Chapter 1

Nursing Images throughout History 1) The angle of mercy 2) The handmaiden 3) The battle-ax 4) The naughty nurse 5) The military image A. Nurses on the battlefield * Hospitalers – specialized soldiers who at the end of battle returned to the outposts to care for the sick and injured * Army nursing service – organize nurses and hospitals and coordinate supplies for the soldiers during the Civil War * Clara Barton a. Provided care in tents set up close to the fighting b. Did not discriminate c. Establishment of the American Red Cross * Harriet Tubman – helped slaves escape to freedom on the underground railroad * Walt Whitman – a poet * Louisa May Alcott – an author * Dorothea Dix – union’s superintendent of female nurses during the Civil War B. Nurses fighting diseases * Florence Nightingale d. Epidemiology – the study of the distribution and origins of disease e. Air, light, nutrition, and adequate ventilation and space assist the patient to recuperate * Lillian Wald & Mary Brewster f. Founded the Henry Street Settlement in NY to improve the health and social conditions of poor immigrants g. Improve health and prevent illness by promoting safe drinking water, adequate sewage facilities, and proper sanitation

Florence Nightingale (1820-1910) * “Lady of the Lamp” * Walked through the camp at night providing care to the sick and wounded during the Crimean War * Major contributions: * Establishment of nursing as a distinct profession * Introduction of a broad-based liberal education for nurses * Major reform in the delivery of care in hospitals * Introduction of standards to control the spread of disease in hospitals * Major reforms in the healthcare for the military

Full-Spectrum Nurse * Clinical judgment – observing, comparing, contrasting, and evaluating the client’s condition to determine whether change has occurred * Critical thinking – reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action * Problem solving – a process by which nurses consider an issue and attempt to find a satisfactory solution to achieve the best outcomes

Dependent Nursing Activities * Administering prescribed medication * Assisting with a diagnostic test (opening trays, handing instruments to the physician) * Administering IV fluids * Ensuring that the patient receives the prescribed diet
Independent Nursing Activities * Evaluating the patient’s response to medication and withholding the next dose if the patient has a negative reaction * Teaching the patient what to expect from the diagnostic test * Preparing the patient for the test (shaving a site) * Supporting the patient during the test * Evaluating the patient’s response to treatment; monitor flow rate; evaluating the injection site for redness or leakage * Teaching a pregnant woman about additional nutrients needed in her diet

How Is Nursing Defined? * International council of nurses (ICN) – an organization representing nurses throughout the world * The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge (Henderson, 1966) * Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles (ICN, 2007) * Nursing association (ANA, CNA) * The diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980) * Six essential features of professional nursing (ANA, 2004): 1. Provision of a caring relationship 2. A holistic approach (human responses to health and illness within the physical and social environments) 3. Integration of objection data with knowledge of the patient’s subjective experience 4. Application of scientific knowledge through the use of judgment and critical thinking 5. Advancement of professional nursing knowledge through scholarly inquiry 6. Influence of social and public policy to promote social justice * The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and population (ANA, 2010) * Reasons for multiple nursing definitions: * Help the public understand the value of nursing * Describe what activities and roles belong to nursing versus other health professions * Help students and practicing nurses understand what is expected of them within their role as nurses

Roles & Functions of the Nurse ROLE | FUNCTION | EXAMPLES | Direct care provider | Addressing the physical, emotional, social, and spiritual needs of the client | Assessing the clientGiving medicationsPatient teaching | Communicator | Using interpersonal and therapeutic communication skills to address the needs of the client, to facilitate communication in the healthcare team, and to advise the community about health promotion and disease prevention | Counseling a clientDiscussing unit staffing needs at a meetingProviding HIV education at a local school | Client/family educator | Assessing and diagnosing the teaching needs of the client, group, family, or community. Once the diagnosis is made, nurses plan how to meet these needs, implement the teaching plan, and evaluate its effectiveness | Preoperative teachingPrenatal education for siblingsCommunity classes on nutrition | Client advocate | Supporting clients’ right to make healthcare decisions when they are able to voice their opinions and protecting clients from harm when they are unable to make decisions | Helping a client explain to his family that he does not want to have further chemotherapy | Counselor | Using therapeutic communication skills to advise clients about health-related issues | Counseling a client on weight-loss strategies | Change agent | Advocating for change on an individual, family, group, community, or societal level that enhances health. The nurse may use counseling, communication, and educator skills to accomplish this change | Working to improve the nutritional quality of the lunch program at a preschool | Leader | Inspiring others by setting an example of positive health, assertive communication, and willingness to improve | Florence NightingaleWalt WhitmanHarriet Tubman | Manager | Coordinating and managing the activities of all members of the team | Charge nurse on a hospital unit (assigns patients and work to staff nurses) | Case manager | Coordinating the care delivered to a client | Coordinator of services for clients with tuberculosis | Research consumer | Applying evidence-based practice to provide the most appropriate care, to identify clinical problems that warrant research, and to protect the rights of research subjects | Reading journal articlesAttending continuing education; seeking additional education |

Is Nursing a Profession, Discipline, or Occupation? * To be considered a profession (Starr, 1982): * The knowledge of the group must be based on technical and scientific knowledge * The knowledge and competence of members of the group must be evaluated by a community of peers * The group must have a service orientation and a code of ethics * To be considered a discipline: * A profession must have a domain of knowledge that has both theoretical and practical boundaries * Theoretical boundaries of a profession are the questions that arise from clinical practice and are then investigated through research * Practical boundaries are the current state of knowledge and research in the field * Occupation or job – nurses are hourly wage earners

Improving the status of nursing: * Standardizing the educational requirements for entry into practice * Enacting uniform continuing education requirements * Encouraging the participation of more nurses in professional organizations * Educating the public about the true nature of nursing practice

Formal Education 1) Practical and vocational nursing education * Prepares nurses to provide beside care to clients * 1 year * Must pass the NCLEX-PN exam * Works under the direction of the registered nurse or the PCP 2) Registered nursing entry education * Diploma programs – lasts 3 years and focuses on clinical experience in direct patient care * Associate degree programs – lasts 2 years and prepare nurses to provide direct patient care; 53% * Baccalaureate degree programs – lasts 4 years (8 semesters) and prepares nurses provide direct patient care, to work in community care, to use research, and to enter graduate education; 42% * Master’s entry programs – lasts 3 years of full time study and prepares RNs to function in a more independent role (advanced practice nurses or educators) * Doctoral entry – nursing doctorate path parallels the pathway through which physicians enter the healthcare field * Doctor of nursing science (DNS) – prepares the nurse for advanced clinical practice * Doctor of philosophy (PhD) – research degree * Continuing education – a professional strategy to keep up with current clinical knowledge * In-service education – offered at work site; institution specific, product specific, or non-generalization information (use of new equipment or the introduction of new policies)

Informal Education * Socialization – informal education that occurs as you move into your new profession; knowledge is gained from direct experience, observation in the real world, and informal discussion with peers and colleagues * Benner’s Model: 1) Stage 1: Novice * Begins with the onset of education * “Learning the rules” of the profession 2) Stage 2: Advanced beginner * Nurses improve in performance through repeated experiences or mentoring * Begins to recognize the elements of a situation * Use more facts and is more sophisticated with use of the rules * New graduate function at this level 3) Stage 3: Competence * Able to handle their patient load and prioritize situations * Involved in their caregiving role and may be emotionally involved in the clinical choices made * Do not fully grasp the overall scope and most important aspects 4) Stage 4: Proficient * Sees the “big picture” and can coordinate services and forecast needs 5) Stage 5: Expert * Sees what needs to be achieved and how to do it * Nursing organization guidelines – ANA provides guidelines for nurses to conduct themselves in their day to day practice

Nursing Values & Behaviors * The nurse’s primary concern is the good of the patient * Nurses ought to be competent * Nurses demonstrate a strong commitment to service * Nurses believe in the dignity and worth of each person * Nurses constantly strive to improve their profession * Nurses work collaboratively within the profession

How Is Nursing Practice Regulated? * Nurse practice act – laws that regulate nursing practice * Board of nursing is responsible for: A. Defining the practice of nursing B. Establishing criteria that allow a person to be considered a RN or LPN/LVN C. Determine activities that are in the scope of practice of nursing D. Enforcing the rules that govern nursing * Standards of practice – provide a means by which a profession clearly describes the focus of its activities, the recipients of service, and the responsibilities for which its practitioners are accountable * Standard of care – assessment, diagnosis, outcome identification, planning, implementation, coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment, and evaluation * Standard of professional performance – ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collegiality, collaboration, professional practice evaluation, resource utilization, environmental health * CNA standards of nursing practice: * Professional service to the public * Knowledge-based practice * Continuing competence * Ethical practice * Professional responsibilities and accountability * Self-regulation and professional accountability * Professional leadership

