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PERINEAL-GENITAL CARE
Purpose
1. Remove normal perineal secretions and odors
2. Prevent infection
3. Promote client comfort
4. Promote hygiene
5. Teach personal hygiene.

Assessment
- Irritation
- Excoriation
- Inflammation
- Swelling
- Excessive discharges
- Odor
- Pain or discomfort
- Urinary and fecal incontinence
- Recent rectal or perineal surgery
- Indwelling catheter
- Perineal-genital hygiene practices
- Self-care abilities

Equipment
- Bath towel
- Bath blanket
- Clean gloves
- Solution bottle, pitcher with prescribed solution or warm water
- Bedpan
- Perineal pad or rubber sheet

Ward
- Pitcher with warm water
- Soap suds (could be feminine wash)
- Dry cotton balls
- Betadine solution (soaked cotton)
- Curved forceps (dominant hand)
- Straight forceps (non-dominant hand)
Note: always point downwards
- Rubber sheet/kelly pad
- Sterile gloves (for packed forceps/catheterization)
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- Clean gloves (for forceps in a cup)

Special Consideration
- Use anterior to posterior. (up-downward stroke)
- Use one cotton ball for each stroke
- Cleanse perineum with soap/anti-septic solution. Include the inner thigh)

General Principles
- Nurse safety
- Patient safety
o In clamping the cotton ball, clamp it halfway.
- Work within time constraints
- Allow privacy and dignity
o Only body part being washed is uncovered
o Curtain is closed
- Change water, washcloths, towels, linen as needed
- Call bell available

Principle
1. To clean the perineum, form the cleanest to the less clean area.
2. Follow standard precautions
3. Maintain patient’s privacy
4. Proximal level of functioning

Strokes:
1. From clitoris to mons pubis area in a zigzag motion
2. From inguinal to 2/3 of the thigh
3. Labia Majora to the inguinal area
4. Use non-dominant hand to open the labia minora and majora
5. From clitoris to the orifice of the vagina
6. Form the orifice of the vagina to the anus

Procedures
- Always the cleanse from the urinary meatus towards the anus (clean to dirty)
- May have a prepackaged kit or use wet washcloths
- use a different part of the washcloth for each stroke
- to clean the anal area, cleanse from the vagina toward the anus (clean to dirty)

Male Peri-Care
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1. start at the urinary meatus and use circular motions as you wipe downward to the base
2. retract the foreskin if the patient is uncircumcised
3. return the foreskin to its natural position when you are finished.

Woman Peri-Care
Steps
1. check the doctor’s order
2. gather the materials
3. wash hands
4. introduce and identify
5. explain
6. provide privacy
7. don clean gloves
8. position the patient (dorsal recumbent)
9. insert perineal pads
[Link] the patient (in a diamond shape
[Link] the bedpan under the buttocks
a. pour warm water and rinse
[Link] the perineal area
[Link] warmed-sterile water over genitalia.
[Link] clean gloves
[Link] on sterile gloves
[Link] mons pubis using soap suds
[Link] both the inguinal area with soap suds towards thigh in zigzag motion.
[Link] and dry with cotton balls or gauze
[Link] the labia majora at alternate sides
[Link] the labia to wash the folds between the labia majora and labia minora
[Link] from the clitoris to the rectum
[Link] used cotton balls on waster receptacle
[Link] the genital area with sterile water
[Link] the genital area with gauze
[Link] client to raise buttocks or turn to side lying away from the nurse
[Link] bed pan, under the buttocks
[Link] and dry the rear perineum and buttocks
[Link] drape and position client comfortably
[Link] used materials
[Link] and dispose gloves
[Link] hands
[Link] the procedure and assessment made.
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- Note for any skin breakdown redness,
Document any assessments swelling, discharges
- Type of procedure - Time and date
- Client response
- Observe assessment before and after
the procedure.
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INTRAVENOUS THERAPY
Purpose
- Efficient and effective method of supplying fluids directly into the intravascular fluid
compartment and replacing electrolyte losses.

