URINARY AND BOWEL ELIMINATION
urination
URINARY ELIMINATIONN
THE URINARY BLADDER
PHYSIOLOGY OF URINARY ELIMINNATION
URINARY ELIMINATION (voiding, urination)
The KIDNEYS form the urine.
The URETERS carry urine to the bladder.
The BLADDER acts as a reservoir for the
urine.
The URETHRA is the passageway for the
urine to exit the body
- both the RENAL PELVIS and URETERS consist
primarily of smooth muscle
PERISTALSIS (muscular contraction) moves urine from
the upper to the lower urinary tract.
- Occurs during the prolonged phases of Bladder
filling and storage
FACTORS AFFECTING URINATION
1. DEVELOPMENTAL CONSIDERATIONS
- From child to adult, difference in frequency or
2. FOOD AND FLUID INTAKE
- More food, more elimination and vice versa
3. PSYCHOLOGICAL VAARIABLES
4. ACTIVITY AND MUSCLE TONE
- More active, better elimination
5. PATHOLOGIC CONDITIONS
6. MEDICATIONS
7. SURGICAL AND DIAGNOSTIC PROCEDURES
MEDICATIONS AFFECTING COLOR OF URINE
a. ANTICOAGULANTS (red)
b. DIURETICS (pale yellow)
c. PYRIDIUM (orange to orange-red)
d. ELAVIIL (green or blue-green)
e. LEVODOPA (brown or black)
ALTERED URINE PRODUCTION
POLYURIA - refers to the production of abnormally large
amount of urine by the kidneys
OLIGURIA - low urine output, usually 500 ml a day or 30
ml per hour for an adult
ANURIA - refers to a lack of urine production
ALTERED URINARY ELIMINATION
- Frequency and Nocturia
Frequency is voiding at frequent intervals (more than 4
-6 times per day)
Nocturia is voiding two or more times at night
- Urgency is the sudden strong desire to void
- Dysuria means voiding that is either painful or
difficult
- Enuresis is involuntary urination in children
beyond the age when voluntary bladder control
is normally acquired, usually 4 or 5 years of age.
- Urinary incontinence or involuntary urination is
a temporary or permanent inability of the
external sphincter muscles to control the flow
of urine from the bladder
- Urinary Retention is the accumulation of urine
in the bladder and inability of the bladder to
empty itself.
SELECTED FACTORS ASSOCIATED WITH ALTERED
URINARY ELIMINATION
PATTERN SELECTED ASSOCIATED
FACTORS
POLYURIA Ingestion of fluids
containing caffeine or
alcohol
 Prescribed diuretic Lack of privacy or other
Presence of thirst, factors inhibiting
dehydration, and weight micturition
loss
History of diabetes CHARACTERISTICS OF NORMAL AND ABNORMAL URINE
mellitus, diabetes
insipidus, or kidney
disease Characteris Normal Abnormal Nursing
OLIGURIA, ANURIA Decrease in fluid intake tic Considerati
Signs of dehydration on
Presence of hypotension, Amount in 1,200-1,500 Under 1.200 Urinary
shock, or heart failure 24hrs mL mL output
History of kidney disease (adult) A large normally is
Signs of renal failure such amount approximat
as elevated blood urea over intake ely equal to
nitrogen (BUN) and fluid intake.
serum, creatinine, Output of
edema, hypertension less than
FREQUENY OF NOTURIA Pregnancy 30mL/hr
Increase in fluid intake may
Urinary tract infection indicate
URGENY Presence of psychologic decreased
stress blood flow
Urinary tract infection to the
DYSURIA Urinary tract kidneys and
inflammation, infection, should be
or injury immediatel
Hesitancy, hematuria, y reported.
pyuria (pus in the urine), Color, Straw, Dark amber Concentrat
and frequency clarity amber, Cloudy ed urine is
ENURESIS Family history of enuresis Transparent Dark orange darker in
Difficult access to toilet Red or dark color.
facilities brown Dilute urine
Home stresses Mucous may appear
INCONTINENCE Bladder inflammation or plugs, almost
other disease viscid, thick clear or
Difficulties in very pale
independent toileting yellow.
(mobility, impairment) Some foods
Leakage when coughing, and drugs
laughing, sneezing may color
Cognitive impairment urine. Red
RETENTION Distended bladder on blood cells
palpation and percussion in the urine
Associated signs, such as (hematuria)
pubic discomfort, may be
restlessness, frequency evident as
and small urine volume pink, bright
Recent anesthesia red, or
Recent perineal surgery rusty
Presence of perineal brown
swelling urine.
Medications prescribed Menstrual
 bleeding urine may
can also indicate a
color urine state of
but should alkalosis,
not be urinary
confused tract
with infection,
hematuria. or a diet
White high in
blood cells, fruits and
bacteria, vegetables.
pus, or More acidic
contaminan urine (low
ts such as pH) is
prostatic found in
fluid, starvation,
sperm, or diarrhea, or
vaginal with a diet
drainage high in
may cause protein
cloudy food or
urine. cranberries.
Odor Faint Offensive Some foods Specific 1.010-1.025 Over 1.025 Concentrat
aromatic (e.g., gravity Under 1.010 ed urine
asparagus) has a
cause a higher
musty specific
odor; gravity;
infected diluted
urine can urine has a
have a fetid lower
odor; urine specific
high in gravity.
glucose has Glucose Not present Present Glucose in
a sweet the urine
odor. indicates
Sterility No Microorgani Urine high blood
microorganis sm present specimens glucose
ms present may be levels (>
contaminat 180 mg/dL)
ed by and may be
bacteria indicative
from the of
perineum undiagnose
during d or
collection. uncontrolle
pH 4.5-8 Over 8 Freshly d diabetes
Under 4.5 voided mellitus.
urine is
normally
somewhat
acidic,
Alkaline
Ketone Not present Present Ketones, - how would you describe your urine in terms of
bodies the end color, clarity (clear, transparent, or cloudy), and
(acetone) product of odor (faint or strong)?
the URINARY ELIMINATION PROBLEMS
breakdown - what problems have you had or do you now
of fatty have with passing your urine?
acids, are
- passage of small amounts of urine?
not
- voiding at intervals that are more frequent?
normally
present in - trouble getting to the bathroom in time of
the urine. feeling an urgent need to void?
They may - painful voiding?
be present - difficulty starting urine stream?
in the urine - frequent dribbling of urine of feeling of bladder
of clients fullness associated with voiding small amounts
who have of urine?
uncontrolle - reduced force of stream?
d diabetes - accidental leakage of urine? if so, when does
mellitus, this occur (e.g., when coughing, laughing, or
are in a sneezing; at night; during the day)?
state of
- past urinary tract illness such as infection of the
starvation,
kidney, bladder or urethra; urinary calculi;
or who
have surgery of kidney, ureters or bladder
ingested FACTORS INFLUENCING URINARY ELIMINATION
excessive - MEDICATIONS do you take any medication
amounts of that could increase urinary output or cause
aspirin. retention of urine? note specific medication and
Blood Nor present Occult Blood may dosage
(microscopi be present - FLUID INTAKE what amount and kind of fluid
c) in the urine do you take each day (e.g. 6 glasses of water, 2
Bright red of clients cups of coffee, 3 cola drinks with or without
who have caffeine)?
urinary - ENVIRONMENTAL FACTORS do you have any
tract
problems with toileting (mobility, removing
infection,
clothing, toilet seat to low, facility without grab
kidney
disease, or bar)?
bleeding - STRESS are you experiencing any major
from the stress? if so, what are the stressors? Do you
urinary think these affect your urinary pattern?
tract. - DISEASE have you had or do you have any
illnesses that may affect urinary function such
as hypertension, heart disease, neurologic
ASSESSENT INTERVIEW URINARY ELIMINATION
disease, cancer, prostatic enlargement,
VOIDING PATTERN
diabetes?
- how many times do you urinate during a 24-
- DIAGNOSTIC PROCEDURES have you recently
hour period?
had a cystoscopy or anesthetic?
- has this pattern changed recently?
PRACTICE GUIDELINES maintaining normal voiding
- do you need to get out of bed to void at night?
habits
how often?
POSITIONING
DESCRIPTION OF URINE AND ANY CHANGES
 - assist the client to a normal position for voiding;
standing for male clients; for female clients,
squatting or leaning slightly forward when
sitting. These positions enhance movement of
urine through the tract by gravity.
- If the client is unable to ambulate to the
lavatory, use a bed-side commode for females
and a urinal for males standing at bedside
- if necessary, encourage the client to push over
the pubic area with the hands or to lean
forward to increase intra-abdominal pressure
and external pressure on the bladder
RELAXATION
- provide privacy for the client. many people
cannot void in the presence of another person
- allow the client sufficient time to void
- suggest the client read or listen to music
- provide sensory stimuli that may help the client
relax. pour warm water over the perineum of aa
female client of have the client sit in a warm
bath to promote muscle relaxation. Applying a
hot water bath to promote muscle relaxation.
applying a hot water bottle to the lower
abdomen of both mean and women may also
