MEDICAL COLLEGES OF NORTHERN PHILIPPINES MEASURES TO PROMOTE ADEQUATE RESPIRATORY

FUNCTION
FUNDAMENTALS OF NURSING

SEMI-FINAL COVERAGE
1. Man requires 21% of oxygen from the environment.
The higher the altitude, the lower the oxygen
INTERVENTIONS TO IMPROVE: concentration

 OXYGENATION 2. Deep breathing and coughing exercises (DBCE) to

promote lung expansion and loosen mucous secretions.
 NUTRITION
PROCEDURE: inhale deeply through the nose, hold
 ELIMINATION breath for few seconds and exhale through mouth slowly.
On the third breath, hold breath and cough to
 ACTIVITY AND EXERCISE
expectorate secretions
 SLEEP AND COMFORT
3. Positioning. Semi-Fowler’s or high-fowler’s position
 HYGIENE promotes maximum lung expansion. By gravity, the
diaphragm moves down and abdominal organs do not
 SAFETY AND COMFORT compress the diaphragm.

4. Maintain a patent airway to promote adequate

 OXYGENATION gaseous exchange.

Causes of Airway Obstruction:

-Respiratory system replenishes the body’s oxygen supply - tongue

and eliminates waste (CO2) - mucous secretions

- edema of the airways

- spasm of airways
Overview of the Anatomy and Physiology of Respiratory - foreign bodies (aspiration)
System
5. Maintain adequate hydration to maintain moisture of
the mucous membrane. This is to liquefy retained
A. Upper Airways secretions. Intake should be atleast 8 glasses a day.

- Nasal cavity 6. Avoid environmental pollutants such as alcohol and

smoking. These factors inhibit mucociliary function
- Pharynx
7. Perform Chest Physiotherapy
- Larynx
Procedure:
Functions:
PERCUSSION
-Transport gases to lower airways
- “clapping”
- Protects lower airways
- forceful striking of the back with cupped hands to
- Warming, filtration and humidification of air mechanically dislodge tenacious secretions
B. Lower Airways

- trachea

- Bronchi

- Pleura

- Lungs

Functions:
VIBRATION
- clearance mechanism (coughing)
- vigorous quivering produced by hands that are
- immunologic response
placed flat against chest wall or back to loosen secretions
- exchange of gases

Respiratory Centers: medulla and pons

 - to administer medications

- dependent nursing fxn

- Inform client and explain the procedure

- Position: SF or HF

- Cover eyes with washcloth

- place spout 12-18 inches away from the client

- WOF first degree burns

POSTURAL DRAINAGE
- render therapy for 15-20 minutes
- expulsion of secretions from various lung segments by
- instruct pt to do DBCE post procedure
gravity.
- provide oral hygiene
- involves positioning based on the location of secretions
9. SUCTIONING
- each position is maintained for 10-15 mins

- to clear airways from secretions

Nursing considerations during CPT:
Procedure:
- the entire procedure should last for 30 minutes only
- assess indications for suctioning (audible
- do gradual change in position to prevent exhaustion
secretions during respiration and adventitious breath
and postural hypotension
sounds upon auscultation)
- administer bronchodilator as ordered before CPT
- Position: For conscious pts: SF
- Best done in the morning upon waking up, before
Unconscious pts: Lateral
meals and before bedtime
- Identify proper pressure on the suction
- offer oral hygiene after the procedure
machine/ identify appropriate catheter size
- Contraindicated in patients with:
GROUP PORTABLE WALL SIZE (Fr)
- increased ICP
ADULT 10-15 mmHg 100-120 12-18
- active bleeding
CHILD 5-10 mmHg 95-110 8-10
- hemoptysis
INFANT 2-5 mmHg 50-95 5-8
- head and neck injury
- don sterile gloves to prevent introduction of
8. BRONCHIAL HYGIENE microorganisms
MEASURES
- lubricate catheter using a water soluble lubricant/
STEAM INHALATION sterile water
- apply suction during withdrawal of the suction
catheter to prevent trauma to the mucous membranes
- to liquefy secretions
- apply suction for 5-10 seconds, with 20-30 second
- to warm and humidify inspired air interval in between suctions

- to relieve edema of the airways - hyperoxygenate pt before and after suctioning to

prevent hypoxia
- to soothe irritated airways
 - provide oral and nasal hygiene -assess effectiveness of O2 therapy by checking VS
especially RR
- assess effectiveness of suctioning