- 60% of total fluid is intracellular – inside of the cells

- 40% of total fluid is extracellular – outside the cells
- interstitial spaces – between the cells and in tissues
- Intravascular – inside blood vessels.
Factors affecting body fluid, electrolytes and acid-base balance
- Age (infants/kids to old people i.e., 70+)
- Gender and body size (BMI)
- Environmental temperature
- Lifestyle
Disturbances in fluid volume electrolyte and acid-base balances
- Fluid imbalances
o Fluid volume deficit (vomiting, diarrhea)
o Fluid volume excess (renal problems = fluid retention)
o Dehydration (loss of sodium and potassium)
o Overhydration (too much dilutes the sodium and potassium)
- Electrolyte imbalances
- Acid-base imbalances
- ABG – alkalosis, acidosis, chu2x
Nursing management
Assessment
- Common risk factors for fluid, electrolyte, acid-base imbalances
- Chronic diseases and conditions
- Acute conditions
- Medications
- Treatments
- Other factors
Physical Assessment
1. Daily weights
2. Vital signs
3. Fluid intake and output
4. Laboratory tests

Laboratory Test
1) CBC (high hematocrit level = dehydrated)
2) Osmolality
3) Urine PH
4) Urine specific gravity (high = dehydration)
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5) Urine sodium and chloride excretion
6) Arterial blood gas

Diagnosing
- Deficit fluid volume
- Excess fluid volume
- Risk for imbalanced fluid volume
- Risk for deficient fluid volume
- Impaired oral mucous membrane
Planning

Maintain or Restore normal fluid

balance

Maintain or resotre balance of

electrolytes in the intracellualr
and extrecellualr compartments.

Maintain or restore pulmonary

ventilation and oxygention

Prevent

Implementation
1. Promoting wellness
2. Enteral fluid and electrolyte replacement
a. Fluid intake modifications
b. Dietary changes
c. Oral electrolyte supplements
3. Parenteral fluid and electrolyte replacement
a. Intravenous solutions

Intravenous Solution
Classification
- Isotonic
- Hypotonic
- Hypertonic
Simple Nursing (2023). IV Therapy, IV Insertion and Cautions Nursing | intravenous Insertion Demo

Lecturio Nursing. (July 7, 2020). Intravenous (IV) Fluids, Intravenous (IV) Solutions and Tonicity –
Pharmacology| Lecturio Nursing
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Isotonic
- Equal

- Causes no fluid shift (from intra to extra and vice-versa)

- The GREEN COLORED LABEL
- Dextrose in water (D5W)
- Lactated Ringer’s
- Normosol
- Normal Saline Sodium Chloride
- Hetastarch

Hypotonic
- Causes fluid to shift cells and interstitial.
- Shift of fluid from the vascular to the cells
- 103 mOsm/L
- 0.33% sodium chloride
- Dextrose in water
- Sodium chloride

Contraindication
o Elevated increase cranial pressure (ICP)
o Risk for cardiovascular collapse
o Third spacing

Hypertonic
- Causes fluid shift out of cells
- Fluid shift from cells to interstitial spaces.
- Dextrose in sodium chloride
- Dextrose in 0.9% sodium chloride

Contraindication:
o Dehydrated cells
o Patients with Diabetic Keto-acidosis (pts wDKA especially at risk

Note:
- Fluid retention can lead to congestion
- Hand that the IV is attached to is should be lower than the heart to prevent backflow.
- Blood leaking: Alarming: IV suspected to be detach; remove and change IV site.
- Inflammation of the IV site means it is no longer in the intravascular but is it in the interstitial
spaces (infiltration); remove and change IV site.

