Elimination and Self-Concept

Elimination and Self-Concept

Elimination: The Urinary Tract Anatomy and Physiology

• Primary Function:
    - Eliminate waste and excess fluid as urine.

• Additional Functions:
    - Regulates electrolytes, blood pressure, RBC production, and bone strength.

• Organs:
    - Kidneys, ureters, bladder, urethra.
  

Kidneys

• Description:
    - Bean-shaped organs located below the ribcage.

• Function:
    - Filter 120-150 quarts of blood daily, producing 1-2 quarts of urine.
  

Ureters

• Description:
    - Thin muscular tubes that transport urine from the kidneys to the bladder.
  

Bladder

• Description:
    - Hollow, muscular organ that stores urine.

• Capacity:
    - Normally holds up to 2 cups (approximately 500 mL).

• Functionality:
    - Contains stretch receptors that signal the brain when full, initiating the urge to urinate.
  

Urethra

• Description:
    - The tube that carries urine from the bladder out of the body.
  

Muscles Preventing Unwanted Urination

• Involved Muscles:
    - Urethra, internal sphincter (bladder neck), and pelvic floor muscles.

Urine Production and Output

• Normal Urine Characteristics:
    - Clear, light yellow, and odorless.

• Factors Affecting Output:
    - Fluid intake, food intake, exercise (sweating), and medications.

Expected Urine Output

• Adults: Approximately $0.5 ext{ mL/kg/hr}$.

• Infants: Approximately $2 ext{ mL/kg/hr}$.

• Toddlers: Approximately $1.5 ext{ mL/kg/hr}$.

• Teens: Approximately $1 ext{ mL/kg/hr}$.

Abnormal Urine Characteristics

• Dark Yellow:
    - Indicates dehydration.

• Dark Brown:
    - Possible kidney or liver issues.

• Red:
    - Possible hematuria (blood in urine); dietary factors (e.g., beets) can also cause red urine.

• Cloudy/Foul Odor:
    - Possible infection.

Hormonal Regulation

• Antidiuretics:
    - Minimize fluid loss by increasing urine production.
    - ADH (Vasopressin):
      - A natural hormone that instructs kidneys to reabsorb water, leading to less urine production and more concentrated urine.
    - Desmopressin:
      - Synthetic form of ADH.

• Diuretics:
    - Increase urination by preventing urine production or increasing the excretion of water and electrolytes.

Alterations in Urinary Elimination

• Urinary Incontinence:
    - Involuntary leakage of urine.
    - Types of Incontinence:
      - Stress Incontinence: Leakage due to increased pressure on the bladder (coughing, sneezing, laughing, physical activity).
      - Urge Incontinence: Strong, sudden urge to urinate, leading to leakage before reaching the toilet.
      - Reflex Incontinence: Urinary leakage due to nerve damage (no normal urge sensation).
      - Overflow Incontinence: Bladder does not empty completely, causing overfilling and leakage.
      - Functional Incontinence: Physical inability to reach the toilet in time (e.g., mobility issues, arthritis).
      - Nocturnal Enuresis (Bedwetting): Incontinence during sleep.

• Urinary Retention:
    - Inability to fully empty the bladder.
    - Symptoms:
      - Inability to urinate, pain, abdominal distention, urinary frequency, hesitancy, weak/slow urine stream, urinary leakage.

• Urinary Tract Infections (UTIs):
    - Cause:
      - Bacteria entering the urinary tract; more common in women due to a shorter urethra.
    - Risk Factors:
      - Sexual activity, menopause, urinary retention, urinary obstruction, frequent catheter use, diabetes, urinary tract abnormalities.
    - Symptoms:
      - Burning/painful urination, frequent urgency despite not having much urine to pass.
    - Complication:
      - Pyelonephritis (kidney infection) if untreated.

• Kidney Stones (Renal Calculi):
    - Hard formations of minerals and salts in the kidneys, causing pain and potential obstruction.

Elimination: The Gastrointestinal (GI) Tract Anatomy and Physiology

• Organs:
    - Mouth, esophagus, stomach, small intestine, large intestine, anus.

• Accessory Organs:
    - Liver, pancreas, gallbladder.

• Function:
    - Digest food and drink, absorb nutrients, and eliminate waste as feces.

Process of Digestion

• Mouth:
    - Chewing begins digestion.

