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NCM 100

CLAIRE R. HATTON RN, MAN


CONCEPT: PERCEPTION
and COORDINATION
SENSORY PERCEPTION
COMPONENTS OF SENSORY PERCEPTION
A. RECEPTION
B. PERCEPTION

SENSORY RECEPTION - process of receiving


stimuli or data.
external
visual stimuli
auditory
olfactory
tactile
gustatory
internal
kinesthetic
visceral
Kinesthetic refers to awareness of the position
and movement of body parts.
e.g a person walking- is aware which leg is forward.

Stereognosis- ability to perceive and understand an


object through touch by size, shape and texture.

Visceral- refers any large organ within the body


Stimuli example: Visceral organs may produce
stimuli that make a person aware of them
e.g full stomach
Sensory Perception- involves the
conscious organization and translation of
the data into meaningful information.

Perception- awareness and interpretation of


stimuli that takes place in the brain, where
specialized brain cells interpret the nature and
the quality of the sensory stimuli.
Awareness- the ability to perceive environmental stimuli and
body reactions and to respond appropriately through thought
and action.

States of Awareness
Full consciousness: -Alert, oriented to time, place,person;
understand verbal and written work.
Disoriented: -Not oriented to time, place, person.
Confused: -Reduced awareness; easily bewildered;
poor memory; misinterprets stimuli; impaired
judgement.
Somnolent: -Extreme drowsiness but will respond to
stimuli
Semi comatose: -Can be aroused by extreme or repeated
stimuli
Coma: -Will not respond to vernal stimuli
SAFETY
Promoting Healthy Sensory Function
Detecting sensory problems early is one step
towards preventing serious problems.
Early screening to detect problems in the visual
and hearing functions is essential
All infants should be screened for hearing loss by
1 month age, preferably before hospital
discharge.
infants with hearing loss should get follow-up
evaluation before 3 months.
those who are deaf or hard of hearing should be
enrolled in an intervention program by 6 months
(CDC and Prevention, 2004)
children with chronic ear infection should receive
routine auditory testing
SAFETY
Promoting Healthy Sensory Function
People who live or work in an environment with high noise level
should receive routine auditory testing
Women who considers pregnancy should test for syphilis and
rubella (can cause hearing impairment in newborns).
Periodic vision screening of all newborns and children is recommended
to detect congenital blindness, strabismus and refractive errors.
A childs visual acuity develops during early childhood 20/20 vision by
6 years old
Healthy sensory function can be promoted with environmental
stimuli that provide appropriate sensory input.
Neither excessive nor too limited
Nurses can teach parents to stimulate infants and children, and
teach family members to stimulate elderly persons
Social activities often help stimulate the mind and the senses.
Nurses should also teach clients at risk of sensory loss how to
prevent or reduce the loss and should teach general health
measures.
e.g getting regular eye examinations and controlling chronic
diseases such as DM
Assignment: Read and Write in your
notes preventing Sensory Disturbances
pp. 988 Kozier
and Erb , Fundamentals of Nursing
Practice.
ENSURING CLIENT SAFETY

Nurses must implement safety precautions


in health care settings for client with
sensory deficits.
example of precautions:
keeping the bed in lowest positions
placing call light within reach
EYE FUNCTION

Organ for sight and vision


Provides people with important information
about the environment and the things in it.
it is estimated that around 80% of the sensory
information perceived is visual.
EYE CARE
Ensuring the eyes are clean and free from
crusting (part of General Hygiene)
PRINCIPLES OF EYE CARE
Prepare the patient by explaining what you are
about to do.
Follow local infection control protocols
Always use new eye care pack.
Position the patient, can sit or lie down with the
head tilted backwards.
Ask the patient to close the eyes.
If there is an infected eye, clean the non-infected
eye first.
PRINCIPLES OF EYE CARE
continuation
Gently swab the lower eyelid with a lint-free swab,
lightly moistened with sterile normal saline form the
inner canthus outwards.
Ensure that the swab does not touch the lid margin
opening the eye as corneal damage may occur.
Use each swab only once.
Continue swabbing until all the crusting has gone.
Dry away excess saline with a dry swab.
Prescribed medication may then be instilled into
the eyes.
Wash your hands.
SENSORY AIDS FOR VISUAL DEFICIT
Eyeglasses of the correct prescription, clean
and in good repair.
Adequate room lighting, including night-lights.
Sunglasses or shades on windows to reduce
glare.
Bright contrasting colors in the environment
Magnifying glass
Phone dialer with large numbers
Clock and wristwatch with large numbers
Color code or texture code on stoves, washer,
medicing containers and so on
SENSORY AIDS FOR VISUAL DEFICIT
Color code or texture code on stoves, washer,
medicine containers and so on
Colored or raised rims on dishes
Reading materials with large print
Braille or recorded books
Seeing-eye dog
For clients with visual impairments nurses need to
do the following in a health care setting:
Orient the client to the arrangement of room furnishings
and maintain an uncluttered environment.
Keep pathways clear and do not rearrange furniture
without orienting the client. Ensuring that housekeeping
personnel are informed about this.
Organize self-care articles within the clients reach and
orient the client to his or her location.
Keep the call light within easy reach and place the bed in
the low position.
Assist with ambulation by standing at the clients side
walking about 1 foot ahead, and allowing the person to
grasp your arm. Confirm whether the client prefers
grasping your arm with the dominant or nondominant
hand.
Signs of visual impairment
Holding written material very close to the eyes
Tendency to explore items by touch
Appearing startled when someone approaches
quietly
Reluctance to move around, especially in
strange environment
Avoidance of visual tasks or not noticing things
that are nearby
Rubbing the eyes
Obvious signs of eye problems, e.g. swelling
EAR FUNCTIONS

A sensory organ that provides important


information about the environment
Enables people to hear sounds that are
interpreted by the brain.
Also enable people to maintain balance
Prevention of hearing loss
Newborn babies should have their hearing
assessed
OAE otoaccoustic emission testing
AABR automated auditory brainstem response
(Less reliable) distraction test using simple sounds at 6-8 mos.

