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Nursing Skills I Assisting with Basic Client Needs Reference: DeWit Chapter 22, 25, 26, 27 I.

Data Collection A. Body Fluids 1. 60% of adults total body weight = fluid a. Variations with age or body mass in a infant it is higher it is 75% of their body is water or fluid, it is higher in men then it is in women, it is lower in the elderly about 40-50% and is lower in obese people adipose tissue does not store water

b.

Why sudden or severe fluid loss is critical in: children, have a high need for fluid or water they can lose fluid and it will have a impact quickly the elderly their fluid is less than that of a average adult and the obese

2.

Fluid Compartments a. Intracellular (60%) inside the cells b. Extracellular (25%) 1) Interstitial surrounding the cells
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Intravascular fluid that is found in blood or plasma

3)

Secretions/Excretions this would include digestive juices it also includes bile and spinal fluid. There is also lymphatic fluid

3.

Intake a. Oral the average intake is 2000-3000cc/ml

SKILLS-BASIC NEEDS OUTLINE-2010

1) Amounts liquids about 1500cc/ml we get about 800cc/ml from food and metabolism accounts for about 200cc/ml 2) Types a) Clear liquid diet would include any fluid we can see threw they will supply water and carbohydrates broth jello tea sprite b) Full liquid diet includes something that would liquefy at room temperature ice cream sherbert milk coffee cream soups

b.

Intravenous we have a variety of IV solutions that contain fluid electrolytes and nutritional replacement

c.

Gastric Gavage (tube feedings) there are a variety of supplements of tube feedings you can get some ensure some are diabetic formulas and it all depends on what the patient needs.

4.

Output Sources urine, the normal range for urine is 1000-2000cc/ml sweat is another source of output is around 500cc/ml feces accounts for 200cc/ml and the lungs you lose about 400cc/ml on average per day
a.

b. Abnormal sources include vomiting diarrhea diaphoresis (excessive sweating) wounds from there drainage, suctioning such as a NG tube, and hemorrhage

c. Influences on fluid loss weather, especially humidity disease, fever, surgery, stress, activity, medications and the metabolic rate.

d. Obligatory/Insensible loss or senseless loss breathing, sweat, feces, you have no control over this loss if NPO they need 1500cc/ml of fluid per day in an adult it leads to dehydration

SKILLS-BASIC NEEDS OUTLINE-2010

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Balance if intake equals output we maintain the internal environment the sense of homeostasis and the sense of survival if it is not balanced your body will try to compensate for it for instance say you become dehydrated your body will secrete a antidiretic to help with the dehydration

6.

Terminology a. Diaphoresis excessive sweating profuse sweating


b.

Dehydration is a condition where the output is greater than the intake it is the most frequent cause of fluid imbalance

c.

Anuria a lack of urine production this maybe normal for someone on kidney dialysis Oliguria a decreased amount of urine they may go frequently but not enough Polyuria excessive urination sign of diabetes

d.

e.

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S/S of Fluid imbalances include weight loss or gain that is why daily weights are important again vital signs include elevated temp changes in the BP it will decrease if you are having edema BP will increase changes in our pulse rate and characteristics of the pulse also urine output changes in appears

Also temperature and pitting edema you want to check all pulses start at the feet and work your way up there sensory state are they irritable or confused could indicate dehydration and their strength

SKILLS-BASIC NEEDS OUTLINE-2010

A. Nutrition 1. Nutrients a. Identified carbohydrates proteins, fats, vitamins and minerals, and water

b.

Nutrients essential for: growth, healing, and for energy Malnutrition is a decreased amount of nutrients or food that interferes with growth energy and healing Hospital Malnourishment includes might be the effects of disease it could be the patient could be suffering anorexia it could be related to anxiety, medications, NPO, and it also could be a knowledge deficit or noncompliance.

c.

d.

e.

Energy Sources 1) Food for energy it will break down carbs. To glucose to provide energy
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Glycogen is stored in the liver and the muscles you have between 12 and 48 hours of glycogen stored in the liver Break down body fats and proteins for energy this will then result in weight loss also in acids in the urine, and it will also result in delayed healing it will also result at increased risk of infection

3)

f.