• Epiglottis:
    - Prevents food from entering the airway.

• Esophagus:
    - Peristalsis (wave-like muscle contractions) moves food to the stomach.

• Stomach:
    - Mixes food with digestive secretions.

• Small Intestine:
    - Continues digestion and absorbs nutrients.

• Large Intestine:
    - Absorbs water and forms stool from waste products.

• Anus:
    - Elimination of stool through bowel movements.

Stool Characteristics

• Normal Stool:
    - Soft, formed, easy to pass.

• Frequency:
    - Varies from 1-3 times/day to 3 times/week.

• Bristol Stool Chart:
    - Classifies stool consistency:
      - Type 1-2: Constipation
      - Type 3-4: Normal
      - Type 5-7: Diarrhea

Alterations in Bowel Elimination

• Constipation:
    - Definition: Fewer than three bowel movements per week.
    - Symptoms: Dry, hard stools; sensation of incomplete emptying.
    - Causes: Low fiber diet, insufficient fluid intake, certain medications.

• Diarrhea:
    - Frequent loose, watery stools.
    - Causes: Infection, medications (antibiotics), GI disorders.
    - Complications: Dehydration, malabsorption.

• Bowel Incontinence:
    - Involuntary loss of stool.
    - Causes: Nerve damage, weak pelvic muscles, reduced mobility.

• Diverticulosis:
    - Small sacs (diverticula) form in the colon.

• Diverticulitis:
    - Inflammation or infection of diverticula, often due to trapped food.

• Irritable Bowel Syndrome (IBS):
    - Abdominal pain and altered bowel patterns (diarrhea, constipation, or mixed).

• Ulcerative Colitis (UC):
    - Chronic inflammation and ulcerations of the large intestine (colon).

• Crohn's Disease:
    - Chronic inflammation that can affect any part of the GI tract, commonly the small intestine.

Medications Affecting Bowel Motility

• Can Slow GI Motility (Cause Constipation):
    - Antacids, anticholinergics, antispasmodics, antiseizure medications, calcium channel blockers, diuretics, anti-Parkinson's medications, iron supplements, narcotic pain medications, antidepressants.

• Can Increase GI Motility (Cause Diarrhea):
    - Antibiotics, magnesium antacids.

Self-Concept Definition and Components

• Self-Concept:
    - The overarching perception of who a person is; how they think about themselves.
    - It is unique, dynamic, subjective, and evolves throughout the lifespan.

• Self-Esteem:
    - How a person feels about themselves; the evaluative component of self-concept, reflecting overall self-worth.

• Roger's Theory of Self-Concept:
    - Self-Image:
      - How an individual views their unique qualities (genetic, physical, personality traits).
    - Self-Esteem:
      - The evaluative component; overall sense of self-worth.
    - Ideal Self:
      - What a person aspires to be; their personal goals and aspirations.
    - Congruence:
      - When self-image aligns with the ideal self, leading to a positive self-concept.
    - Incongruence:
      - A mismatch between self-image and ideal self, leading to anxiety and confusion.

Factors Influencing Self-Concept Development

• Experience:
    - Responding to life situations and challenges shapes self-perceptions.

• Emotional Intelligence (EI):
    - Ability to perceive, understand, control, and manage emotions.

• Self-Awareness:
    - Ability to see oneself clearly and objectively through reflection.

• Body Image:
    - Perceptions, feelings, and thoughts about one's body.

• Self-Efficacy:
    - Perceived ability to successfully complete tasks.

• Culture:
    - Shared values, beliefs, and norms that guide thinking and behavior.

• Role Performance:
    - Perceptions of one's ability to fulfill various life roles (e.g., student, parent, nurse).

Erikson's Psychosocial Stages

• Each stage presents a developmental task that impacts self-concept.

• Identity vs. Role Confusion Stage:
    - Particularly crucial for identity formation during adolescence (12-19 years).

Stressors Affecting Self-Concept

• Identity Stressors:
    - Events threatening one's sense of self (e.g., job loss, divorce, discrimination, gender dysphoria).

• Body Image Stressors:
    - Changes affecting physical appearance or function (e.g., illness, injury, aging, weight changes).

• Self-Esteem Stressors:
    - Factors reducing self-worth (e.g., failure, criticism, abuse, chronic illness, financial changes).