ALTERATION IN RESPIRATORY FUNCTION

10. Incentive spirometry to enhance deep inspiration and to
prevent atelectasis

11. Administer supplemental oxygen HYPOXIA

- indication: HYPOXEMIA - insufficient oxygenation of tissues

Signs of hypoxemia:

- restlessness EARLY SIGNS LATE SIGNS

- increased PR - tachycardia - Bradycardia

- rapid, shallow respiration - Increased RR -Dyspnea

- dyspnea -Slight increase in SBP - decrease SBP

- light-headedness -Cough

- flaring of nares -Hemoptysis

- intercostal retractions

- cyanosis Other signs of Acute Other signs of Acute

Hypoxia: Hypoxia:
OXYGEN DELIVERY SYSTEMS

1. LOW FLOW DEVICES

- N&V - fatigue, lethargy
- Nasal cannula (24-45% at 2-6 LPM)
-Oliguria, anuria -polycythemia
- Simple Face mask (40-60% @ 5-8 LPm)
-headache -increased Hgb
- Partial Rebreather (60-90% @ 6-10 LPM)
concentration
-apathy
-Non rebreather (95-100% @ 6-15 LPm)
- clubbing of finger
-dizziness
2. HIGH FLOW DEVICES
-irritability
- venturi mask ( for patients with COPD)
-memory loss
- oxygen hood

- Isolette
Altered Breathing Patterns:
(see attached document for detailed discussion)
Tachypnea

Bradynea
Nursing considerations:
Apnea
- assess signs of hypoxemia

- verify DO

- Position: SF or HF

- Regulate O2 flow accurately

-Place a NO SMOKING sign at the bedside

(oxygen supports combustion)

- avoid oil, greases, alcohol near the client

- avoid materials that generate static electricity such as wool

blankets. Use cotton blankets instead

- humidify oxygen by placing sterile water in the O2

humidifier

- provide oral hygiene to prevent dryness of mucous

membrane
 - 1 g (CHO) - 4 CAL

Volume: - 1 G (CHON) - 4 CAL

HYPERVENTILATION - 1 G (FAT) - 9 CAL

- excessive amount of air in the lungs

-results from deep, rapid respirations Variable affecting Caloric Needs

HYPOVENTILATION 1. Age and growth

- decreased rate and depth of respiration 2. Gender (higher BMR in males)

-causes retention of carbon dioxide 3. Climate (cold=higher BMR)

4. Sleep (lower BMR)

Rhythm 5. Activity

CHEYNE-STOKES 6. Fever

-waxing and waning respirations (very deep to shallow 7. Illness

breathing with episodes of apnea)

KUSSMAUL’S RESP
Food and Fluid Regulatory Center: HYPOTHALAMUS
-increased rate and depth of respiration

APNEUSTIC
(SEE ATTACHED DOCUMENT FOR LIST OF
- prolonged gasping inspiration followed by a very short, VITAMINS )
usually inefficient expiration

BIOT’S
MINERALS
- shallow breaths interrupted by apnea

1. CALCIUM
 NUTRITION
- necessary for bone and teeth formation
- study of nutrients and the processes by which they are used
-promotes muscular contraction
by the body
- promotes blood coagulation

TERMINOLOGIES: - activates other enzymes for biological reactions

- deficiency: rickets, osteomalacia, tetany

DIGESTION
- excess: calcium rigor (tonic contraction)
-process by which food is broken down for the body to
use in growth, development, healing and prevention of SOURCES: milk and dairy prod, greean and leafy
diseases vegetables, whole grains, nuts, legumes, carrots, seafood,
tofu
ABSORPTION

-process by which digested CHO, CHON, fats, minerals

and vitamins are actively and passively transported into 2. POTASSIUM
organs and tissues
-promotes fluid and electrolyte balance
METABOLISM
-major cation in the intracellular fluid
-process by which nutrients are converted to energy to
support cellular growth and repair -affects muscular and cardiac activities

Hypokalemia: loss of K; manifested by apathy,

muscular weakness, mental confusion, abdominal
(PLS REVIEW ANATOMY AND PHYSIOLOGY OF GIT) distention, nausea, lack of appetite, nervous irritability,
dysrhythmias

Hyperkalemia: excess K; weakened cardiac contraction,

MACRONUTRIENTS: CHO,CHON, FAT
mental confusion, numbness of extremities
MICRONUTRIENTS: VITAMINS AND MINERALS
SOURCES: Banana, Avocado, Oranges, Strawberries,
Cantaloupe, Raisins, Raw tomatoes, Carrots, Mushroom,
Pork, Beef, Fish
CALORIE (KILOCALORIE)
 -Nitrogen Balance

