1.

Rest and Sleep

a. Physical and emotion health depends on adequate sleep and rest
i. Without proper amount of rest and sleep, the pts ability to
concentrate, make judgments, promote healing, and participate
in daily activities decreases
b. While caring for pts. You need to individualize an approach to sleep and
rest based on their personal sleep habits and patterns of sleep to
provide effective therapies
c. Sleep Vs. Rest
i. Sleep
1. Cyclical states/altered consciousness
2. Decreased motor activity/perception
3. Selective response to external stimuli
ii. Rest
1. Mild to no activity
2. Relaxation; stress-free
3. Leads to feeling refreshed
d. Physiology of Sleep
i. Sleep is a cyclical physiological process that alternates with
periods of wakefulness
ii. Circadian rhythms
1. It is everyones day-night 24-hour clock
a. Why we need to pay attention to the pts work,
school, and life patterns and be aware of how they
are affected when hospitalized
2. Affected by light, temperature, social activities, and work
routines.
iii. The biological rhythm of sleep frequently becomes synchronized
with other body functions.
1. People have biological clocks that synchronize their sleep
cycles
2. Hospitals and extended stay care facilities usually do not
adapt care to an individuals sleep-wake cycle preferences
3. Anxiety, restlessness, irritability, and impaired judgment
are other common symptoms of sleep cycle disturbances
iv. Sleep Regulation
1. Regulated by a sequence of physiological states
integrated by central nervous system (CNS) activity
a. Control and regulation of sleep demand on a
balance among regulators within the CNS
b. Changes in peripheral nervous, endocrine,
cardiovascular (CV), respiratory, and muscular
systems will affect pt.s sleep pattern
c. Instruments that provide information about some
structural physiological aspects of sleep:
i. Electroencephalogram (EEG)
1. Measures electrical activity in the
cerebral cortex
ii. Electromyogram (EMG)

2.
3.

4.
5.

1. Measure muscle tone

iii. Electro-oculogram
1. Measures eye movements
Hypothalamus The major sleep center
a. Secretes hyopcreatins (orexins) promote
wakefulness and rapid eye movement (REM) sleep
Reticular activating system (RAS)
a. Releases catecholamines (e.g. norepinephrine)
from neurons
i. Promotes arousal, wakefulness, and
maintenance of consciousness
ii. As people try to fall asleep, they close their
eyes and assume relaxed positions
1. Stimuli to the RAS decline
2. If the room is dark and quiet,
activation of the RAS further declines
3. At some point, the bulbar
synchronizing region takes over
causing sleep
Bulbar synchronizing region (BSR)
a. Causes sleep
Together the RAS and BSR control sensory input
a. Intermittently activate and suppress the higher
centers of the brain to control sleep and
wakefulness.

b.
e. Stages of the Adult Sleep Cycle
i.
Presleep Sleepiness

NREM Stage 1 NREM Stage 2

NREM stage 3

NREM Stage 4

REM Sleep

NREM Stage 2

NREM Stage 3

ii. Sleep stages

1. Stage 1
a. Lasts a few minutes
b. Includes lightest level of sleep
c. Decreased physiological activity begins with
gradual fall in vital signs and metabolism
d. Sensory stimuli such as noise easily arouses person
e. Awakened, person feels as though daydreaming
has occurred
2. Stage 2
a. Lasts 10 to 20 minutes
b. Is a period of sound sleep
c. Relaxation progresses
d. Body functions continue to slow
e. Arousal remains relatively easy
3. Stage 3
a. Lasts 15-30 minutes
b. Involves the initial stages of deep sleep
c. Muscles are completely relaxed
d. Vital signs decline but remain regular
e. Person is difficult to arouse and rarely moves
4. Stage 4
a. Lasts about 15 to 30 minutes
b. The deepest stage of sleep
c. If sleep loss has occurred, the person spends
considerable portion of night in this stage
d. Vital signs are significantly lower than during
waking hours
e. Sleepwalking and enuresis sometimes occur
f. Very difficult to around sleeper
5. REM Sleep
a. Stage usually begins about 90 minutes after sleep
has begun
b. Duration increases with each sleep cycle and
averages 20 minutes
c. Vivid, full-color dreaming occurs; less vivid dreams
occur during other stages
d. Stage is typified by rapidly moving eyes, fluctuating
heart and respiratory rates, increased or fluctuating
blood pressure, loss of skeletal muscle tone, and
increase of gastric secretions
e. Very difficult to arouse sleeper
iii. Sleep enters into a cycle
1. Seen above in diagram:123432REM
iv. Normal sleep involves two phases:
1. Nonrapid eye movement (NREM)
2. Rapid eye movement (REM)
v. Lighter sleep is characteristic of stages 1 and 2
1. Stage in which a person in more easily aroused

vi. Deeper sleep called slow-wave sleep Stages 3 and 4

vii. A person enters through four or five complete sleep cycles per
night
viii. Each cycle contains three NREM stages of sleep and period of
REM sleep
1. Not all people progress consistently through the stages of
sleep
f. Functions of Sleep
i. Purpose of sleep
1. Remains unclear
2. Physiological and psychological restoration
3. Maintenance of biological functions
4. During sleep, a persons heart rate can fall to 60 bpm
5. Sleep is important to the preservation of cardiac function
as well as to decrease respirations and blood pressure and
to relax muscle tone
6. During sleep the body also conserves energy and skeletal
muscles relax
ii. Dreams
1. Occur in nonrapid eye movement (NREM) and rapid eye
movement sleep (REM) sleep
2. Important for learning, memory, and adaptation to stress
3. The interpretation of dreams oftentimes will help patients
resolve personal concerns or fears
4. Personality also influences the quality of dreams
5. Most dreams are forgotten
a. To remember a dream, a person must consciously
think about it upon waking
g. Physical illness
i. Physical illness can cause pain, physical discomfort, anxiety,
depression, and sleep distrubances
1. Hypertension
2. Respiratory disorders
a. Such as chronic obstructive pulmonary disease
(COPD_, emphysema, asthma, allergies, or the
common cold - often interferes with sleep
3. Nocturia disrupts the sleep patters
4. Pain
5. Restless leg syndrome can occur before sleep onset
h. Sleep Disorders
i. Insomnia
1. Adjustment sleep disorder (acute insomnia), inadequate
sleep hygiene, behavioral insomnia of childhood, insomnia
caused by medical condition
2. The most common sleep disorder
3. Is a symptom that patients experience when they
chronically have difficulty falling asleep
ii. Sleep apnea

1. Primary central sleep apnea, central sleep apnea caused

by medical condition, obstructive sleep apnea syndromes,
excessively daytime sleepiness
2. A disorder characterized by lack of airflow through the
nose and mouth for periods of 10 seconds or longer
3. Rarely achieve deep sleep
4. Three types of sleep apnea known:
a. Central
i. Central sleep apnea involves dysfunction in
the respiratory control center of the brain
ii. Impulse to breath fails temporarily
iii. Nasal airflow and chest wall movement
cease
iv. Common in people with brain stem injuries,
muscular dystrophy, and encephalitis
b. Obstructive
i. Occurs when muscles or structures of the
oral cavity or throat relax during sleep
ii. The upper airway becomes partially or
completely blocked, diminishing nasal airflow
or stopping it (apnea) for as long as 30
seconds
iii. Obstructive apnea causes a serious decline
in arterial oxygen levels
c. Mixed
5. Excessive daytime sleepiness is the most common
complaint
a. Is an obstructive type of sleep apnea
iii. Narcolepsy
1. Falls asleep uncontrollably at inappropriate times
2. Achieve REM sleep within 15 minutes of falling asleep
3. Cataplexy
a. A type of narcolepsy
b. Sudden and transient episode of muscle weakness
accompanied by full conscious awareness, typically triggered
by emotions such as laughing, crying, terror, etc.
4. Sleep paralysis
5. A dysfunction of mechanisms that regulate the sleep and
waking cycles
iv. Sleep deprivation
1. Emotional stress, medications, environmental
distrubances, symtpoms
2. Is a problem many patients experience as a result of
dyssomnia
3. Causes include
a. Fever
b. Difficulty breathing
c. Pain
d. Emotional stress

i.

j.

e. Medications
f. Disturbances in the health care setting
4. Health care providers are often prone to sleep deprivation
because of long work schedules and rotations
5. Hospitalization make patients prone to sleep deprivation
caused by environmental noises and interruptions for care
v. Parasomnias
1. Include these sleep problems:
a. Somnambulism (sleep walking)
b. Sleep talking
c. Night terrors screaming upon awakening due to
perceived threat
d. Nightmares
e. Nocturnal enuresis (bed wetting)
f. Body rocking
g. Bruxism (teeth grinding)
h. Sleep-related eating disorder
2. Parasomnias are more common in children
3. Parasomnias associated with SIDS
Rest
i. Rest contributes to
1. Mental relaxation
2. Freedom from anxiety
3. State of mental, physical, and spiritual activity
ii. Bes rest does not guarantee that a patient will feel rested
iii. Rest does not imply inactivity
iv. When rested, people experience feeling of rejuvenation, feeling
refreshed and able to carry out of activities of daily living
v. Illness and unfamiliar health care routines affect the usual rest
and sleep patterns of hospitalized patients
1. Important to allow patients periods of rest
vi. Nurses frequently care for patients who are on bedrest to
reduces physical and psychological demands on the body in a
variety of health care settings
1. However, these people do not necessarily feel rested
2. Some still have emotional worries that prevent complete
relaxation
vii. Must always be aware of a pt.s need for rest
1. Lack of rest for long periods causes illness or worsening of
existing illness
Normal sleep requirements
i. Neonates
1. 16 hours a day
ii. Infants
1. 8 to 10 hours at night for a total of 15 hours a day
iii. Toddlers
1. Total 12 hours a day
iv. Preschoolers
1. 12 hours at night
v. School age

1. 9 to 10 hours
vi. Adolescence
1. Get ~7 hours
2. Shortened sleep time often results in excessive daytime
sleepiness which frequently leads to reduced performance
in school, vulnerability to accidents, behavior and mood
problems, and increased use of alcohol
vii. Young adults
1. Get 6-8 hours
viii. Middle and older adults
1. Total number of hours declines
2. In middle age, the amount of stage 4 sleep begins to fall
3. This decline continues with advancing age
ix. Sleep duration and quality will differ across the life span
k. Factors affecting sleep
i. Physical illness
1. Hypertension
2. Respiratory
3. Musculoskeletal
4. Chronic illness
5. GI
6. Nausea
ii. Drugs an substances
1. Hypnotics
a. Interfere with reaching deeper sleep stages
b. Provide only temporary (1 week) increase in
quantity of sleep
c. Eventually cause hangover during day; excess
drowsiness, confusion, decreased energy
d. Sometimes worsen sleep apnea in older patients
2. Diuretics
a. Nighttime awakenings caused by nocturia
3. Narcotics
a. Suppress REM sleep
b. Cause increased daytime drowsiness
4. Antidepressants
a. Suppress REM sleep
b. Decrease total sleep time
5. Alcohol
a. Speeds onset of sleep
b. Reduces REM sleep
c. Awakens person during the night and causes
difficulty returning to sleep
6. Caffeine
a. Prevents person from falling asleep
b. Causes person to awaken during night
c. Interferes with REM sleep
7. Beta-blockers
a. Cause nightmares
b. Cause insomnia

l.