• Role Performance Stressors:
    - Difficulty fulfilling expected roles (e.g., role conflict, role ambiguity, role overload).

Nurse's Role

• Nurses play a vital role in promoting a positive self-concept through holistic, client-centered care.

• Interventions Include:
    - Encouraging self-expression, supporting coping strategies, promoting independence, and providing education and emotional support.

Patient-Centered Care Core Principles

• Definition:
    - A concept that places the client at the center of nursing care, respecting their preferences, values, and cultural considerations.

• Goal:
    - To provide the best possible care, leading to improved outcomes, increased patient satisfaction, and enhanced trust.

• Key Elements:
    - Caring, client preferences, cultural considerations.

Caring Theories

• Watson's Theory of Human Caring:
    - Emphasizes the importance of nurses caring for themselves to effectively care for others.
    - Focuses on establishing presence, building trust, and developing human-to-human connections (transpersonal caring).
    - 10 Caritas Processes:
      - A framework for caring that includes practicing loving-kindness, being present, developing trust, supporting patient beliefs, encouraging expression of feelings, creating healing environments, and assisting with basic needs respectfully.

• Swanson's Theory of Caring:
    - Views caring as a process with five categories:
      - Maintaining Belief: Supporting hope and a positive outlook.
      - Knowing: Understanding the client's situation and perspective.
      - Being With: Providing emotional and physical presence; active listening.
      - Doing For: Performing care that the client cannot do for themselves.
      - Enabling: Supporting client independence and guiding them through healthcare experiences.

Key Nursing Behaviors

• Listening:
    - Active and intentional listening, including observing nonverbal cues and allowing for silence.

• Touch:
    - Providing physical presence and demonstrating caring, used appropriately and with permission.

• Being Present:
    - Giving full attention to the client, fostering trust and emotional support.

• Client Preferences:
    - Actively seeking and respecting the client's choices in their care.

• Culturally Competent Care:
    - Providing care that aligns with the client's cultural beliefs, values, and practices.

Spiritual Assessment

• Nurses should assess clients' spiritual needs, sources of strength, beliefs about meaning and purpose, relationship with a higher power, and spiritual practices.

• Tools:
    - The FICA (Faith/Beliefs, Importance, Community, Address in care) and HOPE (Hope, Organized religion, Personal practices, Effects on care/end-of-life) models can guide this assessment.

Inclusion, Equity, and Diversity

Culture and Care

• Leininger's Theory of Culture Care Diversity and Universality:
    - Guides nurses in providing culturally appropriate care by recognizing the diversity of clients' backgrounds (race, religion, socioeconomic status, age, gender identity, sexuality, etc.).

• Culture:
    - The integration of human behaviors, including communication, beliefs, values, customs, and institutions of groups.
    - Significantly impacts how clients perceive health, illness, and healthcare.

• Leininger's Sunrise Enabler:
    - A cultural assessment tool to guide culturally congruent care.

Key Concepts

• Cultural Awareness:
    - Understanding differences between perceptions, beliefs, and values within one's own culture and those different from one's own.
    - Includes self-awareness of personal biases.

• Cultural Diversity:
    - Differences among individuals and groups (e.g., age, ethnicity, religion, language, socioeconomic status).

• Cultural Competence:
    - The ability to appreciate, accept, and respect all individuals' cultural influences, beliefs, customs, and values, integrating this knowledge into practice.

• Emic Knowledge:
    - The insider's viewpoint of a culture.

• Etic Knowledge:
    - The outsider's (professional/clinical) viewpoint of a culture.
    - Both are essential for holistic care.

Equality vs. Equity

• Equality:
    - Distributing the same resources to all individuals.

• Equity:
    - Distributing resources based on individual needs to achieve the highest level of health for all.

Health Disparities

• Definition:
    - Differences in health outcomes among populations, often due to barriers in social, economic, and environmental resources.
    - Vulnerable populations are at higher risk.

LGBTQIA+ Inclusion

• Providing respectful and affirming care, using correct names and pronouns, and avoiding assumptions.

Health History Interview: Present Health

Urinary System Assessment

• Voiding Patterns:
    - Assess frequency, urgency, nocturia.

• Symptoms:
    - Difficulty urinating (hesitancy, weak stream, dribbling, incomplete emptying), dysuria (painful urination), suprapubic pain.

