risk
nursing diagnosis or the presence of risk factors. It’s not possible to
have a third part for risk or possible diagnoses because signs and
symptoms do not exist. Examples of two-part nursing diagnosis
statement include:

 Risk for Infection as evidenced by compromised host defenses

 Risk for Injury as evidenced by abnormal blood profile
 Possible Social Isolation related to unknown etiology

Three-part Nursing Diagnosis Statement

An actual or problem-focus nursing diagnosis has three-part

statements: diagnostic label, contributing factor (“related to”), and
signs and symptoms (“as evidenced by” or “as manifested by”). Three-
part nursing diagnosis statement is also called the PES format which
includes the Problem, Etiology, and Signs and Symptoms. Examples of
three-part nursing diagnosis statement include:

 Impaired Physical Mobility related to decreased muscle control as

evidenced by inability to control lower extremities.
 Acute Pain related to tissue ischemia as evidenced by statement
of “I feel severe pain on my chest!”

Variations on Basic Statement Formats

Variations in writing nursing diagnosis statement formats include the

following:
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 Using “secondary to” to divide the etiology into two parts to make
the diagnostic statement more descriptive and useful. Following
the “secondary to” is often a pathophysiologic or disease process
or a medical diagnosis. For example, Risk for Decreased Cardiac
Output related to reduced preload secondary to myocardial
infarction.
 Using “complex factors” when there are too many etiologic
factors or when they are too complex to state in a brief phrase.
For example, Chronic Low Self-Esteem related to complex factors.
 Using “unknown etiology” when the defining characteristics are
present but the nurse does not know the cause or contributing
factors. For example, Ineffective Coping related to unknown
etiology.
 Specifying a second part of the general response or NANDA label
to make it more precise. For example, Impaired Skin Integrity
(Right Anterior Chest) related to disruption of skin surface
secondary to burn injury.

TYPES OF NURSING DIAGNOSIS

An actual nursing diagnosis indicates that the problem exists; it is

composed of the diagnostic label, related factors, and signs and
symptoms. An example of an actual diagnosis is Situational Low Self-
Esteem R/T loss (first chair trumpet in the band) as evidenced by self-
negating verbalization “I’m no good anymore.”

A risk nursing diagnosis (potential problem) indicates that a problem

does not yet exist but that specific risk factors are present. A risk
diagnosis begins with the phrase Risk for followed by the diagnostic
label and a list of the risk factors.

An example of a risk diagnosis is Risk for infection; as evidenced by

improper maintaining of personal hygiene, poor sanitation as
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evidenced by dirty clothes and scattered waste material around the

house.

A wellness nursing diagnosis denotes the client’s statement of a desire

to attain a higher level of wellness in some area of function. It begins
with the phrase Readiness for Enhanced followed by the diagnostic
label.

For example, a wife who has been caring for her husband who had a
stroke two months ago asks the nurse about meeting with other wives
who are/have been in a similar situation. The nurse would make a
wellness diagnosis of Readiness for Enhanced Family Coping.

After formulation, the nursing diagnoses are discussed with the client,
but if this is not possible, the diagnoses are discussed with family
members. The list of nursing diagnoses is recorded on the client’s
record, and the remainder of the client’s care plan is completed.

Prioritizing the nursing diagnosis

Prioritizing the nursing diagnoses involves deciding which diagnoses are

the most important and require attention first. Maslow’s hierarchy of
needs is one of the most common methods of selecting priorities. After
basic physiological needs (e.g., respiration, nutrition, temperature,
hydration, and elimination) are met to some degree, the nurse can then
consider needs on the next level of the hierarchy (e.g., safe
environment, stable living condition, affection, and self-worth) and so
on up the hierarchy until all the nursing diagnoses have been
prioritized.

Alfaro-LeFevre (2008) suggests a three-level approach to prioritizing

client problems (nursing diagnoses):
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 First-level priority problems (immediate): Airway problems

Breathing problems
Signs (vital sign problems)
 Second-level priority problems(immediate, after treatment for
first-level problems, is initiated): Mental status change
Acute pain Acute urinary elimination problems
Untreated medical problems requiring immediate attention (e.g.,
a diabetic who has not had insulin) Abnormal lab values
Risks of infection, safety, or security (for client or others)
 Third-level priority problems:
Health problems that do not fit in the above categories
She also proposes that sometimes the priority order may change. For
example, if acute pain causes breathing problems, managing the pain
may have a higher priority; if abnormal lab values are life-threatening,
then they have a higher priority.

Purpose of Nursing Diagnosis

The nursing diagnosis serves the following purposes:

 Identifies nursing priorities

 Directs nursing interventions to meet the client’s high-priority
needs
 Provides a common language and forms a basis for
communication and understanding between nursing professionals
and the healthcare team
 Guides the formulation of expected outcomes for quality
assurance requirements of third-party payers
 Provide a basis of evaluation to determine if nursing care was
beneficial to the client and cost effective
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 Is of help when making staff assignments

Diagnostic Reasoning

Classification: The initial step of data analysis is classification of the

data. Data need to be organized in order to be clearly analyzed and the
most logical means to organize data is classify them. The body systems
approach functional health pattern approaches are two convenient
methods of classification. When these methods are used for taking a
history and performing a physical examination, the data are already
classified

Validation: The next step of data analysis is validation. In this step the
nurse verifies the diagnosis by speaking to the client. The nurse can
validate finding with the family, especially if the client is unable to
communicate. For example, the nurse could ask about scars or wounds
and therefore, expand the data base on the client. The nurse can also
validate the diagnosis by comparing it to textbook material or by talking
to other nurses

Nursing and medical diagnosis

Inductive versus deductive reasoning: The nurse may use inductive or

deductive reasoning to interpret data. Inductive reasoning begins with
a set of facts from which a conclusion is drawn. Inductive reasoning is
the use of cues to draw a conclusion

Deductive reasoning begins with the facts that the client is on bed rest
and taking narcotics and concludes (deduces) that the client is at an
increased risk.

Errors in Diagnosis
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Incomplete data: Common cause of incomplete data occurs during the

interview phase of assessment. Some clients withhold information
intentionally because some they feel embarrassed or are unsure how
the nurse would react to the information.

Inaccurate interpretation: Data from the client can be misinterpreted in

several ways. The problem can be diagnosed in several ways. The
problem can be diagnosed before the data are completely collected.
Sometimes the nurse can have a personal prejudice about the client

Lack of knowledge or experience: The clinical experience and

knowledge may result in inaccurate data processing. Failure to
recognize a problem is a common experience for most nurses. The
inexperienced nurse may overlook important data or fail to realize the
significance of the data

Using a Nursing Diagnosis

 The diagnosis is anything abnormal or that concerns the client, or

strengthens of the client. Diagnoses within the realm of nursing
are the response of the client to a state of health or illness and
include physical, psychological, spiritual and educational areas
 This nursing diagnosis and their treatment are within the legal
scope of nursing practice. The actual conditions that nurses are
educated to handle and licensed to treat are called nursing
diagnosis
 The role of the nurses can vary greatly between settings; there
has always been difficulty in describing the work in nursing.
NANDA has provided national leadership in the development of
standardized statements or nursing diagnosis, to describe human
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response to actual or potential health problems which nurses

treat.

Writing a Nursing Diagnosis

A nursing diagnosis should be written in three parts indicating the

human response, related factors and defining characteristics.

Human response: The human response is the client’s problem attached

as a nursing diagnosis. Most nurses use NANDA nursing diagnosis as the
human response statement, but other form of problem statements are
possible.

The human response should always be stated as a response to care

rather than as a need for care. Needs for care such as needs to be fed
or needs to be turned every 2 hours, describe a nursing intervention
rather than a client problem.

The related factors: The related factors are the possible causes or
etiology of the problem. This section of the statement describes the
factors associated with the problem. These factors may be
environmental, psychological, physiological, sociocultural or spiritual.

Because these factors direct nursing actions aimed at resolving,

preventing or reducing the problem, the related factor should be
directed at an aspect of the client response on which the nurse have an
impact.

The defining characteristics are the data indicating the problem is

present. When the client is at risk of developing a problem, the risk
factors are identified rather than defining characteristics.

Ten Rules for Writing a Nursing Diagnosis

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1. Write the diagnosis in terms of the client’s response rather than

nursing need
2. Use “related to” rather than “due to” or “caused by” to connect
the first two parts of the statement
3. Write the diagnosis in legally advisable terms
4. Write the diagnosis without the value judgments
5. Avoid reversing the parts of the statement
6. Avoid using single cues as the first part of the statement
7. The two parts of the statement should not mean the same thing
8. Express the related factor in terms that can be changed
9. Do not include the medical diagnosis in the nursing diagnosis
10. State the diagnosis clearly and concisely

Collaborative Problems

 As nurses have continued to work with nursing diagnosis,

shortcomings of the system have been identified
 Carpenito defines collaborative problems as the psychological
complications that have resulted or may result from the
pathophysiologic and treatment related conditions, and from
other situations
 Nurses monitor to detect the onset and status of complications
and collaborate with physicians in treatment

NURSING PLANNING
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The next step in the nursing process is planning activities to promote

healthy client responses or prevent, correct or reduce unhealthy client
responses.

Planning and setting expected outcomes begins by determining the

priority of human response

NURSING CARE PLAN

Step 1: Data Collection or Assessment

The first step in writing a nursing care plan is to create a client database
using assessment techniques and data collection methods (physical
assessment, health history, interview, medical records review,
diagnostic studies). A client database includes all the health
information gathered. In this step, the nurse can identify the related or
risk factors and defining characteristics that can be used to formulate
a nursing diagnosis. Some agencies or nursing schools have their own
assessment formats you can use.

Step 2: Data Analysis and Organization

Now that you have information about the client’s health, analyze,
cluster, and organize the data to formulate your nursing diagnosis,
priorities, and desired outcomes.

Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a uniform way of identifying, focusing

on, and dealing with specific client needs and responses to actual and
high-risk problems. Actual or potential health problems that can be
prevented or resolved by independent nursing intervention are termed
nursing diagnoses.
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Step 4: Setting Priorities

Setting priorities is the process of establishing a preferential sequence

for address nursing diagnoses and interventions. In this step, the nurse
and the client begin planning which nursing diagnosis requires
attention first. Diagnoses can be ranked and grouped as having a high,
medium, or low priority. Life-threatening problems should be given
high priority.

The client’s health values and beliefs, client’s own priorities, resources
available, and urgency are some of the factors the nurse must consider
when assigning priorities. Involve the client in the process to enhance
cooperation.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the
client set goals for each determined priority. Goals or desired
outcomes describe what the nurse hopes to achieve by implementing
the nursing interventions derived from the client’s nursing diagnoses.
Goals provide direction for planning interventions, serve as criteria for
evaluating client progress, enable the client and nurse to determine
which problems have been resolved, and help motivate the client and
nurse by providing a sense of achievement.

One overall goal is determined for each nursing diagnosis. The

terms goal, outcome, and expected outcome are often used
interchangeably.

Short Term and Long Term Goals

Goals and expected outcomes must be measurable and client-

centered. Goals are constructed by focusing on problem prevention,
resolution, and rehabilitation. Goals can be short-term or long-term.
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Most goals are short-term in an acute care setting since much of the
nurse’s time is spent on the client’s immediate needs. Long-term goals
are often used for clients who have chronic health problems or live at
home, in nursing homes, or in extended-care facilities.

 Short-term goal – a statement distinguishing a shift in behavior

that can be completed immediately, usually within a few hours or
days.
 Long-term goal – indicates an objective to be completed over a
longer period, usually over weeks or months.
 Discharge planning – involves naming long-term goals, therefore
promoting continued restorative care and problem resolution
through home health, physical therapy, or various other referral
sources.

Components of Goals and Desired Outcomes

Goals or desired outcome statements usually have four components: a

subject, a verb, conditions or modifiers, and criterion of desired
performance.

 Subject. The subject is the client, any part of the client, or some
attribute of the client (i.e., pulse, temperature, urinary output).
That subject is often omitted in writing goals because it is
assumed that the subject is the client unless indicated otherwise
(family, significant other).
 Verb. The verb specifies an action the client is to perform, for
example, what the client is to do, learn, or experience.
 Conditions or modifiers. These are the “what, when, where, or
how” that are added to the verb to explain the circumstances
under which the behavior is to be performed.
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 Criterion of desired performance. The criterion indicates the

standard by which a performance is evaluated or the level at
which the client will perform the specified behavior. These are
optional.

When writing goals and desired outcomes, the nurse should follow
these tips:

1. Write goals and outcomes in terms of client responses and not as

activities of the nurse. Begin each goal with “Client will […]” help
focus the goal on client behavior and responses.
2. Avoid writing goals on what the nurse hopes to accomplish,
and focus on what the client will do.
3. Use observable, measurable terms for outcomes. Avoid using
vague words that require interpretation or judgment of the
observer.
4. Desired outcomes should be realistic for the client’s resources,
capabilities, limitations, and on the designated time span of care.
5. Ensure that goals are compatible with the therapies of other
professionals.
6. Ensure that each goal is derived from only one nursing diagnosis.
Keeping it this way facilitates evaluation of care by ensuring that
planned nursing interventions are clearly related to the diagnosis
set.
7. Lastly, make sure that the client considers the goals important
and values them to ensure cooperation.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to

achieve client goals. Interventions chosen should focus on eliminating
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or reducing the etiology of the nursing diagnosis. As for risk nursing

diagnoses, interventions should focus on reducing the client’s risk
factors. In this step, nursing interventions are identified and written
during the planning step of the nursing process; however, they are
actually performed during the implementation step.

Types of Nursing Interventions

Nursing interventions can be independent, dependent, or collaborative:

 Independent nursing interventions are activities that nurses are

licensed to initiate based on their sound judgement and skills.
Includes: ongoing assessment, emotional support, providing
comfort, teaching, physical care, and making referrals to other
health care professionals.
 Dependent nursing interventions are activities carried out under
the physician’s orders or supervision. Includes orders to direct the
nurse to provide medications, intravenous therapy, diagnostic
tests, treatments, diet, and activity or rest. Assessment and
providing explanation while administering medical orders are also
part of the dependent nursing interventions.
 Collaborative interventions are actions that the nurse carries out
in collaboration with other health team members, such as
physicians, social workers, dietitians, and therapists. These actions
are developed in consultation with other health care professionals
to gain their professional viewpoint.

Nursing interventions should be:

 Safe and appropriate for the client’s age, health, and condition.
 Achievable with the resources and time available.
 Inline with the client’s values, culture, and beliefs.
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 Inline with other therapies.

 Based on nursing knowledge and experience or knowledge from
relevant sciences.

When writing nursing interventions, follow these tips:

1. Write the date and sign the plan. The date the plan is written is
essential for evaluation, review, and future planning. The nurse’s
signature demonstrates accountability.
2. Nursing interventions should be specific and clearly stated,
beginning with an action verb indicating what the nurse is
expected to do. Action verb starts the intervention and must be
precise. Qualifiers of how, when, where, time, frequency, and
amount provide the content of the planned activity. For example:
“Educate parents on how to take temperature and notify of any
changes,” or “Assess urine for color, amount, odor, and turbidity.”
3. Use only abbreviations accepted by the institution.

Step 7: Providing Rationale

Rationales, also known as scientific explanations, explain why the

nursing intervention was chosen for the NCP.

Rationales do not appear in regular care plans. They are included to

assist nursing students in associating the pathophysiological and
psychological principles with the selected nursing intervention.

Step 8: Evaluation

Evaluating is a planned, ongoing, purposeful activity in which the

client’s progress towards achieving goals or desired outcomes and the
effectiveness of the nursing care plan (NCP). Evaluation is an essential
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aspect of the nursing process because conclusions drawn from this step
determine whether the nursing intervention should be terminated,
continued, or changed.

Step 9: Putting it on Paper

The client’s NCP is documented according to hospital policy and

becomes part of the client’s permanent medical record which may be
reviewed by the oncoming nurse. Different nursing programs have
different care plan formats. Most are designed so that the student
systematically proceeds through the interrelated steps of the nursing
process, and many use a five-column format.

Phases of Planning

 The assessment of priorities to nursing diagnosis

 The specification of short-term, intermediate and long-term goals
of nursing action
 The identification of specific nursing interventions appropriate for
attaining the goals
 The documentation of the nursing diagnosis, goals nursing
interventions and expected outcomes in the nursing care plan.

Setting Priorities

 The assignment of priorities to the nursing diagnosis should be a

joint effort by the nurse and the patient or his family members
 Consideration must be given to the urgency of the problems. The
most critical receiving the highest priorities
 Maslow’s hierarchy of needs provides a useful framework for the
determination of priority problems. The use of this hierarchy
requires that high priorities be given to physical needs.
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Establishing Goals for Nursing Action

 After the priorities of the nursing diagnoses have been establish,

the short-term goals and the nursing actions appropriate for
attainment of the goals are identified
 The patient and his family should be included in the establishment
of the short-term intermediate and long-term goals of the nursing
actions
 Short-term goals are those that are of immediate concern and
that can be reached in a short period of time
 The critical time periods provide a time for determining the
effectiveness of the nursing interventions and the existence of a
need for additional or altered nursing care

Team Planning

 Ideally the accomplishment of all aspects of the planning phase of

the nursing process is a group effort
 The nurse collaborates with other members of the nursing team,
with the patient and his family and with appropriate resource
persons from the health care agency and community agencies
 It is also important to remember that the patient is part of a
family. The family members have need that arises from the
patient’s illness
 Another aspect of care planning takes into the account the fact
that the patient come from the community. Community agencies
have an interest in the patient and are involved in planning

Formulating the Nursing Care Plan

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The nursing care plan serves to communicate the following information

to all members of the nursing team:

 Nursing diagnosis and their priorities

 The goals of the nursing interventions
 The nursing interventions which are expressed in the form of
nursing orders
 The outcomes criteria, which identify the expected behavioral
outcomes of the patient
 The critical time period within which each outcome must be met

NURSING IMPLEMENTATION

Nursing intervention is the actual implementation of the care plan.

Nursing interventions are designed to promote, maintain or restore the
client’s health

Nursing interventions have following seven characteristics

1. Be congruent with the overall plan of care

2. Be based on scientific principles
3. Be individualized to the client
4. Be designed to provide a safe and therapeutic environment
5. Consider the need for teaching and learning
6. Use resources appropriately
7. Be clearly communicated

Providing self-care: The nurse should identify what skills are required
for providing the intervention. It is important to remember that when a
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skill is delegated to another health care team member, the registered

nurse remains legally responsible for the client’s outcome

Another aspect of providing self-care is continuous monitoring for

complication. There are many complications that can allow surgery,
medication administration and disease states.

While the care is being given, the nurse continues to assess the client
and evaluate his or her response to the care. The nurse also needs to
consider which of the interventions could be modified, if the client
shows no progress toward the desired outcome.

Nursing roles: Providing care teller into seven categories, according to

Benner: Helper role, teaching coaching, diagnostic and patient
monitoring, management of rapidly changing conditions, administering
and monitoring therapeutic regimens, monitoring and ensuring quality
of health care practices and organizational and work role
competencies.

Rationale: At times, the scientific rationale for an intervention is

required on a student care plan or listed within a standardized plan of
care. It is important that the care given has its basis in scientific study,
not in habit or old wives tales. The use of rationale assists in identifying
the professional nurse from other providers of health care.

NURSING EVALUATION

The last step in the process is evaluation. Evaluation examines the

degree of goal attainment and basically asks, “Did the client achieve the
goal he or she was supposed to?” and if not why not?
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Evaluation begins with collecting data about the client’s health status,
closely re-examining the outcome criteria. The degree of outcome
attainment is determined and a revised plan of care is established, if
needed.

Evaluation will answer the Following Questions

 Were the nursing diagnoses accurate?

 Did the patient meet the outcome criteria?
 Did the patient meet the criteria within the critical time periods?
 Have the patient’s nursing problems been resolved?
 Have the patient’s nursing need been met?
 Should the nursing interventions be retained, altered or
discontinued?
 Have new problems evolved for which nursing interventions have
not been planned or implemented?
 What factors influenced the achievement or lack of achievement
of the goals?
 Do priorities need to be reassigned?
 Should changes be made in the goals and outcome criteria?

Formal Evaluation Models

This type of evaluation can be viewed as informal. There is also a formal

method of evaluation through a system called quality assurance.

 Quality assurance is the planned and systematic evaluation of

care given to group of clients. The organization most actively
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involved in formal quality assurance is the joint commission for

accreditation of health care organizations.
 Quality assurance programs in nursing are viewed as evaluation
system composed of three dimension – structure, process and
outcome
 The structural dimension: focuses on the organization within
which nursing care is provided
 The process dimension: focuses on patient welfare and end
results of the care provided to the patient

Outcome Criteria

Goals for accountability and quality assurance in nursing are being

realized. The American Nurse Association has developed basic
standards that provide a general model for nursing practice by which
the quality of nursing practice may be evaluated.

Record-keeping has been revised to provide a problem-oriented

approach to documentation of data. The use of outcome criteria as
validations of the nursing process has become an accepted trend.

The nursing audit has become an accepted method for comparing

results of the actual nursing performance with the established criteria.
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UNIT – 3 NUTRITIONAL NEEDS

IMPORTANCE
Nutrition is a critical part of health and development. Better nutrition is
related to improved infant, child and maternal health, stronger immune
systems, safer pregnancy and childbirth, lower risk of non-
communicable diseases (such as diabetes and cardiovascular disease),
and longevity.

A healthy diet throughout life promotes healthy pregnancy outcomes,

supports normal growth, development and ageing, helps to maintain a
healthy body weight, and reduces the risk of chronic disease leading to
overall health and well-being.

Benefits of healthy eating

A diversified, balanced and healthy diet will vary depending on:

 age
 gender
 lifestyle
 degree of physical activity
 cultural context
 locally available foods
 dietary and food customs.

The basic principles of what constitute a healthy diet remain the same.

Healthy food starts with a healthy diet in pregnancy (external site),

continues with breastmilk for babies (external site) and is important
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for children and teenagers (external site) and adults (external site) and
with ageing.

People who regularly eat:

More foods high in energy, fats, free sugars or salt/sodium and do not
eat enough fruit, vegetables and foods with whole grains are more
likely to develop chronic diseases (external site) like diabetes, heart
disease and cancer.

FUNCTIONS OF FOOD

 To supply heat and energy for work and play

 For growth and repair of the body
 For regulation or control of body process
 For protection of body from diseases

BASIC FOOD KINDS

A well balanced diet contains food from the basic food groups:

 Milk and milk products

 Meat, fish and poultry
 Bread and cereals
 Fruits and vegetables

PURPOSE

 Food gives nourishment to body

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 It gives a feeling a security

 It is used to promote a feeling of social acceptance
 It is vitally important for our physical well-being
 Food is the fuel with which we run our bodies

ESSENTIAL NUTRIENTS

 Carbohydrates: these are used as a source of energy. All cereals

and root vegetables contain carbohydrate
 Fats: they are also a source of energy. They are found in animals
and plant seeds also in egg and milk
 Proteins: the function of proteins in human body is the release of
energy and building and repair of body tissues

FACTORS AFFECTING NUTRITIONAL NEEDS

The five major factors that influence the nutritional supplements your
body needs:

1) Age

Age is an important determinant of nutritional needs. For example,

vitamin C requirements increase steadily throughout childhood.
Calcium and phosphorous needs also increase in childhood but drop
back down in adulthood.

In older adults, there is often decreased vitamin B12 and magnesium

absorption by the gastrointestinal tract. Older adults are also less able
to produce vitamin D in their skin. Lutein, a carotenoid found in spinach
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and kale, may be particularly important in older adults to protect

against age-related macular degeneration.

2) Gender

Gender also has a significant impact on nutrient requirements. Women

have higher calcium and iron requirements than men. And since
vitamin D aids in the absorption of calcium, the two nutrients combined
are often recommended for women. During pregnancy, nutrients
especially important for fetal development are folate and other B
vitamins, as well as calcium, vitamin D, and iron. Moreover, the
absorption of several nutrients, including calcium, iron, and zinc,
actually increases during pregnancy.

For men and postmenopausal women, iron requirements are much

lower. In fact, too much iron can raise the risk for heart disease. Since
men have a higher risk of heart disease than women, certain nutrients,
such as vitamin E and folic acid, may be especially beneficial to men.
Additionally, the carotenoid lycopene, a naturally-occurring antioxidant
found in tomatoes and watermelons, may reduce the risk of both
cardiovascular disease and prostate cancer.

3) Diet

A person’s diet provides a lot of information about potential nutrient

shortfalls. For example, a diet low in fruits and vegetables is also likely
to be low in vitamin A, vitamin C, potassium, and folate, whereas a
vegan diet may be low in vitamin B12. A very low-fat diet may affect
certain vitamin levels since fat aids in the absorption of the fat-soluble
vitamins A, D, E, and K.
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Another consideration is nutrient interactions. For example, iron

absorption is improved by vitamin C but inhibited by calcium. Iron
absorption is also inhibited by polyphenols, which are found in a variety
of foods, including tea and coffee. Furthermore, excess protein intake
increases the excretion of calcium in the urine.

4) DNA

DNA is now understood to have important effects on an individual’s

nutrient needs. Variations on genes can impact how nutrients are
utilized in the body, and they differ from person to person. A field of
study known as nutrigenomics is paving the way to truly personalized
nutrition. This is why genetic health testing has become an essential
component of personalized nutrition. Gene variants have been
discovered that are linked with lower levels of vitamin A, vitamin D,
folate, and choline. There are also gene variants linked to a dangerously
high accumulation of iron in the body.

5) Medications

Medications are sometimes necessary for curing disease, preventing

disease, and improving quality of life. Every medication has side effects,
and some of those side effects can be subtle. Many medications affect
nutrient absorption, either through physiological processes or through
side effects that cause people to avoid certain foods. Many commonly-
used medications, such as NSAIDS, anti-hypertensives, and
antidepressants affect nutrient levels, and hence the types of
supplements that are beneficial in addressing nutritional deficits. Many
medications also contraindicate with supplements, so it is important to
carefully select supplements in order to prevent undesired side effects.
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ASSESSMENT OF NUTRITIONAL STATUS

Nutritional Status
The nutritional status of an individual

 is a balance between the intake of the nutrients and the

expenditure of these in processes of growth, reproduction and
health maintenance.
 is influenced by food intake , quantity , quality and physical
health.

The spectrum of nutritional status spreads from obesity to severe

malnutrition.

 To obtain precise information on prevalence and geographic

distribution of nutritional problems of given community.
 To identify individuals or populations
 who are at risk of becoming malnourished &
 who are already malnourished
 To develop health-care programs.
 To measure the effectiveness of nutritional programs and
interventions once initiated.

METHODS OF NUTRITIONAL ASSESSMENT

 Direct – deal with the individuals and measure the objective

criteria
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 Indirect – use community health indices that reflect nutritional

influences

1. Direct Methods of Nutritional Assessment

These can be summarized as ABCD

 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods

2. Indirect Methods of Nutritional Assessment

These include three categories

 Ecological variables
 Economic factors
 Vital health statistics

DIRECT METHODS

A. Anthropometric methods

Anthropometry is the measurement of

 Height
 Weight & other measurements like
 Mid Upper-arm circumference
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 Skin fold thickness

 Head and chest circumference
 Hip/waist ratio

A. Anthropometric methods
1. Height measurement
 The subject stand erect on stadiometer
 The movable head piece is leveled with head vault
 Height is recorded to nearest 0.5 cm.
 For infants infantometer is used.

A. Anthropometric Methods
 growth monitoring of a child by comparing with international /
national standards using growth charts over a period of time.
2. Weight measurement
 Can be used to assess infants, children, pregnant women and
adults.
 Uses a regularly calibrated electronic or balanced-beam scale.
 Measured in light clothes nearest to 100g.

3. Mid Upper-arm Circumference

 Circumference left upper arm at mid point between acromion
process and olecranon process
 Fiber-glass tape which does not stretch
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4. Skin-fold thickness
 skin fold calipers are used (Harpenden and Lange)
 measures the thickness of the skin and subcutaneous fat using
constant pressure applied over a known area
 Common sites: triceps and in the sub-scapular region
 It has value in assessing the amount of fat and therefore the
reserve of energy in the body

5. Head and chest circumference

6. Waist/hip ratio
 Waist measurement
 Measured at the level of umbilicus nearest to 0.5cm
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 Subject stands erect with relaxed abdominal muscles, arms at the

side and feet together
 Measurement taken at the normal expiration
 Hip measurement
 Measured at the point of greatest circumference around hips to
nearest 0.5cm
 Close contact with the skin without indenting the soft-tissues
 Subject should be standing and measurer beside him.
 Interpretation of WHR
 High-risk WHR=>0.8 in females and =>0.95 in males indicates
central obesity and considered high-risk for diabetes and cvs
disorders.

Advantages

 Objectives with high specificity and sensitivity.

 Measures many variables of nutritional Significance. (ht, wt,
MUAC, WHR , BMI)
 Readings are numerical and gradable on standard growth charts.
 Readings are reproducible.
 Non-expensive and needs minimal training.

Limitations of Anthropometry

 Inter-observers error in measurement.

 Limited nutritional diagnosis.
 Problems with reference standards i.e. local versus international.

Direct Methods
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b. Biochemical and laboratory methods

1. INITIAL LABORATORY ASSESSMENT

 Haemoglobin estimation
 most important test when accurately measured, tells about
overall state of nutrition (anemia, and also protein and trace
element nutrition)
 Blood is collected from a finger, ear lobe or heel prick
 Haemoglobinometres which are simple, cheap and reasonably
accurate are used
 Haematocrit or packed cell volume (PCV)
 percentage of the blood volume composed of red cells.
 important in the diagnosis of anemia.
 Red cell counts and blood films
 the size and uniformity of the red blood cells can be seen.
 Use of such slides may facilitate the diagnosis of malaria and the
haemoglobinopathies.
 Parasites if present can be seen.
 Stool examination
 For presence of ova and/ or intestinal parasites
 When assessed quantitatively parasite load can be known
 Urine examination
 Dipstick and microscopy for albumin, sugar and blood

2. SPECIFIC LAB TESTS

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Measurement of nutrients in body fluids

 e.g. serum retinol, serum iron

Measurement of abnormal metabolites

 e.g. urinary iodide, urinary creatinine/ hydroxyapatite ratio

Advantages
 Useful in detecting early changes in body metabolism and
nutrition
 precise , accurate and reproducible.
 Useful to validate data obtained from dietary methods e.g.
comparing salt intake with 24-hour urinary excretion.

Limitations of biochemical & laboratory methods

 Time consuming and expensive

 Cannot be applied on large scale
 Reveal only current nutritional status

Direct Methods

C. Clinical Methods

 Essential feature of all nutritional surveys

 Simplest and most practical method
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 Utilizes a number of physical signs (specific and non-specific) that

are known to be associated with malnutrition and deficiency of
vitamins and other micro-nutrients

C. Clinical methods

General Clinical examination with special attention to organs like hair,

angles of mouth, gums, nails, skin, eyes, tongue, muscles, bones &
thyroid gland.

Detection of relevant signs helps in establishing the nutritional

diagnosis.

ASSESSEMENT OF DIETARY INTAKE

 This is actually an assessment of food consumption through

dietary surveys.
 It provides information about dietary intake patterns, specific
foods consumed and estimated nutrient intakes.
 Reviewing dietary data may suggest risk factors for chronic
diseases and help to prevent them.
 Diet surveys may be carried out by the following methods:
 weighment of raw foods
 weighment of cooked foods
 Oral questionnaire method

Other methods include

 Food records or diaries (including weighed intakes)

 Food frequency questionnaires (FFQ's)
 Dietary histories
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 Observed intakes

Weighment of raw foods:

 It is the most widely used method in India.

 The survey team visits the household and weighs all the food that
is going to be cooked and eaten as well as that which is wasted or
discarded.

Duration of survey: varies between 1 and 21 days. Most commonly for

7 days which is called the dietary cycle.

Weighment of cooked foods: Foods are analyzed in the state in which

they are consumed.

This method is not easily acceptable.

Food Frequency Questionnaires (FFQ) –

FFQ's are standardized forms inquiring about the frequency of intake

 of different foods or food groups.

 not as accurate as other measures but useful in large population
studies
 or when studying the association of a specific food (s) and a
disease.
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REVIEW: SPECIAL DIETS – SOLID, LIQUID, SOFT

Regular Diet

The regular diet can also be referred to as a general or normal diet. Its
purpose is to provide a well-balanced diet and ensure that individuals
who do not require dietary modifications receive adequate
nutrition. Based on the Dietary Guidelines and the Food Guide
Pyramid, it incorporates a wide variety of foods and adequate caloric
intake.

Mechanical Soft Diet

The mechanical soft diet consists of foods soft in texture, moderately

low in fiber, and processed by chopping, grinding or pureeing to be
easier to chew. Most milk products, tender meats, mashed potatoes,
tender vegetables and fruits and their juices are included in the
diet. However, most raw fruits and vegetables, seeds, nuts and dried
fruits are excluded.

Clear Liquid Diet

To leave little residue in the GI tract, this short-term diet provides clear
liquids that supply fluid and calories without residue. It is often used
with acute illness, before and after surgery, and other procedures such
as x-ray, CT scan, etc. It includes coffee, tea, clear juices, gelatin and
clear broth.

Full Liquid Diet

As a transition between clear liquid and a soft or regular diet, this plan
provides easily tolerated foods. The diet includes milk, strained and
creamed soups, grits, creamed cereal and fruit and vegetable
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juices. We also serve scrambled eggs because of their high water

content and they are an excellent source of protein.

GI Soft Diet

This diet can serve as a transition between a full liquid and a regular
diet by providing foods low in fiber and soft in texture. Most raw fruits
and vegetables, nuts, seeds, coarse breads and cereals are
avoided. Milk, lean meats, fish, most forms of potatoes and white
breads are served on this diet plan.

Low Residue/Low Fiber Diet

This type of diet tried to limit fiber, a kind of carbohydrate found in

some plant-derived foods. The diet limits intake around ten grams of
fiber daily and is designed to minimize the frequency and volume of
residue in the intestinal tract.

Salt-restricted (Low Sodium) Diet

Sodium controlled diets are usually prescribed for patients with

hypertension and for those with excess fluid accumulations. Intake of
commercially prepared foods such as cured or smoked meats, canned
vegetables and regular soups as well as buttermilk, salt and salty foods
are limited or avoided. White milk, fresh or frozen meats, unsalted
vegetables and fruits and low sodium foods are included.

Fat-Restricted Diet

This diet is often prescribed for patients with gastrointestinal disorders

or excessive body weight. It limits the intake of fatty food such as
margarine, mayonnaise, dressings, oils and gravies. The diet usually
includes whole wheat breads, lean cuts of meat, skim milk, low-fat
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cheese products, eggs, vegetables, and other food items prepared

without extra fat.

Cholesterol-Restricted Diet

Lowering blood cholesterol can reduce your risk of heart

disease. Cholesterol is found only in foods of animal origin. Certain
oats, beans, and fruits are actually effective at lowering cholesterol
levels in the body. A cholesterol-restricted diet limits the intake of
meats, poultry, fried foods, egg yolks, and whole milk products. Food
high in saturated fat and trans fatty acids such as palm kernel oil,
coconut oil, margarine, and shortening are also limited. The diet
includes skim milk, lean meats, fruits, vegetables, and whole grain
products.

Vegetarian Diet

This diet varies widely depending on personal choice. It may include

only plant foods- grains, vegetables, fruits, legumes, nuts, seeds, and
vegetables fats. Some variations designed to be lower in cholesterol
and saturated fat and higher in dietary fiber. Thus, it may be helpful in
the prevention of heart disease and cancer risk.

Consistent Carbohydrate (Diabetic Diet)

A diabetic diet varies from patient to patients depending on the type

and intensity of the diabetes, the patients’ personal history, and
individual nutrient needs. The Exchange List for Meal Planning
established the serving size amount of carbohydrates per meal based
on calorie recommendations. Meals are basically like those found on a
regular menu, but carbohydrate servings are carefully controlled and
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small snacks may be included in the meal plan. Carbohydrates are

starches, starchy vegetables, juice, fruit, milk, and sugars.

Renal Diet

A renal diet is carefully planned with special consideration of nutrients,

and it is often adjusted as kidney disease progresses. A renal diet may
serve the purpose of attempting to slow down the process of renal
dysfunction. If dialysis treatments are not being taken, the doctor may
restrict protein intake of foods such as potatoes, tomatoes, oranges,
and bananas. A phosphorous restriction may limit the intake of milk
and dairy products, dried beans and peas, while grain breads and
cereals, coffee, tea, and “dark-colored” soda beverages.

REVIEW ON THERAPEUTIC DIETS

Types of Therapeutic

A therapeutic diet is a meal plan that controls the intake of certain

foods or nutrients. It is part of the treatment of a medical condition and
are normally prescribed by a physician and planned by a dietician. A
therapeutic diet is usually a modification of a regular diet. It is modified
or tailored to fit the nutrition needs of a particular person.

Therapeutic diets are modified for (1) nutrients, (2) texture, and/or (3)
food allergies or food intolerances.

Common reasons therapeutic diets may be ordered:

• To maintain nutritional status

• To restore nutritional status

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• To correct nutritional status

• To decrease calories for weight control

• To provide extra calories for weight gain

• To balance amounts of carbohydrates, fat and protein for control of

diabetes

• To provide a greater amount of a nutrient such as protein

• To decrease the amount of a nutrient such as sodium

• To exclude foods due to allergies or food intolerance

• To provide texture modifications due to problems with chewing

and/or swallowing

Common therapeutic diets include:

1. Nutrient modifications

• No concentrated sweets diet

• Diabetic diets

• No added salt diet

• Low sodium diet

• Low fat diet and/or low cholesterol diet

• High fiber diet

• Renal diet
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2. Texture modification

• Mechanical soft diet

• Puree diet

3. Food allergy or food intolerance modification

• Food allergy
• Food intolerance
4. Tube feedings
• Liquid tube feedings in place of meals
• Liquid tube feedings in addition to meals
4. Additional feedings – In addition to meal, extra nutrition
may be ordered as:
• Supplements – usually ordered as liquid nutritional shakes
once, twice or three times per day; given either with meals
or between meals
• Nourishments – ordered as a snack food or beverage items
to be given between meals mid-morning and/or mid-
afternoon
• HS snack – ordered as a snack food or beverage items to
be given at the hour of sleep

The following list includes brief descriptions of common therapeutic

diets:

Clear liquid diet –

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• Includes minimum residue fluids that can be seen through.

• Examples are juices without pulp, broth, and Jell-O.
• Is often used as the first step to restarting oral feeding
after surgery or an abdominal procedure.
• Can also be used for fluid and electrolyte replacement in
people with severe diarrhea.
• Should not be used for an extended period as it does not
provide enough calories and nutrients.

Full liquid diet –

• Includes fluids that are creamy.
• Some examples of food allowed are ice cream, pudding,
thinned hot cereal, custard, strained cream soups, and juices
with pulp.
• Used as the second step to restarting oral feeding once
clear liquids are tolerated.
• Used for people who cannot tolerate a mechanical soft
diet.
• Should not be used for extended periods.

No Concentrated Sweets (NCS) diet –

• Is considered a liberalized diet for diabetics when their weight and

blood sugar levels are under control.

• It includes regular foods without the addition of sugar.

• Calories are not counted as in ADA calorie controlled diets.

Diabetic or calorie controlled diet (ADA) –

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• These diets control calories, carbohydrates, protein, and fat intake in

balanced amounts to meet nutritional needs, control blood sugar
levels, and control weight.

• Portion control is used at mealtimes as outlined in the ADA “Exchange

List for Meal Planning.”

• Most commonly used calorie levels are: 1,200, 1,500, 1,800 and
2,000.

No Added Salt (NAS) diet –

• Is a regular diet with no salt packet on the tray.

• Food is seasoned as regular food.

Low Sodium (LS) diet –

• May also be called a 2 gram Sodium Diet.

• Limits salt and salty foods such as bacon, sausage, cured meats,
canned soups, salty seasonings, pickled foods, salted crackers, etc.

• Is used for people who may be “holding water” (edema) or who have
high blood pressure, heart disease, liver disease, or first stages of
kidney disease.

Low fat/low cholesterol diet –

• Is used to reduce fat levels and/or treat medical conditions that

interfere with how the body uses fat such as diseases of the liver,
gallbladder, or pancreas.
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• Limits fat to 50 grams or no more than 30% calories derived from fat.
• Is low in total fat and saturated fats and contains approximately 250-
300 mg cholesterol.

High fiber diet –

• Is prescribed in the prevention or treatment of a number of

gastrointestinal, cardiovascular, and metabolic diseases.

• Increased fiber should come from a variety of sources including fruits,

legumes, vegetables, whole breads, and cereals.

Renal diet –

• Is for renal/kidney people.

• The diet plan is individualized depending on if the person is on

dialysis.

• The diet restricts sodium, potassium, fluid, and protein specified

levels.

• Lab work is followed closely.

Mechanically altered or soft diet –

• Is used when there are problems with chewing and swallowing.

• Changes the consistency of the regular diet to a softer texture.

• Includes chopped or ground meats as well as chopped or ground raw

fruits and vegetables.
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• Is for people with poor dental conditions, missing teeth, no teeth, or a

condition known as dysphasia.

Pureed diet –

• Changes the regular diet by pureeing it to a smooth liquid

consistency.

• Indicated for those with wired jaws extremely poor dentition in which
chewing is inadequate.

• Often thinned down so it can pass through a straw.

• Is for people with chewing or swallowing difficulties or with the

condition of dysphasia.

• Foods should be pureed separately.

• Avoid nuts, seeds, raw vegetables, and raw fruits.

• Is nutritionally adequate when offering all food groups.

Food allergy modification –

• Food allergies are due to an abnormal immune response to an

otherwise harmless food.

• Foods implicated with allergies are strictly eliminated from the diet.

• Appropriate substitutions are made to ensure the meal is adequate.

• The most common food allergens are milk, egg, soy, wheat, peanuts,
tree nuts, fish, and shellfish.
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• A gluten free diet would include the elimination of wheat, rye, and
barley. Replaced with potato, corn, and rice products.

Food intolerance modification –

• The most common food intolerance is intolerance to lactose (milk

sugar) because of a decreased amount of an enzyme in the body.

• Other common types of food intolerance include adverse reactions to

certain products added to food to enhance taste, color, or protect
against bacterial growth.

Common symptoms involving food intolerances are vomiting, diarrhea,

abdominal pain, and headaches.

Tube feedings –

• Tube feedings are used for people who cannot take adequate food or
fluids by mouth.

• All or parts of nutritional needs are met through tube feedings.

• Some people may receive food by mouth if they can swallow safely
and are working to be weaned off the tube feeding.

CARE OF PATIENT WITH DYSPHAGIA

Severe dysphagia
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 A special liquid diet. This may help you maintain a healthy weight
and avoid dehydration.
 A feeding tube. In severe cases of dysphagia, you may need a
feeding tube to bypass the part of your swallowing mechanism
that isn't working normally.
 Follow feeding/swallowing strategies as recommended by
speech therapy.
 Based on recommendations of speech therapist, collaborate
with nutritional services to provide appropriate texture and
consistency of food.
 Conduct ongoing assessment of adequacy of fluid and
caloric intake.
 For meals, position patient upright (90 degrees). Patient
should remain positioned at 90 degrees for 30 minutes after
meals.
 Permit adequate time and verbal prompts for chewing and
swallowing.
 Check patient’s mouth for pocketing of food or incomplete
swallowing.
 If feeding tube is present and patient is receiving continuous
feedings, check tube position every four (4) hours and as
needed. If patient is receiving intermittent feedings, check
tube position before each feeding. Note that NG and ND
tube feedings are generally not recommended if gag reflex is
absent.
 If the patient is receiving NG feedings in addition to oral
feedings, it may be helpful to stop tube feedings for 1 to 2
hours prior to oral feeding to help stimulate the appetite.
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 Consult with occupational therapy if assistive devices are

needed to facilitate feedings.
 After thorough training, encourage family members/SO to
assist with feeding. Often, a patient will eat more if fed by a
family member than by staff
 Thicken liquids to appropriate consistency, if needed.

CARE OF PATIENT WITH ANOREXIA

Anorexia (an-o-REK-see-uh) nervosa — often simply called anorexia —
is an eating disorder characterized by an abnormally low body weight,
an intense fear of gaining weight and a distorted perception of weight.
People with anorexia place a high value on controlling their weight and
shape, using extreme efforts that tend to significantly interfere with
their lives.

MEAL FOR ANOREXIA PATIENT

 Day 1–4: 1,200–1,600 calories/day

 Day 5–7: If no weight gain is observed, increase by 400 calories
per day to 1,600–2,000 calories/day (If weight gain is occurring
you may increase more gradually.)
 Day 10–14: If weight gain is not reaching 1 to 2 pounds per week,
increase daily intake again by 400–500 calories/day to 2,000–
2,500
 Day 15–21: 2,500–3,000 calories/day
 Day 20–28: 3,000–3,500 calories/day
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CARE OF PATIENT WITH NAUSEA AND VOMITING

Nausea and vomiting are not diseases, but rather are symptoms of
many different conditions, such as infection ("stomach flu"), food
poisoning, motion sickness, overeating, blocked intestine, illness,
concussion or brain injury, appendicitis and migraines. Nausea and
vomiting can sometimes be symptoms of more serious diseases such
as heart attacks, kidney or liver disorders, central nervous system
disorders, brain tumors, and some forms of cancer.

DIET FOR NAUSEA AND VOMITING

 Drink clear or ice-cold drinks.

 Eat light, bland foods (such as saltine crackers or plain bread).
 Avoid fried, greasy, or sweet foods.
 Eat slowly and eat smaller, more frequent meals.
 Do not mix hot and cold foods.
 Drink beverages slowly.
 Avoid activity after eating.
 Avoid brushing your teeth after eating.
 Choose foods from all the food groups as you can tolerate them
to get adequate nutrition.

Treatment for vomiting (regardless of age or cause) includes:

 Drinking gradually larger amounts of clear liquids

 Avoiding solid food until the vomiting episode has passed
 Resting
 Temporarily discontinuing all oral medications, which can irritate
the stomach and make vomiting worse

If vomiting and diarrhea last more than 24 hours, an oral rehydrating

solution should be used to prevent and treat dehydration.
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Nausea can be prevented by:

 Eating small meals throughout the day instead of three large

meals
 Eating slowly
 Avoiding hard-to-digest foods
 Consuming foods that are cold or at room temperature to avoid
becoming nauseated from the smell of hot or warm foods

Resting after eating and keeping your head elevated about 12 inches
above your feet helps reduce nausea.

If you feel nauseated when you wake up in the morning, eat some
crackers before getting out of bed or eat a high protein snack (lean
meat or cheese) before going to bed. Drink liquids between (instead of
during) meals, and drink at least six to eight 8-ounce glasses of water a
day to prevent dehydration. Try to eat when you feel less nauseated.

VOMITING

Vomiting can be prevented by consuming small amounts of clear,

sweetened liquids such as soda pop, fruit juices (except orange and
grapefruit because these are too acidic) and popsicles. Drinks
containing sugar calm the stomach better than other liquids. Rest
either in a sitting position or in a propped lying position. Activity may
worsen nausea and may lead to vomiting.

For children, control persistent coughs and fever with over-the-counter

medicines. To treat motion sickness in a car, seat your child so that he
or she faces the front windshield (watching fast movement out the side
windows can make the nausea worse).