c. Cause awakening from sleep

8. Anticonvulsants
a. Decrease REM sleep
b. Cause daytime drowsiness
9. Nicotine
a. Decreases total sleep time
b. Decreases REM sleep time
c. Causes awakening from sleep
d. Causes difficulty staying asleep
10.Benzodiazepines
a. Alter REM sleep
b. Increase sleep time
c. Increase daytime drowsiness
iii. Lifestyle
1. Work schedule
2. Social activities
3. Routines
iv. Usual sleep patterns
1. May be disrupted by social activity or work schedule
v. Emotional stress
1. Worries
2. Physical health
3. Death
4. Losses
vi. Environment
1. Noises
2. Routines
vii. Exercise and fatigue
1. Moderate exercise and fatigue cause restful sleep
viii. Food and calorie intake
1. Time of day
2. Caffeine
3. Alcohol
ix. Often, several factors contribute to a sleep disorder
x. Physiological, psychological, and environmental factors inhibit
sleep
Nursing process in sleep
i. Assessment
1. Sleep assessment
a. Sources for sleep assessment = patient, family
i. Usually patients are the best resource for
describing sleep problems and how they
represent a change from their usual sleep
and waking patterns
ii. Also, bed partners are able to provide
information about the patients sleep
patterns that helps reveal the nature of
certain sleep disorders
iii. When caring for children, seek information
about sleep patterns from or guardians

because they are usually a reliable source of

information
b. Tools for sleep assessment
i. Three effective subjective measures of sleep
1. Epworth Sleepiness Scale
2. Pittsburgh Sleep Quality Index
3. One that assesses sleep in a numeric
scale with a 0 10 sleep rating
c. Sleep history
i. When a patient has a sleep problem, conduct
a complete sleep history
ii. Diagnosing sleep problems depends on
identifying factors that impair sleep
iii. Description of sleeping problems, usual sleep
pattern, current life events, physical and
psychological illness, emotional and mental
status, bedtime routines, bedtime
environment, behaviors of sleep deprivation
1. If a patients sleep is inadequate,
assess their usual bedtime, normal
bedtime ritual, preferred environment
for sleeping, and usual preferred rising
time
d. Review Figure 42-3 on critical thinking model for
sleep assessment on page 947
ii. Diagnosis
1. Common etiologies for nursing diagnoses
a. Physical or emotional discomfort or pain
b. Changes in bedtime rituals of sleep environment
c. Disruption of circadian rhythm
d. Exercise and diet before sleep
e. Drug dependency and withdrawal
f. Symptoms of physical illness
iii. Planning
1. It is important for a plan of care for sleep promotion to
include strategies appropriate to the patients sleep
routines, living environment, and lifestyle
2. When developing goals and outcomes, it is important for
the nurse and patient to collaborate
3. Address other health problems that interfere with sleep as
a first priority
4. Involve sleep partner as needed in the selection of
interventions
5. When patients have chronic sleep problems, the initial
referral for a patient is often to a comprehensive sleep
center for assessment of the problem
a. Consult with health professionals as needed
iv. Implementation
1. Environmental controls

a. Acute care settings especially

b. Patients benefit most from instructions based on
information about their homes and lifestyles such
as which types of activities promote sleep in a
night-shift worker, or how to make the home
environment more conducive to sleep
c. They will likely apply information that is useful and
valued
d. Prepare restful environment
2. Promoting bedtime routines
a. They are disturbed especially in acute care settings
b. Rituals
3. Promoting safety
4. Promoting comfort
a. Helpnmg a patient find a comfortable slepp position
b. Acute care/restorative or continuing care
c. Promote relaxation and comfort
5. Establishing periods of rest and sleep
a. Respect sleep-wake patterns
b. Schedule nursing care to avoid disturbances
6. Stress reduction
7. Bedtime snacks
8. The nursing interventions implemented in the acute care
setting are also used in the restorative or continuing care
environemnt
a. Offer appropriate bedtime snacks and beverages
9. Pharmacological approaches
a. Use medications to promote sleep
b. Note that long-term use of sleeping pills often lead
to difficulty initiating and maintaining sleep
10.Considerations for older adults
a. Sleep-wake pattern
i. Maintain a regular bedtime and wake up
schedule
ii. Eliminate naps unless they are a routine part
of the schedule
iii. Limit naps to 20 minutes of less twice a day
iv. Go to bed sleepy
v. Use warm bath and relaxation techniques
vi. Avoid stimulating activities before bedtime
(like exercise or watching TV)
b. Environment
i. Sleep where you sleep best
ii. Keep noise to a minimum; use soft music if
necessary to cover up other unwanted noises
iii. Use nightlight and keep path to BR clear
iv. Set room temp to preference; use socks to
promote warmth
v. Listen to relaxing music

vi. Increase exposure to bright light during the

day
c. Medications
i. Use sedatives and hypnotics with caution as
last resort and then only short term if
absolutely necessary
ii. Adjust medications being taken for other
conditions and assess for drug interactions
that may cause insomnia or excessive
daytime drowsiness
d. Diet
i. Limit alcohol, caffeine, and nicotine late
afternoon and evening
ii. Consume carbs or milk as a light snack
before bedtime
iii. Decrease fluids 2 to 4 hours before sleep
e. Physiologic/illness factors
i. Elevate HOB and provide extra pillows as
preferred
ii. Use analgesics 30 minutes before bed to
ease aches and pains
iii. Use therapeutics to control symptoms of
chronic conditions as prescribed
11.Continuous Positive Airway Pressure (CPAP)
a. One of the most effective therapies is the use of a
nasal continuous positive airway pressure (CPAP)
device at night
b. Requires patient to wear a mask over the nose
c. A mask delivers room air at high pressure which
prevents airway collapse
d. It is portable and effective particularly for
Obstructive Sleep Apnea (OSA)
e. Another treatment option is the use of an oral
appliance
i. They advance the mandible or tongue to
relieve pharyngeal obstruction
f. In cases of severe sleep apnea, the tonsils, uvula,
or portions of the soft palate are surgically removed
i. Success of surgical procedures varies
v. Evaluation
1. Patient outcomes
a. Determine whether expected outcomes have been
met
i. Use evaluative measures shortly after
therapy has been tried, like observing
whether a patient falls asleep after reducing
noise and darkening a room
ii. Use other evaluative measures after a
patient awakens from sleep, like asking a

patient to describe the number or

awakenings during the previous night
2.

Nutrition
a. Background
i. Food security is critical for all members of a household
1. Food security means that all household members have
access to sufficient, safe, and nutritious food to maintain
a healthy lifestyle
2. Sufficient food is available on a consistent basis
3. The household has resources to obtain appropriate food
for a nutritious diet
ii. Food holds symbolic meaning
1. Giving or taking food is part of ceremonies, social
gatherings, holiday traditions, religious events, the
celebration of birth, and the mourning of death
2. The difficulty of the decision to withdraw food in a
terminal illness, even in the form of IV nutrients, is a
testament to the symbolic power of food an feeding
iii. Medical nutrition therapy uses nutrition therapy and counseling
to manage disease
1. In some illnesses, like type 1 diabetes or mild
hypertension, diet therapy is often the major treatment
for disease control
2. Enteral nutrition (EN) and parental nutrition (PN)
a. Other conditions such as severe inflammatory
bowel disease require specialized nutritional
support such as enteral nutrition (EN) or parenteral
nutrition (PN)
b. Current standards of care promote optimal nutrition
in all patients
b. Nutritional Guidelines
i. Healthy People 2020; Health for All (WHO)
1. The US Department of Health and Human Services
(USDHHS) and the Public Health Service have established
nutritional goals and objectives for Healthy People 2020
2. Healthy People 2020 is the United States contribution to
the Health for All strategy of the World Health
Organization (WHO)
3. Healthy People 2020 continues the objectives initiated in
Healthy People 2000 and 2010, with overall goals of
promoting health and reducing chronic disease
ii. Guidelines for dietary change recommend reduced fat, saturated
fat, sodium, refined sugar, and cholesterol intake and increased
intake of complex carbs and fiber
1. All nutrition-related objectives include baseline data from
which progress is measured
2. The challenge remains to motivate consumers to put
these dietary recommendations into practice

iii. Guidelines outlined in Health People 2020

1. Weight and growth
a. Increase proportion of adults who are at a healthy
weight (BMI 18.5 24.9)
b. Reduce proportion of adults who are obese
c. Reduce proportion of children (2 11 years) who
are overweight or obese
2. Food and nutrient consumption
a. Decrease saturated fat intake in population 2 years
and older
b. Increase the variety of vegetables and fruit intake
in population 2 years and older
c. Increase grain product intake and consumption of
calcium in population 2 years and older
d. Reduce daily sodium intake in population 2 years
and older
3. Iron deficiency and anemia
a. Reduce prevalence of iron deficiency in children
and childbearing women
b. Reduce prevalence of anemia in pregnant women in
the third trimester to 20%
4. Schools, work sites, and nutrition counseling
a. Increase work-site nutrition education and weightmanagement program offerings
b. Offer nutrition assessment and individualized
planning at primary care sites
c. Increase the percentage of schools that offer
nutritious foods and beverages outside of school
meals
d. Increase number of states with nutrition standards
for food and beverages provided to preschool-age
children in child care
5. Food security
a. Increase food security to 94% of households
c. Energy requirements
i. Basal metabolic rate the energy needed to maintain lifesustaining activities for a specific period of time at rest
1. The body requires fuel to provide energy for cellular
metabolism and repair, organ function, growth, and body
movement
2. Life-sustaining activities include
a. Breathing
b. Circulation
c. Heart rate
d. Temperature
ii. Resting energy expenditure (REE) [AKA resting metabolic rate]
the amount of energy that an individual needs to consume over
a 24-hour period for the body to maintain all of its internal
working activities while at rest

iii. In general, when energy requirements are completely met by

kilocalorie intake in food, weight does not change
1. When the kilocalories ingested exceed a persons energy
demands, the individual gains weight
2. When kilocalories ingested fail to meet a persons energy
requirements, the individual loses weight
iv. Factors that affect energy requirements
1. Age
2. Gender
3. Body mass
4. Fever
5. Starvation
6. Menstruation
7. Illness
8. Injury
9. Infection
10.Activity level
11.Thyroid function
v. Factors that affect metabolism
1. Illness
2. Pregnancy
3. Lactation
4. Activity level
d. Scientific knowledge base: Nutrients
i. Nutrients are the elements needed for body processes and
functions
1. Ingestion of a diet balanced with carbs, fats, proteins,
vitamins, and minerals provides the essential nutrients to
carry out normal physiological functioning of the body
throughout the lifespan
ii. Food is sometimes described according to its nutrient density
1. i.e. the proportion of essential nutrients to the number of
kilocalories
2. High-nutrient dense foods such as fruits and vegetables
provide a large number of nutrients in relation to
kilocalories
3. Low-nutrient dense foods such as alcohol or sugar are
high in kilocalories but nutrient poor
iii. Carbohydrates
1. Carb ingestion is best if supplied by complex carbs, not
simple saccharides
a. Fiber is a polysaccharide that is the structural part
of plants not broken down by human digestive
enzymes
b. Polysaccharides such as glycogen are made up of
many carb units = complex carb
c. Simple carbs are monosaccharides and
disaccharides
2. Main source of energy