• Urine Characteristics:
    - Color (clear, yellow normal; cloudy, foul odor, blood abnormal), amount.

• Incontinence:
    - Assess type (stress, urge, reflex, overflow, functional).

• Systemic Signs:
    - Weight gain, edema, shortness of breath may indicate kidney failure.

Bowel/Anus Assessment

• Bowel Habits:
    - Changes in frequency, consistency (diarrhea, constipation), incontinence.

• Stool Characteristics:
    - Color, presence of blood, pus, mucus, steatorrhea (fatty stools).

• Hemorrhoid Symptoms:
    - Pain, itching, burning.

Reproductive System Assessment

• Approach:
    - Nonjudgmental, culturally sensitive communication; respect privacy.

• Key Areas:
    - Assess gender identity, sex assigned at birth, current anatomy, and any gender-affirming treatments.

• Sexual Health:
    - Ask about sexual practices and frequency of genital/reproductive checkups.

Health History Interview: Past Health

Urinary System

• History:
    - Recurrent UTIs, personal/family history of kidney disease, prostate problems (BPH).

• Clinical Significance:
    - Recurrent UTIs can lead to kidney damage.
    - BPH can cause urinary retention.
    - Kidney disease may be hereditary.

Bowel/Rectal

• History:
    - Anal surgery, hemorrhoids, rectal/anal problems.

Reproductive System

• History:
    - Personal/family history of reproductive cancers (cervical, ovarian, breast, prostate, testicular, colon), past reproductive surgeries.
    - Menstrual History (Females):
      - LMP, age at menarche, cycle frequency/duration.
    - Obstetric History (Females):
      - Pregnancies, deliveries, miscarriages, abortions, living children, fertility issues.

• Menopause Assessment (Females):
    - Symptoms (hot flashes, vaginal dryness), hormone therapy use.

• Male Reproductive History:
    - Changes in testicles/scrotum (lumps, swelling, size changes), testicular self-exams.

Diagnostic Tests Related to Elimination

Urinary Diagnostics

• Urine Specimen Collection:
    - Urinalysis (UA) for infection, kidney disease, diabetes; Urine Culture & Sensitivity (C&S) to identify bacteria and determine antibiotic sensitivity.

• Urodynamic Testing:
    - Evaluates bladder and sphincter function (uroflowmetry, cystometry, PVR measurements).

• Endoscopic Procedures:
    - Cystoscopy (bladder/urethra), Ureteroscopy (ureters/kidneys).

• Imaging:
    - CT scan, ultrasound, cystography, pyelogram.

• Blood Tests:
    - BUN, Creatinine, GFR (kidney function).

GI Diagnostics

• Imaging:
    - Barium swallow (upper GI series), Small Bowel Series, Barium Enema (lower GI series), Cholangiography, X-ray, CT Scan, MRI, Ultrasound.

• Endoscopy:
    - EGD (esophagus, stomach, duodenum), Colonoscopy (large intestine), Flexible sigmoidoscopy.

• Stool Specimen Collection:
    - Fecal Occult Blood Test (FOBT) to detect hidden blood; Stool Culture to identify infection.

Nursing Interventions to Facilitate or Maintain Elimination Patterns

Urinary Interventions

• Lifestyle Changes:
    - Reduce bladder irritants (caffeine, alcohol, carbonated drinks), maintain fluid balance, smoking cessation, weight loss.

• Bladder Training:
    - Gradually increasing time between voids to retrain bladder control.

• Pelvic Floor Exercises (Kegels):
    - Strengthen pelvic floor muscles.

• Urinary Catheterization:
    - Types:
      - Straight (Intermittent): For temporary emptying.
      - Indwelling (Foley): Continuous drainage with a balloon to secure.
      - External (Condom Catheter for Males): Lower UTI risk.
    - CAUTI Prevention:
      - Crucial to prevent infection (maintain hygiene, use sterile technique for indwelling, keep bag below bladder, limit use).

• Bladder Scanning:
    - Measures post-void residual (PVR) to assess bladder emptying.

• Promoting Urination:
    - Positioning (standing for males, sitting/squatting for females), sensory stimulation (running water).

Bowel Interventions

• Lifestyle Changes:
    - Increase fiber and fluids, increase activity, respond to the urge to defecate, stress management.