3. SODIUM -Creatinine Excretion

-maintains fluid balance

-major extracellular cation  Clinical signs

-maintain acid-base balance - hair, skin, tongue, mucous membrane, abdominal

girth
-allows passage of glucose through the cell wall

-maintains normal muscle excitability

 Dietary History

- 24 hr diet recall; 72 hr diet recall

4. IRON

- most abundant trace element

MEASURES TO STIMULATE APPETITE
-constituent of hemoglobin and myoglobin necessary in
maintaining adequate oxygenation in the blood 1. Serve food in pleasant and attractive manner

- contributes to antibody formation, collagen synthesis
SOURCES: pork liver, organ meats, enriched rice, kamote
leaves, soybeans, sea weeds, clams, malunggay, ampalaya
leaves, peanuts, pechay, sitaw leaves, eggs
-Iron deficiency leads to anemia
-excess Fe leads to hemosiderosis
2. Place patient in a comfortable position (SF/HF to
prevent aspiration)
3. Provide good oral hygiene measures
4. Promote comfort
5. Remember that color affects color
6. Engage in pleasant conversation

7. Assist weak patient in feeding

5. IODINE

-synthesis of thyroxine (thyroid gland)

-Cretinism: congenital disorder due to decrease Iodine during
pregnancy
-Hypothyroidism/Hyperthyroidism
SOURCES: iodized salt, seafood, milk, eggs, bread
NURSING INTERVENTIONS FOR NAUSEA AND
VOMITING
1. Position conscious clients in SF or HF position;
unconscious patients in lateral position to prevent
aspiration
2. Provide good oral hygiene measures

3. Suction the mouth as needed if the client is unable to

ASSESSMENT OF NUTRITIONAL STATUS
expel vomitus

4. Relieve nausea by offering the client:

 ANTHROPOMETRIC MEASUREMENTS
- ice chips
-height - hot tea with lemon/ lime
-weight (best indicator of nutritional status)
- hot ginger ale
-Skin folds (Fat folds)
- dry toast or crackers
-Arm Muscle circumference
- cold cola beverage
-BMI = wt in kg / (ht in meter)2
5. Replace loss fluid by hydration and IV therapy
-
BMI result:
6. Observe for potential complications:
20-25%- Normal
a. DEHYDRATION
27.5-30%- mild obesity
- Thirst (first sign)
30-40%- moderate obesity
- dry mouth and mucous membrane
Above 40%- severe obesity - warm, flushed, dry skin

- fever, tachycardia, low bp

 Biochemical data
- weight loss
- Hgb and Hct indices
- sunken eyeballs
-Serum Albumin
 - oliguria - commonly used tube: LEVIN TUBE

- dark, concentrated urine Purposes:

- high urine SG -to provide feeding (gastric gavage)

- poor skin turgor -to irrigate stomach (gastric lavage)

- altered LOC -For decompression

- elevated BUN, Crea -administration of meds

-elevated Hct -administer supplemental fluid

b. Acid-base balance

Metabolic Alkalosis: excessive vomiting Insertion procedure:

Metabolic Acidosis: excessive diarrhea 1. Inform pt and explain procedure

7. Administer antiemetic as ordered by the physician for 2. Place in HF position to facilitate insertion
vomiting
3. Measure length of tube to be inserted starting from the
Metoclopramide (Plasil) tip of the nose to the tip of the earlobe, to the xiphoid
process)
Trimethobenzamide (Tigan)
4. Lubricate tip of catheter with water-soluble lubricant to
Promethazine (Phenergan)
reduce friction. Oil based lubricant may cause lipid
Prochlorperazine maleate (Compazine) pneumonia

5. Hyperextend the neck and gently advance the catheter

toward the nasopharynx
SPECIAL DIETS
6. Tilt the patient’s head forward once the tube reaches
the oropharynx (throat)and ask the patient to swallow or
sip fluid as tube is advanced.
1. CLEAR FLUIDS
7. Secure the NGT by taping it to the bridge of the nose
-include only liquids that lack residue
after checking the tube’s placement
Ex: water lemonade

Bouillon coffee/tea without dairy

Clear broth hard candy

Gelatin carbonated beverage

Popsicles

2. FULL LIQUID

- includes all fluids and food that become liquid at room

temperature; with residue

Ex: plain ice cream strained soup

Sherbet strained vegetable juices

Administering Tube Feeding (gastric gavage)
Milk
1. Position pt in SF
Pudding/custard
2. Assess tube placement and patency