foster muscle relaxation
- turn on running water within hearing distance
of the client to stimulate the voiding reflex and
to mask the sound of voiding for people who
find this embarrassing
- provide ordered analgesics and emotional
support to relieve physical and emotional
discomfort to decrease muscle tension
TIMING
- assist client who have the urge to void
immediately. delays only increase the difficulty
in starting to void and the desire to void may
pass
- offer toileting assistance to the client at usual
times of voiding for example, on awakening,
before or after meals and at bedtime.
FOR BED-CONFINED CLIENTS
- warm the bedpan. A cold bedpan may prompt
contraction of the perineal muscles and
inhibiting voiding
- -
position, place a small pillow or roiled towel at
the small of the back to increase physical
support and comfort, and have the client flex
the hips and knees. This position stimulates the
normal voiding position as closely as possible
NURSING DIAGNOSES
- Impaired Urinary Elimination
- Stress Urinary Incontinence
- Reflex Urinary Incontinence
- Urge Urinary Incontinence
- Functional Urinary Incontinence
- Urinary Retention
- Overflow Urinary Incontinence
- Total urinary Incontinence
OTHER NURSING DIAGNOSES
- Low Self-Esteem
- Deficient Knowledge
- Risk for Infection
- Risk for Impaired Skin Integrity
- Toileting Self-Care Deficit
OUTCOME IDENTIFICATION AND PLANNING
- Target outcomes center around restoring and
maintaining regular eliminations habits and
preventing complications
PLANNING
- Maintain or restore a normal voiding pattern
- Regain normal urine output
- Prevent associated risks such as infection, skin
breakdown, fluid and electrolyte imbalance, and
lowered self-esteem
- Perform toilet activities independently with or
without assistive devices
- Contain urine with the appropriate device
- Maintain skin integrity
PLANNED PATIENT GOALS
- Urine output about equal to fluid intake
- Maintain fluid and electrolyte balance
- Empty bladder completely at regular intervals
- Report ease of voiding
- Maintain skin integrity
MAINTANING NORMAL VOIDING HABITS
- SCHEDULE
- PRIVACY
- POSITION
HYGIENE
IMPLEMENTATION
MAINTAIN NORMAL URINARY ELIMINATION
- Promoting fluid intake
 - maintaining normal voiding habits
- assisting with toileting
PREVENTING URINARY TRACT INFECTIONS
- avoid tight- fitting pants or other clothing that
creates irritation in the urethra
- wear cotton rather than nylon underclothes
- Girls and women should always wipe the
perineal area from front to back following
urination or defecation
- Take showers rather than bath if recurrent
urinary infections are a problem
MANAGING URINARY INCONTINENCE
- Continence bladder training (habit training,
prompted voiding)
- Pelvic muscles exercises
- Maintaining skin integrity
Application of external draining device (condom -type
catheter device)
IMPLEMENTATION
Maintaining elimination health
- Fluid intake
- Diet
- Lifestyle and prevention
LIFESTYLE AND PREVENTION
- Pelvic muscle exercise
- Bladder training urge continence
- Management of urinary retention
- Management of functional urinary incontinence
- Environmental modifications
- Perform catheterization
- Intermittent catheterization
COMPLEMENTARY THERAPIES
- Holistic approach to effective elimination of
waste products and toxins
- Diuretics
- Antimicrobials
- Antiseptics
- Stimulants and cathartics
EVALUATION
- Clients level of maintenance or restoration of
elimination patterns and return to an
appropriate level of independence
- Prevention of skin breakdown and infection
- Client understanding of procedure and self-care
- Evaluating effectiveness of plan
- Maintain fluid, electrolyte, and acid-base
balance
- Empty bladder completely at regular intervals
with no discomfort
- Provide care for urinary diversion and not when
to notify physician
- Develop a plan to modify factors contributing to
problem
- Correct urinary unhealthy habits
BOWEL ELIMINATION
FACTORS AFFECTING BOWEL ELIMINATION
- Development
- Diet
- Activity
- Psychologic factors
- Defecation habits
- Medications
- Diagnostic procedures
- Anesthesia and surgery
- Pathologic conditions
- Pain
ASSESSMENT INTERVIEW fecal elimination
DEFECATION PATTERN
- when do you usually have a bowel movement?
- has this pattern changes recently?
DESCRIPTION OF FECES AND ANY CHANGES
- have you noticed any changes in the color,
texture (hard, soft, watery)? shape, or odor of
your stool recently?
FECAL ELIMINATION PROBLEMS
- what problems have you had or do you now
have with your bowel movements
(constipation, diarrhea, excessive flatulence,
seepage, or incontinence)?
- when and how often does it occur?
- what do you think causes it (food, fluids,
exercise, emotions, medications, disease
surgery)?
- what have you tried to solve the problem, and
how effective was it?
FACTORS INLFUENCING ELIMINATION
- use of elimination aids. what routines do you
follow to maintain your usual defecation
 pattern? do you use natural aids such as specific - is the passage of liquefied stool with increased
foods of fluid (e.g. a glass a hot lemon juice frequency and consistency
before breakfast), laxatives or enemas to MAJOR CAUSES OF DIARRHE
maintain elimination?
- DIET what foods do you believe affect CAUSE PHYSIOLOGIC EFFECT
PHYSIOLOGIC STRESS (e.g. Increased intestinal
defecation? what foods do you typically eat?
anxiety) mobility and mucus
what foods do you avoid? do you take meals at
secretion
regular times? MEDICTIONS
- FLUID what amount and kind of fluid do you - antibiotics Inflammation and
take each day (e.g. 6 glasses of water, 2 cups of infection of mucosa due
coffee)? to overgrowth of
- EXERCISE what is your usual daily exercise pathogenic intestinal
pattern? (obtain specifics about exercise rather microorganisms
than asking whether it is sufficient; ideas of - iron Irritation of intestinal
what is sufficient vary among individuals) mucosa
- MEDICATIONS have you taken any - cathartics Irritation of intestinal
medications that could affect the intestinal tract mucosa
(e.g. iron antibiotics) ALLERGY TO FOOD, FLUID, Incomplete digestion of
DRUGS flood or fluid
- STRESS are you experiencing any stress? Do
you think this affects your defecation pattern?
INTOLERANCE OF FOOD Increased intestinal
how? OR LIQUID mobility and mucus
PRESENCE AND MANAGEMENT OF OSTOMY secretion
DISEASE OF THE COLON
- what is your usual routine with your colostomy/ e.g Reduced absorption of
ileostomy? - malabsorption fluids
- what problems, if any, do you have with it? syndrome Inflammation of the
- how can the nurses help you manage your - mucosa often leading to
colostomy/ ileostomy? ulcer formation
TEACHING: CLIENT CARE managing
FECAL ELIMINATION PROBLEMS diarrhea
1. CONSTIPATION - Drink at least 8 glasses of water per day to
- is the infrequent and difficult passage of prevent dehydration
hardened stool. - Ingest foods with sodium and potassium. Most
SAMPLE DEFINING CHARACTERISTICS FOR foods contain sodium. Potassium is found in
CONSTIPATION meats and many vegetables and fruits,
- decreased frequency of defecation especially tomatoes, potatoes, bananas,
- hard, dry, formed stools peaches and apricots
- straining at stool; painful defecation - increase foods containing soluble fiber such as
- reports of rectal fullness or pressure or oatmeal and skinless fruits and potatoes
incomplete bowel evacuation - avoid alcohol and beverages with caffeine,
- abdominal pain, cramps, or distention which aggravate the problem
- use of laxatives - limit foods containing insoluble fiber, such as
- decreased appetite whole-wheat and whole-grain breads and
- headache cereals and raw fruits and vegetables.
2. FECAL INCONTINENCE - limit fatty foods
- or Bowel Incontinence refers to the loss of - thoroughly clean and dry the perineal are after
voluntary ability to control fecal and gaseous passing stool to prevent skin irritation and
discharges through the anal sphincter breakdown. use soft toilet tissue to clean and
3. DIARRHEA dry the area, apply a moisture- barrier cream or
 ointment such as zinc oxide or petrolatum as - Bowel diversions
need - Ileostomy
- if possible, discontinue medications that cause - Colostomy
diarrhea
EVALUATION
- when diarrhea has stopped, reestablish normal
-
bowel flora by taking fermented dairy products,
elimination patterns and return to an
such as yogurt or buttermilk
appropriate level of independence
- Prevention of skin breakdown and infection
- Client understanding of procedure and self-care
4. FECAL IMPACTION
- bolus of hardened stool
- further slows colonic transit time and passage
of further fecal contents
- is a mass or collection of hardened feces in the
folds of the rectum
5. FLATULENCE
- Is the presence of excessive flatus in the
intestines and leads to stretching and inflation
of the intestines

