Exam 3
Mobility, Nutrition and Fluid & Electrolytes
Objectives
•Assess factors that put patients at risk for problems with mobility
•Identify factors related to mobility across the life span
•Assess the effects of immobility on body systems
•Detail the nursing measures to prevent complications of immobility
•Promote the use of effective techniques of body mechanics among caregivers, patients, and significant others
Mobility
- The ability of a patient to change and control their body position
- Requires muscle strength and energy, skeletal stability, joint function, and neuromuscular synchronization
- Exists on a continuum from no impairment to complete immobility
Functional Mobility
Bed Mobility- Ability to move in bed
Lying to sitting
Sitting to lying
Transferring- Ability to move from one surface to another.
Bed into chair
One chair to another.
Ambulation- The ability to walk.
Includes assistance from a person or device.
Interventions
Maintain highest level of activity possible
Musculoskeletal – passive/active ROM, ambulation
Integumentary - turn or reposition at least every 2 hr., OOB as much as possible, Braden scale, ambulation
Cardiovascular – support circulation with antiembolism stockings, sequential compression device, thrombosis prophylaxis, ambulation
Respiratory – TCDB, incentive spirometer, ambulation
Gastrointestinal – encourage fluids, high fiber diet, use narcotics as little as possible, ambulation
Nutrition Basics
Review information on the digestive system and essential nutrients
Macronutrients
Carbohydrates
Proteins
Fats
Micronutrients
Vitamins – water soluble & fat soluble – where do we get these?
Minerals – macro and trace minerals
Nutritional guidelines
Factors Affecting Nutritional Status
Physiological
Cultural & religious beliefs
Economic resources
Drug and nutrient interactions
Surgery
Altered metabolic states
Alcohol & drug abuse
Psychological state
Elimination
Objectives
Assess factors that put a patient at risk for alterations in urinary and bowel elimination
Identify factors related to alterations in elimination across the lifespan
Discuss the data that must be collected for identification of alterations in bowel/urine elimination
Identify nonpharmacologic measures to promote urinary and bowel elimination
THE CONCEPT
Food and fluids taken in
waste products eliminated through the urinary and gastrointestinal systems
Common Alterations
Urinary Tract Infections
Urinary Incontinence
Urinary Retention
Constipation
Diarrhea
Bowel Incontinence
What about elimination?
What are the terms used to document condition of both systems
What are the age-related differences?
Urinary System- The most common problems!
Urinary Tract Infection
UTI Risk
UTI Symptoms
Interventions
Urinary Incontinence
Types of incontinence
Assessment
Interventions
Urinary Retention
Causes
Interventions
GI System
Constipation
Causes
Interventions
Other issues -
intestinal obstruction & paralytic ileus
Diarrhea
Causes
Interventions
Bowel Incontinence
Causes
Interventions
Body Fluids
Review basics
•Body fluids
•Fluid movement
•Solute movement
•Fluid & electrolyte regulation
Fluid Imbalance
Hypovolemia/Dehydration Signs & Symptoms
Adults
Feeling very thirsty
Dry mouth
Headache
Dry skin
Urinating and sweating less than usual
Dark, concentrated urine
Feeling tired
Changes in mental status
Dizziness due to decreased blood pressure
Elevated heart rate
Children
Crying without tears
No wet diapers for three hours or more
Being unusually sleepy or drowsy
Irritability
Eyes that look sunken
Sunken fontanel
IV Therapy
The best way to rehydrate someone is with oral fluids, if possible.
Isotonic solutions, e.g., 0.9% sodium chloride (normal saline)
Hypotonic solutions, e.g., 0.45% sodium chloride (used to treat cellular dehydration)
Hypertonic solutions, e.g., 3% sodium chloride (used with great caution)
Electrolytes
Important in bodily functions and fluid regulation
Very narrow normal ranges
As a nurse, need to know normal ranges, causes of imbalances, S/S of imbalances, and appropriate treatments
Sodium
Calcium
Magnesium
Potassium
Phosphorous
Acid-Base Balance
Organs of Balance
Two organs are primarily responsible for maintaining the acid-base balance.
Lungs (fast)
Kidneys (slow)
Arterial Blood Gas
pH: 7.35-7.45
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L
PaO2: 80-100 mmHg (Does not affect acid-base balance)
Interpreting ABGs
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Grief & Loss and Spirituality
Grief & Loss Learning Objectives
Discuss how to advocate for the ethical/legal concerns of the patient and family members making end-of-life decisions
Identify evidence-based practices associated with end-of-life care
Describe nursing measures to support palliative care and hospice care during the dying process
Identify variations in the cultural and spiritual beliefs of the patient, caregiver(s), and family members experiencing grief and loss
Outline available personal and community resources
Describe nursing responsibilities associated with postmortem care
Grief and Loss
Content based on the End-of-Life Nursing Education Consortium (ELNEC) curriculum.