Limit snacks, and do not serve sweet snacks with regular soda pop.
Don't let your kids eat and play at the same time. Encourage them to
take a break during their snack time.
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MEETING NUTRITIONAL NEEDS: PRINCIPLES,

EQUIPMENT, PROCEDURE, INDICATIONS
Principles

 The diet must be planned in relation to changes in metabolism

occurring as a result of disease
 The diet must be planned according to the food habits of the
patient based on culture, religion, socio-economic status,
personal preferences (likes and dislikes), physiological and
psychological conditions, hunger, appetite and satiety
 As far as possible, changes in the diet should be brought
gradually, and adequate explanations are given with the changes
made, if any
 In short and acute illness, the food should not be forced, because
his appetite is very poor but he may soon recover the normal
appetite. But in prolonged illness it is essential to provide
adequate amount of food to prevent wasting of tissues
 Whatever the diet prescribed, there should be variety of foods for
selection
 Small and frequent feeds are preferred to the usual 3 meals
 Hot foods should be served hot and cold foods should be served
cold

FEEDING METHODS
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Enteral

The term, enteral, refers to nutrition administered via the

gastrointestinal tract. It may be administered orally or via tube feeding.

Oral

Oral nutritional supplements (ONS) are nutrition support products that

provide an effective and non-invasive way for people to meet their
nutrition needs or increase their nutritional intake. People who take
ONS may also be able to eat regular food but cannot meet all their
nutritional requirements through a regular diet alone and thus require
supplemental nutrition. In other instances, a patient can benefit from
ONS if they require a liquid-based diet. ONS products are often
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prescribed or recommended by a physician or registered dietitian. In

some cases, people rely on ONS as their sole source of nutrition.

Tube Feeding

If a person has a condition or illness which limits or impairs oral intake,

enteral nutrition (EN) therapy can be administered directly into the
gastrointestinal tract as a tube feeding.¹ Enteral nutrition via tube
feeding provides life-sustaining nutrients and is often required as a first
option feeding method when a person is unable to consume food orally
and/or has an impaired digestive system. EN therapy includes
specialized liquid feedings containing protein, carbohydrates, fats,
vitamins, minerals, and other nutrients needed to live. These nutrition
support products are formulated to meet individual needs for a variety
of disease states and conditions.

Parenteral

Parenteral nutrition (PN) is the intravenous administration (feeding into

a vein) of nutrients directly into the systemic circulation, bypassing the
gastrointestinal tract.² It is a special liquid mixture containing protein,
carbohydrates, fats, vitamins, minerals, and other nutrients needed to
live. PN represents an alternative or additional approach for nutrition
intervention when nutrition needs cannot be met from the oral or
enteral routes alone, or are contraindicated.

GASTROJEJUNOSTOMY FEEDING
Gastrojejunostomy feeding is defined as enteral nutrition is a liquid
food preparation directly into the stomach or small intestine via a tube
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It is an ideal method of providing nutrition for the person who is unable

to swallow food and drink normally but has intact gastrointestinal
function

It is the introduction of liquid good through a tube or catheter which

the surgeon has already introduced into the stomach through the
abdominal wall

Indications

 Tumors or operations on the upper gastrointestinal tract

 Cancer of the esophagus
 Stricture of the esophagus caused by poisoning in case of fistula

General Instructions

 It is essential that the area of the skin around the tube be kept
clean and dry
 A water proof ointment such as zinc oxide may be applied around
the tube to protect the skin from the irritation of the hydrochloric
acid
 Foods given through the gastrostomy tube are some as those
given by nasogastric tube and the same amounts are given at the
same intervals

Methods of Administration

 Intermittent feeding: given four to six times a day rather the

continuously is delivered as a bolus through a longer lumen tube.
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Volume for formula usually 250-450 ml is placed in a large syringe

and inserted into the proximal end of the tube
 Intermittent gravity drip: administration delivers a similar volume
250-450 ml of feeding over 20-30 ml a minute, four to six times a
day
 Continuous administration: delivers fluid through a small lumen
tube at a constant rate via orogastric and nasogastric routes. The
rate of flow is carefully regulated. The nurse should calculate the
amount of fluid to be infused during an hour and regulates the
infusion pump accordingly

Preliminary Assessment

Check

 The doctors order for specific instruction

 Level of consciousness of the patient
 Self-care ability of the patient
 Mental status to follow instructions
 Articles available in the unit

Operation of the Patient and Environment

 Explain the sequence of the procedure

 Provide privacy
 Arrange the articles at the bedside
 Place the patient in a comfortable position
 Keep the environment clean and tidy
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 Keep ready with feed to be given

Equipment

A clean tray containing

 A funnel, rubber tubing, glass connection screw and a clamp

 A glass of drinking water
 Required amount of fed, temperature 100 degree F
 Sterile lubricant to protect surrounding area
 Sterile dressing and forceps in a dressing tray
 Medicine as per odor
 Kidney tray
 Many tailed binder if required
 Mackintosh and towel
 Stethoscope
 Syringe

Procedure

 Wash hands thoroughly

 Place the mackintosh or towel; clean the surrounding area of the
opening. Cover the wound with sterile piece of gauze
 Unscrew the clamp from the gastrostomy tube and attach the
funnel and rubber tubing; keep the tube pinched to prevent air
from setting in
 Aspirate the gastric contents by attaching a syringe
 Pour some clean water into the funnel and lower a little to let our
air
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 Then pour the feed before the funnel is empty

 If any medicines are ordered, these are given after feed
 Give water after giving medicines
 Disconnect the tabbling and funnel
 Clean and apply sterile instrument around the wound, dress it
with sterile dressing and apply the binder

After Care

 Remove the Mackintosh and towel

 Position the patient comfortable
 Secure the tube with plaster
 Replace the articles to utility room
 Hand wash

Record the procedure in nurse record sheet

GASTROSTOMY
A gastrostomy is a surgical procedure used to insert a tube, often
referred to as a "G-tube", through the abdomen and into the stomach.
Gastrostomy is used to provide a route for tube feeding if needed for
four weeks or longer, and/or to vent the stomach for air or drainage.

If your child is unable to eat enough food by mouth or needs extra

calories to grow, a gastrostomy can help him get the nutrition he
needs. A gastrostomy can also act as a drainage tube to bypass an
obstruction, so that your child's stomach does not accumulate acid and
fluids. Sometimes, when a patient cannot tolerate a nasogastric tube
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(or NG-tube, which reaches the stomach through the nose), doctors use
a gastrostomy instead to drain and empty the stomach after surgery.

A gastrostomy may be in place permanently or only temporarily. It is

considered a more long-term method of alternate feeding than NG- or
nasojejunal (NJ) tube feeding. (NJ-tube feeding also goes through the
nose, but instead of the stomach it goes into the part of the intestine
just after the stomach – the jejunum.) However, once your child is able
to eat safely and to eat enough by mouth to keep up his nutrition,
surgeons may remove the gastrostomy tube.

TOTAL PARENTERAL NUTRITION (TPN)

Total Parenteral Nutrition or (TPN feeding) is a method of
administration of essential nutrients to the body through a central vein.
TPN therapy is indicated to a client with a weight loss of 10% the ideal
weight, an inability to take oral food or fluids within 7 days
post surgery, and hypercatabolic situations such as
major infection with fever.

TPN solutions require water (30 to 40 mL/kg/day), energy (30 to 45

kcal/kg/day, depending on energy expenditure), amino acids (1.0 to 2.0
g/kg/day, depending on the degree of catabolism), essential fatty
acids, electrolytes, vitamins, minerals, and trace elements. These
solutions can be adjusted, depending on the presence of organ system
impairment or the specific nutritional needs of the client. TPN is usually
used in hospital, subacute and long-term care, but it is also used in the
home care settings.
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UNIT – 4 HYGIENE
The word hygiene has evolved from the Greek term “Hygia” which
means “Goodness of Health”. Hygiene is the science of health and
includes all factors which contribute to healthful living. Hygiene is the
science of health and it preservation, it also refers to practices that are
conducive to good health. Good personal hygiene is important to a
person’s general health.

Definition

Hygiene defined as “the science and art which is associated with the
preservation and promotion of health”.

Hygiene is defined as that “science of health, which includes all the

factors contributing to the healthful living”

Types of Hygiene

 Social hygiene: social medicine has replaced the word social

hygiene, it objective to study man as a social animal in its total
environment. The scope of social medicine includes science of
social structure and functions, social pathology and social
treatment, etc
 Industrial hygiene: occupational health, which has broader
meaning. Its scope is extended up to the health of labor working
in all types of occupation and different aspects of health
 School hygiene: school hygiene or school health is an important
branch of community health, which facilitating optimum health to
school children
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 Preventive medicine: nowadays, a broader term community

medicine is used. Preventive medicine plays primary role in
immunization as specific protection and general methods of
improvement in health
 Personal hygiene: personal hygiene or personal health implies to
those principles of physical cleanliness and mental health.
Personal hygiene is not only limited to taking care of body and
keeping it clean, rather the mental and spiritual aspects are also
an integral part of it

FACTORS INFLUENCING HYGIENIC PRACTICE

Factors Influencing Hygiene Practices

 Personal preferences: each individual has his own desires and

preferences about when to bathe, shave, and perform hair care.
Same way each individual select different products according to
the personal preferences, needs and financial resources. The
nurse assists the client in delivering individualized care to the
client
 Social practices: social groups influence hygiene practices and
preferences. During childhood, hygiene practices are influenced
by family customs and as children enter their adolescent years,
hygiene practices may be influenced by the peer group behavior.
During the adult years, work groups and friends shape the
expectations of people and in the older adults hygiene practices
may change because of living conditions and available resources
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 Socioeconomic status: the type and extent of hygiene practices

are influenced by a person’s economic resources. The nurse
determines which products/supplies, the client can afford
 Health belief and motivation: knowledge regarding the
importance of hygiene for well-being influences hygiene practices.
Only knowledge is not enough. The client must be motivated to
maintain self-care
 Cultural beliefs: a client’s cultural beliefs and personal values
influence hygiene care
 Physical condition: certain type of physical limitations or
disabilities often lacks the physical energy to perform hygiene
care e.g. a client with traction or who has an intravenous line, will
need assistance for hygiene maintenance

HYGIENIC CARE: INDICATIONS AND PURPOSES, EFFECTS

OF NEGLECTED CARE
PERSONAL HYGIENE
Personal hygiene has a significant role in every society. Every culture
develops and maintains its standards and methods of maintaining
personal cleanliness. Habits are formed for performing actions to keep
the body clean and functioning normally.

Personal hygiene includes all those personal factors which influence the
health and well-being of an individual. It consists of the body regarding
bathing and washing, care of hair, nails and feet, mouth cleanliness and
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care of the teeth, care of the nose and ears, clothing, postures,
exercises, recreation, rest and relaxation, sleep habits and nutrition

Personal hygiene is necessarily maintained for a person’s comfort and

well-being. A variety of personal and socio-cultural factors influence the
client’s hygiene practices. The nurse determines a client’s ability to
perform self-care and provides hygienic care according to the client’s
needs and preferences. While providing hygiene, the nurse must
preserve as much client’s independence as possible, ensure privacy,
convey respect and foster the client’s physical comfort.

Definition

Personal hygiene defined as that “the healthy practices and lifestyle

helps in the maintenance and promotion of individual health physically,
emotionally, socially and spiritually”

Purposes of Personal Hygiene and Protect from Disease

 To prevent illness
 To promote good health
 To improve the standard of health
 To maintain quality life of an individual
 To promote mental well-being
 To promote socially and spiritually health
 To improve the self-esteem in the society
 To maintain resistance and prevent form infection

Principles of Personal Hygiene

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 Hygiene practices are learnt

 Changes occur throughout the life span, it also affects the health
care practices
 Individual differences exit from one individual to other
 Health practices of people vary with cultural values and personal
values
 Health practices directly influences the physical, mental, social
and spiritual health of an individual
 Good health practices prevent entry of microorganisms into the
body
 Nature acts as a first line of defense on human health natural light
and ventilation

Factors Influences on Personal Hygiene

 Social practices: social groups influence including the type of

personal care. During childhood, hygiene is influenced by family
customs
 Personal preferences: each person has individual desires and
preferences about when to bath, shave and perform hair care.
Individual selects different products according to personal
preferences, needs and financial resources
 Body language: an individual general holds for the person. Body
image is a person’s subjective concept of his or her physical
appearance. These images can change frequently. When
individual undergo surgery, illness or a change in functional
status, body image can change dramatically
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 Socioeconomic status: a person’s economic resources influence

the type and extent of hygiene practices used. Socioeconomic
status may influence his or her ability to regularly maintain
hygiene
 Health beliefs and motivation: knowledge about importance of
hygiene and its implication for well-being influences hygiene
practices. However, knowledge alone is not enough. The
individual also must be motivated to maintain self-care
 Cultural variables: an individual’s cultural beliefs and personal
values hygiene care. People from diverse cultural background
follow different self-care practices. Culturally maintaining
cleanliness may not hold the same importance for some ethnic
groups as it does for others.
 Physical condition: the nurse quickly learns that clients with
certain types of physical limitations or disabilities often lack of
physical energy and dexterity to perform hygienic care. A client in
traction or a cast or who has an intravenous line or other device
connected to the body will need assistance with hygiene

Importance of Personal Hygiene

 Maintenance of physical hygiene in a state of health is a personal

value and individual responsibility
 Personal hygiene helps maintenance of physical and psychological
homeostasis
 Personal hygiene helps to promote individuals comfort, safety and
well-being
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 A clean mouth and teeth aids to the patients a feeling of self-

approval
 Healthy hygienic practices and technique, which provides
economy of time, material and energy
 Stimulation of circulation by massage and brushing is essential to
maintain the hair healthy
 Keeping the scalp clean by brushing and shampooing will help to
relieve form dandruff
 Moving the body joints in their whole range of movement helps to
prevent muscle contraction and improve circulation
 Good personal hygiene is essential during sickness as well as in
health

Nurses Role in Personal Hygiene

 Direct provision of hygienic care provides the nurse with an ideal

opportunity for daily assessment of the patient’s physical and
emotional state
 The process of daily bathing, oral hygiene, care of the hair, nails
and massage forms a vital part of the nurse-patient interaction
 The nurse should assess the needs of patients and identifying
related nursing problems
 The nurse needs to collect further information about the patient’s
identified problems
 The nurse needs to develop an appropriate nursing care plan in
terms of the data collected and relevant nursing principles
 The nurse has to implement the nursing care plan to provide
optimum quality of nursing care for individual patients
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 The nurse has to evaluate the success of the nursing care plan and
adjusting it to meet the patient’s changing needs
 The nurse also participates in carrying out the physician’s orders
and refers to the physician pertinent observations and
information about the patient
 The nurse has to motivate the patient to resume independence
and responsibility for care as the condition permits
 The nurse must apply knowledge of pathophysiology to provide
good preventive hygienic care. The nurse has to integrate
knowledge of anatomy, physiology and pathology during hygienic
care

EFFECTS OF NEGLECTED CARE

Poor personal hygiene habits, however, can lead to some minor side
effects, like body odor and greasy skin. They can also lead to more
troublesome or even serious issues.

For example, if you don’t wash your hands frequently, you can easily
transfer germs and bacteria to your mouth or eyes.

Body Odor

This is probably the most common evidence of poor personal hygiene.

Not only does it lead to discomfort and an embarrassing situation for
those around you, but there are also other consequences. You could
develop allergies, constant itching, and the result of being socially
isolated due to your condition.
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When your sweat and the bacteria produced from your apocrine glands
interact, it produces body odor. So the more there’s unwashed sweat,
the bacteria increases, and the odor gets even worse. But it all starts
with poor personal hygiene and bad behaviors like:

 Infrequent showering.
 Wearing dirty, smelly socks
 Not airing your shoes
 Not taking the time to wash your feet
 Wearing smelly, stained, or dirty clothes each day
 Not changing your underwear regularly
 Bad Breath And Other Oral Health Concerns

Bad breath (or halitosis) is another of the effects of poor hygiene that
impacts your oral health. When you eat, the bacteria that are present
on the food particles get stuck on your teeth. Unfortunately, as these
bacteria digest, they produce a strong unpleasant odor that is
associated with halitosis.

Poor oral hygiene leads to other problems like tooth decay and
bleeding gums. The behaviors that lead to these oral diseases include:

 Irregular brushing of your teeth

 Not flossing every time you brush your teeth
 Neglecting to clean your tongue when brushing your teeth
 Drinking too many acidic drinks too often
 Excessive smoking
Influenza
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Did you know that having the flu can be one of the effects of poor
hygiene? You must know how to prevent contamination from any
pathogens. You also need to know how to stop the spreading of your
germs to other people. Some examples of poor hygiene behaviors in
this instance include:

 Not wearing a face mask when you don’t feel well

 Not covering your sneezes and coughs with a cloth or your elbow
 Still going to social gatherings even when you’re ill
 Infrequent hand washing
 Lice Infestation

Body lice infestation is quite uncomfortable and hazardous to your

health. These lice are small insects that live and lay eggs in clothing and
bedding. They also feed on the residues found on your skin.

Lice tend to colonize in your armpits and groin, as these are the areas
with a lot of humidity. So, it’s important to take regular baths, and wear
clean, fresh clothes each day to avoid any lice infestation.

 Avoid doing the following to stave off any such infestation:

 Infrequent showering
 Not changing your bedding at least every week
 Not washing your clothes very well
 Wearing dirty and/or smelly clothes

CARE OF SKIN – (BATH, FEET AND NAIL, HAIR CARE)

CARE OF HAIR
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Care of hair is part of the personal hygiene. It is another way of helping

the patient feel good about him and maintain a good mental attitude. A
patient’s hair should be combed daily. In addition, other care is
necessary to enhance morale, stimulate circulation of the scalp and
prevent tangled, matted hair

Purposes of Hair Care

 Hair care improves the morale of the patient

 It stimulates the circulation of the scalp
 Shampooing removes bacteria, microorganisms, oils, and dirt that
cling to the hair

Objectives

 To maintain cleanliness of the scalp and hair

 To prevent matting of hair
 To promote comfort and to stimulate circulation of the scalp
 It gives an opportunity of observation of the scalp and hair
 It maintains a glossy and healthy appearance of hair and gives
satisfaction to the patient

Scientific Principles

 Well-combed and attend hair provide comfort to the patient and

make appearance more attractive
 Neglected hair and scalp contain dirt and microorganism and also
produce infection of the scalp
 Unbroken skin acts as a barrier to infection
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Types of Hair Care

 Daily care: the hair should be thoroughly combed and brushed

daily. A woman usually needs more attention to the hair due to its
length
 Hair shampoo: shampooing the hair in order to maintain its
cleanliness
 Treatment of hair: pediculosis treatment – it is the treatment
given with DDT 5% of carbolic lotion 1:40 applied thoroughly on
the scalp and it is left for overnight, and the next day a thorough
bath is given and the linen is change

MAINTAINING HAIR CARE

Care of hair means maintaining cleanliness of hair, i.e. free from

dandruff, dirt, nits, lice, flakes, dryness and irritation

Purpose

 To keep hair clean and healthy

 To promote growth of hair
 To have a neat and tidy appearance
 To prevent itching, infection, dandruff, lice, flakes, dryness and
irritation
 To prevent loss of hair
 To prevent accumulation of dirt
 To stimulate circulation
 To prevent tangles
 To promote comfort
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 To have a sense of well-being

Three Aspects of Hair Care

1. Daily care by brushing and combing

2. Head bath in order to maintain to cleanliness
3. Treatment of hair for lice infestation

Factors Influence on Hair

 General health of a person

 A well-balanced diet
 Light and fresh air
 Daily practices (hair wash and combing)
 Hair brushing and massage
 Endocrine disorder

Factors Affecting Hair

 Altered level of consciousness

 Physical weakness or disease condition
 Immobility and aging
 Insect bite and infestations
 Accumulated secretions
 Hormonal changes
 Physical and emotional stress
 Poor health practices
 Effects on drug

Common Hair Scalp Problems

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 Dandruff - sealing of scalp accompanied by itching

 Pediculosis – lice infestation
 Alopecia – hair loss
 Tangled and matted hair
 Dryness
 Flakes
 Irritation

HAIR COMBING

The hair can be combed and washed in the morning so that the patient
can feel refreshed and appear well-groomed before starting daily
activities

General Instructions

 Hair needs to be brushed daily in order to be healthy

 Long air should be combed at least once a day to prevent it from
matting
 Teeth of the comb should be dull to prevent scratching of the
scalp
 Hair must be kept free from snarls, combed and brushed without
hurting the patient

Preliminary Assessment

Check

 Doctors order for specific precautions

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 General condition and self-care ability

 Condition of the scalp and hair
 Mental status to follow directions
 Articles available in the unit

Preparation of the Patient and Environment

 Explain the procedure

 Arrange the article at the bedside
 Provide privacy and adequate light
 Make the patient to sit on a bedside chair or stool
 Protect the bottom sheet and pillow case with a towel
 Protect the nurse’s uniform by wearing aprons

Equipment

 Clean comb
 Mackintosh and towel
 Coconut oil in a container
 Kidney tray and paper bag
 Kidney tray with carbolic lotion 1:20 to destroy the lice and to
disinfect the comb

Procedure

 Wash hands and take required articles at bedside

 If possible as patient to sit on a stool otherwise side lying or
fowler’s position
 Place the Mackintosh under the head of the patient
 Each half of the hair is treated separately without causing strain
on the patient
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 Separate the hair in small strands. To prevent pulling hold strands

above the part being combed, so that there will be no pain to the
patient
 Comb the tangle out from the ends first and then go up gradually.
Use oil to remove tangles
 After combing the hair thoroughly, use ribbon to tie the hair
 Discard loose hair into the paper bag

After Care

 Place the patient comfortable and tidy

 Replace the articles to the utility room
 Wash hands thoroughly
 Record and report the procedure in nurse’s record sheet

Problems of Neglected Hair Care

Neglected hair care cause sticky and heavy and acquires a sour,
unpleasant odor, which may be quite distressing the patient.
Pediculosis is associated with poor hygiene, crowded living condition
and exposure to other individuals.

The people with pediculosis have complaints of severe itching of the

scalp and scratch the head continuously giving rise to abscess
formation. The lice are blood suckers and cause anemia. They also
spread disease, e.g. typhus fever, relapsing fever, trench fever.

CARE OF THE EYES, NOSE AND EARS

The eyes, nose and ears are important organs which require no special
care in daily life. Hygienic care of these organs is always done as part of
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the general bathing procedure. Hygienic care of the eyes, ears and nose
prevents infection and helps to maintain their functions. Assessments
must be made of the patient’s knowledge and methods used to care for
the aids, as well as any problems he might be having with the aids.
Patients with limited mobility cannot grasp small objects. Patients that
have reduced vision or are seriously fatigued will also require assistance
from the specialist

Important points: the eyes, ears, and nose are sensitive and therefore
extra care should be taken to avoid injury to these tissues. Never use
bobby pins, toothpicks, or cotton-tipped applicators to clean the
external auditory canal. Such objects may damage the tympanic
membrane (eardrum) or cause wax (cerumen) to impact within the
canal

Essential Steps in Eye, Ear and Nose

 Eyes are cleaned from the inner to the outer cantus

 During a bath, each eye is cleaned with a separate portion of the
wash cloth
 Excessive accumulation of secretions make patient sniff or blow
the nose
 The patients who cannot remove secretions needs assistance to
clear the congestion and protect from nasal mucosa
 Babies and small children a wisp of cotton moistened with warm
water or oil, introduced into the anterior nares and rotated
gently, cleanses the nostrils

Common Problems of Neglected Care

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Poor eye, ear causes debris may accumulate behind the ear and in the
anterior aspect of the external ear. This can lead to ulceration of the
skin. Collection of cerumen or ear wax, in the external auditory canal
cause difficulty in hearing

Purpose

 To maintain the cleanliness of eye, ear and nose

 To prevent infection
 To keep the organ in normal functioning
 To prevent obstruction
Factor Affecting

 Systemic disease condition (diabetes and hypertension)

 Acute illness (viral or bacterial infection)
 Trauma (blow or foreign bodies)
 Medication (toxic drugs)
 Allergic substances
 Congenital anomalies

Common Problems

Eye: conjunctivitis (burning, itching, red-watery and painful eyes with

increased secretions) cataracts, glaucoma, strabismus and squint

Ear: otitis media, impacted cerumen and foreign bodies

Nose: mechanical irritation and obstruction

General Instructions
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Eye

 Unconscious patients are at risk for eye injury. Daily swabbing of

eye with wet sterile cotton is important
 Cleaning is done from the inner canthus of eye to the outer
canthus of the eye
 Use normal saline to remove the crust
 During bath, each eye is cleaned with a separate portion of the
wash cloth
 When sterile procedure is required, each eye cleaned with
separate swabs, swabbing each once only

Ear

 Do not use pins or slides to clean ears. Only use clean buds to
clean ears
 Poor hygiene of ear, debris may accumulate behind the ear and in
the anterior aspect of the external ear

Nose

 Observation of nose for signs of discharge, lesions, edema and

deformity is required
 External crusted secretions can be removed with a wet wash cloth
or a cotton applicator moistened with oil, normal saline or water
 Foreign bodies and small children a wisp of cotton moistened with
water or oil, introduced into the anterior flares, and rotated
gently cleanse the nostrils

Preliminary Assessment

Check
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 Patients diagnosis
 Doctors order for specific instructions
 Assess the general condition
 Self-care ability
 Articles available in the unit

Preparations of the Patient and Environment

 Explain the procedure

 Arrange the articles at the bedsides
 Place the patient in flat if the condition permits
 Protect the pillow and the bed with a Mackintosh and towel
under the head

Eye Care

Eye care is carried out for a number of reasons: to clean the eye of
discharge and crusts; prior to eye drop installation; to soothe eye
irritation; to prevent corneal damage/abrasion in the
unconscious/sedated patient

Equipment Needed

 Clean trolley
 Sterile dressing pack containing a gallipot, gauze swabs and
disposable towel
 Sterile 0.9% sodium chloride
 Sterile gloves
 Appropriate eye ointment/drops (as prescribed)
 Good light source
 Disposable bag for rubbish
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The patient should be sitting or lying with their head tilted backwards
and chins pointing upwards. This allows for easy access to the eyes and
is a good position for patient comfort.

Procedure: explain to the patient what you are about to do even if the
patient is unconscious. Make sure the bed area is clear of any
obstructions to enable you to move around the bed freely, and that you
have all the equipment-ensuring you are prepared means you will not
have to leave the patient unnecessarily during the procedure

 Make sure that the patient is in a comfortable position and that

there is a good light source
 Ensure patients privacy
 Make an assessment of the patients eyes
 Wash hands, put on gloves and open sterile pack
 Place disposable towel around the patient’s neck
 Ask the patient to close their eyelids, to avoid damage to the
cornea
 With a gauze swab dampened in the saline 0.9% gently swab from
the inner aspect (nasal corner) of the eye outwards. Use a new
swab each time until all discharge has been removed
 Repeat the procedure for both eyes
 Dry the patient’s eyelids gently to remove excess fluid
 Dispose of equipment
 Ensure that patient is comfortable
 Wash hands thoroughly
 At this point, if required, eye ointment/drops are instilled
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 The medicine prescription should be checked against the label on

the eye ointment/drops prior to cleaning patient’s eyes. The
expiry date should also be checked on the medication
 Check the patient’s prescription sheet for the date and time of
administration
 Make sure that you have the correct eye ointment/drop for each
eye
 Ensure the patient is in a comfortable position head titled back
and supported
 The patient should be warned if the medication is likely to cause
side effects, such as blurred vision

After Care

 Instill any medications that are ordered

 Remove the Mackintosh and towel from under the patient head
 Adjust the position of the patient
 Replace the articles to the utility room
 Wash hand thoroughly
 Record and report the procedure in the nurse’s record

Care of the Ears

 The ears are cleaned during the bed bath. A clean corner of a
moistened washcloth rotated gently into the ear is used for
cleaning. Also, a cotton-tipped applicator is useful for cleansing
the pinna
 The care of the hearing aid involves routine cleaning, battery care
and proper insertion techniques. The specialist must assess the
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patient’s knowledge and routines for cleaning and caring for his
hearing aid. The specialist will also determine whether the patient
can hear clearly with the use of the aid by talking slowly and
clearly in a normal tone of voice. Have the patient suggest any
additional tips for care of the hearing aid
When not in use, the hearing aid should be stored where it will
not become damaged. The hearing aid should be turned off when
not in use. The outside of the hearing aid should be cleaned with a
clean, dry cloth. Hearing loss is a common health problem with
the elderly, and the aid assists in the ability to communicate and
react appropriately in the environment

Care of the Nose

 Secretions can usually be removed from the nose by having
the patient blow into a soft tissue. The specialist must teach
the patient that harsh blowing causes pressure capable of
injuring the eardrum, nasal mucosa, and even sensitive eye
structures
If the patient is not able to clean his nose, the specialist will
assist using a saline moistened washcloth or cotton tipped
applicator. Do not insert the applicator beyond the cotton
tip
 Suctioning may be necessary if the secretions are excessive.
When patients receive oxygen per nasal cannula, or have a
nasogastric tube, you should cleanse the nares every 8
hours. Use a cotton-tipped applicator moistened with saline.
Secretions are likely to collect and dry around the tube;
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therefore, you will need to cleanse the tube with soap and
water

ORAL HYGIENE
Oral hygiene means maintaining the cleanliness of the mouth. Oral
hygiene includes measures to prevent the spread of disease from the
mouth and increase the comfort of the patient

It is important because mouth is the portal entry of food and digestion

starts from mouth. So, the entry of any pathogen in mouth directly
affects health.

Oral hygiene means the cleanliness of the mouth oral hygiene includes
measure to prevent the spread of disease from the mouth and increase
the comfort

Objectives

 To keep the mouth and teeth in good condition

 To prevent the mucous membrane from becoming dry and
cracked
 To prevent sores which resulting in ulceration
 To prevent bacterial in the mouth from causing local and
general infections
 Emollients help to soften the dry mucus membrane to
prevent cracking

Purpose

 To prevent and treat mouth infections

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 To keep the mouth fresh and clean

 To prevent the mucus membrane from becoming dry and cracked
 To prevent dental caries and tooth decay
 To prevent sores which resulting in ulceration
 To stimulate salivation and increase appetite
 To prevent infection of parotid glands
 To prevent complications such as stomatitis, glossitis, pyorrhea
and parotitis, etc
 To stimulate circulation in gums thus maintaining health firmness
 To maintain oral hygiene among bedridden patients
The Patient who may require Frequent Mouth Care

 Unconscious patients
 Helpless patient
 Patient with higher pyrexia
 Malnourished and dehydrated patients
 Patients who are not taking oral feeds
 Patients have local diseases of mouth
 Paraplegic patients
 Patients having a local disease of mouth
 Postoperative patients

Scientific Principles

 Any new treatment or exposure to unfamiliar situation produces

fear and anxiety
 Food particles left in the mouth promote the growth of
microorganism
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 Soap which is constituent of most dentrifrice has a low surface

tension and spreads readily and penetrate in between teeth
 Cold water reduces friction and hot water destroys dentures
 Cough reflex is depressed in unconscious patients
 Giving mouth care provides opportunity to observe the condition
of mouth and teeth
 Knowledge about the technique of keeping the mouth healthy
helps in practicing it and maintains
 A clean mouth and teeth aids to the patient a feeling of self-
approval
 Emollient help to soften the dry mucous membrane to prevent
cracking
 Patients comfort and safety may be enhanced by practice of good
techniques, which provide economy of time, material and energy

Solutions Commonly Used for Mouth Wash

 Potassium permanganate (KMnO4) 1:5000 (crystal to a glass of

water)
 Sodium chloride – one teaspoon to a pint of water
 Potassium chloride – 4-6%
 Hydrogen peroxide (H2O2) 1:8 solution

Dentifrices Used

 Glycerin with lime juice equal parts

 Sodium bicarbonate paste
 Reliable tooth paste or powder
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Emollient Used Commonly

 Clean or butter
 White Vaseline
 Liquid paraffin
 Glycerin borax
 Olive oil

Preliminary Assessment of the Patient and Environment

 Identify the patient and observe the general condition of the

patient
 Check the condition of the mouth
 Assess the ability of the patient to cooperate
 Prepare the patient for acceptance and realization
 Assess the status of health habits
 Decide the type of dentifrice and emollient to be used
 Assess the frequency of mouth care needed
 Note the precautions to be observed while moving the patient
 Articles available in the unit
 Make sure about any or drink to be given after mouth care if
advisable

Equipment

A tray containing of:

 Mackintosh and towel

 Small jug with warm water
 Feeding cup
 Small cups – 2
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 Artery forceps – 1
 Dissecting forceps – 1

A small container containing of:

 Paper bag
 Kidney tray
 Choose one of the solutions for mouthwash
 Choose one of the emollients
 Gauze piece
 Face towel – 1

Procedure

 Bring patient to edge of bed

 Position pillow according to comfort of patient
 Place small mackintosh with face towel on patient’s chest
 Place K-basin close to chin of patient
 Raise head end of the bed to 45 degree
 Pour antiseptic solution into cup
 Soak gauze piece in solution and squeeze out excess solution by
using artery clump
 Use same clamp to clean patient’s mouth (avoid mixing of clamps)
 Clean using up and down movements from gums to crown, clean
oral cavity from proximal to distal, outer to inner aspect
 Discard used cotton balls into K-basin
 Provide tumbler of water and instruct the patient to gargle
mouth. Position K-basin so that spillage is avoided
 Clean tongue from inner to outer aspect
 Provide water to rinse mouth and dry face with towel
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 Lubricate lips using swab stick

 Rinse the used articles and replace equipment
 Document time, solution used, condition of oral cavity,
abnormalities noticed and patient’s response

Complication of Neglected Mouth Care

Local Complications

 Parotitis: inflammation of the parotid glands

 Stomatisis: inflammation of the mucus membrane of the mouth
 Gingivitis: inflammation of the gums
 Glossitis: inflammation of the tongue
 Dental caries: forms cavity in the teeth
 Root abscesses: pus formation in the root of the teeth
 Periodontal diseases: it is also known as pyorrhea or pus
formation in the sockets of teeth
 Bleeding gums: deficiency of vitamin C and use a hard brushing of
the teeth

Complication Neighboring Structure

 Parotitis: inflammation of the parotid gland

 Rhinitis: inflammation of sinus cavity
 Otitis media: inflammation of middle ear
 Tonsillitis: inflammation of the tonsils
 Adenitis: inflammation of the adenoids

Systemic Complication

 Anorexia: loss of appetite

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 Bacterial endocarditis: inflammation of the endocardium

 Gastritis: inflammation of the stomach
 Nephritis: inflammation of the kidneys
 Rheumatic arthritis: inflammation of the joints

Recording and Reporting

 Record the procedure with date, time and condition of the mouth,
teeth, etc, on nurse’s record
 Report and record any abnormal condition to the ward sister and
physician
 Give health education to the patient and relatives on oral hygiene

CARE OF DENTURES
Care of dentures of artificial teeth is the responsibility of the nurse to
guard against offending patient, by helping them to take care of their
mouth

Equipment Needed

 Soft bristled tooth brush

 Denture tooth brush
 Dentifrice
 Warm and cold water in glasses
 Gauze pieces
 Wash cloth
 Plastic denture cup
 Gloves
 Basin
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Care of Dentures

Procedure

 Explain and secure the cooperation of the patient

 Remove the denture and inspect the oral cavity for abnormalities
if any
 Wash hands and keep the articles near the bed side sink
 Take a basin and fill half of it with water
 Put on gloves to reduce transmission of infection
 Ask the patient to remove dentures and place them in the basin
 Brush the dentures. Use back and front motion. Clean inside and
outside by brushing
 Rinse dentures thoroughly in running water
 Return them to the patient to keep them in a denture cup in cold
water
 With a soft bristled tooth brush the gum with tooth paste as well
as the palate of tongue also
 Rinse the mouth thoroughly with cold water
 Wipe the face and make the patient comfortable

Procedure

Precautions

 In cleaning dentures, they should be held firmly as water reduces

friction between the teeth and finger. They are liable to slip and
fall down
 Denture should be dipped in cold water to prevent friction
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 Hot water may destroy dentures, dentures are expensive and may
be difficult to replace if broken or lost
 Privacy should be maintained
 Discourage the use of brushed with hard bristles because they
cause grooves in dentures
 If the patient is capable of self-care, arrange the articles within
the easy reach of the patient
 Encourage the patients to wear the denture during the day. This
will improve the eating technique, speck appearance and contour
of the mouth
 Seriously ill patient or a patient who is under anesthesia or an
unconscious patient, the denture is removed for fear of dislodging
the denture and blocking the respiratory passage
 When dentures are removed from the patient mouth, they should
be stored in a labeled container to prevent lost and breakage

CARE 0F EYE GLASSES

Rinse

Always rinse your glasses off with water before wiping or cleaning
them. Even tiny particles of dust or dirt can settle on your lens, and if
you wipe those around on a dry lens, it can be abrasive.

Spray Carefully

If you're going to use a chemical, use sprays or cleansers that are

specifically made to clean eyeglass lenses. Never use household
cleaners like Windex, because these chemicals contain ammonia, which
will actually tear off the any coating that is on the lens.
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Air Dry

If you can, allow your glasses to air dry. This is another great way to
keep any materials from getting on to your lens. If you can't set them
down to air dry, wipe them down with a soft, clean, lint-free cloth.

Use the Right Cloth

NEVER use paper towels, tissue, or napkins to dry your lenses. All of
these materials, regardless of how soft they are on your skin, have a
textured surface and can easily scratch your lenses.

Also, refrain from using the tail of your shirt. If the clothing is not 100%
cotton, the fibers in the fabric will scratch the lens of your eyeglasses
over time. The clothing can also have dirt on it, which means the
residue ends up transferred to your lenses.

Grip Firmly

Hold your frames by gripping the piece that crosses the bridge of the
nose. This will keep you from accidently bending the frame while you
clean. Bent glasses can negatively affect the way you see out of your
glasses. Plus, if your frames are bent out of shape, they're more likely
to feel uncomfortable.

Store Properly

Store your glasses when you're not wearing them. This isn't just a great
way to keep dust and dirt away from your eyeglasses, but it also
protects your specs from getting scratched, bent or broken.

If you don't want a big, bulky case, sleeker ones are available.
Microfiber pouches are also great to keep at your office desk or on your
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night stand for glasses you don't necessarily wear all the time, like
reading glasses.

Place Carefully

Don't lay your glasses lens down. This is just asking for scratched lenses.

Wash Often

Washing your glasses at least once a day will keep your lenses in their
optimal state. The cleaner your glasses, the less your eyes have to
strain to see through smudges, dirt and dust.

Follow these great tips, and we are sure you'll never want to leave your
super clean specs behind.

CARE OF CONTACT LENS

You must clean and disinfect any contact lens you remove from your
eye before you put the lens back in. There are many types of cleansing
systems. The choice depends on the type of lens you use, if you
have allergies or if your eyes tend to form protein deposits. Ask your
eye doctor what kind of cleaning solutions you should use.
Take special care to clean and store your lenses correctly to avoid
dangerous eye infections.

Clean and rewet carefully

 Wash your hands with soap and water and dry them with a lint-
free towel before touching your contact lenses.
 Use a “rub and rinse” cleaning method no matter what type
of lens cleaning solution you buy. Rub your contact lenses with
clean fingers, and then rinse the lenses with solution before
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soaking them. Use this method even if the solution you are using
is a “no-rub” type.
 Never put contacts in your mouth to wet them. Saliva (spit) is not
a sterile solution.
 Do not rinse or store contacts in water (tap or sterile water).
 Never use a homemade saline solution.
 Do not use saline solution or rewetting drops to disinfect your
lenses. They are not disinfectants.
 Use new solution each time you clean and disinfect your contact
lenses. Never reuse or top off old solution.
 Do not pour contact lens solution into a different bottle. The
solution will no longer be sterile.
 Make sure the tip of the solution bottle does not touch any
surface. Keep the bottle tightly closed when you are not using it.

Care for your contact case

 Keep your contact lens case clean. Rinse it with sterile contact
lens solution (not tap water) then leave the empty case open to
air dry.
 Replace the case at least every 3 months or right away if it gets
cracked or damaged.

CARE OF HEARING AID

Proper care and cleaning of your hearing aid will help it work properly
and can help avoid the need for repeated repairs. Hearing aids come in
many different shapes and forms. On every model, there are three
places that need regular care:

1. The shell
2. The microphone
3. The receiver
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The Shell

The shell is the outer surface of the hearing aid. Wax or debris on the
shell of a hearing aid can affect proper fit, cause discomfort in the ear
or affect the movement of working parts such as the volume control.

For in-the-ear (ITE) varieties, wax is most likely going to build up in the
bent areas of the shell. Hearing aids that fit behind the ear can
accumulate dirt and oils in any groove or seam.

Tips for Cleaning the Shell

 Never use a dripping wet cloth or any chemical cleaners on your

hearing aid.
 Slightly dampen the tissue or cloth for more stubborn wax
buildup.
 For particularly difficult buildup, try using the brush included with
your hearing aid.

The Microphone

The microphone is one of the most delicate parts of your hearing aid,
so you should clean it with special care.

Tips for Cleaning the Microphone

 Never poke anything into the microphone port.

 When cleaning the microphone, turn your hearing aid upside
down so the microphone port faces the floor. That way, any loose
debris will fall out of the microphone and not into it.
 Using the brush provided with your hearing aid, gently brush
across the microphone port to sweep away any debris.
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The Receiver

Second only to a dead battery, wax buildup in the receiver is the most
common cause of hearing aid failure. The receiver is the hole that
directs the sound from the speaker of the hearing aid to your ear. Daily
cleaning with the brush will help prevent most buildup. Further
cleaning may be necessary if wax blocks the receiver.

Tips for Cleaning the Receiver

 Always be gentle while cleaning out the receiver — too much

force may damage it.
 Use the wax pick (small wire loop) provided with your hearing aid.
Insert the pick into the opening until you meet resistance, then
scoop back out. Repeat until the opening is free of wax.
 Some hearing aid styles may have other wax prevention systems
for the receiver, such as a wax guard or wax filter (cerustop). Your
audiologist can suggest the best way to clean these special
systems.