Osmolality
- Number of osmoles per kilogram of water
- Usually used to des

Osmolarity

Isotonic Solutions
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Intramuscular
- Expand the intravascular compartment
- Watch for fluid overload

o HTN/CHF

Isotonic
- Same concentration of solutes with blood plasma
- Use to restore vascular volume
- Assess for hypovolemia (bounding pulse/shortness of breath)
- Used to correct dehydration, sodium depletion and replace GI losses
- Also used for acute blood loss, burns, hypovolemia due to 3rd spacing, mild metabolic acidosis.
- Risk of over hydration, hypernatremia, hyperkalemia, metabolic alkalosis.
- Ex: 0.9% naCl - normal saline

Hypotonic
- Cause fluid shift from blood vessels into cells
- Extracellular to intracellular
- Use to provide free water and treat cellular dehydration
- Promote waste elimination by kidneys
- Indicated for hypertonic dehydration, ha
- Ex:
o 0.45% NaCl
o 0.33% NaCl
o 2.5% dextrose in water
- Patients at risk:
o Elevated ICP, head trauma, CVA, neurosurgery
o Third Spacers – burns, trauma, low serum protein.

Hypertonic
- Draw fluid out of the intracellular and interstitial compartments into the vascular
- Shift fluid form cells and the interstitial spaces into the extracellular spaces
- Used to replace electrolytes
- Psot-op reduces risk for edema, stabilize BO, regulate urine output

Contraindications
- Clients with kidney or heart disease or clients who are dehydrates
- Watch for signs of hypervolemia

Search for hypertonic solutions examples

Nutrient soltuon
- Contains carbs
Electro

Procedure:
No order form the doctor, no IV therapy

Needle type – microset Not

needle type – macroset
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Types of IV Canula

1. Color identification
2. Size
3. Flow rate
4. Uses

KVO rate = 10 to 12 qtts/min

- Mostly 10 drops
*insert types of canula image
Search what cause phlebitis

*insert parts of a canula

Primary IV Tubing
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URINARY ELIMINATION
Nursing Management  nephrons, is the functional units of the
- Assessing kidneys, filter the blood and remove
- Factors Affecting metabolic wastes.
Voiding  In the average adults, 1200mL of blood, or
about 21% of the cardiac output, passes
- Terms related to altered through the kidneys every minute.
urine production and
altered urinary
Glomerulus
elimination
 A tuft of capillaries surrounded by from
- Assessing Urine Bowman’s capsule filtrate moves into –
- Characteristics of tubule of the nephrons.
Normal and
Abnormal Urine Proximal Convoluted Tubule
- Nursing Diagnoses
- Planning - most of water, electrolytes are reabsorbed.
- Implementation Ureters
- Maintaining Normal - The ureters are form 25 to 30 cm long in
Urinary Elimination the adult and about 1.25 cm in diameter.
- Preventing UTI - At the junction between the ureters and
- Managing Urinary the bladder, a flap like fold of mucous
Incontinence membrane acts as a valve to prevent
- Managing Urinary reflux (backflow) of urine up the ureters.
Retention
- Assisting the Client to Nice to Know!
Use a Bedpan/Urinal *albumin helps maintain the fluid in the
intravascular spaces.
- Specimen Collection
Urinary Elimination
Bladder
- Elimination from the urinary tract is  Urinary bladder is a hollow, muscular
usually taken for granted organ that serves as a reservoir for urine
- Habits depend on social culture, and as the organ of excretion.
personal habits, and physical abilities.  In men, the bladder lies in front of the
- Personal habits regarding urination are rectum and above the prostate gland.
affected by the social politeness of leaving  In women it lies in front of the uterus and
to urinate, the availability of a private vagina.
clean facility, and initial bladder training.

*insert info about usual foods that damage the

kidney
Physiology of Urinary System

Kidneys
 are situated on either side of the spinal
column, behind the peritoneal cavity.
 they are the primary regulators of fluid and
acid – base balance in the body.
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Urine
- the formation of urine has 3 processes,
filtration, reabsorption, and tubular
secretion.
- Urine consists of 95% water and 5%
solid substances.
- The need to urinate is usually felt at
300-350 mL of urine in the bladder.
- Typically, 1000-1500 mL is voided daily.