3. Each gram of carb produces 4 kcal

iv. Proteins
1. Provide source of energy of 4 kcal/g
2. Amino acids = simplest form
a. The body does not synthesize indispensable amino
acids, thus they need to be provided in the diet
3. Necessary for nitrogen balance because proteins provide
nitrogen
a. Nitrogen balance is essential for a normal
functioning body
b. Positive nitrogen is required for growth, normal
pregnancy, wound healing, and vital organ
functioning
c. Negative nitrogen occurs in infection, burns, fever,
starvation, and trauma
4. Essential for tissue growth, maintenance, and repair
5. Complete proteins (aka high-quality protein) contains all
essential amino acids in sufficient quantity to support
growth and maintain nitrogen balance
6. Examples of foods that contain complete proteins:
a. Fish
b. Chicken
c. Soybeans
d. Turkey
e. Cheese
7. Incomplete proteins are missing one of more of the nine
indispensable amino acids
a. Indispensable amino acids (are not synthesized in
body)
i. Histidine
ii. Lysine
iii. Phenylalanine
b. Dispensable amino acids (are synthesized in the
body)
i. Alanine
ii. Asparagine
iii. Glutamic acid
8. Complementary proteins are pairs of incomplete proteins
that when combined supply the total amount of protein
provided by complete protein sources
9. Albumin and insulin are simple proteins because they
only contain amino acids or their derivatives
a. The combination of a simple protein with a
nonprotein substance produces a complex protein
(like lipoprotein made from combination of a
protein and a lipid)
v. Fats (lipids)
1. Most calorie-dense nutrients
a. Provide 9 kcal/g

b. Calorie-dense
2. Fats are composed of triglycerides and fatty acids
a. Fatty acids may be essential or nonessential
i. Linoleic acid is the only essential fatty acid in
humans
ii. Linolenic and arachidonic acids are
manufactured body if linoleic acid is
available
iii. Composed of chains of carbon and hydrogen
atoms with an acid group at one end of the
chain and a methyl group at the other end
iv. Can be saturated or unsaturated
b. Triglycerides circulate in the blood
i. Are composed of three fatty acids attached
to a glycerol
3. Saturated or unsaturated (polyunsaturated, and
monounsaturated) fatty acids
a. Saturated each carbon in the chain has 2
attached hydrogen atoms
b. Unsaturated Unequal numbers of hydrogen atoms
are attached and the carbon atoms attach to each
other with a double bond
i. Monounsaturated have one double bind
ii. Polyunsaturated have 2 or more double
bonds between carbon atoms
vi. Water
1. Water is critical because all cell function depends on a
fluid environment
2. Humans are water-based systems!
3. In everyone, 60% to 70% of total body weight is water
vii. Vitamins
1. Vitamins are organic substances present in small amounts
in foods that are essential to normal metabolism
2. Essential for metabolism
3. Water-soluble or fat-soluble
a. Water-soluble vitamins
i. C
ii. B complex
b. Fat-soluble vitamins
i. A
ii. D
iii. E
iv. K
viii. Minerals
1. Are inorganic elements essential to the body as catalysts
for enzymatic reactions
2. Macrominerals
a. Help balance pH

b. Specific amounts needed in blood to promote acidbase balance

c. Need 100mg daily or more of these
3. Trace elements
a. Need 100 mg or less of these
e. Dietary guidelines
i. Dietary reference intakes (DRIs)
1. Acceptable range of quantities of vitamins and minerals
for each gender and age group
2. 4 components of DRIs
a. Estimated average requirement (EAR)
amount of nutrient that appears sufficient to
maintain a specific body function for 50% of
population based on age and gender
b. Recommended dietary allowance (RDA)
average needs of 98% of population, not exact
needs of on individual
c. Adequate intake (AI) suggested intake for
individuals based on observed or experimentally
determined estimates of nutrient intakes used
when not enough evidence to set RDA
d. Tolerable upper level intake (UL) highest level
that poses no risk of adverse health events
ii. Food guidelines
1. Dietary guidelines, average daily consumption
iii. Daily values
1. Needed protein, vitamins, fats, cholesterol, carbs, fiber,
sodium, and potassium
2. The FDA created daily values for food labels in response
to the 1990 Nutrition Labeling and Education Act
a. Did not replace RDAs but provided a separate,
more understandable format for the public
b. Daily values are based on percentages of a diet
consisting of 2000 kcal/day for adults and children
4 years or older
iv. Students need to be cognizant of the needs of the young, the
old, and the culturally diverse to ensure that these populations
receive the nutrients necessary to meet their needs
v. US Department of Agriculture and US Department of Health and
Human Services publish Dietary Guidelines
1. Adopt a balanced eating pattern with a variety of nutrientdense foods and beverages among the basic food groups
2. Maintain body weight in a health range
3. Encourage physical activity and decrease sedentary
activities
4. Encourage fruits, vegetables, whole-grain products,
seafood, and fat-free of low-fat milk
5. Reduce amount of foods containing sugars
6. Eat moderate amount of lean meats, poultry, and eggs

7. Keep total fat intake between 20% and 35% of total

calories, with most fats coming from polyunsaturated or
monounsaturated fatty acids
8. Choose and prepare foods and beverages with little added
sugar or sweeteners
9. Choose and prepare foods with little salt and eat
potassium-rich foods
10.Limit intake of alcohol (1/day for women, 2/day for men)
11.Practice food safety to prevent bacterial foodborne illness
a. Use food safety principles of Clean, Separate,
Cooks, and Chill
f. ChooseMyPlate
i. Is a program developed by the US Department of Agriculture to
replace the My Food Pyramid program
ii. ChooseMyPlate provides a basic guide for making food choices
for a healthy lifestyle
iii. The program includes guidelines for balancing calories,
decreasing portion size, increasing healthy foods, increasing
water consumption, and decreasing fats sodium, and sugars
g. Nursing knowledge base
i. Factors influencing nutrition
1. Environmental factors
a. The likelihood of healthy eating and participation in
exercise or other activities of healthy living is
limited by environmental factors
b. Lack of access to full-service grocery stores, high
costs of healthy food, widespread availability of less
healthy foods in fast food restaurants, widespread
advertising of less healthy food, and lack of access
to safe places to play and exercise are
environmental factors that contribute to obesity
2. Developmental factors each group has specific needs
a. Infants through school age
i. Breastfeeding
1. Recommended for first 6 months of
life with benefits including reduced
food allergies and intolerances, easier
digestion, and fewer infant infections
ii. Formula
1. Protein in the formula is whey, say,
cows milk, casein hydrolysate, or
elemental amino acids
2. Infants should not have regular cows
milk during the first year because it is
too concentrated for the kidneys to
handle and is a poor source of iron and
vitamins C and E
iii. Solid foods

1. Introduce solid foods one at a time 4

to 7 days apart to identify allergies
2. Keep in mind that the growth rate
slows in toddlers
3. They exhibit strong food preferences
b. Toddlers
i. Consume more than 24 ounces of milk daily
in place of other foods
ii. Sometimes develop milk anemia because
milk is a poor source of iron
c. School age (6-12 years)
i. Assess diets for adequate protein and
vitamins A and C
ii. They grow at a slower and steadier rate with
a gradual decline in energy requirements per
unit of body weight
d. Adolescence
i. Physiological age is better than chronological
age for estimating nutritional needs
ii. They have increased energy needs owing to
higher metabolic growth demands
iii. Protein increase is needed
iv. Calcium and continuous iron are especially
important in females
v. B complex vitamins assist in metabolic
activity
vi. Pregnancy occurring within 4 years of
menarche places a mother and fetus at risk
because of anatomical and physiological
immaturity
vii. The onset of eating disorders such as
anorexia nervosa or bulimia nervosa often
occurs during adolescence
viii. Anorexia Nervosa
1. Refusal to maintain body weight over
a minimal normal weight for age and
height
2. Or failure to make expected weight
gain during period of growth, leading
to body weight less than 85% of that
expected
3. Intense fear of gaining weight of
becoming fat, although underweight
4. Disturbance in the way in which ones
body weight, size, or shape is
experienced

5. In females absence of at least three

consecutive menstrual cycles when
otherwise expected to occur
ix. Bulimia Nervosa
1. Recurrent episodes of binge eating
2. A feeling of lack of control over eating
behavior during eating binges
3. Regularly engages in self-induced
vomiting, use of laxatives or diuretics,
strict dieting or fasting, or vigorous
exercise to prevent weight gain
4. Minimum average of two binge-eating
episodes a week for at least 3 months
e. Young and middle adults
i. Energy requirements for maintenance and
repair only as growth slows
ii. Pregnancy and lactation become significant
in considering energy needs are related to
mothers body weight and activity
iii. Lactation requires an additional 500 calories
above usual allowance with greater protein
requirements in pregnancy
f. Older adults
i. Decreased needs for energy due to slowing
of their metabolic rate
ii. Age-related changes in appetite, taste, smell,
and the digestive system affect nutrition
iii. Fixed incomes influence the ability to
purchase food
iv. The elderly often have difficulty chewing,
missing teeth, or oral pain, causing difficulty
in food consumption
v. The diet of older adults needs to contain
choices from all food groups and often
requires a vitamin and mineral supplement
vi. The USDHH Administration on Aging requires
states to provide
vii. Factors affecting nutritional status in older
adults
1. Age-related GI changes that affect
digestion of food and maintenance of
nutrition include changes in teeth and
gums, reduced saliva production,
atrophy or oral mucosal epithelial
linings, increased taste threshold,
decreased thirst sensation, reduced
gag reflex, and decreased esophageal
and colonic peristalsis