BED BATH
Bed bath means bathing a patient who is confined to bed and cannot
have the physical and mental capability of self-bathing

Bath is the act of cleaning the body. Baths are given for therapeutic
purposes

Purposes

 To cleanse body of dirt, debris and perspiration

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 To refresh
 To stimulate circulation
 To provide comfort and relaxation
 To enhance self-concept
 To provide tactile stimulation
 To facilitate head to be assessment
 To regulate body temperature
 To induce sleep
 To prevent pressure sore
 To remove toxic substances from body surface
 To maintain an effective nurse-patient relationship
 To give health instruction to patient
 To remove unpleasant odors due to perspiration
 To relieve fatigue
 To prevent contractures by giving exercises
 To minimize the skin irritation

Types of Patients Needing Bed Bath

 Unconscious or semiconscious patients

 Postoperative patients
 Patients with strict bed rest
 Paraplegic patients
 Orthopedic patients in plaster – cast and traction
 Seriously ill patients

Types of Cleansing Bath

Bed bath: it is the bathing of a patient who is confined to bed

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Therapeutic bath: doctor specifies the temperature of the water,

medications to be added and the body part to be treated

Partial bath: it is the act of cleaning particular areas in the body part.
They are face, axilla, and genitalia, upper and lower-limbs

Self-administered bath: this is same as in bed bath except the patient is

assisting in taking bath

Tub bath or bath room bath: this bath is allowed to the patient only if
he has enough confidence for self-help and to withstand procedure

Scientific Principles

 Heat is conveyed to the body by convection

 The tolerance of heat is different in different persons
 The skin is sometimes irritated by the chemical composition of
certain soaps
 Moving the joints through their full range of movement helps
prevent loss of muscle tone and improves circulation
 Long smooth strokes on the arms and legs that are directed from
the distal end to proximal increases the rate of venous flow
 Healthy unbroken skin is a defense against harmful agents and
assures resistance to injuries to a certain extent
 Hygiene practices vary in society according to the socioeconomic
standard and culture of the individual
 Practice of food technique save time, energy material and adds to
the comfort of the patient
 Sensory receptors in the skin are sensitive to heat, pains, touch
and pressure
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Factors Affecting the Skin

 Impaired self-care
 Immobilization
 Exposure to pressure and moisture
 Vascular insufficiency
 Reduced sensation
 Nutritional alternation
 Constrictive external devices

General Instructions

 Explain the procedure to the patient

 Maintain privacy of the patient
 Put off the fans and close the windows and doors to avoid chill
 Do not give bath immediately after the lunch
 Cleaning is to be done from the cleanest area to the less clean
area
 The temperature of the water should be 110 – 115 degree F
 A thorough inspection of the skin and back is necessary to find out
early signs of pressure sore
 Use soap which contains less alkali
 Special attention must be given to the creases and folds and bony
prominences between fingers and toes and pubic region
 Remove the soap completely to avoid the drying effect of the
soap on the skin
 Do not touch the body with wet hands it is unpleasant to the
patient
 Creams or oils used to prevent drying or excoriation of the skin
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 The nurse should maintain good posture and balances of the body
during bed bath

Preliminary Assessment

 Identify the patient and assess the need

 Check doctors order for any specific precautions
 Assess the general condition of the patient
 Assess the patient’s ability of self-help
 Assess the patient’s mental status to follow directions
 Check the patient’s preference for soap, powder, etc
 Check whether the patient has taken the meal in the previous one
hour
 Find out the available articles in the unit
 Provide privacy avoid draught and maintain proper light
 Teach the patient and relatives about personal hygiene

Preparation of the Patient and Environment

 Explain the sequence of the procedure to the patient

 Close the windows and doors to prevent draughts put off the skin
 Arrange the necessary articles at the bedside
 Maintain the room temperature which will be must comfortable
for patient
 Adjust the height of the bed to the comfortable work of the nurse
 Bring the patient to the edge of the bed and towards the nurse to
prevent overreaching
 Provide privacy by means of curtains
 Offer bed pan or urinals if necessary
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 Keep the patient flat if the condition permits remove extra pillows
and back rest
 Remove the personal clothing and cover the patient with the bath
blankets

Equipment

 Basins – 2 (big land small 1)

 Soap and soap dish
 Wash cloth – 2
 Bath touch – 2
 Face towel – 1
 Bath blanket of sheet – 1
 Surgical spirit and powder
 Nail cutter
 Comb and oil
 Kidney tray or paper bag
 Jugs – 2
 Bucket – 1
 Clean bed linen
 Clean dress to patient
 Bucket or a laundry bag
 Bath thermometer – 1

Procedure

 Explain the procedure

 Remove the patients dress, cover with bath sheet while removing
top sheet and dress
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 Mix hot and cold water in basin half full and check the
temperature on the back of your hand
 Spread face towel around neck
 Wet sponge towel and form mitten around gingers after removing
excess water
 Clean body in following

Face

 Wet and apply soap to forehead, face, over and behind ear and
neck
 Clean eyes from inner to outer canthus
 Rinses sponge towel and allow patient to wipe face
 Dry with face towel, replace at head end of bed

Arms

 Place towel lengthwise under the farthest arm if there is IV do not

disturb it
 Take soapy bath mitt and soap the arm and axilla
 Massage the pressure areas
 Place the hand in basin of water to wash
 Rinse and dry well, paying attention to skin under breast
 Recover with towel

Chest

 Avoid unnecessary exposure

 Cover chest with towel and turn bath sheet down to abdomen
 Wet chest and apply soap in rotatory movment, paying attention
to skin creases
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 Remove soap thoroughly by wiping from neck to check

 Dry with bath towel

Abdomen

 Fold top sheet up to suprapubic region cover the chest with bath
towel
 Wet and clean abdomen with soap
 Clean umbilicus and dry with bath towel
 Cover the patient with top water and remove towels

Back

 Turn the patient on side or left lateral position. Close to edge of

bed, with back towards nurse
 Expose back including buttocks, spread bath towel on bed, close
the patients back
 Wet the area and apply soap with rotatory movements clean and
remove soap and dry the area
 Give massage by applying firm pressure with palms and fingers
from sacrum to shoulder in sequence, covering whole back
 Help the patient to return to supine position

Legs

 Uncover the farthest leg and place towel under leg

 Apply soap to the leg and give special attention to the groin
 Massage the pressure points
 Place foots in basin of water to wash
 Rinse and dry well, paying special attention in between the toes
 Repeat the procedures on the near leg
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Pubic Region

 Clean pubic region with wet large rag piece (for helpless patient)
 Permit patient to clean if so desired
 Discard rag pieces into large K-basin
 Give perineal care for helpful patient

After Care

 Provide clean gown and pajama

 Replace articles after cleaning
 Discard dirty water in sluice room
 Clean the bed linen if needed
 Offer a hot drink (coffee or tea) if permitted
 Position the patient for comfortable and proper alignment
 Cut short the finger nails and toe nails
 Comb the hair and arrange the hair
 Hand wash
 Record the procedure in the nurse’s record with time, date, type
and abnormalities noticed

CARE OF HANDS, FEET AND NAILS

Hands are more contaminated area and soaking in water enables the
nurse to clean them thoroughly

Feet are considered to be the least clean area. Placing the foot in the
water and cleaning facilitates through cleaning
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Care nail is done by cut short finger nails and the toe nails. To prevent
skin injury and injection

Purpose

 To keep clean
 To prevent skin injury (% scratching)
 To prevent infection
 To promote comfort
 To improve grooming
 To promote self-esteem
 To detect or examine the abnormalities
 To prevent worm infestations

Patients with diabetes mellitus or peripheral vascular disease should be

observed for adequate circulation of the feet. Because of poor vision
and decreased mobility, the elderly are at risk for foot disorders. Care
of hands and feet can be administered during the morning bath or at
another convenient time

Important Points

 Notice general physical conditions that may place the patient at

risk for infections
 Prevent interruptions during the procedure
 Soak in warm water to soften nails and loosen foreign particles
 Prevent spread of microorganisms

Factors Affecting the Care

 Infection and injury

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 Vascular insufficiency
 Systemic disease condition
 Poor health practices
 Sociocultural background

Examination Includes

Examination of all skin surfaces, areas between fingers and between

toes, shape, size and number of fingers and toes. The condition of the
nails such as nail plate, nail color, the lunula, shape, thickness, texture,
angle and then tissues around the nails

Common Problems

 Calculus: thickened position of epidermis. It is painless

 Corns: eratosis caused by friction and pressure from shoes
 Plantar warts: fungal lesions on sole of foot
 Ingrown nails: it occurs due to improper nail trimming
 Athletics foot: tinea pedis – fungal infection of foot
 Rams horn nails: long curved nails
 Paronychia: inflammation of tissues surrounds nails

Foot Care

Special Foot Care

Patients with diabetes and peripheral vascular diseases

 Clean the feet daily in lukewarm water using soap

 Dry the feet and the part between toes
 Do not cut corns of calculus
 Wear shoes with porous uppers
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 If dryness is noted along the feet, use olive oil or lanolin and rub
gently into the skin
 Avoid wearing elastic stocking
 Inspect the feet the soles, the heels and the area between toes
daily
 Wear clean socks and stockings daily
 Do not walk bare foot
 Wear shoes or chapels, especially designed soft ones
 Exercise lower extremities to improve circulation
 Avoid burns to feet by hot water or hot water bag
 Treat minor injuries immediately under strict aseptic techniques
 Consult doctor for even minor injuries

Equipment

 Clean basin – 2 with warm water

 Large tray – 1
 Basin to dip foot or hand – 1
 Sponge cloths
 Towel – 1
 Nail clipper – 1
 Mackintosh and towel – 1
 Over bed table – 1
 Bath thermometer – 1

Procedure

 Collect the articles and place near the bed side to save time and
energy
 Explain the procedures to allay fear and anxiety
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 Wash hand to prevent cross-infection

 Provide privacy by screening
 Take the warm water 100-110 degree F in a basin
 Wash the hands first and then feet with soap and water and dry it
with clean towel
 Soak the nails in the warm water and apply soap
 Brush the nails and place between fingers and toes and clean if
with water
 Remove the water basin and dry the areas with towel
 Cut short the nails and collect it in the K-basin or paper bag
 Use wet cotton balls or gauze pieces to clean the tips of the nails

After Care

 Place the patients hand, feet comfortably

 Replace the articles and equipment
 Discard the dirty water in sluice room
 Wash the articles used and keep ready for the next use
 Wash hands
 Record and report the date, time, procedure and abnormalities
noted in the nurse’s record

BACK CARE/BACK MASSAGE/BACK RUB

Back care means cleaning and massaging back, paying special attention
to pressure points
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Back massage provides comfort pleases and relaxes the patient;

thereby it facilitates the physical stimulation to the skin and the
emotional relaxation

Back rub means attending the back and pressure points of body with
special care it is often called as back care or back massage

Purpose

 To give comfort to the patient

 To stimulate blood circulation
 To promote rest and sleep
 To prevent pressure sores
 To assess the skin condition
 To relax and relieve tension in tissues and muscles
 To refresh patient and relieve fatigue

General Instructions

 Back care given as a part of morning care and evening care

 Pressure points are attended more frequently and the position is
changed
 When the skin is greasy, moist, thin about to break or patient is in
continent or edematous used spirit or powder to reduce friction
 When the skin is dry, use oil for back rub. Spirit toughens the skins
and powder reduces friction oil lubricates the skin and, hence
friction
 When giving back rub, use more pressure on upward strokes
towards the head and less pressure on the downward strokes
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 Back rub may be contraindicated in patients susceptible to

clotting disorders

Equipment

A tray containing of:

 A basin of warm water

 Sponge cloths – 2
 Soap and towel
 Surgical spirit or back-rub lotion and powder
 Mackintosh and towel
 Kidney tray and paper bag

Procedure

 Wash hands and explain the procedure

 Screen the patient and explain the procedure
 Turn the patient on his side
 Turn back top bedding and expose only required part
 Spread towel close to the patients back to protect bed linen
 Wash back thoroughly from cervical spine to the coccyx
 Apply soap in the same manner. Run hands firmly and slowly up
the back on either side of the vertebral column up the neck and
down across the shoulders
 Pour some spirit in to hand applies firmly in a circular motion
repeat until back is thoroughly rubbed with it
 Wash off soap and dry thoroughly with towel
 The back must be rubbed three to five minutes especially over
pressure points
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 Apply back powder after through drying of the spirit

 Remove the towel
 Cover the patient with top bedding

After Care

 Make the patient comfortable

 Remove the screen and equipment
 Clean the articles with soap and water and keep ready for next
use
 Wash hands
 Record the date, time treatment and observation made on
nurse’s record

CARE OF PRESSURE POINTS/BEDSORE

A bedsore or pressure sore decubitus ulcer is an ulcer occurring on the
skin of any bed-ridden patient, particularly over bony prominences or
where two skin surfaces press against each other

Bedsore is a term applied to the local gangrene or ulcer caused by

certain conditions associated with the confinement of bed. Due to
constant pressure, circulation becomes slow and finally death of tissues
occurs

Definitions

Pressure injury: a localized injury to the skin and/or underlying tissue

usually over a bony prominence, as a result of pressure, shear and/or
friction, or a combination of these factors
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pH: a measure on a scale from 0 to 14 of the acidity or alkalinity of a

solution, with 7 being neutral, greater than 7 is more alkaline and less
than 7 is more acidic

Blanching erythema: reddened skin that blanches white under light

pressure

Risk assessment scale: a formal scale or score used to help determine

the degree of pressure injury risk. At the Royal Children’s Hospital the
Glamorgan Risk Assessment Scale is currently used

Shear: it is a mechanical force created from parallel loads that cause

the body to slide against resistance between the skin and a contact
surface. The outer layers of the skin (the epidermis and dermis) remain
stationary while deep fascia moves with the skeleton, creating
distortion in the blood vessels between the dermis and deep fascia.
This leads to thrombosis and capillary occlusion

Friction: it is a mechanical force that occurs when two surfaces move

across one another, creating resistance between the skin and contact
surface that leads shear

Extrinsic factors: originating outside of the body

Intrinsic factors originating within the body

Moisture: alters resilience of the epidermis to external forces by

causing maceration, particularly when the skin is exposed for prolonged
periods. Moisture can occur due to split fluids, incontinence, wound
exudates and perspiration
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Aims: the primary objectives are to promote prevention of pressure

injuries and provide optimal care to patients at risk of, or with existing
pressure injuries. The guideline specifically seeks to assist health
professionals to:

 Improve knowledge of the underlying physiology of pressure

injury formation
 Recognize factors which contribute to pressure injuries
 Identify high risk patients
 Implement and document intervention and prevention strategies
 Prevent or delay complications associated with pressure injuries
 Optimize management of pressure injuries
 Provide adequate parent and care education

Purpose

 To improve circulation
 To facilitate healing
 To prevent infection
 To prevent further damage
 To treat bedsores

Clients Susceptible to Bedsores

 Actually ill clients, whose general condition is rapidly deteriorating

 Elderly bedridden clients who make very little movements in bed
 Obese clients
 Very thin and emaciated clients, having very little subcutaneous
tissue to pad the bony prominences
 Sedated clients who have suffered spinal cord injuries
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 Paralyzed clients, who have suffered spinal cord injuries

 Neurologic clients with lack of sensations that they cannot feel
any irritation of the skin
 Edematous clients especially those with edema of the sacrum and
buttocks
 Malnourished clients with protein and vitamin deficiencies
 Agitated clients in restraints
 Surgical clients with limited movements
 Clients on complete bed rest or with limited movements

Cause of Pressure Sores

 Direct or immediate cause: the pressure is caused by the weight

of the body continuously remaining in one position, splints, casts
and bandages
 Friction: friction of the skin with rough bedding causes injury to
the skin. The friction is caused by wrinkles in the bed cloths,
cramps of food in the bed, chipped or rough bed pans and hand
surfaces of plaster casts and splints
 Moisture: the skin contact with moisture for a prolong period can
lead maceration of the skin
 Pressure of pathogenic organisms due to unhygienic condition
pathogenic organism multiplies and infection settles on the skin

Predisposing Factors

 Patient with long term illness, fracture patients

 Patients with spinal injury
 Paralysis and limited movements
 Emaciated and malnourished patients
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 Elderly with circulatory problems

 Obese patients
 Edematous patients
 Patients with incontinence
 Diabetic patients with ulcers (diabetic foot)

Common Sites Liable to Get Bedsore

 In supine position: occiput, scaptula, sacral region, hips and elbow

 In side lying position: ears, acromion process of shoulder, ribs,
greater trochanter of hips medial and lateral condyles of knee and
malleolus of ankle joint
 In prone position: ears cheeks acromion process, breast in female
genitalia, knees and toes

Clinical Manifestations of Pressure Sore

 Redness, heat, tenderness, and discomfort in the area

 The area becomes cold to touch and insensitive
 Local edema
 Later, the area becomes blue, purple of mottled
 Due to continued pressure that circulation is cut off, the gangrene
develops and affected area is sloughed

Preventive Measures of Bedsores

 Confirm the high-risk patients and daily examination for the signs
and symptoms
 Relieve pressure by using special mattress, beds and comfort
devices
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 Change position and giving back care four times a day for all
bedridden patients
 Loosening tight bandages and restraints
 Avoid friction by providing smooth, firm and wrinkle free bed,
keep the bottom clothes free from crumbs and foreign bodies
 Prevent moisture by changing linen when, it is wet or soiled.
Giving back care to patients immediately following micturition
and defecation
 Avoid mechanical or physical injury to the skin from improper
fitting of prosthesis or from burns caused by excessively hot or
cold applications
 Use a bed cradle to lift the weight of bed linen off the patient to
enable him or her to move in bed freely
 Supply well-balanced diet and adequate fluids to maintain general
health of the patient

Stages/Degree of Pressure Sores Based on

The early symptoms of pressure sore are redness, tenderness,

discomfort, and smarting. The area becomes cold to touch and
insensitive. There is local edema. Later the area becomes blue, purple
or muted. Due to continued pressure, the circulation is cut off, the
gangrene develops and the affected area is sloughed off

Clinical Manifestations

First degree: the skin is red, tender, inflamed and painful

Second degree: the skin is blue or mottled insensitive, circulation cut

off, gangrene develops and epidermis breaks
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Third degree: suppuration and sloughing occurs which may burrow

right down to the bones

Curative Measures Based on Degrees of Pressure Sores

First degree: detect the early signs and symptoms of bedsore and
report them to the sister in charge and the doctor

Carry out all the preventive measure with special care to prevent
extension of bedsore and further occurrence of pressure sores

While giving back care/massage, do not over the reddened or inflamed

area itself but start just outside the affected area and move outwards in
a circle using circular motion

Consult the doctor for further treatment

Second degree: if the pressure sore is blue or mottled insensitive,

circulation cut off gangrene develops or epidermis breaks

The treatment included:

 Inform and report to the ward sister and physician

 Prevent and ulcerated area from infection
 Use normal saline for cleaning the area
 Sloughing is more; use hydrogen peroxide solution also for
cleaning, cut off the slough
 Apply heat for healing of the wound. Use 100 watt electric bulb
for 10 minutes
 Apply zinc oxide ointment on the surface of the wound
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Third degree: if the bedsore is suppuration and sloughing occurs which

may burrow right down to the bones

 Inform and report to the ward sister and physician

 To treat infection, apply soframycin ointment locally and give
systemic antibiotics after culture and sensitivity
 Provide nutritious diet (high in protein and vitamins) sunlight and
fresh air
 If slough is present, clean the wound with hydrogen peroxide
twice daily if the slough is loose, it may be cut off
 If there is delay in wound healing, skin grafting can be done

After Care

 Place the patient in comfortable position

 Use proper and adequate comfort devices
 Change the patient’s position at frequent intervals
 Remove the articles from the bedside and replace it in a proper
place
 Hand washing
 Recording and reporting-date time, type of pressure sore and
treatment in the nurses record

CARE OF THE PERINEUM

Perineal care defined as clean the perineum from the cleanest to the
less clean area, the urethral orifice to the anal orifice
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Perineal care includes the external genitalia and surrounding area.

During perineal care, clean the area around the urinary meatus before
cleaning the area around the anus

Purpose

 To prevent sepsis
 To remove discharges and prevent bad odor
 To relieve itching
 To promote healing of stitches
 To promote comfort

Washing a Woman’s Perineum

Fill the basin with clean warm water. Fold the towel in hair. Ask or help
the woman to lift her buttocks. Put the towel under the buttocks. Ask
the woman to bend her knees and spread her legs. With a soapy
washcloth in one hand, separate the labia (“lips” of the vagina) with the
other hand. Wash the labia from front to back. Do not touch the anus
with the washcloth. Germs from the anus could get into the vagina and
cause an infection

Rinse the washcloth and remove the soap from the perineum. It is
important to remove all the soap because it can irritate the skin. Dry
the area with a dry towel. Do not put powder on the perineum because
the powder may harden

Wash the anus next. Ask the woman to turn onto her side so that she is
facing away from you. Ask her to rise up her top leg. This will let you
see and clean the skin around the anus. Slide the towel under the
woman’s buttocks. Use toilet paper or a paper towel to remove BM
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that may be on the skin. You need to wet the toilet paper or paper
towel if the BM has dried. Throw the toilet paper or paper towel away
in a trash bag. Wash, rinse, and dry the anal area.

Washing a Man’s Perineum

Empty the dirty water into the sink. Fill the basin with clean warm
water. Ask or help the man to lie on his back. Fold the towel in half and
put in under the man’s buttocks. Ask the man to bend his knees slightly
and spread his legs. Hold the penis with one hand. With the other hand,
wash the tip of the penis with a soapy washcloth. Rinse the washcloth
and remove the soap from the penis

If the man has a foreskin, gently push it back. The foreskin is the skin
that covers the rounded end of the penis. Wash the end of the penis.
Rinse the washcloth and remove the soap from the end of the penis

Using a soapy washcloth, wash the rest of the penis and the scrotum.
The scrotum is the bag of skin that hangs under the penis. Rinse and dry
well

The anus should be washed next. Ask the man to turn onto his side with
the top leg raised. This will let you see and clean the anal area easier.
Fold the towel in half and put it under the man’s buttocks. Use toilet
paper or a paper towel to remove BM that may be on the skin. You may
need to wet the toilet paper or paper towel if the BM has dried. Throw
the toilet paper or paper towel away in a trash bag. Wash, rinse and dry
the anal area

Perineum Care for Special Group of Patients

 Unable to do self-care or bedridden patients

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 After surgery on the genitourinary system

 Patients with indwelling catheters
 Patients with excessive vaginal discharges
 Postpartum patients
 Incontinence of urine and stool
 Genitourinary tract infections

Preliminary Assessment

Check

 Doctors order for any specific instruction

 Assess the condition of the perineal skin-itching, irritation, ulcers,
edema, drainage, etc
 Assess the need and frequency of care
 Assess the self-care ability of the patients
 Mental state to follow instructions
 Articles available in the patients unit

Preparation of the Patient and the Environment

 Explain the sequence of the procedure

 Provide privacy
 Arranged the needed articles at the bed side
 Place the Mackintosh under the buttocks, over the draw sheet
 Place a clean bedpan on the bed on your working side
 Unite the pads – if any, and observe the discharges its color, odor,
amount, etc
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Equipment

A tray containing:

 Mackintosh
 A jug with warm water or antiseptic solution
 Wet cotton balls or rag pieces in a bowl
 Gauze or rag pieces in a container
 Long artery forceps in the kidney tray
 Paper bag
 Clean (personal and bed linen) dressing pads, etc. as needed
 Soap, soap dish, towel and wash cloth of the patient is able to do
himself
 Bed pain

Procedure

 Wash hands thoroughly to prevent cross infection

 Pour water over the perineum to wash off the discharges from the
perineal area
 Hold the swabs with forceps and clean from above downwards
towards the anal canal
 Use one swab for one swabbing
Clean the perineum from the midline outward in the following
order – vulva, the labia minora on both sides, inside of the labia
majora on both sides (start cleaning from more clean area to less
clean area)
Clean the perineal region and the anus thoroughly
 Remove the bed pan by supporting the hip. Turn the patient to
one side and dry the buttocks with a dry rag pieces
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After Care

 Apply the medicine and pad if necessary

 Remove the Mackintosh if an extra one is used
 Change the linen if necessary
 Provide comfortable position to the patient
 Clean the articles and replace it in a proper place
 Wash hands thoroughly
 Record and report the procedure in a nurses record sheet
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UNIT – 5 ELIMINATION NEEDS

URINARY ELIMINATION
Urinary elimination, a natural process in which the body excretes waste
products and materials those exceeded bodily needs, usually is taken
for granted. When the urinary system fails to function properly,
virtually organ systems can be affected. Persons with alternations in
urinary elimination may also suffer emotionally from body image
changes. The proper functioning of the urinary system is vital to the
body’s physical well being, to life itself, and a person’s general sense of
well bring.

Nursing therapies promote or minimize factors that influence urinary

elimination. Each client has a different pattern of elimination. The
nurse must assess this pattern and design therapies to promote normal
urinary elimination when necessary. The nurse uses devices such as a
condom or an indwelling catheter to assist the client with urinary
elimination. The nurse assisting a client with urination or intervening to
resolve health related to urinary needs may have specialized abilities

DEFINITION
Urinary elimination is defined as expulsion of waste products from the
body through the urinary system.

Elimination from the urinary tract helps to remove the waste products
from body. It is essential to the body’s physical well-being

PHYSIOLOGY OF URINE ELIMINATION

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Urinary elimination depends on the function of the kidneys, ureters,

bladder, and urethra. Kidneys remove waste from the blood to form
urine. ureters transport urine from the kidneys to the bladder. The
bladder holds urine until the urge to urinate develops

Growth and development of individual: it influences urination. Usually

infants or children with 6 to 8 kg excrete 400 to 500 ml per day and
child cannot withhold urination. The adult normally voids 1500 to 1600
ml per day and has normal urine color; also has control over urination.
Aging impairs urination, e.g. elder adults

Food and fluid: foods high in water content increased urine production.
Certain foods affect the color and odor of urine. Certain fluid needed to
urinate develops. Urine leaves the body through the urethra. All organs
of the urinary system must be intact and functional for successful
removal of urinary wastes

The process of emptying the bladder is known as micturition or voiding

or urination. The bladder normally holds as much as 600 ml of urine.
However, the desire to urinate can be sensed when the bladder
contains only a small amount of urine (150 to 200 ml in adults and 50 to
200 ml in a child). As the volume increases, the bladder walls stretch,
sending sensory impulses to micturition center in the sacral spinal cord.
Parasympathetic impulses from the micturition center stimulate the
detrusor muscle to contract rhythmically. The internal sphincter also
relaxes so that urine may enter the urethra, although voiding does not
yet occur. As the bladder contracts, nerve impulses travel up the spinal
cord to the midbrain and cerebral cortex. A person is thus conscious of
the need to urinate. If the person chooses not to void, the external
urinary sphincter remains contracted, and the micturition reflex is
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inhibited. However, when a person is ready to void, the external

sphincter relaxes, the micturition reflex stimulates the detrusor muscle
to contract and urination occurs. The act of micturition normally is
painless.

COMPOSITION AND CHARACTERISTICS OF URINE

Normal urine consists of water, urea, salts, and pigments.

Urine is a liquid byproduct of the body secreted by the kidneys through

a process called urination and excreted through the urethra. The
normal chemical composition of urine is mainly water content, but it
also includes nitrogenous molecules, such as urea, as well as creatinine
and other metabolic waste components.

Other substances may be excreted in urine due to injury or infection of

the glomeruli of the kidneys, which can alter the ability of the nephron
to reabsorb or filter the different components of blood plasma.

Normal Chemical Composition of Urine

Urine is an aqueous solution of greater than 95% water, with a

minimum of these remaining constituents, in order of decreasing
concentration:

 Urea 9.3 g/L.

 Chloride 1.87 g/L.
 Sodium 1.17 g/L.
 Potassium 0.750 g/L.
 Creatinine 0.670 g/L.
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Other dissolved ions, inorganic and organic compounds (proteins,

hormones, metabolites).

Urine is sterile until it reaches the urethra, where epithelial cells lining
the urethra are colonized by facultatively anaerobic gram-negative rods
and cocci. Urea is essentially a processed form of ammonia that is non-
toxic to mammals, unlike ammonia, which can be highly toxic. It is
processed from ammonia and carbon dioxide in the liver.

Abnormal Types of Urine

There are several conditions that can cause abnormal components to

be excreted in urine or present as abnormal characteristics of urine.
They are mostly referred to by the suffix -uria. Some of the more
common types of abnormal urine include:

 Proteinuria—Protein content in urine, often due to leaky or

damaged glomeruli.
 Oliguria—An abnormally small amount of urine, often due to
shock or kidney damage.
 Polyuria—An abnormally large amount of urine, often caused by
diabetes.
 Dysuria—Painful or uncomfortable urination, often from urinary
tract infections.
 Hematuria—Red blood cells in urine, from infection or injury.
 Glycosuria— Glucose in urine, due to excess plasma glucose in
diabetes, beyond the amount able to be reabsorbed in the
proximal convoluted tubule.
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CHARACTERISTICS OF URINE

Table. Normal Urine Characteristics

Characteristic Normal values

Color Pale yellow to deep amber

Odor Odorless

Volume 750–2000 mL/24 hour

pH 4.5–8.0

Specific gravity 1.003–1.032

Osmolarity 40–1350 mOsmol/kg

Urobilinogen 0.2–1.0 mg/100 mL

White blood cells 0–2 HPF (per high-power field of microscope)

Leukocyte esterase None

Protein None or trace

Bilirubin <0.3 mg/100 mL

Ketones None

Nitrites None

Blood None

Glucose None
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Table. Urine Volumes

Volume
Volume Causes
condition

Normal 1–2 L/day

Diabetes mellitus; diabetes insipidus; excess caffeine or alcohol; kidney disease; certain
Polyuria >2.5 L/day
drugs, such as diuretics; sickle cell anemia; excessive water intake

300–500
Oliguria Dehydration; blood loss; diarrhea; cardiogenic shock; kidney disease; enlarged prostate
mL/day

Anuria <50 mL/day Kidney failure; obstruction, such as kidney stone or tumor; enlarged prostate

FACTORS INFLUENCING URINATION

Developmental Considerations: infants are born without voluntary
control of urination and with the little ability to concentrate urine.
Older children and adults have general control of urination voluntarily.
Physiological may affect urination

Lifestyle: many individual’s families and sociocultural variables

influence a person’s normal voiding habits. For some individuals voiding
is a very personal and private act

Fluid and food intake: the healthy body maintains a sensitive balance
between the amount of fluid ingested and the amount of fluid
eliminated. When fluid intake increases, the output also increases

Environment: during summer, due to excessive perspiration urine

output is less. During winter, due to lack of perspiration, urine output is
more
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Psychological factors: stress can also interfere with the ability to relax
external urethral sphincter as a result, emptying the bladder completely
becomes difficult or impossible

Medication: Many medications interfere with the normal urination

process and may cause retention. Diuretics, e.g. frusemide, increase
urine formation by preventing the reabsorption of water and
electrolytes from the tubules of the kidney into the bloodstream

Muscle tone and activity: People who exercise regularly will have good
muscle tone increased body metabolism and good urine production

Pathological conditions: endocrine disorders such as diabetes insipidus

increase urine formation. Diseases of the kidney themselves can reduce
kidney function and perhaps eventually result in renal failure

Surgical and diagnostic procedure: surgery on structures adjacent to

the urinary tract can also voiding because of swelling in the lower
abdomen and often necessitates the use of retention catheter for a
short time

ALTERATION IN URINARY ELIMINATION

Urination micturation, voiding, and urination all mention to the process
of emptying the urinary bladder. Collection of urine in the bladder till
the pressure evokes special sensory nerve which results in the finishing
to the bladder called Stretcher receptor. The adult bladder contains
between 250 ml and 450 ml of urine. In children the bladder contains
50 ml to 200 ml of urine.
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The Urinary elimination is caused by productive functioning of four

urinary tract namely

1) Kidney

2) Ureters

3) Bladder

4) Urethra.

Categorizing the issues that occur in Urinary Elimination is as follows

1) Pre renal (before the nephron)

2) Intra renal (within the nephron)

3) Post renal (beyond the nephron and within the urinary tract)

Altered Urinary Productions

There are various terms which are described below

1) Polyuria

It refers to the manufacturing of large amount of urinary which is

abnormal by its characteristics by the kidneys.

2) Oliguria and Anuria

Reduced urinary output can be described by it.

Altered Urinary Elimination has various process which are described

below

1) Urinary Frequency

At often intervals they are ejected than the normal.

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2) Nocturia

Number of times a person goes to void is referred as Nocturia

3) Urgency

It is the feeling that the person must void where urine in the bladder
may or may not be there.

4) Dysuria

Painful or disturbing voiding is called Dysuria.

5) Urinary hesitancy

Late starting of the voiding

6) Enuresis

Reflex urination in the children comprising the age group of 4 to 5 years

7) Nocturnal enuresis

Reflex passing of urine during sleep resulting of bed wetting.

8) Urinary incontinence

Involuntary urination is symptom and not a disease, physiologic or

psycho logic.

9) Urinary retention

Damage of the bladder during emptying of the urine gathers the urine
and results in distended

10) Nurogrninc bladder

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Weak neurological function can result in the normal appliance of urine

elimination

FACILITATING URINE ELIMINATION: ASSESSMENT,

TYPES, EQUIPMENT, PROCEDURES AND SPECIAL
CONSIDERATIONS

ASSESSMENT

Assessment Rationales

Assess voiding pattern

(frequency and Identifies characteristics of bladder function
amount). Compare (effectiveness of bladder emptying, renal
urine output with fluid function, and fluid balance). Note: Urinary
intake. Note specific complications are a major cause of mortality.
gravity.

Bladder dysfunction is variable but may include

Palpate for bladder loss of bladder contraction and inability to relax
distension and observe urinary sphincter, resulting in urine retention and
for overflow. reflux incontinence. Note: Bladder distension can
precipitate autonomic dysreflexia.

Note reports of urinary This provides information about degree of

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Assessment Rationales

frequency, urgency, interference with elimination or may indicate

burning, incontinence, bladder infection. Fullness over bladder following
nocturia, and size or void is indicative of inadequate emptying or
force of urinary stream. retention and requires intervention.
Palpate bladder after
voiding.

A number of medications such as some

Review drug regimen, antispasmodics, antidepressants, and narcotic
including prescribed, analgesics; OTC medications with anticholinergic
over-the-counter (OTC), or alpha agonist properties; or recreational drugs
and street. such as cannabis may interfere with bladder
emptying.

Patients may need a bedside commode if mobility

Assess the availability
limitations interfere with getting to the
of toileting facilities.
bathroom.

Assess the patient’s

usual pattern of Many patients are incontinent only in the early
urination and morning when the bladder has stored a large
occurrence of urine volume during sleep.
incontinence.

Common Assessment
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Assessment Rationales

Findings

Strong desire to void my be caused by

Urgency inflammations or infections in the bladder or
urethra

Dysuria Painful or difficult voiding

Voiding that occurs more than usual when

compared with the person’s regular pattern or
Frequency
the generally accepted norm of voiding once
every 3 to 6 hours

Hesitancy Undue delay and difficulty in initiating voiding

A large volume of urine or output voided at any

Polyuria
given time

A small volume of urine or output between 100

Oliguria
to 500 mL/24 hr

Anuria Lack of urine production

Nocturia Excessive urination at night interrupting sleep

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Assessment Rationales

Hematuria RBCs in the urine

EQUIPMENT
Urinary Elimination Devices

This section will focus on the devices used to facilitate urinary

elimination. Urinary catheterization is the insertion of a catheter tube
into the urethral opening and placing it in the neck of the urinary
bladder to drain urine. There are several types of urinary elimination
devices, such as indwelling catheters, intermittent catheters,
suprapubic catheters, and external devices. Each of these types of
devices is described in the following subsections.

Indwelling Catheter
An indwelling catheter, often referred to as a “Foley catheter,” refers to a urinary catheter that remains
in place after insertion into the bladder for the continual collection of urine. It has a balloon on the
insertion tip to maintain placement in the neck of the bladder. The other end of the catheter is
attached to a drainage bag for the collection of urine.
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Anatomical Placement of an Indwelling Catheter

The distal end of an indwelling catheter has a urine drainage port that is
connected to a drainage bag. The size of the catheter is marked at this
end using the French catheter scale. A balloon port is also located at
this end, where a syringe is inserted to inflate the balloon after it is
inserted into the bladder. The balloon port is marked with the amount
of fluid required to fill the balloon.
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Parts of an Indwelling Catheter

Catheters have different sizes, with the larger the number indicating a
larger diameter of the catheter.

There are two common types of bags that may be attached to an

indwelling catheter. During inpatient or long-term care, larger
collection bags that can hold up to 2 liters of fluid are used. An image of
a typical collection bag attached to an indwelling catheter. These bags
should be emptied when they are half to two-thirds full to prevent
traction on the urethra from the bag. Additionally, the collection bag
should always be placed below the level of the patient’s bladder so that
urine flows out of the bladder and urine does not inadvertently flow
back into the bladder. Ensure the tubing is not coiled, kinked, or
compressed so that urine can flow unobstructed into the bag. Slack
should be maintained in the tubing to prevent injury to the patient’s
urethra. To prevent the development of a urinary tract infection, the
bag should not be permitted to touch the floor.
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Urine Collection Bag

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Placement of Urine Collection Bag

A second type of urine collection bag is a leg bag. Leg bags provide
discretion when the patient is in public because they can be worn
under clothing. However, leg bags are small and must be emptied more
frequently than those used during inpatient care.

Leg Bag
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Indwelling Catheter Attached to Leg Bag

Straight Catheter

A straight catheter is used for intermittent urinary catheterization. The

catheter is inserted to allow for the flow of urine and then immediately
removed, so a balloon is not required at the insertion tip. Intermittent
catheterization is used for the relief of urinary retention. It may be
performed once, such as after surgery when a patient is experiencing
urinary retention due to the effects of anesthesia, or performed several
times a day to manage chronic urinary retention. Some patients may
also independently perform self-catheterization at home to manage
chronic urinary retention caused by various medical conditions. In some
situations, a straight catheter is also used to obtain a sterile urine
specimen for culture when a patient is unable to void into a sterile
specimen cup. According to the Centers for Disease Control and
Prevention (CDC), intermittent catheterization is preferred to
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indwelling urethral catheters whenever feasible because of decreased

risk of developing a urinary tract infection.

Straight Catheter

Other Types of Urinary Catheters

COUDE CATHETER TIP

Coude catheter tips are curved to follow the natural curve of the
urethra during catheterization. They are often used when catheterizing
male patients with enlarged prostate glands. An example of a urinary
catheter with a coude tip. During insertion, the tip of the Coude
catheter must be pointed anteriorly or it can cause damage the urethra.
A thin line embedded in the catheter provides information regarding
orientation during the procedure; maintain the line upwards to keep it
pointed anteriorly.
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Coude Tipped Catheter

IRRIGATION CATHETER

Irrigation catheters are typically used after prostate surgery to flush the
surgical area. These catheters are larger in size to allow for larger
amounts of fluid to flush. An image comparing a larger 20 French
catheter (typically used for irrigation) to a 14 French catheter (typically
used for indwelling catheters).

Comparison of a 20 French and a 14 French Catheter

SUPRAPUBIC CATHETERS
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Suprapubic catheters are surgically inserted through the abdominal wall

into the bladder. This type of catheter is typically inserted when there is
a blockage within the urethra that does not allow the use of a straight
or indwelling catheter. Suprapubic catheters may be used for a short
period of time for acute medical conditions or may be used
permanently for chronic conditions. The insertion site of a suprapubic
catheter must be cleaned regularly according to agency policy with
appropriate steps to prevent skin breakdown.

Suprapubic Catheter

MALE CONDOM CATHETER

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A condom catheter is a noninvasive device used for males with

incontinence. It is placed over the penis and connected to a drainage
bag. This device protects and promotes healing of the skin around the
perineal area and inner legs and is used as an alternative to an
indwelling urinary catheter.

Condom Catheter

Condom Catheter Attached to Leg Bag

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FEMALE EXTERNAL URINARY CATHETER

Female external urinary catheters (FEUC) have been recently

introduced into practice to reduce the incidence of catheter-associated
urinary tract infection (CAUTI) in women. The external female catheter
device is made of a purewick material that is placed externally over the
female’s urinary meatus. The wicking material is attached to a tube that
is hooked to a low-suction device. When the wick becomes saturated
with urine, it is suctioned into a drainage canister. Preliminary studies
have found that utilizing the FEUC device reduced the risk for CAUTI.

PROVIDING URINAL/BED PAN

USE OF BEDPAN

Bedpan is made from steel or plastic device to meet elimination need

of patient confined to bed.

Bedpan may be used by a person who is unable to get out of bed.

Bedpans used by females for elimination of urine and feces of by males
for elimination of feces

PURPOSE

 To provide comfort
 To facilitate bowel and bladder elimination
 To collect specimen for diagnostic purposes
 To promote continence during bowel and bladder training
 To give perineal wash
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INDICATIONS

 Patient with spinal injury

 Postoperative patients
 Patients with fracture and traction
 Chronic bedridden patients
 Patients those who are strict bed rest

TYPES OF BEDPANS

 The regular high back pan

 The slipper pan fracture pan

PRELIMINARY ASSESSMENT

Check

 The doctors order for specific precautions such as movements of

positions
 General condition of the patient
 Level of consciousness
 Mentally healthy to follow instructions
 Self-care ability
 Articles available in the unit

PREPARATION OF PATIENT AND ENVIRONMENT

 Explain to assist (hip to lift)

 Arrange the article at the bedside
 Provide privacy
 Position the patient for easy lifting
 Place Mackintosh under the buttocks to prevent soiling
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EQUIPMENT

 Bedpan with lid

 Clean gloves
 Draw Mackintosh if needed
 Water and mug
 Tissue paper
 Soap with soap dish K-Basin and towel

PROCEDURE

 Encourage patient to assume normal position for defecation (if

possible)
 Place the dry bed pan under patient’s buttocks
 Assist patient to lift buttocks by supporting the back with left
hand
 Instruct and assist patient to raise hips or turn patient to side and
place bed pan firmly close to buttocks
 Provide adequate time to pass motion/urine
 Check the well covered bed pan to avoid embarrassment
 Once patient has passed, permit to clean self. Assist by pouring
water
 If patient is unable to clean, pour water and clean using long
artery clamp and cotton balls rag pieces
 Remove bedpan by lifting patient carefully

AFTER CARE

 Cover bedpan immediately and try Mackintosh of wet

 Secure draw sheet and position the patient comfortably
 Provide water and soap to wash hands
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 Empty the articles into stop – hopper in sluice room

 Replace the articles after cleaning
 Wash hands thoroughly
 Record the procedure in the nurse’s sheet

CARE OF PATIENTS WITH

CONDOM DRAINAGE
Condom drainage (also known as male sheaths, uridomes, urisheaths,
condom catheter or male external catheters) is a method for men
experiencing urinary incontinence to collect and drain their urine. A
condom connects to a drainage bag, which drains the urine into a urine
storage bag.

One way to empty the bladder is by using a condom catheter. This

device looks like a typical condom with a tube that is connected to a
urinary drainage bag. It is only used for males. This lesson will talk
about how to use the condom catheter.

Putting on a Condom: Step-by-Step Process

1. Gather supplies.

 Correct condom type and size

 Soapy and wet washcloths
 Condom strap (if using this product)

2. Wash hands with soap and water.

3. Take off old condom if one is currently on.

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Roll it off the penis. Do not pull it off, as this could harm the skin.

4. Wash the penis with the soapy washcloth and rinse with the wet
cloth.

Remember to pull the foreskin (if present) back and clean the head of
the penis. Roll the foreskin back down to cover the penis when done.

5. Dry penis well.

6. Take condom out of package.

 Roll up the condom toward the funnel shaped end.

 Some people use Skin Prep applied to the penis before putting on
the condom. The Skin Prep helps keep the condom in place.

7. Place the funnel end of the condom over the head of the penis.

8. Roll the condom down over the head of the penis all the way to the
base of the penis.
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If this is a self-adhesive type of condom, hold it in place after it is fully

rolled down for 10 seconds. If it is not a self-adhesive condom, continue
to the next step.

9. Get the condom holder out of the package.

 Wrap the condom holder about one inch above the base of the
penis.
 Pull the strap over one finger to make sure the strap is not too

tight.

10. Fasten the condom holder.

Fasten the elastic strap to the Velcro (if using this product). The
condom strap should be changed at least daily when doing ICs or when
using the condom without ICs.

11. Connect the condom to a leg bag or bedside bag.

12. Wear the leg bag below the knee.

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INTERMITTENT CATHETERIZATION
Introduction to Male Intermittent Catheterization

One method of emptying the bladder is by doing what is called an

intermittent catheterization (IC). An IC is also known as an "in and out"
catheterization. This means that the catheter is inserted and left in only
long enough to empty the bladder and then is removed. ICs are usually
done every 4 or 6 hours, depending on the person's emptying needs.
This lesson will talk about how to do an IC on a male.

IC: Step-by-Step Process (Clean Technique)

1. Gather the supplies.

 Catheter -Lubricating jelly -Soapy washcloth and wet washcloth -

Moist towelettes that state “antibacterial” (only if soapy and wet
washcloths are not available)
 Clean paper towel -IC bag or container for urine to drain

2. Wash hands with soap and water.

3. Prepare all needed supplies.

Catheter, lubricating jelly, IC bag or container, soapy and wet clothes or

wipes, clean paper towel.

4. Wash the penis.

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Wash with the soapy cloth and rinse with the wet cloth. Remember to
pull the foreskin back (if present) and wash the head of the penis well.

5. Open the catheter.

If you are reusing your current catheter, take it out of your storage bag.

6. Connect the IC bag to the catheter or place the container in near

reach.

7. Lubricate the catheter.

Squeeze the jelly onto the tip of the catheter, but do not let the jelly
tube actually touch the catheter.

8. Wash your hands again with soap and water

9. Pick up Catheter.

Pick up the catheter about 2-3 inches from the tip. Make sure the other
end of the catheter is either attached to the drainage bag or in the
container.

10. Hold the penis.

Hold the penis straight up with the other hand and insert the catheter
slowly until urine starts to drain. Then push the catheter in about one
more inch.

11. Let the penis lie down naturally.

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The bladder will empty better by letting the penis lie down naturally
while holding the catheter in place.

12. When the urine stops flowing, gently press on the bladder area.

13. Withdraw the catheter slowly.

This helps to completely empty the bladder.

14. Wash the penis.

When the catheter is out, wash the penis with a soapy cloth and rinse
with a wet cloth. Dry well. Remember to pull the foreskin (if present)
down over the head of the penis.

15. Empty the container or leg bag.

Rinse it out and clean with bleach water (the bleach/water

concentration should equal 1 tablespoon of bleach to 1/2 cup of water).

16. Clean the catheter.

Clean the catheter with antimicrobial soap and water. Rinse with clean
water, air dry and store the clean catheter in an envelope or paper bag
(not a plastic bag). When putting it in the envelope, place it “tip first” so
the next time you use it, the connection port comes out first and is
ready to be attached to the leg bag.

17. Reuse catheter for up to 7 days.

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Replace with a new catheter after 7 days.

18. Clean leg bag (if used).

Urinary drainage bags should be cleaned after each use. It is important

to clean the bags properly to prevent germs from causing infections.

Cleaning leg bag:

 Mix 1 tablespoon of bleach and 1/2 cup of water in a cup.

 Mix solution and then pour it into a squeeze container/bottle.
 Empty all of the urine from the bag.
 Rinse bag with water for 10 seconds.
 Empty water into the toilet.
 Pour/squeeze about 2 tablespoons of the premixed bleach
solution into the bag.
 Squeeze bag and allow bleach to get on all sides of the bag.
 Swish solution around inside the bag for at least 30 seconds.
 Discard solution into the toilet.
 Place bag on a clean paper towel.
 Leave any clamps on the bag open until the next time the bag is
used.

The bags (Foley bags and leg bags) should be changed at least every
month, but more often if needed.

19. Wash hands.

Introduction to Female Intermittent Catheterization

One method of emptying the bladder is by doing what is called an
intermittent catheterization (IC). An IC is also known as an "in and out"
catheterization. This means that the catheter is inserted and left in only
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long enough to empty the bladder and then is removed. ICs are usually
done every 4 or 6 hours depending on the person's emptying needs.
This lesson will talk about how to do an IC on a female. Some of the
photos in this lesson show the use of gloves.

ICs: Step by Step Process

1. Gather the Supplies

 Catheter
 Lubricating Jelly
 Soapy Washcloth and Wet Wash Cloth
 Moist towelettes that state “antibacterial” (only if soapy and wet
washcloths are not available)
 Clean paper towel
 IC bag or container for urine to drain

2. Wash hands with soap and water

3. Prepare all needed supplies

Catheter, lubricating jelly, IC bag or container, soapy and wet cloth or

baby wipes, clean paper towel

4. Using one hand, spread the labia open so you can find the urinary
opening.
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5. Clean urinary opening

Wash with soapy cloth and rinse with the wet cloth. Remember to wash
from top to bottom each time.

6. Open the catheter

If you are reusing your current catheter, take it out of your storage bag.

7. Connect the IC bag to the catheter or place the container in near

reach.

8. Lubricate the catheter

Squeeze the jelly onto the tip of the catheter but do not let the jelly
tube actually touch the catheter.

9. Wash hands again

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10. With one hand, spread the labia and find the urethra.

11. Pick up Catheter

Pick up the catheter about 2-3 inches from the tip. Make sure the other
end is either attached to the drainage bag or in the container

12. Insert the catheter slowly and gently into the urinary opening until
urine begins to flow. Insert the catheter another one inch and allow
urine to drain. Hold the catheter in place.
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13. When urine stops flowing, press over the bladder area with your
free hand.

Pushing on the bladder may be necessary to help it empty completely.

When the urine stops flowing, slowly and gently withdraw the catheter.

14. Wash the urethral opening

Clean area with soapy cloth and rinse with wet cloth.

15. Empty Container or Leg bag

Rinse it out two times and clean with bleach water. (the bleach/water
concentration should equal 1 tablespoon of bleach to 1/2 cup of water)

16. Clean the Catheter

Clean the catheter with antibacterial soap and water. Rinse with clean
water, air dry and store the clean catheter in an envelope or paper bag
(not a plastic bag). When putting it in the envelope, place it 'tip first' so
the next time you use it the catheter, the connection port comes out
first and is ready to be attached to the leg bag.

17. Reuse Catheter for up to 7 days.

18. Clean Leg Bag (if used)

Urinary drainage bags should be cleaned after each use. It is important

to clean the bags properly to prevent germs from causing infections.

Cleaning the bags:

 Mix 1 tablespoon of bleach and 1/2 cup of water in a cup.

 Swish it around (to mix) and then pour it into a squeeze
container/bottle.
 Empty all of the urine from the bag.
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 Rinse bag with water for 10 seconds. Empty water into the toilet.
 Pour/squeeze about 2 tablespoons of the premixed bleach
solution into the bag.
 Squeeze bag and allow bleach to get on all sides of the bag.
 Swish it around inside the bag for at least 30 seconds.
 Discard solution into the toilet
 Place bag l on a clean paper towel
 Leave any clamps bag open until the next time the bag is used

19. Wash hands

INDWELLING URINARY CATHETER AND URINARY

DRAINAGE
MALE FOLEY CATHETER
An indwelling catheter is also called a foley catheter or "Foley.” It can
be used in males or females. A Foley is usually left in the bladder and
drains the bladder continuously.

Foley Catheter: Step by Step Process

1. Gather the Supplies

 Indwelling Foley Catheter Tray with a 10 cc balloon (size 16fr is a

common size used for adults.) The tray comes with all the needed
supplies
 Syringe to deflate the balloon of the existing catheter (if there is
one already in the bladder)
 Soapy wash cloth and wet wash cloth

2. Wash hands with soap and water

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3. Prepare all needed supplies

4. Lie flat on back with legs flat

5. If there is already a catheter in place, remove it by deflating the

balloon.

 Attach the syringe to the end of the "Y" pigtail (side port).
 Withdraw the plunger of the syringe. This will deflate the balloon
on the catheter inside the bladder.
 You will know it is completely deflated when you are unable to
pull anymore water into the syringe.

6. Gently pull the catheter out from the bladder.

7. Wash penis

Wash with the soapy cloth and rinse with the wet cloth. Dry well.

8. Wash hands again.

9. Open the Indwelling Catheter Tray carefully. Set up the supplies.

 Place paper pad under hips.

 Put on the gloves if this is not a self catheterization.
 Pour the Betadine onto the cotton balls
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 Remove the plastic cover from the catheter (be careful not to
touch the catheter tube) & squirt the lubricating jelly onto the
catheter.
 Remove the rubber cap from the syringe with the water in it.
 Connect the end of the catheter to the drainage bag

10. Choose your "clean" and "dirty" hand.

Whatever hand comes in contact with the body, the one that holds the
penis, is dirty. The one that touches the catheter supplies is clean.
Never mix clean and dirty hands in regard to the catheter supplies. It is
important that this procedure stay "super clean" so as not to allow
germs to enter the bladder.