- introduce 5-20 ml of air into NGT and auscultate at

3. SOFT DIET the epigastric area. Gurgling sound indicates patency
- soft food with reduced fiber content which require less -aspirate gastric content (yellowish/greenish)
energy for digestion (puree, chopped meat, mashed potato,
scrambled egg, porridge) -immerse tip of the tube in water, no bubbles should
be produced
Related Nursing procedures
-measure pH of aspirated fluid (acid)
Alternative Feeding Methods
Note: the most effective method of checking the NGT
placement is radiograph verification.
A. NASOGASTRIC TUBE
3. Assess residual feeding contents. To assess absorption of - passage of small, dry, hard stools
the last feeding, should be less than 50ml
Nursing interventions:
4. Introduce feeding slowly to prevent flatulence, cramping
-increase OFI (1500-2000 ml/day)
and vomiting
-increase fiber intake to provide bulk of the
5. Height of tube should be 12 inches above insertion point.
stool (fresh or cooked fruits and vegetables, whole
6. Instill 30-60 ml of water into the NGT after feeding to grain, breads and cereals, fruit and vegetable juices)
cleanse the lumen of the tube
- establish regular pattern of defecation
7. Clamp the NGT to prevent entry of air into the stomach
-respond stat to urge to defecate
8. Maintain Fowler’s position for atleast 30 mins to prevent
-minimize stress. SNS activation decreases
aspiration.
peristalsis
9. Document
- maintain exercise to promote muscle tone and
stimulate peristalsis

BOWEL AND BLADDER ELIMINATION - assume sitting or semi-squatting position.

Allows gravity to assist the elimination of feces and
easier contraction of abdominal and pelvic muscles
 Defecation
-administer laxatives as ordered
- expulsion of feces from the rectum

TYPES OF LAXATIVES
Characteristics of Stool
1. CHEMICAL IRRITANTS
 Color: yellow or golden brown (due to bile pigment)
-provide chemical stimulation to intestinal wall
 Odor: aromatic upon defecation thereby increasing peristalsis. Ex. Dulcolax (Bisacodyl),
castor oil, Senokot (Senna)
 Amount: depends on the bulk of the food intake
(150-300 g/day) 2. STOOL LUBRICANT

 Consistency: soft, formed - lubricates feces and facilitates expulsion (mineral

oil)
 Shape: cylindrical
3. STOOL SOFTENERS
 Frequency: variable; usual range 1-2 per day to 1 every
2-3 days - Na Docussate

4. BULK FORMERS

 Alteration on the characteristics of Stool -increases bulk of stool, increasing mechanical

pressure and distention of the intestine, thereby
increasing peristalsis (ex. Psyllium)
Alcoholic Stool 5. OSMOTIC AGENTS
- gray, pale or clay colored stool due to absence of - attract fluids from the intestinal capillaries
stercobilin caused by biliary obstruction (Lactulose, Magnesium Hydroxide)
Hematochezia

-passage of stool with bright red blood due to lower GI 2. FECAL IMPACTION
bleeding
- mass or collection of hardened, putty-like
Melena feces in the folds of the rectum.
-passage of black,tarry stool due to UGIB - inability to evacuate stool voluntarily
Steatorrhea S/sx:
-greasy, bulky, foul-smelling stool due to undigested fats - absence of bowel movement for 3-5 days
like in hepato-biliary obstructions
- passage of liquid fecal seepage

- hardened fecal mass palpated during DRE

Common Fecal Elimination Problems
- nonproductive desire to defecate and rectal pain

- anorexia, body malaise

1. CONSTIPATION
- subjective feeling of abdominal fullness or bloating
 - apparent abdominal distension -gum chewing, candy sucking, smoking

- N&V -abdominal surgery

MNGT: MNGT:

- manual extraction or fecal disimpaction as ordered -avoid gas forming food

- Increase OFI -provide warm liquids to drink to increase peristalsis

- Sufficient bulk in the diet -promote early ambulation among post op pts

- Adequate activity and exercise -promote adequate rest and activity

-limit carbonated beverages

3. DIARRHEA -Rectal tube insertion as ordered

- frequent evacuation of watery stool due to - position: left lateral

increased gastric motility
-insert 3-4 inches of lubricated tube in rotating
MNGT: motion

- replace fluid and electrolyte losses -use appropriate size (Fr. 22-30)