Audiometric testing when hearing problem is


suspected
Compliance with childhood immunization
programs is recommended
Occupational health nurse must be involved
in preventing noise-induced hearing loss
Prevention of hearing loss
Employers must:
Provide workers with advice about minimizing the
risks of noise-induced hearing deficit
Provide personal protective equipment (PPE)
Earmuffs
Earplugs

Avoidance of exposure to regular noise


above 100 decibels
CHARACTERISTIC SIGNS OF
HEARING IMPAIRMENT
Turning 1 ear towards the speaker
Apparent lack of attention or poor
concentration
Inappropriate responses
Often seeing withdrawn or alone
No response to sounds in the environment
Asking for information to be repeated
Speech which is unusually loud or soft
Easily startled when the speaker initiates
conversation
COMMUNICATION TIPS FOR PEOPLE
WITH HEARING IMPAIRMENT
Gently alert the person to your arrival
Check the hearing aid, if used, is switched on
Minimize background noise if appropriate
Sit or stand at the same level at an
appropriate distance from the person
About 1m if wearing hearing aid or 1-2m for lip reading
Face the person, making sure your lips and
face are visible
If the person lipreads, allow use of spectacles
COMMUNICATION TIPS FOR PEOPLE
WITH HEARING IMPAIRMENT
Speak slowly and clearly using normal tone
and inflection
Use non-verbal communication skills to
reinforce verbal skills
Check the person is following the
conversation by asking them to contribute
actively at times
If you are not understood:
Try using other words to explain yourself
Raise your voice slightly but use lower tones , never shout
use gestures or writing to enhance understanding
CARE OF THE EARS

Important to wash the skin covering the


external ear as part of bathing or
showering.
Ears should be cleaned daily
Nothing should be inserted into the ear except
tympanic thermometer or otoscope
Cotton buds and other objects should not be used to
remove wax
First aid to foreign body in the ears

Do not attempt to remove the foreign body


unless a live insect.
A live insect can be removed by pouring
tepid water into the casualtys ear
Reassure and stay calm
Organize transfer to the hospital
CONCEPT: PERCEPTION
and COORDINATION
COORDINATION:
PROPER BODY MECHANICS
Body mechanics
-is the term used to describe the efficient,
coordinated and safe use of the body to
move objectives and carry out the activities
of daily living.
When a person moves, the center of
gravity shifts continuously in the
direction of the moving body parts.
Balance depends on the interrelationship
of the center of gravity, the line of
gravity, and the base of support.
Body mechanics

The closer the line of gravity is to the


center of the base of support, the greater
the persons stability.
Conversely, the closer the line of gravity is
to the edge of the base of support, the
more precarious the balance.
If the line of gravity falls outside the base
of support, the person falls.
Body mechanics

The broader the base of support and the


lower of the center of gravity, the greater
the stability and balance. Body balance,
therefore, cam be greatly enhanced by:
(a) widening the base of support and
(b) lowering the center of gravity bringing it
closer to the base of support.
Body mechanics
The base of support is easily widened by
spreading the feet further apart. the center
of gravity is readily lowered by flexing the
hips and knees until a squatting position is
achieved.
Two movements to avoid because of their
potential for causing back injury are:
Twisting (rotation) of the thoracolumbar spine
acute flexion of the back with hips and knees
straight (stooping)
LIFTING
It is important to remember that nurses
should not lift more than 51 lbs without
assistance from proper equipment and/or
other persons.
When a person lifts or carriers an objects,
for example, a suitcase, the weight of the
object becomes part of the persons body
weight. This weight affects the persons
center of gravity, which displays in the
direction of the added weight.
LIFTING
To counteract this potential imbalance,
body parts (arm and trunk) move in a
direction away from the weight.
By holding the lifted object as close as
possible to the bodys center of gravity, the
lifter avoids undue displacement of the
center of gravity and achieves greater
stability.
The nurse must use the major muscle
groups of the thighs, knees, upper and
lower arms, abdomen and pelvis to prevent
back strain.
LIFTING
The nurse can increase overall muscle
strength by synchronized use of as many
muscle groups as possible during an
activity. For instance, when the arms are
used in an activity, dividing the work
between the arms and legs helps prevent
back strain.
LIFTING
Another technique based on the principle of
leverage can be used in lifting objects from
the floor to waist level.
The back and knees are flexed until the load is at
thigh level, at which at point the knees remain
flexed to provide thrust as the back begins to
straighten.
This technique provides for balance, leverage,
synchronized use of muscles which help avoid back
pain and injury.
In all positions, it is important to maintain a
distance of at least 30 cm (12 in.) between the
feet and to keep the load close to the body,
especially when it is a knee level.
PULLING AND PUSHING
When pulling or pushing an object, a person
maintains balance with least effort when the base
of support is enlarged in a direction in which the
movement is ti be produced of opposed.
Example: When pushing an object, a person
enlarge the base of support by
(a) moving the rear leg back if the person is facing the object.
(b) moving the front foot forward of the person is facing away
the object.
It is easier and safer to pull an object toward ones
own center of gravity than to push it away, because
a person can exert more control of the objects
movement when pulling it.
PIVOTING
Pivoting- a technique in which the body is
turned in a way that avoids twisting of the
spine.
To pivot, place one foot ahead of the other, raise
the heels very slightly and put the weight on the
balls of the feet.
When the weight is off the heels, the
frictional surface is decreased and the kees
are not twisted when turning.
Keeping the body aligned, turn (pivot) about
90 in the desired direction. The foot that was
forward will now behind.
ACTIVITY-EXERCISE PATTERN

