Semes1_NursingTheory_Wk5-9_Elisa_GBC_1

• 1. Nausea
• 2. Vomiting
• 3. dehydration
• 4. Diarrhea
• 5. Constipation

• 1.Medication
• 2. Odors
• 3. Heavy activity (Roller coasters)
• 4. Food intake

An upleasent wave like motion in the back of the thoart or same motion in the abdonmen

• * GI disease
• * Could be related to medication
• * Could be related to Chemotheraphy
• * Anesthesia etc

VOMITING

EMESIS

Yes Emesis does vary in content and colour. 

• * Emesis may contain undigested food
• * Emesis may containg blood

• Note:
• *  Fresh blood is bright red
• *  Dark blood looks like coffee grounds)

HEMATEMESIS

Imbalanced nutrition (less than what the body requires) related to nausea and vomiting

Client will report fewer episodes of nausea and during a dietry change and two weeks after being placed on a customer diet with proper amt of nutrition

• * Abdominal assesment (listening for bowel sounds)
• * Keeping track of ACCO- Amt, Colour, Consistency and Odour
• * Intake and Output of fluid
• * Vital signs (BP)
• * Skin tugor

• A great loos of fluid from the body
• A form of dehydration

heard every 5 to 20 seconds

you can hear 1 to 2 sounds every 2mins

• When no sounds are heard in 3 -5mins
• This could mean there is a possible bowel obstruction)

5-6 sounds heard in less then 30 seconds

• * Decrease clients activity level
• * ensure there is an empty emesis basin in reach for client
• * Remove triggers for N&V from client area (odours)
• * Offer smal amts of bland food
• * Offer small amts of oral fluids

• * A drug that prevents and treats N&V and dizziness
• * This drug is used for many types of N&V

* Serotonin receptors agonist blocks CNS that affect vomiting pathways.

* it is used to trear vomiting due to chemotheraphy

• * Inhibits vomiting centre in the brain
• * used for short term vomiting

• Dehydration (lossof fluid in the body) is related to:
• * Lack of fluid intake
• * Excessive sweating
• * Frequent vomiting and the ability to keep any liquids down

• * Antibiotic indueced
• * Polyuria
• * Excessive fluid loss (like high fever, sweating, hot climate etc)

Mobilities is the skin ease of raising when pinched or testing for dehydration of the skin

Turgor is the skins ability to return back to normal promptly when the pinch is released.

Blood Urine Nitrogen

Deficit fluid volume related to

• 1. Fluid lost through vomiting
• 2. Diarrhea 
• 3. Inadequate fluid intake

• Blood Urea Nitrogen ratio increases >20mg
• sodium increases >150mEq/L
• Serum osmolality increased >300mmol/kg
• Urine Specific gravity increase >1.020
• urine color os dark yellow
• urine amt is 800-1200ml/day

Deficit fluid volume related to fluid lost through vomiting, diarrhea and inadequate fluid intake.

• *Offer fluids that contain electrolytes
• *Frequent mouth care

• Intake and output quality more often
• clients weight, HR, BP, Temp. skin etc

When the urine output is less then 30ml/h

• output and intake are at the same levels
• Client reports normal skin turgor within 1day
• Client reports absence of vomiting/diarrhea
• Client reports formed stool in 2-3days

abdominal pain and diarrhea or constipation, often associated with stress, depression, anxiety, or previous intestinal infection.

• Body's immune system begins attacking healthy cells in your GI tract, causing inflammation.
• Classified medically as an autoimmune disorder. (means the body is producing antibodies that work against itself.)

It is a chronic, or long-lasting, disease that causes inflammation and sores, called ulcers, in the inner lining of the large intestine.