• Enemas:
    - Instill fluid into the rectum to stimulate defecation or cleanse the bowel.
    - Types:
      - Cleansing, retention (oil), return-flow, medicated, and carminative.
        - Safety:
          - Left lateral (Sim's) position for insertion, warm solution, slow infusion, monitor for cramping, do not exceed 3 enemas without order.

• Laxatives/Stool Softeners:
    - Medications to promote bowel movements.

• Bowel Training:
    - Establishing a regular bowel pattern through scheduled toileting, fiber, hydration, and possibly laxatives.

• Rectal Tubes:
    - Used for severe incontinence or ICU patients to manage output and protect skin.

• Ostomy Care:
    - Managing stomas (colostomy, ileostomy, urostomy) with pouching systems, skin protection, and regular emptying.

Nasogastric (NG) Tubes

Purpose

• Decompression:
    - Remove gas and fluid from the stomach to relieve pressure, especially after surgery or with obstructions/ileus.

• Lavage:
    - Wash out the stomach (e.g., in cases of poisoning or overdose).

• Aspiration:
    - Obtain gastric contents for analysis.

• Administration:
    - For tube feedings, medications, or contrast media.

Types and Setup

• Single-Lumen (Levin Tube):
    - For decompression, specimen collection, or medication administration.
    - Uses low intermittent suction (safer for mucosa).

• Double-Lumen (Sump Tube):
    - Most common for decompression.
    - Has a large lumen for suction and a smaller air vent (blue pigtail) allowing continuous suction without damaging the mucosa.
    - The air vent must always remain open to the air.

• Three-Lumen (Sengstaken-Blakemore Tube):
    - Used for esophageal variceal bleeding, with balloons for gastric and esophageal compression.
    - Requires airway protection (endotracheal intubation).

• Suction:
    - Can be intermittent (cycles on/off) or continuous.
    - Intermittent is generally safer.

Insertion and Verification

• Procedure:
    - Measure tube length (nose-ear xiphoid process), lubricate tip, insert into the selected nostril (most patent), advance toward the posterior pharynx, encourage deep breaths and swallowing.

• Verification of Placement (CRITICAL):
    - Radiographic (X-ray): Gold standard.
    - pH Testing: Aspirate gastric contents; expected pH is $ext{≤5.5}$.
    - NEVER use air auscultation method (unreliable).

• Securing the Tube:
    - Tape to the nose, anchor to the gown to prevent tension.

Maintenance and Complications

• Irrigation:
    - Performed as needed (or per policy) to maintain patency.
    - Use only saline or water for decompression tubes.
    - Flush the air vent of a sump tube with air.

• Monitoring:
    - Intake and output (subtract irrigant from output), drainage characteristics (color, consistency), bowel sounds, abdominal distention.

• Complications:
    - Aspiration, fluid/electrolyte imbalance, mucosal damage, tube displacement, infection.

• Oral/Nasal Care:
    - Essential to prevent dryness and skin breakdown.

Self-Concept and Identity Formation

Understanding Self-Concept

• Self-Concept:
    - An individual's perception of who they are, influenced by experiences, interactions, and societal/cultural attitudes.

• Self-Esteem:
    - How a person feels about themselves; their sense of self-worth.

• Identity Formation:
    - A lifelong process of understanding oneself within social contexts.
    - Critical Period:
      - Adolescence (12-19 years) is the critical period for identity development (Erikson's Identity vs. Role Confusion).

Factors Influencing Self-Concept

• Internal Factors:
    - Self-image, self-esteem, ideal self, emotional intelligence, self-awareness, body image, self-efficacy.

• External Factors:
    - Culture, family, social norms, role performance, life experiences, stressors.

Stressors

• Identity Stressors:
    - Threaten one's sense of self (e.g., job loss, discrimination).

• Body Image Stressors:
    - Impact physical appearance (e.g., illness, aging).

• Self-Esteem Stressors:
    - Reduce feelings of worth (e.g., failure, criticism).

• Role Performance Stressors:
    - Difficulty fulfilling roles (e.g., role overload).

Nurse's Role

• Promote positive self-concept through holistic, client-centered care.

• Assess for stressors and support coping mechanisms.

• Encourage self-expression and independence.

Patient-Centered Care Core Principles

• Definition:
    - Care that places the client at the center of all healthcare decisions, respecting their needs, preferences, values, and cultural background.

• Essential Elements:
    - Caring, client preferences, cultural considerations.