11. Hold the penis.

Remember, the hand touching the body will now be the dirty hand.

12. Clean urinary opening on penis

 Use clean hand to touch items in the kit

 Clean penis with the cotton balls soaked in Betadine.
 Use 1 cotton ball per wipe.
 Always wipe from the tip of the penis toward the shaft of the
penis.
 Never re-use a cotton ball.
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13. Insert the catheter slowly and gently into the urinary opening on
the penis.

14. See the urine flow into the catheter

Continue to insert the catheter until the "Y" pigtail section of the
catheter becomes very close to the end of the penis.

15. Blow up the balloon

While holding the catheter in place, attach the pre-filled syringe in the
kit to the "Y" pigtail port and insert all of the water from the syringe.

If it is easier, you can attach the syringe before you insert the catheter
so it is ready when you need it. Do not blow up the balloon until the
catheter is in and you see urine flowing.

Below is a picture of a catheter with an inflated balloon...this is what it

would look like inside the bladder

16. Wash off the extra Betadine from the penis.

17. Always hang/attach the drainage bag to chair/bed frame below

the level of the penis.
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This will allow for the best drainage.

18. Consider wearing a leg strap.

The leg strap attaches the catheter to the inner thigh. It helps to keep
the catheter secure.

19. If wearing a leg bag, always wear it below the knee.

FEMALE FOLEY CATHETER

An indwelling catheter is also called a foley catheter or "Foley." It can
be used in males or females. A Foley is usually left in the bladder and
drains the bladder continuously. This lesson will review how to insert a
foley catheter. Some of the photos in this lesson show the use of
gloves. It is not necessary to use gloves when doing this on yourself;
however, if you have a helper in the home/community setting, they
may choose to wear them.

Foley Catheter: Step by Step Process

1. Gather the Supplies

 Indwelling Foley Catheter Tray with a 10 cc balloon. (Size 16fr is a

common size used for adults). The tray comes with all the needed
supplies.
 Syringe to deflate the balloon of the existing catheter (if there is
one already in the bladder).
 Soapy wash cloth and wet wash cloth.

2. Wash hands with soap and water.

3. Prepare all needed supplies.

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4. Lie flat on back with legs flat.

5. If there is already a catheter in place, remove it by deflating the

balloon(the balloon is what holds the catheter in place inside the

bladder).

 Attach the syringe to the end of the "Y" pigtail (side port)
 Withdraw the plunger of the syringe. This will deflate the balloon
on the catheter inside the bladder. (The balloon is what holds the
catheter in place inside the bladder).
 You will know it is completely deflated when you are unable to
pull anymore water into the syringe.

6. Gently pull the catheter out from the bladder.

7. Wash urinary opening

Wash with the soapy cloth and rinse with the wet cloth. Dry well.

8. Wash hands again.

9. Open the indwelling catheter tray carefully. Set up the supplies.

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 Place paper pad under hips.

 Put on the gloves if this is not a self catheterization.
 Pour the betadine onto the cotton balls
 Remove the plastic cover from the catheter (be careful not to
touch the catheter tube) & squirt the lubricating jelly onto the
catheter.
 Remove the rubber cap from the syringe with the water in it.
 Connect the end of the catheter to the drainage bag

10. Choose your "clean" and "dirty" hand.

Whatever hand comes in contact with the body, the one that holds the

labia, is dirty. The one that touches the

catheter supplies is clean. Never mix clean and dirty hands in regard to
the catheter supplies. It is important that this procedure stay "super
clean" so as not to allow germs to enter the bladder.

11. Using one hand, spread the labia open so you can find the urinary
opening.

This hand is now your "dirty" hand. Do not use it to touch supplies in
the kit.

12. Clean urinary opening

 Use clean hand to touch items in the kit

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 Clean urinary area with the cotton balls soaked in betadine.

 Use one cotton ball per wipe.
 Always wipe from the top of the area towards the bottom.
 Never re-use a cotton ball.

13. Insert the catheter slowly and gently into the urinary opening

14. See the urine flow into the catheter

Continue to insert the catheter slowly for another 2 inches

15. Blow up the balloon

While holding the catheter in place, attach the pre-filled syringe in the
kit to the "Y" pigtail port and insert all of the water from the syringe.

If it is easier, you can attach the syringe before you insert the catheter
so it is ready when you need it. Do not blow up the balloon until the
catheter is in and you see urine flowing.

Never blow up the balloon until you see flowing urine inside the
catheter.

Below is a picture of a catheter with an inflated balloon...this is what it

would look like inside the bladder
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16. Wash off the extra Betadine from the urinary area.

17. Always hang/attach the drainage bag to chair/bed frame below

the level of the bladder.

This will allow for the best drainage.

18. Consider wearing a leg strap.

The leg strap attaches the catheter to the inner thigh. It helps to keep
the catheter secure.

19. if wearing a leg bag, always wear it below the knee.

20. Clean around the catheter and urethra daily

 Use unscented antibacterial soap and water.

 Dry the area carefully.
 Wash area after each bowel movement.

URINARY DIVERSION
Urinary diversion is a surgical procedure that creates a new way
for urine to exit your body when urine flow is blocked or when there is
a need to bypass a diseased area in the urinary tract.

The urinary tract is your body’s drainage system for removing urine,
which is made of wastes and extra fluid. Your urinary tract is designed
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to have the urine flow from the kidneys, through the ureters, to
the bladder, and out the urethra. When the urine can’t flow normally, it
may build up in your bladder, ureters, or kidneys. This buildup of urine
may cause pain, urinary tract infections, urinary stones or calculi,
damage to your urinary tract, or kidney failure. If left untreated, a
buildup of urine in the urinary tract can be life-threatening.

Urinary diversion may be temporary—the flow of urine is rerouted for

several days, weeks, or sometimes months until the urine can flow
normally again—or permanent—surgery is done to create a permanent
change to the way urine flows through the body.

The main types of urinary diversion include

 bladder catheterization
 cystostomy
 nephrostomy
 ureteral stent
 urostomy
 continent urinary diversion

Bladder catheterization

Bladder catheterization involves inserting a thin, flexible tube—called a

catheter—into the bladder to drain urine. The urine drains into a
collection bag outside the body. The two types of urinary catheters
include

 Foley catheter, inserted into the bladder through the urethra

 suprapubic catheter, inserted into the bladder through a small
hole in the skin beneath the belly button
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Urinary catheters may remain in place for several days or weeks while
tissues heal after urinary tract surgery or treatment of urinary blockage
and, in some cases, may be permanent. Catheters that are in place for
longer periods of time need to be replaced with a new catheter
periodically.

Cystostomy

A cystostomy is a surgical procedure where a doctor inserts a small

tube into your bladder through the skin of the lower abdomen. The
tube allows urine to drain from your bladder into a bag outside your
body.

Nephrostomy

Similar to a cystostomy, during a nephrostomy a surgeon

or radiologist makes a tiny incision and inserts a small tube, called a
nephrostomy tube, through the skin of your back into your kidney. The
nephrostomy tube allows urine to drain from your kidney into a bag
outside your body.

You may need a nephrostomy when being treated for a kidney stone or
when your ureters are narrowed, blocked, or inflamed. Depending on
the reason for the nephrostomy and how quickly your body heals, the
nephrostomy tube may be used for different lengths of time.

Ureteral stent

A ureteral stent is a thin flexible tube that is inserted into the ureter to
help urine flow from the kidney to the bladder. The ureteral stent is
guided with a cystoscope into your ureter, then one end of the stent is
placed in the kidney and the other end is placed in the bladder.
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You may need a ureteral stent if one of your ureters is blocked as a

result of surgery, a kidney stone, a tumor, or infection. A ureteral stent
is usually temporary but, in some cases, can be used to permanently
manage a blockage of the ureter. Ureteral stents that are in place for
longer periods of time need to be replaced periodically.

Urostomy

A urostomy is a stoma, or opening, in your abdomen that connects to

your urinary tract to allow urine to drain freely from your body. Urine is
collected and stored in a small bag, called a urostomy pouch, which you
can empty at your convenience. The pouch is attached to the skin
around your stoma and worn outside your body.

The two main types of urostomy include

 Ileal conduit. A surgeon removes a piece of your intestine to

create a passageway for urine. The ureters are attached to the
piece of intestine, then the intestine is attached to an opening in
your abdomen, creating a stoma. The urine flows from the
ureters, through the piece of intestine, and out the stoma.
 Cutaneous ureterostomy. A surgeon attaches one or both ureters
directly to a stoma in your abdomen.

Continent urinary diversion

Continent urinary diversion collects and stores urine inside the body
until you drain the urine using a catheter or you urinate through the
urethra. The urine flows through the ureters and is stored in an internal
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pouch created from part of your bowel or in your bladder. Continent

urinary diversion allows you to control when urine leaves your body.

The main types of continent urinary diversion include

 Continent cutaneous reservoir. A surgeon uses a piece of your

bowel to create an internal pouch, or reservoir, to hold urine. The
internal pouch is placed inside your abdomen. The ureters are
attached to the internal pouch, and the internal pouch is attached
to a stoma in your abdomen. Urine flows through the ureters and
into the internal pouch, where it is stored until you drain the urine
by inserting a catheter into the stoma. The stoma is the end of a
channel that connects to the reservoir. The channel has a valve
that prevents urine from exiting the body until a catheter is
inserted. The channel can be created from a piece of intestine or
by using the appendix.
 Bladder substitute, or neobladder. A surgeon uses a piece of your
bowel to create an internal reservoir, called a bladder substitute
or neobladder, to hold urine. The bladder substitute is placed in
the pelvis. The ureters are attached to the bladder substitute, and
the bladder substitute is attached to the urethra. Urine flows
through the ureters, into the bladder substitute, and you urinate
through the urethra.

BLADDER IRRIGATION
Bladder irrigation or wash is defined as washing of the urinary bladder
by directly a stream of solution into the bladder through the urinary
meatus by means of a catheter tubing and funnel
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Purpose

 To cleanse the bladder from decomposed urine bacteria, excess

mucus and pus
 To medicate the lining of the bladder of antiseptic irrigation
 To prepare the bladder for surgery as a preoperative measure
 To promote healing
 To relieve congestion and pain in case of inflammatory conditions
of cystitis
 To arrest bleeding and prevent clothing of blood

Solution Used

 Normal saline 0.9%

 Boric acid solution 2%
 Sterile water
 Acetic acid 1:4000 to treat pseudomonas infection
 Sodium nitrate 1:8000 to prevent clot formation
 KMO4 1:5000 – 1:10,000
 Acriflavin 1:10,000
 Silver nitrate 1:5,000
 Mercury compounds in low concentration

General Instructions

 The temperature of the solution needed for cleaning purpose

body temperature in enough
 The temperature of the solution needed for therapeutic purposes
ranging from 100-110 degree F
 The maximum amount of solution used for cleaning is 2 pints and
also depends on the patient’s condition
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Methods of Administration

 Funnel and tubing method (open method)

 Irrigation can, rubber tubing and Y connection
 Asepto syringe (open method)

Preliminary Assessment

Check

 Doctors order for specific precautions and instructions

 General condition of the patient
 Diagnosis of the patient
 Self care ability of the patient
 Mental status to follow instructions
 Articles available in the unit
Preparation of the Patient and Environment

 Explain the sequence of the procedure

 Arrange the articles at the bed side
 Provide privacy
 Place the patient in comfortable position
 Place the Mackintosh under the buttocks

Equipment

Sterile Catheterization Pack

A sterile tray containing:

 Funnel, tubing 3 feet long which fits the connection screw clip and
glass connection
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 A small mug or pint measures to pour solution

 A sterile pint jug with required solution
 Solution thermometer kept in antiseptic solution in a bottle if
available
 Medication if ordered
 Bucket for emptying the return flow
 Litmus paper

Procedure

 Wash hands thoroughly

 Wear gloves and empty the bladder keeping outlet of catheter
uncontaminated
 After urine withdrawal, attach glass, connection, tubing and
funnel to the catheter
 Place bucket or kidney tray conveniently near the meatus
 Hold the funnel lowered with one hand and with other hand pour
75-100 ml of solution along sides of the funnel
 Raise the tube and keep the funnel 30 cm above bed level
 Never allow the funnel to be empty, lower the funnel and slowly
invert in over the bucket
 Repeat procedure until the return flow is clear
 At the end of the procedure, clamp tubing disconnects glass
connection, tubing and funnel, gently remove catheter and
complete
 In case of self-retaining catheter connect it to the drainage bag

After Care

 Provide catheter care

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 Remove the Mackintosh and position the patient comfortably

 Cover the patient with bed sheets
 Replace the articles after cleaning
 Wash hand thoroughly
 Record the procedure and observations in the nurse’s record
sheet

BOWEL ELIMINATION
REVIEW OF PHYSIOLOGY OF BOWEL ELIMINATION,
COMPOSITION AND CHARACTERISTICS OF FECES
Defecation is the expulsion of feces from the anus and the rectum. It is
also called a bowel movement. The peristaltic waves move the feces
into the sigmoid colon and the rectum, the sensory nerves in the
rectum are stimulated and the individual becomes aware of the need to
defecate.

There are two centers governing the reflex to defecate. One is situated
in the medulla and subsidiary one is in the spinal cord. When
parasympathetic stimulation occurs, the internal anal sphincter relaxes
and the colon contracts. The defection reflex is stimulated chiefly by
the fecal mass in the rectum. When the rectum is distended the
intrarectal pressure rises, the defecation reflex is stimulated by the
muscle stretch, and the desire to eliminate results.

REVIEW OF PHYSIOLOGY OF BOWEL ELIMINATION

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Bowel control is actually a complex process involving the coordination

of many different muscles and nerves.

The beginning of the bowel is the small intestine, sometimes referred

to as the small bowel. This is where the useful nutrients are absorbed
from what you eat. The small bowel delivers the waste to the colon, or
large bowel. The colon is a 5-6 foot long muscular tube that delivers
stool to the rectum. As the stool moves through the colon, the fluids
are removed and absorbed into the body. The consistency of the stool
is dependent upon many things, including how long the stool sits in the
colon, how much of the water has been absorbed from the waste, and
the amount of fiber and fluids in your diet. Stool consistency can vary
from hard lumps to mushy to very loose, watery stool.

The best and easiest consistency of stool is soft, like toothpaste; this
consistency may be attained by adding fiber to your diet. Fiber helps
move waste through the colon because it is indigestible by the human
body. In other words, fiber adds ‘bulk’ to the stool. It is important to eat
a diet high in fiber, however, most Americans lack fiber in their diet. Up
to 25-35 grams of fiber may be required by the body to keep the
bowels healthy and moving. If your bowel movements are too loose,
fiber can make them firmer; on the other hand, if your stools are too
hard, fiber can make them softer.

Stool enters the rectum (2) from the colon (1). There are two major
muscles the stool must pass through to exit the body, the internal
sphincter muscle and the external sphincter muscle (4). The internal
sphincter muscle is “involuntary”. It automatically relaxes and opens at
the top of the anal canal to allow stool to pass through. As the stool
enters the upper anal canal, it is “sampled” by the sensitive nerve cells.
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People with normal nerve sensation have the urge to have a bowel
movement. The external sphincter muscle is a “voluntary” muscle; you
have control over this muscle. It assists in keeping the stool in the
rectum until you are ready to have a bowel movement. In fact,
squeezing the external sphincter muscle pushes the stool out of the
anal canal (5) and the rectum relaxes. The urge to have a bowel
movement is gone until the next colon contraction hits the rectum.

Frequent holding of stools can cause constipation and desensitization

of nerve cells. The longer the stool remains in the colon and rectum,
the more fluid is absorbed, and the harder the stool becomes. This is
why it is important to move your bowels when you feel the urge to
have a bowel movement. A person with very loose or runny stools
(diarrhea) will need urgent access to a restroom. Loose stool can slip
through the sphincter muscles quickly without the person knowing.

COMPOSITION AND CHARACTERISTIC OF FECES

Composition of Feces
i. Water:

65%

ii. Solid:

35%

iii. Ash:

15% (mainly calcium, phosphates, iron and magnesium)

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iv. Ether-Soluble Substances (Fats):

15% (neutral fats, fatty acids, lecithin, cholic acid and coprosterol).

v. Nitrogen:

5% (derived from purine bases, about 0.11 gm per day). Desquamated

epithelial cells, bacteria, mucus, undigested and unabsorbed food.

The reaction of stool is generally neutral or acid, but may be slightly

alkaline.

It is composed of:

(a) Food residues,

(b) Intestinal secretions,

(c) Bile,

(d) Leucocytes,

(e) Bacteria,

(f) Epithelial cells, and

(g) Substances excreted through the large intestine.

CHARACTERISTICS OF FECES
The form of the stool depends on the time it spends in the colon.

The seven types of stool are:

1. Separate hard lumps, like nuts (hard to pass)

2. Sausage-shaped but lumpy
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3. Like a sausage but with cracks on the surface

4. Like a sausage or snake, smooth and soft
5. Soft blobs with clear-cut edges
6. Fluffy pieces with ragged edges, a mushy stool
7. Watery, no solid pieces. Entirely liquid

Types 1 and 2 indicate constipation. Types 3 and 4 are optimal,

especially the latter, as these are the easiest to pass. Types 5–7 are
associated with increasing tendency to diarrhea or urgency.

Color

Human fecal matter varies significantly in appearance, depending on

diet and health.

Brown

Human feces ordinarily has a light to dark brown coloration, which

results from a combination of bile, and bilirubin derivatives
of stercobilin and urobilin, from dead red blood cells. Normally it is
semisolid, with a mucus coating.

Yellow

Yellowing of feces can be caused by an infection known as giardiasis,

which derives its name from Giardia,
an anaerobic flagellated protozoan parasite that can cause severe and
communicable yellow diarrhea. Another cause of yellowing is a
condition known as Gilbert's Syndrome. Yellow stool can also indicate
that food is passing through the digestive tract relatively quickly. Yellow
stool can be found in people with gastroesophageal reflux
disease (GERD).
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Pale or gray

Stool that is pale or grey may be caused by insufficient bile output due
to conditions such as cholecystitis, gallstones, giardia parasitic
infection, hepatitis, chronic pancreatitis, or cirrhosis. Bile pigments
from the liver give stool its brownish color. If there is decreased bile
output, stool is much lighter in color.

Black or red

Feces can be black due to the presence of red blood cells that have
been in the intestines long enough to be broken down by digestive
enzymes. This is known as melena, and is typically due to bleeding in
the upper digestive tract, such as from a bleeding peptic ulcer.
Conditions that can also cause blood in the stool include hemorrhoids,
anal fissures, diverticulitis, colon cancer, and ulcerative colitis. The
same color change can be observed after consuming foods that contain
a substantial proportion of animal blood, such as black pudding or tiết
canh. Black feces can also be caused by a number of medications, such
as bismuth subsalicylate (the active ingredient in Pepto-Bismol), and
dietary iron supplements, or foods such as beetroot, black liquorice, or
blueberries.

Hematochezia is similarly the passage of feces that is bright red due to

the presence of undigested blood, either from lower in the digestive
tract, or from a more active source in the upper digestive
tract. Alcoholism can also provoke abnormalities in the path of blood
throughout the body, including the passing of red-black stool.
Hemorrhoids can also cause surface staining of red on stools, because
as they leave the body the process can compress and burst
hemorrhoids near the anus.
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Blue

Prussian blue, or blue, a coloring used in the treatment

of radiation, cesium, and thallium poisoning, can turn the feces blue.
Substantial consumption of products containing blue food dye, such as
blue curaçao or grape soda, can have the same effect.

Silver

A tarnished-silver or aluminum paint-like feces color characteristically

results when biliary obstruction of any type (white stool) combines
with gastrointestinal bleeding from any source (black stool). It can also
suggest a carcinoma of the ampulla of Vater, which will result in
gastrointestinal bleeding and biliary obstruction, resulting in silver
stool.

Green

Feces can be green due to having large amounts of unprocessed bile in

the digestive tract and strong-smelling diarrhea. This can occasionally
be the result from eating liquorice candy, as it is typically made
with anise oil rather than liquorice herb and is predominantly sugar.
Excessive sugar consumption or a sensitivity to anise oil may cause
loose, green stools. It can also result from consuming excessive
amounts of blue or green dye.

Violet or purple

Violet or purple feces are a symptom of porphyria or more likely the

consumption of beetroot.

Odor
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Feces possesses physiological odor, which can vary according to diet

and health status. For example, meat protein is rich in the amino
acid methionine, which is a precursor of the sulfur-containing odorous
compounds listed below. The odor of human feces is suggested to be
made up from the following odorant volatiles:

Methyl sulfides

 methylmercaptan/methanethiol (MM)

 dimethyl sulfide (DMS)

 dimethyl disulfide (DMDS)
 dimethyl trisulfide (DMTS)

 Benzopyrrole volatiles
 indole
 skatole

 Hydrogen sulfide (H2S)

(H2S) is the most common volatile sulfur compound in feces. The odor
of feces may be increased when various pathologies are present,
including:

 Celiac disease
 Crohn's disease
 Ulcerative colitis
 Chronic pancreatitis
 Cystic fibrosis
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 Intestinal infection, e.g. Clostridium difficile infection.

 Malabsorption
 Short bowel syndrome

FACTORS AFFECTING BOWEL ELIMINATION

Age and Development: there is a marked difference between the stools
of an infant and an older person. The very young are unable to control
elimination until the neuromuscular system is developed, usually
between the ages of 2 to 3 years.

Daily Patterns: most people have regular patterns of bowel elimination

which include frequency, timing considerations, position and place
changes in any of these may upset a person routine and actually lead to
constipation

Lifestyles: many individual’s family and sociocultural variables

influences a person’s usual elimination habits. The long-term effect of
bowel training, the availability of toilet facilities, embarrassment about
odors and need to privacy, also affect the fecal elimination patterns.

Fluids: both the type and amount of fluid digested affect elimination.
Healthy fecal elimination is facilitated by a daily intake of 2000 to 3000
ml.

Activity and muscle tone: regular exercise improves gastrointestinal

motility and muscle tone while inactivity decreases both. Adequate
tone in the abdominal muscles, the diaphragm and the perineal
muscles is essential to case in defecation.
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Psychological factors: emotional stress affects the body in many ways.

Persons with anxiety causes increased intestinal motility and persons
with depression causes slower intestinal motility resulting in
constipation

Pathological conditions: spinal cord and head injuries decrease sensory

stimulation for defecation. Impaired mobility limits the patient’s ability
to respond to the urge to defecate. Ribbon like stools in appearance
due to tumor in the colon

Medications: narcotic analgesics cause constipation by decreased

gastrointestinal mobility. Many medications have diarrhea as
undesirable side effect

Diagnostic procedure: barium salts used in radiologic examinations. It

hardens if allowed to remain in the colon, producing constipation and
sometimes an impaction

Surgery and anesthesia: direct manipulation of the bowel during

abdominal surgery inhibits peristalsis causing a condition termed as
paralytic ileus. General anesthetic agents that are inhaled also inhibit
peristalsis by blocking the parasympathetic impulses to the intestinal
muscle

Irritants: spicy foods, bacterial toxins and poisons can irritate the
intestinal tract and produce diarrhea and often large amounts of flatus

Pain: patients who are experience discomfort when defecating. E.g.

following hemorrhoid surgery will often suppress the urge to defecate
to avoid the pain
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ALTERATION IN BOWEL ELIMINATION

Regular elimination of bowel waste products is essential for normal
body functioning. Alterations in bowel elimination are often early signs
or symptoms of problems within either the gastrointestinal (GI) or
other body systems. Because bowel function depends on the balance of
several factors, elimination patterns and habits vary among individuals.

Common Bowel Elimination Problems

Caring for patients who have or are at risk for elimination problems
because of emotional stress (anxiety or depression), physiological
changes in the GI tract such as surgical alteration of intestinal
structures, inflammatory diseases, prescribed therapy, or disorders
impairing defecation is common in the practice of nursing.

Constipation

Constipation is a symptom, not a disease. Improper diet, reduced fluid

intake, lack of exercise, and certain medications can cause constipation.
For example, patients receiving opiates for pain after surgery often
require a stool softener or laxative to prevent constipation. The signs of
constipation include infrequent bowel movements (less than every 3
days), difficulty passing stools, excessive straining, inability to defecate
at will, and hard feces. When intestinal motility slows, the fecal mass
becomes exposed over time to the intestinal walls, and most of the
fecal water content is absorbed. Little water is left to soften and
lubricate the stool. Passage of a dry, hard stool causes rectal pain
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Bristol stool form scale

Constipation is a significant health hazard. Straining during defecation

causes problems for the patient with recent abdominal, gynecological,
or rectal surgery. The effort to pass a stool often causes sutures to
separate, reopening the wound. In addition, patients with histories of
cardiovascular disease, diseases causing elevated intraocular pressure
(glaucoma), and increased intracranial pressure need to prevent
constipation and avoid using the Valsalva maneuver.

Impaction

Fecal impaction results from unrelieved constipation. It is a collection of

hardened feces wedged in the rectum that a person cannot expel. In
cases of severe impaction the mass extends up into the sigmoid colon.
If not resolved or removed, severe impaction often results in intestinal
obstruction. Patients who are debilitated, confused, or unconscious are
most at risk for impaction. They are dehydrated or too weak or
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unaware of the need to defecate, and the stool becomes too hard and
dry to pass.

An obvious sign of impaction is the inability to pass a stool for several

days, despite the repeated urge to defecate. You suspect impaction
when a continuous oozing of diarrhea stool occurs. The liquid portion of
feces located higher in the colon seeps around the impacted mass. Loss
of appetite (anorexia), nausea and/or vomiting, abdominal distention
and cramping, and rectal pain often accompany the condition. If an
impaction is suspected, gently perform a digital examination of the
rectum and palpate for the impacted mass.

Diarrhea

Diarrhea is an increase in the number of stools and the passage of

liquid, unformed feces. It is associated with disorders affecting
digestion, absorption, and secretion in the GI tract. Intestinal contents
pass through the small and large intestine too quickly to allow for the
usual absorption of fluid and nutrients. Irritation within the colon
results in increased mucus secretion. As a result, feces become watery,
and the patient is unable to control the urge to defecate. Normally an
anal bag is safe and effective in long-term treatment of patients with
fecal incontinence at home, in hospice, or in the hospital. Fecal
incontinence is expensive and a potentially dangerous condition in
terms of contamination and risk of skin ulceration.

Excess loss of colonic fluid results in serious fluid and electrolyte or

acid-base imbalances. Infants and older adults are particularly
susceptible to associated complications. Because repeated passage of
diarrhea stools also exposes the skin of the perineum and buttocks to
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irritating intestinal contents, meticulous skin care and containment of

fecal drainage is necessary to prevent skin breakdown.

Many conditions cause diarrhea. Antibiotic use via any route of

administration alters the normal flora in the GI tract. Patients receiving
enteral nutrition are also at risk for diarrhea. Consult a dietitian when
diarrhea occurs. Food allergies and intolerances increase peristalsis and
cause diarrhea. Surgeries or diagnostic testing of the lower GI tract also
cause diarrhea. The aim of treatment is to remove precipitating
conditions and slow peristalsis.

Another common causative agent of diarrhea is Clostridium difficile (C.

difficile), in which symptoms range from mild diarrhea to severe
colitis. C. difficile infection is acquired in one of two ways: by factors
that cause an overgrowth of C. difficile, and by contact with the C.
difficile organism. A new strain of C. difficile has been identified that is
more virulent with more toxic effects. Antibiotics (cephalosporins,
ampicillin, amoxicillin, and clindamycin, chemotherapy, and invasive
bowel procedures such as surgery or colonoscopy disrupt normal bowel
flora and may cause an overgrowth of C. difficile. Some patients acquire
the organism from a health care worker’s hands or direct contact with
the environmental surfaces contaminated with it. Only hand hygiene
with soap and water is effective to physically remove C. difficile spores
from the hands. In addition, evidence supports the use of diluted
bleach (1 : 10) as an environmental disinfectant to decrease the
incidence of C. difficile. The most common diagnostic test for the
bacteria is the enzyme-linked immunosorbent assay (ELISA) test, which
detects C. difficile A and B in the stool.
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Communicable foodborne pathogens also cause diarrhea. Hand hygiene

following the use of the bathroom, before and after preparing foods,
and when cleaning and storing fresh produce and meats greatly
reduces the risk of foodborne illnesses. When diarrhea is the result of a
foodborne virus, the goal usually is to rid the GI system of the pathogen
rather than slow peristalsis.

Incontinence

Fecal incontinence is the inability to control passage of feces and gas

from the anus. Incontinence harms a patient’s body image. In many
situations the patient is mentally alert but physically unable to avoid
defecation. The embarrassment of soiling clothes often leads to social
isolation. Physical conditions that impair anal sphincter function or
control cause incontinence. It occurs in a variety of settings. Conditions
that create frequent, loose, large-volume, watery stools also predispose
to incontinence. Using an anal bag or a bowel management system
helps to prevent perineal skin breakdown.

FACILITATING BOWEL ELIMINATION: ASSESSMENT,

EQUIPMENT, PROCEDURES
ENEMAS
Enema (clysis) is defined as an introduction of the fluid into the rectum.

An enema is an introduction of fluid into the bowel through the rectum

for the purpose of cleansing or to introduce nourishment
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An enema is an introduction of fluid into the lower bowel through the

rectum for the purpose cleaning, medicinal, diagnostic or such other
purpose

PURPOSE

 To remove fecal matter

 To relieve flatulence
 To relieve constipation
 To prevent involuntary defecation during surgery
 To reduce temperature, e.g. cold edema
 To check diarrhea, e.g. starch opium enema
 To stimulate peristalsis, e.g. purgative enema
 To make diagnosis, e.g. barium enema
 To cleanse the bowel before X-ray studies
 To induce anesthesia, e.g. anesthetic enema
 To administer medications
 To destroy intestinal parasites, e.g. anthelmintic enema
 To administer fluids and nutrients
 To relieve inflammation
 To establish regular bowel functions during bowel training
program

CONTRAINDICATIONS

 Acute myocardial infarction and cardiac problems

 Acute renal failure
 Appendicitis
 Obstetrical and gynecological contraindications
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CLASSIFICATION OF ENEMA

Soap water enema: it is otherwise called saline enema. In this normal

saline (sodium chloride 1 teaspoon) to half liter of water

The amount of solution used for adult 500 to 1000 ml, children 250 to
500 ml and infants 250 ml or less. The temperature of the solution in
adult 105 to 110 degree F and children 100 degree F

Oil enema: it is given to soften fecal matter in cases of serve

constipation. The enema must be retained ½ or 1 hour to soften the
feces

Carminative enema: It is also called antispasmodic enema. It is given to

relieve gaseous distension of abdomen by increasing peristalsis and
expulsion of flatus. The solution used is 8 to 16 ml of turpentine mixed
thoroughly with 600 to 1200 ml of soap solution. Milk and molasses 90
to 230 ml well mixed with equal quantity of warm milk

Anthelmintic Enema: It is given to destroy and expel worms from the

intestine cleansing enema must be given prior to anthelmintic enema
so that the drug comes in direct contact with worms and the lining of
intestine.

The solution used is infusion of quassia 15g of chips to 600 mL of water

or hypertonic saline solution sodium chloride 60 mL with 600 mL of
water. The amount of solution given is 250mL.

Cold Enema: Cold enema or ice-water enema is given to reduce body

temperature in hyper pyrexia and heat stroke. It is given in the form of
colonic irrigations. The temperature of the solution is 80 to 90 degree
Fahrenheit (27 to 32 degree Celsius).
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Glycerin Enema: Glycerin enema is given to children to fever patients

and postoperative patient. Pure glycerin and water 1:2 are used.

Astringent Enema: Astringent enema contracts the tissues and blood

vessels checks bleeding and inflammation lessens the amount of mucus
discharge and gives a temporary relief in the inflamed area. It is usually
given in colitis and dysentery.

The solution used are tannic acid – 25g to 600 mL water, alum 30g to
600 mL of water and silver nitrate 2% (silver nitrate is dissolved in the
distilled water).

Sedative Enema: Sedative enema contains an anesthetic drug to

produce anesthesia in the patient. The commonly used drugs are
paraldehyde and over tin. Dose is given as per doctor’s order.

Stimulant Enema: Stimulant enema is given in the treatment of shock

and collapse. Coffee enema is given in case of opium poisoning.
Solution used are black coffee – 1 tables spoon coffee powder to
300mL of water and 15mL of brandy added to 120 to 180mL of glucose
saline. The amount of solution used is 180 to 240mL and the
temperature of solution used is 180 to 240mL and the temperature of
solution is 108 to 110 degree Fahrenheit (42 to 43 degree Celsius).

Emollient Enema: Emollient enema or starch enema is given in case of

diarrhea to relieve irritation in an inflamed mucus membrane. The
solution used is starch and opium Tr. Opium 1 to 2mL added to 120 to
180mL of starch mucilage or rice water. The temperature of the
solution is 100 to 105 degree Fahrenheit (37.8 to 40.5 degree Celsius).
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Nutrient Enema: It is given to supply food and fluids to the body.

Selection of the fluids depends upon the ability of the colon to absorb
it. Nutrient enema is particularly useful in conditions like hemophilia.

The solution used is normal saline; Glucose saline 250mL 5%

peptonized milk 120mL. The amount of solution used is 110 to 1700mL
in 24 hours or 180 to 270mL at 4 hourly intervals. The temperature of
solution is 100 degree Fahrenheit (37.8 degree Celsius).

METHODS OF GIVING ENEMAS

 Enema can and tube method – when large amounts of fluids are
to be given, this method is used, e.g. soap and water enema
 Funnel and catheter method – when a small quantity of fluids is to
be given, this method is used, e.g. oil enema
 Glycerin syringe and catheter method when a small quantity of
fluid is to be given, this method is used, e.g. Purgative enema
 Rectal drip method – when the fluid is to be administered very
slowly in order to aid in its absorption, e.g. nutrient enema

GENERAL INSTRUCTION

 The appropriate size of rectal catheter or rectal tube of cleansing

enema is 22 French for adults, 12 French for infant and 14 to 18
French for children (School-age child)
 The rectal tube need to be smooth and flexible
 The rectal tube is lubricated with a water soluble lubricant or
Vaseline to facilitate insertion and to decrease irritation of the
rectal mucosa
 The temperature of the solution needs to be adjusted according
to the purpose of the enema
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 The amount of the solution to be administered depends up on the

type of enema and the age and size of the person
 The patient usually placed in left lateral position, when an enema
is administered. In this position, sigmoid colon is below the
rectum, thus facilitating instillation of the fluid
 The distance to which the tube is inserted depends upon the age
and the size of the patient. For an adult, it is normally inserted 7.5
to 10 cm (3 to 4 inches), for children it is 2.5 to 3.75 cm (into 1 ½
inches)
 The height of the enema can should not be above 18 inches (20
cm) from the anus
 The length of time that the enema solution is retained will depend
up on the purpose of enema oil retention enema are usually
retained for 2 to 3 hours. Other cleansing enemas are normally
retained 5 to 10 minutes
 Prepacked enema will have their own instruction which need to
be followed
 Prevent air from entering into rectum, by expelling air from the
tube
 If the rectum is impacted, attempt to remove the fecal matter
with a gloved finger
 Make sure the whole apparatus use for the administration of
enemas is in a good working condition
 Regulate the flow of fluid according to the type of enema
 Listen to the complaints of the patients and should not ignore any
discomfort however small they are

PRELIMINARY ASSESSMENT
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 Doctors order for any specific precautions

 Diagnosis of the patient
 Abilities and limitations concerning movements
 Level of consciousness to follow directions
 Availability of the articles
 Extra help needed
 Lesions on the rectal and perineal area
 Nature of enema ordered

PREPARATION OF THE PATIENT AND ENVIRONMENT

 Explain the sequence of the procedure

 Arrange the articles at the bed side
 Provide privacy
 Cover the patient with bed sheet
 Place the Mackintosh and towel under the patient’s buttocks
 Place the patient in the left lateral position
 Keep the bedpan under the bed over a stool
 Adjust the IV pole to hold the enema can at the required height

EQUIPMENT

A clean tray containing:

 Enema cans, rubber tubing, glass connection, screw clamp

 Mackintosh and towel
 Rectal tube (adjusts) or rectal catheter placed in a kidney tray
 Vaseline
 Pint measure
 Soap jelly in a bottle
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 IV stand
 Toilet tray
 Bedpan – 2
 Clean linen if needed
 Bath thermometer
 Rag pieces and K-basin

PROCEDURE

 Wash hands thoroughly

 Attach tubing to enema can and clamp tube
 Prepare solution at required temperature and check temperature
with bath thermometer
 Attach rectal tube to tubing, expel air and clamp tube. Air entry
into rectum may cause discomfort
 Hang enema can with solution on IV stand and adjust height to 18
inches from bed
 Lubricate tip of rectal tube
 Use rag pieces to separate patients buttocks and visualize anus
clearly. Insert rectal tube gently to a distance of 2-4 inches
 Encourage patient to take a deep breath while inserting tube.
Note level of fluid and make sure ther is free flow
 Encourage patient to take deep breaths during administration of
fluid
 Clamp or pinch the rectal tube if the fluid is about to get over
 Use rag pieces to remove the rectal tube
AFTER CARE

 Instruct patient to hold solution for 10 to 15 minutes

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 Discard rag pieces in K-basin, detach rectal tube and place in same
K-basin
 Position the patient in supine and assist to toilet or provide a bed
pan
 Assist patient to wash perineal area if not able to do so
 Remove the articles to utility room, clean and replace it
 Keep the patient dry and comfortable
 Wash hands
 Record the procedure in the nurse’s record

SUPPOSITORY

Suppositories are another way to deliver drugs to the body when other
routes, such as oral, cannot be used.

A suppository is small and may be round, oval, or cone-shaped. A

substance, such as cocoa butter or gelatin, surrounds the medication.
The suppository dissolves to release the drug once inside the body.

Suppositories may treat the local area, or the medicine may travel to
other parts of the body through the bloodstream.

Suppositories deliver many types of medication, and a person may

need to use them if they:

 are having seizures and cannot take medicines by mouth

 are unable to swallow medication for any reason
 are vomiting and cannot keep pills or liquids down
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 have a blockage that stops the medication moving through the

digestive system

People may also take suppositories if the medication:

 tastes too bad to take by mouth

 would break down too quickly in the gut
 could be destroyed in the gastrointestinal tract

Types of suppositories and their uses

There are three types of suppositories:

Rectal suppositories

Rectal suppositories go in the rectum or anus. They are typically an inch

long and have a rounded tip.

They treat conditions, such as:

 constipation
 fever
 hemorrhoids
 mental health issues such as anxiety, schizophrenia, or bipolar
disorder
 nausea, including motion sickness
 pain
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Vaginal suppositories

People may insert vaginal suppositories into the vagina to treat:

 bacterial or fungal infections

 vaginal dryness

Vaginal suppositories are typically oval and come with an applicator.

Urethral suppositories

Men may use a type of urethral suppository to treat erection problems

in rare cases.

These suppositories are the size of a grain of rice and deliver a drug
called alprostadil.

How to insert a rectal suppository

Anyone using a rectal suppository may want to refer to the following

steps for guidance:

1. Get prepared

 Try to pass stool to empty the colon, as suppository medication is

most effective when the bowel is empty.
 Wash hands thoroughly with soap and warm water or use a hand
sanitizer. Dry the hands thoroughly on a clean towel or paper
towel.
 Carefully remove the suppository from its wrapper.
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 If it is necessary to cut the suppository, use a clean, single-edge

razor blade to slice it lengthwise.
 Use a disposable glove, if desired.

2. Get ready to insert the suppository

 Dip the tip of the suppository in water, or apply a small amount of

water-based lubricant, such as K-Y Jelly. A lubricant helps the
suppository more easily slide into the rectum.
 Remove clothing from the lower half of the body.
 Find the correct position. Either stand up with one foot on a chair
or lie down on one side with the top leg bent slightly toward the
stomach. Caregivers giving the suppository to another person
often find it easier if the person is lying down.

3. Insert the suppository

 Relax the muscles of the buttocks and open the cheeks.

 Gently insert the suppository into the anus, narrow end first.
 Push it in about 1 inch for adults, or half an inch for infants.
 In older children, push the suppository in approximately half to
one inch, depending on their size.

4. Relax and clean up

 Sit or lie still for 10 minutes after inserting the suppository.

Staying still allows time for the suppository to dissolve in the
body. Parents may need to hold a child’s buttocks closed during
this time.
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 Dispose of all materials, including the suppository wrapper and

any tissue paper.
 Wash the hands thoroughly with soap and warm water.

Try to avoid passing stool for up to 60 minutes after inserting the

suppository, unless it is a laxative. Not passing stool gives the
medication enough time to enter the bloodstream and start working.

How to insert a vaginal suppository

To place a suppository into the vagina, follow these tips:

1. Get prepared

 Wash hands with soap and warm water, or use a hand sanitizer if
these are not available. Dry the hands well on a clean towel or
paper towel.
 Unwrap the suppository, and place it in the accompanying
applicator.
 Either stand with the knees bent and feet apart or lie down with
the knees bent toward the chest.

2. Insert the suppository

 Place the applicator into the vagina, as far as possible, without

causing discomfort.
 Press down on the plunger to push in the suppository.
 Remove the applicator from the vagina, and dispose of it.

3. Relax and clean up

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 Lie down for 10 minutes to allow the medicine to enter the body.
 Wash the hands once more with soap and warm water.

Consider using a sanitary towel for a few hours, as some of the

suppository may leak out onto the underwear.

How to insert a urethral suppository

To place a suppository into the urethra try the following tips:

1. Get prepared

 Empty the bladder.

 Wash the hands with soap and warm water or use a hand
sanitizer. Dry the hands thoroughly on a clean towel or paper
towel.
 Remove the applicator cover.

2. Insert the suppository

 Stretch out the penis to open the urethra.

 Place the applicator into the hole at the tip.
 Push the button on the applicator and hold for 5 seconds.
 Gently move the applicator from side to side to ensure the
suppository has entered the urethra.
 Remove the applicator.

3. Relax and clean up

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 Massage the stretched penis firmly for 10 to 15 seconds to allow

the medicine to be absorbed.
 Dispose of the applicator and any other materials.
 Wash the hands once more with soap and warm water.

BOWEL WASH
Bowel wash or colonic lavage or enteroclysis is defined as washing out
colon with large quantities of solution.

Bowel irrigation or enteroclysis is defined as washing out of the colon

after the feces has been expelled by using large quantities of prescribed
solution

PURPOSE

 To prepare for diagnostic examination or before certain surgery

 To relieve inflammation
 To stimulate peristalsis
 To supply fluid and electrolyte those are absorbed from intestine
 To dilute and remove toxic agents
 To reduce temperature in hyperpyrexia
 To relieve fecal incontinence
 To supply medications locally
 To clean the colon of feces, gas and barium
 To treat infection and other pathological condition of colon

CONTRAINDICATIONS

 Rectal infection
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 Fistula in anus
 Painful and bleeding hemorrhoids
 Painful skin lesions around the anus
 Massive carcinoma or tumors of the rectum
 Loose sphincter
 Polypus and diverticula of the intestine

GENERAL INSTRUCTIONS

 A cleaning enema should be given one hour before the colon

irrigation
 The bladder should be emptied before colonic irrigations
 The temperature of the solution is kept constant throughout the
procedure
 Allow only 200 to 300 ml of fluid to run into the rectum at a time
 Make sure that the return flow is not blocked
 Use a smooth and flexible rectal tube and lubricate it well
 Prevent air entry into the intestines
 Stop the procedure temporarily the patient complaints of pain
 Listen to the complaints of the patient and should not ignore any
discomfort however small they may be

METHODS USED FOR BOWEL IRRIGATION

 Funnel and catheter

 Y connection and a rectal tube
 Two tube method

SOLUTION USED

 Tap water
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 Cold water
 Normal saline
 Sodium bicarbonate 1 to 2 %
 Antiseptic solution KNMO4
 Boric solution 1 to 2 %
 Tannic acid 1: 100
 Alum 1: 100

TEMPERATURE OF THE SOLUTION

 Cleaning purpose 104 degree F (40 degree Celcius)

 Thermal effect 110 to 115 degree F (43.3 to 46 degree celcius)
 Reducing temperature 80 to 90 degree F (27 to 32 degree celcius)
amount of water used for bowl, irrigation is 2 to 3 liters or till the
return flow is clear

PRELIMINARY ASSESSMENT

Check

 Doctors order for any specific precautions

 Diagnosis of the patient
 General condition of the patient
 Self-care ability of the patient
 Mental status to follow instructions
 Any contraindications
 Need for any extra help
 Articles available in the unit
PREPARATION OF THE PATIENT AND ENVIRONMENT

 Explain the sequence of the procedure

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 Arrange the articles at the bed side

 Provide privacy
 Place the Mackintosh and towel under the patient
 Place the patient in left later position
 Keep the bucket on a low stool or receive the out flow of fluid
 Remove the back rest and extra pillows

EQUIPMENTS

A clean tray containing

 Funnel and tubing with glass connection

 Mackintosh and towel
 Rectal tube placed in a kidney tray
 Vaseline
 Rag pieces in a container
 Hot and cold water in jugs
 Prescribed solution in jug
 Paper bag
 Bucket
 Toilet tray if needed
 Clean linen if needed
 Bath thermometer

PROCEDURE

 Wash hands thoroughly

 Prepare the solution at the required temperature
 Attach the tubing and the rectal tube with the funnel, pour
solution in it and check for any leakage
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 Lubricate the tip of the rectal tube about 4 inches

 Separate patient’s buttocks to visualize anus clearly and insert tip
of tube about 4 to 5 inches, while patient takes deep breath
 Lower funnel below level of rectum and empty return flow into
bucket
 Fill funnel again. Pour 200 to 300 ml of fluid each time. Raise
funnel and allow fluid to run continuously. When 200 to 300 ml of
fluid has gone in pinch tube before tunnel is completely. Lower
and invert tunnel over bucket and siphon fluid, noting
characteristics of return flow
 Repeat this process, till return flow is clear
 Remove the rectal tube by using rag pieces

AFTER CARE

 Remove rectal tube by using rag pieces

 Discard rag piece in to K-basin
 Place patient comfortably, provide bedpan if needed
 Change linen if soiled, replace equipment after cleaning
 Hand wash and record the procedure in nurse’s record sheet

DIGITAL EVACUATION OF IMPACTED FECES

Digital disimpaction is the use of fingers to aid in the removal of stool
from the rectum. This may be done by a person who is
experiencing constipation or by a medical professional who is assisting
a person with a spinal cord injury or another health problem that
results in a problem with defecation.
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A particular form of digital evacuation in women is called vaginal

splinting. This is when a woman massages the inside of her vagina in
order to encourage the passage of stool from her rectum.

Digital stimulation is a way to empty the reflex bowel after a spinal cord
injury. It may also be called a "dil." It involves moving the finger or dil
stick around in a circular motion inside the rectum. By doing this, the
the bowel reflex is stimulated and the rectal muscles open and allow
the stool to leave the body.

This procedure is best done on people who do not have painful

sensation in the rectal area. Pressure may be felt in the rectal area, but
it should not be painful. The dil should be done at the same time every
day or every other day to stay on a schedule and avoid bowel accidents.
The time and how often a dil is done depends on the individual.

How to do a Dil (digital stimulation)

1. Gather supplies

 Gloves
 Dil stick (if ordered)
 Lubricant
 Soap, water, washcloth
 Toilet paper, underpads (if done in bed)
 Plastic bag to throw away waste
 Raised toilet seat, commode chair or shower chair if done in the
bathroom

2. Wash hands

3. Prepare all needed supplies and place on a towel

4. Position yourself
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If doing the dil in bed:

If doing the dil in bed, lie on the left side with knees flexed (right leg
over left leg) and place disposable pad under the buttocks.