Refers to a persons routine of exercise,


activity, leisure and recreation.
Includes:
(a) activities of daily living (ADLs) that require
energy expenditure such as hygiene, dressing,
cooking, shopping, eating, working and home
maintenance;
(b) the type, quality, and quantity of exercise
including sports.
MOBILITY
ability to move freely, easily, rhythmically,
and purposely in the environment is an
essential part of living. It is vital to
independence; a fully immobilized person
is as vulnerable as an infant.
people often define their health and
physical fitness by their activity because
mental well being and the effectiveness of
body functioning depend largely on their
mobility status .
NORMAL MOVEMENT
Normal movement and stability are the result
of an intact musculoskeletal system, an intact
nervous system, and intact ear structures
responsible for equilibrium.
Body movement requires coordinated muscle
activity and neurologic integration.
Involves four basic elements:
body alignment(posture),
joint mobility,
balance, and
coordinated movement.
ALIGNMENT AND POSTURE

proper body alignment and posture bring


body parts into position in a manner that
promotes optimal balance and maximum
body function. Whether the client is sitting,
or lying down.
a person maintains balance as long as the
line of gravity (an imaginary vertical
line drawn to the body center of
gravity) passes through the center of
gravity (the point at which all the
bodys mass is centered) and the base
of support ( the foundation on which
the body rests).
ALIGNMENT AND POSTURE
In humans, the usual line of gravity begins at
the top of the head and falls between the
shoulders through the trunk, slightly anterior
to the sacrum, and between the weight-
bearing joints and base of support.
When the body is well aligned, strain on the joints,
muscles, tendons, or ligaments is minimized and
internal structures and organs are supported.
Proper body alignment enhances lung
expansion, and promotes efficient circulatory,
renal, and gastrointestinal functions.
a persons posture is one
criterion for assessing general
health, physical fitness and
attractiveness.
JOINT MOBILITY
Joint- functional units of musculoskeletal system.
range of motion- Maximum movement that is possible
for that joint.
the bones of the skeleton articulate the joints, and most
of the skeletal muscles attach to the two bones at the
joint.
these muscles are categorized according to type of
joint movement they produce on contraction.
muscles are, therefore, called flexors, extensors,
internal rotators and the like.
The flexor muscles are stronger than the extensors
muscles. Thus, when a person is inactive, the joints
are pulled into a flexed (bent) position. If this tendency
is not counteracted with exercise and position
changes, the muscles permanently shortened and the
joint becomes fixed in a flexed position (contracture).
MOVEMENT ACTION
Decreasing the angle of the joint
Flexion e.g bending the elbow

Increasing the angle of the joint


Extension e.g straightening the arm at the elbow

Further extension or straightening of the joint.


Hyperextension e.g Bending the head backward

Abduction Movement of the bone away from the midline of the body

Adduction Movement of the bone toward the midline of the body

Rotation Movement of the bone around its central axis

Movement of the distal part of the bone in a circle while the proximal end
Circumduction remains fixed

Eversion Turning the sole of the foot outward by moving the ankle joint

Inversion Turning of the sole of the foot inward by moving the ankle joint
Moving of the bones of the forearm so that the palm of the hand faces
Pronation downward when held in front of the body.

Moving the bones so that the palm of the hand faces upward when held in
Supination front of the body.
BALANCE
mechanisms involved in maintaining balance and
posture are complex and involved informational
inputs from the labyrinth (inner ear), from vision
(vestibulo-ocular input), and from stretched
receptors of muscles and tendons (vestibule-
spinal input).
Mechanism of equilibrium (sense of balance)
respond, frequently without awareness, to various
head movements.

proprioception- term used to describe awareness


of posture, movement, and changes in equilibrium
and the knowledge of position, weight, and
resistance of objects in relation to the body.
COORDINATED MOVEMENT

balanced, smooth, purposeful movement


is the result of proper functioning of the
cerebral cortex, cerebellum and basal
ganglia.

COORDINATION:
EXERCISE
physical activity
is a bodily movement produced by skeletal muscle
contraction that increases energy expenditure.
Exercise
type of physical activity defined as a planned structured,
and repetitive bidy movement performed maintain one or
more components of physical fitness
activity tolerance
type and amount of exercise or daily living activities an
individual is able to perform without experiencing adverse
effects.
functional strength
is another goal of exercise, and defined as the ability of
the body to perform work.
TYPES OF EXERCISES

Isotonic (dynamic) exercises- are those


in which the muscle shortens to produce
muscle contraction and active movement.
Most physical conditioning exercises-
running, walking, swimming, cycling, and
other such activities- are isotonic , as are
ADLs and active ROM exercises (those
initiated by the client).
TYPES OF EXERCISES
Isometric (static or setting) exercises-
those in which there is muscle contraction without moving the
joint (muscle length does not change).
This exercises involve exerting pressure against a solid object
and are useful:
for strengthening abdominal, gluteal, and quadriceps muscles used in
ambulation;
for maintaining strength in immobilized muscles in casts or traction;
and
for endurance training.
example of isometric exercise for the knees and the
legs:
client sit or lies on a flat surface with legs straight out. using
a rolled towel between the knees, the person pushes the
knees together and tightens the muscles in the front of the
thighs by forcing the knees downward and folding it for 10
seconds
Isokenitic (resistive) exercises
involve muscle contraction or tension against
resistance; thus, they can be either isotonic or
isometric.
During isokinetic exercises, the person moves
(isotonic) or tenses (isometric) against
resistance.
Aerobic exercises
Activity during which the amount of oxygen
taken in the body is greater than that used to
perform that activity.
Aerobic exercises use large muscle groups that
move repetitively
Improve cardiovascular conditioning.
Anaerobic exercises
Involves activity in the muscle cannot grow
enough oxygen from the bloodstream, and
anaerobic pathways are used to provide
additional energy for a short time.
Used in endurance training for athletes such as
weight lifting and sprinting
NEW CONCEPT: DIET
HEALTHY DIET