Nursing Organizations 1) American and Canadian Nurses Associations (ANA, CNA) * Official professional organizations for nurses * Previously known as the Nurses’ American Alumnae of the U.S. and Canada * Focused on establishing standards of nursing to promote high-quality care and work toward licensure * CNA is responsible for administering the nursing licensure exam; publishing Canadian Nurse * Board of nursing are responsible for administering the nursing licensure exam in the U.S. 2) National League for Nursing (NLN) * First nursing organization with a goal to establish and maintain a universal standard of education * Publishes the journal Nursing Education Perspectives * Originally founded as the American Society of Superintendents of Training Schools for Nurses in 1893 3) International Council of Nursing (ICN) * Represents nursing on a global level * Ensure quality nursing care for all * Supports global health policies that advance nursing and improve worldwide health * Strives to improve working conditions for nurses throughout the world 4) National Student Nurses Association (NSNA) * Represents nursing students in the U.S. * Sponsors yearly conventions to address the concerns of nursing students * Publishes Image – a journal dedicated to nursing student issues 5) Sigma Theta Tau International (STTI) * National honor society for nursing * The goal of this organization is to foster nursing scholarship, leadership, and research 6) Specialty Organizations * Clinical specialty: * AORN – association of operating room nurses * ANAC – association of nurses in AIDS care * HPNA – hospice and palliative nurses association * ENA – emergency nurses association * AWHONN – American association of women’s health, obstetric and neonatal nurses * Group identification: * NOADN – national organization for association degree nursing * NAHN – national association of Hispanic nurses * AMN – American assembly for men in nursing * NBNA – national black nurses association * Similar values: * NCF – nurses Christian fellowship * NEN – nursing ethics network

Recipients of Nursing Care * Direct care – involves personal interaction between the nurse and clients (giving medications, dressing a wound, or teaching a client about medicines or care) * Indirect care – when nurses work on behalf of an individual, group, family, or community to improve their health status (restocking the code blue cart, ordering unit supplies, or arranging unit staffing)

Purpose of Nursing Care 1. Health promotion * Health – a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 1948) * Health promotion – activities foster the highest state of well-being of the recipient of the activities 2. Illness prevention * Illness prevention – focuses on avoidance of disease, infection, and other comorbidities * Teach the importance of hand hygiene to decrease the transmission of infection * Advocate for and administer pneumonia immunization to those at high risk * Promote smoking cessation 3. Health restoration * Health restoration – activities foster a return to health for those already ill * Provide direct care to all ill individuals * Provide hygiene and nutrition for someone unable to do so independently * Administer medications to treatments * Counseling individuals or groups * Lobby for policy changes to improve access to care for an underserved group 4. End of life care * Promote comfort * Maintain quality of life * Provide culturally relevant spiritual care * Ease the emotional burden of death

Where Do Nurses Work? * 60% of nurses work in the hospitals; the remaining 40% work in extended care facilities, ambulatory care, home health settings, public health, or nursing education * Hospitals – provide services to patients who require around the clock nursing care; acute care (24 hour observation) * Extended care facilities – provide care for clients for an extended period of time (more than 1 month) * Skilled care – services of trained professionals that are needed for a limited period of time after an injury or illness * Custodial care – consists of help with activities of daily living (bathing, dressing, eating, grooming, ambulation, toileting, and other care that people typically do for themselves) * Types of extended care facilities: * Nursing home – provides custodial care for people who cannot live on their own but are not sick enough to require hospitalization * Skilled nursing facility (convalescent hospital) – primarily provides skilled nursing care for patients who can be expected to improve with treatment * Rehabilitation facilities * Ambulatory care (outpatient care) – private health and medical offices, clinics, and outpatient therapy centers; treats only common ailments * Home care – provided to clients who are homebound or unable to get to ambulatory care centers for services; particularly when the client is terminally ill * Community health – provide services to at risk populations and devise strategies to improve the health status of the surrounding community (healthcare for the homeless and school-based programs designed to decrease the incidence of teen pregnancies)

QSEN Commission & Quality Improvement * Quality and safety education for nurses project and the institute of medicine (IOM) have identified the following quality and safety competencies for nurses: * Patient centered care * Teamwork and collaboration * Evidence-based practice * Quality improvement * Safety * Informatics * One important QSEN competency is quality improvement (QI) – the ability to “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems”

Factors That Influence Contemporary Nursing Practice (Trends in Society) * The national economy * Health insurance coverage is linked to full-time employment with health insurance benefits * Fearing the high cost of healthcare, many uninsured people delay seeking treatments * Downturns in the economy affect institutional investments and profits, and the amount of taxes the government can collect; these in turn limit the medications and services that are available * The growing proportion of older adults in the U.S. creates a need for more medical and nursing care * The role of the healthcare consumer * Consumers are demanding greater choice in the decisions that affect their health * Patients have access to vast amounts of health and medical information, particularly through the internet * Direct-to-consumer marketing – advertise medications and therapies directed at the potential user (appears on the internet, in magazines, on television, on billboards, and in newspapers) * Consumer interest has also generated legislation that affects nursing care * Confidentiality of patient records * Patient’s right to know (informed consent) * Patient’s right to a dignified death (living will/advanced directives) * The women’s movement – opened up more career choices for women * Collective bargaining * A form of negotiating that allows nurses to seek better wages and working conditions as a group rather than individually * Union or organization * Improvements in wages, benefits, and working conditions for nurses, as well as safer conditions for patients

Factors That Influence Contemporary Nursing Practice (Trends in Nursing & Healthcare) * Increased use of complementary and alternative medicine * Complementary and alternative medicine (CAM) – healthcare treatments or services outside the traditional healthcare system * Homeopathy, naturopathy, chiropractic, herbal medications, dietary changes, massage therapy, yoga, aromatherapy, prayer, and hypnotism * Factors that have contributed to the interest in CAM: * Rising costs of traditional care, including the costs of insurance and medications * Widespread media reporting of treatment errors * Growing distrust of the role of insurance and managed care organizations in determining treatment options * Constantly changing health recommendations over the last 20 years * Increasing cultural diversity of the population, and the accompanying exchange of information about therapies from different cultural traditions * Creation of the national center for complementary and alternative medicine at the national institutes of health * Expanded variety of settings for care * More than 30% of RNs now work outside the hospital settings * Nurses must be prepared to function more autonomously and creatively * Interest in interprofessional collaboration * Collaboration – the process of joint decision-making among independent parties, involving joint ownership of decisions and collective responsibility for outcomes * Increased use of advanced practice nurses * High patient satisfaction with APNs * Better understanding of and compliance with treatment regimen * Fewer hospitalizations * Greater cost effectiveness when it compared with physician providers * Increased use of nursing assistive personnel * Healthcare providers who help nurses and physicians provide patient care * Nurse aide, assistant, orderly, and technician * Perform simple tasks (bathing, taking temperature, or making beds) under the direction of the licensed nurse * Influence of nurses on healthcare policy * Divergence between high-tech and high-touch * Advances in clinical knowledge and technology have contributed to improved care for many patients who are critically ill * Prolonging life, technology has created numerous legal and ethical dilemmas, particularly about end-of-life care

Chapter 35
Part 1: Oxygenation

Oxygenation – how well the cells, tissues, and organs of the body are supplied with oxygen; the pulmonary, cardiovascular, musculoskeletal, and neurological systems work together to achieve oxygenation

Pulmonary System * The airway: nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles * Moisten the air * Warm the air * Filter the air * Upper airway – located above the larynx, includes the nasal passages, mouth, and pharynx * Lower airway – located below the larynx, includes the trachea, bronchi, and bronchioles; sterile * The lungs: * Separated by the mediastinum, which contains the heart and great vessels * Type I alveolar cells – gas exchange cells * Type II alveolar cells – produce surfactant, a lipoprotein that lowers the surface tension within alveoli to allow them to inflate during breathing

Functions of the Pulmonary System A. Ventilation – the movement of air into and out of the lungs through the act of breathing B. Respiration – the exchange of the gases oxygen and carbon dioxide in the lungs

Pulmonary Ventilation A. How does ventilation occur? * Inhalation – caused by expansion of the chest cavity and lungs, which causes negative pressure inside the lungs * Diaphragm – major muscle of breathing * Exhalation – occurs when the diaphragm and intercostal muscles relax, allowing the chest and lungs to return to their normal resting size B. What factors affect the adequacy of ventilation? * Respiratory rate and depth – rate is how fast you breathe and depth is how much your lungs expand to take in air * Hyperventilation * Occurs when a person breathes fast and deeply to move a large amount of air through the lungs, causing too much carbon dioxide to be removed by the alveoli * Occurs in response to hypoxemia – low level of oxygen in the blood * Triggered by medications, central nervous system abnormalities, high altitude, heat, exercise, panic, fear, or anxiety * Hypoventilation * Occurs when a decreased rate or shallow breathing moves only a small amount of air into and out of the lungs * Hypoxemia will lead to hypoxia – an oxygen deficiency in the body tissues * Lung compliance * Ease of lung inflation * Reduced by conditions that cause elastin fibers to be replaced with scar tissues (collagen), increased lung water (edema), or loss of surfactant * Lung elasticity (elastic recoil) * Refers to the tendency of the elastin fibers to return to their original position after being stretched * Emphysema * Loss of elasticity allows the lungs to inflate easily but inhibits deflation, leaving stale air trapped in the alveoli

* Airway resistance – resistance to airflow within the airway * Secretions in the airway or mild bronchospasm increase airway resistance
Respiration
* Respiration – gas exchange, the oxygenation of blood and elimination of carbon dioxide in the lungs * External respiration (alveolar-capillary gas exchange) – oxygen diffuses across the alveolar-capillary membrane into the blood of the pulmonary capillaries; carbon dioxide diffuses out of the blood and into the alveoli to be exhaled * Conditions that slow diffusion: * Pleural effusion – fluid in the lungs * Pneumothorax – lung collapse * Asthma – bronchospasms * If blood is not adequately oxygenated in the alveoli, hypoxemia occurs * Internal respiration (capillary-tissue gas exchange) – oxygen diffuses from the blood through the capillary-cellular membrane into the tissue cells, where it is used for metabolism. From the cells, carbon dioxide diffuses through the capillary-cellular membrane into the blood, from where it is transported to the lungs and exhaled