Three major concepts
Loss – the absence of a possession or future possession – health, change in relationships and roles, and loss of life
Grief – the emotional response to real, perceived, or anticipated loss
Includes feelings of anger, frustration, loneliness, sadness, guilt, regret, and peace
Impacts the individual physically, psychologically, socially, and spiritually
Mourning – the outward, social expression of loss
Influenced by cultural norms, customs, and practices
Affected by the individual’s personality and previous life experiences
Types of Grief
Anticipatory Grief – grief before a loss – associated with diagnosis of an acute chronic and/or terminal illness and experienced by the patient, family, or caregivers
Acute Grief – begins immediately after the loss, often a death, and includes the separation response and response to stress – the grieving person may be confused about their identity or social role
Normal Grief – common feelings, behaviors, and reactions to loss – reactions can include:
Physical symptoms
Emotional symptoms
Cognitive symptoms
Behavioral symptoms
Disenfranchised Grief – grief over a loss that is not validated or recognized – the affected do not feel that they can openly acknowledge their grief
Complicated Grief – 10-20% of individuals who experience the death of a romantic partner and higher numbers for parents who have lost a child
Chronic grief – normal grief reactions that do not subside and continue over a very long period of time
Delayed grief - Normal grief reactions that are suppressed or postponed by the survivor consciously or unconsciously to avoid the pain of the loss
Exaggerated Grief - An intense reaction to grief that may include nightmares, delinquent behaviors, phobias, and thoughts of suicide
Masked Grief – Grief that occurs when the survivor is not aware of behaviors that interfere with normal functioning as a result of the loss - For example, an individual cancels lunch with friends so they can go to the cemetery daily to visit their loved one’s grave.
Stages of Grief
Denial – individual refuses to acknowledge the loss
Anger – often masks pain and sadness
Depression – can occur with intense sadness over the loss of a loved one or the situation; may involve fatigue and loss of energy and may struggle with own sense of personal worth
Bargaining - can occur as an attempt to regain control of the loss
Acceptance – the individual understands the loss and, while recognizing it will be hard, acknowledges the new reality – does not mean no sadness, but recognition of the ability to cope with the grief experience
Grief Tasks
Palliative Care & Hospice
Palliative care – improving the quality of life of patients with life-limiting illnesses and their family members, through the prevention and relief of physical, psychosocial, and spiritual suffering – focus on comfort and quality of life with continued curative treatments (See 17.4)
Hospice care – a type of palliative care for those who have a terminal illness and are expected to live six months or less - focus on comfort and quality of life but curative treatments are stopped
Ethical and Legal Considerations
The nurse is ethically responsible for advocating for the patient’s wishes
Do-Not –Resuscitate Orders
Advanced Directives
Health care power of attorney
Living will
Care of the Family
Dimensions of the fading away process
Redefining - a shift for patients and families from “what used to be” to “what is now”
Burdening - As patients become more dependent, they may feel as if they are a burden to their family–physically, financially, emotionally, socially, and spiritually; family members typically do not feel the care they are providing is a burden, but rather, “something you do for someone you love”
Searching for Meaning - Patients journey inward, seek spiritual reflection, and become more connected to important family members and friends; family members may search for meaning inwardly through spiritual reflection or explore for meaning with family members and friends
Living Day to Day - patients who eventually find meaning in their illness live each day with a more positive attitude; family members who try to “make the best of it” make efforts to enjoy the limited time left with their loved one
Preparing for Death - patients often want to leave a legacy; spouses often want to meet every need of their ill spouse; patients and family members may begin to make pre-arrangements for the funeral, as well as get their will and other financial matters in order
Contending with Change - patients and family members change roles, social patterns, and work patterns;; they know the life they used to have will soon be gone
Caregiver Support
Support, assistance, and practical help (e.g., finding others to assist with grocery shopping, going to the pharmacy, and food preparation)
Honest conversations with the health care team
Assurance their loved one is being honored
Inclusion in the decision-making
Desire to be listened to and their concerns heard
Remembrance as a good and compassionate caregiver
Assurance that they did all they possibly could for their loved one
Considerations about Death for Various Populations
Comprehensive assessment and documentation is important to be able to provide culturally sensitive care
Culture influences patients and family decisions about and approach to illness, pain, spirituality, grief, dying, death, and bereavement. (See Table 17.2)
Children experience loss of a friend or family member based on their developmental stage - may have difficulty verbalizing feelings
Parents/Grandparents/Spouses
Therapeutic Communication
Self-Care
Compassion fatigue
Burnout
Nursing Care During the Final Hours
Managing Symptoms
Pain & Dyspnea
Terminal Secretions
Caring for the Family
Rituals
Spiritual Support
Phases of Dying
Actively dying
Transitioning
Imminent
Death and postmortem care
Spirituality
Spirituality Learning Objectives
Defined by the Interprofessional Spiritual Care Education Curriculum (ISPEC) as, “A dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence and experience relationship to self, family, others, community, society, nature, and the significant or sacred.”
A broader concept than religion
Elements include faith, meaning, love, belonging, forgiveness, and connectedness
Spiritual Assessment & Care
Example questions
Who or what provides you with strength or hope?
How do you express your spirituality?
What spiritual needs can we advocate for you during this health care experience?
Consider contacting the chaplain if signs of spiritual distress are noted in a patient or family member
See 18.3 for information on a variety of religions and spiritual practices
Personal spiritual care