A healthy diet comprises the correct


nutrients in appropriate amounts.
Varies during:
the lifespan;
during injury and
ill health
STIMULATING THE APPETITE
Factors that may depress the appetites of many clients
Physical illness,
unfamiliar and unpalatable food,
environmental
psychologic factors
physical discomfort or pain
A short-term decrease in food intake usually is not a
problem for adults; over time, however, it leads to
weight loss, decreased strength and stamina and
other nutritional problems.
A decreased food intake is often accompanied by a
decreased in fluid intake, which may cause fluid and
electrolyte problems.
STIMULATING THE APPETITE

Stimulating a persons appetite requires


the nurse to determine the reason for the
lack of appetite and then deal with the
problem which then may increase the risk
of people developing nutritional problems
such as:
Malnutrition caused by inadequate food intake
MAINTAINING NUTRITIONAL
STATUS

NURSING INTERVENTIONS INCLUDE:


Nutritional screening and assessment
Helping people to eat and in feeding
Nutritional support such as sip feeding
and enteral feeding
MAINTAINING NUTRITIONAL STATUS
Nutritional screening and assessment

Anthropometric measurements
Use of nutritional screening audit tools
Biochemical indicators
MAINTAINING NUTRITIONAL STATUS
Helping people to eat
Nurses should help in making appropriate
healthy choices
The nurse needs to ensure that the
environment is conducive to eating:
Dining area should be away from bed area
With bedpans, commodes and vomit bowels
removed
Use mealtimes to socialize
Breastfeeding mothers have support and
privacy
The nurse needs to ensure that the
environment is conducive to eating:
continuation:
Ensure that dining area is quiet and treatment and
visitors do not disrupt mealtimes.
Handwashing before meals
Facilities for mouth rinsing and cleaning of dentures
if necessary
Help people sit up, bed tables are at a correct height
and food is within easy reach.
Appropriate cutlery and utensils
Food is served at correct temperature and attractive
Making sure that a meal is available if a person
misses a meal.
ASSISTING CLIENTS WITH MEALS

Two groups of people frequently require


help with their meals:
elders who are weakened; and
person with disabilities
Nurses role in assisting with meals
The nurse must be sensitive to clients feelings of
embarrassment, resentment, and loss of autonomy.
whenever possible, the nurse should help
incapacitated clients feed themselves rather than feed
them
When feeding a client, ask in which order the client
would like to eat the food.
If the client cannot see, tell the client which food is
being given.
always allow ample time for the client to chew and
swallow the food before offering more.
also, provide fluids as requested, or, if the client is
unable to communicate, Offer fluids after every 3 or 4
mouthfulls of solid food.
MAINTAINING NUTRITIONAL STATUS:
ENTERAL FEEDING
ENTERAL FEEDING
An alternative feeding method to ensure
adequate nutrition
Provided when :
the client is unable to ingest foods or
the upper GI is impaired
Transport of food to the small intestine is interrupted
Administered through:
nasogastric tube
Small-bore feeding tubes
Gastrostomy or jejunostomy tube
NASOGASTRIC TUBE

Is inserted through one of the nostrils


down the nasopharynx and into the
alimentary tract.
Tubes:
Large-bore tubes- larger than 12 Fr in diameter
Example:
LEVIN TUBE
SALEM PUMP TUBE
Small-bore tubes- smaller than 12 Fr
NASOGASTRIC INSERTION
purpose:
to administer tube feedings and medication to
clients unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into
the lungs;
establish a means for suctioning stomach contents
to prevent stomach distention, nausea and
vomiting
to remove gastric contents for laboratory analysis.
To lavage( wash ) the stomach in case of
poisoning or overdose
NASOGASTRIC INSERTION

Assessment:
Check for history of nasal surgery, or
deviated septum
Assess for patency of nares
determine presence of gag reflex;
assess mental status or ability to
cooperate with the procedure.
NASOGASTRIC INSERTION

Planning:
before inserting an NGT:
determine the size of tube to be inserted
and whether if the tube is to be attached to a
suction
NASOGASTRIC INSERTION
EQUIPMENT: BILIRUBIN DIPSTICK
LARGE OR SMALL
BORE TUBE STETHOSCOPE
ADHESIVE TAPE DISPOSABLE PAD
CLEAN GLOVES OR TOWEL
LUBRICANT CLAMP OR PLUG
FACIAL TISSUES
GLASS OF WATER ANTIREFLUX VALVE
;DRINKING STRAW SUCTION
20-50 ML SYRINGE APPARATUS
BASIN
SAFETY PIN AND
PH STRIP OR METER
ELASTIC BANDAGE
NASOGASTRIC INSERTION
IMPLEMENTATION
PREPARATION
Assist the client to a high Fowlers position
of his or her health condition permits, and
support the head on a pillow
Rationale: it is often easier to swallow in this
position and gravity helps the passage of the
tube.
Place a towel or disposable pad across
the chest.
PERFORMANCE
( FUNDA BOOK: KOZIER AND ERB. pp
1267)
Concept: elimination
PHYSIOLOGY OF DEFECATION
Elimination of the waste product of digestion
from, the body is essential to health. The
excreted waste products are referred to as
feces or stool.
Ingestion- the act of taking food.
Chyme- waste products leaving the stomach
thought the small intestine and then passing
through the ileoceccal valve.
Flatus- largely air and the by-products of the
digestion of carbohydrates.
three types of movements occur in
the large intestine:
Haustral churning- involves movement of the
chyme back and forth within the haustra
Peristalsis- wavelike movement produced by the
circular and longitudinal muscle fibers of the
intestinal walls; it propels the intestinal contents
forward. colon peristalsis is very sluggish and is
thought to move the chyme very little along the
large.
Mass peristalsis- involves a wave powerful
muscular contraction that moves over large areas
over the colon. Occurs after eating, stimulated by
the presence of food and the stomach, and
intestine. In adults, mass peristaltic waves occur
only a few times a day.
Defecation- the expulsion of feces from the
anus and rectum; it is also called.
frequency of defecation (varies from several
times per day to two or three times per week)
and amount of defecated varies per individual.
normal defecation is facilitated by: (a) thigh
flexion, which increases the pressure within the
abdomen and (b) a sitting position, which
increases the downward pressure of the
rectum.