- provide good perianal care. Diarrheal stool is -retain rectal tube for 30 minutes
oftentimes acidic and can cause soreness and irritation in the
-administer carminative enema as ordered
area

- promote rest -administer cholinergics as ordered

(neostigmine)
-eat small amount of bland food

-low fiber diet

-BRAT diet (Banana, Rice Am, Apple, Toast)
-avoid excessively hot or cold fluid
-increase intake of K-rich food
-administer antidiarrheal drugs as ordered
- Demulcents: mechanically coat the irritated bowel
and act as protectives
- Absorbents: absorbs gas or toxic substances from
the bowel
5. FECAL INCONTINENCE
-involuntary elimination of bowel contents often
associated with neurologic, mental or emotional
impairments
-seen in patients with injury to cerebral cortex
(pt is unable to perceive that rectum is distended or
unable to initiate the motor response required to
inhibit defecation voluntarily)
-pts with spinal cord injury (sacral region)

- Astringents: shrink swollen or inflamed tissues in

the bowel

Note: Do not administer antidiarrheal at the start of diarrhea ENEMAS

as it is the body’s protective mechanism to get rid of toxins or
bacteria

4. FLATULENCE

- presence of excessive gas in the intestines

Common causes:

- constipation

-codein, barbiturates and other meds that decrease

intestinal motility

-anxiety

-eating gas forming food (cabbage, onions, Purposes:

rootcrops, legumes)
-relieve constipation and fecal impaction
-rapid food or fluid ingestion
-relieve flatulence
-excessive drinking of carbonated drinks
 -administer medication in 500-1000 ml or cottonseed oil)
of water)
-evacuate feces in prepartion for diagnostic
procedure or surgery

-Normal saline
(9ml of NaCl to
TYPES OF ENEMAS
1000ml of water)

1. CLEANSING ENEMA
-Hypertonic
- stimulates peristalsis by irritating the colon Solution/Fleet
and rectum and or by distending the intestine with enema (90-120
the volume of fluid introduced ml)

A. HIGH cleansing enema: cleanse as much of HT OF SOL. 18 inches above 12 inches above
the colon as possible; 1000 ml of sol’n is rectum rectum
administered in adults
TEMP OF SOL 115-125 F 105-110 F
B. LOW cleansing enema: to cleanse the
TIME REQUIRED 5-10 mins 1-3 hrs
rectum and sigmoid colon only; 500 ml of sol’n is
administered in adults

Nursing considerations when administering

enema:
2. CARMINATIVE

- to expel flatus
-check the doctor’s order
-60-80 ml of fluid is introduced
-provide privacy

-promote relaxation to facilitate insertion of tube

3. RETENTION ENEMA
-position the pt (adult: left lateral position; children:
-introduces oil into the rectum and sigmoid
dorsal recumbent)
colon; oil is retained in the colon for 1-3 hrs
-identify appropriate catheter size:
-softens feces and lubricates the rectum and
anal canal to facilitate passage of stool Adult: Fr 22-32

Children: Fr. 14-18

4. RETURN FLOW ENEMA/HARRIS Infant: Fr. 12
FLUSH/COLONIC IRRIGATION
-lubricate 5 cm (2in) of the rectal tube
- done also to expel flatus
-allow solution to flow through the tube to expel air
-300-500 ml of fluid is introduced into and out before insertion.
of the large intestine
-insert 7-10 cm (3-4 inches) of rectal tube in gentle
-solution container is lowered so that the fluid rotation motion to prevent irritation of anal and rectal
backs out through the rectal tube container tissues
-the inflow-outflow process is repeated 5-6 -introduce solution slowly to prevent sudden stimulation
times of peristalsis
-replace the sol’n several times as it becomes -change the position to distribute solution well in the
thick with feces colon (high enema), if low, remain in LLP.
-procedure may take 15-20 mins to be -if abdominal cramps occur, temporaily stop the flow of
effective solution by clamping the tube

-after the procedure, press the buttocks to inhibit the

urge to defecate
NON RETENTION
RETENTION -assist pt to the toilet
SOLUTIONS -Tap water Carminative -do perianal care
USED (500-1000 mls) enema
-document

-Soap suds (20 Oil (90-120 of

ml of castile soap mineral oil, olive
URINARY ELIMINATION

ALTERED URINARY FREQUENCY

Function/s of the urinary tract: Frequency

- maintains homeostasis by maintaining body fluid -Voiding at frequent intervals

composition and volume
Nocturia

-Increased frequency at night

(PLS REVIEW ANATOMY AND PHYSIOLOGY OF THE
Urgency
URINARY SYSTEM AND URINE FORMATION AS WELL)
-Strong feeling that the person wants to void