If doing the dil in the bathroom, transfer to appropriate bowel

equipment (raised seat, Activeaid).

Perform the dil

Put gloves on both hands or place place dil stick in the hand.

Lubricate pointing finger or dil stick (whichever will be entering the

rectum).

Gently put finger or dil stick into the rectum past the muscle.

Gently move the finger or dil stick around in a circular motion.

When the stool begins to empty from the rectum, move the finger or dil
stick to one side or remove so the stool can pass.
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Do this for at least 20 minutes if no stool is coming. If stool is produced,

do the dil as long as the stool is coming dil and for five additional
minutes afterward without getting any more stool.

You may need to gently remove stool from your rectum with your
finger if it does not come out on it's own.

Finish up

When finished with the dil, wipe rectal area and buttocks with toilet
paper; wash with soap and water; dry with a towel

Clean dil stick with soap and water; dry well

Throw out waste and wash hands

The dil may cause dysreflexia in persons with spinal cord injuries at T6
and above. Always observe for symptoms of autonomic dysreflexia:

 Increased blood pressure

 Headache
 Blotchy skin
 Sweating
 Stuffy nose

CARE OF PATIENTS WITH OSTOMIES (BOWEL DIVERSION

PROCEDURES)
An ostomy is a surgically created opening from the urinary tract or
intestines, where effluent (fecal matter, urine, or mucous) is rerouted
to the outside of the body using an artificially created opening called
a stoma. A stoma typically protrudes above the skin, is pink to red in
colour, moist, and round, with no nerve sensations. Ostomy surgeries
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are performed when part of the bowel or urinary system is diseased

and therefore removed. The output from the stoma (urine, feces, or
mucous) is called effluent.
An ostomy is named according to the part of intestine used to construct
it. A colostomy is the creation of a stoma from part of the colon (large
bowel), where the intestine is brought through the abdominal wall and
attached to the skin, diverting normal intestinal fecal matter through
the stoma instead of the anus. An ileostomy is created from the ileum
(small bowel), which is brought through the abdominal wall and used to
create a stoma.
A urostomy or ileal conduit is a stoma created using a piece of the
intestine to divert urine to the outside of the body. The ureters are
sewn to a piece of the intestine, brought through the abdominal wall,
and sutured to create the stoma. These surgeries are performed on
patients with diseases such as cancer of the bowel or bladder,
inflammatory bowel diseases (such as colitis or Crohn’s), or perforation
of the colon. Emergencies that may require an ostomy include
diverticulitis, trauma, necrotic bowel, or radiation complications. An
ostomy may be permanent or temporary, depending on the reason for
the surgery. Other types of ostomies are called jejunostomy, double-
barrel ostomy, and loop ostomy.

CHANGING A POUCHING SYSTEM/OSTOMY APPLIANCE (COLOSTOMY)

Safety considerations:

 Pouching system should be changed every 4 to 7 days, depending on

the patient and type of pouch.
 Always consult a wound care specialist or equivalent if there is skin
breakdown, if the pouch leaks, or if there are other concerns related to
the pouching system.
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 Patients should participate in the care of their ostomy, and health care
providers should promote patient and family involvement.
 Encourage the patient to empty the pouch when it is one-quarter to
one-half full of urine, gas, or feces.
 Ostomy product choices are based on the patient’s needs and
preference.
 Follow all post-operative assessments for new ostomies according
to agency policy.
 Medications and diet may need adjusting for new ileostomies/
colostomies.
 An ostomy belt may be used to help hold the ostomy pouch in place.
 Factors that affect the pouching system include sweating, high heat,
moist or oily skin, and physical exercise.
 Always treat minor skin irritations right away. Skin that is sore, wet, or
red is difficult to seal with a flange for a proper leakproof fit.

STEPS
1. Perform hand hygiene.
2. Gather supplies.
3. Identify the patient and review the procedure. Encourage the
patient to participate as much as possible or observe/assist
patient as they complete the procedure.
4. Create privacy. Place waterproof pad under pouch.
5. Apply gloves. Remove ostomy bag, and measure and empty
contents. Place old pouching system in garbage bag.
6. Remove flange by gently pulling it toward the stoma. Support the
skin with your other hand. An adhesive remover may be used.
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7. If a rod is in situ, do not remove.

8. Clean stoma gently by wiping with warm water. Do not use soap.
9. Assess stoma and peristomal skin.
10. Measure the stoma diameter using the measuring guide
(tracing template) and cut out stoma hole.
11. Trace diameter of the measuring guide onto the flange, and
cut on the outside of the pen marking.
11. Prepare skin and apply accessory products as required or
according to agency policy.
12. Remove inner backing on flange and apply flange over
stoma. Leave the border tape on. Apply pressure. Hold in place for
1 minute to warm the flange to meld to patient’s body. Then
remove outer border backing and press gently to create seal.
12. If rod is in situ, carefully move rod back and forth but do not
pull up on rod.
13. Apply the ostomy bag. Attach the clip to the bottom of the
bag.
14. Hold palm of hand over ostomy pouch for 2 minutes to
assist with appliance adhering to skin.
15. Clean up supplies, and place patient in a comfortable
position. Remove garbage from patient’s room.
16. Perform hand hygiene.
17. Document procedure.

BOWEL DIVERSION PROCEDURES

A colostomy creates an opening from the colon to the outside of the
body through the abdominal wall. An ileostomy creates an opening
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from the ileum to the outside of the body through the abdominal wall.
The opening created by a colostomy or an ileostomy is called a stoma.

A colostomy or an ileostomy can be temporary or permanent. The

doctor may do a temporary colostomy or ileostomy to allow the
intestine to rest and heal after surgery. It will be permanent if the anal
sphincter and the lower part of the rectum are removed.

A colostomy or an ileostomy may also be called a bowel diversion.

A colostomy or an ileostomy is done when part of the intestine needs

to be removed or bypassed. A colostomy or an ileostomy may be done
as part of treatment for:

 cancer of the colon, rectum or anus

 an inflammatory bowel disease, such as ulcerative colitis or
Crohn’s disease
 familial adenomatous polyposis (FAP)
 a blockage in the intestine (called a bowel obstruction)
 an injury that damages the intestine
 diverticulitis
 birth defects of the intestines

Sites of a colostomy or an ileostomy

The site of a colostomy or an ileostomy depends on the part of the

intestine that is affected. The different types of colostomies are named
based on where they are in the colon.

 A sigmoid colostomy is in the sigmoid colon, which is the part of the

colon that connects to the rectum. A sigmoid colostomy is the most
common type of colostomy.
 A descending colostomy is in the descending colon, which is the
part of the colon that goes down the left side of the abdomen.
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 A transverse colostomy is in the transverse colon, which is the part

of the colon that goes across the upper abdomen.
 An ascending colostomy is in the ascending colon, which is the first
part of the colon. It starts at the cecum and goes up the right side
of the abdomen. An ascending colostomy is not commonly done
because doctors prefer to do an ileostomy.
 An ileostomy is in the ileum, which is the last part of the small
intestine.

The location of the colostomy or ileostomy will affect the type and
consistency of stool (poop). Your colon normally absorbs water so when
some or all of the colon is removed or bypassed, water may not be
absorbed from stool as usual. For example, the stool from an ileostomy
is mostly liquid because it doesn’t travel through the colon, which
would normally remove most of the water. If you have a descending or
sigmoid colostomy, your stool will be formed and solid as usual.

Types of colostomy and ileostomy

End colostomy or ileostomy

An end colostomy or ileostomy attaches one end of the colon or ileum

to an opening in the abdominal wall (called the end stoma). An end
colostomy is often in the sigmoid colon. An end ileostomy is often in
the last part of the ileum. The rest of the colon may be completely
removed.

End colostomy or ileostomy with rectal stump

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An end colostomy or ileostomy can be made with a rectal stump. This

surgery may also be called the Hartmann procedure.

It involves attaching one end of the colon or ileum to an opening in the

abdominal wall (called the end stoma). The rectum and anus are left in
place, and the cut end is closed with staples or stitches. The rectal
stump is not functional (stool doesn’t pass through it), but it may still
make mucus that passes out of the body through the anus.

This type of colostomy or ileostomy can be temporary. After the

intestine has healed, the doctor can join the remaining intestine to the
rectum.

End colostomy with mucous fistula

An end colostomy with mucous fistula is also called a double-barrel

colostomy. It is usually done when part of the transverse colon or
descending colon is removed and the sigmoid colon, rectum and anus
are not removed.

This type of colostomy is created with 2 stomas. Part of the colon is

removed, and each cut end of the colon is attached to a separate
opening in the abdominal wall (called the end stoma). One stoma is
created from the first part of the colon on the right side of the body.
This is called a functional stoma (end stoma) because stool passes
through it. A second stoma (called a mucous fistula) is created from the
last part of the colon. The mucous fistula passes mucus out of the body.

Loop colostomy or ileostomy

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A loop colostomy or ileostomy is usually temporary. It is done so that

stool leaves the body before it reaches the diseased or injured part of
the intestine. The intestine can be connected again after it has healed.

To create a loop colostomy or ileostomy, a loop of the colon or ileum is

brought out through a cut (incision) in the abdomen. A plastic rod is
sometimes placed through the loop to hold it in place and to support
the area during healing. Sometimes flaps of skin are used instead of a
plastic rod.

The doctor then makes a cut in the colon or ileum to open it, but
doesn’t cut all the way through it. The 2 sides of the opening become a
stoma on the abdomen. Stool and mucus leave the body through the
stoma. Some stool and mucus may also leave through the anus.
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UNIT – 6 DIAGNOSTIC TESTING

PHASES OF DIAGNOSTIC TESTING (PRE-TEST, INTRA-
TEST AND POST-TEST) IN COMMON INVESTIGATIONS
AND CLINICAL IMPLICATIONS
The pre-analytic testing phase occurs first in the laboratory process.
This phase may include specimen handling issues that occur even prior
to the time the specimen is received in the laboratory. Important errors
can occur during the pre-analytic phase with specimen handling and
identification. Therefore, the pre-analytical phase must have rigorous
control measures to avoid unwittingly allowing problems or errors to
travel further "downstream."

The second phase is the analytic phases. This phase includes what is
usually considered the "actual" laboratory testing or the diagnostic
procedures, processes, and products that ultimately provide results.

The post-analytic phase is the final phase of the laboratory process.

This phase culminates in the production of a final value, result, or in the
case of histology, a diagnostic pathology report.
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The phases of laboratory testing

The pre-pre-analytical phase, which is primarily composed of test

ordering, and the post-post-analytical phase, which is primarily
composed of test result interpretation, can be regarded as the
diagnostic phases (as opposed to the analytical phases) and sub-divide
it into a pre-laboratory and post-laboratory phase.
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COMPLETE BLOOD COUNT

Complete Blood Count (CBC) is also known as CBC, hemogram, CBC
with Differential (CBC with diff)

Aim

To determine your general health status; to screen for, diagnose, or

monitor any one of a variety of diseases and conditions that affect
blood cells, such as anemia, infection, inflammation, bleeding
disorder or cancer

Sample: A blood sample drawn from a vein in your arm or a fingerstick

or heelstick (newborns)

The complete blood count (CBC) is a group of tests that evaluate the
cells that circulate in blood, including red blood cells (RBCs), white
blood cells (WBCs), and platelets (PLTs). The CBC can evaluate your
overall health and detect a variety of diseases and conditions, such as
infections, anemia and leukemia.
Blood cells are produced and mature primarily in the bone marrow and,
under normal circumstances, are released into the bloodstream as
needed. The three types of cells evaluated by the CBC include:
Red Blood Cells
Red blood cells, also called erythrocytes, are produced in the bone
marrow and released into the bloodstream when they mature. They
contain hemoglobin, a protein that transports oxygen throughout the
body. The typical lifespan of an RBC is 120 days. Thus, the bone marrow
must continually produce new RBCs to replace those that age and
degrade or are lost through bleeding. A number of conditions can affect
the production of new RBCs and/or their lifespan, in addition to those
conditions that may result in significant bleeding.
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RBCs normally are uniform in size and shape, but their appearance can
be affected by a variety of conditions, such as vitamin B12 and folate
deficiencies and iron deficiency. An example of a common condition
affecting RBCs is anemia, which results from low red blood cell counts
and low hemoglobin. Various diseases can lead to anemia, so additional
tests are often needed to determine the cause. For more details, see
the articles on Red Blood Cell Count, Hemoglobin, and Hematocrit.
White Blood Cells
White blood cells, also called leukocytes, are cells that exist in the
blood, the lymphatic system, and tissues and are an important part of
the body’s natural defense (immune) system. They help protect against
infections and also have a role in inflammation, and allergic reactions.
There are five different types of WBCs and each has a different
function. They include neutrophils, lymphocytes, basophils, eosinophils,
and monocytes.
WBCs are present in the blood at relatively stable numbers. However,
these numbers may temporarily shift higher or lower depending on
what is going on in the body. For instance, an infection can stimulate
your bone marrow to produce a higher number of neutrophils to fight
off a bacterial infection. With allergies, there may be an increased
number of eosinophils. An increased number of lymphocytes may be
produced with a viral infection. In certain diseases, such as leukemia,
abnormal (immature or mature) white cells may rapidly multiply. For
additional details, see the articles White Blood Cell Count and WBC
Differential.
Platelets
Platelets, also called thrombocytes, are actually tiny cell fragments that
circulate in blood and are essential for normal blood clotting. When
there is an injury and bleeding begins, platelets help stop bleeding by
adhering to the injury site and clumping together to form a temporary
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plug. They also release chemical signals that attract and promote
clumping of additional platelets and eventually become part of a stable
blood clot at the site of the injury that remains in place until the injury
heals.
If you have a disease or condition that causes low platelets
(thrombocytopenia) or dysfunction of platelets, you may be at an
increased risk of excessive bleeding and bruising. An excess of platelets
(thrombocytosis) can cause excessive clotting. For more information,
see the article Platelet Count.
A CBC is typically performed using an automated instrument that
measures various parameters, including cell counts and the physical
features of some of the cells. A standard CBC includes:
Red blood cell (RBC) tests:

 Red blood cell (RBC) count is a count of the actual number of red
blood cells in your blood sample.
 Hemoglobin measures the total amount of the oxygen-carrying
protein in the blood, which generally reflects the number of red
blood cells in the blood.
 Hematocrit measures the percentage of your total blood volume
that consists of red blood cells.
 Red blood cell indices provide information on the physical features
of the RBCs:
 Mean corpuscular volume (MCV) is a measurement of the
average size of your red blood cells.
 Mean corpuscular hemoglobin (MCH) is a calculated
measurement of the average amount of hemoglobin inside your
red blood cells.
 Mean corpuscular hemoglobin concentration (MCHC) is a
calculated measurement of the average concentration of
hemoglobin inside your red blood cells.
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 Red cell distribution width (RDW) is a measurement of the

variation in the size of your red blood cells.
 The CBC may also include reticulocyte count, which is a
measurement of the absolute count or percentage of newly
released young red blood cells in your blood sample.

White blood cell (WBC) tests:

 White blood cell (WBC) count is a count of the total number of

white blood cells in your blood sample.
 White blood cell differential may be included as part of the CBC or
may be done in follow up if the WBC count is high or low. The WBC
differential identifies and counts the number of the five types of
white blood cells present (neutrophils, lymphocytes, monocytes,
eosinophils, and basophils). The individual count can be reported as
an absolute count and/or as a percentage of total.

Platelet tests:

 The platelet count is the number of platelets in your blood sample.

 Mean platelet volume (MPV) may be reported with a CBC. It is a
measurement of the average size of platelets.
 Platelet distribution width (PDW) may also be reported with a CBC.
It reflects how uniform platelets are in size.

CBC results that are outside the established reference intervals may
indicate the presence of one or more diseases or conditions. Typically,
other tests are performed to help determine the cause of abnormal
results. Often, a blood smear will be examined using a microscope. A
trained laboratory professional will evaluate the appearance and
physical features of the blood cells, such as size, shape and color,
noting any abnormalities that may be present. This information gives
the healthcare practitioner additional clues as to the cause of abnormal
CBC results.
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SERUM ELECTROLYTES
Electrolytes is also known as lytes and anion gap

Aim: to detect a problem with body’s electrolyte balance

Sample: A blood sample drawn from a vein in person arm

Electrolytes are minerals that are found in body tissues and blood in the
form of dissolved salts. As electrically charged particles, electrolytes
help move nutrients into and wastes out of the body’s cells, maintain a
healthy water balance, and help stabilize the body’s acid/base (pH)
level.
The electrolyte panel measures the blood levels of the main
electrolytes in the body:

 Sodium—most of the body’s sodium is found in the fluid outside of

the body’s cells, where it helps to regulate the amount of water in
the body.
 Potassium—this electrolyte is found mainly inside the body’s cells. A
small but vital amount of potassium is found in the plasma, the
liquid portion of the blood. Potassium plays an important role in
regulating muscle contraction. Monitoring potassium is important
as small changes in the potassium level can affect the heart’s
rhythm and ability to contract.
 Chloride—this electrolyte moves in and out of the cells to help
maintain electrical neutrality (concentrations of positively charged
cations and negatively charged anions must be equal) and its level
usually mirrors that of sodium. Due to its close association with
sodium, chloride also helps to regulate the distribution of water in
the body.
 Bicarbonate—the main job of bicarbonate (or total CO2, an estimate
of bicarbonate), which is released and reabsorbed by the kidneys, is
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to help maintain a stable pH level (acid-base balance) and,

secondarily, to help maintain electrical neutrality. Bicarbonate also
plays an important role in the transport of CO2: much of the
CO2 produced by the body’s tissues is transported in the blood as
bicarbonate to the lungs, where it is exhaled.

The foods you eat and the fluids you drink provide the sodium,
potassium, and chloride your body needs. The kidneys help maintain
proper levels by reabsorption or by elimination into the urine. The
lungs provide oxygen and regulate CO2. The CO2 is produced by the
body and is in balance with bicarbonate. The overall balance of these
chemicals is an indication of the functional well-being of several basic
body functions. They are important in maintaining a wide range of body
functions, including heart and skeletal muscle contraction and nerve
signaling.
Any disease or condition that affects the amount of fluid in the body,
such as dehydration, or affects the lungs, kidneys, metabolism, or
breathing has the potential to cause a fluid, electrolyte, or pH
imbalance (acidosis or alkalosis). Normal pH must be maintained within
a narrow range of 7.35-7.45 and electrolytes must be in balance to
ensure the proper functioning of metabolic processes and the delivery
of the right amount of oxygen to tissues. (For more on this, see the
condition articles on Acidosis and Alkalosis and Dehydration.)
A related “test” is the anion gap, which is a value calculated using the
results of an electrolyte panel. It reflects the difference between the
positively charged ions (called cations) and the negatively charged ions
(called anions). An abnormal anion gap is non-specific—it does not
diagnose a specific disease or illness—but it can suggest certain kinds of
metabolic or respiratory disorders or the presence of toxic substances.
While sodium, potassium, chloride, and bicarbonate are commonly
measured together as the electrolyte panel, they can also each be
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ordered individually for diagnosis/monitoring of conditions that affect

specific electrolytes. The body also contains other electrolytes that are
not part of the “electrolyte panel” but may also be ordered by your
healthcare practitioner. These include: calcium (Ca2+), magnesium
(Mg2+), and phosphate (PO43-).
PURPOSE
The electrolyte panel is used to identify an electrolyte, fluid, or pH
imbalance (acidosis or alkalosis). It is frequently ordered as part of a
routine health exam. It may be ordered by itself or as a component of
a basic metabolic panel (BMP) or a comprehensive metabolic panel
(CMP). These panels can include other tests such as BUN, creatinine,
and glucose.
Electrolyte measurements may be used to help investigate conditions
that cause electrolyte imbalances such as dehydration, kidney
disease, lung diseases, or heart conditions. A series of electrolyte
panels may also be used to monitor treatment of the condition causing
the imbalance.
Since electrolyte and acid-base imbalances can be present with a wide
variety of acute and chronic illnesses, the electrolyte panel is frequently
used to evaluate patients who seek medical care in the emergency
room as well as hospitalized patients.
The results for an electrolyte panel may also include a calculation for
anion gap that can be used to help detect disorders or the presence of
toxic substances.
If you have an imbalance of a single electrolyte, such as sodium or
potassium, your healthcare practitioner may order repeat testing of
that individual electrolyte, monitoring the imbalance until it resolves. If
you have an acid-base imbalance, your healthcare practitioner may also
order tests for blood gases, which measure the pH and oxygen and
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carbon dioxide levels in an arterial blood sample, to help evaluate the

severity of the imbalance and monitor its response to treatment.

An electrolyte panel may be ordered as part of a routine health exam,

as recommended by your healthcare practitioner. It may also be
ordered as a diagnostic aid when you have signs and symptoms, such
as:

 Fluid accumulation (edema)

 Nausea or vomiting
 Weakness
 Confusion
 Irregular heart beat (cardiac arrhythmias)

It is frequently ordered as part of an evaluation when you have an

acute or chronic illness and at regular intervals when you have a
disease or condition or is taking a medication that can cause an
electrolyte imbalance. Electrolyte tests are commonly ordered at
regular intervals to monitor treatment of certain conditions, including
high blood pressure (hypertension), heart failure, lung diseases, liver
disease and kidney disease.

High or low electrolyte levels can be caused by several conditions and

diseases. Generally, they are affected by how much is consumed in the
diet and absorbed by the body, the amount of water in your body, and
the amount eliminated by the kidneys. Electrolyte levels are also
affected by some hormones such as aldosterone, which conserves
sodium and promotes the elimination of potassium, and natriuretic
peptides, which increase elimination of sodium by the kidneys.
Electrolyte levels can be affected by changes in the amount of water in
your body. For example:
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 If your kidneys are not functioning properly (i.e., kidney disease),

you may retain excess fluid. This results in a dilution effect on
sodium and chloride so that they fall below normal levels.
 On the other hand, if you experience severe fluid loss (dehydration),
you may show an increase in potassium, sodium, and chloride
levels.

Some conditions such as heart disease and diabetes may also affect the
fluid and electrolytes balance in your body and cause abnormal levels
of electrolytes. Several other conditions can cause electrolyte and pH
imbalances.
Knowing which electrolytes are out of balance can help your healthcare
practitioner determine the underlying cause and make decisions about
treatment to restore proper balance. Left untreated, an electrolyte
imbalance can lead to various problems, including dizziness, cramps,
irregular heartbeat, and possibly death.
See the individual test articles for additional information on what
results might mean:

 Sodium
 Potassium
 Chloride
 Bicarbonate

ANION GAP

Anion gap (AG or AGAP) is a value calculated using the results of an

electrolyte panel. It is used to help distinguish between anion-gap and
non-anion-gap metabolic acidosis. Acidosis refers to an excess of acid in
the body; this can disturb many cell functions and should be recognized
as quickly as possible, when present. The anion gap is frequently used
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in the hospital and/or emergency room setting to help diagnose and

monitor acutely ill patients. If anion-gap metabolic acidosis is identified,
the AG may be used to help monitor the effectiveness of treatment and
the underlying condition.
Specifically, the anion gap evaluates the difference between measured
and unmeasured electrical particles (ions or electrolytes) in the fluid
portion of the blood. According to the principle of electrical neutrality,
the number of positive ions (cations) and negative ions (anions) should
be equal. However, not all ions are routinely measured. The calculated
AG result represents the unmeasured ions and primarily consists of
anions, hence the name “anion gap.” The most commonly used formula
is:
Anion Gap (AG) = Sodium – (Chloride + Bicarbonate [total CO2])
However, there are other AG formulas, so reference ranges are not
interchangeable. Each laboratory formula will have an established
normal range that should be referenced.
The anion gap is non-specific. It is increased when the number of
unmeasured anions increases, indicating a state of anion-gap metabolic
acidosis, but it does not tell the healthcare practitioner what is causing
the imbalance. The metabolic acidosis must be treated to restore the
acid/base balance, but the underlying condition must also be identified
and treated. Causes can include uncontrolled diabetes, starvation,
kidney damage, and ingestion of potentially toxic substances such as
antifreeze, excessive amounts of aspirin (salicylates), or methanol. A
low anion gap can also occur; this is most commonly seen
when albumin (an anion as well as a protein) is low, while
immunoglobulins (cations as well as proteins) are increased.
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LFT (Liver Function Test)

Liver panel is also known as liver profile, liver function tests, LFTs, liver
enzyme test, liver blood test and liver test

The liver panel is a test with multiple measurements that help to assess
the health and function of the liver. The test is conducted with a blood
sample that is normally taken from a vein in your arm.
A liver panel can be used to help diagnose and monitor liver diseases. It
can also provide information about other health conditions that affect
the liver.
The liver panel is a test with multiple measurements that help to assess
the health and function of the liver. The test is conducted with a blood
sample that is normally taken from a vein in your arm.
A liver panel can be used to help diagnose and monitor liver diseases. It
can also provide information about other health conditions that affect
the liver.

Purpose of the test

The liver panel has many applications in medical care. While sometimes
called a liver function test, it is better understood as a method of
detecting liver disease and/or other health problems, including many
that involve the liver.
Some of the specific ways that a liver panel can be used include:

 Diagnosis: Although a liver panel alone is not able to diagnose liver

diseases, its measurements can help identify the type of problem in
people who have symptoms of liver conditions. The test can also
help in the diagnostic process of other health concerns.
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 Evaluating disease severity: A liver panel can help determine the

extent of illness in people who have known liver problems.
 Monitoring: Follow-up testing can provide information about how
well treatment for liver problems is working. A liver panel can also
monitor for side effects when people take medications that can
impact liver health.
 Screening: Some people may have a liver panel as part of broader
blood testing, known as the comprehensive metabolic panel, during
routine medical checkups. If screening is abnormal, it may warrant
more specific follow-up testing.

As a panel test, the liver panel involves multiple measurements. When

the test is ordered, doctors can modify exactly which measurements to
take.
For this reason, there is not a universal standard for what is measured
on a liver panel. Nevertheless, some components of the test are more
common. In most cases, a liver panel includes the following
measurements:

 Aspartate aminotransferase (AST): AST is a type of protein called an

enzyme that is found in the liver as well as many muscles and
organs.
 Alanine aminotransferase (ALT): ALT is an enzyme found primarily in
the liver.
 Alkaline phosphatase (ALP): ALP is an enzyme found in the liver,
bones, and other tissues in the body.
 Bilirubin: Bilirubin is a yellow-colored waste product that is the
result of normal breakdown of red blood cells. The liver works to
remove bilirubin from the body.
 Albumin: Albumin is a protein made by the liver that prevents fluids
from leaking out of the bloodstream.
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Additional measurements may be added to a liver panel if the doctor

believes they can provide more information to evaluate your situation.
These measures may be tested on an initial liver panel, or they may be
included in repeat testing after an abnormal result on a previous test.

 Gamma-glutamyl transferase (GGT): GGT is an enzyme found in the

liver and other organs.
 5’ nucleotidase (5’-NT): 5’-NT is an enzyme that exists in the liver
and other organs.
 Total protein: This measures the sum of two kinds of protein in the
blood known as albumin and globulin. The test may measure the
relative levels of albumin and globulin, which is reported as the A/G
ratio.
 Globulins: Globulins are a class of proteins in the blood.
 Prothrombin time: Prothrombin is a protein made by the liver that
facilitates normal blood clotting. Prothrombin time measures how
long it takes for the blood to clot.
 Lactate dehydrogenase (LDH): LDH is an enzyme found in tissues
throughout the body.

LIPID/LIPOPROTEIN PROFILE
Lipid panel is also known as coronary risk panel, lipid profile, fasting
lipid panel, non-fasting lipid panel, and cholesterol panel and lipid test

The lipid panel measures the amount of specific fat molecules called
lipids in the blood. As a panel test, it measures multiple substances,
including several types of cholesterol.
The lipid panel is used in both children and adults to evaluate risk of
cardiovascular diseases like heart disease, heart attack, and stroke.
Purpose of the test
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The lipid panel helps evaluate cardiovascular health by analyzing

cholesterol in the blood. Too much cholesterol can build up in the
blood vessels and arteries, damaging them and heightening the risk of
problems like heart disease, stroke, and heart attack.
A lipid panel can be ordered for several reasons:

 Screening: This is routine testing to determine if your cholesterol is

normal or falls into a borderline-, intermediate-, or high-risk
category.
 Monitoring: If you have abnormal results on earlier testing or other
risk factors for heart disease, lipid testing can monitor the
cholesterol in your blood.
 Measuring response to treatment: If you have been told to make
lifestyle changes or take cholesterol medications, a lipid panel can
evaluate your response to treatment.
 Diagnosis: Testing lipid levels can be part of the diagnosis of other
medical conditions, such as diseases that affect the liver.

Lipids are types of fat molecules in the blood. Cholesterol and

triglycerides are two important types of lipids that are carried inside
particles called lipoproteins.
The lipid panel analyzes your blood to measure different types of lipids:

 Total cholesterol: This measures your overall cholesterol level.

 Low-density lipoprotein (LDL) cholesterol: This type of cholesterol,
known as “bad cholesterol,” can collect in blood vessels and
increase your risk of cardiovascular disease.
 High-density lipoprotein (HDL) cholesterol: This type of “good
cholesterol” helps reduce the buildup of LDL.
 Triglycerides: Excess amounts of this type of fat are associated with
cardiovascular disease and pancreatic inflammation.
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There are a number of circumstances in which it is appropriate to get a

lipid panel test. Depending on the medical context, the test may be
used for screening, diagnosis, or monitoring.
Screening
Screening is looking for a health problem before any immediate signs or
symptoms have appeared. The lipid panel can be used to identify
people at high risk of cardiovascular disease before they develop
problems like heart disease or heart attack.
Recommendations for cardiac screening with the lipid panel vary
between medical organizations. Screening may provide early warning
to prevent problems, but it can be costly, cause anxiety, and lead to
potentially unnecessary treatments. Different groups of experts
evaluate the evidence and come to different conclusions about who
should get screened and how often screening should take place.
In adults without risk factors for cardiovascular disease, screening may
be done about every five years. Evidence is unclear about the optimal
age to start screening in low-risk patients. A doctor may recommend a
first lipid test in a person’s 20s, 30s, or 40s depending on their
situation.
People who have one or more risk factors typically have more frequent
screening and often have their first test at a younger age. Examples of
risk factors include:

 Age over 45 for men and 50-55 for women

 High cholesterol on a prior test
 Previous cardiovascular problem
 Smoking cigarettes
 Being overweight or obese
 Eating an unhealthy diet
 Not getting enough physical activity
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 Having high blood pressure (hypertension)

 Having a first-degree relative who developed heart disease at an
early age (under 55 in men and under 65 in women)
 Having diabetes or prediabetes

If you have one or more risk factors, you may receive a lipid test every
year or every few years. The frequency of testing may depend on the
results of prior tests.
For adults over 65, annual lipid testing is recommended by some
experts. Other doctors may slow or stop regular screening if a patient’s
levels appear to be stable.
In children, screening may begin once risk factors are identified starting
at the age of two. Follow-up testing is generally continued at least
every few years depending on test results and risk assessment.
Children without risk factors may still have a lipid panel test before
starting puberty. Another test may be performed after age 16. Changes
to blood lipids during puberty can reduce test accuracy from ages 12-
16, so the test is less often used in children of that age range who do
not have risk factors.
Children who are at a high risk of an inherited condition called familial
hypercholesterolemia generally have more regular screening. Because
this condition can cause heart problems at a young age, screening is
often done at age 3, between 9-11, and at age 18.

SERUM GLUCOSE – AC, PC, HbA1c

Glucose testing is also known as Fasting Blood Glucose (FBG), Blood
Sugar, Fasting Blood Sugar (FBS) and Fasting Plasma Glucose (FPG)
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Types of Glucose Tests

Several different glucose tests are commonly performed for screening
and diagnosis.

 Fasting plasma glucose test: This test measures the amount of

glucose in your blood after you have gone without eating or
drinking anything but water for at least 8 hours. This test is usually
performed in the morning.
 Random plasma glucose test: This test also measures the amount of
glucose in the blood but may be performed at any time of the day,
whether or not you’ve eaten recently. It is often conducted on a
sample of blood drawn from a vein in your arm and may be included
in a panel of blood tests, such as a comprehensive metabolic panel.
People diagnosed with diabetes may also test their glucose
throughout the day using a fingerstick blood sample and a special
device that provides results at home.
 Glucose tolerance test: This test measures how much glucose is in
your bloodstream after you fast overnight and then drink a sugary
drink. A glucose tolerance test typically requires more than one
blood draw over the course of several hours.
 Urine glucose test: Urine glucose testing is often part of
routine urinalysis. Urinalysis tests for the presence of many
substances in the urine. Urine glucose test results are less accurate
than blood glucose testing, but your doctor may order this test if
you are not able to have a blood test.
 Continuous glucose monitoring: A continuous glucose monitor
reads glucose levels through a tiny wire implanted just below the
skin’s surface. This type of monitoring can show blood glucose
trends over time.
 Hemoglobin A1c: Although the hemoglobin A1c test does not
measure glucose directly, it does reflect your average blood glucose
levels over the past three months by measuring the amount of
hemoglobin that has attached glucose.
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Although glucose tests most often use blood or urine samples to test
for and monitor diabetes, they can also be performed on samples
of cerebrospinal fluid (CSF) or joint fluid. Abnormal levels of glucose in
the CSF or synovial fluid can be due to viral, bacterial, or fungal
infections and other conditions.
If you have abnormal results on a glucose test, your doctor may want to
repeat the test or have you take a different type of glucose test to
confirm the results. The type of glucose test your doctor may
recommend, how often it’s given, when and where you will receive the
test, and whether you will need additional testing will depend on your
unique situation.
Glucose Serum Results
Test results are interpreted by looking at the levels of glucose found in
the blood. Glucose is measured in milligrams per deciliter (mg/dL) and
can fall into one of four categorizations that have different medical
implications. Normal results vary based on what test is being used. The
following results are representative numbers based on the glucose
serum fasting test.
 Below 70 mg/dL: blood glucose levels lower than 70 mg/dL after
the fasting test indicate an abnormally low level of blood sugar
and may be cause for a diagnosis hypoglycemia.
 70 mg/dL to 99 mg/dL: blood glucose levels that fall within this
range after fasting for 10-12 hours are considered to be normal
and healthy.
 100 mg/dL to126 mg/dL: after fasting blood glucose levels in this
range indicate a possible diagnosis of pre-diabetes and a
heightened risk of developing diabetes.
 Above 126 mg/dL: If a blood glucose level is above 126 on the
glucose plasma test, then a diagnosis of diabetes will likely be
made.
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MONITORING CAPILLARY BLOOD GLUCOSE (Glucometer

Random Blood Sugar – GRBS)
Capillary blood glucose monitoring (CBGM) plays an important part in
achieving levels of diabetes control which are associated with reduction
in the risk of developing diabetes complications. It is vital that the
results of CBGM are used to adjust treatment to achieve the
recommended blood glucose targets.

A blood glucose test is a blood test that screens for diabetes by

measuring the level of glucose (sugar) in a person's blood. Normal
blood glucose level (while fasting) range within 70 to 99 mg/dL (3.9 to
5.5 mmol/L). Higher ranges could indicate pre-diabetes or diabetes.

Glucometer Procedure

1. First, set out your glucometer, a test strip, a lancet, and an alcohol
prep pad.
2. Wash your hands to prevent infection. If you are not by a sink, it's
okay to just use the alcohol swab. If you are by a sink and wash
your hands thoroughly, you do not have to use an alcohol swab.
3. Sometimes it helps to warm your hands first to make the blood
flow easier. You can rub your hands together briskly or run them
under warm water—just be sure to dry them well as wet hands
can dilute the blood sample, resulting in a lower number.
4. Turn on the glucometer and place a test strip in the machine
when the machine is ready. Watch the indicator for placing the
blood on the strip.
5. Make sure your hand is dry and wipe the area you've selected
with an alcohol prep pad and wait until the alcohol evaporates.
6. Pierce your fingertip on the side of your finger, between the
bottom of your fingernail to the tip of your nail (avoid the pads as
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this can pinch more). The type of drop of blood required is

determined by the type of strip you are using (some use a
"hanging drop" of blood versus a small drop for strips that draw
blood in with a capillary action).
7. Place the drop of blood on or at the side of the strip.
8. The glucometer will take a few moments to calculate the blood
sugar reading. Follow your healthcare provider's orders for
whatever blood sugar reading you get.
9. You may use the alcohol prep pad to blot the site where you drew
the blood if it is still bleeding.
10. Write down your results. Keeping a record makes it easier
for you and your healthcare provider to establish a good
treatment plan. Some glucometers can store your results in a
memory, for easier record keeping.

STOOL ROUTINE EXAMINATION

A stool analysis is a series of tests done on a stool (feces) sample to
help diagnose certain conditions affecting the digestive tract. These
conditions can include infection (such as from parasites, viruses,
or bacteria), poor nutrient absorption, or cancer.
For a stool analysis, a stool sample is collected in a clean container and
then sent to the laboratory.
Laboratory analysis includes microscopic examination, chemical tests,
and microbiologic tests. The stool will be checked for color, consistency,
amount, shape, odor, and the presence of mucus. The stool may be
examined for hidden (occult) blood, fat, meat fibers, bile, white blood
cells, and sugars called reducing substances. The pH of the stool also
may be measured. A stool culture is done to find out if bacteria may be
causing an infection.
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Stool analysis is done to:

 Help identify diseases of the digestive tract, liver, and pancreas.
Certain enzymes (such as trypsin or elastase) may be evaluated in
the stool to help see how well the pancreas is working.
 Help find the cause of symptoms affecting the digestive tract, such
as prolonged diarrhea, bloody diarrhea, an increased amount of
gas, nausea, vomiting, loss of appetite, bloating, belly pain and
cramping, and fever.
 Screen for colon cancer by checking for hidden (occult) blood.
 Look for parasites, such as pinworms or Giardia.
 Look for the cause of an infection, such as bacteria, a fungus, or a
virus.
 Check for poor absorption of nutrients by the digestive tract
(malabsorption syndrome). For this test, all stool is collected over a
72-hour period and then checked for fat (and sometimes for meat
fibers). This test is called a 72-hour stool collection or quantitative
fecal fat test.

Collect the samples as follows:

 Urinate before you collect the stool so that you do not get any urine
in the stool sample.
 Put on gloves before handling your stool. Stool can contain germs
that spread infection. Wash your hands after you remove your
gloves.
 Pass stool (but no urine) into a dry container. You may be given a
plastic basin that can be placed under the toilet seat to catch the
stool.
o Either solid or liquid stool can be collected.
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o If you have diarrhea, a large plastic bag taped to the toilet seat
may make the collection process easier; the bag is then placed
in a plastic container.
o If you are constipated, you may be given a small enema.

o Do not collect the sample from the toilet bowl.

o Do not mix toilet paper, water, or soap with the sample.

 Place the lid on the container and label it with your name, your
doctor's name, and the date the stool was collected. Use one
container for each day's collection. Collect a sample only once a day
unless your doctor gives you other directions.

Stool analysis

Normal: The stool appears brown, soft, and well-formed in

consistency.

The stool does not contain blood, mucus, pus, undigested

meat fibers, harmful bacteria, viruses, fungi, or parasites.

The stool is shaped like a tube.

Abnormal: The stool is black, red, white, yellow, or green.

The stool is liquid or very hard.

There is too much stool.

The stool contains blood, mucus, pus, undigested meat

fibers, harmful bacteria, viruses, fungi, or parasites.

The stool contains low levels of enzymes, such as trypsin

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or elastase.

URINE TESTING – ALBUMIN, ACETONE, pH, Specific

Gravity
Urinalysis is also known as urine test, urine analysis and UA

To screen for, help diagnose and/or monitor several diseases and

conditions, such as kidney disorders or urinary tract infections (UTIs)

Sample: One to two ounces of urine—a sufficient sample is required for

accurate results; sometimes you may be directed to collect a sample
using a “clean-catch” technique: women should spread the labia of the
vagina and clean from front to back; men should wipe the tip of the
penis. Start to urinate, let some urine fall into the toilet, then collect
one to two ounces of urine in the container provided, then void the rest
into the toilet.

PURPOSE
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A urinalysis is a group of physical, chemical, and microscopic tests. The

tests detect and/or measure several substances in the urine, such as
byproducts of normal and abnormal metabolism, cells, cellular
fragments, and bacteria.
Urine is produced by the kidneys, two fist-sized organs located on
either side of the spine at the bottom of the ribcage. The kidneys filter
wastes out of the blood, help regulate the amount of water in the body,
and conserve proteins, electrolytes, and other compounds that the
body can reuse. Anything that is not needed is eliminated in the urine,
traveling from the kidneys through ureters to the bladder and then
through the urethra and out of the body. Urine is generally yellow and
relatively clear, but each time a person urinates, the color, quantity,
concentration, and content of the urine will be slightly different
because of varying constituents.
Many disorders may be detected in their early stages by identifying
substances that are not normally present in the urine and/or by
measuring abnormal levels of certain substances. Some examples
include glucose, protein, bilirubin, red blood cells, white blood cells,
crystals, and bacteria. They may be present because:

1. There is an elevated level of the substance in the blood and the

body responds by trying to eliminate the excess in the urine.
2. Kidney disease is present.
3. There is a urinary tract infection present, as in the case of bacteria
and white blood cells.

A complete urinalysis consists of three distinct testing phases:

1. Visual examination, which evaluates the urine’s color and clarity

2. Chemical examination, which tests chemically for about 9
substances that provide valuable information about health and
disease and determines the concentration of the urine
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3. Microscopic examination, which identifies and counts the type of

cells, casts, crystals, and other components such as bacteria and
mucus that can be present in urine

SAMPLE COLLECTION

One to two ounces of urine is collected in a clean container. A sufficient

sample is required for accurate results.
Urine for a urinalysis can be collected at any time. In some cases, a first
morning sample may be requested because it is more concentrated and
more likely to detect abnormalities.
Sometimes, you may be asked to collect a “clean-catch” urine sample.
For this, it is important to clean the genital area before collecting the
urine. Bacteria and cells from the surrounding skin can contaminate the
sample and interfere with the interpretation of test results. With
women, menstrual blood and vaginal secretions can also be a source of
contamination. Women should spread the labia of the vagina and clean
from front to back; men should wipe the tip of the penis. Start to
urinate, let some urine fall into the toilet, then collect one to two
ounces of urine in the container provided, then void the rest into the
toilet.
A urine sample will only be useful for a urinalysis if taken to the
healthcare provider’s office or laboratory for processing within a short
period of time. If it will be longer than an hour between collection and
transport time, then the urine should be refrigerated or a preservative
may be added.
Urinalysis results can have many interpretations. Abnormal findings are
a warning that something may be wrong and should be evaluated
further. A healthcare practitioner must correlate the urinalysis results
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with a person’s symptoms and clinical findings and search for the
causes of abnormal findings with other targeted tests, such as
a comprehensive metabolic panel (CMP), complete blood count
(CBC), renal panel, liver panel, or urine culture (for urinary tract
infection).
Generally, the greater the concentration of the atypical substance, such
as greatly increased amounts of glucose, protein, or red blood cells, the
more likely it is that there is a problem that needs to be addressed.
However, the results do not tell the healthcare practitioner exactly
what the cause of the finding is or whether it is a temporary or chronic
condition.
A normal urinalysis does not guarantee that there is no illness. Some
people will not release elevated amounts of a substance early in a
disease process, and some will release them sporadically during the
day, which means that they may be missed by a single urine sample. In
very dilute urine, small quantities of chemicals may be undetectable.
For additional details on what specific results may mean, see the
sections below on:

 Visual examination
 Chemical examination
 Microscopic examination

RESULTS

Urine color
Urine can be a variety of colors, most often shades of yellow, from very
pale or colorless to very dark or amber. Unusual or abnormal urine
colors can be the result of a disease process, several medications (e.g.,
multivitamins can turn urine bright yellow), or the result of eating
certain foods. For example, some people can have red-colored urine
after eating beets; the color is from the natural pigment of beets and is
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not a cause for worry. However, red-colored urine can also occur when
blood is present in the urine and can be an indicator of disease or
damage to some part of the urinary system. Another example is yellow-
brown or greenish-brown urine that may be a sign of bilirubin in the
urine

Urine clarity
Urine clarity refers to how clear the urine is. Usually, laboratorians
report the clarity of the urine using one of the following terms: clear,
slightly cloudy, cloudy, or turbid. “Normal” urine can be clear or cloudy.
Substances that cause cloudiness but that are not considered unhealthy
include mucus, sperm and prostatic fluid, cells from the skin, normal
urine crystals, and contaminants such as body lotions and powders.
Other substances that can make urine cloudy, like red blood cells, white
blood cells, or bacteria, indicate a condition that requires attention.

CHEMICAL EXAMINATION

Specific gravity
Urine specific gravity is a measure of urine concentration. This test
simply indicates how concentrated the urine is. Specific gravity
measurements are a comparison of the amount of substances dissolved
in urine as compared to pure water. If there were no substances
present, the specific gravity of the urine would be 1.000 (the same as
pure water). Since all urine has some substances in it, a urine SG of
1.000 is not possible. If a person drinks excessive quantities of water in
a short period of time or gets an intravenous (IV) infusion of large
volumes of fluid, then the urine specific gravity may be very close to
that of water. The upper limit of the test pad, a specific gravity of 1.035,
indicates concentrated urine, one with many substances in a limited
amount of water.
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pH
As with specific gravity, there are typical but not “abnormal”
urine pH values. The urine is usually slightly acidic, about pH 6, but can
range from 4.5-8. The kidneys play an important role in maintaining
the acid-base balance of the body. Therefore, any condition that
produces acids or bases in the body, such as acidosis or alkalosis, or the
ingestion of acidic or basic foods can directly affect urine pH.
Some of the substances dissolved in urine will precipitate out to form
crystals when the urine is acidic; others will form crystals when the
urine is basic. If crystals form while the urine is being produced in the
kidneys, a kidney stone or “calculus” can develop. By modifying urine
pH through diet or medications, the formation of these crystals can be
reduced or eliminated.