Feces-
made of about 75% of water and 25% solid materials.
They are soft but formed.
If the feces are propelled very quickly along the large intestine there is not time
for most of the water in the chyme to be reabsorbed in the feces will be more
fluid, containing perhaps 95% water.
Normal feces require a normal fluid intake; Feces contain less water maybe
hard and difficult to expel.
Normally brown, chiefly due to:
the presence of stercobilin and urobilin which are derived from bilirubin (a
red bile pigment)
Factor that affects fecal color is the action of bacteria such as Escherichia coli
or Staphylococci which are normally present in the large intestine.
The action of microorganisms on the chime is also responsible for the odor of
feces.
An adult usually forms 7-10 L of flatus (gas) in the large intestine every
24 hours.
The gases include Carbon dioxide, methane, hydrogen, oxygen, and
nitrogen.
Some are swallowed with food and fluid taken by mouth, others are
formed through the action of bacteria on the chyme in the large
intestine, and other gas diffuses from the blood into the GI tract.
FACTORS THAT AFFECT
DEFECATION
Development
Diet
Activity
Psychologic factors
Defecation habits
Medications diagnostic procedures
Anesthesia and surgery
Pathologic conditions
Pain
FECAL ELIMINATION PROBLEMS

CONSTIPATION
DIARRHEA
BOWEL INCONTINENCE
FLATULENCE
FECAL ELIMINATION PROBLEMS
constipation- defined as fewer than three
bowel movements per week.
This infers the passage of dry, hard stool or
the passage of no stool.
It occurs when the movement of feces
through the large intestine is slow, thus
allowing time for additional reabsorption of
fluid from the large intestine
associated with constipation are difficult evacuation
of stool and increased effort or straining of the
voluntary muscles of defecation.
causes and factors contribute to constipation
insufficient fiber intake
insufficient fluid intake
insufficient activity or immobility
irregular defecation habits
change in daily routine
lack of privacy
chronic use of laxatives and enemas
irritable bowel syndrome (IBS)
pelvic floor dysfunction or muscle damage
poor motility or slow transit
neurological conditions e.g Parkinsons disease, stroke, or
paralysis
emotional disturbances such as depression or mental confusion
medications such as opioids, iron supplement, antihistamines,
antacids and antidepressants.
straining associated with constipation often is accompanied by
holding the breath.
valsalva maneuver- can present serious
problems to people with heart disease,
brain injuries, or respiratory diseases.
Holding breath while bearing down
increases intrathoracic pressure and vagal
tones slowing the pulse rate (Lemone &
Burke, 2004).
sample defining characteristics for
constipation:
decreased frequency of defecation
hard, dry, formed stools
straining at stool; painful defecation
reports of rectal fullness or pressure or
incomplete bowel evacuation
abdominal pain, cramps, or distention
anorexia, nausea
headache
Fecal impaction- mass or collection of hardened feces in the
folds of the rectum.
Impaction results from prolonged retention and accumulation of
fecal material.
in severe impactions,
the feces accumulate and extend well up into the sigmoid colon and
beyond.
can be recognized by the passage of liquid fecal seepage
(diarrhea) and no normal stool.
The liquid portion of the feces sips out around the impacted mass.
Along with fecal seepage and constipation, symptoms include:
frequent but non-productive desire to defecate and rectal pain.
a generalized feeling of illness results the client becomes anorexic,
the abdomen becomes distended, nausea and vomiting may occur.
causes of fecal impaction:
usually poor defecation habits and
constipation.
although fecal impaction can generally be prevented, treatment of
impacted feces is sometimes necessary.
When fecal impaction is suspected:
oil retention enema should be given as a cleansing enema 2-4 hours later
and daily additional cleansing enemas, suppositories or stool softeners.
Diarrhea-
refers to the passage of liquid feces and an increased
frequency of defecation.
opposite of constipation and results from rapid
movement of fecal contents through the large intestine.
Rapid passage of chyme reduces the time available for
the large intestine to reabsorb water and electrolytes.
Some people pass stool within increased frequency but
diarrhea is not present unless the stool is relatively
unformed and excessively liquid.
a person with diarrhea finds it difficult or impossible to
control the urge to defecate for very long
diarrhea and threat of incontinence are sources of
concern and embarrassment.
spasmodic cramps are associated diarrhea,
bowel sounds are increased with persistent diarrhea,
irritation of the anal region extending the perineum and
buttocks generally results.
Results of prolonged diarrhea