How Is Breathing Controlled? * Chemoreceptor – located in the medulla of the brainstem, the carotid arteries, and the aorta detect changes in blood pH, oxygen, and carbon dioxide levels, and they send messages back to the central respiratory center in the brain stem (CO2 level is the primary stimulus to breathe) * Lung receptors – located in the lung and chest wall, are sensitive to breathing patterns, lung expansion, lung compliance, airway resistance, and respiratory irritants

Factors Influence Pulmonary Function 1. Developmental stage * Premature infants are at high risk for respiratory distress syndrome (RDS) * Toddlers – high risk for upper respiratory infection; airway obstruction, and drowning * Preschool and school age children – viral infection (croup and pneumonia), exercise induced asthma, social habits (tobacco use) * Adolescents – tobacco use (addiction) and exercise induced exercise * Young, middle, and older adults * Reduced lung expansion and less alveolar inflation * Difficulty expelling mucus or foreign material * Diminished ability to increase ventilation and exhalation becomes less efficient (causes air trapping) * Gastroesophageal reflux disease is more common in older adults, creating a risk for aspirating stomach contents into the lungs * Pneumonia and hypoxemia 2. Environmental factors * Stress – stimulates the release of catecholamine from the sympathetic nervous system: increased tendency of blood to clot (pulmonary embolus) * Allergic reactions * Allergy – hypersensitivity, or over-response, to an antigen (dust mite, cockroach particles, pollen, molds, newsprint, tobacco smoke, animal dander, foods) * Hay fever – an allergic reaction affecting the eyes, nose, and/or sinuses; causes the release of histamine (treated with anti-histamine) * Asthma – an allergic reaction occurring in the bronchioles of the lungs; slow reacting substance of anaphylaxis is released, which causes bronchoconstriction and lower airway edema and spasms, making breathing difficult and ineffective * Air quality – automobile exhaust emissions, carbon monoxide, nitrogen oxides, radon, and suspended particles (dust, mold spores, aerosols, and tobacco smoke) may cause headache and coughing

* Altitude * Low oxygen levels at high altitudes can cause hypoxemia and hypoxia * Changes include increase in the following: 1. Ventilation – brings more oxygen into the lungs 2. Production of red blood cells (RBCs) – transport oxygen to organs and tissues 3. Lung volume and pulmonary vasculature – increase surface area for alveolar-capillary gas exchange 4. Vascularity of body tissues – improve oxygen delivery to the tissues 5. Production of hemoglobin – readily bind with oxygen 3. Lifestyle * Pregnancy – oxygen demand and metabolism increases; maternal respiratory rate increases in order to increase minute ventilation (amount of air moved into and out of the lungs in 1 minute) * Occupational hazards * Chemicals and their fumes – irritate the sensitive membranous lining of the lungs and airways and may lead to lung cancer or leukemia * Products of combustion (carbon monoxide) – causes lung cancer and chronic lung disease * Microorganisms (viruses, fungi, mold) – lead to infections and precipitate asthmas * Fine particles (coal dust and asbestos) – suspended in the air can be inhaled into the smallest airways, causing irritation and toxic reactions (cancer) * Nutrition – poor nutrition can lead to loss of ventilatory muscle strength, making breathing difficult * Obesity * Respiratory infections – excess abdominal fat presses upward on the diaphragm, preventing full chest expansion, leading to hypoventilation and dyspnea on exertion; lower lung lobes are poorly ventilated and secretions are not removed effectively * Sleep apnea – excess neck girth and fat deposits in the upper airway often lead to obstructive sleep apnea, a condition characterized by daytime sleepiness, loud snoring, and periods of apnea lasting 10-120 seconds * Exercise – increases metabolic demands; sedentary lifestyle reduces the capacity to increase ventilation * Smoking * Mainstream smoke – inhaled directly from the cigarette and then exhaled * Sidestream smoke – released from the burning tip of a cigarette into the air * Constricts bronchioles, increases fluid secretion into the airways, causes inflammation and swelling of the bronchial lining, and paralyzes cilia – reduce airflow and increase production of secretions * Leads to chronic bronchitis, obstruction of bronchioles and alveolar walls, and emphysema * Substance abuse * Excess use or overdose of respiratory depressants such as opioids, sedatives, antianxiety agents, and hypnotics can cause death due to hypoventilation, apnea, and respiratory failure * Large amounts of alcohol depress respiratory and vasomotor centers of the brain * Illicit drugs, including stimulants (amphetamines, cocaine, hallucinogens: LSD, PCP) and marijuana depress respirations and increase the risk for aspiration 4. Medications * Respiratory depressants (general anesthetics, opioids: morphine, antianxiety drugs: diazepam, valium, sedative-hypnotics: barbiturates, neuromuscular blocking agents, magnesium sulfate) depress central nervous system control of breathing or by weakening the muscles of breathing * Drugs that block beta-2 adrenergic receptor can lead to serious bronchiole constriction in people with asthma * Medications used to improve respiratory function: bronchodilators, anti-inflammatory agents (corticosteroids), cough suppressants, expectorants, and decongestants

5. Pathophysiological conditions * Problems with gas exchange * Hypoxemia – low arterial blood oxygen levels * Hypoxia – inadequate oxygenation of organs and tissues; altered level of consciousness, poor urine output, muscle weakness and pain with exercise * Hypercarbia (hypercapnia) – an excess of dissolved carbon dioxide in the blood; can lead to somnolence progressing to coma and death, a syndrome known as carbon dioxide narcosis * Hypocarbia (hypocapnia) – a low level of dissolved carbon dioxide in the blood; causes muscle twitching or spasm (hand and feet) and numbness and tingling in the face and lips * Poor peripheral circulation is characterized by weak or absent pulses, mottling (skin marbling), pale, ashen, or cyanotic skin and mucous membranes, and cool skin temperature * Respiratory infections * Upper respiratory infection – symptoms include stuffy nose, sore throat, cough, sneezing, tearing, and a mild fever * Influenza – in addition to cold-like symptoms, the person may experience headache, fatigue, weakness, exhaustion, and high fever * Lower respiratory tract infections – acute bronchitis, respiratory syncytial virus, pneumonia, tuberculosis * Pulmonary system abnormalities * Structural abnormalities – restrict or limits the free movement of the chest wall, interruptions in the chest cavity that inhibit inflation of the lungs, or a collection of fluid in the pleural space that inhibits lung expansion * Airway inflammation & obstruction * Alveolar-capillary membrane disorders – change in the consistency of the lung tissue; pulmonary edema, acute respiratory distress syndrome, and pulmonary fibrosis * Atelectasis – tumor or obstructed airway can cause alveolar collapse * Pulmonary circulation abnormalities * Pulmonary embolus – obstruction of pulmonary arterial circulation by blood clot, air, or fat * Pulmonary hypertension – elevated pressure within the pulmonary arterial system; causes right-sided heart failure, with a reduced amount of blood pumped into the pulmonary circulation * Central nervous system abnormalities * Trauma * Cerebrovascular accident (stroke) * Spinal cord injuries – limit diaphragm function * Neuromuscular abnormalities * Guillain barre syndrome, amyotrophic lateral sclerosis, myasthenia gravis – affect the nerves involved in breathing can also depress respiratory function

Signs of Respiratory Effort/Dyspnea 1. Nasal flaring 2. Retractions 3. Use of accessory muscles during inspiration 4. Grunting – caused by involuntary muscle contraction during expiration to help keep alveoli open and enhance gas exchange 5. Body positioning to facilitate respirations 6. Paroxysmal nocturnal dyspnea – sudden awakening due to SOB that begins during sleep 7. Conversational dyspnea 8. Stridor – high pitched, harsh, crowing, inspiratory sound caused by partial obstruction of the larynx or trachea 9. Wheezing – musical sound produced by air passing through partially obstructed small airways (patients with asthma and lung congestion) 10. Diminished or absent breath sounds – requires oxygen therapy

Significance of Sputum Appearance * White or clear – viral infection (common cold, viral bronchitis) * Yellow or green – sign of infection * Black – caused by coal dust, smoke, or soot inhalation * Rust colored – pneumococcal pneumonia, TB, possibly the presence of blood * Hemoptysis – coughing up of blood or bloody sputum * Pink and frothy – pulmonary edema

Diagnostic Testing 1. Skin testing * Tuberculin skin testing – used to detect exposure and antibody formation to the tubercle bacillus * Allergy testing – used to identify antigens that may cause hypersensitivity reaction in susceptible individuals 2. Pulse oximetry * A noninvasive estimate of arterial blood oxygen saturation (Sao2) * Sao2 – reflects the percentage of hemoglobin molecules carrying oxygen * 95-100% 3. Capnography * Measures carbon dioxide in inhaled and exhaled air * Directly measures ventilation and indirectly measures the partial pressure of CO2 in the arterial blood * More reliable indicator of respiratory depression * Situation in which it is used: * Patient receiving opioids * During general anesthesia * Critical care patients * Obstructive sleep apnea * Monitoring infants with respiratory distress * Adjusting parameter settings in mechanically ventilated patients * Validating endotracheal tube placement * CO2 detectors – chemically treated papers that changes color when exposed to CO2 4. Spirometry – measures the air that moves into and out of the lungs 5. Arterial blood gases * Measures the levels of oxygen and carbon dioxide in arterial blood * Measure pH, partial pressure of oxygen (Po2), partial pressure of carbon dioxide (Pco2), saturation of oxygen (Sao2), and bicarbonate (HCO3) * Hemoglobin – iron containing pigment of red blood cell that, as oxyhemoglobin, carries oxygen in the blood * Partial pressure of oxygen (Po2) – the amount of oxygen available to combine with hemoglobin to make oxyhemoglobin * Saturation of oxygen (Sao2) – reflects oxygen that is bound to hemoglobin * Partial pressure of carbon dioxide (Pco2) – measure of the CO2 dissolved in the blood; 35-45 mm Hg 6. Peak flow monitoring * Peak expiratory flow rate (PEFR) – measures the amount of air that can be exhaled with forcible effort * Expressed in liters per minute