NURSING DIAGNOSES
- Constipation
- Perceived constipation
- Diarrhea
- Bowel incontinence
- Risk for constipation
(use NANDA base on manifestation of the
client)

IMPLEMENTATION
LIFE STYLE AND PREVENTION

- Alcohol and tobacco use

- Stress management
- Weight reduction
- Elimination habits
- Positioning

ADMINISTER MEDICATIONS
- Over the counter prescription

ADMINISTER ENEMAS Enema is a solution introduced

into the rectum and large intestine.
- Cleanse the lower bowel
- Assist in evacuation
- Instill medication

INITIATE RECTAL STIMULATION

MONITOR ELIMINATION DIVERSION
- Urinary diversion
- Ileal conduit
- Continent urinary diversion
FLUIDS AND ELECTROLYTES

In good health, a delicate balanced of fluids, electrolytes, and acids and bases is maintained in the body.
This balance, or physiologic homeostasis, depends on multiple physiologic processes that regulate fluid
intake and output and the movement of water and the substances dissolved in it between the body
components.

BODY FLUIDS AND ELECROLYTES

The proportion of the human body composed of fluid is surprisingly large.
Water is vital to health and normal cellular function, serving as
A medium for metabolic reactions within cells
A transporter of nutrients, waste products, and other substances
A lubricant
An insulator and shock absorber
One means of regulating and maintaining body temperature

Distribution of Body Fluids

The body fluid is divided in to two major compartments, Intracellular and Extra cellular.
Intracellular Fluid (ICF) is found within the cells of the body. It constitutes approximately two thirds of
the body fluid in adults.
Extra cellular fluid (ECF) is found outside the cells and accounts for about one-third of total body fluids.
The two main compartments of ECF are intravascular and interstitial. Intravascular fluid, or plasma, is
found within the vascular system. Interstitial fluid surrounds the cells.

Composition of Body Fluids

Extracellular and intracellular fluids contain oxygen from the lungs, dissolved nutrients from the
gastrointestinal tract, excretory products of metabolism such as carbon dioxide, and charged particles
called ions.
Many salts dissociate in water, that is, break up, into electrically charged ions. The salt sodium chloride
breaks up into one ion of sodium (Na+) and one ion of chloride (CL¯). These charged particles are called
electrolytes because they are capable of conducting electricity. Ions that carry a positive charged are
called cations, and ions carry a negative charge are called anions. Examples of cations are Sodium (Na+),
potassium (K+), calcium (Ca²+), and magnesium (Mg²+). Examples of anions include chloride (CL¯),
bicarbonate HCO¯ p .

Movement of Body Fluids and Electrolytes

The methods by which electrolytes and other solutes move are osmosis, diffusion, filtration, and active
transport.
1. Osmosis is the movement of water across cell membranes, from the less concentrated solution
to the more concentrated solutions.
Solutes are substances dissolves in a solution. For example, when sugar is added to coffee, the
sugar is the solute.
Solvent is the component of a solution that can dissolve the solute. In the previous example,
coffee is the solvent for the sugar.
In the body, water is the solvent; the solvents include electrolytes, oxygen and carbon dioxide,
glucose, urea, amino acids, and proteins.

The concentration of solutes in body fluids is usually expressed as the osmolality. The term
tonicity may be used to refer to the osmolality of a solution. An isotonic solution has the same
osmolality as body fluids. Normal saline, 0.9% sodium chloride, is an isotonic solution. Hypertonic
solution have a higher osmolality than body fluids; 3%sodium chloride is hypertonic solution. Hypotonic
solution such as one-half normal saline (0.45% sodium chloride), by contrast, have a lower osmolality
than body fluids.
Osmotic pressure is the power of a solution to draw water across a semipermeable membrane.
When two solutions of different solute concentrations are separated by a semipermeable, the solution
of higher solute concentration exerts a higher osmotic pressure, drawing water across the membrane to
equalize the concentrations of the solutions.