2. The presence of chronic illnesses (like

diabetes, end-stage renal disease,
cancer) often affects nutrition intake
3. Adequate nutrition in older adults is
affected by multiple causes such a lifelong eating habits, ethnicity,
socialization, income, educational
level, physical functional level to meet
ADLs, loss, dentition, and
transportation
4. Adverse effects of medications may
cause anorexia, GI bleeding,
xerostomia, early satiety, and
impaired smell and taste perception
5. Cognitive impairments such as
delirium, dementia, and depression
affect ability to obtain, prepare, and
eat healthy foods
ii. Alternative food patterns
1. Based on religion, cultural background, ethics, health
beliefs, and preference
2. Vegetarian diet consists predominantly of plant foods:
a. Ovolactovegetarian
i. Avoids meat, fish, and poultry, but eats eggs
and milk
b. Lactovegetarian
i. Drinks milk but avoids eggs
c. Vegan
i. Consumes only plant foods
ii. Vegans lack complete proteins in single
foods, although they can use complementary
proteins from two or more foods to get all the
amino acids
iii. Knowledge of complementary proteins is
necessary
iv. They are at risk for vitamin B12 deficiency
because it is available only from animal
sources
d. Fruitarian
i. Consumes fruit, nuts, honey, and olive oil
e. Children who follow a vegetarian diet are especially
at risk for protein and vitamin deficiencies such as
vitamin B12
3. Zen macrobiotic
a. Consist primarily of brown rice, other grains, and
herb teas
b. Zen macrobiotic and fruitarian diets are nutrientpoor and frequently result in malnutrition

4. Though careful selection of foods, individuals following a

vegetarian diet can meet recommendations for proteins
and essential nutrients
5. Students need to consult with dieticians to ensure that
patients receive the nutrients needed for recovery and
rehab
iii. Religious dietary considerations
1. Muslim
a. Pork
b. Alcohol
c. Ramadan fasting sunrise to sunset for the month
d. Ritualized methods of animal slaughter required for
meat ingestions
2. Christianity
a. Some faiths, such as Baptists, have minimal or no
alcohol
b. Some meatless days may be observed during the
calendar year, commonly during Lent
3. Hinduism
a. All meats
b. Fish, shellfish with some restrictions
c. Alcohol
4. Judaism
a. Pork
b. Predatory fowl
c. Shellfish (eat only fish with scales)
d. Rare meats
e. Blood (e.g. blood sausage)
f. Mixing of milk or dairy products with meat dishes
g. Must adhere to kosher preparation methods
h. 24 hour of fasting on Yom Kippur, a day of
atonement
i. No leavened bread eaten during Passover (8 days)
j. No cooking on the Sabbath from sundown Friday to
sundown Saturday
5. Church of Jesus Christ of Latter-Day Saints (Mormons)
a. Alcohol
b. Tobacco
c. Caffeine, such as teas, coffees, and sodas
6. Seventh-Day Adventists Church
a. Pork
b. Shellfish
c. Fish
d. Alcohol
e. Caffeine
f. Vegetarian or ovolactovegetarian diets encouraged
h. Nursing process
i. Assessment

1. Screening a patient is a quick method of identifying

malnutrition or risk of malnutrition using simple tools
a. Height
b. Weight
c. Weight change
d. Primary diagnoses
e. Comorbidities
f. Screening tools
2. A nutritional assessment is more than taking a diet history
3. Some prescription drugs, many OTC drugs, and
herbal/natural therapy can affect a patients nutritional
state
4. Its also important to know food interactions and
medication administration, especially between milk and
citrus fruits and between juices and alcohol
5. Screening is an essential part of initial assessment
a. Standardized nutrition screening tools include
Subjective Global Assessment (SGA)
i. An inexpensive technique to predict
nutrition-related complications
b. Mini-Nutritional Assessment (MNA)
i. An 18-item tool divided into screening and
assessment
ii. Used to assess older adults in home care
programs, nursing homes, and hospitals
c. Malnutrition Screening Tool (MST)
i. An effective measure of nutritional problems
in a variety of health care settings
6. Identification of risk factors such as unintentional weight
loss, the presence of a modified diet, or the presence of
altered nutritional symptoms
a. Nausea
b. Vomiting
c. Diarrhea
d. Constipation
7. Anthropometry is a measurement system of the size and
makeup of the body
a. An ideal body weight (IBW) provides an estimate of
what a person should weigh
b. Body mass index (BMI) measures weight corrected
for height and serves as an alternative tradition
height-weight relationships
8. Laboratory and biochemical tests
a. No single laboratory or biochemical test is
diagnostic for malnutrition
b. Factors that frequently alter test results include
fluid balance, liver function, kidney function, and
the presence of disease

c. Common laboratory tests used to study nutritional

status include:
i. Measures of plasma proteins like albumin,
transferrin, prealbumin, retinol binding
protein, total iron-binding capacity, and
hemoglobin
d. Nitrogen balance can be calculated to determine
serum protein status
e. Factors that affect serum albumin levels include
hydration; hemorrhage; renal or hepatic disease;
large amounts of drainage from wounds, drains,
burns, or the GI tract; steroid administration; and
the exogenous albumin
9. Serial measures of weight over time provide more useful
information than a single measurement
a. The patient needs to be weighed at the same time
each day, on the same scale, and with the same
clothing or linen
b. Rapid weight gain or loss in important to note
because it usually reflects fluid shifts
c. One pint or 500 mL of fluid equals 1 lb (0.45 kg)
10.Dietary and health history
a. Health status; age; cultural background; religious
food patterns; socioeconomic status; personal food
preferences; psychological factors; use of alcohol or
illegal drugs; use of vitamin, mineral, or herbal
supplements; prescription or OTC drugs; and the
patients general nutrition knowledge
i. The diet history focuses on a patients
habitual intake of foods and liquids and
includes information about preferences,
allergies, and other relevant topics such as
the patients ability to obtain food
b. Physical examination
i. The physical exam is one of the most
important aspects of nutritional assessment
because improper nutrition affects all body
systems
c. Dysphagia (difficulty swallowing)
i. This may cause difficulty for patients while
eating, drinking, or taking medications
ii. Validated screening tools for dysphagia
include Bedside Swallowing Assessment,
Burke Dysphagia Screening Test, Acute
Stroke Dysphagia Screen, and Standardized
Swallowing Assessment

iii. Dysphagia leads to disability or decreased

functional status, increased length of stay
and cost of care, and increased mortality
ii. Planning
1. Nutrition education and counseling are important for all
patients to prevent disease and promote health
a. Planning to maintain optimal nutritional status
requires a higher level of care than just nutritional
problem corrections
2. Refer to professional standards for nutrition
a. Referring to professional standards for nutrition is
especially important during this step because
published standards are based on scientific findings
3. Collaboration with a registered dietitian (RD) helps
develop appropriate nutrition treatment plans
4. Goals and outcomes of care reflect a patients
physiological, therapeutic, and individualized needs
a. Patients on therapeutic diets need to understand
the implications of their diets and how prescribed
diets help to control their illnesses
b. Individualized planning is essential
i. Explore the patients feelings about their
weight and diet, and help them set realistic
and achievable goals
5. Considerations
a. Perioperative food intake
i. During acute illness or surgery, intake of
food is often altered in the perioperative
period
ii. The priority of care is to provide optimal
preoperative nutrition support in patients
with malnutrition
iii. The priority for the resumption of food intake
after surgery depends on the return of bowel
function, the extent of the surgical
procedure, and the presence of any
complications
iv. It is important that discharge planning
include nutritional interventions as patients
return to their homes or extended care
facilities
b. Enteral and parenteral feedings
i. Enteral tube feedings are often administered
into the stomach or intestines via a tube
inserted through the nose or a percutaneous
access
ii. These enteral feedings supplement a
patients oral nutritional intake in the home,

acute care, extended care, or rehabilitation

setting when they cannot meet their
nutritional needs by mouth
iii. Patients who cannot tolerate nutrition
through the GI tract receive parenteral
nutrition, a solution consisting of glucose,
amino acids, lipids, minerals, electrolytes,
trace elements, and vitamins, through an
indwelling peripheral or central venous
catheter
c. Assistive devices
i. When patients have difficulty feeding
themselves, occupational therapists work
with them and their families to identify
assistive devices
iii. Implementations
1. Health promotions
a. Education
i. Focus of health promotion is to educate
patients and family caregivers about
balanced nutrition and to assist them in
obtaining resources to eat high-quality meals
b. Early identification of potential or actual problems
i. The best way to avoid more serious problems
c. Meal planning
i. This takes into account the familys budget
and different preferences of family members
d. Weight loss plans
i. Considers their preferences and resources
and includes awareness of portion sizes and
knowledge of the energy content of foods
e. Food safety
i. Health care professionals not only need to be
aware of factors related to food safety but
also should provide patient education to
reduce risks for foodborne illnesses
2. Acute care
a. Risk factors in acutely ill patient
b. Advancing diets = gradual progression on dietary
intake or therapeutic diet to manage illness
c. Promoting appetite
d. Assisting with oral feedings
i. When a patient needs help with eating, it is
important to protect they safety,
independence, and dignity
e. What factors influence nutritional intake in the
acutely ill patient?

f.

i. Diagnostic testing and procedures in the

acute care setting disrupt food intake
1. Often as preparation for or
immediately following diagnostic a
procedure, a patient is to receive
nothing by mouth (NPO)
ii. Mealtimes in a health care setting are
frequently interrupted, or patients have poor
appetites
iii. Patients often are too fatigued or
uncomfortable to eat
1. It is important to continuously assess
a patients nutritional status and adopt
interventions that promote normal
intake, digestion, and metabolism of
nutrients
iv. Patients who are NPO and receive inly
standard IV fluids for longer than 4 to 7 days
are at nutritional risk
Acute and chronic conditions affect a patients
immune system and nutritional status
i. Patients with decreased immune function
(from cancer, chemotherapy, HIV/AIDS, or
organ transplant) require special diets that
decrease their exposure to microorganisms
and are higher in selected nutrients
ii. Patients who are ill, who have had surgical
procedures, or who were NPO for a period of
time have specialized dietary needs
iii. Health care providers order a gradual
progression of dietary intake or a therapeutic
diet to manage patients illness
1. Clear liquid broth/bullion, tea,
carbonated beverages, clear fruit
juices, gelatin, fruit ices, popsicles
2. Full liquid Clear liquids with addition
of smooth-textured dairy products,
strained or blended cream soups,
custards, refined cooked cereal,
pureed vegetables, all fruit juices,
puddings, frozen yogurts
3. Pureed All in full liquids with addition
of scrambled eggs, pureed meats,
vegetables, mashed potatoes and
gravy
4. Mechanical soft All in pureed with
addition of all cream soups, ground or