Children and elderly

• Urinary output less than 30ml for 2-3 consecutively
• If Potassium levels drop to less than 3.0mEq/L

Low levels of potassium can cause cardiac dysrhythmias which can lead to death.

shock caused by severe blood or fluid loss

barium sulfate is injected into the rectum and X-rays are taken to search for lesions

• Focus on what caused the symptoms
• treating underlying causes
• Certain meds can reduce the severity of diarrhea

Deficient fluids volume related to fluid losses secondary to diarrhea. (secondary to chemo)

• MONITOR:
• Stool characteristics
• Abdominal assessment (sounds/ how frequent)
• Vital signs, HR↑, BP↓, Temp. ↑
• Skin integrity / turgur

• Bed rest for acute episodes
• Good skin care with mild soap
• frequent fluids, low bulk bland foods
• commode at side of bed

Increases blood flow to the anal and perinal area and soothing to the external tissues

• Stool is normal in colour, in odour frequency and consistancy
• Client has his/her regular pattern of BM
• Signs and symptoms have or will be been resolved in 1 -2days (short term)
• Clients Perianal area skin remains intact

Abnormal, infrequency or irregular defecation (less than 3x a week)

• Colon absorbs to much water
• weak colon muscles contraction (meaning as you get older the muscles are getting weaker which means less contraction and as a result the feces doesn't move along the GI tract)

• low exercise
• pregnancy
• overuse of laxitives
• stress
• medication (opioids, anitdepressions)
• Low fibre

• Hemorrhoids
• bowel obstruction
• Endocrine disorders (hyperthyroidism)
• Muscle disorders, metabolic etc

• abdominal distenion
• decreased appetite
• idigestion
• gurgling/rumbling sounds in the abdomen (Borborgymus)

• Sigmoidoscopy (Colonscopy)
• Stool specimens

examination of the sigmoid colon by means of a flexible tube inserted through the anus.

an abnormal enlargement of the colon

a swollen vein or group of veins in the region of the anus

• Constipation related to
• *side effects of medication (Opiods antidepressants)
• Pain on defecation
• (For ex. side effect from general surgery rectal surgery)

• Restore/maintain a regular pattern of elimination within 2 day
• Ensure lots of fluid intake with a high fiber deit
• Long term:  Client learns method to prevent constipation. Like training body to go at a certain time
• * client is able to manage anxiety related to constipation
• complications are avoided

• Clients pattern of bowel function is re-established within 2 day
• Client responds immediately to the urge to defecate daily by sitting on the toilet
• Client passes soft semi-formed stool consistently without straining

The bladder, also known as the urinary bladder, is an expandable muscular sac that stores urine before it is excreted out of the body through the urethra

DETRUSOR MUSCLE

• The internal & external sphincter muscles form a ring around the urethra to keep urine in the bladder.
• When you are ready to urinate, these muscles relax to allow urine to flow out of the bladder.

• 1. Voiding diary to asses pattern and type
• 2. Measure intake and output
• 3. Ensure sufficient fluid intake
• 4. Ensure privacy for toileting

• 1. Habit training - timed voiding schedule
• 2. Modify environment and easy clothing
• 3. Introduce pelvic floor exercises (Kegels)

Tapping the hand over the pelvic area

If this patient has spinibiffida

when the bladder is unable to empty itself

2000-3000ml

yes

• 1. Urethral obstruction (ie. enlarged prostate)
• 2. Surgical trauma
• 3. Motor/sensory alterations (I. MS)
• 4. Diabetes
• 5. Post anesthesia

• *Drugs that block the action of the neurotransmitter acetylcholine in the brain.
• *The drugs help to block involuntary movements of the muscles associated with these diseases

• 1. absence of urinary output
• 2. Bladder distension
• 3. Diaphoresis (sweating)
• 4. Abdominal discomfort

Diaphoresis

• 1. Palpate bladder
• 2. Monitor volume and frequency
• 3. Monitor post void residuals (PVR) (left over pee)

• Post
• Void
• Residual

E-coli

it promotes bladder emptying

Promotes bladder filling

• Weakened Pelvic muscle
• Neurogical diesease
• Imparied imobility
• Constipation
• UTI
• Side effects from some medications

• 1. Urge
• 2. Reflex
• 3. Stress
• 4. Over flow
• 5. Functional
• 6. Mixed

involuntary elimination of urine is associated with a strong need to void

Neurogenic - spinal cord lesion results in no sensory awarness of the need to void an interrupts control by the brain.

Weakend perineal muscles permits leakage of urine when intra-abdominal pressure is increased.( ie. laugh sneeze)

associated with over distension of bladder and abnormal bladder emptying

Urinary system is intact, but problems such as mobility, cognition, or environment prevent client frm reaching toilet before soiling occurs

this is the presence of more then one typ of incontinence.  (ie. stress and urge etc.)