Diets
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Purposes of different types treating disease it could be the promotion of health or it could be to prepare for a exam, Types of diets a clear liquid diet a full liquid diet, a soft diet, a regular or house diet or also called general diet, diabetic diet it is like a carb counting diet, bland diet, fat restricted, protein restricted, American heart association diet, a caffeine free diet, and a brat diet it is for a child that has a lot of diarrhea includes bananas toast rice and apple sauce

2)

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Electrolytes a. defined as minerals and chemicals that when in solution carry a electrical charge b. all body fluids contain substances contained salt break down all substances Importance they maintain water distribution it also maintains nerve and muscle function electrolytes also maintain cell activities the internal environment requires a stable amount of fluids and electrolytes
b.

SKILLS-BASIC NEEDS OUTLINE-2010

c. Control by kidney excretion and reabsorbtion most important are sodium and potassium B. Elimination 1. Normal Function/Terminology a. Amounts of urination people will go 1000-2000cc/ml a day 1) females bladder need to fill with about 250 cc/ml before you feel the need tovoid or urinate on average

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males bladder needs to fill with 300-500cc/ml before you feel the need tovoid or urinate on average

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Terms
1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11)

void - urinate micturate all means to need to pee frequency- how often a person voids nocturia- voiding at night incontinence- inability to control retention-a failure to empty the bladder urgency- you have to go now catamenia- menses when you urinate on your period defecation- is a bowel movement flatus- gas feces-stool diarrhea-frequent rapid watery stool

c.

Voluntary control = learned ability to do so we also have physical ability to control it things that can impact our control are illness, medications, antibiotics because it can cause diarrhea, anxiety, decrease mental awareness, not a social topic something you dont talk about in public or to family or friends the general public hesitate to ask for assistance because it is embarrassing so make people feel accepted, anticipate there needs such as offering the bed pan

d.

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2.

Urine a. Characteristics it is normally clear, normally urine is staw or amber in color, they say that urine normally has a faintly aromatic oder, it has a slightly acid pH and normally the urine in the body is sterile b. Minimum urine amount to eliminate waste 600cc/ml in a 24 hour period to get rid of waste your patient needs to eliminate 30cc/ml a hour

3.
a.

Bowel Elimination Intestine Functions 1) absorption of nutrients, electrolytes and water


2) waste removal of the byproduct of digestion it is the removal of un-digestable food

stuff such as corn peanuts water, and also GI tract matter this would include cells and bacteria and secretion. b. Feces 1) Normal
a) b) c)

contents is 75% water and is 25% solid color is brown and that is due to the bile odor it is caused by bacterial action

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Abnormal Stool a) Color 1] meds can change the color iron will turn stool black/dark green it will be kind of tarry and sticky it can also cause constipation, 2] bleeding is reported immediately bright red is from the rectum which could be hemorrhoids it could be because they strain and it could be from colitis and could be cancer Bleeding can also be a dark color or black color in the stool this is a bleed from the upper GI tract Henoccult blood is blood we cannot see so they do that to see if there is blood present 3] clay/pale white this can indicate if we have a absence of bile 4] chalky white that could be barium 5] Light tan could indicate undigested fat 6] Dietary tube feeding the stool will be yellow if it is green it could be because they are getting to much clorophile if it is dark they could eat to much beets b) mucus: this indicates irritation or inflammation in the intestines

SKILLS-BASIC NEEDS OUTLINE-2010

c) Pus: that could indicate we have a infected would in the intestines purlant means pussy consistency it can be liquid which is diarrhea if it is pencil thin then you could have a bowel obstruction someone that has a fecal impaction can get liquid around it but nothing else Parasitic worms can have worms in the stool

c. Incontinency of feces physical causes skin breakdown psychological include loss of self respect, embarrassment, anxiety II. Basic Needs- Contributing to the Nursing Diagnosis A. Nutrition Metabolic 1. Fluid Volume Excess that just means they have too much fluid in the body it could be heart disease it could be kidney disease it could be to much sodium in the diet
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Fluid Volume Deficit not enough fluid because of diahrrea, vomiting, excessive urination, medication Altered Nutrition could be related to medications, recent surgery Self Care Deficit, Feeding that could be related to stroke recent brain injury recent trama recent surgery

3. 4.

