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