Week 4: Elimination

Cognition

comprehensive term used to refer to all the processes involved in human thought; they relate to reception of sensory input, its processing, its storage, its retrieval, and its use

Scope of Cognition

Ranges from Higher order cognitive function to cognition impairment which can be mild moderate or severe

Attributes of cognition

• consciousness

• memory

• executive function

• confusion

Consciousness

Patient’s state of awareness of self and environment, including the ability to respond to stimuli appropriately

• monitor critical to detecting neurological decline or acute conditions such as hypoxia, stroke or head injury

• assessed through levels of alertness (eg drowsy, alert, stuporous, comatose) and orientation (person, place, time, situation)

Memory

cognitive function that allows patient to encode, store, and retrieve information. Impaired memory can affect a pts ability to follow treatment plans, take medications correctly, or participate in self care

• assess by asking for short-term, long-term, and working memory recall

Confusion

State of impaired cognition characterized by disorientation, difficulty focusing, poor memory and altered perception of reality

• assessed in context of acute or chronic conditions such as delirium, dementia, infection or medication effects

Executive function

higher-order thinking processes that regulate goal-directed behavior such as planning decision making, problem solving, impulse control, and judgement — future oriented used to anticipate, predict, organize and carry out function

Perception

interpretation of the environment; dependent on sensory input

Motor Function

observing the patient’s ability to follow commands, perform purposeful movements, and maintain coordination and balance

Language

conducting observational assessments, administering standardized screening tools like Mini-Mental State Examination (MMSE), CAM, and Mini-Cog, evaluating receptive and expressive language abilities and gathering information from patients and their families

Learning and memory

the ability to retain and recall past experiences and learning— mini mental state examination (MMSE), CAM, and Mini-Cog

Social Cognition

direct observation, structured cognitive screening tools, and specific social cognition tests that evaluate abilities like theory of mmind, emption recognition, and social reasoning

complex attention

test concentration, orientation, and memory and by observing pateitn responses to multi-step commands or tasks that require sustained focus

Populations at risk

elderly and children

independent risk factors

substance abuse, trauma, chronic and acute condition (eg uncontrolled diabetes)

Prenatal risks

• genetics

• intrauterine infections can damage brain development

• intrauterine toxin exposure from alcohol, drugs, and nicotine

• poor maternal diet - inadequate nutrition, folic, acid, B12, eating deli meats

neonatal risks

• birth risks like birth trauma 

• premature birth

• hypoxia

• neonatal infection if mother has herpes or syphilis and baby is born vaginally

• newborn hypoglycemia

• newborn jaundice

• exposure to phenylketonurics if newborn has PKU sensitivity

Situational risks

• acute or chronic stress

• interpersonal violence and abuse

Personal high risk behavior

• Traumatic brain injury (TBI) if lack of hear protection

• toxin consumption (eg alcohol, ilicit drugs, smooking)

• High risk sexual behavior (syphilis leads to neurological issues)

• risky driving: not using seat belt, speeding

Health condition risks

• chronic diseases that reduce blood flow (ischemia) leading to decrease oxygen delivery (hypoxia)

• common underlying conditions linked to delirium: electrolyte imbalance, pain, infection, hypoxia, low blood sugar, medication SE

• Diabetes, cardiovascular disease, COPD, Chronic Kidney disease, Hypertension, HIV, liver disease, obstructive sleep apnea

Delirium

Acute confusion 

• onset: hours to days

• fluctuating consciousness

• reversible

• cause: medical illness or meds

  • delirium is a symptom of an underlying cause including infection, pain, hypoxia, dehydration , hypoglycemia, medication side effect, or environmental factors: sleep deprivation, psychosocial factors, emotional distress.

  • once we treat/alleviate the underlying cause, the delirium should go away

Dementia

Chronic Confusion

• onset: months to years

• progressive and irreversible decline in mental abilities

• Cause: physical changes in the brain from diseases like alzheimer’s, vascular dementia, and lewy bodies

• wandering behavior associated with unmet needs like hunger, need to eliminate, pain or anxiety

Restraints, least to most restrictive

1. mittens

2. wrist restraints

3. vest restrain

4. arm and leg restraints

5. leather restraints

Preventative measures for restraints

1. patient education about behaviors that indicate need for restraints

2. moving IV and things out of sight

3. having sitter to watch pt

Does a nurse need orders to use restraints

Yes— complete doctors order is need except under extreme emergency circumstances

How often will a nurse need to monitor patient with restraints?