B. Elimination 1. Self Care Deficit, Toileting could be related to brain injury, they are on bed rest, they had a fall, surgery, cant get up III. Nursing Measures A. Hydration 1. I & O c a. Provide/encourage/restrict fluids it will be according to your doctors orders and patients needs follow what the doctor writes if there is a restriction and encourage fluids if possible for patients that have a cath, drain, suction, and patients that are on diuretics

b. Pt teaching r/t I & O- you want to explain the measurements you want to record all the liquids a patient takes and include all water and ice chips, if they are a independent patient make sure you use a hat to measure the output C. record all fluid losses ( qh q8h) Urine Wound vac every 1-8 hours when they use the bathroom emises, total it once a shift or more if its orders and make sure you chart it there will be a area on the chart d. Maintain Accurate I & 0 records this is a nursing responsibility meaning it is not the patients responsibility or dietaries responsibility one of the nurses main responsibilities to help maintain normal fluid and electrolyte balance especially post-op patients
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2. Measures for Fluid Imbalances 1) Dehydration is the rapid loss of fluids it is the most frequent cause of fluid imbalance the a. rapid loss signs and symptoms would be skin that is cold and clammy they will have a increase pulse rate, it might be light to palpate the blood pressure goes down, apprehension, oligeuria, and confusion b.) Slower loss would include a elevated temperature, they will be flush, the urine is concentrated it will be a darker color and will smell more a decreased amount of urine less then 500ml/cc in 24 hours, weight loss, thirst, decreased skin turgor, elevated hemoglobin, muscle weakness and cramps, its because you sweat to much and didnt replace b. Edema 1) Defined as excess fluid in the interstical spaces, weight gain, puffy eye lids, sweel can be localized meaning just in feet or ankles, there is also dependent edema means it depends on position, if they are laying on their back they can get edema in there back move them and it gets better, anasarca edema is generalized edema means they are swollen all over, this fluid is trapped so you get some of the signs and symptoms of dehydration
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s/s confusion, you also measure the specific gravity 1.010-1.025 is the normal range for specific gravity it measures the weight of urine compared to the weight of water. You have a decreased hemoglobin with edema,

c.

Ascites ascites fluid accumulates in the peritoneal cavity, weight gain because retaining fluid in the abdomen, also distension, they will have dyspnea, we will also measure abdominal girth measurements the patient will be on there back

d.

Fluid overload 1) cause: diseased kidneys, cardiac disease, and someone that is receiving to many fluids to fast,

2)

s/s: pulmonary edema if this they will be short of breath, the lung sound you will hear is rails or crackles, and also congestion and peripheral edema, we have to make sure we turn these patients every two hours

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B. Nutrition 1. Serving Trays A. preparation begins with preparation of the patient offer the bed pan or for them to go to the bathroom assist with washing there hands and there face , oral care brushing their teeth and mouth washing, remove distracting articles such as urinal, emesis basin, remove unpleasant odors, clear the bedside table, avoid unpleasant treatment prior to the meal B. Positioning: we need to our patient comfortable, sitting up, some like to be sitting at the side of the bed, some like to sit at the bedside chair, also laying on there side, dorsal recumbent which is on their back with knees flexed, monitor side laying and back laying more frequent C.. Serving trays check their diet make sure you know what diet is ordered make sure you know if they are on a holding order, make sure you know if they are NPO, make sure it is correct diet again and make sure they have everything they need, make sure you deliver it promptly so it is still hot or cold, make sure you identify the patient name and the tray, assist as need such as taking the lid off cutting of food opening milk cartons, D.. follow-up allow them enough time to eat dont rush them and if you want to talk make it light conversation check and record I & Os and record the percentage that they eat if they have a calorie count document any problems with there eating if they refused to eat ask them why they refused to eat if it was pain, they didnt like the food, if they had difficulty chewing or swallowing 2. Feeding Clients a. Who to feed elderly and if they are handicap by non-use of there hands, and sometimes forgetful people b. Emotional response to being fed are varied this could include embarrassment, they may feel like a burden, but then again they may enjoy the company c. Procedure cut the food into small pieces, you want to feed them slowly and in small amounts, also ask them how they like to eat such as do you like to eat all of one thing first, or ask what they want off of the plate first. Allow them to do thing and what they are able for them selves