1
 2. Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by
the random movement of the molecules.
3. Filtration is a process whereby fluid and solutes move together across a membrane from one
compartment to another. The movement is from an area of higher pressure to one of lower
pressure.
4. Active Transport. Substances can move across cell membranes from a less concentrated
solution to a more concentrated one by active transport. In active transport, a substance
combines with a carrier on the outside surface of the cell membrane.

Regulating Body Fluids

Fluid Intake
During periods of moderate activity at moderate temperature, the average adult drinks about 1,500 ml
per day but needs 2,500 ml per day, an additional 1,000 ml. The thirst mechanism is the primary
regulator of fluid intake. The thirst center is located in the hypothalamus of the brain.

Average Daily Fluid Intake for An Adult

SOURCE AMOUNT (ml)
Oral fluids 1,200 1,500
Water in foods 1,000
Water as by-product of Metabolism 200
Total 2,400 2,700

Fluid Output

routes of fluid output are:

1. Urine
2. Insensible loss through the skin as perspiration and through the lungs as water vapour in the
expired air.
3. Noticeable loss through the skin.
4. Loss through the intestines in feces

Factors affecting body fluids

Age
Gender and body size
Environmental temperature
Lifestyle

Maintaining Homeostasis
The volume and composition of body fluids is regulated through several homeostatic
mechanisms including kidneys (primary regulator of body fluids and electrolyte balance and they
regulate the volume and osmolality of ECF by regulating water and electrolyte excretion), endocrine
system, cardiovascular system, the lungs and the gastrointestinal system.

2
Regulating Electrolytes
Electrolytes, charged ions capable of conducting electricity, are present in all body fluids and fluid
compartments. Just as maintaining the fluid balance is vital to normal body function, so is maintaining
electrolyte balance. Electrolytes are important for
Maintaining fluid balance
Contributing to acid-based regulation
Facilitating enzymes reactions
Transmitting neuromuscular reactions

ACID-BASED BALANCE
An important part of regulating the chemical balance or homeostasis of body fluids is regulating their
acidity or alkalinity. An acid is a substance that releases hydrogen ions (H+) in solution. Bases or alkalis
have a low hydrogen ion concentration and can accept hydrogen ions in solution. The relative acidity or
alkalinity of a solution is measured as pH. The pH reflects the hydrogen ion concentration of the
solution: The higher the hydrogen ion concentration (and the more acidic the solution), the lower the
pH.

Regulation of Acid-Based Balance

Body fluids are maintained within a narrow range that is slightly alkaline. The normal pH of
arterial blood is between 7.35 and 7.45. Acids are continually produced during metabolism.
Several body systems, including buffers, the respiratory system, and the renal system, are
actively involved in maintaining the narrow pH range necessary for optional function.
Buffers help maintain acid-based balance by neutralizing excess acids or bases
The lungs and the kidneys help maintain a normal pH by either excreting or retaining acids and
bases.
Adding a strong acid to ECF can change this ratio as bicarbonate is depleted in neutralizing the
acid. When this happens, the pH drops, a condition called acidosis.
The ratio can also be upset by adding a strong base to ECF, depleting carbonic acid as it
combines with the base. In this case the pH rises and the client has alkalosis.

Disturbances in Fluid Volume, Electrolyte and Acid-Base Balances

Fluid volume deficits
Fluid volume excess
Dehydration
Overhydration

DIAGNOSING
NANDA includes the following diagnostic labels that relate to fluid and acid-base imbalances:
Deficient Fluid volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers
to dehydration, water loss alone without change in sodium.
Excess Fluid Volume: Increased isotonic fluid retention.
Risk for Imbalanced Fluid Volume: At risk for a decreased, increase, or rapid shift from one to the
other of intravascular, interstitial, and/or intracellular fluid. This refers to body loss, gain, or
both
Risk for Deficient Fluid Volume: At risk for experiencing vascular, cellular, or intracellular
dehydration.
Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at
the alveolar-capillary membrane.

Fluid, electrolyte, and acid-based imbalances affect many other body areas and as a consequence may
be the etiology of other nursing diagnoses, such as
Impaired Oral Mucous Membrane related to fluid volume deficit
Impaired Skin Integrity related to dehydration and/or edema
Decreased Cardiac Output related to hypovolemia and/or cardiac dysrhythmias secondary to
electrolyte imbalance (K+ or Mg²+)
Ineffective Tissue Perfusionrelated to decreased cardiac output secondary to fluid volume deficit
or edema
Activity Intolerance related to hypervolemia

3
 Risk for Injury related to calcium shift out of bones into extracellular fluids
Acute Confusion related to electrolyte Imbalance.

PLANNING
When planning care the nurse identifies nursing interventions that will assist the client to achieve these
broad goals:
Maintain or restore normal fluid balance
Maintain or restore normal balance of electrolytes in the intracellular and extracellular
compartments
Maintain or restore pulmonary ventilation and oxygenation
Prevent associated risk (tissue breakdown, decreased cardiac output, confusion, other
neurologic signs).

IMPLEMENTING
Promotion Wellness
Enteral Fluid and Electrolyte Replacement
Dietary Changes
Oral Electrolyte Supplements
Parenteral Fluid and Electrolyte Replacement

Evaluating
Using the overall goals identified in the planning stage of maintaining or restoring fluid balance,
maintaining or restoring pulmonary ventilation and oxygenation, maintaining or restoring normal
balance of electrolyte, and acid-based imbalances, the nurse collects data to evaluate the effectiveness
of interventions.

Body water distribution

45% to 75% of total weight
Fat: free of water
Replenish through ingestion

Regulators of fluid balance

Fluid and food intake and loss
Skin
Lungs
Gastrointestinal tract
Kidneys

4
OXYGENATION

Oxygen - a clear, odorless gas that constitutes approximately 21% of the air we breathe
- is necessary for all living cells. The absence of oxygen can lead to death. Although the
delivery of oxygen to body tissues is affected at least indirectly by all body systems, the
respiratory system is most directly involved in this process.
- Impaired function of the system significantly affect our ability to breath, transport gasses,
and participate in everyday activities.

Respiration - is the process of gas exchange between the individual and the environment. The process
of respiration involves three components:
1. Pulmonary ventilation or breathing; the movement of air between the atmosphere and the
alveoli of the lungs.
2. Diffusion of oxygen and carbon dioxide between the alveoli and pulmonary capillaries
3. Transport of oxygen from the lungs to the tissues, and carbon dioxide from the tissues to the
lungs.

Pulmonary Ventilation
Ventilation of the lungs is accomplished through the act of breathing: inspiration (inhalation) when air
flows into the lungs and expiration (exhalation) as air moves out of the lungs. Adequate ventilation
depends on several factors:
1. Clear airways
2. An intact central nervous system and respiratory center
3. An intact thoracic cavity capable of expanding and contracting
4. Adequate pulmonary compliance and recoil

The Breathing Process

Breathing begins with inhalation. This starts with the contraction of the diaphragm, which flattens on
contraction pulling the lungs down. The intercostal muscles contract to move the lungs up and out. The
contraction of these muscles increases the volume of the lungs, this reduces the air pressure in the lung
to below that of the external air. This pressure difference forces air to move into the lungs where gas
exchange occurs. The relaxation of the diaphragm and intercostals reduces the volume of the lungs
which therefore increases the air pressure inside the lung to that above the external air. This forces air
out of the lungs. The cycle is then repeated.