fatigue,
weakness,
malaise, and
emaciation
Bowel Incontinence-
also called fecal incontinence;
refers to the loss of voluntary ability to control fecal
and gaseous dischargers through the anal
sphincter.
may occur at specific times, such as after meals or it
may occur irregularly;
two types of bowel incontinence are described:
partial incontinence- inability to control flatus or to prevent
minor soiling
major incontinence- inability to control feces of normal
consistency
fecal incontinence is generally associated with impaired
functioning of the anal sphincter or its nerve supply,
such as some neuromuscular diseases, spinal cord
trauma, or tumors of the external anal sphincter
muscle.
Flatulence-
presence of excessive flatus in the intestines and
leads to stretching and inflation of the intestines
(intestinal distention).
Most gasses that are swallowed are expelled
through the mouth eructation (belching).
can occur in the colon from a variety of causes such
as foods (e.g cabbage, onions), abdominal surgery, or
narcotics.
if excessive gas cannot be expelled through the anus,
it may be necessary to insert rectal tube to remove it.
three primary sources of flatus:
action of bacteria on the chyme in the large intestine
swallowed air
gas that diffuses between the bloodstream and the intestine.
Promoting Regular Defecation
The nurse can help the clients achieve regular
defecation by:
Provision of privacy
Timing
Nutrition and fluids
Exercise
positioning
the provision of privacy-
privacy during defecation s extremely important to many
people.
The nurse should therefore provide as much privacy as
possible for such clients but may need to stay with those
who are too weak to be left alone.
Some clients also prefer to wipe, wahs, and dry
themselves after defecating.
A nurse may need to provide water and a wash cloth and
towel for this purpose
timing-
a client should be encouraged to defecate when the urge
is recognized.
To establish regular bowel elimination, the client and
nurse can discuss when mass peristalsis normally
occurs and provide time for defecation.
Many people have well-established routines.
Other activities such as bathing and ambulating should
not interfere with the defecation time
Nutrition and Fluids-
a client needs for regular normal elimination varies depending on:
the kind of feces the client currently has,
the frequency of defecation, and
the types of foods that the client finds assist with normal defecation.
For constipation-
increase daily fluid intake, and
instruct the client to drink hot liquids and fruit juices, especially prune juice.
Include fiber in the diet that is, foods such as raw fruit, bran products, and
whole-grain cereals for diarrhea.
For diarrhea-
encourage oral intake of fluids and bland food.
Eating small amounts can be helpful because it is more easily absorbed.
Excessively hot or cold fluids should be avoided because they stimulate
peristalsis.
In addition, highly spiced foods and high-fiber foods can aggravate diarrhea.
For flatulence-
Limit carbonated beverages, the use of drinking straws, and chewing gums- all
of which increase the ingestion of air.
Gas-forming foods such as cabbage, beans, onions, and cauliflower should be
avoided.
Exercise-
regular exercise helps client develop a regular
defecation pattern.
a client with weak abdominal and pelvic muscles
(which impede normal defecation) may be able to
strengthen them with the following isometric
exercises:
in supine position,
the client tightens the abdominal muscles as though
pulling them inward, holding them for 10 seconds and
then relaxing them.
This should be repeated 5-10 times, four times a day,
depending on the clients health.
Again in a supine position,
the client can contract the thigh muscle and hold them
contracted for about 10 seconds.
Repeating the exercise 5-10 times four times a day.
This helps the client confined to bed gains strength in the
thigh muscles, thereby making it easier to use a bedpan.
Positioning-
Although the squatting position best facilitates defecation,
on a toilet seat,
the best position for most people seems to be leaning
forward.
For clients who have difficulty sitting down and getting up
from the toilet, an elevated toilet seat can be attached to a
regular toilet.
Clients then do not have to lower themselves as far unto
the seat and do not have to lift as far off the seat. elevated
toilet seats can be purchased for use in the home.
Managing Diarrhea
drink at least 8 glasses of water per day to prevent dehydration.
Consider drinking a few glasses of electrolyte replacement fluids a day.
eat foods with sodium and potassium,. Most food contain sodium. Potassium is found in meats
and many vegetables and fruits, especially purple grape juice, tomatoes, potatoes, bananas,
cooked peaches and apricot.
increased foods containing soluble fiber such as rice, oatmeal, and skinless fruits and potatoes.
avoid alcohol and beverages with caffeine which aggravate the problem.
limit foods containing insoluble fiber such as high-fiber, whole-wheat, whole-
grain breads and cereals and raw fruits and vegetable.
limit fatty foods.
thoroughly dry and clean the perianal area after passing stool to prevent skin
irritation and breakdown.
Use soft toilet tissue to clean and dry the area.
Apply Dimethicone-based cream or alcohol-free barrier film as needed.
If possible, discontinue medications that cause diarrhea.
when diarrhea has stopped, re-establish normal bowel flora by taking daily
products such as yogurt and buttermilk.
Seek a primary care provider consultation right away of weakness, dizziness or
loosed stools persist more than 48 hours.
ASSIGNMENT: READ client teaching
on FECAL ELIMINATION (PP 1336
KOZIER AND ERB, FUNDAMENTALS
OF NURSING)
ADMINISTERING ENEMA

Enema- a solution introduced into the


rectum and large intestine.
the action of an enema is to distend the intestine
and sometimes to irritate intestinal mucosa,
thereby increasing peristalsis and the excretion of
feces and flatus.
Enema
classified into four groups:
Cleansing
Carminative
Retention
Return-flow
CLEANSING enema
Purpose- remove feces
given to prevent escape of feces during surgery;
prepare the intestine for certain diagnostic test such as x-ray or
visualization tests e.g. colonoscopy
remove feces in instances for constipation or impaction.
uses variety of solutions such as:
Hypertonic solutions,
e.g. Saline solution,
exert osmotic pressure, which draws fluid from the interstitial space of the
colon.
Common hypertonic enema is commercially prepared fleet phosphate
enema.
Hypotonic solutions
(e.g. tap water)
exert a lower osmotic pressure than surrounding interstitial fluid causing
water to move from the colon into the interstitial space
Isotonic solutions
such as physiologic (normal) saline
are considered the safest enema solutions to use.
They exert the same osmotic pressure as the interstitial fluid surrounding the
colon.
CARMINATIVE ENEMA
Purpose: to expel flatus
The solution instilled into the rectum
releases gas, which in turn distends the
rectum and the colon, thus stimulating
peristalsis.
For an adult, 60-80 mL of fluid is instilled.
RETENTION ENEMA
Purpose:
introduces oil or medication into the rectum and sigmoid
colon.
liquid is retained for a relatively long period e.g. 1-3
hours
an oil retention enema acts :
to soften the feces and
to lubricate the rectum and the anal canal, this facilitating
the passage of the feces.
antibiotic enemas are used to treat infections
locally.
antihelmintic enemas kill helminths such as
worms and intestinal parasite
nutritive enemas to administer fluids and nutrients
to the rectum.
RETURN-FLOW ENEMA

used occasionally to expel flatus


alternating flow of 100-200 mL of fluid in
and out of the rectum and sigmoid colon
stimulates peristalsis repeated 5-6 times
until flatus is expelleD and abdominal
distention is relieved.