Dysuria
Micturition
-painful or difficult voiding
-act of expelling urine from the bladder
Hesitancy
-urination, voiding
-difficulty initiating voiding
-initiated by parasympathetic nervous system activation
Enuresis

-repeated involuntary voiding beyond 4-5 years of

Normal Characteristics of Urine:
age
Color: Amber/straw
Pollakuria
Odor: Aromatic
-Frequent, scanty urination
Transparency: Clear
Urinary Incontinence
pH: slightly acidic (4.6 - 8; average: 6)
 Total Incontinence:
Specific gravity: 1.010- 1.025
-continuous and unpredictable loss of urine

 Stress Incontinence
ALTERATION IN URINE COMPOSITION
- leakage of less than 50 ml of urine as a
RBC in the urine - hematuria result of a sudden increase in intra-abdominal
pressure
Pus in the urine - pyuria
 Urge Incontinence
Bacteria - bacteriuria
- follows a sudden strong desire to urinate
(signs of UTI)
and leads to involuntary detrusor contraction
Albumin in the urine: Albuminuria
 Functional Incontinence
Protein in the urine: Proteinuria
- involuntary unpredictable passage of
Glucose: - Glycosuria urine

Ketones: - Ketonuria  Reflex Incontinence

- Involuntary loss of urine occurring at

somewhat predictable intervals when specific
ALTERED URINE PRODUCTION bladder volume is reached
Polyuria Retention
- excessive urine production; more that 100 ml/hr or - accumulation of urine in the bladder with
2500 ml/day; diuresis associated inability of the bladder to empty itself

(240-450 ml triggers micturition)

Oliguria

- decreased amount of urine; less than 30 ml/hr or less Clinical Signs of Bladder Retention
than 500ml/day
A. Discomfort in the pubic area

B. Bladder distension (palpation and percussion)

Anuria
C. Inability to void or frequent voiding of small volumes
- little to no urine production; 10 ml/hr; urinary (25-50 ml)
suppression
D. A disproportionately small amount of output in relation to -position: Male> supine with legs abducted
fluid intake
Female> dorsal recumbent
E. Increasing restlessness and feeling of need to void
-don sterile gloves

-locate meatus: Male> tip of glans penis

NURSING INTERVENTIONS TO INDUCE VOIDING
Female> between clitoris and
vaginal orifice

-provide privacy
-provide fluids to drink unless contraindicated
-assist pt in anatomical position of voiding
-serve clean, warm and dry bedpan or urinal
-allow the patient to listen to the sound of running water
-dangle fingers in warm water
-cleanse the meatus with antiseptic sol’n from front
to back
-lubricate cathete with water-soluble sol’n
-insert the catheter and advance until urine flows
through the tubing
-anchor the catheter by inflating the balloon with
5-10 ml of sterile water

-pour warm water over the perineum -anchor the tubing: M>laterally upward over the
lower abdomen to prevent penoscrotal pressure
-promote relaxation
F>inner aspect of the thigh
-provide adequate time for voiding

-perform crede’s maneuver as ordered. Apply pressure on the

suprapubic area

-administer cholinergics as ordered

-LAST RESORT: URINARY CATHETERIZATION

Urinary Catheterization

ACTIVITY, MOBILITY AND EXERCISE

Purposes:
BODY MECHANICS
-to relieve bladder distension
- efficient, coordinated and safe use of the body to
-to instill medications into the bladder produce motion and maintain balance during the activity.
It prevents injury to self and clients
-to irrigate the bladder

-to measure hourly urine output accurately

PRINCIPLES OF BODY MECHANICS
-to collect urine specimen

-to empty bladder in preparation for diagnostic

procedure and surgery 1. Balance is maintained and muscle strain is avoided as
long as the line of gravity passes through the base of
support
Nursing considerations: a) Start body movement with proper alignment
-verify doctor’s order and identify the pt b) Stand as close as possible to the object to be
-explain procedure and provide privacy moved

-do perineal care

-use appropriate catheter size:

Male: 16-18

Female: 12-14
 10. The heavier an object, the greater the force needed
to move an object

-encourage the client to assist as much as possible

by pushing or pulling\

-use own body weight to counteract the weight of

the object

-obtain the assistance of other persons or use

mechanical devices to move objects that are too heavy

11. Moving an object along a level surface requires less

energy than moving an object up an inclined surface or
c) Avoid stretching, reaching and twisting
lifting it against the force of gravity