Problems of Ventilation & Gas Exchange * Ineffective airway clearance – inability to maintain a clear airway * Ineffective breathing pattern – inadequate ventilation: hypoventilation, hyperventilation, tachypnea, or bradypnea * Impaired gas exchange – patient is ventilating adequately but diffusion of gases across the alveolar-capillary membrane is impaired * Impaired spontaneous ventilation – unable to maintain breathing adequate to support life * Dysfunctional ventilatory weaning response – patient who is being mechanically ventilated cannot adjust to lower levels of ventilator support, prolonging the ventilatory weaning process * Risk for aspiration – risk for secretions, solids, or fluids entering into tracheobronchial passages (head or neck surgery)

Nursing Interventions/Implementation A. Administering respiratory medications

CLASS | ACTION | EXAMPLES | Bronchodilators | Relax the smooth muscles lining the airways Oral or inhaled medicines | Beta-2 adrenergic agonistsAnticholinergicMethylxanthine | Respiratory anti-inflammatory agents | Combat inflammation in the airwaysTreat and control respiratory conditions characterized by hypersensitive airways inflammation (asthma) | CorticosteroidsCromolynLeukotriene modifiers | Nasal decongestants | Relieve stuffy, blocked nasal passages by constricting local blood vessels through stimulating the alpha-I adrenergic nerve receptors in the vesselsElevate blood pressure, tachycardia, palpitations | EphedrinePseudoephedrinePhenylephrine | Antihistamine | Prevent the effects of histamine releaseTreat upper respiratory and nasal allergy symptoms | Diphenhydramine (Benadryl)Chlorpheniramine (Chlor-Trimeton)Brompheniramine (Dimetane)Loratadine (Claritin)Fexofenadine (Allegra)Cetirizine (Zyrtec) | Cough preparations | Antitussive (cough suppressants) – reduce the frequency of an involuntary, hacking, nonproductive coughExpectorants – help make coughing more productive | |

B. Promoting optimal respiratory function * Prevent upper respiratory infections * URIs may be viral or bacterial * Viral infections last about 10-21 days and are self-limiting * Overuse of antibiotics to treat URIs has contributed to the current crisis of antimicrobial resistance * Prevent influenza * The most effective strategy for preventing influenza is annual vaccination * Avoid contact with people who are sick * Hand hygiene

* Prevent pneumonia * Leading cause of infectious death in the U.S. with a mortality rate of approximately 50% in people older than age 65 * Vaccination * Support smoking cessation * Motivational counseling includes discussion about the connection between tobacco use and current health status, the risks of continued tobacco use, the rewards of quitting, anticipated barriers to quitting, and strategies for addressing barriers * Combining medication and counseling is more effective * 5A’s – ask, advise, assess, assist, arrange * Position for maximum ventilation – upright or elevated position; tripod position for patients with impaired respiratory function * Assist with incentive spirometry * Incentive spirometer – designed to encourage patient to take deep breaths by reaching a goal-directed volume of air * Reserved for patients at risk for developing atelectasis or pneumonia (abdominal, chest, or pelvic surgery, prolonged bed rest, or history of respiratory problems) * Take aspiration precautions – aspiration is at risk for patients with a decreased level of consciousness, diminished gag or cough reflex, or difficulty with swallowing C. Mobilizing secretions * Teach deep breathing and coughing – coughing after deep breathing mobilizes secretions, which keeps airways and alveoli open and provides greater surface area for gas exchange * Maintain hydration * Encourage oral fluid intake; supplement oral intake by intravenous fluid administration if the patient cannot ingest adequate amounts of fluids * Nebulizer – a device that turns liquids into an aerosol mist that can be inhaled directly into the lungs; used to deliver medications to the lungs * Humidifier – a device that delivers small water droplets from a reservoir * Perform chest physiotherapy * Moves secretions to the large, central airways for expectoration or suctioning * Postural drainage – use of positioning to promote drainage from the lungs; uses gravity to drain the lungs * Chest percussion – rhythmic clapping of the chest wall using cupped hands * Chest vibration – vibration of the chest wall with the palms of the hands D. Providing oxygen therapy * Wall outlets – connected to a large central tank of oxygen provided in healthcare facilities * Compressed oxygen in portable tanks * Liquid oxygen tank – home oxygen therapy * Oxygen concentrator – removes nitrogen from room air and concentrates oxygen * Low flow devices – nasal cannula, simple face masks, rebreather masks * High flow devices – venturi masks, aerosol face masks, face tents, and tracheostomy collars * Tracheostomy – surgical opening into the trachea through the neck * Transtracheal catheter - placed into the tracheostomy to deliver oxygen into the trachea * Oxygen hazards: * Reduce surfactant production – leads to alveolar collapse and reduces lung elasticity * Combustion * Oxygen tanks contain oxygen under pressure

E. Using artificial airways * Pharyngeal airways: * Oropharyngeal airways – used in unconscious patients because they trigger gagging, vomiting, or laryngospasm in responsive patients * Nasopharyngeal airways – flexible rubber tubes that are inserted through a nostril into the pharynx

* Endotracheal airways: * Pliable tubes inserted into the trachea through the mouth, nose, an opening directly into the trachea * Cuffed tube is used for patients who are being ventilated or who have difficulty swallowing F. Suctioning airways * Signs that indicate the need for suctioning include: * Agitation * Gurgling sounds during respiration * Restlessness * Labored respirations * Decreased oxygen saturation * Increased heart and respiratory rates * Adventitious breath sounds on auscultation * Yankauer tube – a rigid device for suctioning the oral cavity * Pharyngeal suctioning – performed to prevent oral and nasal secretions from entering the lower airway when the patient is too weak to cough up secretions G. Caring for a patient requiring mechanical ventilation * Mechanical ventilator – a machine that assists a patient to breathe; patient is intubated * Negative pressure ventilator – consists of shells that fit externally around the chest; negative pressure generated inside the shell pulls the chest outward and forces the patient to inhale air; used for chronic conditions (muscle weakness from neuromuscular disease) * Positive pressure ventilator – most widely used and requires the patient to have an artificial airway; can cause barotrauma (injury to the airways due to pressure changes) and drop in cardiac output as the positive pressure in the chest decreases venous return to the heart * Patients being mechanically ventilated are at high risk for developing ventilator-associated pneumonia H. Caring for a patient requiring chest tubes * Hemothorax – accumulation of fluid and blood in the pleural space interferes with lung expansion, ventilation, and gas exchange * Pneumothorax – air in the pleural space creates positive pressure, causing lung tissue to collapse * Tension pneumothorax – occurs when positive pressure builds up in the pleural space and pushes the lungs, great vessels, and heart toward the other side of the chest * Chest-drainage system – remove air or fluid from the pleural space without allowing it to re-enter * Type of drainage systems: * Water-seal systems – consist of one, two, or three chambers * One chamber device – handle only small volumes of fluid or air (from empyema, a collection of pus in the pleural space); serves as both a collector and a water seal * Two chamber device – one chamber connects with the chest tube and serves as a collection bottle, second chamber serves as a water seal; maintains negative pressure as air flows through it; can contribute to labored breathing * Three chamber device – one connected to suction, one connected to the water seal chamber, a long middle tube with one end open to air at the top: control negative pressure * Dry seal systems – one piece device with 3 chambers: fluid collection, dry seal, and dry suction control; mechanical automatic control valve and an air leak monitor allows air to pass out of the patient and prevents it from returning to the patient * Portable systems – drain by gravity; improve ambulation and reduce the risk of deep vein thrombosis and pulmonary embolism

Part 2: The Cardiovascular System

Perfusion – circulation of blood to all body regions

Structures of the Cardiovascular System A. The heart * Four-chambered muscular organ encased in the pericardium (a sac of connective tissue) * Atria – receives blood into the heart * Ventricles – pump blood out of the heart * Deoxygenated blood from organs and tissues flows through the venous system into the right side of the heart and then into the pulmonary circulation * Oxygenated blood flows from the lungs into the left side of the heart and out into the arterial circulation * Cardiac cycle – sequence of mechanical events that occurs during a single heartbeat * Electrical conduction: * Sinoatrial (SA) node – pacemaker; located in the right atrium, it initiates an impulse that triggers each heartbeat * Atrioventricular (AV) node – from the AV node, impulses pass into the left and right bundles of his and into the purkinje fibers to the ventricle B. Systemic & pulmonary blood vessels * Arteries – thick, elastic walls that allow them to stretch during cardiac contraction (systole) and to recoil when the heart relaxes (diastole) * Arterioles – smaller branches of arteries that constrict or dilate to vary the amount of blood flowing into capillaries to help maintain blood pressure * Capillaries – microscopic vessels that facilitate the exchange of gases, nutrients, and wastes between the tissue cells and the blood; connect the arterial and venous systems and carry blood from arterioles to venules * Venous system – returns deoxygenated blood to the heart C. Coronary arteries * Supply the heart muscle with blood * Only arteries in the body that fill during diastole