ADMINISTERING ENEMA
(procedure)
Purpose : to achieve one or more of the
following actions:
cleansing
carminative
retention
return-flow
ADMINISTERING ENEMA
(procedure)
Assessment:
when the client last had a bowel movement and
the amount, color and consistency of the feces.
presence of abdominal distention (the distended
abdomen appears swollen and feels firm rather
than soft when palpated.
whether the client has sphincter control
whether the client can use a toilet or commode or
must remain in bed and use a bedpan.
ADMINISTERING ENEMA
(procedure)
Equipment:
disposable linen-saver pad
Bath blanket
bedpan or commode
clean gloves
water-soluble lubricant if tubing not prelubricated
paper towel
large volume enema:
solution container with tubing of correct size and tubing
clamp
correct solution, amount, and temperature
small-volume enema
pre-packaged container of enema solution with lubricated tip
ADMINISTERING ENEMA
(procedure)
Implemetation:
Preparation
Lubricate about 5 cm (2 in) of the rectal tube (some
commercially prepared enema sets already have
lubricated nozzles) lubrication facilitates insertion
through the sphincters and minimize trauma.
Run some solution through the connecting tubing of
a large volume enema set and the rectal tube to
expel any air in the tubing; then close the clamp.
rationale: air instilled into the rectum, although not
harmful causes unnecessary distention.
Performance:
Prior to performing the procedure, introduce self and
verify clients identity using agency protocol.
Explain to the client what you are going to do, why is it
necessary and how he/she can cooperate.
Discuss the results how it will be used in planning further care
or treatments. Indicate that the client can experience a feeling
of fullness while the solution is being administered.
perform hand hygiene, apply clean gloves, and
observe appropriate infection control procedures.
provide client privacy
assist the adult client to a left lateral position with the
right leg is acutely flexed as possible and the linen-
saver pads under the buttocks
rationale: this position facilitates the flow of solution by gravity
into the sigmoid and descending colon, which are on the left
side and the right leg acutely flexed provides for adequate
exposure of the anus.
insert the enema tube
for clients in the left lateral position, lift the upper buttock to
ensure good visualization of anus.
insert the tube smoothly and slowly into the rectum, directing
it toward the umbilicus. rationale: the angle follows the
normal contour of the rectum. Slow insertion prevents spasms
of the sphincter.
Insert the tube 3-4 inches (7-10cm). rationale: because the
anal canal is about 2.5-5 cm (1-2 in) long in the adult insertion
to this point places the tip of the tube beyond the anal
sphincter into the rectum.
if persistence is encountered at the internal sphincter, ask the
client to take a deep breath, then run a small amount of
solution through the tube to relax the internal anal sphincter.
never force tube or solution entry. Check for any stool that
may have block the tube during insertion. If present, flush it
and retry the procedure. You may also perform digital rectal
examination to determine impaction of other mechanical
blockage. If resistance persists end the procedure and report
the resistance to the primary care provider or nurse in charge.
slowly administer the enema solution
raise the solution container and open the clamp to allow fluid flow
or compress pliable container by hand.
during most low enemas, hold or hang the solution container no
higher than 30 cc (12 in) above the rectum. rationale: the higher
the solution container is held above the rectum, the faster the flow
and the greater the force pressure in the rectum. During a high
enema, hang a solution container 45 cm (18 in) rationale: the fluid
must be instilled further to clean the entire bowel. See agency
protocol.
Administer the fluids slowly. if the client complains of fullness or
pain, lower the container or use the clamp to stop the flow for 30
seconds, and then restart the flow in a slower rate.
rationale: administering the enema slowly and stopping the flow
momentarily decrease the likelihood of intestinal spasm and premature
ejection of the solution
if you are using a plastic commercial container, roll it up as the fluid
is instilled. This prevents subsequent suctioning of the solution.
after all the solution has been instilled or when the client cannot
hold anymore and feels the desire to defecate (the urge to defecate
usually indicates that sufficient fluid has been administered), close
the clamp, and remove the enema tube from the anus.
place the enema tube in a disposable towel as you withdraw it.
encourage the client to retain the enema
ask the client to remain lying down. it is easier for
the client to retain the enema when lying down
than when sitting or standing because gravity
promotes drainage and peristalsis.
request that the client retain a solution for the
appropriate amount of time, for example, 5-10
minutes for a cleansing enema for at least 30
minutes for a retention enema.
assist the client to defecate.
assist the client to a sitting position on the bedpan,
commode or toilet. a sitting position facilitates the
act of defecation.
ask the client who is using the toilet not to flush it.
the nurse needs to observe the feces.
if a specimen of feces is required, ask the client to
use a bedpans or commode.
document the type and volume if appropriate
of enema given. describe the results.
Fluids and electrolytes
BODY FLUIDS AND ELECTROLYTES

The proportion of human body composed


of fluid is surprisingly large.
Approx. 60% of the average healthy adults
weight is water, the primary body fluid.
In good health this volume remains
relatively constant and the person weight
varies by less than 0.2 kg (0.5lbs) in 24
hours, regardless of the amount of the fluid
ingested.