12. Continuous muscle exertion can result in muscle

2. The wider the base of support and the lower the center of strain and injury. Alternate rest periods with periods of
gravity, the greater the stability. Before moving objects put muscle use to help prevent fatigue
your feet apart, flex the hips, knees and ankles

3. Balance is maintained with minimal effort when the base of

PHYSIOLOGIC RESPONSES TO IMMOBILITY
support is enlarged in the direction in which the movement
will occur Decrease in muscle strength

-when pushing an object, enlarge the base of support by Muscle atrophy

moving the front foot forward
Disuse osteoporosis
-when pulling an object, enlarge the base of support by
either moving the rear leg back if facing the object or moving Fibrosis and ankylosis
the front foot forward if facing away from the object Contracture

PATHOGENESIS OF PRESSURE ULCERS

-also known as Pressure sores, decubitus ulcers,

bedsores or distortion sores

-reddened areas, sore or ulcers of the skin occurring over

bony prominences

-occurs due to interruption of the blood circulation to the

tissue

4. Objects that are close to the center of gravity are moved CAUSES OF PRESSURE SORES
with least effort
1. Pressure
5. The greater the preparatory isometric tensing or
contraction of muscles before moving an object, the less - primary cause; perpendicular force exerted on the
energy required to move it and the less musculoskeletal skin by gravity
strain injury. 2. Friction
6. The synchronized use of as many large muscle groups as -parallel force acting on the skin
possible during an activity increases overall strength and
prevents muscle fatigue and injury 3. Shearing Force

7. The closer the line of gravity to the center of the base of -combination of friction and pressure
support the greater its stability

-when moving or carrying objects, hold them as close as

STAGES OF PRESSURE ULCERS
possible to the center of gravity

-pull an object toward self whenever possible rather

than pushing it away Stage I
8. The greater the friction against the surface beneath an >Non-blanchable erythema of intact skin
object, the greater the force required to move the object.
Provide a firm, smooth, dry bed foundation when moving the Stage II
client

9. Pulling creates less friction than pushing

 >Partial thickness skin loss involving epidermis and or Done by the client
dermis. The ulcer is superficial and presents clinically as
Passive ROM
abrasion, blister.
Done for the client by health care providers
Stage III
Active-Resistive ROM
>Full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to but not -Done by the client against a weight or force
through underlying fascia.
Active Assistive ROM
>deep crater
-done by the stronger arm and leg to the weaker
Stage IV arm and leg
>Full thickness skin loss involving damage to Isotonic
muscle,bone or supporting structures such as tendon or joint
capsule -involves change in muscle strength and
tension(running, walking)

Isometric

-involves change in muscle tension only (kegel’s

exercise)

COMFORT, REST AND SLEEP

PAIN

>sensation of physical or mental hurt or suffering

that causes distress or agony to the one experiencing it

PREVENTING AND TREATING PRESSURE SORES

>Provide smooth, firm, wrinkle free foundation on which the THEORIES OF PAIN
client can lie 1. Pattern Theory
>use foam, rubber pads, egg crate mattress under pressure - states that pain is perceived whenever the stimulus
areas is intense enough
>apply thin layer of cornstarch to the bedsheet 2. Specificity Theory
>reduce shearing force by elevating the head of the bed to - states that there are specific nerve receptors for
no more than 30 degrees particular stimuli
>frequent position changes -nociceptor: noxious stimuli
>provide meticulous hygiene -thermoreceptors: heat or cold
>keep skin clean and dry -mechanoreceptore: pressure
>avoid massaging bony prominences with soap -chemoreceptor: chemicals

3. Gate Control Theory

TREATMENT
>clean pressure sore daily
>clean and dress pressure sore using surgical asepsis
>if sore is not infected, cover it with occlusive dressing
>if sore is infected, obtain sample for C&S
>reposition client q 2 hours
>encourage ambulation in post op patients
>provide ROM exercises
-there is a gate in the spinal cord called substantia
gelatinosa. When gate is open, pain is transmitted and is
perceived.
4. Affect Theory
- it avers that pain is emotional. The intensity of pain
perceived depends on the value of the organ affected to
the individual
5. Parallel Processing Model
- the physiologic or neurologic deciphering

PHYSIOLOGY OF PAIN
TYPES OF EXERCISES

Active ROM
 -person adapts to pain may be due to endorphins.