How is Cardiovascular Function Regulated? * Autonomic nervous system * Sympathetic fibers – stimulate the heart to beat faster and contract more strongly * Parasympathetic stimulation – slows the heart rate * Vascular tone – maintains blood pressure and blood flow even when a person is resting or asleep * Brain stem centers * Vasomotor center – controls sympathetic stimulation of the heart and vascular system * Cardioinhibitory center – controls parasympathetic slowing of the heart rate * Baroreceptors – located in the walls of the heart and blood vessels are sensitive to pressure changes; regulate heart rate and vascular tone * Chemoreceptors – located in the aortic arch and the carotid arteries are sensitive to changes in blood pH, oxygen levels, and carbon dioxide levels; regulate ventilation

Cardiovascular depressants are used to slow the heart rate or reduce the force of myocardial contraction: reduce cardiac output and impair tissue oxygenation * Beta-adrenergic blocking agents * Reduce the work load of the heart * Control abnormal heart rhythms (dysrhythmias) * Control hypertension * Slows the heart and decrease the strength of myocardial contraction * Bisoprolol fumarate (zebetal)

* Calcium channel blocking agents * Block the flow of calcium into cells of the heart and blood vessels * Decrease blood pressure and the strength of myocardial contraction * Slow the heart rate * Dilate the arteries and arterioles * Nifedipine (procardial)

Cardiovascular Abnormalities * Heart failure – the heart becomes an inefficient pump and is unable to meet the body’s demands * Cardiomyopathy – a heart muscle disorder that results in heart enlargement and impaired cardiac contractility * Cardiac ischemia – oxygenation requirements of the heart are unmet; leads to myocardial infarction * Angina pectoris – transient chest pain due to myocardial ischemia * Coronary artery disease – a leading cause of cardiac ischemia, a condition in which plaque builds up inside the coronary arteries * Dysrhythmias – alterations in heart rate or rhythm can lower cardiac output and decrease tissue oxygenation * Heart valve abnormalities – create turbulent flow, leading to a decrease in cardiac output and compromised tissue oxygenation; murmur

Peripheral Vascular Abnormalities * Compromised arterial blood flow – pallor, pain, weak or absent pulses, poor capillary refill, cool skin, and tissue dysfunction; disrupt flow of oxygenated blood to tissues * Compromised venous blood flow – edema, brown skin discoloration, tissue dysfunction (stasis ulcers); disrupt blood return to the heart

Oxygen Transport Abnormalities * Anemia – abnormally low level of red blood cells, hemoglobin, or both * Carbon monoxide poisoning – carbon monoxide binds to hemoglobin at the oxygen receptor sites, making it impossible for hemoglobin for hemoglobin

Assessing For Risk Factors * Pain * Fatigue * Dyspnea

Assessing Peripheral Circulation – weak pulses, cool feet, lack of hair, and shiny skin on lower legs and feet accompany peripheral vascular disease

Diagnostic Testing 1. Test for blood oxygenation – pulse oximetry, capnography, and arterial blood gases 2. Cardiac monitoring * Identify the patient’s baseline rhythm and rate * Recognize significant changes in the baseline rhythm and rate * Recognize lethal dysrhythmias that require immediate intervention * Electrocardiogram – monitor of the electrical activity of the heart * P wave – firing of the SA node and conduction of the impulse through the atria; leads to atrial contraction * QRS complex – ventricular depolarization and leads to ventricular contraction * T wave – represents the return of the ventricles to an electrical resting state; ventricular repolarization

Nursing Diagnosis * Decreased cardiac output – the heart is unable to pump adequate amounts of blood to meet the metabolic demands of the body * Ineffective tissue perfusion – poor perfusion to an organ or tissue (organ dysfunction) * Risk for shock - inadequate blood flow to body tissues that may lead to life threatening cellular dysfunction (patients with sepsis or hypovolemia)

Nursing Intervention/Implementation * Manage anxiety * Promote circulation * Promote venous return * Prevent clot formation * Administer medications * Vasodilators – causes vessel dilatation * Afterload – drugs that dilate arterioles decrease the resistance against which the heart pumps * Preload – drugs that dilate veins decrease venous return to the heart * Can cause hypotension * Angiotensin-converting enzyme (ACE), angiotensin II receptor blockers, and nitrates * Beta-adrenergic agents – block stimulating of beta receptors (located in the heart, lungs, and blood vessels) * Treat angina, acute myocardial infarction, and congestive heart failure * Decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility * Diuretics – increase removal of sodium and water from the body by increasing urine output * Positive inotropes – increase cardiac contractility * Improve pumping effectiveness without creating excess heart work and oxygen demand * Cardiac glycosides and phosphodiesterase inhibitors * Performing cardiopulmonary resuscitation * Cardiac arrest – cessation of heart function; pale, cool, grayish skin; absence of femoral or carotid pulses; apnea; and pupil dilation * Respiratory (pulmonary) arrest – cessation of breathing * In-hospital arrests – “code blue” for announcing cardiac or respiratory arrest * Hands-only CPR – call 911, push hard and fast in the center of the victim’s chest * Use hands-only CPR for adults they observe to suddenly collapse * Use CPR that combines breaths and compression for: * Adults found already unconscious and not breathing normally * Victims of drowning or collapse due to breathing problems * All infants and children

Chapter 17: Vital Signs

Vital Signs – assessment of vital or critical physiological functions 1. Blood pressure 2. Temperature 3. Pulse 4. Respiration 5. Pain

When Should I Measure a Patient’s Vital Signs? * On admission to the hospital * At the beginning of a shift, for inpatients * At a visit to the healthcare provider’s office * Before, during, and after surgery or certain procedures * To monitor the effects of certain medications or activities * Whenever the patient’s condition changes * In the hospital – every 4-8 hours * In the home health setting – at each visit * In the clinic – at each visit * In skilled nursing facilities (convalescent hospitals) – weekly to monthly

Body Temperature – the degree of heat maintained by the body * Normal internal temperature – 97-100.8 degree * Core temperature – rectal and tympanic * Surface temperature – oral and axillary * Core temperature is 1-2 degree higher than surface (skin) temperature * Thermoregulation – process of temperature regulation; controlled by the hypothalamus * Decreasing the body temperature – peripheral vasodilation, sweating, inhibition of heat production * Increasing the body temperature – shivering and release of epinephrine (increases metabolism); to reduce heat loss, the blood vessels constrict * Behavioral control of temperature – turn up the thermostat, put on more clothing, move to a warmer place, turn on the air conditioner, remove clothing, take a cool shower

How Is Heat Produced In The Body? * Metabolism * Basal metabolic rate – the amount of energy required to maintain the body at rest * Hyperthyroidism – increases BMR; complaint of feeling warm * Hypothyroidism – less heat is produced; report feeling cold * Epinephrine and norepinephrine – increase BMR and heat production * Movement of skeletal muscles * Nonshivering thermogenesis – metabolism of brown fat to produce heat; used by infants because they cannot produce heat through shivering

How Is Heat Produced In The Body? * Radiation * Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air * A cool room warms by radiation when it is filled with many people * 50% of body heat loss * Convection * Transfer of heat through currents of air or water * Immersion in a warm bath for a hypothermic patient; currents of cool air produced by a fan can help reduce a fever * Convection and conduction – 15-20% of heat loss to the environment * Evaporation * Water is converted to vapor and lost from the skin (perspiration) or the mucous membranes (through the breath) * Insensible loss – water loss by evaporation * Affected by the humidity (moisture in the environment) * Conduction * Heat is transferred from a warm to a cool surface by direct contact

Fever (Pyrexia) * Fever – temperature above the person’s usual range of normal * Febrile – a person with fever * Afebrile – a person without fever * Hyperpyrexia – fever about 105.8; dangerous and requires intervention * Pyrogens – fever producing substances * Pyrogens induce secretion of prostaglandins – substances that reset the hypothalamic thermostat at a higher temperature * Set point – reset value * Fever stages: 1. Initial phase (febrile episode or onset) * Body temperature is rising but has not yet reached the new set point * Sudden or gradual * Chilly, uncomfortable, may shiver 2. Second phase (course) * Body temperature reaches it maximum (set point) and remains fairly constant at the new higher level * Patient is flushed, feels warm and dry 3. Third phase (defervescence or crisis) * Temperature returns to normal * Feels warm and flushed in response to vasodilation * Diaphoresis occurs * Four types of fever: 4. Intermittent fever – temperature alternates regularly between periods of fever and periods of normal without pharmacological intervention; temperature returns to normal at least once every 24 hours 5. Remittent fever – fluctuations in temperature (>3.6F), all above normal, during a 24 hour period 6. Constant (sustained) fever – temperature may fluctuate slightly (<1F) but is always above normal 7. Relapsing (recurrent) fever – short periods of fever alternating with periods of normal temperatures, each lasting 1-2 days

Heat Stroke (Hyperthermia) * Body temperature is higher than the set point * Hypothalamic regulation is overwhelmed and does not reset the set point * Heat exhaustion – core temperature of 98.6-103F; weakness, nausea, vomiting, syncope, tachycardia, tachypnea, muscle aches, headaches, diaphoresis, and flushed skin * Heat stroke – hyperthermia progresses to a temperature above 103F; rapid, strong pulse, throbbing headache, delirium, confusion, impaired judgment, dizziness, seizures, and coma

Hypothermia * Abnormally low core temperature, <95F * Early signs of hypothermia: * Shivering, cyanosis of lips and fingers, and poor coordination * Pain in extremities * Mental impairment, confusion, disorientation, slowing of the heart rate and respirations * Severe hypothermia: * Body temperature drops below 82.4F * Unconscious and stops shivering * Pulse and respirations are irregular and difficult to detect