finely diced meats, flaked fish, cottage

cheese, rice, potatoes
5. Soft/low residue Addition of low-fiber,
easily digested foods like pastas,
casseroles, moist tender meats,
canned cooked fruits and veggies,
desserts WITHOUT nuts or coconut
6. High fiber Addition of fresh uncooked
fruits, steamed veggies, bran,
oatmeal, and dried fruits
7. Low sodium 4-g (no added salt), 2g,
1g, or 500mg sodium diets
8. Low cholesterol 300 mg/day
cholesterol in keeping with American
Heart Association guidelines for serum
li[id reduction
9. Diabetic nutrition recommendations
by the American Diabetes Association:
focus on total energy, nutrient and
food distribution; include a balanced
intake of carbs, fats, and proteins;
varied caloric recommendations to
accommodate patients metabolic
demands
10.Regular No restrictions; unless
specified
iv. Patients who are ill or debilitated often have
poor appetites (anorexia)
1. Anorexia has many causes
2. Help patients understand the factors
that cause anorexia, and use creative
approaches to stimulate appetite
3.
v. A pleasant environment will improve a
patients appetite
1. The environment should be clean and
free of odor
2. Oral hygiene will remove unpleasant
tastes
3. Mealtime is often a social time, so
company may help
vi. Make sure patients can feed themselves, can
swallow, and are positioned properly
1. If patients have visual difficulties, they
may need assistance with feeding
2. You can also help patients by telling
them where food is placed, according
to the face of a clock

vii. Patients with dysphagia are at risk for

aspiration
1. Four levels of diet include:
a. Dysphagia puree
b. Dysphagia mechanically altered
c. Dysphagia advanced
d. Regular
2. The four levels of liquid include:
a. Thin liquids (low viscosity)
b. Nectar thick liquids (medium
viscosity)
c. Honey thick liquids (viscosity of
honey)
d. Spoon-thick liquids (viscosity of
pudding)
3. Feed patients slowly, smaller-size
bites, with more frequent chewing and
swallowing
3. Adaptive equipment
a. Types
i. Two-handled cups with lids
ii. Plate with plate guard
iii. Utensils with splints
iv. Utensils with enlarged handles
b. Patients with impaired vision and those with
decreased motor skills are more independent
during mealtimes with the use of large-handled
adaptive utensils
i. These are easier to grip and manipulate
4. Enteral tube feeding
a. EN provides nutrients into the GI tract It is
physiological, safe, and economical nutrition
support
b. When oral feeding assistance is inadequate in
providing appropriate nutrition enteral or parental
feeding is required
c. EN is the preferred method of meeting nutritional
needs if a patient is unable to swallow of take in
nutrients orally, yet has a functioning GI tract
i. Nasogastric (NG), jejunal (J), gastric (G) tube
ii. Surgical or endoscopic placement
1. Nasointestinal
2. Gastronomy
3. Jejunostomy
4. PEG (percutaneous endoscopic
gastrostomy)
5. PEJ (percutaneous endoscopic
jejunostomy)
iii. Risk of aspiration

d.

e.

f.
g.

h.

i.

j.

k.
l.

1. Studies about turning off the tube feed

while repositioning patient
Patients at low risk for gastric reflux receive gastric
feedings; however, if risk of gastric reflux, with
leads to aspiration, is present, jejunal feeding is
preferred
Types of formulas include:
i. Polymeric: milk-based, blenderized; the
patients GI tract needs to be able to absorb
whole nutrients
ii. Elemental formulas: predigested nutrients;
easier for partially dysfunctional GI tract to
absorb
iii. Specialty formulas: designed to meet specific
nutritional needs in certain illnesses
Before beginning tube feeding, you will learn in
skills lab to flush the line with a small amount of
water to ensure that the tube is clear and patent
Tube feedings typically are started at full strength
and slow rates
i. Increase the hourly rate every 8 to 12 hours
per health care providers order if no signs of
intolerance appear
Feeding by the enteral route reduces sepsis,
minimizes the hypermetabolic response to trauma,
decreases hospital mortality, and maintains
intestinal structure and function
Tubes are inserted through the nose (nasogastric or
nasointestinal), surgically (gastrostomy or
jejunostomy), or endoscopically (percutaneous
endoscopic gastrostomy or jejunostomy)
If for less than 4 weeks total, nasogastric or
jasojejunal feeding tubes may be used
i. Surgical or endoscopically places tubes
are preferred for long-term feeding
A serious complication associated with enteral
feeding is aspiration of formula into the
tracheobronchial tree, which leads to infection
Tubes
i. Most health care settings use small-bore
feeding tubes because they create less
discomfort for a patient
ii. For the adult, most of these tubes are 8- to
12- French and 36 to 44 inches long
iii. A stylet is often used during insertion of a
small-bore tube to stiffen it

1. The stylet is removed when correct

positioning of the feeding tube is
confirmed
iv. Measurement of the pH of secretions
withdrawn from the feeding tube helps the
differentiate the location of the tube
m. Complications of enteral tube feedings
i. Problem: Pulmonary aspiration
1. Cause: regurgitation of formula
2. Feeding tube displaced
3. Deficient gag reflex
ii. Diarrhea
1. Hyperosmolar formula or medication
2. Antibiotic therapy
3. Bacterial contamination
4. Malabsorption
iii. Constipation
1. Lack of fiber
2. Lack of free water
3. Inactivity
iv. Tube occlusion
1. Pulverized medications given per tube
2. Sedimentation of formula
3. Reaction of incompatible meds or
formula
v. Tube displacement
1. Coughing or vomiting
2. Not tapes securely
vi. Abdominal cramping, nausea/vomiting
1. High osmolality of formula
2. Rapid increase in rate/volume
3. Lactose intolerance
4. Intestinal obstruction
5. High-fat formula used
6. Cold formula used
vii. Delayed gastric emptying
1. Diabetic gastroparesis
2. Serious illnesses
3. Inactivity
viii. Serum electrolyte imbalance
1. Excess GI losses
2. Dehydration
3. Presence of disease states such as
cirrhosis, renal insufficiency, heart
failure, or diabetes
ix. Fluid overload
1. Refeeding syndrome in malnutrition
2. Excess free water of diluted
(hypotonic) formula
x. Hyperosmolar dehydration

1. Hypertonic formula with insufficient

free water
5. Parenteral nutrition
a. Nutrients are provided IV
i. Consists of concentrated nutrients delivered
directly to the superior vena cava near the
right atrium of the heart
ii. IV fat emulsions sometimes are added to
parenteral nutrition (PN) to provide
supplemental kilocalories, prevent essential
fatty acid deficiencies, and help control
hyperglycemia during periods of stress
b. Patients unable to digest or absorb enteral nutrition
or are in highly stressed physiological states
i. Sepsis
ii. Head injury
iii. Burns
c. Peripheral or central line
i. PN greater than 10% dextrose requires a
central venous catheter, placed into a highflow central vein
ii. Patients with short-term nutritional needs
often receive IV solutions less than 10% in
the peripheral vein
iii. Placement of the line needs to be confirmed
by x-ray
d. Initiating parenteral nutrition
i. Before beginning any PN infusion, verify the
health care providers order and inspect the
solution for particulate matter or a break in
the fat emulsion
e. Preventing complications
i. Complications can occur at the site, with
tubing, with infusion rate, and with
electrolyte imbalances
ii. Examples of complications:
1. Pneumothorax
2. Air embolus
a. Possibly occurs upon insertion
of the catheter or changing the
tubing or cap
3. Catheter occlusion
a. Sluggish or no flow through the
catheter
4. Catheter sepsis
a. Inspect if patient develops
chills, fever, or, glucose
intolerance and has a positive
blood culture

5. Osmotic diuresis
a. Too-rapid administration of
hypertonic dextrose
6. Dehydration
a. Too-rapid administration of
hypertonic dextrose
f. The goal is to move patients from PN to enteral
(EN) and/or oral feeding
i. When 1/3 or 1/2 of kilocalorie needs are met,
PN is decreased to half of the original volume
ii. When 75% of needs are met by EN or dietary
intake, PN therapy is discontinued, preparing
the patient for discharge and restorative and
continual care
g. Metabolic complication of parenteral nutrition
i. Problem: electrolyte imbalance
1. Signs/symptoms: multiple depending
on electrolyte
ii. Hypercapnia
1. Increased O2 consumption, CO2,
respiratory quotient (>1), and minute
ventilation
iii. Hypoglycemia
1. Diaphoresis, shakiness, confusion, loss
of consciousness
iv. Hyperglycemia
1. Thirst, headache, lethargy, increased
urination
v. Hyperglycemic hyperosmolar nonketotic
coma (HHNKC) or hyperosmolar
hyperglycemic nonketotic syndrome (HHNS)
1. Hyperglycemia (>500), glycosuria,
serum osmolarity >350, confusion,
azotemia, headache, sever signs of
dehydration, hypernatremia,
metabolic acidosis, convulsions, coma
h. Types of parenteral nutrition
i. TPN total parenteral nutrition (in central
line because it is more caustic to be put in
peripheral line
1. Complications
a. Insertion problems
b. Infection and sepsis
c. Metabolic alterations
d. Fluid, electrolyte, and acid-base
imbalances
e. Phlebitis
f. Hyperlipidemia
g. Liver and gallbladder disease

ii. PPN Peripheral parenteral nutrition

Routes of administration of parenteral nutrition
i. Superior vena cava
ii. Subclavian vein
iii. Peripheral vein
1. PICC in peripheral places but is
threaded up through into heart if
placement is verified
6. Restorative and continuing care
a. Medical nutrition therapy (MNT)
i. Specific nutritional therapy usage for treating
illness, injury, or certain condition
ii. Necessary for
1. Metabolizing certain nutrients
2. Correcting nutritional deficiencies
3. Eliminating foods that worsen disease
states
iii. Most effective with collaborative health care
team and dietitian
iv. Optimal nutrition is significant in health and
illness and thus modified in patients with
particular diseases
1. Thus medical nutrition therapy (MNT)
is needed
v. MNT is extremely significant in GI diseases
1. Peptic ulcer etiology
a. Helicobacter pylori
b. Stress
c. Acid overproduction
2. Peptic ulcer treatments
a. Avoid caffeine
b. Avoid spicy foods
c. Avoid aspirin, NSAIDs
d. Consume small, frequent meals
3. Inflammatory bowel disease
a. Crohns and idiopathic
ulcerative colitis
i. Elemental diets are
formulas with nutrients in
their simplest form ready
for absorption
ii. Parenteral nutrition
iii. Vitamins and iron
supplements
iv. Fiber increase
v. Fat reduction
vi. Large meal avoidance
vii. Lactose and sorbitol
avoidance
i.