Initially - every 15 minutes

Adult - every 4 hours

pediatrics - every 2 hours for 9-17yo; every hour for less than 9

Where can a nurse attach a restraint

The non moveable part of the bed— moves with patient but not an insecure part

Chemical restraint use?

indicated as last resort for dangerous uncontrolled aggressive violent behavior to ensure pt and care giver safety

What does HEENT stand for?

Head, ears, eyes, nose, throat

What does PERRLA acronym stand for?

Pupils Equal Round Reactive to Light and Accommodating 

PERRLA Assessment

P- size of each pupil in mm comparing left to right; clear or cloudy, any rapid abnormal mvmnt

E - bilateral comparison

R - shape of pupils, circular or oval?

R/L - pupil should constrict bilaterally when light shown 

A - focus on distant object and shifting focus to a closer object; pupil constriction when focusing closer

When is Mini-Cog used?

used when doing a quick screening for general cognitive impairment and dementia, especially when concerns for memory and thinking

When would a Confusion assessment Method (CAM) be used?

used when suspicion of delirium— more in hospital and acute care than in long term care

Alert and Oriented

person, place, time, situation; additionally care giver identity

Where do you check a pusle

Posterior tibial pulse, pedis dorsalis pulse, radial pulse

• temporal used for temp

• in baby: take pulse at brachial and femoral pulses

Why do we check pulses multiple places and bilaterally?

in order to make sure that the entire body is receiving blood at the same rate— inequal pulses or absent pulses indicate injury or blood vessel obstruction and needs further assessment

Elimination

removal, clearance, and excretion or waste products

Elimination attributes

output, sensible & insensible

Lifespan considerations/Populations at risk

• infants & toddlers: lack of control

  • holding it in because having fun

  • wetting bed

• pregnant women: urinary frequency due to pressure on bladder, increased volume due to vascular changes, slowed peristalsis can lead to constipation or hemorrhoids

  • increased risk for UTI

  • dehydration

• older adults: reduced renal blood flow and function, decrease bladder capacity and urethral tone, reduced smooth muscle tones, neural impulses, and mucus secretions

  • nocturia

  • slowed peristalsis

Individual risks

• Drug and alcohol use

  • narcotics slow body systems → constipation

  • antidiuretics and diuretics

• Sedentary Lifestyle

  • slows peristalsis because nor moving

  • increase risk for UTI → not able to wipe as well, not moving a lot, not wanting to get up and go to bathroom

• Post-operative

  • Ozempic type meds decrease hunger — in surgery can cause aspiration vomiting

  • decrease movement → stall in peristalsis

What consistency is constipated stool?

1. separate hard lumps = very constipated

2. lumpy and sausage like = slightly constipates

What consistency is normal stool

1. sausage with cracks

2. smooth soft sausage or snake

What consistency is stool when you lack fiber

soft blobs with clear-cut edges

What is stool consistency when GI inflammation

mushy with ragged edges

What consistency is stool with GI inflammation and diarrhea?

liquid consistency with not slid pieces

Impaction

large, hard mass of stool gets suck in the colon or rectum 

• causes: chronic constipation, inadequate fluid or fiber, prolonger immobility, medications, neurological disorder, ignoring urge to defecate

• Sx: liquid stool, loss of apetite, no pooing even with urge to defecate, nausea/vomiting, distention, cramping, rectal pain

Constipation can cause:

• Fecal incontinence

• poor quality of life

• hemorrhoids

• urinary retention

• pelvic floor dysfunction

• rectal prolapse

Dehydration can cause

• UTI

• seizure that can lead to coma

• hypovolemic shock

Responses to GI Concerns

Non-invasive

• Bowel and bladder training

• Pharmalogical - diuretic and laxatives

• patient education

• increase or decrease in fluids depending on problem

• exercise/movement

• lateral side lying 

  • constipation - left

  • diarrhea - right

• diet changes

• abdominal massages

Invasive

• enema

• Stoma

• manual disimpaction

• suppository

Types of urinary incontinence

1. Stress incontinence: due to increase abdominal pressure under stress (weak pelvic floor muscles)

2. Urge Incontinence: due to involuntary contraction of the bladder muscles

3. Overflow incontinence: due to blockage of urethra

4. Neurogenic incontinence: due to impaired functioning of the nervous system

CAUTI

catheter associated urinary tract infection

• these are preventable and often the fault of the caregivers that are supposed to be taking care of them

Responding to UTI

Bladder exercise (kegel exercise)

proper wiping technique

sterile technique when dealing with catheter

patient education

increase fluids

intake and output recording

antibiotics

Expected intake per day

Men: ~15.5cup

Women: ~11.5 cups

Expected Measurable Output per day

~800-2000 mL per day

0.5ml/kg/hr

How much unmeasurable fluid is lost per day

~30-50% of water

• perspiration: ~300-400mL/day

• respiration: ~300-400mL/day

Indication that intervention for UTI worked

• regular output

• normal color and odor

• 5-6 times per day

• no dysuria

What would a nurse ask before GI assessment?

Pain, flatus, when eat, what/how much ate, any nausea or vomiting, content (shape, color, odor) of last BM, when was last BM, any pain or discomfort

steps of abdominal assessment in the right order?

inspection, auscultation, percussion, palpation

Direction of palpation of colon?

RLQ, RUQ, LUQ, LLQ

Reasons a person may need a bedpan?

Immobile or bed bound, fall risk, convenience, clean catch

Keep in mind with bed pan

pressure sores, hyperextension of spine, cleanliness

Reasons for enema?

constipation/impaction with hard stool stuck in the rectum, cleaning/washing rectum for procedure, medication administarion

Pre-enema assessments?

Allergies? Ask patient if they need to go to the bathroom, Assess GI status noting bowel sounds and any distension, any recent surgeries

Position of patient receiving enema?

left side with knees bent or knee to chest position with anus exposed

Why may someone need a foley catheter?

urinary retention, incontinence, surgery

How can nurses prevent CAUTI

perform hand hygiene, regularly performing catheter hygiene

Sx tht indicate CAUTI

Dysuria, burning, fould smelling cloudy urine, confusion, dehydration, catheter leakage or blockage, fever and chills, sepsis

Pre-catheter questions?

Genital sweelling concerns, inflammation, pain, itching; pain urinating, change in urination, recent sexual activity

What should be assessed with Foley?

color, clarity, unusual odor, drainage, leakage, or irritation around urethral meatus

Where is NG tube placed?

Through nose down into stomach

Why might pt get NG tube?

unable to feed themselves, test for GI bleeding, medication administration

Salem Sump Tube vs Levin Tube

Salem Sump

• Used for gastric decompression

• Double lumen NG tube

  • main lumen drains stomach

  • air vent lumen allows suction without damaging gastric mucosa

Levin Tube

• used for gastric decompression and feeding

• Single lumen NG tube

• soft and flexible

What does NG maintenance include?

Assessment of tube not being kinked or coiled, flushing the tube with sterile water or normal saline, assessing skin around the nose for irritation

How does nurse confirm NG tube placement?

X ray confirmation, checking pH of aspirate gastric contents

What if gastric tube has no drainage?

checking system to make sure that suctioning is on at the right pressure, assessing tube position and make sure there is no dislodging

when would someone need a close wound drain?

to prevent fluid build up, reduce infection risk, reduce pressure and pain, and promote healing

Purpose of close wound drain?

make sure that fluid build up inside the wound are flushed out

How often should a closed wound drain be emptied?

every 4-8 hrs, when ½ - 2/3 fullWh

What should nurse assess when emptying the closed wound drain?

amount of drainage, color, consistency, how it has changed over time

What can net intake and output tell a nurse?

if the pt is getting adequate amounts of liquid, if the pt is eliminating the proper amount per day, if pt has imbalance of input and output

mL → oz

30mL=1oz