Bilirubin
This test screens for bilirubin in the urine. Bilirubin is not present in the
urine of normal, healthy individuals. It is a waste product that is
produced by the liver from the hemoglobin of RBCs that are broken
down and removed from circulation. It becomes a component of bile, a
fluid that is released into the intestines to aid in food digestion.
In certain liver diseases, such as biliary obstruction or hepatitis, excess
bilirubin can build up in the blood and is eliminated in urine. The
presence of bilirubin in urine is an early indicator of liver disease and
can occur before clinical symptoms such as jaundice develop.
The results of this test will be considered along with the result of
urobilinogen (below). If positive, the healthcare practitioner will likely
follow up with other laboratory tests, such as a liver panel, to help
establish a diagnosis.
Urobilinogen
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This test screens for urobilinogen in the urine. The results are
considered along with those for urine bilirubin (above).
Urobilinogen is normally present in urine in low concentrations. It is
formed in the intestine from bilirubin, and a portion of it is absorbed
back into the blood. Positive test results may indicate liver diseases
such as viral hepatitis, cirrhosis, liver damage due to drugs or toxic
substances, or conditions associated with increased RBC destruction
(hemolytic anemia). When urine urobilinogen is low or absent in a
person with urine bilirubin and/or signs of liver dysfunction, it can
indicate the presence of hepatic or biliary obstruction.
Protein
The protein test pad provides a rough estimate of the amount
of albumin in the urine. Albumin makes up about 60% of the total
protein in the blood. Normally, there will be no protein or a small
amount of protein in the urine. When urine protein is elevated, a
person has a condition called proteinuria.
Proteinuria may occasionally be seen in healthy individuals. Healthy
people can have temporary or persistent proteinuria due to stress,
exercise, fever, aspirin therapy, or exposure to cold, for example.
Repeat testing may be done once these conditions have resolved to
determine whether the proteinuria is persistent.
If trace amounts of protein are detected, and depending on the
person’s signs, symptoms and medical history, a repeat urinalysis and
dipstick protein may be performed at a later time to see if there is still
protein in the urine or if it has dropped back to undetectable levels.
If a large amount of protein is detected on a urinalysis and/or if the
protein persists in repeated tests, a 24-hour urine protein test may be
used as a follow-up test. Since the dipstick primarily measures albumin,
the 24-hour urine protein test also may be ordered if a healthcare
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practitioner suspects that proteins other than albumin are being

released into the urine.
Protein in the urine may be a sign of kidney disease. Small amounts of
albumin may be found in the urine when kidney dysfunction begins to
develop. A different test called a urine albumin test detects and
measures small amounts of albumin in the urine. The urine albumin
test is more sensitive than a dipstick urinalysis and is routinely used to
screen people with chronic conditions that put them at risk for kidney
disease, such as diabetes and high blood pressure.
Glucose
Glucose is normally not present in urine. When glucose is present, the
condition is called glucosuria. It results from either:

1. An excessively high glucose level in the blood, such as may be seen

with people who have uncontrolled diabetes
2. A reduction in the “renal threshold;” when blood glucose
levels reach a certain concentration, the kidneys begin to eliminate
glucose into the urine to decrease blood concentrations. Sometimes
the threshold concentration is reduced and glucose enters the urine
sooner, at a lower blood glucose concentration.

Some other conditions that can cause glucosuria include hormonal

disorders, liver disease, medications, and pregnancy. When glucosuria
occurs, other tests such as a fasting blood glucose are usually
performed to further identify the specific cause.

Ketones
Ketones are not normally found in the urine. They are intermediate
products of fat metabolism. They are produced when glucose is not
available to the body’s cells as an energy source. They can form when a
person does not eat enough carbohydrates (for example, in cases of
fasting, starvation, or high-protein diets) or when a person’s body
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cannot use carbohydrates properly. When carbohydrates are not

available, the body metabolizes fat instead to get the energy it needs to
keep functioning. Strenuous exercise, exposure to cold, frequent,
prolonged vomiting, and several digestive system diseases can also
increase fat metabolism, resulting in ketonuria.
In a person who has diabetes, ketones in urine may also be an early
indication of insufficient insulin. With insufficient insulin, a diabetic
cannot process glucose and instead metabolizes fat. This can cause
ketones to build up in the blood, resulting first in ketosis and then
progressing to ketoacidosis, a form of metabolic acidosis. Excess
ketones and glucose are dumped into the urine by the kidneys in an
effort to flush them from the body. This condition, called diabetic
ketoacidosis (DKA), is most frequently seen with uncontrolled type 1
diabetes and can be a medical emergency.

Blood (Hemoglobin) and Myoglobin

This test is used to detect hemoglobin in the urine (hemoglobinuria).
Hemoglobin is an oxygen-transporting protein found inside red blood
cells (RBCs). Its presence in the urine indicates blood in the urine
(known as hematuria).
A small number of RBCs are normally present in urine and usually result
in a “negative” chemical test. An increased amount of hemoglobin
and/or increased number of RBCs are detected as a “positive” chemical
test result. Results of this test are typically interpreted along with those
from the microscopic examination of the urine to determine whether
RBCs are present in the urine. A positive result on this test with no RBCs
present may indicate the presence of hemoglobin in the urine (which
can occur when RBCs have broken apart) or myoglobin from muscle
injury.
Leukocyte esterase
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Leukocyte esterase is an enzyme present in most white blood cells

(WBCs). A few white blood cells are normally present in urine and
usually give a negative chemical test result. When the number of WBCs
in urine increases significantly, this screening test will become positive.
Results of this test will be considered along with a microscopic
examination for WBCs in the urine.
When this test is positive and/or the WBC count in urine is high, it may
indicate that there is inflammation in the urinary tract or kidneys. The
most common cause for WBCs in urine (leukocyturia) is a
bacterial urinary tract infection (UTI), such as a bladder or kidney
infection. In addition to WBCs, bacteria and RBCs may also be seen in
the microscopic examination. If bacteria are present, the chemical test
for nitrite may also be positive

Nitrite
This test detects nitrite and is based upon the fact that many bacteria
can convert nitrate (a normal substance in urine) to nitrite. Normally,
the urinary tract and urine are free of bacteria and nitrite. When
bacteria enter the urinary tract, they can cause a urinary tract infection.
A positive nitrite test result can indicate a UTI. However, since not all
bacteria are capable of converting nitrate to nitrite, someone can still
have a UTI despite a negative nitrite test. The results of this test will be
considered along with the leukocyte esterase (above) and a microscopic
examination.

Ascorbic Acid (Vitamin C)

Occasionally, people taking vitamin C or multivitamins may have large
amounts of ascorbic acid in their urine. When this is suspected to be
the case, a laboratorian may test the sample for ascorbic acid (vitamin
C) because it has been known to interfere with the accuracy of some of
the results of the chemical test strip, causing them to be falsely low or
falsely negative. Examples of tests that may be affected include the
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urine dipstick tests for glucose, blood, bilirubin, nitrite, and leukocyte
esterase.

MICROSCOPIC EXAMINATION

Red blood cells (RBCs)

Normally, a few RBCs are present in urine sediment (0-5 RBCs per high
power field, HPF). A positive chemical test for hemoglobin and an
increase in the number of RBCs seen under the microscope indicates
that there is blood in the urine. However, this test cannot be used to
identify where the blood is coming from. For instance, contamination of
urine with blood from hemorrhoids or vaginal bleeding cannot be
distinguished from a bleed in the urinary tract. This is why it is
important to collect a urine specimen correctly and for women to tell
their healthcare provider that they are menstruating when asked to
collect a urine specimen.
Blood in the urine is not a normal finding, but it is not uncommon and is
not necessarily a cause for alarm. Hematuria is a sign or an indicator
that prompts a healthcare practitioner to investigate further to try to
determine the underlying cause of the blood. As part of the
investigation, a healthcare practitioner will evaluate an individual’s
medical history, physical examination, and accompanying signs and
symptoms. Additional urine and blood tests may be done to help
determine the source.
White blood cells (WBCs)
The number of WBCs in urine sediment is normally low (0-5 WBCs per
high power field, HPF). WBCs can be a contaminant, such as those from
vaginal secretions.
An increased number of WBCs seen in the urine under a microscope
and/or positive test for leukocyte esterase may indicate
an infection or inflammation somewhere in the urinary tract. If also
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seen with bacteria (see below), they indicate a likely urinary tract
infection.

Epithelial cells
Epithelial cells are usually reported as “few,” “moderate,” or “many”
present per low power field (LPF). Normally, in men and women, a few
epithelial cells can be found in the urine sediment. In urinary tract
conditions such as infections, inflammation, and malignancies, an
increased number of epithelial cells are present. Determining the kinds
of cells present may sometimes help to identify certain conditions. For
example, epithelial cells containing large amounts of broken-down
hemoglobin (called hemosiderin) may indicate that there were red
blood cells or hemoglobin in the urine recently, even if there are none
now.

Bacteria, yeast and parasites

In healthy people, the urinary tract is sterile and, if the urine sample is
collected as a “clean-catch” sample, there will be no microbes seen in
the urine sediment under the microscope. Special care must be taken
during specimen collection, particularly in women, to prevent bacteria
that normally live on the skin or in vaginal secretions from
contaminating the urine sample.
If microbes are seen, they are usually reported as “few,” “moderate,”
or “many” present per high power field (HPF).

 Bacteria from the surrounding skin can enter the urinary tract at
the urethra and move up to the bladder, causing a urinary tract
infection (UTI). If the infection is not treated, it can eventually move
to the kidneys and cause kidney infection (pyelonephritis). If a
person has an uncomplicated lower urinary tract infection, then the
person may be treated without need for a urine culture. However, if
the person has had recurrent UTIs, suspected complicated infection,
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or is hospitalized, a urine culture and susceptibility testing may be

performed to help guide treatment. (See the article on Urine
Culture for details.)
 In women (and rarely in men), yeast can also be present in urine.
They are most often present in women who have a vaginal yeast
infection because the urine has been contaminated with vaginal
secretions during collection. If yeast are observed in urine, then the
person may be treated for a yeast infection.
 Trichomonas vaginalis is a parasite that may be found in the urine of
women, or rarely, men. As with yeast, T. vaginalisinfects the vaginal
canal and their presence in urine is due to contamination during
sample collection. If these are found during a urinalysis,
then Trichomonas testing may be performed to look for a vaginal
infection.
 Casts
 Casts are cylindrical particles sometimes found in urine that are
formed from coagulated protein released by kidney cells. They are
formed in the long, thin, hollow tubes of the kidneys known
as tubules and usually take the shape of the tubule (hence the
name). Under the microscope, they often look like the shape of a
“hot dog” and in healthy people they appear nearly clear. This
type of cast is called a “hyaline” cast. Normally, healthy people
may have a few (0–5) hyaline casts per low power field (LPF).
After strenuous exercise, more hyaline casts may be detected.
 Other types of casts are associated with different kidney diseases,
and the type of casts found in the urine may give clues as to which
disorder is affecting the kidney. Cellular casts, such as red blood
cell and white blood cell casts, indicate a kidney disorder. Some
other examples of types of casts include granular casts, fatty
casts, and waxy casts. When a disease process is present in the
kidney, cells or other substances can become trapped in the
protein as the cast is formed. When this happens, the cast is
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identified by the substances inside it, for example, as a red blood

cell cast or white blood cell cast.
Crystals
Urine contains many dissolved substances (solutes) – waste chemicals
that the body needs to eliminate. These solutes can form crystals, solid
forms of a particular substance, in the urine if:

1. The urine pH is increasingly acidic or basic;

2. The concentration of dissolved substances is increased; and
3. The urine temperature promotes their formation.

Crystals are identified by their shape, color, and by the urine pH. They
may be small, sand-like particles with no specific shape (amorphous) or
have specific shapes, such as needle-like. Crystals are considered
“normal” if they are from solutes that are typically found in the urine;
these usually form as urine cools after collection and were not present
in the body. Some examples of crystals that can be found in the urine of
healthy individuals include:

 Amorphous urates
 Crystalline uric acid
 Calcium oxalates
 Amorphous phosphates

If the crystals are from substances that are not normally in the urine,
they are considered “abnormal.” Abnormal crystals may indicate an
abnormal metabolic process. Some of these include:

 Calcium carbonate
 Cystine
 Tyrosine
 Leucine
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Normal or abnormal crystals can form within the kidneys as urine is

being made and may group together to form kidney “stones” or calculi.
These stones can become lodged in the kidney itself or in the ureters,
tubes that pass the urine from kidney to the bladder, causing extreme
pain.

URINE CULTURE, ROUTINE, TIMED, URINE SPECIMEN

Urine culture is also known as Urine Culture and Sensitivity, Urine C and
S

Purpose: To diagnose a urinary tract infection (UTI)

Sample:

A few ounces of urine; the mid-stream clean catch urine sample is the
most common type of sample collected. (The genital area is cleaned
before collecting your urine.) Urine may also be collected using a
catheter and, rarely, a needle is used to aspirate urine directly from the
bladder. For infants, a collection bag may be attached to the genital
area to catch any urine produced.

 For a urine culture, a small sample of urine is placed on one or more

agar plates (a thin layer of a nutrient media) and incubated at body
temperature. Any bacteria or yeast that are present in the urine
sample grow over the next 24 to 48 hours.
 A laboratory professional studies the colonies on the agar plate,
counting the total number and determining how many types have
grown. The size, shape, and color of these colonies help to identify
which bacteria are present, and the number of colonies indicates
the quantity of bacteria originally present in the urine sample. The
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quantity can differentiate between normal levels of bacteria versus

infection.
 Ideally, if a good clean catch sample was collected for the test, only
bacteria causing a UTI are present. Typically, this will be a single
type of bacteria that will be present in relatively large numbers.
 Sometimes, more than one type of bacteria will be present. This
may be due to an infection that involves more than one pathogen;
however, it is more likely due to skin, vaginal, or fecal
contamination picked up during the urine collection.
 The laboratorian will take a colony from each type and perform
other tests, such as a gram stain, to identify the type (species) of
bacteria or other microbe (i.e., yeast). Susceptibility testing may be
done to determine which antibiotics will likely cure the infection.

If there is no or little growth on the agar after 24 to 48 hours of

incubation, the urine culture is considered negative and the culture is
complete, suggesting an infection is not present.
Sample Collection

Although there are several types of urine samples, the mid-stream

clean catch is the type most commonly submitted for culture.

 It is important to first clean the genital area before collecting your

urine because of the potential to contaminate the urine with
bacteria and cells from the surrounding skin during collection
(particularly in women).
 Start first by washing your hands.
 Women should then spread the labia of the vagina and clean from
front to back using a wipe provided by your healthcare practitioner
or the laboratory. It is recommended to repeat with a second towel
or wipe.
 Men should wipe the tip of the penis.
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 Start to urinate, let some urine fall into the toilet, and then collect
one to two ounces of urine directly into the sterile container
provided, then void the rest into the toilet. Do not allow the inside
of the container to come into contact with skin and do not scoop
the urine from the toilet (or any other container).

For catheterized specimens, a urine sample is taken by inserting a thin

flexible tube or catheter through the urethra into the bladder. This is
performed by a trained healthcare practitioner. The urine is collected in
a sterile container at the other end of the tube. Rarely, a needle and
syringe may be used to collect by aspirating urine directly from the
bladder. For infants, a collection bag may be placed on the genital area
to collect any urine produced.
Results and Interpretation

Results of a urine culture are often interpreted in conjunction with the

results of a urinalysis and with regard to how the sample was collected
and whether symptoms are present. Since some urine samples have
the potential to be contaminated with bacteria normally found on the
skin (normal flora), care must be taken with interpreting some culture
results.
Positive urine culture: Typically, the presence of a single type of
bacteria growing at high colony counts is considered a positive urine
culture.

 For clean catch samples that have been properly collected, cultures
with greater than 100,000 colony forming units (CFU)/milliliter of
one type of bacteria usually indicate infection.
 In some cases, however, there may not be a significantly high
number of bacteria even though an infection is present. Sometimes
lower numbers (1,000 up to 100,000 CFU/mL) may indicate
infection, especially if symptoms are present.
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 Likewise, for samples collected using a technique that minimizes

contamination, such as a sample collected with a catheter, results of
1,000 to 100,000 CFU/mL may be considered significant.

Results from a urinalysis can be used to help interpret results of a urine

culture. For example, a positive leukocyte esterase (a marker of white
blood cells) and nitrite (a marker for bacteria) help confirm a UTI.
If a culture is positive, susceptibility testing may be performed to guide
treatment. (See the article on Antibiotic Susceptibility Testing for more
details on results.)
Although a variety of bacteria can cause UTIs, most are due
to Escherichia coli (E. coli), bacteria that are common in the digestive
tract and routinely found in stool.
Other bacteria that commonly cause UTIs include:

 Proteus
 Klebsiella
 Enterobacter
 Staphylococcus
 Acinetobacter

Occasionally, a UTI may be due to a yeast, such as Candida albicans.

Negative urine culture: A culture that is reported as “no growth in 24
or 48 hours” usually indicates that there is no infection. If the
symptoms persist, however, a urine culture may be repeated on
another sample to look for the presence of bacteria at lower colony
counts or other microorganisms that may cause these symptoms. The
presence of white blood cells and low numbers of microorganisms in
the urine of a symptomatic person is a condition known as acute
urethral syndrome.
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Contamination: If a culture shows growth of several different types of

bacteria, then it is likely that the growth is due to contamination. This is
especially true in voided urine samples if the organisms present
include Lactobacillus and/or other common nonpathogenic vaginal
bacteria in women. If the symptoms persist, the healthcare practitioner
may request a repeat culture on a sample that is more carefully
collected. However, if one type of bacteria is present in significantly
higher colony counts than the others, for example, 100,000 CFUs/mL
versus 1,000 CFUs/mL, then additional testing may be done to identify
the predominant bacteria.

SPUTUM CULTURE
Sputum culture is also known as Respiratory Culture, Bacterial Culture
and Bacterial Sputum Culture

Purpose

To detect and identify the cause of bacterial pneumonia or some other

lower respiratory tract infections; to monitor the efficacy of treatment

Sample

A sputum sample (deep respiratory secretions, not saliva), usually

collected first thing in the morning; sometimes, depending on the
infection, up to 3 sputum samples might be collected over consecutive
days.

Sputum Test

Sputum is the thick mucus or phlegm that is expelled from the lower
respiratory tract (bronchi and lungs) through coughing; it is not saliva or
spit. Care must be taken in the sample collection process to ensure that
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the sample is from the lower airways and not from the upper
respiratory tract. Sputum samples may be expectorated or induced (See
the section below on sample collection.)
Bacterial sputum cultures detect the presence of disease-causing
bacteria (pathogens) in people who are suspected of having bacterial
pneumonia or other lower respiratory tract infections. Bacteria in the
sample are identified and susceptibility testing is performed to guide
antibiotic treatment.
Sometimes a respiratory infection is caused by a pathogen that cannot
be grown and identified with a routine bacterial sputum culture. Other
tests, such as an AFB smear and culture, fungal culture, or viral culture,
may be ordered in addition to or instead of a routine culture.
Typically, the first step in the routine analysis of a sputum sample is
a Gram stain to identify the general type of bacteria that may be
present. The sample is then placed on or in appropriate nutrient media
and incubated. The media encourages the growth of bacteria that are
present, allowing for further testing and identification.
Sputum is not sterile. That means that when a person has a bacterial
respiratory infection, there will typically be harmless bacteria that are
normally present in the mouth, throat, etc. (normal flora) as well as
disease-causing (pathogenic) bacteria present.
A trained laboratorian differentiates normal flora from pathogenic
bacteria and identifies the various types of bacteria present in the
culture. Identification is a step-by-step process that may involve several
biochemical, immunological, and/or molecular tests and observations
of the organism’s growth characteristics.
Antimicrobial susceptibility testing is frequently required to guide the
treatment and to determine whether the bacteria present are likely to
respond to specific antibiotics.
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The sputum culture, Gram stain(s), and susceptibility testing all

contribute to a report that informs the health practitioner which
pathogen(s) are present and which antibiotic therapies are likely to
inhibit their growth.
Sputum Collection

Sputum samples may be coughed up or induced. Samples that are

coughed up are expelled into a sterile cup provided by the laboratory.
Deep coughing is generally required, and the person should be
informed that it is phlegm/mucus from the lungs that is necessary, not
saliva. If someone cannot produce a sputum sample, then it can often
be induced by following instructions provided and inhaling a sterile
saline or glycerin aerosol for several minutes to loosen phlegm in the
lungs. Steam inhalation or a hot shower can also be useful in loosening
the phlegm. Sometimes, induction of sputum might be assisted by a
respiratory therapist technician.
All samples collected should be taken to the laboratory promptly for
processing while they are fresh. Sputum samples must be evaluated
and accepted by the laboratory before they are processed.
Useful sputum culture results rely heavily on good sample collection. If
examination of a Gram stain of the sample reveals that it contains a
significant number of normal cells that line the mouth (squamous
epithelial cells), then the sample is not generally considered adequate
for culture and a re-collection of the sample may be required. If the
sample contains a majority of white blood cells that indicate a body’s
response to an infection, then it is considered to be an adequate
sample for culturing.
RESULTS
A bacterial sputum culture is used to detect and diagnose bacterial
lower respiratory tract infections such as bacterial pneumonia or
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bronchitis. It is typically performed with a Gram stain to identify the

bacteria causing a person’s infection.
Sometimes lower respiratory tract infections are caused by pathogens
that cannot be detected with routine bacterial sputum cultures. This is
either because the pathogens require very specific nutrients to grow in
culture or because they grow very slowly. When this is suspected to be
the case, specialized tests may be done in addition to or instead of a
routine culture to help identify the cause of infection. These additional
tests include, for example, an AFB smear and culture to
detect tuberculosis and non-tuberculous mycobacteria infections,
a fungal culture, or a Legionella culture.
A bacterial sputum culture may be ordered by itself, along with
a complete blood count (CBC) to evaluate the type and number of
white blood cells as an indication of infection, and/or along with
a blood culture to test for septicemia.
Sputum is not sterile, so when a person has an infection, there will
typically be both normal flora and pathogenic bacteria present. If
pathogenic bacteria are identified during a sputum culture, then
antimicrobial susceptibility testing is usually performed so that the
appropriate antibiotics can be prescribed.

OVERVIEW OF RADIOLOGIC AND ENDOSCOPIC

PROCEDURES
ENDOSCOPE

Endoscopy is a procedure that lets your doctor look inside your body. It
uses an instrument called an endoscope, or scope for short. Scopes
have a tiny camera attached to a long, thin tube. The doctor moves it
through a body passageway or opening to see inside an organ.
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Sometimes scopes are used for surgery, such as for

removing polyps from the colon.
There are many different kinds of endoscopy. Here are the names of
some of them and where they look.

 Arthroscopy: joints
 Bronchoscopy: lungs
 Colonoscopy and sigmoidoscopy: large intestine
 Cystoscopy and ureteroscopy: urinary system
 Laparoscopy: abdomen or pelvis
 Upper gastrointestinal endoscopy: esophagus and stomach

Endoscopy is a medical procedure where a doctor puts a tube-like

instrument into the body to look inside.

 Bronchoscopy
 Colonoscopy
 Cystoscopy
 Laparoscopy
 Laryngoscopy
 Mediastinoscopy
 Thoracoscopy
 Upper Endoscopy

Bronchoscopy is a procedure a doctor uses to look inside the lungs. This

is done with a bronchoscope, a thin, flexible tube with a light and a lens
or small video camera on the end. The tube is put in through your nose
or mouth, down your throat, into your trachea (windpipe), and into the
airways (bronchi and bronchioles) of your lungs.

Colonoscopy is a procedure a doctor uses to look at the inside of the

colon and rectum with a colonoscope, which is a long, flexible tube
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about the width of a finger with a light and small video camera on the
end. It’s put in through the anus and into the rectum and colon. Special
instruments can be passed through the colonoscope to biopsy (sample)
or remove any suspicious-looking areas such as polyps, if needed.

Cystoscopy is a procedure a doctor uses to look at the inside of the

bladder and urethra (the tube that connects the bladder to the outside
of the body). This is done with a cystoscope, a thin tube with a light and
a lens or small video camera on the end. The tube is put in through
your urethra.

There are two main types of cystoscopes: flexible and rigid. The type
your doctor uses will depend on why the cystoscopy is being done.

Laparoscopy is a procedure a doctor uses to look inside the abdomen

(belly) and pelvis. This is done with a laparoscope, a thin, flexible tube
with a light and a small video camera on the end. The tube is put in a
small cut made through the abdominal wall near the navel (belly
button). A second or third incision may also be made in other parts of
the belly to put in other instruments. Laparoscopy is also known
as minimally invasive surgery or keyhole surgery.

Laryngoscopy is a procedure a doctor uses to look at the larynx (voice

box), including the vocal cords, as well as nearby structures like the
back of the throat. There are different types of laryngoscopy:

 In a direct laryngoscopy, the doctor can use different types of

laryngoscopes, which are long, thin instruments with a light and a
lens or small video camera on the end. The laryngoscope is put in
through your nose or mouth and down your throat. Some
laryngoscopes are flexible (fiber-optic), while others
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are rigid (stiff). The choice of which type to use depends on why
it’s being done.
 For an indirect laryngoscopy, the doctor aims a light at the back of
the throat, usually by wearing headgear that has a bright light
attached
Mediastinoscopy is a procedure a doctor uses to look inside the
mediastinum – the area behind the breastbone and between the lungs.
This is done with a mediastinoscope, a thin, flexible tube with a light,
small video camera and cutting tool on the end. The tube is put through
a small cut made just above the breastbone and slowly moved into the
mediastinum.

Thoracoscopy is a procedure a doctor uses to look at the space inside

the chest (outside of the lungs). This is done with a thoracoscope, a
thin, flexible tube with a light and a small video camera on the end. The
tube is put in through a small cut made near the lower end of the
shoulder blade between the ribs. Thoracoscopy is sometimes done as
part of a VATS procedure, which is short
for video assisted thoracic surgery.

An upper endoscopy is a procedure a doctor uses to look at the inner

lining of the upper digestive tract (the esophagus, stomach, and
duodenum, which is the first part of the small intestine).

This test is also sometimes called an esophagogastroduodenoscopy,

or EGD.

This procedure is done with an endoscope, a thin, flexible tube with a

light and a small video camera on the end. The tube is put in through
your mouth, down your throat, and into your esophagus, stomach, and
small intestine.
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IMAGING (RADIOLOGY)
An imaging test is a way to let doctors see what’s going on inside your
body. These tests send forms of energy (like x-rays, sound waves,
radioactive particles, or magnetic fields) through your body. Your body
tissues change the energy patterns to make an image or picture. These
pictures show how your insides look and work so that health care
providers can see changes that may be caused by diseases like cancer.

Imaging tests provide a picture of the body’s interior—of the whole

body or part of it. Imaging helps doctors diagnose a disorder, determine
how severe the disorder is, and monitor people after the disorder is
diagnosed. Most imaging tests are painless, relatively safe, and
noninvasive (that is, they do not require an incision in the skin or the
insertion of an instrument into the body).
Imaging tests may use the following:
 Radiation, as in x-rays, angiography, computed tomography (CT),
and radionuclide scanning including positron emission
tomography (PET)
 Sound waves, as in ultrasonography
 Magnetic fields, as in magnetic resonance imaging (MRI)
 Substances that are swallowed, injected, or inserted to highlight or
outline the tissue or organ to be examined (called contrast agents)

There are some risks of using radiation in medical imaging.

For information regarding imaging tests common for specific diagnoses
and screenings, see the following:
 Heart and Blood Vessel Disorders
 Lung Disorders
 Musculoskeletal Disorders
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 Brain, Spinal Cord, and Nerve Disorders

 Digestive Disorders
 Liver and Gallbladder Disorders
 Urinary Tract Disorders
 Eye Disorders
 Gynecologic Disorders
 Medical Care During Pregnancy: Ultrasonography
 Mammography

Types of imaging tests

Many different kinds of scans are used to get images of what’s

happening inside the body. Some of the more common types of
imaging tests, how they are done, and when you might need them can
be found in these sections:

 Computed tomography (CT) scan

 Magnetic resonance imaging (MRI) scan
 Breast MRI
 X-rays and other radiographic tests
 Mammography
 Nuclear medicine scans (bone scans, PET scans, Thyroid scans,
MUGA scans, gallium scans)
 Ultrasound
The tests your health care provider recommends may depend on a
number of factors, such as:

 Where the tumor is and what type it is. Some imaging tests work
better for certain parts of the body
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 Whether or not a biopsy (tissue sample) is needed

 Your age, gender, and overall health
 The balance between any risks or side effects and the expected
benefits
 Your preference
 Cost

Contrast Agents

 During imaging tests, contrast agents may be used to distinguish

one tissue or structure from its surroundings or to provide greater
detail.
 Contrast agents include
 Radiopaque contrast agents (sometimes inaccurately called dyes):
Substances that can be seen on x-rays
 Paramagnetic contrast agents: Substances that are used
in magnetic resonance imaging (MRI)

ANGIOGRAPHY

 In angiography, x-rays are used to produce detailed images of

blood vessels. It is sometimes called conventional angiography to
distinguish it from computed tomography (CT)
angiography and magnetic resonance angiography (MRA). During
angiography, doctors can also treat disorders of blood vessels.
Angiography, although invasive, is relatively safe.
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 Angiography can provide still images or motion pictures (called

cineangiography). Cineangiography can show how fast blood
travels through blood vessels. (See also Coronary
Angiography and Overview of Imaging Tests.)

Uses of Angiography

 Angiography is used to check for abnormalities in blood vessels,

usually arteries. Abnormalities may include
 Blockages
 Narrowing
 Abnormal connections between arteries and veins (arteriovenous
malformations)
 Inflammation (vasculitis)
 Bulges (aneurysms) in a weakened blood vessel wall
 Tears (dissection) in a blood vessel wall
 During angiography, procedures to treat the abnormalities
detected can sometimes be done:
 Narrowed arteries can be widened.
 Blockages can be removed.
 A tube made of wire mesh (stent) can be placed to keep an artery
open.
 Tears or weakened areas in a blood vessel can be repaired.
 Blood flow to tumors or arteriovenous malformations can be
blocked.
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COMPUTED TOMOGRAPHY (CT)

 In computed tomography (CT), which used to be called computed

axial tomography (CAT), an x-ray source and x-ray detector rotate
around a person. In modern scanners, the x-ray detector usually
has 4 to 64 or more rows of sensors that record the x-rays that
pass through the body. Data from the sensors represent a series
of x-ray measurements taken from multiple angles all around the
person. However, the measurements are not viewed directly but
are sent to a computer. The computer converts them into images
that resemble 2-dimensional slices (cross-sections) of the body.
(Tomo means slice in Greek.) The computer can also construct 3-
dimensional images from the recorded images.

USES OF CT

 The highly detailed images provide more detail about tissue

density and location of abnormalities than plain x-rays, so doctors
can precisely locate structures and abnormalities. CT enables the
examiner to distinguish between different types of tissue, such as
muscle, fat, and connective tissues. Thus, CT can provide detailed
images of specific organs not visible on plain x-rays and is more
useful for imaging most structures in the brain, head, neck, chest,
and abdomen.
 CT can detect and provide information about disorders in almost
every part of the body. For example, doctors can use CT to detect
a tumor, measure its size, precisely locate it, and determine how
far it has spread into nearby tissues. CT can also help doctors
monitor the effectiveness of treatment (such as antibiotics for a
brain abscess or radiation therapy for a tumor).

MAGNETIC RESONANCE IMAGING (MRI)

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 In magnetic resonance imaging (MRI), a strong magnetic field and

very high frequency radio waves are used to produce highly
detailed images. MRI does not use x-rays and is usually very safe.

USES OF MRI

 MRI is preferred to computed tomography (CT) when doctors

need more detail about soft tissues—for example, to image
abnormalities in the brain, spinal cord, muscles, and liver. MRI is
particularly useful for identifying tumors in these tissues.
 MRI is also used to do the following:
 Measure certain molecules in the brain that distinguish a brain
tumor from a brain abscess
 Identify abnormalities in female reproductive organs and
fractures in the hip and pelvis
 Help doctors evaluate joint abnormalities (such as tears in
ligaments or cartilage in the knee) and sprains
 Help doctors evaluate bleeding and infection
 MRI is also used when the risks of CT are high. For example, MRI
may be preferred for people who have had a reaction to
the iodinated contrast agents used in CT and for pregnant women
(because radiation can cause problems in the fetus).
 MRI done after a gadolinium contrast agent is injected into a vein
helps doctors evaluate inflammation, tumors, and blood vessels.
Injecting this agent into a joint helps doctors get a clearer picture
of joint abnormalities, particularly if they are complex (as in
injuries or degeneration of ligaments and cartilages in the knee).
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UNIT – 7 OXYGENATION NEEDS

REVIEW OF CARDIOVASCULAR AND RESPIRATORY
PHYSIOLOGY
CARDIOVASCULAR PHYSIOLOGY

The human cardiovascular system is composed of a heart which pumps

blood through a closed system of blood vessels. The heart is composed
mostly of cardiac muscle, or myocardium. Its primary function is to
transport nutrients, water, gases, wastes, and chemical signals
throughout the body. More information on the heart as a pump, blood
flow and control of blood pressure, and components of blood will be
discussed in related pages.

The cardiovascular system transports materials throughout the body:

1. Materials entering the body, such as oxygen via the lungs and
nutrients and water via the intestinal tract, are carried to all cells.
2. Materials moved from cell to cell (intercellular communication)
including:
a) wastes products from some cell cells to the liver for processing;
b) immune cells that are present in the blood continuously for other
cells,
c) hormones from endocrine cells to their target cells
d) stored nutrients from liver and adipose tissue to all cells.
3. Materials that are expelled from the body, such as metabolic wastes,
heat, and carbon dioxide that are removed via the kidneys, skin, and
lungs, respectively.

As a general overview, the cardiovascular system is composed of the

heart, the blood vessels (or vasculature), and the cells and plasma of
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the blood.
1. Arteries are blood vessels that carry blood away from the heart and
veins return the blood to the heart. A system of valves in the heart and
veins ensures that the blood flows in one direction.
2. The heart is anatomically divided into two halves by a central wall, or
septum, into left and right halves. Each half is composed of an atrium
which receives blood returning to the heart and a ventricle that pumps
the blood out into the blood vessels that serve the body. The atria and
ventricles and exiting blood vessels are separated by closable valves.
Functionally, the heart serves as a pump in series that generates
pressure to propel the blood through the system.
3. The lungs are oxygen is picked up and carbon dioxide is expelled. The
pulmonary circulation goes from the right side of the heart
(deoxygenated blood) and returns it to the left side of the heart, with
oxygenated blood.
4. The systemic circulation consists of the vessels that go from the left
side of the heart to the tissues and back to the right side of the heart.

The systemic circulation and the pulmonary circulation can be traced

together:
Deoxygenated blood returning from body enters the heart in the right
atrium. From the right atrium the blood passes through the tricuspid
valves to enter the right ventricle. The blood is then pumped into the
pulmonary arteries, passing the pulmonic valves, where it goes to the
lungs. After becoming oxygenated in the lung's capillaries, the blood is
carried by the pulmonary veins to the left atrium. It then passes
through the bicuspid or mitral valves into the left ventricle, where it is
pumped into the aorta through the aortic valves. The aorta branches
into smaller and smaller arteries that finally lead to capillary beds in the
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tissue. Here oxygen is exchanged for carbon dioxide and returned via
veins which join into the inferior vena cava (veins coming from the
lower body) and superior vena cava (from the upper body). The IVC and
the SVC empty into the right atrium.

RESPIRATORY PHYSIOLOGY
The Lungs and Respiratory System allow us to breathe.

They bring oxygen into our bodies (called inspiration, or inhalation) and
send carbon dioxide out (called expiration, or exhalation).

 The respiratory system of animals is crucial for the life as it allows

the exchange of gases between an organism and the environment.
 This exchange of oxygen and carbon dioxide is called respiration.
 The average human exhales 0.35 L of water each day. The amount
varies with air temperature, relative humidity, and level of activity,
so the range is probably 0.3 L to 0.45 L per day.
 Dysfunction of the respiratory system ultimately leads to hypoxia.
There are four classifications of hypoxia etiology: hypoventilation,
right-to-left-shunt, V/Q mismatch, and diffusion limitations.

The cells in our bodies need oxygen to stay alive. Carbon dioxide is a by-
product of respiration. The lungs and respiratory system allow oxygen
in the air to be taken into the body, while also letting the body get rid
of carbon dioxide in the air breathed out.

 When you breathe in, the diaphragm moves downward toward the
abdomen, and the rib muscles pull the ribs upward and outward
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(making the chest cavity bigger and pulling air through the nose or
mouth into the lungs). See muscles of Respiration.
 In exhalation, the diaphragm moves upward and the chest wall
muscles relax, which causes the chest cavity to get smaller and push
air out of the respiratory system through the nose or mouth.
 With each inhalation, air fills a large portion of the millions of alveoli.
Oxygen diffuses from the alveoli to the blood through the capillaries
lining the alveolar walls. Once in the bloodstream, oxygen gets
picked up by the hemoglobin in red blood cells. This oxygen-rich
blood then flows back to the heart, which pumps it through the
arteries to oxygen needy tissues throughout the body.
 In the capillaries of the body tissues, oxygen is freed from the
hemoglobin and moves into the cells.
 Carbon dioxide produced moves out of the cells into the capillaries,
where most of it dissolves in the plasma of the blood.
 Blood rich in carbon dioxide then returns to the heart via the veins.
 From the heart, this blood is pumped to the lungs, where carbon
dioxide passes into the alveoli to be exhaled.

FACTORS AFFECTING RESPIRATORY FUNCTIONING

There are several factors affects the respiratory functioning. They are

 Sleep
 CO2 is higher
 O2 is lower
 Ventilation is lower
 Inspiratory decreases
 Rib cage contribution to ventilation increases
 Airway resistance increases
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 Obesity
 Adipose tissue around the rib cage and abdomen loads the
chest wall, therefore reducing functional capacity
 Decreased lung compliance
 More weight to carry = more energy/O2 used
 Risks for surgery = heart attacks, wound infection, nerve
injury, urinary tract infections

 Smoking
 Leads to overproduction of mucus
 Paralyses the cilia, meaning they do not work (cannot propel
mucus upwards/cannot trap bacteria)
 Tobacco can destroy lung elastic walls, decreasing
expandability capacity
 Cause lung cancer, many lung diseases, etc

 Stress
 Makes you breathe harder (leading to hyperventilation/pain
attack)
 Leads you to exercise – leading to an increased metabolism
of working muscles – increasing O2 demands
 Tidal volume increases

 Immobility
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 Lung volume changes = tidal volume decreases//residual

volume increases//amount of air that can get into lungs is
reduced
 Mucus gets stuck in the airways easier
 Diameter of airways decreases causing fewer but deeper
breaths
 Decrease O2 consumption as less energy is needed

 Exercise
 Increases O2 consumption, delivery and extraction
 Benefits = decrease in weight, increase muscle strength, get
rid of fatty acids (cholesterol), improves general health

ALTERATIONS IN RESPIRATORY FUNCTIONING

Alterations in Respiratory Function

Common Signs and Symptoms of Respiratory Alteration

 Coughing - accumulation of secretions, irritating or destructive

substances
 Dyspnea - lung/heart/neuromuscular causes
 Altered Breathing Patterns
 Apnea--- Bradypnea ---Tachypnea
 Hypoventilation --- Hyperventilation
 Patterns - Cheyne-Stokes

Ventilation Determinants and Deterrents

 NEED
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 patent airways with adequate diameter

 neuromuscular pump
 surfactant to reduce alveolar surface tension

 REDUCED by
 bronchospasm
 mucus plugs
 loss of elasticity
 thickening of airway
 trauma, anesthesia
 premature birth
 destruction of surfactant

PERFUSION OF LUNGS

 NEED
 Evenly distributed pulmonary blood flow
 Low pressure/low flow
 Match of V/Q
 REDUCED by
 Positional changes
 Obstruction - emboli
 Vasoconstriction
 Pulmonary hypertension
 Areas of poor ventilation

DIFFUSION

 NEED
 Partial pressure differences in gases
 Adequate surface area in alveoli
 Minimal distance for diffusion
 REDUCED by
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 Low oxygen partial pressure

 Decreased area due to emphysema, lung cancer, deficient
surfactant
 Pulmonary edema, exudate

GAS TRANSPORT

 NEED
 Partial pressure of oxygen above 80 mm in alveoli, arterial blood
 Hemoglobin and RBCs to transport gases

 REDUCED by
 Shifts in Hgb-O2 dissociation curve - Binding of Hgb-oxygen
affected pH, pCO2, temp., 2,3DPG
 Hypoxemia
 Anemia

CONDITIONS AFFECTING AIRWAY, MOVEMENT OF AIR,

DIFFUSION AND OXYGEN TRANSPORT
AIRWAY
Airway diseases -- These diseases affect the tubes (airways) that carry
oxygen and other gases into and out of the lungs. They usually cause a
narrowing or blockage of the airways. Airway diseases include asthma,
chronic obstructive pulmonary disease (COPD) and bronchiectasis.
People with airway diseases often say they feel as if they're "trying to
breathe out through a straw."

Types of Airway Conditions

Airway conditions include:

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Asthma: A chronic lung condition that causes inflammation and

narrowing of the airway

Benign airway tumors: Noncancerous masses that arise in the airway

Lung diseases: Including chronic obstructive pulmonary disease (COPD)

and cystic fibrosis

Airway stenosis: A narrowing of the airway

Airway cancer: A rare cancer that occurs in the airway

Airway fistulas: Holes that occur in the membranes that separate the
airway from adjacent structures

MOVEMENT OF AIR
Asthma also causes swelling of the airways and mucus in the lungs, but
it's a chronic -- usually lifelong -- condition rather than a temporary one
caused by an infection. If you have asthma, your lung capacity may be
lower because swelling and mucus limit the movement of air in your
lungs. During an asthma attack, the airways narrow, which may make
you wheeze and can become dangerous.

DIFFUSION
Gas exchange is the process by which oxygen and carbon dioxide move
between the bloodstream and the lungs. This is the primary function of
the respiratory system and is essential for ensuring a constant supply
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of oxygen to tissues, as well as removing carbon dioxide to prevent its

accumulation.

The movement of gases in a contained space (in this case, the lungs) is
random, but overall diffusion results in movement from areas of high
concentration to those of low concentration. The rate of diffusion of a
gas is primarily affected by

 Concentration gradient: The greater the gradient, the faster the

rate.
 Surface area for diffusion: The greater the surface area, the faster
the rate.
 Length of the diffusion pathway: The greater the length of the
pathway, the slower the rate.

Factors That Affect the Rate of Diffusion

There are many properties which can affect the rate of diffusion in the
lungs. The main factors include:

Membrane thickness – the thinner the membrane, the faster the rate
of diffusion. The diffusion barrier in the lungs is extremely thin,
however some conditions cause thickening of the barrier, thereby
impairing diffusion. Examples include:

 Fluid in the interstitial space (pulmonary oedema).

 Thickening of the alveolar membrane (pulmonary fibrosis).

Membrane surface area – the larger the surface area, the faster the
rate of diffusion. The lungs normally have a very large surface area for
gas exchange due to the alveoli.
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 Diseases such as emphysema lead to the destruction of

the alveolar architecture, leading to the formation of large air-
filled spaces known as bullae. This reduces the surface area
available and slows the rate of gas exchange.

Pressure difference across the membrane

Diffusion coefficient of the gas

OXYGEN TRANSPORT
Factors Affecting Oxygen Affinity
Various factors can affect the affinity of haemoglobin for oxygen:

 pH/pCO2 – When H+/pCO2 increases and pH decreases, Hb enters the T

state and its affinity for oxygen decreases. This is known as the Bohr
effect. Inversely, when H+/pCO2 decreases and pH increases, the
affinity of haemoglobin for oxygen increases.
 2,3-diphosphoglycerate (2,3-DPG) – 2,3-DPG, sometimes referred to as
2,3-BPG, is a chemical found in red blood cells from the glucose
metabolic pathway. 2,3-DPG binds to the beta chains of haemoglobin,
so increased 2, 3-DPG levels results in it binding to haemoglobin,
decreasing the affinity of haemoglobin for oxygen. Inversely, when
there are decreased 2,3-DPG levels, for example when there is
decreased tissue metabolism, there are less 2,3-DPG molecules binding
to haemoglobin, hence it has a higher affinity for oxygen as there are
more opportunities for it to bind.
 Temperature – At increased temperatures, for example in active
muscles, there is an increase in heat production which decreases the
affinity of haemoglobin for oxygen. At decreased temperatures, for
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example when there is decreased tissue metabolism, there is decreased

heat production and the affinity of haemoglobin for oxygen increases.

The affinity of haemoglobin for oxygen also results in a shift in

the oxyhaemoglobin dissociation curve. An increase in oxygen affinity
results in the curve shifting to the left, whereas a decrease in oxygen
affinity results in the curve shifting to the right.

ALTERATIONS IN OXYGENATION
Oxygen is necessary to sustain life. The cardiac and respiratory systems
supply the oxygen demands of the body. Blood is oxygenated through
the mechanisms of ventilation, perfusion, and transport of respiratory
gases. Neural and chemical regulators control the rate and depth of
respiration in response to changing tissue oxygen demands. The
cardiovascular system provides the transport mechanisms to distribute
oxygen to cells and tissues of the body.

Alterations in Respiratory Functioning

Illnesses and conditions affecting ventilation or oxygen transport cause

alterations in respiratory functioning. The three primary alterations are
hypoventilation, hyperventilation, and hypoxia.

The goal of ventilation is to produce a normal arterial carbon dioxide

tension (PaCO2) between 35 and 45 mm Hg and a normal arterial
oxygen tension (PaO2) between 80 and 100 mm Hg. Hypoventilation
and hyperventilation are often determined by arterial blood gas
analysis. Hypoxemia refers to a decrease in the amount of arterial
oxygen. Nurses monitor arterial oxygen saturation (SpO2) using a
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noninvasive oxygen saturation monitor pulse oximeter. Normally

SpO2 is greater than or equal to 95%.

Hypoventilation.

Hypoventilation occurs when alveolar ventilation is inadequate to meet

the oxygen demand of the body or eliminate sufficient carbon dioxide.
As alveolar ventilation decreases, the body retains carbon dioxide. For
example, atelectasis, a collapse of the alveoli, prevents normal
exchange of oxygen and carbon dioxide. As more alveoli collapse, less
of the lung is ventilated, and hypoventilation occurs.

In patients with COPD, the administration of excessive oxygen results in

hypoventilation. These patients have adapted to a high carbon dioxide
level so their carbon dioxide–sensitive chemoreceptors are essentially
not functioning. Their peripheral chemoreceptors of the aortic arch and
carotid bodies are primarily sensitive to lower oxygen levels, causing
increased ventilation. Because the stimulus to breathe is a decreased
arterial oxygen (PaO2) level, administration of oxygen greater than 24%
to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm
Hg) that stimulates the peripheral receptors, thus destroying the
stimulus to breathe. The resulting hypoventilation causes excessive
retention of carbon dioxide, which can lead to respiratory acidosis and
respiratory arrest.

Signs and symptoms of hypoventilation include mental status changes,

dysrhythmias, and potential cardiac arrest. If untreated, the patient’s
status rapidly declines, leading to convulsions, unconsciousness, and
death.

Hyperventilation.
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Hyperventilation is a state of ventilation in which the lungs remove

carbon dioxide faster than it is produced by cellular metabolism. Severe
anxiety, infection, drugs, or an acid-base imbalance induces
hyperventilation. Acute anxiety leads to hyperventilation and
exhalation of excessive amounts of carbon dioxide. Increased body
temperature (fever) increases the metabolic rate, thereby increasing
carbon dioxide production. The increased carbon dioxide level
stimulates an increase in the patient’s rate and depth of respiration,
causing hyperventilation.

Hyperventilation is sometimes chemically induced. Salicylate (aspirin)

poisoning and amphetamine use result in excess carbon dioxide
production, stimulating the respiratory center to compensate by
increasing the rate and depth of respiration. It also occurs as the body
tries to compensate for metabolic acidosis. For example, the patient
with diabetes in ketoacidosis produces large amounts of metabolic
acids. The respiratory system tries to correct the acid-base balance by
overbreathing. Ventilation increases to reduce the amount of carbon
dioxide available to form carbonic acid. This can also result in the
patient developing respiratory alkalosis. Signs and symptoms of
hyperventilation include rapid respirations, sighing breaths, numbness
and tingling of hands/feet, light-headedness, and loss of consciousness.

Hypoxia.

Hypoxia is inadequate tissue oxygenation at the cellular level. It results

from a deficiency in oxygen delivery or oxygen use at the cellular level.
It is a life-threatening condition. Untreated it produces possibly fatal
cardiac dysrhythmias.
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Causes of hypoxia include (1) a decreased hemoglobin level and

lowered oxygen-carrying capacity of the blood; (2) a diminished
concentration of inspired oxygen, which occurs at high altitudes; (3) the
inability of the tissues to extract oxygen from the blood, as with cyanide
poisoning; (4) decreased diffusion of oxygen from the alveoli to the
blood, as in pneumonia; (5) poor tissue perfusion with oxygenated
blood, as with shock; and (6) impaired ventilation, as with multiple rib
fractures or chest trauma.