CLASSIFICATION OF PAIN

A. TYPES OF PAIN

 CUTANEOUS/SUPERFICIAL

-occurs over the body surface or skin segment

 SOMATIC

- may be deep or superficial

-occurs in the skin, mucles, joints

 VISCERAL PAIN

-arises from stimulation of pain receptors in the

abdominal cavity or thorax

 REFERRED PAIN

- pain is perceived at an area other than the site of

injury

 INTRACTABLE

- resistant to cure or relief

 PHANTOM

-actual pain felt in a body part that is no longer

present

 RADIATING

-felt at the source and extends to surrounding

tissues

 PSYCHOGENIC

- primarily due to emotional factors with no

physiologic basis
TYPES OF RESPONSES TO PAIN  INTERMITTENT
1. INVOLUNTARY RESPONSES -pain stops and starts again
- mediated by the autonomic nervous system.

-mild to moderate: SNS B. LOCATION

-severe: PNS C. DURATION
2. VOLUNTARY RESPONSE Acute: lasts for less than 6 months
-Behavioral responses: crying, grimacing, splinting area, Chronic: lasts for more than 6 months
tossing in bed
D. CHARACTER/QUALITY
-Emotional responses: depression, withdrawal, social
isolation E. INTENSITY/SEVERITY

F. AGGRAVATING/ALLEVIATING FACTORS

STAGES OF PAIN RESPONSE

 ACTIVATION

- begins with the perception of pain; body assumes a NURSING INTERVENTIONS TO RELIEVE PAIN
fight or flight response

 REBOUND
1. Techniques that stimulate the skin
-pain is intense but brief. PNS dominates
Rationale: enhances secretion of serotonin which blocks
 Adaptation transmission of pain impulses
 Therapeutic touch

 Contralateral stimulation: stimulating the skin in an area STAGE 2

opposite to the painful area
- light sleep
 Vibration
- eyes are still
 Heat and cold application
- HR and RR decreases slightly
 Acupuncture/ Acupressure
- body temperature falls
 TENS (Transcutaneous Electrical Nerve Stimulation)

2. Techniques to distract attention

STAGE 3
 Staring
- domination of PNS
 Slow, rhythmic breathing
- body process slows further
 Recite, sing
- difficult to arouse
 Listening to music

3. Techniques to promote relaxation

STAGE 4
 Conventional Methods
- deep sleep
-relax muscles
- difficult to arouse
-listen to music - decrease BP, RR, PR, Temp

-guided imagery - decrease metabolism, brain waves, muscles

relaxed
-meditation, yoga

 Analgesics
2. REM (RAPID EYE MOVEMENT) STAGE
 Placebo
(increase in systhetic processes in the brain)

Eyes appear to roll

REST AND SLEEP
Close to wakefulness but difficult to arouse

Dreamstate of sleep
REST
SNS dominates
- diminished state of activity, calmness, relaxation
without emotional stress; freedom from anxiety Flow of gastric acid increases

Sleeper’s reviews the day’s events and processes

and stores information
SLEEP

-state of consciousness in which the individual’s

perception and reaction to the environment are decreased Nursing interventions to Promote Sleep

1. Promote comfort and relaxation

>RETICULAR ACTIVATIONG SYSTEM: maintains wakefulness 2. Create a restful environment

>Serotonin: neurotransmitter associated with sleep 3. Attend to bedtime rituals

4. Provide adequate exercise atleast 2 hours before

sleep to enhance NREM
Stages of Sleep
5. Encourage intake of high Protein food. It contains
Tryptophan which enhances sleep
1. NREM (NON-RAPID EYE MOVEMENT) STAGE
6. Avoid caffeine and alcohol in the evening
(body restoration)
7. Go to bed when sleepy
STAGE 1
8. Use the bed mainly for sleep
- very light sleep

- drowsy, relaxed

- readily awakened
Common Sleep Disorders
1. Insomnia

-difficulty in falling asleep

-premature awakening

2. Hypersomnia

-excessive sleep

-r/t psychological problems, CNS damage

3. Narcolepsy

- sleep attack

- overwhelming sleepiness

- REM uncontrolled

4. Sleep Apnea

-periodic cessation of breathing during asleep

characterized by snoring

5. Parasomnias

Somnambolism - sleep walking

Night Terrors - child bolts upright in bed, shakes,

screams, appears pale and terrified

Nocturnal Enuresis- bed wetting

Soliloquy - Sleep talking

Nocturnal Erections - “wet dreams”

Bruxism - clenching and grinding of teeth during

sleep