FACTORS AFFECTING RESPIRATORY FUNCTION

Factors that influence oxygenation affect the cardiovascular system as well as the respiratory system.
These factors include age, environment, lifestyle, health status, medications, and stress.
1. Age 5. Medications
2. Environment 6. Stress
3. Lifestyle
4. Health Status

ALTERATIONS IN RESPIRATORY FUNCTION

Three major alterations in respiration are hypoxia, altered breathing patterns, and obstructed or
partially obstructed airways.
1. Hypoxia is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the
tissues. It can be related to any of the parts of respiration ventilation, diffusion of gasses, or
transport of gases by the blood and can be caused by any condition that alters one or more
parts of the process.
Clinical manifestations of Hypoxia
- Rapid pulse
- Rapid, shallow respirations and dyspnea
- Increase restlessness or light-headedness
- Flaring of the nares
- Substernal or intercostals retractions
- Cyanosis
Hypoventilation, that is, inadequate alveolar ventilation, can lead to hypoxia. Hypoventilation
may occur because of diseases of the respiratory muscles, drugs, or anesthesia. With

5
 hypoventilation, carbon dioxide often accumulates in the blood, a condition called hypercarbia
(hypercapnia).

Hypoxia can also be develop when the diffusion of oxygen from alveoli into the
arterial blood decreases or can result from problems in the delivery of oxygen to the tissues. The
term hypoxemia refers to reduced oxygen in the blood.
Cyanosis (bluish discoloration of the skin, nailbeds, and mucus membranes, due to reduced
hemoglobin-oxygen saturation) may also be present when there is hypoxemia.

2. Altered Breathing Patterns

Breathing patterns refer to the rate, volume, rhythm, and relative ease or effort of respiration.
Normal respiration (eupnea) is quiet, rhythmic, and effortless.
Tachypnea (rapid rate) is seen with fevers, metabolic acidosis, pain, and with hypercapnia or
hypoxemia.
Bradypnea is an abnormally slow respiratory rate, which may be seen in clients who have taken
drugs such as morphine, who have metabolic alkalosis, or who have increased intracranial
pressure (e.g., from brain injuries).
Apnea is the cessation of breathing.
Hyperventilation, often called alveolar hyperventilation, is an increased movement of air
into and out of the lungs. During hyperventilation, the rate and depth of respirations increase,
and more Carbon dioxide is eliminated than is produced. One particular type of hyperventilation
that accompanies metabolic acidosis is , by which the body attempts to
compensate (give off excess body acids) by blowing off the carbon dioxide through deep and
rapid breathing.
Abnormal respiratory rhythms create an irregular breathing pattern. Two abnormal
respiratory rhythms are:
Cheyne-Stokes respirations. Marked rhythmic waxing and waning of respirations from
very deep from very shallow breathing and temporary apnea; common cause include
congestive heart failure, increased intracranial pressure, and drug overdose.
pirations. Shallow breaths interrupted by apnea; may be seen in
clients with central nervous system disorders.
Orthopnea is the inability to breath except in an upright or standing position.
Dyspnea is difficult or uncomfortable breathing.

3. Obstructed Airway
Stridor, a harsh, high-pitched sound, may be heard during inspiration. The client may have
altered arterial blood gas levels, restlessness, dyspnea, and adventitious breath sounds

DIAGNOSING
NANDA includes the following diagnostic labels for clients with oxygenation problems:
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
Activity Intolerance

The preceding nursing diagnoses may also be the etiology of several other nursing diagnoses. Example
follow:
Fatigue related to ineffective breathing pattern
Fear related to chronic disabling respiratory illness
Powerless related to inability to maintain independence in self-care activities because of
ineffective breathing pattern
Disturbed Sleep Pattern related to orthopnea and required Oxygen therapy
Social Isolation related to activity intolerance and inability to travel to usual social activities

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PLANNING
The overall goals for a client with oxygenation problems are to:
Maintain a patent airway
Improved comfort and ease of breathing
Maintain or improve pulmonary ventilation and oxygenation
Improve ability to participate in physical activities
Prevent risk associated with oxygenation problems such as skin and tissue breakdown, syncope,
acid-base imbalances, and feelings of hopelessness and social isolation.

IMPLEMENTING
1. Promoting Oxygenation
Interventions by the nurse to maintain the normal respirations of clients include:
Positioning the client to allow for maximum chest expansion
Encouraging or providing frequent changes in positioning
Encouraging ambulation
Implementing measures that promote comfort, such as giving pain medications
The semi- - chest expansion in bed-confined
clients, particularly dyspneic clients. The nurse also encourages clients to turn from side to side
frequently, so that alternate sides of the chest are permitted maximum expansion.

2. Deep Breathing and Coughing

The nurse facilitating respiratory functioning by encouraging deep breathing exercises and
coughing to remove secretions from the airways. When coughing raises secretions high enough, the
client may either expectorate (spit out) or swallow them. Swallowing the secretions is not harmful
but does not allow the nurse to view the secretions for documentation purposes or to obtain a
specimen for testing.
A commonly employed breathing exercise is abdominal (diaphragmatic) and pursed-lip
breathing. Abdominal breathing permits deep full breaths with little effort. Pursed-lip breathing
helps the client develop control over breathing. The pursed-lip create a resistance to the air flowing
out of the lungs, thereby prolonging exhalation and preventing airway collapse by maintaining
positive airway pressure. The client purses the lips as if about to whistle and breathes out slowly and
gently, tightening the abdominal muscles to exhale more effectively. The client usually inhales to a
count of 3 and exhales to a count of 7.

3. Hydration
Adequate hydration maintains the moisture of the respiratory mucous membranes. Normally,
respiratory tract secretions are thin and are therefore moved readily by ciliary action. However,
when the client is dehydrated or when the environment has a low humidity, the respiratory
secretions can become thick and tenacious. Fluid intake should be as great as the client can tolerate.
Humidifiers are devices that add water vapor to inspired air. Room humidifiers provide cool mist
to room air. Nebulizers are used to deliver humidity and medications. They are also used with
oxygen delivery system to provide moistened air directly to the client. Their purposes are to prevent
mucous membranes from drying and becoming irritated and to loosen secretions for easier
expectoration.

4. Medications
A number of types of medications can be used for clients with oxygenation problems:
Bronchodilators, an anti- inflammatory drugs, expectorants, and cough suppressants are some
medications that may be used to treat respiratory problems.

2
Bronchodilators reduce bronchospasm, opening tight or congested airways and facilitating
ventilation.
Expectorants ore liquid and easier to expectorate.
Guaifenesin is a common expectorant found in many prescription and non- prescription
cough syrups. When frequent or prolonged coughing interrupts sleep, a cough suppressant
such as codeine may be prescribed.
Other medications like Digitalis glycosides and Beta-adrenergic blocking agents

5. Incentive Spirometry
It is also referred to as sustained maximal inspiration devices (SMIs), measure the flow of air inhaled
through the mouthpiece and are used to:
Improve pulmonary ventilation
Counteract the effects of anaesthesia or hyperventilation
Loosen respiratory secretions
Facilitate respiratory gaseous exchange
Expand collapsed alveoli

6. Percussion, Vibration, and Postural Drainage

Percussion, vibration, and postural drainage (PVD) are dependent nursing functions performed

Percussion, sometimes called clapping, is forceful striking of the skin with cupped hands. Mechanical
percussion cups and vibrators are also available. When the hands are used, the fingers and thumbs
are held together and flexed slightly to form a cup, as one would scoop up water. Percussion over
congested lung area can mechanically dislodge tenacious secretions from the bronchial walls.
Cupped hands trap the air against the chest. The trapped air sets up vibrations through the chest
wall to the secretions

Vibrations is a series of vigorous quivering, produced by hands that are placed flat against the
is used after percussion to increase the turbulence of the exhaled air
and thus loosen thick secretions. It is often done alternately with percussion.