The clinical signs and symptoms of hypoxia include apprehension,

restlessness, inability to concentrate, decreased level of consciousness,
dizziness, and behavioral changes. The patient with hypoxia is unable to
lie flat and appears both fatigued and agitated. Vital sign changes
include an increased pulse rate and rate and depth of respiration.
During early stages of hypoxia the blood pressure is elevated unless the
condition is caused by shock. As the hypoxia worsens, the respiratory
rate declines as a result of respiratory muscle fatigue.

Cyanosis, blue discoloration of the skin and mucous membranes caused

by the presence of desaturated hemoglobin in capillaries, is a late sign
of hypoxia. The presence or absence of cyanosis is not a reliable
measure of oxygen status. Central cyanosis, observed in the tongue,
soft palate, and conjunctiva of the eye where blood flow is high,
indicates hypoxemia. Peripheral cyanosis, seen in the extremities, nail
beds, and earlobes, is often a result of vasoconstriction and stagnant
blood flow.
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NURSING INTERVENTIONS TO PROMOTE

OXYGENATION: ASSESSMENT, TYPES, EQUIPMENT USED
AND PROCEDURE
MAINTENANCE OF PATENT AIRWAY
 Airway is called patent whenever there is an open pathway
between a patient’s lungs and the outside world
 An airway obstruction is a blockage in the airway. It may partially
or totally prevent air from getting into your lungs

Causes of Airway Obstruction

1. Foreign body inhalations

2. Allergic/anaphylactic reactions
3. Respiratory tract infections – diphtheria, epiglotitis
4. Trauma – burns, steam inhalations, penetrating injuries
5. Altered consciousness – head injuries, alcohol and drug overdose,
cardio respiratory arrest

How the Airway is Maintained Patent?

 Coughing is the main mechanism for clearing the airway

 The cough may be ineffective in disease states such as pain from
surgical incisions/trauma, respiratory muscle fatigue or
neuromuscular weakness
 Other mechanisms that exist in the lower bronchioles and alveoli
to maintain the airway include the muco-ciliary system and
macrophages
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Signs of Airway Obstruction

 Abnormal breath sounds

 Changes in respiratory rate or depth
 Cough
 Hypoxemia
 Cyanosis
 Dyspnea
 Chest wheezing
 Tachycardia

Interventions to Maintain Patent Airway

 Assist patient in performing deep breathing and coughing

exercises
 Instruct patient in the following:
 Optimal positioning (sitting position)
 Use of pillow or hand splints when coughing
 Use of abdominal muscles for more forceful cough
 Use of incentive spirometry
 Importance of ambulation and frequent position changes
 If cough is ineffective use suctioning as needed to remove
sputum and mucus plugs
 Encourage adequate intake of fluids to prevent dehydration
 Administer medications (e.g. antibiotics, mucolytic agents,
bronchodilators, expectorants) as ordered
 Consult respiratory therapist for chest physiotherapy
 Instruct patient how to use prescribed inhalers
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 Provide steam inhalation to clear the secretions

 If the obstruction is not resolved insert artificial airway

Artificial airways

Most common invasive air ways are

a. Oropharyngeal airway
b. Naso pharyngeal airway
c. Tracheal intubation
 Surgical management:
 Tracheotomy – is a surgically created opening from the skin of the
neck down to the trachea

OXYGEN ADMINISTRATION
Oxygen (O2) is administered as a corrective treatment for conditions
resulting in hypoxia (low level of oxygen in the blood). Oxygen is classed
as a medication and must be prescribed by a doctor and administered
correctly to prevent over or under-oxygenation. Remember oxygen is
non flammable, but it does aid combustion. Patients and visitors should
therefore be educated about the increased risk of fire and the
precautions necessary to reduce the risk when supplementary oxygen is
in use.

Oxygen must only be administered at the rate and percentage

prescribed, as over-oxygenation can be dangerous for some individuals,
particularly those with dangerous for some individuals, particularly
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those with chronic lung disease who are retaining carbon dioxide, and
infants, where there is also a risk of retinopathy.

DEFINITION

Oxygen administration treats the effects of oxygen deficiency

(anoxemia) but it does not correct the underlying causes.

Oxygen therapy is important to keep a healthy level of tissue

oxygenation

INDICATIONS

 Breathlessness due to asthma, pulmonary embolism, emphysema,

cardiac insufficiencies, etc
 Obstructed airway due to growth, enlarged thyroid
 Cyanosis
 Shock and circulatory failure
 After severe hemorrhage
 Anemia
 Patients under anesthesia
 Asphyxia due to any reason, e.g. drowning, inhalation of
poisonous gases, hanging, etc
 Poisoning with chemicals that alter the tissues ability to utilize
oxygen, e.g. cyanide poisoning
 Carbon monoxide poisoning
 Postoperative chest surgery and thyroidectomies
 Insufficient oxygen in atmosphere
 Air hunger
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PURPOSE

 To supply O2 in conditions when there is interference with normal

oxygenation of blood
 To reduce the effects of anoxemia
 To maintain healthy level is tissue oxygenation

CLASSIFICATIONS

Oxygen is administered by either low flow or high flow systems. Low

flow administration devices include nasal cannula, oxygen mask, oxygen
tent, etc. high flow administration devices include venturi mask, some
devices can be used for both low and high flow administration, e.g.
oxygen hood incubator, etc

Nasal Cannula

It is the most important low flow device used to administer oxygen of a

rubber or plastic tube that extends around the face. Curved prongs that
fit into the nostrils. One side of the tube connects to oxygen tubing and
oxygen supply. The cannula is often held in place by an elastic band that
fits around the clients head or under the chin

The nasal cannula is easy to apply and does not interfere with client’s
ability to eat or talk. It is very comfortable and permits some freedom
of movement. Oxygen is delivered via the cannula with a flow rate of up
to 4 L/min. higher flow rates dry air mucous and do not further
increases inspired oxygen concentrations

Equipment
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 Oxygen supply with a flow meter

 Humidifier with sterile distilled water
 Nasal cannula and tubing
 Tape if needed to secure the cannula in place
 Gauze to pad the tubing over the cheek

Procedure

 Determine the need for oxygen therapy and the physicians order
 Assist the client to a semi-Fowler’s position as possible. It permits
easier chest expansion easier breathing
 Explain about the procedure and inform the client and support
persons about safety precautions connected with oxygen use
 Set-up the oxygen equipment and humidified
 Turn on the oxygen at the prescribed rate and ensure proper
functioning
 Put the cannula over the clients face
 If the cannula will not stay in place tape if at sides of face
 Slip gauze pads under the tubing over the cheek bones to prevent
skin irritation as necessary
 Assess the client regularly
 Assess the vital signs, color, breathing pattern and chest
movement
 Check the equipment are working regularly
 Make sure that safety precautions are being followed
 Record initiation of therapy and all nursing assessments

Nasal Catheters
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Nasal catheters are used infrequently, but they are not absolute. The
procedure involves inserting an oxygen catheter into the nose to the
nasopharynx. Because securing the catheter must be changed at least
every 8 hours and inserted into the other nostril, for this reason, the
nasal catheter is a less described method because the client may have
pain when the catheter is passed into nasopharynx and because trauma
can occur to the nasal mucosa. The nasal catheter permits free
movements for the patient and nursing care may be given with much
more ease

Oxygen Mask

An oxygen mask is a device used to administer oxygen, humidity it is

shaped to fit tightly over the mouth and nose and is secured in place
with a strap. There are four types of oxygen masks:

1. Simple face masks: used for short-term oxygen therapy. If delivers

O2 concentration from 40 to 60% at liter flows of 5-8 liter per
minute
2. The partial rebreather mask: delivers O2 concentrated of 60-90%
liter flows of 6-10 L per minute
3. The nonbreather mask: delivers the highest O2 can possible by
means other than inhibition or mechanical ventilation that is 95-
100% at liter flows of 6-15 L/minute
4. Venturi mask: delivers O2 can precise to with 1.1 and is often used
for clients with COPD O2 can at from 24-40% /50% depending on
the brand at liter flows of 4-8 L/minute. Initiating oxygen by mask
in mucus the same as initiating O2 by cannula
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Oxygen Tent

Fact tents can replace oxygen mask when masks are poorly tolerated by
clients. When a face tent alone is used to supply oxygen, the
concentration of 2 varies, therefore, if is often used in conjunction with
a venture system. Face tents provide varying concentration of O2 at 8-
10 L/minute

An oxygen tent consists of canopy over the patient’s bed that may
cover the patient fully or partially and it is connected to a supply of O2
the canopies are transparent and enables the nurse to observe the
patient. The lower part of canopy is tucked under the bed to prevent
the escape of O2. There are some advantages and disadvantages for
using oxygen tent these are:

 If provides an environment for patient with controlled

concentration, temperature regulation and humidity control
 It allows freedom for free movement in bed
 It creates feeling of isolation
 There is an increased chance of fire
 It requires much time and effort to clean and maintain a tent
 Loss of desired concentration occurs each time the tent is opened
to provide care for patient
 Since it requires high volume of oxygen, it cannot be made
available ordinarily

General Instructions

 Since oxygen acts as a drug. It must be prescribed and

administered in specific dose in order to avoid oxygen toxicity.
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The dosage of O2 is started in terms of concentration and rate of

flow
 When using oxygen cylinder uses a regulator and humidifiers. The
purpose of the regulator is to reduce the pressure of the O2 in the
cylinder to a safer level. The humidifier helps to saturate the
oxygen with water vapor to prevent the drying of the mucus
membranes of respiratory tract
 The glass tube should be summered under the water so that
oxygen is bubbled through the water
 Every water of the apparatus should be clean to prevent infection
 Use disposable nasal catheters or sterilized rubbed catheters
 Change the nasal catheters at least every 8 hours or more often
 Lubricate the nasal catheter sparingly while the O2 is flowing.
Then hold tip of the catheter in a glass of H2O to make sure that
the terminal holes are not plugged with lubricant
 During the administration of O2 the valve controlling the rate of
flow should not be handled if any alternation is to be made in the
flow of O2 first take out the catheter from the nose and then
adjust the valve
 Oxygen administration must never be stopped until the factors
that caused hypoxia are reversed
 When oxygen therapy is disconnected, it should be done
gradually. The patient is weaned from dependence on oxygen by
reducing the dosage and then administrating it intermittently
 For all patients receiving oxygen inhalation, the temperature
should be taken rectally to get an accurate record of body
temperature
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 When the nurse leaves the patient even for a short period, she
should leave a calling signal near the patient
 Pay attention to conditions that can interfere with the flow of
oxygen from the source to the patient. This may include kinks in
the tubing loose connection and faulty humidifying apparatus.
Remember that it is not unusual therapy is generally getting less
oxygen than he would get under normal circumstances
 To prevent the deprivation of oxygen resulting from the depletion
of oxygen from the cylinder the nurse should get a new one ready
at hand when the gauge shows about ¼ level of in the pressure
 For fear of retrolental fibroplasia the premature babies are given
oxygen inhalation only for a short period at a very low
concentration
 Watch the patients receiving oxygen therapy continuously to
detect the early signs of oxygen toxicity
 When oxygen is administered through the nasal catheters, the
catheter is not directed distension of abdomen
 Since oxygen supports combustion, fire precautions are to be
taken when the oxygen is a flow

Preparation of Patient and Environment

 Explain the procedure to the patient to win his confidence and

cooperation. Answer his questions and allay the anxiety. Explain
the sequence of the procedure and tell him how he can cooperate
in the procedure. Explain the purpose of the procedure to the
relatives also
 Instruct the patient the family members and the visitors, if any
about the safety precautions required during the oxygen therapy
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 Put-up the instructions regarding fire precautions in the unit

 Remove the cigars matches, electric appliances and other
inflammable articles from patient’s unit
 Assemble the equipment and arrange them conveniently in the
unit
 Place the patient in a comfortable position (Fowler’s position) to
help in the expansion of the lungs
 Clear the nostrils, if there is crust formation
 Protect the bed and garments by spreading the Mackintosh and
towel

EQUIPMENT

 Oxygen cylinder with its stand and accessories

 Nasal cylinder
 Water soluble lubricating jelly
 Adhesive tapes
 Bowl of water
 Flash light and tongue depressor
 Normal saline in a container
 Kidney tray
 Paper bag
 Mackintosh
 Towel rag pieces in a container

Procedure
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 Explain the procedures to the patient and relatives to get the

cooperation and win the confidence. What you are going to do
and reassure him. Explain the purpose of procedure.
 Put the instructions regarding the fire precautions in the ward or
unit. Instruct the relatives or visitors regarding safety measures
required during the oxygen inhalation
 Observe vital signs and breathing pattern
 Collect the necessary articles at the bedside
 Give comfortable position of the patient
 Screen the bed of the patient
 Wash hands to prevent cross-infection
 Measure catheter from the tip of the nose to ear label for
distance to enter, mark the length with ink
 Check the apparatus for working condition. Open the main valve
in an anti-clockwise direction. Observe for pressure reading on
the gauge. Open the wheel valve on the regulator and see the
reading on the meter adjust the flow of O2 2-4 L for adults or as
desired. When the wheel valve is opened the oxygen will start
bubbling through the water in the Wolf’s bottle. Attach the
catheter to the connecting tube oxygen will start bubbling
through the water in the Wolf’s bottle. Attach the catheter to the
connecting tube and check the flow of O2 through the catheter to
prevent by dipping it under the water in the bowl
 Lubricate the tip of catheter with water soluble jelly
 Bring catheter across cheek and scope securely with adhesive
tape
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After Care of the Patient

 Be with the patient fill he is at case

 Keep the patient warm and comfortable
 Observe the patient’s progress by assessing vital signs and color
 Observe patient’s progress at specified intervals to make sure that
the state of anoxemia is treated
 When the O2 is discontinued. Unscrew regulator liter flow
disconnect the catheter and put it in kidney tray
 Clean the catheter, fist with cold water, then with warm soapy
water and finally with clears water bill it for, 3-5 minutes, dry it
and store in a cool dry place
 All other articles must be cleaned with soap and clean water dried
and then replaced to their usual places
 Wash hands

Patient Education

 Educate the client and visitors about the hazard of smoking with
oxygen in use
 Request other clients in the room and visitors to smoke in areas
provided elsewhere in the hospitals
 Educate the patients about the short-circuit spark of electrical
equipment
 Educate the patient, about safety precautions

Complications
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 The use of contaminated equipment can spread infection in the

patient
 Fire is a potential hazard when oxygen is administered
 If there is no sufficient humidity, there is a chance of drying and
irritation of mucus membrane
 Prolonged exposure to a high concentration causes damage to the
lung tissue and atelectasis
 If there are increased oxygen concentration in inspired air, there
is a chance of collapse of alveoli
 The oxygen therapy may affect eyes
 Ulceration, edema and visual impairment, etc, result from the
toxic effects of O2 on the cornea and lens of adult

HOME OXYGEN THERAPY

Home oxygen therapy is available to clients who require continuous

oxygen therapy at home. It is usually delivered by nasal cannula

Purpose: to provide continuous oxygen therapy for patients

Preparation

 Explain the procedure step by step to the patient and their

relatives to confidence
 Explain about the safety precautions

Classification

In this therapy, 3 types of oxygen is used:

1. Compressed oxygen
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2. Liquid oxygen
3. Oxygen concentrations

Equipment

 Nasal cannula equipment

 Primary and portable liquid oxygen source for ambulation

Procedure

 Explain the procedure to client and family

 Wash hands
 Demonstrate steps for preparation ad completion of oxygen
therapy
 Prepare primary and portable oxygen
 Place primary oxygen source in clutter free environment
 Check oxygen level of both sources by reading gauge on top
 Check oxygen gauge to determine fullness of portable source
 Select prescribed rate
 Connect nasal cannula and O2 tubing to oxygen
 Have client and family perform each step with guidance from the
nurse

Patient Education

 Explain or teach about the home oxygen therapy

 The nurse coordinates the efforts of the client and family, home
call nurse, home respiratory therapist, and home oxygen
equipment vendor
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 The nurse must assist the client and family in learning about home
oxygen and ensure their ability to maintain the oxygen delivery
system

Complication: bulky, possibly unsightly, frequent refilling, necessary

with continuous use

CONSIDERATIONS

 Supplemental oxygen relieves hypoxemia but does not improve

ventilation or treat the underlying cause of the hypoxemia.
Monitoring the SpO2 indicates oxygenation not ventilation.
Therefore, beware the use of high FiO2 in the presence of reduced
minute ventilation
 Many children in the recovery phase of acute respiratory illnesses
are characterized by ventilation/perfusion mismatch (e.g. asthma,
bronchiolitis, and pneumonia) and can be managed with SpO2 in
the low 90’s as long as they are clinically improving, feeding well
and do not have obvious respiratory distress
 Normal SpO2 values may be found despite raising the blood
carbon dioxide levels (hypercapnia). High oxygen concentrations
have the potential to mask signs and symptoms of hypercapnia
 Oxygen therapy should be closely monitored and assessed at
regular intervals. Therapeutic procedures and handling may
increase the child’s oxygen consumption and lead to worsening
hypoxemia
 Children with cyanotic congenital heart disease normally have
SpO2 between 60-90% in room air. Increasing SpO2 >90% with
supplemental oxygen is not recommended due to risk of over
circulation to the pulmonary system while adversely decreasing
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systemic circulation. However, in emergency situations with

increasing cyanosis supplemental oxygen should be administered
to maintain their normal level of SpO2

COMPLICATIONS OF OXYGEN

CO2 Narcosis: this occurs in patients who have chronic respiratory

obstruction or respiratory insufficiency which results in hypercapnia
(i.e. raised PaCO2). In these patients the respiratory center relies on
hypoxemia to maintain adequate ventilation. If these patients are given
oxygen this can reduce their respiratory drive, causing respiratory
depression and a further rise in PaCO2

Monitoring of SpO2 or SaO2 informs of oxygenation only. Therefore,

beware of the use of high FiO2 in the presence of reduced minute
ventilation

Pulmonary Atelectasis

Pulmonary oxygen toxicity: high concentrations of oxygen (>60%) may

damage the alveolar membrane when inhaled for more than 48 hours
resulting in pathological lung changes

Retinopathy of prematurity (ROP): an alternation of the normal retinal

vascular development, mainly affecting premature neonates (<32
weeks gestation or 1250 g birth weight), which can lead to visual
impairment and blindness. Substernal pain-due: characterized by
difficulty in breathing and pain within the chest, occurring when
breathing elevated pressures of oxygen for extended periods

OXYGEN SAFETY
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Oxygen is not a flammable gas but it does support combustion (rapid

burning). Due to this, the following rules should be followed:

 Do not smoke in the vicinity of oxygen equipment

 Do not use aerosol sprays in the same room as the oxygen
equipment
 Turn off oxygen immediately when not in use. Oxygen is heavier
than air and will pool in fabric making the material more
flammable. Therefore, never leave the nasal prongs or mask
under or on bed coverings or cushions whilst the oxygen is being
supplied
 Oxygen cylinders should be secured safely to avoid injury
 Do not store oxygen cylinders in hot places
 Keep the oxygen equipment out of reach of children
 Do not use any petroleum products or petroleum byproducts, e.g.
petroleum jelly/Vaseline whilst using oxygen.

SUCTIONING – ORAL AND TRACHEAL

Suctioning

The upper airway warms, cleans and moistens the air we breathe. The
trach tube bypasses these mechanisms, so that the air moving through
the tube is cooler, dryer and not as clean. In response to these
changes, the body produces more mucus. Suctioning clears mucus
from the tracheostomy tube and is essential for proper breathing.
Also, secretions left in the tube could become contaminated and a
chest infection could develop. Avoid suctioning too frequently as this
could lead to more secretion buildup.
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1. Removing mucus from trach tube without suctioning

2. Bend forward and cough. Catch the mucus from the tube, not
from the nose and mouth.
3. Squirt sterile normal saline solutions (approximately 5cc) into the
trach tube to help clear the mucus and cough again.
4. Remove the inner tube (cannula).
5. Suction.
6. Remove the entire trach tube and try to place the spare tube.
7. Continue trying to cough, instill saline, and suction until breathing
is normal or help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube

and stopping the patient's breathing. Suctioning should be considered

 Any time the patient feels or hears mucus rattling in the tube or
airway
 In the morning when the patient first wakes up
 When there is an increased respiratory rate (working hard to
breathe)
 Before meals
 Before going outdoors
 Before going to sleep

The secretions should be white or clear. If they start to change color,

(e.g. yellow, brown or green) this may be a sign of infection. If the
changed color persists for more than three days or if it is difficult to
keep the tracheostomy tube intact, call your surgeon's office. If there is
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blood in the secretions (it may look more pink than red), you should
initially increase humidity and suction more gently. A Swedish or
artificial nose (HME), which is a cap that can be attached to the
tracheostomy tube, may help to maintain humidity. The cap contains a
filter to prevent particles from entering the airway and maintains the
patient's own humidity. Putting the patient in the bathroom with the
door closed and shower on will increase the humidity immediately. If
the patient coughs up or has bright red blood mucus suctioned, or if the
patient develops a fever, call your surgeon's office immediately.

How to suction

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

1. Wash your hands.

2. Turn on the suction machine and connect the suction connection
tubing to the machine.
3. Use a clean suction catheter when suctioning the patient.
Whenever the suction catheter is to be reused, place the catheter
in a container of distilled/sterile water and apply suction for
approximately 30 seconds to clear secretions from the inside.
Next, rinse the catheter with running water for a few minutes
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then soak in a solution of one part vinegar and one part

distilled/sterile water for 15 minutes. Stir the solution frequently.
Rinse the catheters in cool water and air-dry. Allow the catheters
to dry in a clear container. Do not reuse catheters if they become
stiff or cracked.
4. Connect the catheter to the suction connection tubing.
5. Lay the patient flat on his/her back with a small towel/blanket
rolled under the shoulders. Some patients may prefer a sitting
position which can also be tried.
6. Wet the catheter with sterile/distilled water for lubrication and to
test the suction machine and circuit.
7. Remove the inner cannula from the tracheostomy tube (if
applicable). The patient may not have an inner cannula. If that is
the case, skip this step and go to number 8.

a. There are different types of inner cannulas, so caregivers will

need to learn the specific manner to remove their patient's.
Usually rotating the inner cannula in a specific direction will
remove it.

b. Be careful not to accidentally remove the entire tracheostomy

tube while removing the inner cannula. Often by securing one
hand on the tracheostomy tube?s flange (neck plate) one can/ will
prevent?accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable,

then throw it out).
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8. Carefully insert the catheter into the tracheostomy tube. Allow

the catheter to follow the natural curvature of the tracheostomy
tube. The distance to the location of catheter becomes easier to
determine with experience. The least traumatic technique is to
pre-measure the length of the tracheostomy tube then introduce
the catheter only to that length. For example if the patient?s
tracheostomy tube is 4 cm long, place the catheter 4 cm into the
tracheostomy tube. Often, there will be instances when this
technique of suctioning (called tip suctioning) will not clear the
patient?s secretions. For those situations, the catheter may need
to be inserted several mm beyond the end of the tracheostomy
tube (called deep suctioning). With experience, caregivers will be
able to judge the distance to insert the tracheostomy tube
without measuring.
9. Place your thumb over the suction vent (side of the catheter)
intermittently while you remove the catheter. Do not leave the
catheter in the tracheostomy tube for more than 5-10 seconds
since the patient will not be able to breathe well with the catheter
in place.
10. Allow the patient to recover from the suctioning and to
catch his/her breath. Wait for at least 10 seconds.
11. Suction a small amount of distilled/sterile water with the
suction catheter to clear any residual debris/secretions.
12. Insert the inner cannula from extra tracheostomy tube (if
applicable).
13. Turn off suction machine and discard catheter (clean
according to step 3 if to be reused).
14. Clean inner cannula (if applicable).
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CHEST PHYSIOTHERAPY
Chest physical therapy (CPT or Chest PT) is an airway clearance
technique (ACT) to drain the lungs, and may include percussion
(clapping), vibration, deep breathing, and huffing or coughing.

With chest physical therapy (CPT), the person gets in different positions
to use gravity to drain mucus (postural drainage) from the five lobes of
the lungs. Each position is designed so that a major part of the lung is
facing downward. When combined with percussion, it may be known as
postural drainage and percussion (PD&P). This is where a caregiver or
partner can clap and or vibrate the person’s chest to further dislodge
and move the mucus to the larger airways where it can be coughed or
huffed out of the body.

CPT is easy to do. For a child with cystic fibrosis, CPT can be done by
anyone, including parents, siblings, and friends. It can also be done by
physical therapists, respiratory therapists, or nurses during care center
visits or in the hospital.

Procedure

With postural drainage, the person lies or sits in various positions so

the part of the lung to be drained is as high as possible. That part of the
lung is then drained using percussion, vibration, and gravity. Your care
team may tailor these positions to your or your child’s needs.

When the person with CF is in one of the positions, the caregiver can
clap on the person’s chest wall. This is usually done for three to five
minutes and is sometimes followed by vibration over the same area for
approximately 15 seconds (or during five exhalations). The person is
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then encouraged to cough or huff forcefully to get the mucus out of the
lungs.

Clapping (percussion) by the caregiver on the chest wall over the part of
the lung to be drained helps move the mucus into the larger airways.
The hand is cupped as if to hold water but with the palm facing down
(as shown in the figure below). The cupped hand curves to the chest
wall and traps a cushion of air to soften the clapping.

Percussion is done forcefully and with a steady beat. Each beat should
have a hollow sound. Most of the movement is in the wrist with the
arm relaxed, making percussion less tiring to do. If the hand is cupped
properly, percussion should not be painful or sting.

Special attention must be taken to not clap over the:

 Spine
 Breastbone
 Stomach
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 Lower ribs or back (to prevent injury to the spleen on the left, the
liver on the right and the kidneys in the lower back)

Different devices may be used in place of the traditional cupped palm

method for percussion.

Vibration is a technique that gently shakes the mucus so it can move

into the larger airways. The caregiver places a firm hand on the chest
wall over the part of the lung being drained and tenses the muscles of
the arm and shoulder to create a fine shaking motion. Then, the
caregiver applies a light pressure over the area being vibrated. (The
caregiver may also place one hand over the other, then press the top
and bottom hand into each other to vibrate.)

Vibration is done with the flattened hand, not the cupped hand (see the
figure below). Exhalation should be as slow and as complete as
possible.

Deep breathing moves the loosened mucus and may lead to coughing.
Breathing with the diaphragm (belly breathing or lower chest
breathing) is used to help the person take deeper breaths and get the
air into the lower lungs. The belly moves outward when the person
breathes in and sinks in when he or she breathes out.
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CARE OF CHEST DRAINAGE – PRINCIPLES AND

PURPOSES
Chest drains also known as under water sealed drains (UWSD) are
inserted to allow draining of the pleural spaces of air, blood or fluid,
allowing expansion of the lungs and restoration of negative pressure in
the thoracic cavity. The underwater seal also prevents backflow of air
or fluid into the pleural cavity. Appropriate chest drain management is
required to maintain respiratory function and haemodynamic stability.
Chest drains may be placed routinely in theatre, PICU and NICU; or in
the emergency department and ward areas in emergency situations.

Principles of underwater seal drainage

The underwater seal prevents air re-entering the pleural space. Usually,
the distal end of the drain tube is submerged 2cm under the surface
level of the water in the drainage (or collection) chamber. This creates a
hydrostatic resistance of +2cmH20 in the drainage chamber.

Normal intrapleural pressure is negative. However, if air or fluid enters

the pleural space, intrapleural pressure becomes positive. Air is
eliminated from the pleural space into the drainage chamber when
intrapleural pressure is greater than +2cmH20. Thus, air moves from a
higher to lower pressure along a pressure gradient. The drainage
chamber has a vent to allow air to escape the chamber, and not build
up within the chamber.

Fluids will drain by gravity into the drainage chamber, and will not spill
back into the pleural space if the bottle is always kept below the level
of the patient's chest. If the bottle needs to be lifted above the chest,
the tubing should be briefly double clamped as close to the patient as
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possible. The movement and unclamping should take place as quickly

as possible to minimise clamping time.

PULSE OXIMETRY – FACTORS AFFECTING

MEASUREMENTS OF OXYGEN SATURATION USING
PULSE OXIMETER, INTERPRETATION
Pulse oximetry is a test used to measure the oxygen level (oxygen
saturation) of the blood. It is an easy, painless measure of how well
oxygen is being sent to parts of your body furthest from your heart,
such as the arms and legs.

FACTORS AFFECTING MEASUREMENTS OF OXYGEN

 Blood pressure generally needs to be >80 SBP

 Vascular impingement from any cause
 AV fistula can decrease distal flow
 Elevation with respect to the heart
 Compression by the probe
 Cardiac arrest (don't use during arrest)
 Heart Rate extremes <30 or >200

Be aware that multiple factors can affect the accuracy of a pulse

oximeter reading, such as poor circulation, skin pigmentation, skin
thickness, skin temperature, current tobacco use, and use of fingernail
polish. To get the best reading from a pulse oximeter:

 Follow the manufacturer’s instructions for use.

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 When placing the oximeter on your finger, make sure your hand is
warm, relaxed, and held below the level of the heart. Remove any
fingernail polish on that finger.
 Sit still and do not move the part of your body where the pulse
oximeter is located.
 Wait a few seconds until the reading stops changing and displays
one steady number.

Interpretation of Oximetry Reading

 When taking pulse oximeter measurements, pay attention to

whether the oxygen level is lower than earlier measurements, or
are decreasing over time. Changes or trends in measurements
may be more meaningful than one single measurement. Over the
counter products that you can buy at the store or online are not
intended for medical purposes.
 Do not rely only on a pulse oximeter to assess your health
condition or oxygen level.
 If monitoring oxygen levels at home, pay attention to other signs
or symptoms of low oxygen levels, such as:
 Bluish coloring in the face, lips, or nails;
 Shortness of breath, difficulty breathing, or a cough that gets
worse;
 Restlessness and discomfort;
 Chest pain or tightness; and
 Fast or racing pulse rate.
 Be aware that some patients with low oxygen levels may not
show any or all of these symptoms. Only a health care provider
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can diagnose a medical condition such as hypoxia (low oxygen

levels).

RESTORATIVE AND CONTINUING CARE

The purpose of restorative care is to maintain a person’s highest level
of physical, mental, and psychosocial function in order to prevent
declines that impact quality of life.

Continuity of care is concerned with quality of care over time. It is the

process by which the patient and his/her physician-led care team are
cooperatively involved in ongoing health care management toward the
shared goal of high quality, cost-effective medical care.

Continuity of care is a hallmark and primary objective of family

medicine and is consistent with quality patient care provided through a
medical home. The continuity of care inherent in family medicine helps
family physicians gain their patients’ confidence and enables family
physicians to be more effective patient advocates. It also facilitates the
family physician's role as a cost-effective coordinator of the patient's
health services by making early recognition of problems possible.
Continuity of care is rooted in a long-term patient-physician partnership
in which the physician knows the patient’s history from experience and
can integrate new information and decisions from a whole-person
perspective efficiently without extensive investigation or record review.

Continuity of care is facilitated by a physician-led, team-based approach

to health care. It reduces fragmentation of care and thus improves
patient safety and quality of care.
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HYDRATION
Your body depends on water to survive. Every cell, tissue, and organ in
your body needs water to work properly. For example, your body uses
water to maintain its temperature, remove waste, and lubricate your
joints. Water is needed for overall good health.

You should drink water every day. Most people have been told they
should drink 6 to 8, 8-ounce glasses of water each day. That’s a
reasonable goal. However, different people need different amounts of
water to stay hydrated. Most healthy people can stay well hydrated by
drinking water and other fluids whenever they feel thirsty. For some
people, fewer than 8 glasses may be enough. Other people may need
more than 8 glasses each day.

An adequate daily fluid intake is:

 About 15.5 cups (3.7 liters) of fluids a day for men

 About 11.5 cups (2.7 liters) of fluids a day for women

HUMIDIFICATION
Humidifier therapy adds moisture to the air to prevent dryness that can
cause irritation in many parts of the body. Humidifiers can be
particularly effective for treating dryness of the skin, nose, throat, and
lips. They can also ease some of the symptoms caused by
the flu or common cold.

Humidity acts as a natural moisturizing agent that can relieve dryness.

For this reason, humidifiers are often used for relieving:
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 dry skin
 sinus congestion/headache
 dry throat
 nose irritation
 bloody noses
 irritated vocal cords
 dry cough
 cracked lips

Types of humidifiers

The type of humidifier you choose depends on your preferences,

budget, and the size of the area you want to add moisture to. There are
five types of humidifiers:

 central humidifiers
 evaporators
 impeller humidifiers
 steam vaporizers
 ultrasonic humidifiers

Humidifier sizes

Humidifiers are often classified as console or portable/personal.

Console units are meant to add moisture to the entire house. They’re
often very large, but usually have wheels so you can easily move them
around. Console units are meant to add moisture to one room.
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Personal (or portable) humidifiers are the smallest, and are the best
choice if you need a humidifier while traveling.

COUGHING TECHNIQUES
Coughing is the most basic airway clearance technique (ACT). It can be
an involuntary reflex or it can be controlled as a healthy, natural way
for the lungs to get rid of mucus.

Coughing moves mucus out of the large airways. However, moving

mucus out of the small airways requires airway clearance
techniques (ACTs). This is why coughing should be done with other
ACTs.

With cystic fibrosis, you shouldn't try to suppress coughs, or keep

yourself from coughing. Mucus is full of germs, so coughing it out of the
body is very important. To avoid the spread of germs, you can cough
into a tissue, throw it away and then clean your hands with an alcohol-
based hand gel. If you don't have a tissue, cough into your inner elbow.
If you cough into your hands, wash your hands immediately afterward.

If coughing a lot makes you feel worse, not better, you can try huffing.

Huffing

Huffing, also known as huff coughing, is a technique that helps move

mucus from the lungs. It should be done in combination with another
ACT. It involves taking a breath in, holding it, and actively exhaling.
Breathing in and holding it enables air to get behind the mucus and
separates it from the lung wall so it can be coughed out. Huffing is not
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as forceful as a cough, but it can work better and be less tiring. Huffing
is like exhaling onto a mirror or window to steam it up.

The Huff Coughing Technique:

 Sit up straight with chin tilted slightly up and mouth open.

 Take a slow deep breath to fill lungs about three quarters full.
 Hold breath for two or three seconds.
 Exhale forcefully, but slowly, in a continuous exhalation to move
mucus from the smaller to the larger airways.
 Repeat this maneuver two more times and then follow with one
strong cough to clear mucus from the larger airways.
 Do a cycle of four to five huff coughs as part of your airway
clearance.

BREATHING EXERCISES
Alternate-Nostril Breathing

Alternate-nostril breathing (nadi sodhana) involves blocking off one

nostril at a time as you breathe through the other, alternating between
nostrils in a regular pattern. It's best to practice this type of breathing in
a seated position in order to maintain your posture.

 Position your right hand by bending your pointer and middle

fingers into your palm, leaving your thumb, ring finger, and pinky
extended. This is known as Vishnu mudra in yoga.
 Close your eyes or softly gaze downward.
 Inhale and exhale to begin.
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 Close off your right nostril with your thumb.

 Inhale through your left nostril.
 Close off your left nostril with your ring finger.
 Open and exhale through your right nostril.
 Inhale through your right nostril.
 Close off your right nostril with your thumb.
 Open and exhale through your left nostril.
 Inhale through your left nostril.

Do your best to work up to 10 rounds of this breathing pattern. If you

begin to feel lightheaded, take a break. Release both nostrils and
breathe normally.

Belly Breathing

According to The American Institute of Stress, 20 to 30 minutes of belly

breathing each day will reduce anxiety and stress. Find a comfortable,
quiet place to sit or lie down. For example, try sitting in a chair, sitting
cross-legged, or lying on your back with a small pillow under your head
and under your knees.

 Place one hand on your upper chest and the other hand on your
belly, below the ribcage.
 Allow your belly to relax, without forcing it inward by squeezing or
clenching your muscles.
 Breathe in slowly through your nose. The air should move into
your nose and downward so that you feel your stomach rise with
your other hand and fall inward (toward your spine).
 Exhale slowly through slightly pursed lips. Take note of the hand
on your chest, which should remain relatively still.
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Although the sequence frequency will vary according to your health,

most people begin by doing the exercise three times and working up to
five to 10 minutes, one to four times a day.

Box Breathing

Also known as four-square breathing, box breathing is very simple to

learn and practice. In fact, if you've ever noticed yourself inhaling and
exhaling to the rhythm of a song, you're already familiar with this type
of paced breathing. It goes like this:

 Exhale to a count of four.

 Hold your lungs empty for a four count.
 Inhale to a count of four.
 Hold air in your lungs for a count of four.
 Exhale and begin the pattern anew.

4-7-8 Breathing

The 4-7-8 breathing exercise, also called the relaxing breath, acts as a
natural tranquilizer for the nervous system. At first, it's best to perform
the exercise seated with your back straight. Once you become more
familiar with the breathing exercise, however, you can perform it while
lying in bed:

1. Place and keep the tip of your tongue against the ridge of tissue
behind your upper front teeth for the duration of the exercise.
2. Completely exhale through your mouth, making a whoosh sound.
3. Close your mouth and inhale quietly through your nose to a
mental count of four.
4. Hold your breath for a count of seven.
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5. Exhale completely through your mouth, making a whoosh sound

to a count of eight.

Lion’s Breath

Lion’s breath, or simhasana in Sanskrit, during which you stick out your
tongue and roar like a lion, is another helpful deep breathing practice.
It can help relax the muscles in your face and jaw, alleviate stress, and
improve cardiovascular functions.

The exercise is best performed in a comfortable, seated position,

leaning forward slightly with your hands on your knees or the floor.

1. Spread your fingers as wide as possible.

2. Inhale through your nose.
3. Open your mouth wide, stick out your tongue, and stretch it down
toward your chin.
4. Exhale forcefully, carrying the breath across the root of your
tongue.
5. While exhaling, make a “ha” sound that comes from deep within
your abdomen.
6. Breathe normally for a few moments.
7. Repeat lion’s breath up to seven times.

Mindful Breathing

Mindfulness meditation involves focusing on your breathing and

bringing your attention to the present without allowing your mind to
drift off to the past or future.
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 Choose a calming focus, including a sound ("om"), positive word

("peace"), or phrase ("breathe in calm, breath out tension") to
repeat silently as you inhale or exhale.
 Let go and relax. When you notice your mind has drifted, take a
deep breath and gently return your attention to the present.

Pursed-Lip Breathing

Pursed-lip breathing is a simple breathing technique that will help make

deep breaths slower and more intentional. This technique has been
found to benefit people who have anxiety associated with lung
conditions like emphysema and chronic obstructive pulmonary disease.

 Sit in a comfortable position, with your neck and shoulders

relaxed.
 Keeping your mouth closed, inhale slowly through your nostrils
for two seconds.
 Exhale through your mouth for four seconds, puckering your
mouth as if giving a kiss.
 Keep your breath slow and steady while breathing out.

To get the correct breathing pattern, experts recommend practicing

pursed-lip breathing four to five times a day.

Resonance Breathing

Resonance breathing, or coherent breathing, can help you get into a

relaxed state and reduce anxiety.

1. Lie down and close your eyes.

2. Gently breathe in through your nose, mouth closed, for a count of
six seconds. Don't fill your lungs too full of air.
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3. Exhale for six seconds, allowing your breath to leave your body
slowly and gently without forcing it.
4. Continue for up to 10 minutes.
5. Take a few additional minutes to be still and focus on how your
body feels.

Simple Breathing Exercise

You can perform this exercise as often as needed. It can be done

standing up, sitting down, or lying down. If you find this exercise
difficult or believe it's making you anxious or panicky, stop for now. Try
it again in a day or so and build up the time gradually.

 Inhale slowly and deeply through your nose. Keep your shoulders
relaxed. Your abdomen should expand, and your chest should rise
very little.
 Exhale slowly through your mouth. As you blow air out, purse
your lips slightly, but keep your jaw relaxed. You may hear a soft
“whooshing” sound as you exhale.
 Repeat this breathing exercise. Do it for several minutes until you
start to feel better.

INCENTIVE SPIROMETRY
An incentive spirometer is a device that will expand your lungs by helping you to breathe more
deeply and fully.
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Incentive Spirometer

Setting up your incentive spirometer

The first time you use your incentive spirometer, you will need to take
the flexible tubing with the mouthpiece out of the bag. Stretch out the
tubing and connect it to the outlet on the right side of the base. The
mouthpiece will be attached to the other end of the tubing.

Using your incentive spirometer

When you’re using your incentive spirometer, make sure to breathe

through your mouth. If you breathe through your nose, the incentive
spirometer won’t work properly. You can hold your nose if you have
trouble.
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If you feel dizzy at any time, stop and rest. Try again at a later time.

To use your incentive spirometer, follow the steps below.

1. Sit upright in a chair or in bed. Hold the incentive spirometer at

eye level.
 If you had surgery on your chest or abdomen (belly), hug or hold a
pillow to help splint or brace your incision (surgical cut) while
you’re using the incentive spirometer. This will help decrease pain
at your incision.
2. Put the mouthpiece in your mouth and close your lips tightly
around it. Slowly breathe out (exhale) completely.
3. Breathe in (inhale) slowly through your mouth as deeply as you
can. As you take the breath, you will see the piston rise inside the
large column. While the piston rises, the indicator on the right
should move upwards. It should stay in between the 2 arrows.
4. Try to get the piston as high as you can, while keeping the
indicator between the arrows.
 If the indicator doesn’t stay between the arrows, you’re breathing
either too fast or too slow.
5. When you get it as high as you can, hold your breath for 10
seconds, or as long as possible. While you’re holding your breath,
the piston will slowly fall to the base of the spirometer.
6. Once the piston reaches the bottom of the spirometer, breathe
out slowly through your mouth. Rest for a few seconds.
7. Repeat 10 times. Try to get the piston to the same level with each
breath.
8. After each set of 10 breaths, try to cough, holding a pillow over
your incision, as needed. Coughing will help loosen or clear any
mucus in your lungs.
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9. Put the marker at the level the piston reached on your incentive
spirometer. This will be your goal next time.

Repeat these steps every hour that you’re awake.

Cover the mouthpiece of the incentive spirometer when you aren’t

using it.
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UNIT – 8 FLUID, ELECTROLYTE AND ACID-BASE

BALANCES
REVIEW OF PHYSIOLOGICAL REGULATION OF FLUID,
ELECTROLYTE AND ACID-BASE BALANCES
Review of physiological regulation of fluid

Fluid can enter the body as preformed water, ingested food and drink,
and, to a lesser extent, as metabolic water.

Water Intake

Fluid can enter the body as preformed water, ingested food and drink,
and, to a lesser extent, as metabolic water that is produced as a by-
product of aerobic respiration and dehydration synthesis. A constant
supply is needed to replenish the fluids lost through normal
physiological activities, such as respiration, sweating, and urination.

Water generated from the biochemical metabolism of nutrients

provides a significant proportion of the daily water requirements for
some arthropods and desert animals, but it provides only a small
fraction of a human’s necessary intake. In the normal resting state, the
input of water through ingested fluids is approximately 2500 ml/day.

Body water homeostasis is regulated mainly through ingested fluids,

which, in turn, depends on thirst. Thirst is the basic instinct or urge that
drives an organism to ingest water.

Thirst is a sensation created by the hypothalamus, the thirst center of

the human body. Thirst is an important component of blood volume
regulation, which is slowly regulated by homeostasis.
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The hypothalamus: The hypothalamus is the thirst center of the human body.

Hypothalamus-Mediated Thirst

An osmoreceptor is a sensory receptor that detects changes in osmotic

pressure and is primarily found in the hypothalamus of most
homeothermic organisms. Osmoreceptors detect changes in plasma
osmolarity (that is, the concentration of solutes dissolved in the blood).

When the osmolarity of blood changes (it is more or less dilute), water
diffusion into and out of the osmoreceptor cells changes. That is, the
cells expand when the blood plasma is more dilute and contract with a
higher concentration.

When the osmoreceptors detect high plasma osmolarity (often a sign of

a low blood volume), they send signals to the hypothalamus, which
creates the biological sensation of thirst. Osmoreceptors also stimulate
vasopressin (ADH) secretion, which starts the events that will reduce
plasma osmolarity to normal levels.
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Regulation of Water Output

Fluid can leave the body in three ways: urination, excretion (feces), and
perspiration (sweating).

Water Output

Fluid can leave the body in three ways:

1. Urination
2. Excretion (feces)
3. Perspiration (sweating)

The majority of fluid output occurs from urination, at approximately

1500 ml/day (approximately 1.59 qt/day) in a normal adult at resting
state. Some fluid is lost through perspiration (part of the body’s
temperature control mechanism) and as water vapor in expired air;
however these fluid losses are considered to be very minor.

The body’s homeostatic control mechanisms maintain a constant

internal environment to ensure that a balance between fluid gain and
fluid loss is maintained. The hormones ADH (anti-diuretic hormone,
also known as vasopressin) and aldosterone, a hormone created by the
renin–angiotensin system, play a major role in this balance.

If the body is becoming fluid deficient, there will be an increase in the

secretion of these hormones that causes water to be retained by the
kidneys through increased tubular reabsorption and urine output to be
reduced. Conversely, if fluid levels are excessive, the secretion of these
hormones is suppressed and results in less retention of fluid by the
kidneys and a subsequent increase in the volume of urine produced,
due to reduced fluid retention.
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ELECTROLYTES AND ACID-BASE BALANCES

Electrolytes are minerals in your blood and other body fluids that carry
an electric charge.

Electrolytes affect how your body functions in many ways, including:

 The amount of water in your body

 The acidity of your blood (pH)
 Your muscle function
 Other important processes

You lose electrolytes when you sweat. You must replace them by
drinking fluids that contain electrolytes. Water does not contain
electrolytes.

Common electrolytes include:

 Calcium
 Chloride
 Magnesium
 Phosphorus
 Potassium
 Sodium

Electrolytes can be acids, bases, or salts. They can be measured by

different blood tests. Each electrolyte can be measured separately,
such as:

 Ionized calcium
 Serum calcium
 Serum chloride
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 Serum magnesium
 Serum phosphorus
 Serum potassium
 Serum sodium

Note: Serum is the part of blood that doesn't contain cells.

Sodium, potassium, chloride, and calcium levels can also be measured

as part of a basic metabolic panel. A more complete test, called
comprehensive metabolic panel, can test for these and several more
chemicals.

The electrolytes - urine test measures electrolytes in urine. It tests the

levels of calcium, chloride, potassium, sodium, and other electrolytes.

ACID-BASE BALANCES
Normal Acid–Base Balance

Acid–base balance refers to the balance between input (intake and

production) and output (elimination) of hydrogen ion. The body is an
open system in equilibrium with the alveolar air where the partial
pressure of carbon dioxide pCO2 is identical to the carbon dioxide
tension in the blood.

Acid and alkaline levels are measured on a pH scale. An increase in

acidity causes pH levels to fall. An increase in alkaline causes pH levels
to rise.

When the levels of acid in your blood are too high, it’s called acidosis.
When your blood is too alkaline, it is called alkalosis.
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Respiratory acidosis and alkalosis are due to a problem with the lungs.
Metabolic acidosis and alkalosis are due to a problem with the kidneys.

Each of these conditions is caused by an underlying disease or disorder.

Treatment depends on the cause.