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d. Adaptations for a blind client you need to be careful with the blind client tell them the positions of the food on the table such as you peas are at twelve oclock and so on and let them know where the hot liquid or food is so they wont burn themselves

C. Elimination Universal Precautions 1. Measurement: Urine a. Amounts 1oz = 30 ml or 30 cc, minimally you need to have 30 output per hour, 24 hour range is 1000-2000ml the minimum amount is 600 ml in 24 hour
b.

Procedure we are going to use a graduated cup we are going to use a urinal another way we can measure speic hat which is the hat on top of the toilet at the hospital read the amount is while It is on a flat level surface note the urine characteristics, color smell odor, blood or any kind of seta mit, you also what to empty it into the hopper also rinse your measuring device also follow threw with your measurements and the characteristics, if dark increase fluids if you can Considerations: want to offer toileting at regular intervals this helps us to establish a routine for incontint patients make sure the time is consistent and make sure you think about positioning and privacy, watch your non-verbal meaning watch your face such as how bad it smells incontinents is the number one reason for admission into the nursing home dont refer to it as a diaper, activity, fiber and fruit juices help with constipation
c.

2.

Procedures with Bedpan a. Types of bedpans 1) reusable are stainless steal we can serialize these they are meant to be reused and they are very cold to sit on at first
2)

disposable we reuse them for the patient while they are admitted and throw it away when the patient is discharged fracture pan

3)

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b.

Methods of Assisting Pt on/off 1) Pt Assist place the patient in a semi fowlers position we can put powder and on the edge of the bed pan so there is less friction have the patient flex there legs and lift there buttocks off the bed the open rim is to the front once you help your patient on the bed pan please wash hands for 1 minute and also pull thighs apart a little bit in case they are sticking together
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Helpless patient you want the bed flat and the patient rolled to there side place the pan into position and hold it in place until they roll in from of it once you have the pan in place elevate the head of the bed you want to check the position of the bed pan Removal while you roll the patient to there side hold the bed pan so it will not roll with them wipe them clean and dry and in a female wipe front to back you will empty rinse it out and wash your hands Points to be observed these include patient comfort normally people are more comfortable if the head of the bed is elevated make sure you know the doctors orders before positioning and take a look at them make sure everything is the way it should be make sure call light in reach also have toilet paper at the bedside make sure you allow for privacy ALWAYS WEAR GLOVES AND WASH HANDS 1 MIN make sure you record the amounts as needed

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4)

3. Procedures with Urinal a. Use we like to use it with male patients we also like to use it when we need to measure the urine
b.

Positioning they can use the urinal lying down the most comfortable position is standing they can use the urinal if they are sitting or if they are laying down and we put them on every two hours sometimes if they do not say they need to go ever Considerations the nurses responsibility depends on the patient sometimes this is a fine line they say they cant hold the urinal even thought they say they can hold it tell them you need to measure it so they will use the urinal when you handle the urinal wear gloves allow for privacy if they like to stand they may need our assistance on standing dont take
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c.

SKILLS-BASIC NEEDS OUTLINE-2010

there word for it and you need the handle upward make sure the penis is inserted all the way so the urine goes in the urinal act matter of fact dont act grossed out by this. When they are done we need to measure the output they need to wash there hands when they are done so help them with that

3.

Measures to Promote Voiding a. s/s need to void restlessness distended bladder you can palpate the bladder they will also complain of supra pubic pressure or pain
b.

Measures to promote voiding include privacy make sure they are in a natural position, make sure we monitor their intake and monitor fluids as needed give them a glass of water and give them a time frame to drink it in if it is a female you can pour water over the female anatomy to maybe help them go

IV.

Evaluation

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