vi. Malabsorption syndromes

1. Celiac disease
a. Gluten-free diet
b. Gluten is contained in wheat,
rye, barley, and oats
2. Short bowel syndrome
a. Intestinal surface decrease
b. Lifetime EN or PN
3. Diverticulitis
a. Inflammation of diverticula
b. Low- to moderate-residue diet
for infection
c. High-fiber diet for chronic
conditions
vii. Diabetes Mellitus
1. Type 1: insulin and dietary restriction
2. Type 2: exercise and diet therapy
initially
a. Individualized diet
b. Carbohydrate consistency and
monitoring
c. Saturated fat less than 7%
d. Cholesterol intake less than 22
mg/dl
e. Protein intake 15% to 20% of
diet
3. Diabetes is a disease that is focused
on diet and exercise with requirements
limited carb intake
4. Monitoring carb consumption is a key
strategy in achieving glycemic control
5. Goals
a. Normal to near-normal glucose
levels
b. Less than 100 mg/dl low-density
lipoprotein (LDL)
c. Less 130/85 mm Hg
d. Avoidance of hypoglycemia
e. Maintaining these goals will
reduce microvascular (renal and
eye disease), cardiovascular,
neurovascular, and peripheral
vascular complications
f. Be aware of signs and
symptoms of hypoglycemia and
hyperglycemia
g. Increased sugar content
negatively affect vasculature
viii. Cardiovascular diseases

1. American Heart Association (AHA)

dietary guidelines
a. Balance caloric intake and
exercise
b. Maintain a healthy body weight
c. Eat a diet rich in fruits, veggies,
and complex carbs
d. Eat fish twice per week
e. Limit foods and beverages high
in sugar and salt
f. Limit TRANS-saturated fat to
less than 1%
2. By following AHA guidelines,
hypertension and coronary artery
disease can be reduced
3. AHA guidelines are also recommend
limiting saturated fat to less than 7%
and cholesterol to less than 300
mg/day
4. To accomplish this goal, patients
choose lean meats and veggies, use
fat-free dairy products, and limit
intake of fats and sodium
ix. Cancer and cancer treatment
1. Malignant cells compete with normal
cells for nutrients
2. Anorexia, nausea, vomiting, and taste
distortions are common
3. Malnutrition associated with cancer
increases morbidity and mortality
4. Radiation causes anorexia, stomatitis,
severe diarrhea, intestinal strictures,
and pain
5. The goal of nutrition in cancer patients
is to meet the increased metabolic
demands
a. Because malignant cell compete
with normal cells for nutrients, it
increases the patients
metabolic demand
b. It is important to enhance
nutritional status to improve the
patients quality of life
6. Enhanced nutritional status often
improves a patients quality of life
7. Nutrition management
a. Maximize fluid and nutrient
intake

b. Individualize diet choices to

patients needs, symptoms, and
situation
c. Encourage small, frequent
meals and snacks that are easy
to forget
x. HIV/AIDS
1. Body wasting and severe weight loss
2. Severe diarrhea, GI malabsorption,
altered nutrient metabolism
3. Hypermetabolism as a result of
cytokine elevation
4. Maximize kilocalories and nutrients
5. Encourage small, frequent, nutrientdense meals with fluid in between
6. This disease state results in several
consequences that alter nutritional
attainment
7. Diagnose and address each cause of
nutritional depletion in the plan of care
a. Individually tailored nutrition
support progresses in stages
from oral to enteral and finally
to parenteral
8. Good hand hygiene and food safety
are essential because of a patients
reduced resistance to infection

3.

iv. Evaluation
1. Multidisciplinary collaboration remains essential in
providing nutritional support
2. Changes in condition indicate a need to change the
nutritional plan of care
3. Consider the limits of patients conditions and treatments,
their dietary preferences, and their cultural beliefs when
evaluating outcomes
4. Upon care plan completion, it is necessary to evaluate
prior interventions and responses for optimal outcomes
5. If ongoing nutrition therapies do not result in successful
outcomes, patients expect nurses to recognize this and
alter the plan of care accordingly
6. When outcomes are not met, ask questions such as How
has your appetite been? Have you noticed a change in
your weight? How much would you like to gain? or
Have you changed you exercise pattern?
Urinary elimination
a. Urinary system organs
i. The kidneys lie on either side of the vertebral column behind the
peritoneum and against the deep muscles of the back

ii.

iii.

iv.

v.

vi.

1. Kidneys filter waste products of metabolism that collect in

the blood
2. The blood reaches each kidney by a renal artery that
branches from the abdominal aorta
The nephron, the functional unit of the kidney (on the right),
forms in the urine
1. It is composed of the glomerulus, Bowmans capsule,
proximal convoluted tubule, loop of Henle, distal tubule,
and collecting duct
Ureters are the tubular structures that enter the urinary bladder
1. Urine draining from the ureters to the bladder is usually
sterile
2. The ureters enter obliquely through the posterior bladder
wall
3. This arrangement prevents the reflux of urine from the
bladder into the ureters during the act of micturition
(peeing) by compression of the ureter at the
ureterovesical junction (the juncture of the ureters with
the bladder)
4. An obstruction within a ureter such as a kidney stone
(renal calculus) results in strong peristaltic waves that
attempt to move the obstruction into the bladder
5. These waves result in pain, often referred to as renal colic
The urinary bladder is a hollow, distensible, muscular organ
(detrusor muscle) that stores and excretes urine
1. When empty, the bladder lies in the pelvic cavity behind
the symphysis pubis
2. In men, the bladder lies against the anterior wall of the
rectum and in women it rests against the anterior walls of
the uterus and vagina
The trigone (a smooth triangular areas on the inner surface of
the bladder) is at the base of the bladder
1. An opening exists at each of the three angles of the
trigone
2. Two are for the ureters, and one is for the urethra
Urine exits the bladder through the urethra and passes out of
the body through the urethral meatus
1. Normally, the turbulent flow of urine through the urethra
washes it free of bacteria
2. Mucous membrane lines the urethra, and urethral glands
secrets mucous into the urethral canal
3. Thick layers of smooth muscle surround the urethra
4. It descends through a layer of skeletal muscles called the
pelvic floor muscles
a. When these muscles are contracted, it is possible
to prevent flow through the urethra
5. In women, the urethra is approximately 4 to 6.5 cm (1.5
to 2.5 inches)

a. The short length of the urethra predisposes women

and girls to infection
b. It is easy for bacteria to enter the urethra from the
perineal area
6. In men, the urethra, which is both a urinary canal and a
passageway for cell and secretions from the reproductive
organs, is about 20 cm (8 inches) long
a. The male urethra has 2 sections
i. Prostatic
ii. Membranous
iii. Penile
b. Scientific knowledge base
i. Kidneys
1. Remove waste from the blood to form urine
ii. Ureters
1. Transport urine from the kidneys to the bladder
iii. Bladder
1. Reservoir for urine until the urge to urinate develops
iv. Urethra
1. Urine travels from the bladder and exits through the
urethral meatus
v. Urinary elimination depends on the function of the kidneys,
ureters, bladder, and urethra
1. All organs of the urinary system must be intact and
functional for successful removal of urinary wastes
2. Intact efferent and afferent nerves from the bladder to the
spinal cord and brain must be present
vi. Female and male urinary tracts

1.
vii. Kidneys and ureters
1. Maintain composition and volume of body fluids
2. Filter and excrete blood constitutions not needed an retain
those that are needed
3. Excrete waste product (urine)
a. Nephrons remove the end products of metabolism
and regulate fluid balance
b. Urine from the nephrons empties into the kidneys
viii. Bladder
1. Smooth muscle sac
2. Serves as a reservoir for urine
3. Composed of three layers of muscle tissue call detrusor
muscle
4. Sphincter guards opening between urinary bladder and
urethra

5. Urethra conveys urine from bladder to exterior of body

ix. Urethra
1. Conveys urine from the bladder to the exterior
2. Male urethra functions in excretory and reproductive
systems
3. No portion of female urethra is external to the body
c. Additional kidney functions
i. Production of erythropoietin is essential to maintaining a
normal RBC volume
1. Erythropoietin stimulates bone marrow to produce RBCs
and prolongs the life of mature RBCs
2. Patients with chronic kidney conditions cannot produce
sufficient quantities of this hormone; therefore they are
prone to anemia
ii. Production of renin, prostaglandin E2, and prostacyclin affects
blood pressure
1. Renin starts a chain of events that cause water retention,
thereby increasing blood volume
2. Renal hormones affect blood pressure regulation in
several ways
a. In times of renal ischemia (decreased blood
supply), renin is released from juxtaglomerular cells
3. Prostaglandin E2 and prostacyclin aid vasodilation
iii. Kidneys affect calcium and phosphate regulation
1. By producing a substance that converts vitamin D into its
active form
2. Patients with chronic alterations in kidney function do not
make sufficient amounts of the active vitamin D
a. They are prone to develop renal bone disease from
the demineralization of bone caused by impaired
calcium absorption
iv. Renin-Angiotensin Mechanism
1. The physiological effects of the renin-angiotensin
mechanism are shown:

a.
b. Renin functions as an enzyme to convert
angiotensin (a substance synthesized by the liver)
into angiotensin I
i. Angiotensin I is converted to angiotensin II in
the lungs
c. Angiotensin II causes vasoconstriction and
stimulates aldosterone release from the adrenal
cortex
i. Aldosterone causes retention of water, which
increases blood volume
d. The kidneys also produce prostaglandin E2 and
prostacyclin, which help maintain renal blood flow
through vasodilation
i. These mechanisms increase arterial blood
pressure and renal blood flow
d. Urinary elimination
i. Known as voiding, micturition
ii. Process
1. Filling of bladder 200 450 mL of urine
a. Bladder capacity varies with the individual but
ranges from 600 to 1000 mL of urine
b. An adult normally voids every 2 to 4 hours
2. Activation of stretch receptors in bladder wall
a. As volume increases, the bladder walls stretch,
sending sensory impulses to the micturition center
in the sacral spinal cord
b. Damage to the spinal cord above the sacral region
causes reflex incontinence
i. This condition causes loss of voluntary
control of urination, but the micturition reflex
pathway often remains intact, allowing

urination to occur without the sensation of

the need to void
ii. If chronic obstruction caused by neurological
damage such as prostate enlargement
hinders bladder emptying, over time the
micturition reflex changes, causing bladder
overactivity and possibly causing the bladder
to not empty completely
3. Signaling to the voiding reflex center
a. Brain structures that influence bladder function
(cerebral cortex, thalamus, hypothalamus, and
brain stem) inhibit the urge to void or allow voiding
4. Contraction of detrusor muscle
5. Conscious relaxation of external urethral sphincter
a. Voluntary control from higher brain centers and
involuntary control from the spinal cord influence
the act of micturition or voiding
6. Incontinence is classified as:
a. Functional
b. Overflow
i. Occurs when the bladder is overly full and
bladder pressure exceeds sphincter pressure,
resulting in involuntary leakage or urine
1. Causes often include:
a. Head injury
b. Spinal injury
c. Multiple sclerosis
d. Diabetes
e. Trauma to the urinary system
f. Postanesthesia sedativehypnotics, tricyclics, and
analgesia
c. Stress
d. Urge
e. Total
7. Normal voiding required the contraction of the bladder
and coordinated relaxations of the urethral sphincter and
pelvic floor muscles
8. It is vital that nurses understand the process of normal
voiding to be able to assess and determine which form of
incontinence or which bladder problem may be occurring
9. Hyperreflexia, a life-threatening problem that affects
heart rate and blood pressure, is caused by an overly full
bladder
a. It is usually neurogenic in nature
b. However, it can be caused functionally by blockage
iii. Factors affecting urinary elimination
1. Pathological conditions
a. Bladder/kidney infections