• Caring:
    - Nurturing, holistic approach encompassing physical, emotional, and spiritual needs.

Key Nursing Approaches

• Listening:
    - Active, empathetic listening is crucial for assessment and building trust.

• Touch:
    - A way to demonstrate presence and provide comfort, used appropriately and with permission.

• Being Present:
    - Giving full attention to the client, fostering trust and emotional support.

• Client Preferences:
    - Involving the client in decision-making and respecting their choices.

• Culturally Competent Care:
    - Adapting care to align with the client's cultural beliefs and practices.

Spiritual Care

• Assessing spiritual needs, sources of strength, and beliefs is part of holistic care.

• Tools:
    - Assess using the FICA and HOPE models for guidance.

Inclusion, Equity, and Diversity

Cultural Competence

• Culture:
    - Shared beliefs, values, customs, and behaviors influencing health perceptions and practices.

• Cultural Awareness:
    - Recognizing one's own cultural biases and understanding differences in others.

• Cultural Diversity:
    - Differences among individuals and groups.

• Cultural Competence:
    - The ability to provide care that respects and integrates cultural knowledge, applying it in practice.

• Emic vs. Etic Knowledge:
    - Understanding both the client's (emic) and the provider's (etic) perspectives is vital.

Equity and Health Disparities

• Equality:
    - Providing the same resources to everyone.

• Equity:
    - Providing resources based on individual needs to achieve fair health outcomes.

• Health Disparities:
    - Unequal health outcomes among different populations, often linked to social determinants of health (SDOH) and vulnerable populations facing barriers.

LGBTQIA+ Inclusion

• Provide affirming care, using correct names and pronouns, and respecting identity.

Health History Interview: Present and Past Health

Urinary System

• Present Health:
    - Assess voiding patterns, symptoms (dysuria, hesitancy, frequency, urgency, incontinence), urine characteristics (color, odor, clarity), and systemic signs (edema, SOB).

• Past Health:
    - History of UTIs, kidney disease, BPH.

Bowel System

• Present Health:
    - Bowel habits, stool characteristics (color, consistency, presence of blood/mucus), hemorrhoid symptoms.

• Past Health:
    - History of anal surgery, hemorrhoids, rectal issues.

Reproductive System

• Present Health:
    - Assess gender identity, sexual practices, reproductive anatomy, and any gender-affirming treatments.

• Past Health:
    - History of reproductive cancers, surgeries, menstrual history (LMP, cycle details), obstetric history, menopause status, testicular changes.

Diagnostic Tests Related to Elimination

Urinary

• Urinalysis (UA):
    - Assesses color, clarity, odor, pH, protein, glucose, ketones, blood, leukocytes, nitrites.

• Urine Culture & Sensitivity (C&S):
    - Identifies bacteria and determines antibiotic effectiveness.

• Urodynamic Tests:
    - Evaluate bladder function (PVR, cystometry).

• Blood Tests:
    - BUN, Creatinine, GFR for kidney function.

GI

• Endoscopy (EGD, Colonoscopy):
    - Direct visualization.

• Imaging:
    - Barium studies, CT, Ultrasound.

• Stool Tests:
    - FOBT (detects hidden blood), Stool Culture (identifies infection).

Nursing Interventions for Elimination

Urinary Interventions

• Promoting Voiding:
    - Positioning, sensory stimulation (running water).

• Catheter Care:
    - Preventing CAUTI (aseptic technique, hygiene, closed system, bag below bladder).

• Bladder Training:
    - Scheduled voiding.

• Bladder Scanning:
    - Assessing PVR.

Bowel Interventions

• Dietary Modifications:
    - Increase fiber and fluids.

• Promoting Defecation:
    - Responding to the urge, scheduled toileting.

• Enemas:
    - Cleansing, retention, return-flow.

• Laxatives/Stool Softeners:
    - Medications.

• Ostomy Care:
    - Managing pouch systems, protecting skin, emptying pouch when 1/3-1/2 full.

NG Tube Management

• Insertion:
    - Requires verification of placement (X-ray, pH testing).

• Decompression:
    - Connecting to suction (intermittent or continuous, depending on tube type).

• Maintenance:
    - Irrigate as needed, monitor output, provide oral/nasal care.

• Complications:
    - Aspiration, fluid/electrolyte imbalance.