Respiratory acidosis

When you breathe, your lungs remove excess carbon dioxide from your
body. When they cannot do so, your blood and other fluids become too
acidic.

Symptoms of respiratory acidosis

Symptoms may include fatigue, shortness of breath, and confusion.

Causes of respiratory acidosis

There are several different causes of respiratory acidosis including:

 chest deformities or injuries

 chronic lung and airway diseases
 overuse of sedatives
 obesity

Types of respiratory acidosis

There are no noticeable symptoms of chronic respiratory acidosis. This

is due to the fact that your blood slowly becomes acidic and your
kidneys adjust to compensate, returning your blood to a normal pH
balance.

Acute respiratory acidosis comes on suddenly, leaving the kidneys no

time to adjust. Those with chronic respiratory acidosis may experience
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acute respiratory acidosis due to another illness that causes the

condition to worsen.

Metabolic acidosis

Metabolic acidosis occurs either when your body produces too much
acid, or when your kidneys are unable to remove it properly.

Symptoms of metabolic acidosis

Symptoms can include rapid breathing, fatigue, and confusion.

Causes of metabolic acidosis

There are three main types of metabolic acidosis. Diabetic acidosis,

or diabetic ketoacidosis, is a buildup of ketone bodies. This is usually
due to uncontrolled type 1 diabetes. Hyperchloremic acidosis is when
your body loses too much sodium bicarbonate, often after severe
diarrhea.

Lactic acidosis is when too much lactic acid builds up. This can be due
to:

 prolonged exercise
 lack of oxygen
 certain medications, including salicylates
 low blood sugar, or hypoglycemia
 alcohol
 seizures
 liver failure
 cancer
 kidney disease
 severe dehydration
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 poisoning from consuming too much aspirin, ethylene glycol, and

methanol

Alkalosis

Alkalosis is when alkaline levels are too high due to decreased carbon
dioxide or increased bicarbonate. There are five kinds of alkalosis.

Symptoms of alkalosis

Symptoms of alkalosis may include:

 muscle twitching, hand tremor, muscle spasms

 numbness and tingling
 nausea
 vomiting
 lightheadedness
 confusion

Causes and types of alkalosis

Respiratory alkalosis is when your blood has low levels of carbon

dioxide. This can be caused by a number of factors, including:

 lack of oxygen
 high altitude
 fever
 lung disease
 liver disease
 salicylate poisoning

When you have alkalosis your carbon dioxide levels are low. This causes
your body to release more bicarbonate to return your blood pH level
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back to normal. This is called compensated alkalosis. Your blood pH

levels will test normal, however your kidneys are releasing more
bicarbonate, compensating for the lower levels of carbon dioxide.

When your blood has too much bicarbonate, it is called metabolic

alkalosis. This can happen from prolonged vomiting. Prolonged
vomiting can also make you lose too much chloride. This is called
hypochloremic alkalosis. Some diuretic medicines can cause you to lose
too much potassium. This is called hypokalemic alkalosis.

DISTURBANCES IN FLUID VOLUME

Because sodium is the major osmotically active ion in the extracellular
fluid (ECF), total body sodium content determines ECF volume.
Deficiency or excess of total body sodium content causes ECF volume
depletion or volume overload. Serum sodium concentration does not
necessarily reflect total body sodium.

Dietary intake and renal excretion regulate total body sodium content.
When total sodium content and ECF volume are low, the kidneys
increase sodium conservation. When total sodium content and ECF
volume are high, sodium excretion (natriuresis) increases so that
volume decreases.

Renal sodium excretion can be adjusted widely to match sodium intake.

Renal sodium excretion requires delivery of sodium to the kidneys and
so depends on renal blood flow and glomerular filtration rate (GFR).
Thus, inadequate sodium excretion may be secondary to decreased
renal blood flow, as in chronic kidney disease or heart failure.
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Renin-angiotensin-aldosterone axis

The renin-angiotensin-aldosterone axis is the main regulatory

mechanism of renal sodium excretion. In volume-depleted states, GFR
and chloride delivery to the distal nephrons decreases, causing release
of renin. Renin cleaves angiotensinogen (renin substrate) to form
angiotensin I. Angiotensin-converting enzyme (ACE) then cleaves
angiotensin I to angiotensin II. Angiotensin II does the following:

 Increases sodium retention by decreasing the filtered load of

sodium and enhancing proximal tubular sodium reabsorption
 Increases blood pressure (has pressor activity)
 Increases thirst
 Directly impairs water excretion
 Stimulates the adrenal cortex to secrete aldosterone, which
increases sodium reabsorption via multiple renal mechanisms

Angiotensin I can also be transformed to angiotensin III, which

stimulates aldosterone release as much as angiotensin II but has much
less pressor activity. Aldosterone release is also stimulated
by hyperkalemia.

Other natriuretic factors

Several other natriuretic factors have been identified, including atrial

natriuretic peptide (ANP), brain natriuretic peptide (BNP), and a C-type
natriuretic peptide (CNP).

ANP is secreted by cardiac atrial tissue. Concentration increases in

response to ECF volume overload (eg, heart failure, chronic kidney
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disease, cirrhosis with ascites) and primary aldosteronism and in some

patients with primary hypertension. Decreases have occurred in the
subset of patients with nephrotic syndrome who have presumed ECF
volume contraction. High concentrations increase sodium excretion and
increase GFR even when blood pressure is low.

BNP is synthesized mainly in the atria and left ventricle and has similar
triggers and effects to ANP. BNP assays are readily available. High BNP
concentration is used to diagnose volume overload.

CNP, in contrast to ANP and BNP, is primarily vasodilatory.

Sodium depletion and excess

Sodium depletion requires inadequate sodium intake plus abnormal

losses from the skin, gastrointestinal tract, or kidneys (defective renal
sodium conservation). Defective renal sodium conservation may be
caused by primary renal disease, adrenal insufficiency, or diuretic
therapy.

Sodium overload requires higher sodium intake than excretion;

however, because normal kidneys can excrete large amounts of
sodium, sodium overload generally reflects defective regulation of renal
blood flow and sodium excretion (eg, as occurs in heart
failure, cirrhosis, or chronic kidney disease).

Volume depletion

Volume depletion, or extracellular fluid (ECF) volume contraction,

occurs as a result of loss of total body sodium. Causes include vomiting,
excessive sweating, diarrhea, burns, diuretic use, and kidney failure.
Clinical features include diminished skin turgor, dry mucous
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membranes, tachycardia, and orthostatic hypotension. Diagnosis is

clinical. Treatment involves administration of sodium and water.

Because water crosses plasma membranes in the body via passive

osmosis, loss of the major extracellular cation (sodium) quickly results
in water loss from the ECF space as well. In this way, sodium loss always
causes water loss. However, depending on many factors, serum sodium
concentration can be high, low, or normal in volume-depleted patients
(despite the decreased total body sodium content). ECF volume is
related to effective circulating volume. A decrease in ECF (hypovolemia)
generally causes a decrease in effective circulating volume, which in
turn causes decreased organ perfusion and leads to clinical sequelae.

HYPOVOLEMIA

Hypovolemia, also known as volume depletion or volume contraction,

is a state of abnormally low extracellular fluid in the body. This may be
due to either a loss of both salt and water or a decrease in blood
volume. Hypovolemia refers to the loss of extracellular fluid and should
not be confused with dehydration.

DEHYDRATION

Dehydration occurs when more water and fluids leave the body than
enter it. Even low levels of dehydration can cause headaches, lethargy,
and constipation.

Volume Overload

Volume overload generally refers to expansion of the extracellular fluid

(ECF) volume. ECF volume expansion typically occurs in heart failure,
kidney failure, nephrotic syndrome, and cirrhosis. Renal sodium
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retention leads to increased total body sodium content. This increase

results in varying degrees of volume overload. Serum sodium
concentration can be high, low, or normal in volume-overloaded
patients (despite the increased total body sodium content). Treatment
involves removal of excess fluid with diuretics or mechanical fluid
removal via methods such as dialysis and paracentesis.

An increase in total body sodium is the key pathophysiologic event. It

increases osmolality, which triggers compensatory mechanisms that
cause water retention. When sufficient fluid accumulates in the ECF
(usually >2.5 L), edema develops.

Among the most common causes of ECF volume overload are the
following:

 Heart failure
 Cirrhosis
 Kidney failure
 Nephrotic syndrome
 Premenstrual edema
 Pregnancy

HYPOVOLEMIA (FLUID OVERLOAD)

Hypervolemia is a medical condition when you have too much fluid in

your body, also described as having excess water retention or fluid
overload. Healthy people have a certain amount of fluid in their bodies.
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Hypervolemia is common among people with chronic kidney

disease (CKD) and renal failure, because their kidneys aren't working to
remove excess fluid like healthy kidneys would.

Symptoms of hypervolemia can cause discomfort, stress on your body

and even organ trouble. Signs of fluid overload may include:

 Rapid weight gain

 Noticeable swelling (edema) in your arms, legs and face
 Swelling in your abdomen
 Cramping, headache, and stomach bloating
 Shortness of breath
 High blood pressure
 Heart problems, including congestive heart failure

CAUSES

 Kidney failure. Your kidneys are responsible for removing excess

fluid from your body. When your kidneys aren’t working well,
fluid can build up.
 Congestive heart failure. When your heart is not pumping enough
blood, your kidneys aren’t able to work as well, leaving excess
fluid in your body.
 Liver failure or cirrhosis. Your liver processes nutrients and filters
toxins. When your liver isn’t working as it should, fluid can build
up in your abdomen.
 Hormonal changes. Women may experience mild fluid retention
as a normal part of premenstrual syndrome (PMS) or pregnancy.
Excessive fluid retention related to hormonal changes may be a
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sign of high blood pressure and should be checked out by a

doctor.
 IV fluids. Receiving too much IV fluid, especially if there are other
health conditions present, can lead to fluid overload and swelling.

EDEMA
Edema is swelling that is caused by fluid trapped in your body’s tissues.
Edema happens most often in the feet, ankles, and legs, but can affect
other parts of the body, such as the face, hands, and abdomen. It can
also involve the entire body.

Causes

Edema has many possible causes:

 Edema can occur as a result of gravity, especially from sitting or

standing in one place for too long. Water naturally gets pulled
down into your legs and feet.
 Edema can happen from a weakening in the valves of the veins in
the legs (a condition called venous insufficiency). This problem
makes it hard for the veins to push blood back up to the heart,
and leads to varicose veins and a buildup of fluid in the legs.
 Certain diseases — such as congestive heart failure and lung, liver,
kidney, and thyroid diseases — can cause edema or make it
worse.
 Some drugs, such as medications that you are taking for your
blood pressure or to control pain, may cause or worsen edema.
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 An allergic reaction, severe inflammation, burns, trauma, clot(s),

or poor nutrition can also cause edema.
 Too much salt from your diet can make edema worse.
 Being pregnant can cause edema in the legs as the uterus puts
pressure on the blood vessels in the lower trunk of the body.

Signs and Symptoms

Signs that you might have edema include the following:

 The affected area is swollen.

 The skin over the swollen area might look stretched and shiny.
 Pushing in gently on the swollen area with your finger for at least
5 seconds and then removing your finger will leave a dimple in the
skin.
 You may have trouble walking if your legs are swollen.
 You may be coughing or have trouble breathing if you have
edema in the lungs.

ELECTROLYTES IMBALANCE
An electrolyte imbalance can occur if the body has too much or too
little water. Electrolytes are minerals in the blood, tissues, and
elsewhere throughout the body. Their name refers to the fact that they
have an electrical charge.

Electrolytes are minerals, and the body needs them to:

 balance its water levels

 move nutrients into cells
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 remove waste products

 allow nerves to send signals
 enable muscles to relax and contract normally
 keep the brain and heart functioning

An electrolyte imbalance can happen if a person is dehydrated or if

they have too much water in their body.

The things that most commonly cause an electrolyte imbalance are:

 vomiting
 diarrhea
 not drinking enough fluids
 not eating enough
 excessive sweating
 certain medications, such as laxatives and diuretics
 eating disorders
 liver or kidney problems
 cancer treatment
 congestive heart failure

Types of electrolyte disorders

Elevated levels of an electrolyte are indicated with the prefix “hyper-.”

Depleted levels of an electrolyte are indicated with “hypo-.”
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Conditions caused by electrolyte level imbalances include:

 calcium: hypercalcemia and hypocalcemia

 chloride: hyperchloremia and hypochloremia
 magnesium: hypermagnesemia and hypomagnesemia
 phosphate: hyperphosphatemia or hypophosphatemia
 potassium: hyperkalemia and hypokalemia
 sodium: hypernatremia and hyponatremia

Calcium

Calcium is a vital mineral that your body uses to stabilize blood

pressure and control skeletal muscle contraction. It’s also used to build
strong bones and teeth.

Hypercalcemia occurs when you have too much calcium in the blood.
This is usually caused by:

 kidney disease
 thyroid disorders, including hyperparathyroidism
 lung diseases, such as tuberculosis or sarcoidosis
 certain types of cancer, including lung and breast cancers
 excessive use of antacids and calcium or vitamin D supplements
 medications such as lithium, theophylline, or certain water pills

Hypocalcemia occurs due to a lack of adequate calcium in the

bloodstream. Causes can include:

 kidney failure
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 hypoparathyroidism
 vitamin D deficiency
 pancreatitis
 prostate cancer
 malabsorption
 certain medications, including heparin, osteoporosis drugs,
and antiepileptic drugs

Chloride

Chloride is necessary for maintaining the proper balance of bodily

fluids.

Hyperchloremia occurs when there’s too much chloride in the body. It

can happen as a result of:

 severe dehydration
 kidney failure
 dialysis

Hypochloremia develops when there’s too little chloride in the body.

It’s often caused by sodium or potassium problems.

Other causes can include:

 cystic fibrosis
 eating disorders, such as anorexia nervosa
 scorpion stings
 acute kidney failure
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Magnesium

Magnesium is a critical mineral that regulates many important

functions, such as:

 muscle contraction
 heart rhythm
 nerve function

Hypermagnesemia means excess amounts of magnesium. This disorder

primarily affects people with Addison’s disease and end-stage kidney
disease.

Hypomagnesemia means having too little magnesium in the body.

Common causes include:

 alcohol use disorder

 malnutrition
 malabsorption
 chronic diarrhea
 excessive sweating
 heart failure
 certain medications, including some diuretics and antibiotics

Phosphate

The kidneys, bones, and intestines work to balance phosphate levels in

the body. Phosphate is necessary for a wide variety of functions and
interacts closely with calcium.
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Hyperphosphatemia can occur due to:

 low calcium levels

 chronic kidney disease
 severe breathing difficulties
 underactive parathyroid glands
 severe muscle injury
 tumor lysis syndrome, a complication of cancer treatment
 excessive use of phosphate-containing laxatives

Low levels of phosphate, or hypophosphatemia, can be seen in:

 acute alcohol abuse

 severe burns
 starvation
 vitamin D deficiency
 overactive parathyroid glands
 certain medications, such as intravenous (IV) iron
treatment, niacin (Niacor, Niaspan), and some antacids

Potassium

Potassium is particularly important for regulating heart function. It also

helps maintain healthy nerves and muscles.

Hyperkalemia may develop due to high levels of potassium. This

condition can be fatal if left undiagnosed and untreated. It’s typically
triggered by:
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 severe dehydration
 kidney failure
 severe acidosis, including diabetic ketoacidosis
 certain medications, including some blood pressure
medications and diuretics
 adrenal insufficiency, which is when your cortisol levels are too
low

Hypokalemia occurs when potassium levels are too low. This often
happens as a result of:

 eating disorders
 severe vomiting or diarrhea
 dehydration
 certain medications, including laxatives, diuretics,
and corticosteroids

Sodium

Sodium is necessary for the body to maintain fluid balance and is

critical for normal body function. It also helps to regulate nerve
function and muscle contraction.

Hypernatremia occurs when there’s too much sodium in the blood.

Abnormally high levels of sodium may be caused by:

 inadequate water consumption

 severe dehydration
 excessive loss of bodily fluids as a result of prolonged vomiting,
diarrhea, sweating, or respiratory illness
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 certain medications, including corticosteroids

Hyponatremia develops when there’s too little sodium. Common

causes of low sodium levels include:

 excessive fluid loss through the skin from sweating or burns

 vomiting or diarrhea
 poor nutrition
 alcohol use disorder
 overhydration
 thyroid, hypothalamic, or adrenal disorders
 liver, heart, or kidney failure
 certain medications, including diuretics and seizure medications
 syndrome of inappropriate secretion of antidiuretic hormone
(SIADH)

INTRAVENOUS THERAPY
Intravenous therapy (abbreviated as IV therapy) is a medical technique
that delivers fluids, medications and nutrition directly into a
person's vein. The intravenous route of administration is commonly
used for rehydration or to provide nutrition for those who cannot, or
will not - due to reduced mental states or otherwise - consume food or
water by mouth. It may also be used to administer medications or other
medical therapy such as blood products or electrolytes to
correct electrolyte imbalances.
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IV or intravenous (in-trah-VEE-nus) therapy is a way to give fluids,

medicine, nutrition, or blood directly into the blood stream through a
vein. IV therapy uses a type of tiny plastic tubing (cannula) that goes
into the vein, a needle, and plastic tubing that connects the set-up to a
bag of fluid. All together, the pieces are called an “IV.”

IV fluid often contains water, glucose (sugar), and electrolytes

(potassium, sodium, and chloride). An IV may allow more than one fluid
to be given at the same time and into the same place

Intravenous solutions can contain saline, vitamins, minerals and

medication. Some common components of IV bags include:

 Saline: Saline solution is usually the base ingredient of an IV bag.

Saline, made up of water and sodium chloride, serves as a delivery
system for the other components of your IV therapy. Saline also
serves as a way to help hydrate the body.
 Dextrose: Your IV bag may contain dextrose, which is a type of
sugar. Unlike some of your favorite sweet desserts, this kind of
sugar is good for you. Dextrose can be used in IV therapy to help
normalize low levels of blood sugar. As a sugar, your body can also
convert dextrose into energy.
 Lactated Ringer’s: If you are a fan of medical dramas, you have
almost certainly heard the term “Lactated Ringer’s.” This IV
solution contains water, calcium chloride, potassium chloride,
sodium chloride and sodium lactate. Like saline solution, Lactated
Ringer’s can be used as a delivery system for other ingredients. It
is also commonly used during surgery and to treat dehydration.
 Vitamin B: Vitamins B-1, B-2, B-3, B-5, B-6, B-9 and B-12 are
collectively known as vitamin B complex. Vitamin B complex is an
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important element of a healthy diet because it directly

contributes to important bodily functions, like your metabolism
and nerve function. Vitamin B complex is often delivered via IV
therapy for patients who have trouble naturally absorbing
vitamins.
 Vitamin C: Vitamin C, another common IV vitamin, is important
for a healthy immune system function. If you are sick or feel like
you are becoming sick, vitamin C can be a beneficial ingredient in
your IV therapy.
 Calcium: Your IV therapy may include calcium, which is a mineral
that we need to stay healthy. It helps build strong bones and
teeth. We consume calcium in our diet through foods like dairy
and green, leafy vegetables.
 Magnesium: Magnesium, another important mineral, plays a role
in healthy metabolic function. It has a number of benefits,
including reducing inflammation, combating leg cramps in
pregnant women and even helping to prevent migraines.
 Antioxidants: Many foods are touted for their high levels of
antioxidants, which help protect your body’s cells from a number
of different diseases. Your IV therapy may include different types
of antioxidants, such as glutathione, or vitamins A, C or E.
 Antibiotics: In cases of infection, the patient will likely receive
antibiotics via an IV bag.
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PERIPHERAL VENIPUNCTURE SITES

Venipuncture Site Selection:

The median cubital and cephalic veins are most commonly
used for venipuncture.
Procedure and Performance of a Venipuncture:
 Select the proper size needle and attach it to the syringe or
Vacutainer hub.
 When using a syringe, make sure that you pull the plunger in
and out to assure free motion.
 Position the draw site for best visualization and/or palpation.
Apply the tourniquet 3-4 inches above the selected puncture site.
Do not place tightly or leave on for more than 1 minute. Instruct
the patient to make a fist and hold it; do not have them pump their
hand. Select the venipuncture site by palpating with the gloved
index finger.
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 Prepare the patient’s arm using a Chlorhexadine wipe. Allow to

air dry. Do not dry the site with gauze and do not blow on the area
to dry as this will contaminate the site. After cleansing the area, if
it is accidentally touched before performing the venipuncture, it
should be cleansed again.
 Grasp the patient’s arm firmly using your thumb to draw the skin
taut and anchor the vein; do not use the index finger to pull the
skin upward as this increases the risk of sticking yourself. Swiftly
insert the needle through the skin, bevel side up, at a 15 – 30
degree angle with the skin, into the lumen of the vein.
 If the patient complains of “shooting, electric-like pain, or tingling
or numbness proximal or distal to the puncture site,” the needle
should be removed immediately. It is possible that a nerve has
been punctured and possibly damaged. The venipuncture should
be repeated in a different site. A Supervisor or Manager should be
notified and the incident should be documented.
 If an arterial puncture is suspected, as indicated by a bright red,
quick, pulsing flow, with or without rapid development of a
hematoma, the needle should be removed immediately. Forceful,
direct pressure should be applied to the site for a minimum of five
minutes or until the bleeding has stopped. The nursing staff
should be notified, and they in turn must notify the physician. A
laboratory Supervisor or Manager should also be notified and the
incident should be documented.
 If the blood does not begin to flow, reposition the needle by
gently moving the needle either backwards for forwards in the
arm. If the blood is flowing slowly, gently adjust the angle to see if
the needle is sitting up against the wall of the vein. Loosen the
tourniquet, as it may be obstructing blood flow. If you are
vacutaining, try another tube – there may be no vacuum in
the tube.
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 After you have attempted to reposition the needle and are still
not successful, remove the tourniquet, remove the needle and
begin the process with a new site. In the case of a difficult
venipuncture, an individual may make a maximum of two
attempts before having someone else try. A third stick is
allowable if a partial sample has been obtained and you as the
drawer feel reasonably confident that you can obtain the
specimen on the next try.
 When the collection is complete, remove the tourniquet and
place gauze over the venipuncture site. While the needle is still in
the vein, activate the safety button with the tip of the index finger;
the needle will automatically retract from the vein and the safety
device will cover the needle.
 Apply adequate pressure to the puncture site to stop the
bleeding and avoid formation of a hematoma. If you used a
needle and syringe, ask your patient or a parent to apply pressure
to the site so that you can fill your tubes. Do not have the patient
bend his/her arm; this may cause the arm to start bleeding when
the arm is straightened out.
 If blood was drawn with a syringe, attach the blood transfer
device to the syringe and fill tubes according to the ‘Order of Draw
for a Venipuncture’
 Dispose of the contaminated materials and needle in the
appropriate waste containers.
 Mix and label all appropriate tubes at the patient’s bedside.
Return to your patient and assess the site of the puncture. Apply
a band-aid or CoFlex to the site.

Additional Considerations When Performing a Venipuncture:

The following considerations should be taken into account:
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 Preventing a Hematoma: puncture only the uppermost wall of

the vein. Remove the tourniquet before removing the needle.
Make sure the needle fully penetrates the upper-most wall of the
vein; partial penetration may allow blood to leak into the tissue
surrounding the vein. Adequate pressure should be applied to
stop the bleeding once the phlebotomy is complete. A hematoma
can cause a post-phlebotomy compression injury to a nerve.
 Preventing Hemolysis: Mix tubes gently, by inversion, 5-10
times – do not shake them. Avoid drawing blood from a
hematoma. If using a needle and syringe, avoid drawing the
plunger back too forcefully. Make sure the venipuncture site is
dry. Avoid probing for the vein. If using a blood transfer device to
fill vacutainer tubes, allow the vacuum to pull the blood into the
tubes; do not use the plunger on the syringe to force the blood
into the tubes more quickly.
 Preventing Hemoconcentration: An increased concentration of
larger molecules and formed elements in the blood may be due to
several factors including prolonged tourniquet application (greater
than 1 minute), massaging, flicking, squeezing or probing the site,
long-term IV therapy, and sclerosed or occluded veins.
 Preventing injury to a nerve, tendon, or muscle: Use careful
palpitation and appropriate angle of entry. Excessive probing
(uncalculated side-to-side movement) with the needle should be
avoided.
 Preventing dizziness or fainting and potential follow-up injuries
due to a fall: Be sure patient is seated in an appropriate draw
chair and or lying in a bed. Have appropriate back up staff as
available.
 Preventing of infection: Follow proper infection control policies.
 Preventing injury from improper immobilization – Immobilize the
patient with care. If there is any concern regarding injury, contact
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nursing for Inpatients and follow the Policy for Proper Handling of
an Uncooperative Patient.

TYPES OF IV FLUIDS
The 4 Main Types of IV Fluids

All of these solutions can be classified as crystalloid or colloid and as

isotonic, hypotonic, or hypertonic, which has a direct impact on how
the fluids can be used. Crystalloid solutions remain by far the most
common, largely due to the overwhelming presence of normal saline in
most hospital and healthcare settings.

1. Normal Saline

The best-known name is normal saline, sometimes called 9% normal

saline, NS, or 0.9NaCL.

Normal saline is a sterile, nonpyrogenic solution. It’s a crystalloid fluid

(easily passes through the cell membrane) and is generally isotonic.

It’s the most widely used fluid because it’s the most effective fluid for
the widest variety of conditions. It’s the fluid of choice for fluid
resuscitation and works well for most hydration needs due to
hemorrhage, vomiting, diarrhea, or even shock.

It’s most often used to increase the volume of circulating plasma

(assuming that the patient has sufficient red blood cells). It can be used
for things like:

 Blood transfusion
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 Fluid replacement for patients suffering from diabetic

ketoacidosis
 Metabolic alkalosis
 Hypercalcemia
 Hyponatremia

Normal saline is also the only fluid that can be used in conjunction with
blood administration. That said, it has to be used with caution in
patients who have cardiac or renal complications, as the high sodium
content can cause excess fluid retention, which in turn puts additional
stress on the already-weakened heart and kidneys.

2. Half Normal Saline

Half normal saline is also a widespread fluid. It’s sometimes called 45%
normal saline or 0.45NaCl.

It’s a hypotonic, crystalloid solution of sodium chloride dissolved in

sterile water (as opposed to normal saline, which is an isotonic
solution). The difference is that half normal saline contains half the
chloride concentration of normal saline.

It’s designed to treat patients suffering from cellular dehydration and

can be used for things like:

 Raising your overall fluid volume

 Water replacement
 Sodium chloride depletion
 Gastric fluid loss

DKA after normal saline and before dextrose infusions

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It’s especially helpful for patients such as those who are diabetic who
cannot handle additional glucose. It is always avoided in patients who
have burns, liver disease, or trauma, as the solution depletes
intravascular fluids in a way that can be dangerous for patients whose
intravascular fluid levels are already low. Like normal saline, the
solution can pose a risk for those with cardiovascular disease or
increased intracranial pressure. Half normal saline is less useful in
replenishing sodium chloride deficit than normal saline, as it has half
the concentration of sodium chloride. That said, it does still have uses
in maintaining daily fluid levels, much like normal saline.

3. Lactated Ringers

Lactated Ringer’s is another highly common IV fluid used in fluid

resuscitation. In fact, it’s been offered up in many circles as an
alternative to normal saline. Either way, if you’ve been injured and
received surgery, there’s a decent chance you’ve received an injection
of lactated ringers.

Lactated Ringer's are named after the physician who invented them.
Sydney Ringer, a physician in the late 1800s, came up with a solution
containing sodium, chloride, calcium, and potassium. The “lactated”
part of Lactated Ringers comes from one Alexis Hartmann, who figured
out that adding lactate to the solution made it more suitable for use in
pediatric patients.

Lactate is a chemical that’s most commonly encountered in milk,

though our muscles also produce it when we exercise.

It’s basically normal saline with the addition of electrolytes and a buffer
(lactate), which helps explain why the solution is also isotonic.
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It’s the solution that’s most similar to the body’s natural plasma and
serum concentration (but unlike serum, it doesn’t contain magnesium).
It’s used to treat:

 Dehydration
 Burn victims
 Hypovolemia resulting from third-space fluid shifts
 Fluid loss in the lower gastrointestinal tract
 Acute blood loss
 Replacement of fluid and pH buffers

Because Lactated Ringer’s contain potassium, it cannot be used in

patients with renal failure or renal complications as it can result in
hyperkalemia. It also should not be used in patients with liver disease,
as they cannot successfully metabolize the lactate. It also should not be
administered if patients have a pH level greater than 75.

4. Dextrose

Finally, there are many variations on dextrose.

Dextrose itself is a type of simple sugar made from corn. It’s chemically
identical to glucose, which you should recognize as your old pal sugar.
It’s often used in processed foods and added to baking products as a
sweetener, but it has a number of uses in a medical setting.

It’s useful specifically because it’s a simple sugar--that is, your body can
quickly make use of it for energy.

There are three main versions of dextrose solutions:

 Dextrose in water
 Dextrose in saline
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 Dextrose in Lactated Ringer’s

Regardless of the type of dextrose solution, the basic principle is the

same. The IV fluid acts as a carrier for dextrose, which acts as sugar
readily available for cells to gobble up and use as energy.

Dextrose in Water

One of the more common iterations of dextrose is a solution of

dextrose in water.

Dextrose in water is a crystalloid solution. In the bag, it’s isotonic, but

the solution itself is physiologically hypotonic. That’s a fancy way of
saying that it enters your body as an isotonic solution (that is, when
there’s still sugar in the solution), but when the sugar is absorbed by
your cells, you’re left with a hypotonic solution.

Unlike other fluids we’ve listed thus far, dextrose in water is not used in
fluid resuscitation, as it can cause hyperglycemia. Instead, it is used to:

 Raise your total fluid volume

 Rehydration
 Hypernatremia (an electrolyte problem caused by a decrease in
total body water relative to electrolyte content)

Dextrose in water is often used to treat diabetic patients who are not
eating anything by mouth for various reasons. That said, although the
solution contains about 170 calories per liter, it is not sufficient to
replace normal daily calories and should not be used for long-term food
replacement.
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Interestingly, it’s sometimes used as a diluent for preparing injectable

medications for an IV bag (a lot of fluid in which to dilute a small dose
of medicine). This is likely because the dextrose is absorbed so readily.
It should always be avoided in patients with cardiac problems, renal
failure, and increased intracranial pressure (much like the other fluids
on this list) as it can cause fluid overload.

Dextrose in Saline

Another common alternative is dextrose in saline, which is pretty much

exactly what it sounds like.

It’s a sterile, nonpyrogenic solution. As the name implies, it's a solution

of 5% dextrose in normal saline. Like normal saline, it’s isotonic at first,
but it becomes hypertonic when the dextrose is absorbed (remember
earlier when we said that hypertonic solutions are particularly risky to
work with?)

Because dextrose in saline is such a specialized fluid, it’s used for

extremely specific cases, including:

 Temporary treatment of circulatory insufficiency, but only if other

plasma expanders are unavailable
 Hypotonic dehydration
 Addisonian crisis (a potentially life-threatening condition resulting
from acute insufficiency of adrenal hormones)
 Syndrome of inappropriate antidiuretic hormone/SIADH (when
the brain makes too much antidiuretic hormone)

Like many other fluids on this list, dextrose in saline should not be used
in patients with renal or cardiac complications, as it can cause heart
failure or pulmonary edema.
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Dextrose in Lactated Ringers

Finally, dextrose in Lactated Ringer’s is...well, exactly what the name

implies.

It’s a solution of 5% dextrose in Lactated Ringer’s,

a sterile, nonpyrogenic solution used for fluid and electrolyte
replenishment. Like other dextrose solutions, it’s isotonic until the
dextrose is absorbed. This particular solution becomes hypotonic after
the dextrose is metabolized.

It serves much the same purpose as Lactated Ringer’s, with the addition
of 180 calories per liter, though it can be used as an alkalinizing agent.
Because it’s basically Lactated Ringer’s with dextrose, it has many of
the same contraindications as Lactated Ringer’s. It isn’t advisable in
patients with renal issues due to hyperkalemia concerns, nor should it
be used in patients with liver failure (again, they cannot metabolize the
lactate).

The addition of dextrose means that it should be used with care if

patients have issues with glucose (i.e. diabetics). It also should not be
used in infants less than 28 days old, even if separate infusion lines are
used.

CALCULATION FOR MAKING IV FLUID THERAPY

Drip Rates — is when the infusion volume is calculated into drops.

The formula for the Drip Rate: Drip Rate = Volume (mL) /Time (h)
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Note: When the drip rate is given in minutes, convert the minutes to
hours by dividing the required minutes by 60 (since 60 minutes in one
hour).

Calculation of drips rates in drops per minute (dpm)

There are two standard giving sets of drip rates:

1. Macro Drop Factor — drop size is normally 20 drops in 1 mL.

2. Micro Drop Factor — drop size is normally 60 drops in 1 mL.

The formula to calculate drip rates in drops per minute (dpm):

Drip Rate (dpm) = Volume of IV fluid (mL)/ Time to run (h) × Drop
Factor (drops/mL) /60 (min/h)

The formula to calculate how many hours will it take for the IV to
complete before it runs out is:

Time (hours) = Volume (mL)/ Drip Rate (mL/hour).

COMPLICATION OF IV FLUID THERAPY

Complications of IV Therapy

While IV treatment is relatively safe, there can be complications if not

administered properly. The most common include:

1. Phlebitis. Inflammation of the vein. It occurs when the cannula is too

large for the vein or if it’s improperly secured. To prevent this, the
caregiver should use the smallest needle possible suitable for the
patient and fluid being administered.
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Symptoms include:

 Warmth
 Swelling
 Pain
 Redness around the vein

2. Extravasation. This happens when the liquid in the IV leaks to the

tissue surrounding the vein. It can also be caused by inserting a cannula
that’s too big for the patient.

Symptoms include:

 Burning sensation
 Swelling around the IV site

3. Air Embolism. This happens when an air bubble (or air bubbles)
enters the vein. It could be fatal if not caught early, since the air can
travel to the person’s brain, heart, or lungs. The complication can be
avoided by ensuring that the patient is properly hydrated and resting in
a supine position when injecting and removing the IV line.

Symptoms include:

 Blue hue of the patient’s skin

 Difficulty breathing
 Low blood pressure

4. Hypervolaemia. This is an abnormal increase in blood volume. It’s

more likely to happen in pregnant women, young children, elderly
patients, or people with kidney problems.

The most common signs are:

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 Tachycardia (increased heart rate)

 Distended neck veins

5. Infection. If the IV line, port, or skin on the site of injection are not
properly cleaned prior to inserting the IV, the likelihood of infection
increases. This can be prevented with proper sterilization and hygiene.

Symptoms include:

 Pain
 Swelling
 Fever

MEASURING FLUID INTAKE AND OUTPUT

 Defines as the measurement and recording of all fluid intake and
output during a 24-hour period provides important data about the
client’s fluid and electrolyte balance
 Unit of measurement of intake and output is ml (milliliter)
 To measure fluid intake, nurses convert household measures such
as glass, cup or soup bowl to metric units
 Gauge fluid balance and give valuable information about your
patient’s condition

INTAKE

 Oral fluids
 Ice chips
 Food that are tend to become liquid at room temperature
 Tube feedings
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 Parenteral fluids
 Intravenous medications
 Catheter or tube irrigants

OUTPUT

 Urine
 Vomitus and liquid feces
 Tube drainage
 Wound drainage and draining fistulas

MEASUREMENT OF VOLUME

1 tablespoon (tbsp) = 15 milliliters (ml)

3 teaspoons(tsp) = 15 milliliters (ml)

1 cup (C) = 240 milliliters (ml)

8 ounces (oz) = 240 milliliters (ml)

1 cup (C) = 8 ounces (oz)

16 ounces (oz) = 30 milliliters (ml)

CLINICAL DO’S AND DON’T’S

DO’S
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 Identify whether your patient has undergone surgery or if he has

a medical condition or takes medication that can affect fluid
intake or loss
 Measure and record all intake and output. If you delegate this
task, make sure you know the totals and the fluid sources
 At least every 8 hours, record the type and amount of all fluids
he’s received and describe the route as oral, parenteral, rectal or
by enteric tube
 Record ice chips as fluid at approximately half their volume
 Record the type and amount of all fluids the patient has lost and
the route. Describe them as urine, liquid stool, vomitus, tube
drainage and any fluid aspirated from a body cavity
 If irrigating a nasogastric or another tube or the bladder, measure
the amount instilled and subtract it from total output
 For an accurate measurement, keep toilet paper out of your
patient’s urine
 Measure drainage in a calibrated container. Observe it eye level
and take the reading at the bottom of the meniscus
 Evaluate patterns and values outside the normal range, keeping in
mind the typical 24-hour intake and output
 When looking at 8-hour urine output, ask how many times the
patient voided, to identify problems
 Regard intake and output holistically because age, diagnosis,
medical problem, and type of surgical procedure can affect the
amounts. Evaluate trends over 24 to 48 hours

DON’T’S
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 Don’t delegate the task of recording intake and output until you
are sure the person who’s going to do it understands its
importance
 Don’t assess output by amount only. Consider color, color
changes and odor too
 Don’t use the same graduated container for more than one
patient

ADMINISTERING BLOOD AND BLOOD COMPONENTS

BLOOD TRANSFUSION

A blood transfusion is a common procedure in which donated blood or

blood components are given to you through an intravenous line (IV). A
blood transfusion is given to replace blood and blood components that
may be too low.

BLOOD COMPONENTS

In addition to whole blood, a transfusion can provide certain blood

components, or parts. These components include:

 Cryoprecipitate: Helps your blood clot.

 Plasma: Carries nutrients your body needs.
 Platelets: Help your blood clot.
 Red blood cells: Carry oxygen throughout your body.

INTRAVENOUS SOLUTIONS
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Of the various intravenous solutions, only isotonic saline (0.9%) is

recommended for use with blood components. Other commonly used
intravenous solutions will cause varying degrees of difficulty when
mixed with red cells. For example, 5% dextrose in water will hemolyze
red cells. Intravenous solutions containing calcium, such as Lactated
Ringers’s solution, can cause clots to form in blood. Prior to blood
transfusion, completely flush incompatible intravenous solutions and
drugs from the blood administration set with isotonic saline.

STEPS THAT MUST BE TAKEN PRIOR TO BLOOD TRANSFUSION

-- Verify provider’s orders for transfusion and premedication.

-- Verify patient/component identification at the bedside. Before

transfusion, the identification of the patient, using the unit tag on the
bag, must be checked by two people at the patient’s bedside against
the identification of the intended blood recipient using the patient
wristband. This step must never by bypassed. This is to be performed
by qualified individuals (provider and registered nurse, two registered
nurses, or by a registered nurse and a licensed practical nurse), one
being the transfusionists.

-- If possible, ask the patient to state his or her name, and correlate this
information with available identification.

-- Verify the blood to the provider’s order for component, volume and
special preparation.

-- Verify the blood type, donor number, component name,

compatibility, and outdate match between the unit tag and the blood
unit label.
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-- Both persons must sign the unit tag. The person who hangs the blood
must record the date and time of transfusion was started. The date,
time, component, and unit number must be recorded on the
appropriate sheet in the patient’s medical record.

-- Immediately before transfusion, mix the unit of blood thoroughly by

gentle inversion.

-- Follow the manufacturer’s instruction for the use of filters and

ancillary devices. Additional administration instructions for selected
components are printed at the end of this document. If a unit of blood
or a blood component has been entered for any reason by personnel
not working in the Transfusion Service and the unit has not been
transfused, the unit must be discarded and the unit tag must be
completed. Note the volume transfused (indicate “NONE”, if none
administered). The completed unit tag must be returned to the
Transfusion Service.

FLOW RATES

Start the infusion slowly to allow for recognition of an acute adverse

reaction. Complete the transfusion within 2-hours unless the patient
can tolerate only gradual expansion of the intravascular volume. The
infusion time should not exceed 4 hours.

DURING THE TRANSFUSION

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At 15 minutes after initiating transfusion of a unit of blood or blood

component, document the patient’s vital signs including temperature,
blood pressure, respirations, and pulse, and examine the skin for
urticaria. Such monitoring is essential for the prompt recognition of any
adverse reaction to transfusion. The rate of flow of the blood should
also be noted during these periodic inspections. During the infusion,
vital signs should be documented after the first 15 minutes, and after
completion of the transfusion. If vital signs are not within normal range
or if symptoms of a reaction are noted, vitals should be taken more
frequently.

Any transfusion that stops or slows appreciably during administration

should be investigated immediately. This is especially critical when a
blood-warming device is being used. Measures that may enhance blood
flow include elevating the IV pole, changing the filter and tubing,
repositioning the patient’s arm or changing to a larger gauge needle.

MEDICATIONS

Do not add medications directly to a unit of blood during transfusion.

Medications that can be administered “IV PUSH” may be administered
by stopping the transfusion, clearing the line at the medication
injection site with 5 - 10 mL of normal saline, administering the
medication, reflushing the line with saline, and restarting the
transfusion.

FILTERS

-- Follow manufacturer’s instructions for priming.

-- Do not twist the filter when attaching it to the IV tubing cannula.

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-- Do not use an infusion pump or suction (to fill a syringe) unless the
manufacturer’s instructions indicate that infusion pumps may be used.
Inappropriate use of such pumps may result in filter material being
infused.

-- Filters must be changed every 4-6 hours or every 2-4 units.

-- Administer all blood products not received in a syringe through a

standard blood infusion set.

PLATELETS

-- Do not refrigerate platelets as platelet activity is reduced if cooled

below room temperature.

-- Platelets should be transfused immediate after they are available

since platelet activity diminished rapidly during storage.

-- Platelets should be administered at a rapid rate for maximum

effectiveness. A rate of 5 mL/minute is frequently used.

CRYOPRECIPITATED ANTIHEMOPHILIC FACTOR (CRYO)

-- When multiple units of CRYO are ordered, the Transfusion Service will
pool the product in a single bag. -- The component must be
administered within 4 hours of pooling. -- Do not refrigerate CRYO as
this causes reprecipitation and loss of Factor VIII activity.

-- The component must be transfused immediately after it arrives on

the patient care unit because Factor VIII activity diminishes at room
temperature.

-- For maximum effectiveness, transfuse the product rapidly. The usual

flow rate is 1 to 2 mL/minute. -- CRYO does not contain red blood cells.
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CRYO from Rh-positive donors may be given to patients who are Rh

negative.

FRESH FROZEN PLASMA (FFP), FROZEN PLASMA (FP), THAWED

PLASMA

-- The transfusion of plasma should be initiated as soon as it arrives on

the patient unit. The usual flow rate is 1 - 2 mL/minute. Do not store at
room temperature or in non-monitored refrigerators.

-- Thawed Plasma must be transfused within 5 days. -- Previously frozen

plasma does not contain red blood cells. Plasma from Rh-positive
donors may be given to patients who are Rh negative.

GRANULOCYTE, PHERESIS OR WBC CONCENTRATES

-- Do not refrigerate Granulocytes.

-- Administer through a Standard blood filter. Do not use a

microaggregate filter or filter designed to remove white blood cells.

-- Isotonic saline (90%) is the only intravenous solution recommended

for use with this blood component.

-- Infused slowly over 4 hours. The rate of infusion is ultimately

dictated by the recipient’s ability to tolerate the component volume
and by adverse reactions.

-- Premedication is recommended to avoid the need to discontinue

transfusion due to a severe reaction. -- Document vital signs every 15
minutes during the entire procedure, every 30 minutes for 4 hours after
the transfusion and then every 4 hours for 24 hours. Monitor the
patient closely for moderate to severe symptoms such as urticaria,
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hives, wheezing, dyspnea, severe headache, cyanosis, hypotension,

agitation and tachycardia. If such symptoms develop, stop the
transfusion, keep the IV line open and notify the patient’s physician and
the Transfusion Service pathologist on-call for further instructions.

-- In general, transfusion of Granulocytes should be terminated only for

such complication as severe flank pain, chest pain, hemoglobinemia,
hypotension, laryngospasm, or acute pulmonary injury.

RESTRICTING FLUID INTAKE

Fluid restriction means that you need to limit the amount of liquid you
have each day. Fluid restriction is needed if your body is holding water.
This is called fluid retention. Fluid retention can cause health problems,
such as tissue and blood vessel damage, long-term swelling, and stress
on the heart.

 Plan out the amount of liquid you will have during the day: how
much will you drink to take your medications? How much will you
drink with your meals? In order to decide what works best for
you, it is helpful to sit down with a nutritionist or nurse and talk
with friends and family who may be able to support you. By
identifying preferred drinks and your drinking pattern, you will
more easily be able to decide how to adjust to your Fluid
Restriction.
 Use small cups: using a small cup can give the perception of a full
glass.
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 Use a designated container: some people find it helpful to

measure out their daily fluid allowance in one large container and
drink only from there throughout the day.
 Maintain good oral care: by brushing your teeth after meals,
rinsing with alcohol free mouthwash, chewing sugarless gum or
sucking on hard candy you may be able to decrease dry mouth
and urges to drink.
 Avoid foods with high levels of sodium (salt): these types of foods
will increase your thirst;
 Weigh yourself daily: it is important to use the same scale around
the same time each day to get the most accurate information and
report any weight gain of 2 pounds or more in one day to your
physician;
 Record your fluid intake: recording your fluid intake will help
make sure that you are not taking in more fluids than expected. It
is a good idea to write this information on a tracking log/calendar
(a sample is attached).
 You will need to learn the number of cc’s (cubic centimeters) or
ml’s (milliliters) in common servings. Some sample measurements
are included below.
 Soups, food prepared with water, and semi-solids such as
popsicles, and jello, should count toward your total daily fluid
intake.

ENHANCING FLUID INTAKE

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 Drink a water-based beverage (water, juice or milk) with every

meal and snack — between 8 and 16 oz. You should drink a
minimum of 8–10 cups per day, but aim for 10–12 cups if you are
more active. (1 cup = 8 oz.)
 Consume fluids before you are thirsty. By the time you are thirsty,
your body is already dehydrated! Use the color of your urine as an
indicator to know if you are drinking enough. Urine should be a
pale yellow color. If you notice a darker yellow, you may need to
increase your fluid intake.
 If you drink caffeinated beverages (coffee, tea and sodas),
alternate decaffeinated beverage intake throughout the
day. Caffeinated beverages and alcohol are diuretics. Diuretics
increase the excretion of water from the body rather than
hydrating.
 Try calorie-free, fruit-flavored waters to add some variety. Some
versions are flavored no-calorie waters, some are flavored with
low-calorie sweeteners and others contain enhancements like
vitamins (speak with a Registered Dietitian or physician prior to
consuming these).
 Dilute juices. For some people, fruit and vegetable juices taste too
thick or sweet. Some just people just don’t want the extra
calories. Try diluting them with water or, for a fizzy kick, use club
soda.
 Eat your water. Most of your fluid needs are met through the
water and beverages you drink. However, you can get some fluids
through the foods that you eat as well. For example, broth soups
and foods with high water content – such as celery, tomatoes, or
melons – can contribute to fluid intake.
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 Carry a water bottle with you. This is a great way to maintain your
hydration level when doing outdoor activities or running errands,
especially in warmer months. Aim for reusable bottles, and make
sure they are BPA-free.
 Order water when eating out. This will keep you hydrated, save
money and reduce calories all at the same time.
 Add citrus. Adding a slice of lime or lemon to your water may
improve the taste and make you want to drink more water than
you usually do.
 Keep a “water intake” journal. Seeing your track record can help
motivate you to maintain your fluid requirements. Try one of the
many apps that track fluids, calories and nutrients.
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