b. Kidney stones
c. Hypertrophy of the prostate in males
d. Mobility problems
e. Decreased blood flow through glomeruli
f. Communication problems
g. Alteration in cognition
iv. Act of micturition
1. Process of emptying the bladder
a. Detrusor muscle contracts, internal sphincter
relaxes, urine enters posterior urethra
b. Muscles of perineum and external sphincter relax
c. Muscle of abdominal wall contracts slightly
d. Diaphragm lowers, micturition occurs
v. Urinary terms
1. Anuria
a. Synonymous with kidney shutdown or renal
failure
b. Absence of urine production or a urinary
output of less than 50 mL/day
2. Oliguria
a. A decreased urinary output in spite of
adequate fluid intake
3. Polyuria
a. An excessive urine output
4. Dysuria
a. Painful or difficult urination
5. Glycosuria
a. The presence of sugar in the urine
6. Diuresis
a. Increased urine formation
7. Nocturia
a. Awakening to void one or more times a night
8. Pyuria
a. Pus in the urine
vi. Factors affecting micturition
1. Developmental considerations
2. Food and fluid intake
3. Psychological variables
a. Includes anxiety and emotional stress
b. Privacy issues
4. Activity and muscle tone
5. Pathologic conditions
6. Medications
7. Personal
8. Sociocultural
9. Environmental
10.Nutrition
11.Hydration
12.Surgery and anesthesia
13.Symptoms common of urinary disturbances

a.
b.
c.
d.
e.
f.
g.
h.

Frequency
Urgency
Dysuria
Polyuria
Oliguria
Incontinence
Difficulty starting the urinary stream
Fever causes an increase in body metabolism and
accumulation of body wastes
i. Although urine volume is reduces, it is highly
concentrated
14.The kidneys primarily maintain the balance between
retention and excretion of fluids
e. Lifespan Considerations
i. Infants
1. 15-60 mL per kg of body weight
2. Produce 8-10 wet diapers per day
3. No voluntary control
ii. Children
1. Toileting training requires
a. Mature neuromuscular system
b. Adequate communication skills
c. Toilet training at 2 3 years old
2. Problems include
a. Enuresis bed wetting
iii. Older adults
1. Kidney function decreases
2. Urgency and frequency common
3. Loss of bladder elasticity and muscle tone leads to:
a. Nocturia Defined by American Urological
Association as the need to urinate at least twice
during the night
b. Incomplete emptying
c. Urine retention and stasis
4. Voluntary control affected by physical problems
f. Urinary considerations
i. Diuretics cause increased urine production, resulting in:
1. Increased urination
2. Possibly urge incontinence
g. Disease conditions affecting urination
i. Disease processes that affect urine elimination affect renal
function (changes in urine volume or quality), the act of urine
elimination, or both
ii. Conditions that affect urine volume and quality are generally
categorized by origin:
1. Prerenal
a. Decreased blood flow to and through the kidney
2. Renal
a. Disease conditions of renal tissue
3. Postrenal

iii.

iv.

v.
vi.
vii.
viii.
ix.

a. Obstruction in the lower urinary tract that prevents

urine flow from the kidneys
Conditions of the lower urinary tract including
1. Narrowing of the urethra
2. Altered innervation of the bladder
3. Weakened pelvic and/or perineal muscles
Diabetes mellitus and neuromuscular diseases such as multiple
sclerosis
1. Can lead to
a. Possible loss of muscle tone
b. Reduced sensation of bladder fullness
c. Inability to inhibit bladder contractions
Benign prostatic hyperplasia (BPH)
1. Older men suffer from this
2. Makes them prone to urinary retention and incontinence
Cognitive impairments (e.g. Alzheimers)
1. Lose the ability to sense a full bladder or are unable to
recall the procedure of voiding
Diseases that slow or hinder physical activity
1. Degenerative joint disease and parkinsonism are
examples
Conditions that make it difficult to reach and use toilet facilities
1. A little connected with the above point
End-stage renal disease, uremic syndrome
1. Diseases that cause irreversible damage to kidney tissue
result in end-stage renal disease (ESRD)
2. Eventually the patient has symptoms resulting from
uremic syndrome
a. An increase in nitrogenous wastes in the blood
b. Marked fluid and electrolyte abnormalities
c. Nausea
d. Vomiting
e. Headache
f. Coma
g. Convulsions
3. As uremic symptoms worsen, aggressive treatment is
indicated for survival
4. Dialysis and organ transplantation are 2 methods of renal
replacement
a. Dialysis takes one of 2 forms
i. Peritoneal dialysis
1. An indirect method of cleaning the
blood of waste products using osmosis
and diffusion, with peritoneum
functioning as a semi-permeable
membrane
2. This method removes excess fluid and
waste products from the bloodstream
when a sterile electrolyte solution

(dialysate) is instilled into the

peritoneal cavity via a surgically
placed catheter
3. The dialysate remains in the cavity for
a prescribed time interval and then in
drained out by gravity, taking
accumulated wastes and excess fluid
and electrolytes with it
ii. Hemodialysis
1. Requires a machine equipped with a
semi-permeable filtering membrane
(artificial kidney) that removes
accumulated waste products and
excess fluids from the blood
2. In the dialysis machine, dialysate fluid
is pumped through one side of the
filter membrane (artificial kidney),
while the patients blood passes
through the other side
3. The processes of diffusion, osmosis,
and ultrafiltration clean the patients
blood
4. Then the blood returns through a
specially placed vascular access
device
5. Patients can use both dialysis
modalities for a short or long term, but
these treatments require specialized
equipment and nurses with specialized
education
iii. Organ transplantation is the replacement of
a patients diseased kidney with a healthy
one from a loving or cadaver donor of
compatible blood and tissue type
1. The new organ is surgically implanted
into the abdomen
2. Special medications
(immunosuppresives) are
administered, often for life, to prevent
the body from rejecting the
transplanted organ
3. Unlike other treatments, successful
organ transplantation offers patients
the potential for restoration of normal
kidney function
h. Effects of medications of urine productions and elimination
i. Diuretics

i.

1. prevent reabsorption of water and certain electrolytes in

tubules
2. Mechanism of action
a. Thiazides inhibit active exchange of Cl-Na in the
cortical diluting segment of the ascending loop of
Henle
b. K-sparing inhibit reabsorption of Na in the distal
convoluted and collecting tubule
c. Loop diuretics Inhibit exchange of Cl-Na-K in the
thick segment of the ascending loop of Henle
ii. Cholinergics stimulate contraction of detrusor muscle,
producing urination
iii. Analgesics and tranquilizers suppress CNS, diminish
effectiveness of neural reflex
Alterations in urinary elimination
i. Urinary retention
1. An accumulation of urine due to the inability of the
bladder to empty
2. As urinary retention progresses, retention with overflow
develops
3. Bladder distention is apparent
4. With retention, the patient may void small amounts of
urine 2- 3 times an hour with no real relief
ii. Urinary tract infection
1. Results from catheterization or procedure
2. Usually cause by Escherichia coli
3. Bacteriuria (bacteria in the urine) leads to the spread of
organisms into the kidneys, and possibly to bacteremia
(bacteria in the bloodstream)
a. Microorganisms commonly enter the urinary tract
through the ascending urethral route
b. Bacteria inhabit the distal urethra, the external
genitalia, and the vagina in women
c. Women are more susceptible to infection because
of a short urethra and close proximity to the anus
4. Burning during urination is known as dysuria as urine
passes through inflamed tissues
a. An irritated bladder and urethral mucosa causes
hematuria
b. An irritated bladder is known as cystitis
c. If infection spreads to the kidneys, pyelonephritis
occurs, with symptoms of flank pain, tenderness,
fever, and chills
iii. Urinary incontinence
1. Involuntary leakage of urine
2. Can be temporary or permanent and continuous or
intermittent
3. Can affect patients of any age, but is very prevalent in the
elderly

4. Causes can include problems with movement, removing

clothing, and mental incapacity
iv. Urinary diversion
1. Diversion of urine to external source
2. Some patients have a urinary stoma to divert the flow of
urine from the kidneys to an external source
3. This may be necessary because of cancer, trauma,
radiation, fistula, or chronic cystitis
4. The types of diversion include ileal loop or conduit,
continent pouch, and nephrostomy
j. Medication affecting color of urine
i. Anticoagulants red urine
ii. Diuretics pale yellow urine
iii. Pyridium orange to orange-red urine
iv. Elavil green or blue-green urine
v. Levadopa brown or black urine
k. Older adults
i. Provide frequent opportunities to void older adults have a
smaller bladder capacity than younger adults.
ii. Encourage older adults to empty the bladder completely before
and after meals and at bedtime.
iii. Encourage patients to increase fluid intake to at least six to
eight glasses a day unless medically contraindicated.
1. Discourage drinking of coffee, tea, brown cola, and
alcohol because these have a diuretic affect and increase
urinary frequency
2. Make fluids such as cranberry juice available as part of
the patients fluid intake
a. Cranberry juice and vitamin C help acidify the urine
to decrease bacterial infections of the bladder
3. Restricting fluid intake does not decrease urinary
incontinence severity or frequency
4.
iv. Avoid routine use of indwelling catheters
1. If one is necessary, use it no longer than necessary
2. The risk of infection increases dramatically for
catheterized patients
v. Note that incontinence is NOT a normal part of aging
1. Make efforts to assess incontinence and provide
interventions to promote return of continence
l. Use the nursing process
i. Assessing data about voiding patterns, habits, past history of
problems
ii. Physical examination of urinary system, skin, hydration, urine
iii. Correlation of these findings with results of procedures and
diagnostic tests
iv. Assessing a problem with voiding
1. Explore its duration, severity, and precipitating factors
2. Note patients perception of the problem