• 1. Inquiry about fluid intake patterns (caffiene/alcohol etc)
• 2. Inquiry about out put patterns. (How many accidents do you have a day? How often do you have the URGE to void?)
• 3. Bowel patterns
• 4. Have you had any previous UTI's?
• 5. Environment? (Location of BR)
• 6. Functional status - ability to get to BR
• 7. Is client cognitive enough? (do they have the ability to ask for help?

• 1. Keep a voiding diary.
• 2. Fluid Intake/Output
• 3. Inspect gentialia area
• 4. If there is odour (possible UTI)
• 5. Palpate bladder
• 7.  conduct a bladder examine

The client will achieve continence (or significantly decrease incontinent episodes) within 2-6months

The client will maintain optimal dryness at all times effective within 2 weeks (remember this is a liong term goal)

• Specific
• Measureable
• Attainable
• Realistic
• Tangible / timely

• voiding diary
• Ensure privacy
• measure intake output
• Ensure sufficient fluid intake (2-3L per day)

C. 30mins

• True!
• Caffeine is considered an irritant.

• having a tube in the bladder is irritating. (not ideal)
• But is better for the skin if the incontinence is really bad

No it does not.

no they should be used as last resort because that do not solve the problem

• Provide psychological support (the pt can feel humiliated)
• Clean skin right away
• Refer to continence nurse specialist

Functional incontinence related to impaired mobility (or impaired cognition, or not being able to reach the toilet ontime)

Reflex incontinence related to spinal cord lesions which results in no sensory awareness of need to void

URGE incontinence related to involuntary elimination of urine associated with strong need to void

• 1. Absence of urinary output
• 2. Sensation of incomplete emptying
• 3. Bladder distention

• 1. Palpate bladder
• 2. Monitor volume and frequency of voiding (when was the last time pt voided?)
• 3. Bladder scan
• 4. Monitor Post-void residuals

• 1.  Have pt void
• 2.  Use bladder scanner or intermitent catherization to measure amt of urine remaining in bladder

• (This is the left over urine)
• Possible Test question!!

• 1. Consider cause as to why pt isnt voiding
• 2. Take measure to promote voiding. (ie. running water, maintain adequete fluid intake)
• 3. Intermitten catheterization (MD ordered) This will promote urinary drainage/or releive obstruction

Parasympathomimetic medications (Urecholine) to increase contraction of the detrusor muscle

drugs that mirror the action of the parasympathetic nervous system of the brain and spinal column

• Parasympathetic system (rest and digest system) conserves energy as it slows the heart rate, relaxes sphincter muscles in the gastrointestinal tract.
• * Promotes bladder emptying

It could spread upwards towards the KIDNEYS causing more serious illness. (ie. Pyelonephritis, chronic kidney damage or Urosepsis)

Urosepsis is a serious secondary infection which occurs when an infection in the urinary tract spreads to the bloodstream.

An infection caused by microbes—organisms

Mostly infections involve the lower urinary tract — the bladder and the urethra.

• 1. The bladder and urethra are affected
• 2. Pain/buring while urination
• 3. Fequent nocturia
• 4. Confusion in the older adult

• 1. affects urinary tract above bladder (ie. Ureters, Kidneys)
• 2. P/t feels chills, low back pain, N/V,
• 3. Fever

cystitis

pyelonephritis (a kidney infection).

• 1. Impaired Urinary Elimination related to:frequent urination, urgency and hesistancy.
• 2. Disturbed Sleep Pattern related to:pain and nocturia
• 3. Acute pain related to: inflammation and infection of the urethra, bladder and other urinary tract structures.

• 1. Urinary cultures (C&S) (culture sensitivity)
• 2. Urinary R&M (randome and microscopy)

Test done where they take a sample of the culture from the urine. bag it. grow it in a lab and see which antibiotic will kill the bacteria.