Nursing Diagnosis * Hyperthermia – person’s body temperature is above normal; convulsions, flushed skin, tachycardia, tachypnea, and warmth to touch * Hypothermia – person’s body temperature is below normal range; cool skin, cyanotic nail beds, elevated blood pressure, pallor, piloerection, shivering, slow capillary refill, and tachycardia * Ineffective thermoregulation – temperature fluctuates above and below the normal range * Risk for imbalanced body temperature – temperature is normal but the person is at risk for failure to maintain body temperature within normal range

Pulse – rhythmic expansion of an artery produced when a bolus of blood is forced into by contraction of the heart * Normal range – 60-100 beat per minute * Stroke volume – quantity of blood forced out by each contraction of the left ventricle; normal 70 mL * Cardiac output – total quantity of blood pumped per minute (stroke volume x pulse rate = cardiac output)

Pulse sites * Peripheral pulses – radial, brachial, dorsalis pedis, posterior tibial, carotid, femoral, popliteal, and temporal arteries * Apical pulse is the most accurate of the pulses * Use apical pulse when: * Radial pulse is weak or irregular * <60 bpm or >100 bpm * Patient is taking cardiac medication (digitalis) * Assessing infants and children up the age 3

Apical-Radial Pulse * Assess for heart function or the presence of heart irregularities * Pulse deficit – a difference between apical and radial pulse rate

Pulse Rate * Bradycardia – below 60 bpm * Tachycardia – more than 100 bpm

Pulse Rhythm * Rhythm – intervals between heartbeats establish a pulse pattern * Dysrhythmia – rhythm is abnormal * Regularly irregular – an irregular rhythm that forms a patter * Irregularly irregular – an unpredictable rhythm

Pulse Quality * Determine pulse volume and bilateral equality of pulses * Pulse volume – amount of force produced by the blood pulsing through the arteries * 0 – absent: pulse cannot be felt * 1 – weak or thread: pulse is barely felt and can be easily obliterated by pressing with the fingers * 2 – normal quality * 3 – bounding or full: pulse is easily felt with little pressure; not easily obliterated * Pallor – paleness of skin in one area when compared to another part of the body * Cyanosis – bluish or grayish discoloration of the skin due to deficient oxygen in the blood

Nursing Diagnosis * Ineffective tissue perfusion – pulse is absent or weak and cool, pale skin is absent * Risk for impaired skin integrity or tissue integrity – if tissue is not adequately perfused, tissue ischemia and necrosis may occur * Deficient fluid volume – may cause pulse to be weak or thread * Excess fluid volume – may cause pulse to be bounding or full * Decreased cardiac output – may cause tachycardia, bradycardia, or change in pulse volume

Respiration – exchange of oxygen and carbon dioxide in the body * Normal range – 12-20 breath per minute * Regulated by the medulla oblongata, pons of the brain, along with the nerve fibers of the autonomic nervous system * Central chemoreceptors – located in the respiratory centers; sensitive to carbon dioxide and hydrogen ion (pH) concentration * Peripheral chemoreceptors – the carotid and aortic bodies stimulate respiration when partial pressure of oxygen (PaO2) drops below normal (normal: 80-100) * Inspiration – ribs move upward from midline, diaphragm moves downward and out, abdominal organs move downward and forward * Expiration – diaphragm and thoracic muscles relax, chest cavity decreases in size, the lungs recoil, forcing air from the lungs until the pressure within the lungs again reaches atmospheric pressure

Assessment * Respiratory rate – the number of times a person breathes (inhalation and exhalation) within one minute * Respiratory depth * Tidal volume – amount of air taken in on inspiration (300-500 mL) * Deep – taking in a very large volume of air and fully expanding one’s chest or abdomen * Shallow – when the chest barely rises and is difficult to observe * Normal – falling between shallow and deep

* Respiratory rhythm * Regular or irregular breathing pattern * Eupnea – normal respiration, with equal rate and depth; 12-20 breaths/minute * Bradypnea – slow respiration, <10 breaths/min * Tachypnea – fast respiration, >24 breaths/min, usually shallow * Kussmaul’s respirations - regular but abnormally deep and increased in rate * Biot’s respirations – irregular respirations of variable depth (usually shallow), alternating with periods of apnea * Cheyne-Strokes respirations – gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea * Apnea – absence of breathing * Respiratory effort * Degree of work required to breathe * Dyspnea or labored breathing * Orthopnea – difficulty or inability to breathe when in a horizontal position * Breath sounds * Wheezes – high pitched, continuous musical sounds; heard on expiration; caused by narrowing of airways * Rhonchi – low pitched, continuous gurgling sounds caused by secretions in the large airways; clear with coughing * Crackles – high pitched popping sounds or low pitched bubbling sounds heard on inspiration; caused by fluid in the alveoli * Stridor – piercing, high pitched sounds that is heard during inspiration, in infants who are experiencing respiratory distress or in someone with an obstructed airway * Stertor – labored breathing that produces a snoring sound

Intercostal retraction – visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe
Substernal retraction – tissues are drawn in beneath the sternum
Suprasternal retraction – tissues are drawn in above the clavicle

Associated clinical signs * Hypoxia – pallor or cyanosis, restlessness, apprehension, confusion, dizziness, fatigue, decreased level of consciousness, tachycardia, tachypnea, and changes in blood pressure * When evaluating cyanosis – tongue and oral mucosa are the best indicators by hypoxia * Chronic hypoxia causes clubbing (loss of the nail angle) of the fingers

Blood Pressure * Pressure of blood as it is forced against arterial walls during cardiac contraction * Important indicator of overall cardiovascular health * Systolic pressure – peak pressure exerted against arterial walls as the ventricles contract and eject blood * Diastolic pressure – minimum pressure exerted against arterial walls, between cardiac contractions when the heart is at rest * Pulse pressure – the difference between the systolic and diastolic pressure * Pulse pressure is an indication of the volume output of the left ventricle (should be no greater than 1/3 of the systolic pressure) * Normal BP – systolic BP below 120 and diastolic BP below 80

How Does The Body Regulate Blood Pressure? 1. Cardiac function 2. Peripheral resistance – arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls * The amount of friction or resistance depends on blood viscosity (thickness), arterial size, and arterial compliance (elasticity) * Blood viscosity – influences the ease with which blood flows through the vessels; determined by the hematocrit (% of red blood cells in plasma) * Arterial size – sympathetic nervous system controls vasoconstriction and vasodilation; constricted arteries prevent the free flow of blood and dilated arteries allow unrestricted flow of blood * Arterial compliance – arteries with good elasticity can distend and recoil easily and adequately; arteriosclerosis (hardening of the arteries) 3. Blood volume – normal volume of blood in the body is about 5 liters (5000 mL)

Hypotension * Systolic blood pressure is less than 100 mm Hg * Hemorrhage and heart failure are two causes of hypotension * Orthostatic (postural) hypotension – blood pressure drops suddenly on moving from a lying position to a sitting or standing position

Hypertension * Blood pressure reading of 120-139 mm Hg systolic or 80-89 mm Hg diastolic, obtained with two readings taken 6 minutes apart, with the patient sitting * Hypertension – blood pressure is above 140 mm Hg systolic or above 90 mm Hg diastolic on two or more separate occasions * Thickening of the arterial walls and decrease elasticity of the arteries * Primary (essential) hypertension * No known cause for the BP elevation * 90& of all cases of hypertension * Family history, age, race, obesity, diet, heavy alcohol consumption, smoking history, high cholesterol levels, stress * Secondary hypertension * There is an identified cause for the persistent rise in BP * Renal or endocrine disorders * NSAIDs, oral contraceptives, decongestants, and adrenal steroid hormones * Nicotine and caffeine causes transient BP increases * Cocaine, amphetamines, illicit drugs, chronic overuse of alcohol

Chapter 26 – Nutrition

Nutrition – the study of food and how it affects the human body and influences health

Reliable Sources of Nutrition Information * Standards- reference for nutrient intake thought to meet the nutritional needs of most healthy population groups * Food guides – more practical tools that can be used to educate patients and families

Dietary Reference Intakes * Dietary reference intakes (DRIs) – promote the consumption of healthful nutrient levels * Acceptable macronutrient distribution range (AMDR) – used for carbohydrates and lipids * DRIs are a revision of the older recommended dietary allowances (RDAs) for vitamins and minerals, protein, and total kcal that are thought to meet the needs of about 98% of individuals in a group

Canada’s Food Guide to Healthy Eating – advises choosing a variety of foods from each of four groups, plus a small amount of unsaturated fat

USDA Dietary Guidelines * Primary source of dietary health information for nutrition educators, policymakers, and healthcare providers * Based on the latest scientific evidence and provides information about choosing a nutritious diet, maintain healthy weight, achieving adequate exercise, and good safety to avoid food-borne illness * Updated every 5 years

Food Pyramids * Activity * Moderation * Personalization * Proportionality * Variety * Gradual improvement

Food Guides for Older Adults * Tufts university pyramid * Emphasizes nutrient-dense foods and stresses the importance of fluids * Emphasizes whole fruits and vegetables rather than juices * Flag at the top suggests that older adults may need to discuss with their health care providers nutrient supplements such as calcium, vitamin D, and vitamin B12