3
Postural Drainage is the drainage by gravity of secretions from various lung segments. Secretions
that remain in the lungs or respiratory airways promote bacterial growth and subsequent infection.
They also can obstruct the smaller airways and cause atelectasis. Secretions in the major airways,
such as the trachea and the right and left main bronchi, are usually coughed into the pharynx, where
they can be expectorated, swallowed, or effectively removed by suctioning.

7. Oxygen Therapy
Clients who have difficulty ventilating all areas of their lungs, those gas exchange is impaired, or
people with heart failure may require oxygen therapy to prevent hypoxia

4
SELF-CONCEPT

Self-concept -
and physical health. Individual with a positive self-concept are better able to develop and maintain
interpersonal relationships and resist psychologic and physical illness.
It involves all of the self-perception- appearance, values and beliefs- that influence behavior and are
referred to when using the words I or me. It is a complex idea that influences the following:
How one thinks, talks and acts
How one sees and treat another person
Choices one makes
Ability to give and receive love
Ability to take actions and to change things.

Dimensions of self-concept
1. Self-knowledge
abilities, nature and limitations.
2. Self-expectation what one expects of oneself; maybe realistic or unrealistic
3. Social self how a person is perceived by others and society
4. Social evaluation the appraisal of oneself in relationship to others, events, or situations

Self-awareness
perception of him or her. Thus, a nurse who is very self-aware has perceptions that are very congruent.

Components of Self-concept
1. Personal identity - is the conscious sense of individuality and uniqueness that is continually
evolving throughout life. It also includes beliefs and values, personality and character
2. Body image or the image of physical self. It is how a person perceives the size, appearance and
functioning of the body and its parts. It has both cognitive (knowledge of the material body) and
affective (sensation of the body like pain, fatigue, pleasure, physical movement). It also includes
clothing, make-up, hairstyle, jewelry and other things.
3. Role performance what a person does in a particular role in relation to the behaviours
expected of that role.
Role mastery performance of role behaviours that meet social expectation
Role development involves socialization into a particular role.
Role ambiguity unclear role expectations; people do not know what to do or how to
do it and are unable to predict the actions of others to their behaviour
Role strain a generalized state of frustration or anxiety experienced with the stress of
role conflict and ambiguity
Role conflicts a clash between the beliefs or behaviour imposed by two or more roles
fulfilled by one person.
4. Self-esteem the value one has for oneself.
a. Global self-esteem how much one likes oneself as a whole
b. Specific self-esteem how much one approves of a certain part of oneself.

Factors that Affect Self-Concept

1. Stage of development
2. Family and culture
3. Stressors
4. Resources
5. History of success and failure

Enhancing self-esteem
1. Encourage clients to appreciate the situation and express their feelings
2. Encourage clients to ask questions
3. Provide accurate information
4. Became aware of distortions, inappropriate or unrealistic standards and faulty labels in client s
speech
5. strengths

1
 6. Encourage client to express positive self-evaluation more than negative self-evaluation
7. Avoid criticism
8. Teach client to substitute negative self-talk with positive self-talk. Negative self-talk reinforces a
negative self-concept

STRESS and ADAPTATION

Stress is a condition in which the person experiences changes in the normal balance state.
Stressor is any event or stimulus that causes an individual to experience stress.

Sources of Stress
Internal stressors originate within a person (infection, feeling of depression)
External stressors originate outside the individual (move to another city, death in a family)
Developmental stressors occurs
Situational stressors unpredictable and may occur anytime during life (maybe positive or
negative)

Effects of stress
Physical
Emotional can produce negative or nonconstructive feelings about the self
Intellectual -solving abilities
Social
Spiritual

Indicators of stress
Physiologic indicators results from activation of the sympathetic and neuroendocrine systems
of the body
Clinical Manifestations of Stress
Pupils dilate to increase visual perception when serious threats to the body arise
Sweat production (diaphoresis) increases to control elevated body heat due to
increased metabolism.
Heart rate and cardiac output increase to transport nutrients and by-products of
metabolism more efficiently
Skin is pallid due to constriction of peripheral blood vessels, an effect of norepinephrine
Sodium and water retention increase due to release of mineralocorticoids, which
increases blood volume
Rate and depth of respirations increase due to dilation of the bronchioles, promoting
hyperventilation
Urinary output decreases
Mouth may be dry
Peristalsis of the intestines decreases, resulting in possible constipation and flatus
For serious threats, mental alertness improves
Muscle tension increases to prepare for rapid motor activity or defense
Blood sugar increases because of release of glucocorticoids and gluconeogenesis
Psychologic indicators
Anxiety and fear
Anger
Depression
Ego defense mechanism
Problem solving

Cognitive indicators thinking responses

Structuring
Self-control(discipline)
Suppression
Fantasy

2
Coping dealing with change- successfully or unsuccessfully. A coping strategy (coping mechanism) is a
natural or learned way of responding to a changing environment or specific problem or situation.

Types of coping strategies

Problem-focused coping refers to efforts to improve a situation by making changes or taking
some action
Emotion-focused coping includes thoughts and actions that relieve emotional stress. It does not
improve the situation but the person often feels better.
Long-term coping strategies can be constructive and realistic
Short-term coping strategies can reduce stress to a tolerable limit temporarily but are
ineffective ways to permanently deal with reality.

the stressful event. Three approaches to coping with stress are to alter the stressor, adapt to the
h a reappraisal of the
situation. There is never only one way to cope. Some people choose avoidance; others confront a
situation as a means of coping. Still others seek information or rely on religious beliefs.

Encouraging Health promotion Strategies

1. Exercise
2. Nutrition
3. Rest and sleep
4. Time management

SENSORY FUNCTIONING
Components of the Sensory Experience
1. Sensory reception is the process of receiving stimuli or data
a. External stimuli
Visual (sight)
Auditory (hearing)
Olfactory (smell)
Tactile (touch)
Gustatory (taste)
b. Internal stimuli
Kinesthetic refers to awareness of the position and movement of body parts
Visceral refers to any large organ within the body which may produce stimuli that
make a person aware of it
2. Sensory perception involves the conscious organization and translation of the data or stimuli
into meaningful information.
a. Stimulus an agent or act that stimulates a nerve receptor
b. Receptor a nerve cell acts as a receptor by converting the stimulus to a nerve impulse.
c. Impulse conduction the impulse travels along nerve pathway to the spinal cord or directly
to the brain.
d. Perception or awareness, and interpretation of stimuli, takes place in the brain, where
specialized brain cells interpret the nature and the quality of the sensory stimuli.

Awareness is the ability to perceive environmental stimuli and body reactions and to responds
appropriately through thought and action.