• Colony count to identify UTI
• count greater than 10⁵ per mi urine is infected

Antibiotics for UITs (ie. Septra, Nitrofurantoin, Ciprofloxacin

Analgesics for pain of UTI

• 1. A sinal does to get rid og the UTI
• 2. Short course 3 to 4 days
• 3. Regular course 7 - 10 days

• 1. Prevention and early recognition of UTI
• 2. Encourage lots of fluids
• 3. Avoid irritants like caffine, tea alcohol & Spices
• 4. void regularly and avoid distending bladder
• 5. Eat cranberries and Vit C.

Always maintain a closed system

• FALSE!!
• the bag should always be below the level of the bladder to prevent the urine from flowing  back into the bladder

• FALSE!!
• the catheter can become colonzied within 2 weeks

it is inflammation(swollen) of the prostate gland

• microorganisms are carried up the urethra to the prostate
• (Ecoli is most common infection)

• 1. Perineal, rectal, or back pain
• 2. Pain with or after ejectualation
• 3. Dysuria, frequency, nocturia, foul urine
• 4. May be asymptomatic (showing no symptoms)

IS AN ENLARGED PROSTATE GLAND

Prostate gland surrounds the urethra, (tube that carries urine from the bladder out of the body). As the prostate gets bigger, it may squeeze or partly block the urethra. (causes problems with urinating.)

No.  Benign Prostate Hypertrophy (BPH) affects men over 50!!

• 1. catherterization for urinary retention
• 2. SuperPubic (above pubic bone) catheterization if severe
• 3. Prostatectomy surgery (remove tissue)
• 4. TURP (TransUrethral Resection of Prostate)

• 1.  Hormonal theraphy
• 2. Alpha-adrenergic receptor blockers to relax smooth muscle of the bladder. (ie. hytrin type of drug that relaxes the smooth muscles of the prostate)

Urinary Retention related to urethral obstruction secondary to prostate enlargement or tumor

the client will improved pattern of urinary elimination over the next 2 weeks. (??)

• 1. asses for signs and symptoms of urinary retention
• 2. Catheterize as per doc orders to asses residual urine
• 3. monitor intake output

•Removal of PROSTATIC_tissue using an instrument inserted via urethra to an area that is blocking urine flow (no incision)

• 1.  Catheter is used to remove blood or blood clots in the bladder using CBI (continuous bladder irrigation). 
• •Catherter can be removed when urine is clear and no clots present
• 2.  Monitor labs for changes in hemoglobin

• 1. No strenous activities
• 2. Avoid constipation
• 3.Sexual activity should be avoided (6 wks)
• 4. Frequent urination will continue for a while because of irritation and inflammation caused by the surgery, but they should ease during the first 6 weeks

• •Pain control (pain scale, meds etc.)
• •Vital signs
• •Intake and output
• •Assessing for sepsis and infection
• • incisional care
• •Catheter care
• •Continuous bladder infusion (monitoring, measurement)
• • mobility
• •Avoid constipation
• •Provide Psychosocial support

Used after prostate surgery to prevent obstruction of the urinary tract by blood

Solution flows into bladder through one port.

Out of the bladder through another port into the urinary drainage bag

• monitor volume infused into bladder 
• subtract from output from catheter to determine urine volume

Urine is often pink.  If Frank red bleeding occurs it needs to be reported

Large clots need to manually irrigate to remove 

• •Septic shock especially if patient had a history of UTI
• •Uncontrolled bleeding
• •Electrolyte imbalance

• A sudden loss of brain function.
• It is caused by the interruption of flow of blood to the brain

• 1.  Ischemic
• 2.  Hemorrhagic

Occurs when artery to the brain is blocked as a result blood can not get to the brian

is when weakend vessels rupture and bleed out into the brian

Ischemic stroke

• B. Ischemic stroke
• 80-85% of strokes are Ischemic

• 1. Weakness/numbness
• 2. Trouble speaking/understanding
• 3. Vision problems
• 4. headache
• 5. Dizziness

TRANSIENT ISCHEMIC ATTACKS

TIA - are temporary disruption of blood flow to the brain. (sometimes called a "mini stroke")

• Keeping track of it
• Assesment
• Interventions
• Teaching related to risk factors

• 1. Sevre headache
• 2. Loss of consciousness
• 3. Neck pain and stiffness

Intra Cranial Pressure

When there is excessive bleeding in the brain and the pressure builds up and causes damage

Hypertention (high blood pressure)

Carotid Endarterectomy

an operation that removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates plaque from your artery and can restore blood flow.