Energy Nutrients * Macronutrients – supply the body with energy (kilocalories) * Micronutrients – help manufacture, repair, and maintain cells * Metabolism – encompasses all the ways in which the body changes and uses nutrients 1. Anabolism – formation of larger molecules from smaller ones 2. Catabolism – breakdown of larger molecules into smaller components

Carbohydrates (CHOs) * Primary energy source for the body * Functions: * Supply energy for muscle and organ functions * Spare proteins * Enhance insulin secretion, increase satiety, and improve absorption of sodium and excretion of calcium * Enzymes involved in digestion: salivary amylase, ptyalin, pancreatic amylopsin, sucrose, lactase, maltase
Proteins
* Complex molecules made up of amino acids * Essential amino acids – significant in our bodies because the body cannot manufacture them * Essential amino acids – arginine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine * Nonessential amino acid – alanine, asparagine, aspartic acid, cysteine, glutamic acid, glutamine, glycine, proline, serine, tyrosine * Complete protein – foods contain all of the essential amino acids necessary for protein synthesis; animal source * Incomplete protein – foods do not provide all of the essential amino acids; nuts and grains * Protein metabolism and storage: * Protein digestion occurs in the small intestine * When amino acids are catabolized, the nitrogen containing part is converted to ammonia (NH3) and excreted in the urine as urea * Nitrogen balance – intake and output of nitrogen is equal * Positive nitrogen balance – when nitrogen intake exceeds output, making a pool of amino acids available for growth, pregnancy, and tissue maintenance and repair * Negative nitrogen balance – when nitrogen intake is lower than nitrogen loss; occurs in illness, injury (burns), and malnutrition * Functions: * Tissue building – essential for growth, maintenance, and repair of body cells and tissues * Metabolism * Immune system function – lymphocytes and antibodies are proteins * Fluid balance * Acid-base balance * Secondary energy source

Lipids * Organic (carbon-containing) substances that are insoluble in water * Fats – lipids that are solid at room temperature * Oils – liquid at room temperature * Metabolized in the small intestine, where bile and pancreatic enzymes being splitting the fatty acids from their glycerol backbone * Stored in adipose tissue * Functions: * Supply essential nutrients – food fats supply the essential fatty acids and aid in the absorption of fat soluble vitamins * Energy source – when engaging in light activity (walking) * Flavor and satiety * Insulation * Aids in thermoregulation * Protects vital organs * Enables accurate nerve-impulse transmission * Essential to cell metabolism * Cholesterol functions – ingredient of bile and serves as a precursor to all steroid hormones

Types & Sources of Lipids 1. Glycerides (true fats) * Consist of one molecule of glycerol attached to one, two, or three fatty acid chains * Glycerol – an alcohol composed of three carbon atoms * Fatty acids – long chains of carbon and hydrogen atoms ending in an acid * Triglycerides – consist of a glycerol molecule attached to three fatty acids

2. Sterols * Consist of rings of carbon and hydrogen * Cholesterol – a waxlike substance needed for the formation of cell membranes, vitamin D, estrogen, and testosterone * Cholesterol is synthesized in the liver and is found in animal foods 3. Phospholipids * Soluble in water * Lipoproteins –major transport vehicles for lipids in the bloodstream * Low density lipoproteins (LDLs) – transport cholesterol to body cells; “bad cholesterol” * High density lipoproteins (HDLs) – remove cholesterol from the bloodstream, returning it to the liver, where it is used to produce bile; “good cholesterol” 4. Unsaturated fatty acid * One that is not completely filled with all the hydrogen it can hold * Monounsaturated fats – one unfilled spot where hydrogen is not attached * Polyunsaturated fatty acids – contains two or more unfilled spots for hydrogen * Liquid at room temperature * Reduces the risk of heart disease and stroke * Fish and nuts 5. Saturated fatty acid * Every carbon is fully bound to hydrogen * Solid at room temperature * Animal fats are the primary source of saturated fat * Raise LDLs cholesterol level 6. Trans-fatty acids * Saturated fat created when food manufacturers add hydrogen to polyunsaturated plant oils (corn oil) to break the double carbon bond and straighten out the molecules * Solidifies the fat and extends the shelf life of the food * Margarines and other processed foods containing hydrogenated vegetable oils * Raise LDLs cholesterol level 7. Essential fatty acids * Essential fatty acids – the body cannot manufacture it and its absence creates a deficiency disease * Linoleic acid (omega 6) and alpha-linoleic acid (omega 3) * Omega 6 fatty acid is found mainly in polyunsaturated vegetable oils, nuts, and seeds * Omega 3 fatty acid – fatty fish (tuna, shellfish)

Micronutrients * Vitamins * Organic substances that are necessary for metabolism or preventing a particular deficiency disease * Critical in building and maintaining body tissues, supporting our immune system, and ensuring healthy vision * Critical during periods of rapid growth, pregnancy, lactation, and healing * Water soluble vitamins: * Vitamins A, D, E, K * Stored in the liver and adipose tissues * Body can store these vitamins; can lead to toxicity * Diets extremely low in fat and disorders affecting fat digestion and absorption can lead to deficiency of fat soluble vitamins * Water soluble vitamins: * Vitamin C * B-complex vitamins: thiamine, riboflavin, niacin, pyridoxine (vitamin b6), folic acid, pantothenic acid, biotin, and cyanocobalamin (vitamin b12) * Excreted in the urine; need to be consumed every day

Minerals * Inorganic elements found in nature * Major minerals (Macrominerals) – minerals that the body needs in amounts of 100 mg/day or greater * Trace minerals – essential, but in a lower concentration * Calcium deficiency is one of the most common mineral deficiencies * Assist in fluid regulation, nerve impulse transmission, energy production * Essential to the health of bones and blood and help rid the boy of byproducts of metabolism * Adequate calcium intake decreases the likelihood of osteoporosis * Iron deficiency causes anemia * Magnesium may decrease the risk of hypertension and coronary artery disease in women * Consumption of high amount of sodium increases the risk for high blood pressure, heart attacks, and stroke * Absorbed in the small intestine * Salt and potassium are absorbed in the large intestine

Why Is Water an Essential Nutrient? * Made up of hydrogen and oxygen * Intracellular fluid – water contained within each living cell; 40% of the total body weight * Extracellular fluid – external to the cell membrane (in the fluid portion of blood and lymph and in the gastrointestinal tract); 20% of total body weight * Functions: * Solvent * Transport oxygen, nutrients, and metabolic wastes * Body structure and form * Helps maintain body temperature

Basal Metabolic Rate * Measure of the energy used while at rest in a neutral temperature environment * Direct measurement – use of a calorimeter: an insulated unit that measures temperature changes of water that are produced by exposure to a fasting individual at rest * Indirect calculation (resting energy expenditure) * Measuring oxygen uptake per unit of time – done in an exercise lab or with a portable machines for patients in intensive care units * Serum thyroxine levels * A formula for calculating BMR when precise measurement is not required * Factors that affect BMR * Body composition – lean body tissue have greater metabolic activity than fat and bones * Growth periods * Body temperature – BMR increases 7% for each 1F rise in body temperature * Environment temperature – cold weather causes a slight rise in BMR * Disease processes – cancer, anemia, cardiac failure, hypertension, and asthma result in BMR elevation * Prolonged physical exertion

Factors That Affect Nutrition 1. Developmental stage 2. Knowledge 3. Lifestyle 4. Culture 5. Disease process 6. Functional abilities

Developmental Stage * Infants – 1 year * Calories and proteins – infants need adequate protein for tissue building and enough carbohydrates to furnish energy and “spare” the protein * Vitamins and minerals – infant needs calcium for bone growth and development of teeth, calcium and vitamin C for iron absorption, and vitamin D for calcium regulation * Fluids – infant requires 1.5 to 2 ounces of breast milk or formula per pound of body weight per day * Breast milk is the ideal food for infants because it is matched to their nutritional requirements; contains enzymes to digest fats, protein, and carbohydrates * Breast milk – less risk of developing diabetes mellitus later in life * The most common used formula is modified cow’s milk * Should not receive regular cow’s milk because it may cause gastrointestinal bleeding and may place too much strain on the infant’s kidney; contributes to iron deficiency anemia * Honey and corn syrup should not be used as a source of carbohydrates in preparing infant formula; potential source of botulism toxin * Toddlers and preschoolers * Require about 900-1800 kcal and 1250 mL of fluid per day * Sometimes deficient in fat and meat * Deficiency in iron, calcium, vitamin A and C * Preschoolers refuse all green vegetables or drinking less milk, casseroles and foods with sauce * Lifelong food habits are developed during this stage * School-age children * Require 2400 kcal and 1750 mL of fluid per day * An adequate supply of vitamins and minerals is critical * Parents should encourage their children to eat breakfast to provide nutrients and energy to fuel problem solving skills, memory, and sports and playground activities * Leading causes of childhood obesity: * Routine consumption of high fat, high sugar fast foods, nutrient poor foods, and high calories snacks and beverages * Loss of family mealtime * Eating in front of a TV or computer * Lack of regular physical activity to burn the kcal consumed * Adolescents * Need protein, calcium, iron, and B and D vitamins * Most people with eating disorders exhibits their first symptoms before age 20, some as early as age 10 * Majority of eating disorder sufferers are female * Adults * Calcium, vitamin D, folic acid, and iron continue to be critical, especially in women, for bone and reproductive health * Women capable to become pregnancy – daily folic acid supplement of 0.4mg-0.8mg to lower the risk for neural tube defects in the fetus * Dietary modification and exercise are essential to control diseases: diabetes, hypertension, obesity, and hyperlipidemia