States of Awareness
STATE DESCRIPTION
Full consciousness Alert; oriented to time, place, person; understands verbal and written words
Disoriented Not oriented to time, place or person
Confused Reduce awareness, easily bewildered; poor memory, misinterprets stimuli;
impaired judgement
Somnolent Extreme drowsiness but will respond to stimuli
Semicomatose Can be aroused by extreme or repeated stimuli
Coma Will not respond to verbal stimuli

3
Sensory Alterations
1. Sensory deprivation insufficient sensory stimulation for a person to function
2. Sensory overload occurs when a person is unable to process or manage the amount or
intensity of sensory stimuli. These factors contribute to sensory overload:
Increased quantity or quality of internal stimuli (pain, dypsnea, anxiety)
Increased quantity or quality of external stimuli (noisy health care setting, contacts with
many strangers)
Inability to disregard stimuli selectively, perhaps as a result of nervous system
disturbances or medications that stimulate the arousal mechanism
3. Sensory deficits partial or complete impairment of any sensory organ

Sensory Deprivation: Clinical Manifestations

Excessive yawning, drowsiness, sleep
Decreased attention span, difficulty concentrating, decreased problem solving
Impaired memory
Periodic disorientation, general confusion, or nocturnal confusion
Preoccupation with somatic complaints, such as palpitations
Hallucinations or delusions
Crying, annoyance over small matters, depression
Apathy, emotional lability

Sensory Overload: Clinical Manifestations

Complaints of fatigue, sleeplessness
Irritability, anxiety, restlessness
Periodic or general disorientation
Reduced problem-solving ability and task performance
Increased muscle tension
Scattered attention and racing thoughts

Factors affecting sensory function

Developmental stage
Culture
Level of stress
Medication and illness
Lifestyle and personality

LOSS, GRIEVING and DEATH

LOSS an actual or potential situation in which something that is valued is changed or no longer
available

Types of loss
1. Actual loss can be recognized by others
2. Perceived loss experienced by one person but cannot be verified by others
2.1 Psychologic loss
3. Anticipatory loss experienced before the loss actually occurs
3.1 situational (loss of job, death of a child, etc.)
3.2 developmental (retirement from career, death of aged parents, etc.)

Sources of loss:
1. Loss of an aspect of oneself (body part, physiologic function or psychologic attribute)
2. Loss of an object external to oneself
a. Loss of inanimate objects that have importance in a person (ex. money, car, house)
b. Loss of animate (live) objects such as pets that provide love and companionship
3. Separation from familiar environment
4. Loss of a loved or valued person
Ex. Illness, divorce, separation, death

BEREAVEMENT the subjective response experienced by the surviving loved ones after the
death of a person with whom they have shared a significant relationship.

4
 MOURNING the behavioral process through which grief is eventually resolved or altered; It
is often influenced by culture, spiritual beliefs, and custom.

GRIEF the total response to the emotional experience related to loss. It is manifested in thoughts,
feelings and behavior associated with overwhelming distress or sorrow.

Types of Grief Responses

1. Abbreviated grief brief but genuinely felt
2. Anticipatory grief experience in advance of the event
3. Disenfranchised grief occurs when a person is unable to acknowledge the loss to other
persons. (Ex. Suicide, abortion, giving a child for adoption)
4. Complicated (pathologic) grief exists when the strategies to cope with the loss are
maladaptive (Ex. Sudden death, prior traumatic loss, strained relationship between survivor
and the deceased, etc.)
4.1 Unresolved or chronic grief extended in length and severity. Have difficulty expressing
the grief, may deny the loss, or may grieve beyond the expected time.
4.2 Inhibited grief many of the normal symptoms of grief are suppressed, and other effects,
including somatic, are experienced instead.
4.3 Delayed grief occurs when feelings are purposely or subconsciously suppressed until
much later time.
4.4 Exaggerated grief occurs when a survivor appears to be using dangerous activities as a
method to lessen the pain of grieving

Why talk about the grief process?

It effects everyone
It helps us, our patients, and their families to cope with stressful events
It is important to identify those who struggle with this process

Factors Influencing the Loss and Grief Responses

1. Age
2. Culture
3. Spiritual beliefs
4. Gender
5. Socio-economic status
6. Support system
7. Cause of loss or death

Stages of Grief
DENIAL
Involves patient and/or family members
Unable to handle reality
Helps person survive loss
Protects from being overwhelmed
Why the Denial?
Shock. Is this true? Are they gone?
Unable to handle reality
Helps person survive loss
Protects from being overwhelmed

ANGER
May occur once patient faces reality
Questions: Why? How? Now?
Anger towards deceased, healthcare workers, or oneself
How to respond to anger?
Allow patient to talk and express feelings
Engage patient in exercise or activities

BARGAINING

Example: If I spend the rest of my life helping the poor, God will let my husband live.
Provides temporary escape and hope
Allows time to adjust to reality

DEPRESSION
Occurs when reality really sinks in
Sadness, decreased sleep and decreased appetite are common
No sustained functional impairment
Rare to have suicidal thoughts
Remember, this is normal after loss

5
 Give patient the time they need in this stage
Group discussion may help patients express their feelings

ACCEPTANCE
Accepting reality and the fact that nothing can change the reality
Does Not mean patient is okay with loss
Learning to move on
Final stage of healing

Range of Responses
>Sadness >Denial
> Anger > Confusion
> Guilt > Obsession with memories of deceased
>Helplessness > Difficulty with concentration
>Numbness > Sleep and appetite changes
>Yearning > Nightmares
> Relief > Crying
>Loneliness > Social isolation
> Fatigue

How long is the grieving process?

Varies for each individual
Generally, 6-12 months
Longer if complicated by major depression

Role of healthcare worker

Help patient and family to be aware of emotions they may encounter in the grief process
Encourage patient and or family to express their feelings
Encourage healthy coping mechanisms such as exercising or gardening
Identify changes in behavior, communication, mood, eating and sleeping pattern
Identify those with poor coping mechanism.
May need grief counselling or anti-depressant treatment. Early Intervention should be done

Struggling with the grief process

Poor coping mechanisms can lead to:
Major depressive disorder and or anxiety.
20% of grieving individuals 2 months after death of loved one are diagnosed with major
depression
Poor physical health
Grieving individuals stop taking care of themselves
Suicide
Widows and widowers have 8-50 times higher suicide rate than the overall population

Client responses and Nursing Implications in Kubler-Ross s Stages of Grieving

6
DYING AND DEATH
Definitions and Signs of Death
The traditional clinical signs of death were cessation of the apical pulse, respirations and blood
pressure. It is also referred as heart-lung death. The World Medical Assembly (1968) adopted the
following guidelines for physicians as indications of death:
Total lack of response of external stimuli
No muscular movement, especially breathing
No reflexes
Flat encephalogram (brain waves)
Another definition of death is cerebral death or higher brain death which occurs when the higher
brain center, the cerebral cortex, is irreversibly destroyed

Death-Related Religious and Cultural Practices

Various cultural and religious traditions and practices associated with death, dying and the grieving
process help people cope with these experiences. Nurses are often present through the dying process

provide individualized care to clients and their families, even though they may not participate in the
rituals associated with death.