• –Anticoagulant therapy
• –Antiplatelet therapy: aspirin, clopidogrel (Plavix)
• –Statins (decrease lipids and cholesterol)
• –Antihypertensive medications

Must not eat grapefruit.

• 1. National Institutes of Health Stroke Scale
• 2. Canadian Neurological Scale (CNS)
• 3. Glasgow Coma Scale (GCS)

Measures neurologic function relates with stroke severity and long-term outcomes in ischemic stroke

Measures neurological deficit

• –Measures response to stimuli
• –Often used for hemorrhagic stroke, head injury etc.
• –The lower score, the worse the outcome

• 1. Hemiparesis - weakness on one side of body
• 2. Ataxia - lack of co-ordination
• 3. Dysarthria - Difficulty forming words
• 4. Dysphgia - difficulty swallowing

Person is unable to form words. (cant talk)

Person is unable to understand spoken words

Expressive Aphasia is Broca (control of speech in the brain)

Receptive Aphasia is Wernikes (comprehesion of speech in the brain)

 An abnormal sensation, typically tingling or pricking (“pins and needles”),

caused chiefly by pressure on or damage to peripheral nerves.

• •Unable to form words that are understandable
• •Understands others
• •Maybe able to speak in single-word responses

• •Unable to understand spoken words
• •Can speak but do not make sense

• –Short and long-term memory loss
• –Decreased attention span
• –Inability to concentrate
• –

diseases of the central and peripheral nervous system. (ie the brain, spinal cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular junction, and muscles.)

Epilepsy, Alzheimer disease and other dementias, cerebrovascular diseases including stroke, migraine and other headache disorders, multiple sclerosis, Parkinson's disease, neuroinfections, brain tumours, traumatic disorders of the nervous system such as brain trauma, and neurological disorders as a result of malnutrition.

• –Progressive exercise program to improve:
• –muscle strength
• –Posture
• –joint mobility

• –Walking techniques- e.g. concentrate on horizon
• –Warm baths and massage to relax muscles
• –Stretching, ROM exercises

• –Place food on unaffected side of mouth and watch for pocketing.
• –Have suctioning available
• - Cutfood into small pieces to prevent choking
• - ensure proper food texture is used (ie. minced/pureed, thickened)

• –ROM to affected limb and assistive devices if needed
• –Teach client to monitor limb during transfers and when positioning self
• –Be aware of temperature of bath water, food etc.

• –Approach from side of intact vision
• –Explain location of objects to patient
• –Consistently place objects in same location
• –Place objects within field of intact vision

• –Allow sufficient time to respond
• –Encourage practice of exercises to strengthen facial muscles
• –Short instructions supported with visual cues
• - Speech Language Pathologist

• *Teach relaxation exercises
• *Control stressful situations if possible
• *Link to social worker, spiritual care or psychologist as appropriate to situation and need
• *Encourage expression of feelings, concerns, worries

1. •Ineffective airway clearance r/t decreased Level Of Consciousness (LOC), dysarthria (difficulty forming words/speech), dysphagia (swallowing)

1. •Impaired communication r/t dominant hemisphere stroke.

• 2. Impaired swallowing/Risk for aspiration r/t neuromuscular impairment
• (the nerve-muscle (neuromuscular) junction, peripheral nerves in the limbs, and the motor-nerve cells in the spinal cord)

• 1. Anticipatory grieving r/t loss of functional abilities
• 2. •Impaired physical mobility r/t weakness
• 3.•Potential for decreased nutrional intake r/t impaired swallow or decreased LOC

• –Keep mealtimes simple and calm…supervise
• –Provide assistance with food, supervise if needed
• –Special utensils (plate stabilizer or non-spill cup)
• –Monitor weight

–Primary Prevention refers to preventing a FIRST stroke

–Secondary Prevention refers to prevention of stroke following an initial stroke

•May include diet exercise, smoking cessation, weight loss, pharmacological measures etc.

•Key medical concerns: Management of BP, cholesterol, GLUCOSE, depression etc.

• •Recovery is influenced by initial degree of impairment 
• continues for at least 3-6 months. 
• After this point residual (little) progress occurs.

Day ONE