* Older adults * Lean body mass, physical activity, and BMR decreases, so they need fewer kcal * Diets low in salt, simple sugars, or fat * Diminished vision or hearing, limit mobility and interaction, make it more difficult to purchase and prepare food * Tooth loss and gum disease limit chewing ability * Arthritic hands have difficulty preparing and eating food * Need complex carbohydrates (fiber) to maintain bowel function * Drink at least 8 glasses of water and other fluids per day and choose primarily green leafy vegetables and brightly colored fruits to help prevent constipation and dehydration * Need supplements of calcium, vitamin D, and vitamin B12: * Bone density decreases, calcium requirements increase, especially in women at risk for osteoporosis * Low concentrations of vitamin B12 have been linked to cognitive decline * Adult failure to thrive – complex disorder characterized by weight loss, decreased activity and interaction, and increasing frailty * Pregnant and lactating women * A daily supplement of folic acid of 0.6-0.8 mg is recommended during pregnancy * Adequate protein and calcium are important for growing muscle, brain and bone tissues * Iron is essential to maintain maternal and fetal blood supplies and stores during pregnancy * Quantity of the breast milk depends on an adequate supply of fluids and nutrients; nutritional quality of the milk remains the same

Lifestyles * Dietary patterns * Whole foods (fresh fruits and vegetables), whole grains, and legumes – promote health * Foods high in simple sugars, saturated and trans fat, and sodium – increase the risk for health problems * Cooking methods – ½ of the water soluble vitamin content is lost in the cooking water of boiled vegetables * Oral contraceptive use * Using food to cope – skipping meals, binge eating, or consuming too much of a single food (snacks food or chocolate) can result in poor nutrition * Tobacco smoking – smokers use vitamin C faster than nonsmokers * Alcohol * Contributes to obesity * Decrease the rate of fat metabolism * Replace the good in the person’s diet * Depress appetite * Decrease the absorption of nutrients by its toxic effects on intestinal mucosa * Impair the storage of nutrients * Need B vitamins and folic acid * Caffeine * Does not create risk for dehydration, heart disease, or cancer * Has little or no role in hypertension * Associated with bone loss * In high dose, can cause anxiety and stomach upset * Enhance mood and mental and physical performance * Aids the ability to burn fat for fuel instead of carbohydrates * Lower risk of Parkinson’s disease, type 2 diabetes, stroke, and dementia

* Vegetarianism * Semi-vegetarians – are the most inclusive, allowing fish, eggs, and dairy products as well as plant-based foods * Ovo-lacto vegetarians – more strict; they eat eggs and dairy products, but not fish * Lacto-vegetarians – dairy and plant-based foods * Vegans – foods of plant based * Fruitarian – fruits, nuts, honey, and vegetable oils; does not eat soy beans, soy milk, tofu, processed protein products * Reduces the risk of disease and promote wellness by limiting fat intake * Vitamin B12 – vegan must eat foods fortified with B12 or take B12 supplements * Vitamin D – inadequately supplied by vegetarian * Vegans, fruitarians, and others who limit animal foods may need to supplement the diet with calcium, iron, and zinc; children, pregnant women, and lactating women * Protein – inadequate in vegan who does not intake soy milk, tofu, and other soy-based meat substitutes * Dieting for weight loss

Ethnic, Culture, and Religious Practices * Language barriers makes it difficult to understand nutritional information * Ethnic/cultural food choices reflect the foods that were plentiful in the region of origin * Other diet choices reflect a concern for food preservation: eat salted meats, dried fruits, and cook with fiery spices to combat microbes * Certain religions require fasting or abstaining from certain foods * Burden of childhood obesity in not spread equally across the U.S. population * Cultural beliefs, perceptions, and attitudes about weight issues may often not match those of health providers * Mediterranean diet – glass of red wine and is rich in fish, fruits, vegetables, and nuts and low in dairy foods, saturated fats, and red meat, has been linked to decreased risk of death from all causes, including deaths due to cancer and cardiovascular disease in a U.S. population

Disease Processes and Functional Limitation * Poor appetite results in decreased intake of food and therefore of nutrient; common problem in alcoholism * Medications that cause nausea: * Acetylsalicylic acid (aspirin) * Antibiotics * Anticonvulsants * Anti-depressants * Anti-inflammatory agents * Anti-neoplastic agents (chemotherapy) * Asthma medications (theophylline) * Birth control pills * Fluoride supplements * Opioids * Potassium chloride * Vitamin and mineral supplements * Medications that decrease appetite: * Amphetamine and dextroamphetamine (Adderall) * Aspirin * Diphenhydramine (Benadryl) * Lithium carbonate (Lithobid)

* A person with a developmental delay, severe mental illness, confusion, or memory loss may be unable to remember what, when, or whether she has eaten * Paralysis and hemiplegia cause functional limitations that affect mobility and the ability to shop for food * A person with severe dyspnea from chronic obstructive pulmonary disease may not have the stamina to prepare a nutritious meal * Decayed or missing teeth and ill-fitting dentures make chewing difficult; eats only soft food * Pharyngitis, cancer of the larynx or esophageal strictures make swallowing painful or difficult * Bowel inflammation or infection, diverticuli, or tumors may increase peristalsis – decreasing absorption of nutrients

Special Diets * Regular diet (house diet) – balanced meal plan that supplies 2000 kcal per day * NPO – no food or fluid (including water) by mouth before surgery or an invasive procedure to limit the risk of aspiration; intravenous fluids may be given to provide hydration * Clear liquids: * Prevent dehydration * Supply simple carbohydrates to help meet energy needs * Water, tea, coffee, broth, clear juice (apple, green, or cranberry juice), popsicles, carbonated beverages, gelatin * Full liquids: * Contains all the liquids included in the clear liquid diets plus any food items that are liquid at room temperature * Soups, milk, milk shakes, puddings, custards, juices, hot cereals, yogurts * Mechanical soft diet: * For people with chewing difficulties resulting from missing teeth, jaw problems, or extensive fatigue * Includes all items on the full liquid diets plus soft vegetables and fruits, breads, pastries, eggs, and cheese * Low in fiber – results in constipation * Pureed diet – blended diet

Food Diaries * 24 hour recall – name all food eaten within a day; simple, requires no equipment, can be used as often as required * Food frequency questionnaire – identify the number of times per day, week, or month a particular food group is eaten; provide a global image of the client’s nutritional intake * Food record – most accurate food diary; keep a record of measured and weighed amounts of all foods he eats in a 3 day period

How Do I Screen Clients for Nutritional Problems? * Nutritional screening – determine deficiencies or excesses in the diet * Cursory screening – evaluation of height, weight, and body mass index coupled with a brief dietary history * Subjective global assessment – commonly used screening method makes use of information from the overall medical history and physical examination to evaluate a client’s nutritional status * Nutrition screening initiative (NSI) – developed for older adults, identifies indicators of impaired nutritional status * Mini nutritional assessment – developed for older adults, can be used with clients of all ages

Assessing Body Composition * Anthropometric measurements – used to access growth rate in children; to indirectly assess adults’ protein and fat stores; and to diagnose overweight, obesity, and underweight * Skinfold measurements – skinfold thickness reveals information about current nutritional status as well as long term changes in fat stores; caliper (most accurate measurement) * Circumferences – estimate the % of body fat; abdominal circumference if the preferred measurement for obese people * Body mass index – bioelectrical impedance (the conduction of a harmless electrical charge through the client’s body; normal – 18.5-24.9 * Imaging techniques * Dual energy x-ray absorptiometry (DEXA) – assess bone mineral content and density * Computed tomography (CT) – measure volume rather than actual body tissue composition; provide information about the quantity of adipose tissue (body cavities) * Magnetic resonance imaging (MRI) – assess body composition * Underwater weighing * Hydrodensitometry (underwater weighing) – determine body composition by total submersion of the patient in a tank of water * Old standard for body composition measures * Impractical to use with children, the elderly, and individuals who are severely ill

Signs of Severe Malnutrition * Malnutrition – impaired development or function caused by a long term deficiency, excess, or imbalance in energy and/or nutrient intake * Kwashiorkor – malnutrition caused by deficiency of protein in a diet that is primarily starches * Marasmus – protein sources in food are scarce and overall caloric intake is low; in young children * Symptoms of under nutrition: * Reduced physical activity * Weight loss * Reduced height * Abdominal enlargement * Hair loss * Risk for malnutrition * Serum albumin level 3.5g/dL or less * Nausea and vomiting lasting 3 days or more * Clear liquid diet or NPO for 3 days or longer * Increased nutritional requirements (wound healing, burns) * Recent, unplanned loss of 10% or more of patient’s usual weight

Laboratory Values That Indicate Nutritional Status * Blood glucose – indicated the amount of fuel available for cellular energy * Serum protein level and indices * Albumin * Synthesized in the liver and constitutes 60% of total body protein * Low level – malnutrition, malaborption, acute and chronic liver disease, repeated loss of protein through burns and wounds * Prealbumin – a better marker of acute change than albumin * Transferrin – protein that binds with iron; iron deficiency – TIBC increases; anemia – TIBC decreases * Urea – formed in the liver as an end product of protein metabolism and is excreted through the kidneys; indicator of liver and kidney function * Creatinine – end product of skeletal muscle metabolism, excreted through the kidneys and is an indicator of renal function * Lymphocytes – leukopenia is associated with malnutrition, protein deficiency, alcoholism, bone marrow depression, anemia * Hemoglobin – low hemoglobin indicate inadequate iron intake or chronic blood loss; decreased globulin level indicates insufficient protein intake or excessive protein loss