1. I have the right to be treated as a living human being until I die.

2. I have the right to maintain a sense of hopefulness however changing its focus may be.
3. I have the right to express my feelings and emotions about my approaching death in my own
way.
4. I have the right to participate in decisions concerning my care.
5. I have the right to expect continuing medical and nursing attention even though cure goals
must be changed to comfort goals.
6. I have the right to die alone.
7. I have the right to be free from pain.
8. I have the right to have my questions answered honestly.
9. I have the right not to be deceived.
10. I have the right to have help from and for my family in accepting my death.
11. I have the right to die in peace and with dignity.
12. I have the right to retain my individuality and not be judged for my decisions which may be
contrary to the beliefs of others.
13. I have the right to be cared for by caring sensitive, knowledgeable people who will attempt to
understand my needs and will be able to gain some satisfaction in helping me face my death
The Terminally Ill Patient and the Helping Person, Lansing MI: South Western Michigan
Inservice Education Council.

The major nursing responsibility for clients who are dying is to assist the client to a peaceful death.
Specific
Responsibilities are:
To minimize loneliness, fear and depression
-confidence, dignity and self-worth
To help the client accept losses
To provide physical comfort

Hospice and palliative Care

Hospice care focuses on support and care of the dying person and family, with the goal of
facilitating a peaceful and dignified death. It is based on holistic concepts, emphasizes care to improve
quality of life rather than cure, supports the client and family through the dying process, and support
the family through bereavement.

Palliative care (WHO) is an approach that improves the quality of life of clients and their
families facing the problem associated with life threatening illness, through the prevention and relief of
suffering by means of early identification and impeccable assessment and treatment of pain and other
problems, physical, psychosocial and spiritual. Palliative care:
Provides relief from pain and other distressing symptoms
Affirms life and regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates the psychological and spiritual aspects of client care
Offers a
bereavement
Uses a team approach to address the needs of clients and their families, including
bereavement counselling, if indicated
Will enhance quality of life, and may also positively influence the course of illness
Is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life such as chemotherapy or radiation therapy; and includes those
investigations needed to better understand and manage distressing clinical complications.

7
 Sign of Impending Clinical Death

Physiologic Needs of Dying Persons

Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death. It results from
lack of adenosine triphosphate (ATP), which causes the muscles to contract, which in turn immobilizes
the joints. The nurse need to position the body, place dentures in the mouth and close the eyes and
mouth before rigor mortis sets in.

Algor mortis is the gradua

Livor mortis is the discoloration of the skin caused by breakdown of the red blood cells; occurs after
blood circulation has ceased; appears in the dependent areas of the body.

Postmortem Care
Postmortem care is the care of the body after death. Nursing personnel should be responsible for this
and should be carried out according to the policy of the hospital or agency.

Concepts and Principles of Partnership, Collaboration and Teamwork

Partnership state of being a partner and an association of two or more people as partner.
Collaboration a collegial working relationship with another health care provider in the promotion of
health care.
Teamwork the ability to function effectively within the nursing and interpersonal team, fostering
open communication, mutual respect, and shared decision-making.

A. Development of teamwork and collaboration

1. Self-awareness
Its purpose is to develop or use interpersonal strengths. They learn
the group process through participation, involvement, & guided exercises.
2. DYAD -
The word "dyad" comes from the Greek "dyas" meaning the number two. In psychology, a dyad
refers to a pair of persons in an interactional situation.
Ex. a patient and therapist, a woman and her husband, a girl and her stepfather, etc.
https://www.medicinenet.com/script/main/art.asp?articlekey=12897

3. Group two or more people who have shared needs and goals, who take each other into
account in their actions, and are held together and set apart from others by virtue of their
interactions.
Groups exist to help people achieve goals (outcomes) that would be unattainable by individual
effort alone

8
 4. Team Delivery of coordinated care to individual clients by a group of health providers
5. Health care team is the group of professionals who contribute to your care and treatment as a
patient.
6. Multidisciplinary team is a group of health care workers who are members of different
disciplines each providing specific services to the patient. The activities of the team are brought
together using a care plan

B. Role of a Registered Nurse in a healthcare team

The primary role of a nurse is to advocate and care for individuals of all ethnic origins
and religious backgrounds and support them through health and illness. Collaborate with team to
plan for patient care
Provide and coordinate patient care

Observe patients and record observations

Role of a Registered Nurse in a healthcare team
Consult and collaborate with doctors and other members of the healthcare team
Operate and monitor medical equipment
Help perform diagnostic tests and analyze the results
Educate patients and the public about health conditions
Provide advice and emotional support to patients and their family members
https://creakyjoints.org/about/what-is-the-healthcare-team/

A. Role of the nurse as a leader/manager

Manager the nurse manages the nursing care of individuals, families and communities. The
nurse-manager also delegates nursing activities to ancillary workers and other nurses, and
supervises and evaluates their performance

Role of the nurse as a manager

Managing small or large teams of nurses
Overseeing or coordinating the training of staff

Collaborating with other managers to offer a range of health care services

Using evidence-based health care practices

Leader a leader influences others to work together to accomplish a specific goal. Effective
leadership is a learned process requiring an understanding of the needs and goals that motivate
people, the knowledge to apply the leadership skills, and the interpersonal skills to influence
others.

Role of the nurse as a leader

Acting as the strategic lead for patient care initiatives
Directing a group of nurse managers
Influencing others through effective communication and interpersonal skills
Implementing evidence-based practices and rolling them out to other nurses and health
care staff
Mentoring other nurses
americansentinel.edu/blog/2020/02/29/leadership-management-in-nursing-whats-the-difference/

B. Positive Practice Environment

Positive practice environments are health care settings that support excellence & decent work.
http://www.whpa.org/news-resources/positive-practice-environment-toolkit

Elements of Positive practice:

Safe staffing levels
Support and supervision
Open communication and transparency
Recognition programmes
Access to adequate equipment, supplies and support staff

9
 Demands that fit the resources of the person
Positive Practice Environment
A high level of predictability
Good social support from colleagues and managers and access to education and
professional development opportunities
Meaningful work
A high level of influence
A balance between effort and reward

Positive practice environments are characterized by:

Innovative policy frameworks focused on recruitment and retention.
Strategies for continuing education and upgrading.
Adequate employee compensation.
Recognition programmes.
Sufficient equipment and supplies.
A safe working environment
Positive Practice Environment
https://www.slideshare.net/roducado/positive-practice-environment-for-nurses

Concept of Continuing Professional Development

Continuing professional development (CPD) encompasses experiences, activities and processes
that contribute towards the development of a nurse or midwife as a health care professional. CPD is,
therefore, a lifelong process of both structured and informal learning.
https://www.nmbi.ie/Standards-Guidance/Scope-of Practice/Considerations-in-Determining-Scope/Continuing-Professional-Development

A. Lifelong learning
Refers to the voluntary decision to enroll in educational courses or to study a topic on one's
volition. While the term may seem to apply especially to those who have already earned a
college degree or entered the workforce, lifelong learning is vital for everybody, no matter the
age or level of education.
https://study.com/academy/popular/importance-of-lifelong-learning.html

B. Career path/development map

A career path comprises a group of (typically related) jobs that an individual works on the path
toward their career goals.
Career paths tend to result in vertical growth, moving from entry-level to management
positions, but they can also include lateral moves in which an individual maintains similar roles
across disparate industries.
https://learn.g2.com/career-path

A career development plan is a personalized action plan used by individuals to map their
careers. It is like a road map, consisting of:
starting point (Where Am I Now?)
destination (Where Do I Want to Go?)
route (how Will I Get There?)

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