3. Check adequacy of patients self-care behaviors

4. Physical Assessment of urinary functioning
a. Kidneys check for costovertebral tenderness
b. Urinary bladder palpate and percuss the bladder
or use bedside scanner
c. Urethral meatus inspect for signs of infection,
discharge, or odor
d. Skin Assess for color, texture, turgor, and
excretion of wastes
e. Urine assess for color, odor, clarity, and sediment
i. Normal, fresh urine has an aromatic odor
ii. As urine stands, it often develops and
ammonia odor because of bacterial action
iii. Urine tests
1. Must collect sample
2. Urinalysis
3. Specific gravity the weight or degree
of concentration of a substance with
an equal volume of water
4. Culture requires a sterile or cleanvoided urine sample
a. Will take 24 to 48 hours to
reveal the findings of bacterial
growth
b. The test for sensitivity will
determine which antibiotic will
be most effective
c. When collected properly, a
clean-voided urine specimen
does not contain bacteria from
the urethral meatus
5. Noninvasive procedures
a. KUB abd roentgenogram
b. CT computed axial
tomography scan
c. IVP intravenous pyelogram
d. Urodynamic testing
uroflowmetery
6. Invasive procedures
a. Cystscopy
b. Arteriography
7. Remember that each examination has
a specific indication and use, bowel
preparation, and patient education
a. Some examinations will require
a signed consent form
b. Some will require injection of
dye

c. You will need to assess the

patients sensitivity to the dye
5. Measuring urine output
a. Ask pt. to void into bedpan, urinal, or specimen
container in bed or bathroom
b. Ask patient to void into bedpan, urinal, or specimen
container in bed or bathroom.
c. Pour urine into appropriate measuring device.
d. Place calibrated container on flat surface and read
at eye level.
e. Note amount of urine voided and record on
appropriate form.
f. Discard urine in toilet unless specimen is needed.
g. HOURLY OUTPUT OF LESS THAN 30 mL FOR
LONGER THAN 2 CONSECUTIVE HOURS IS CAUSE
FOR CONCERN
6. Urine specimens
a. Routine urinalysis
b. Clean-catch or midstream specimens
c. Sterile specimens from indwelling catheter
d. 24-hour urine specimen
e. Specimens from infants and children
f. The color of urine should be pale-straw to amber
i. Urine will be more concentrated in the
morning
ii. Medications can also change urine color
1. So can beets, rhubarb, or blackberries
iii. Dark amber urine is the result of bilirubin
from liver disease
g. Stagnant urine has a strong ammonia odor
i. A sweet fruity odor is seen with diabetes
mellitus or starvation
h. The nurse collects random, clean-voided or
midstream, sterile, and timed specimens.
i. The method of collection varies according to the
patients developmental level and the type of
specimen ordered.
v. Nursing diagnosis and planning
1. Diagnoses
a. Social isolation
b. Pain (acute, chronic)
c. Risk for infection
d. Impaired skin integrity
e. Constipation
f. Disturbed body image
g. Urinary incontinence (functional, stress, urge,
overflow)
h. Toileting self-care deficit
i. Impaired urinary elimination

2.
3.

4.

5.

6.

7.

j. Urinary retention
k. Caregiver strain
A general goal is often normal urinary elimination, but
sometimes the individual goal differs, depending on the
problem
Consider the patients home environment and normal
elimination routines when planning therapies
a. Collaborate with several health care disciplines, the
patient, and the patients family
Planned pt. goals
a. Produce sufficient quantity of urine to maintain
fluid, electrolyte, and acidbase balance.
b. Empty bladder completely at regular intervals
without discomfort.
c. Provide care for urinary diversion and know when to
notify physician.
d. Develop plan to modify factors contributing to
current or future urinary problems.
e. Correct unhealthy urinary habits.
Promoting normal urination
a. Maintaining normal voiding habits
i. Identify patients pattern
b. Provide privacy curtains, doors
c. Promoting fluid intake
d. Strengthening muscle tone
i. exercises
e. Assisting with toileting
i. Men often need to stand
ii. Women seated upright
f. Provide hygiene
Types of urinary incontinence
a. Stressincrease in intra-abdominal pressure
b. Urgeurine lost during abrupt and strong
desire to void
c. Mixedsymptoms of urge and stress
incontinence present
d. Overflowoverdistention and overflow of
bladder
e. Functionalcaused by factors outside the
urinary tract
f. Reflexemptying of the bladder without
sensation of need to void
g. Totalcontinuous, unpredictable loss of urine
Managing urinary incontinence
a. Prevent skin breakdown
b. Encourage/teach lifestyle modifications
c. Implement bladder training
d. Encourage client to perform Kegels exercises
e. Use anti-incontinence devices as needed

i. Protective garments, pads

Factors to consider with use of absorbent products
i. Functional disability of the patient
ii. Type and severity of incontinence
iii. Gender
iv. Availability of caregivers
v. Failure with previous treatment programs
vi. Patient preference
g. Strategies to promote independent urination
h. Pharmacological interventions
i. Alpha-adrenergic agonists
ii. Anticholinergic agents
iii. Antispasmodic drugs
iv. Tricyclic antidepressants
v. Estrogen
vi. Alpha-adrenergic blockers
vii. Botulinum toxin
i. Surgical interventions
j. Parental teaching for enuresis
8. Managing urinary retention
a. Urinary catheterization
i. Introduction of a sterile tube into the bladder
1. Straight cath
2. Indwelling cath: foley
3. Suprapubic cath
a. Through abdominal wall into
bladder
ii. Reasons for catheterization
1. Relieving urinary retention
2. Obtaining a sterile urine specimen
3. Obtaining a urine specimen when
usual methods cant be used
4. Emptying bladder before, during, or
after surgery
5. Monitoring critically ill patients
vi. Nursing care for pt. with a catheter
1. Prevent urinary tract infection
a. CAUTI
2. Prevent backflow of urine keep bag below level of
bladder
3. Encourage fluids
4. Provide perineal hygiene
vii. Education for urinary diversion
1. Explain reason for diversion and rationale for treatment
a. for patients who have lost the use of the bladder as
a result of irradiation or surgical excision
2. Demonstrate effective self-care behaviors
3. Describe follow-up care and support resources
4. Report where supplies may be obtained in community
5. Verbalize related fears and concerns
f.

6. Demonstrate a positive body image

viii. Types of urinary diversions
1. Two types of continent urinary diversions may be
performed:
a. A continent urinary reservoir is created from a
distal portion of the ileum and a proximal portion of
the colon, the ureters are embedded in the
reservoir.
i. This reservoir is situated under the
abdominal wall and has a narrow ileal
segment brought out through the abdominal
wall to form a small stoma
ii. The ileocecal valve creates a one-way valve
in the pouch, through which a catheter is
inserted to empty the urine from the pouch
iii. Patients must be willing and able to
catheterize the pouch 4 to 6 times a day for
the rest of their lives
b. The second type is an orthotopic neobladder that
also uses an ileal pouch to replace the bladder.
Anatomically, the pouch is in the same position in
which the bladder was before removal, allowing
patients to void normally. Incontinent urinary
diversions are less commonly performed.
c. Surgery involves connecting the ureters to a
section of the intestinal ileum with formation of a
stoma on the abdominal wall.
i. Urine drains continuously because the
patient has no sensation or control over
urinary output, requiring the application of a
collection pouch at all times.
ii. Some patients need urinary drainage directly
from one or both kidneys. In this case, a tube
is placed directly into the renal pelvis.
1. This procedure is called a
nephrostomy.
iii. Any urinary diversion poses threats to a
patients body image.
1. The patient must learn how to
manage the diversion, and those who
do not have a continent urinary
diversion must wear an artificial
device at all times
2. However, most patients are able to
wear normal clothing, engage in
physical activity, travel, and have
sexual relations

3. Care must be taken not to pull on

tubing, especially with a nephrostomy,
because it can be pulled out, causing
tissue and organ damage and
infection.
4. Most nephrostomies are sutured into
the kidney.
iv. Refer patients with a urinary diversion to an
ostomy nurse (a nurse with specialized
education in this area). This specialist is a
valuable resource for assisting a patient and
family with matters pertaining to all aspects
of care. The ostomy nurse often meets with
the patient and family before surgery. In
addition, refer the patient to the United
Ostomy Associations of America
d. Cutaneous Ureterostomy
i. a surgical procedure that detaches one or
both ureters from the bladder, and brings
them to the surface of the abdomen with the
formation of an opening (stoma) to allow
passage of urine
ii. patient wears a bag over the stoma to collect
the urine
e. Ileal Conduit
i. A surgical procedure, where a small urine
reservoir is created from a segment of a
bowel and is placed just under the abdominal
wall.
ii. The end of the ileum is brought out through a
stoma opening in the abdominal wall to drain
the urine gathered in the reservoir.
iii. The patient wears a bag over the stoma to
collect the urine.
f. Kock Pouch
i. An ileostomy with a reservoir and valved
opening surgically created from doubled
loops of ileum
ii. It is a continent ileal reservoir for cutaneous
urinary diversion
iii. Drained with a catheter
ix. Patients at risk for UTIs
1. Individuals with indwelling urinary catheter
2. Individuals with diabetes mellitus
3. Elderly people
4. Postmenopausal women
5. Sexually active women
6. Women who use diaphragms for contraception

4.

7. Safety guidelines
a. Follow principles of surgical and medical asepsis as
indicated when performing catheterizations,
handling urine specimens, or helping patients with
their toileting needs.
b. Identify patients at risk for latex allergy (i.e.,
patients with history of hay fever; asthma; and
allergies to certain foods such as bananas, grapes,
apricots, kiwi fruit, and hazelnuts).
c. Identify patients with allergies to povidone-iodine
(Betadine). Provide alternatives such as
chlorhexidine.
Bowel Elimination
a.

i. Clicker Questions
1. During rounds on the night shift, you note that a patient stops breathing for 1
to 2 minutes several times during the shift. This condition is known as:
a. Cataplexy
b. Insomnia
c. Narcolepsy
d. Sleep apnea
2. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the
best action to take would be
a. Adding a daytime nap
b. Allowing the child to sleep longer in the morning
c. Maintaining the childs home sleep routine
d. Offering the child a bedtime snack
3. A patient suffers from sleep pattern disturbance. To promote adequate sleep,
the most important nursing intervention is
a. Adminstering a sleep aid
b. Synchronizing the medication, treatment, and vital signs schedule
c. Encouraging the patient to exercise immediately before sleep
d. Discussing with the patient the benefits of beginning a long-term nighttime medication regimen
4. What is the normal adult bladder capacity?
a. 50 100 mL
b. 100 200 mL
c. 300 500 mL
d. 600 800 mL
5. There is a 24-hour urine collection in process for a client. The Nursing
Assistant inadvertently empties one specimen into the toilet instead of the
collection hat. The nurse should
a. Continue with the collection of urine until the 24-hour period is finished
b. Make a note to the lab to inform them that one specimen was missed
during the collection
c. Being filling a new collection container and take both containers to the
lab at the end of the collection period
d. Dispose of the urine already collected and begin an entirely new 24hour collection
6. The female client states to the nurse, Im so distressed. It seems like every
time I laugh hard, I wet myself. The nurse knows that this condition is known
as
a. Stress incontinence
b. Urge incontinence
c. Functional incontinence
d. Unconscious incontinence

Clicker Question Answers

1.
2.
3.
4.
5.
6.

D
C
B
D
D
A