water
is vital to health and normal cellular function, serving as:
a medium for metabolic reactions within cells
a transporter for nutrients, waste products and other substances
a lubricant
an insulator and shock absorber
one means of regulating an maintaining body temperature.
age, sex, and body fat affect total body water.
infants have the highest proportion of water, accounting for 70%
to 80% of their body weight.
the proportion of body water decreases with aging.
women also have a lower percentage of body water than men
women and the elderly have reduced body water due to
decreased muscle mass and a greater percentage of fat tissue.
fat tissue is essentially free of water whereas lean tissue
contains a significant amount of water. Water makes up a
greater percentage of a lean persons body weight than an
obese person
DISTRIBUTION OF BODY FLUIDS
Intracellular fluid (ICF)
found within the cells of the body; it constitutes approximately 2/3
of the total body fluid in adults.
Extracellular fluid (ECF)-
is found outside the cells and accounts for about 1/3 of the total
body fluid; it is subdivided into compartments: intravascular and
interstitial.
Intravascular fluid or plasma-
accounts for approximately 20% of ECF and is found within the
vascular system.
Interstitial fluid-
accounting for approximately 75% of the ECF, surrounds the cells
Transcellular fluid-
another ECF compartment which include cerebrospinal,
pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and
synovial fluids.
COMPOSITION OF BODY FLUIDS
extracellular and intracellular fluids contain:
oxygen from the lungs,
dissolved nutrients from the GI tract,
excretory products of metabolism such as carbon dioxide,
and charged particles called ions.
the salt sodium chloride breaks up into 1 ion of sodium
(Na+) and 1 ion of chloride (Cl-).
These charged particles are called electrolytes because they
are capable of conducting electricity.
cations- positively charged ions. an example of which is Na, K, Ca, Mg
anions- negatively charged ions e.g. Cl, HCO3, HPO42- and SO42-
Electrolytes are generally measured by milliequivalent
per Liter of water (mEq/L) or milligrams per 100 milliliters
(mg/100mL).
Milliequivalent- refers to the chemical combining power
of the ion or the capacity of cations to combine with
anions to form molecules.
MOVEMENT OF THE BODY
FLUIDS AND ELECTROLYTES
The body fluid compartment are separated from
one another by:
cell membranes and
capillary membrane
these membranes are completely permeable to water,
they are considered to be selectively permeable to solutes as
substance to moves across them with varying degrees ease.
Small particles such as ions, oxygen and carbon
dioxide is moved across this membranes but
larger molecules like glucose and proteins have
more difficulty moving between fluid
compartments.
MOVEMENT OF THE BODY
FLUIDS AND ELECTROLYTE
The methods by which the electrolytes and
other solutes move are:
Osmosis-
the movement of water across cell membranes
from the less concentrated solution to the more
concentrated solution.
In other words, water moves toward the higher
concentration of solute in an attempt to equalize
the concentrations.
MOVEMENT OF THE BODY
FLUIDS AND ELECTROLYTE
The methods by which the electrolytes and
other solutes move are:
Filtration-
process whereby fluid and solutes move together
across the membrane from one compartment to
another.
The movement is from an area of higher pressure to
one of lower pressure.
Filtration pressure- pressure in the compartment that
results in the movement of the fluids and the substances
dissolve in fluid of the compartment.
Hydrostatic pressure- pressure exerted by a fluid by a
fluid within a closed system on the walls of a container in
which it is contained.
MOVEMENT OF THE BODY
FLUIDS AND ELECTROLYTE
The methods by which the electrolytes and
other solutes move are:
Active Transport-
movement of substances across cell membrane from
a less concentrated solution to a more concentrated
one.
This process differs from diffusion and osmosis in that
metabolic energy is expended.
Average daily Fluid Intake for an
Adult
Source Amount (mL)
Oral fluids 1,200 to 1,500
Water in food 1,000
Water as by-product 200
of food metabolism
TOTAL 2,400 to 2,700
MONITORING FLUID AND INTAKE
AND OUTPUT
teach and provide the rationale for monitoring fluid intake and output to
the client and family as appropriate.
Include how to use a commode, collection device (hat) in the toilet.
How to empty a urinary catheter drainage and how to count or weight the
diapers.
instruct and provide the rationale for regular weight monitoring to the
client and family.
weigh at the same time of day, using the same scale and with the client
wearing the same amount of clothing.
educate and provide rationale to the client and family on when to
contact a health care provider, such as:
in the cases of significant change in urine output;
any change of 5 lbs or more in a 1-2 week period;
prolonged episodes of vomiting, diarrhea or inability to eat or drink;;
dry, sticky mucus membranes;
extreme thirst;
swollen fingers; feet, ankles, or legs;
difficulty breathing, shortness of breath, or rapid heartbeat and
changes in behaviour or mental status.
MAINTAINING FOOD AND FLUID
INTAKE
Instruct the client and family about nay diet or fluid
restrictions such as low Na diet.
Teach family members the rationale for the
importance of offering fluids regularly to clients who
are unable to meet their own needs because of age,
impaired mobility or cognitions or other conditions
such as impaired swallowing due to a stroke.
If the client is on enteral or IV fluids and feeding at
home, teach and provide the underlying rationale to
caregivers about proper administration and care.
Contact a home health or home IV service to provide
services and teaching.
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
AGE
GENDER AND BODY SIZE
ENVIRONMENTAL TEMPERATURE
LIFESTYLE
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
AGE
Infants and children have much greater fluid turn
over than adults
High BMR-increases fluid loss
Lose more fluid bec. Kidneys are immature; less able
to conserve water
Respirations are more rapid
Body surface area is proportionately greater than that
of an adult- increased insensible fluid loss
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
AGE
In elderly, normal aging process may affect fluid
balance
Thirst response is blunted
Nephrons become less able to conserve water
Other diseases increases risk for fluid and electrolytes
imbalance
Thinner, more fragile skin and veins- make IV insertion
more difficult
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
GENDER AND BODY SIZE
Fat cells contain little or no water
Lean tissue has higher water content
People with higher percentage of body fat have less
body fluid
Women have:
more body fat
Less body water
52% of adult womans weight -water
Man
60% of adult mans weight-water
Obese individual:
30-40% of the body weight-water
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
ENVIRONMENTAL TEMPERATURE
ill people
In strenuous activities
Hot environment
FACTORS AFFECTING BODY FLUID,
ELECTROLYTES AND ACID BASE BALANCE
LIFESTYLE
Diet
Exercise
stress