Physical Characteristics of Urine

Odor
Fresh urine is slightly aromatic
- The smooth muscle layers are Standing urine develops an ammonia odor
collectively called the detrusor muscle Some drugs and vegetables (asparagus) alter
that allows the bladder to expand as it the usual odor.
fills with urine, and to contract to
release urine to the outside of the body pH
during voiding. Slightly acidic (pH 6) with a range of 4.5
- Normal bladder capacity is between 300 to 8.)
and 600 mL of urine. Diet can alter pH

Nice to Know! Specific gravity

Benign prostate hyperplasia o Ranges from 1.010 to 1.025
- Usually in elder man o Dependent on solute concentration

Urethra *insert diagram

o The urethra extends from the bladder to
the urinary meatus Nice to Know!
o In the adult women, the urethra lies - The PH level is alkaline because bacteria
directly behind the symphysis pubis, cannot survive in an acidic environment.
anterior to the vagina, and is between 3 - If there is UTI there is the presence of
and 4 cm long. bacteria, ammonia has alkaline
o The urethra serves only as a passageway properties
for the elimination of urine.
Chemical Characteristics of urine
Urination - Urine is 95% water and 5% solutes
Micturition refers to the process of emptying - Nitrogenous wastes (organic solute)
the urinary bladder. include urea, ammonia, uric acid, and
- Urine collects in the bladder creatinine.
- Adult Bladder: 250-450/500 mL of urine - Other normal solutes include:
- Children: 20-200 mL of urine o Sodium, potassium, phosphate,
and sulfate ions
Urine Formation o Calcium, magnesium, and
*insert illustration bicarbonate.
*inerst video link - NaCl is the most abundant inorganic salt in
the urine
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o Stretch
o contractility
- Urea is the chief organic solute.
- Pathologic Conditions
- Abnormally high concentrations of any
o Renal and heart problems
urinary constituents may indicate
o Schock
pathology
o HPN
- Disease states alter urine composition
o Urinary Calculus
dramatically.
- Surgical and Diagnostic Procedures
o Anesthesia
Lifespan Considerations
o Post-operative bleeding due to
Child
cystoscopy
o At 10 weeks gestation the kidney begins
to form
Altered Urine Production
o Newborn’s kidneys are not able to
Polyuria – a.k.a. diuresis
concentrate urine
- Production of abnormally large amounts of
o Kidneys are more susceptible to trauma
urine by the kidneys
o Diapers – more susceptible to UTI
- 2500mL/day for adults
Causes
Older Adults
o Excessive fluid intake
- Kidney lose mass and the blood vessels
o Intake of alcohol and caffeine
degenerate
o Diabetes mellitus
- Kidneys lose their ability to filter
o Hormone imbalances
- Dehydration can happen more quickly.
o Chronic kidney disease (CKD)
- Electrolyte balance happens more
- Other signs associated with diuresis:
quickly
o Polydipsia
- Loss of muscle tine un urinary
o Dehydration
structures (urinary urgency, UTI, and
o Weight loss
stress incontinence)
- Decreased bladder capacity.
Oliguria
5. Voiding scant amounts of urine
Factors Affecting Voiding
6. Less than 500mL/day or 30 mL and hour
- Developmental Factors
for an adult
o Infant
o School age
Anuria
o Elderly
- Refers to a lack of urine production
- Psychosocial Factors
- Voiding less than 100mL/day
o Privacy
- May result from low fluid intake, kidney
o Position
disease, severe heart failure, burns and
o Sufficient time
shock.
o Manner of work
- Usually accompanied by fever and
- Fluid and Food Intake
heavy respiration
o Alcohol
o Water
o Carotene Avergae Daily Urine Output by Age
o Na Age Amount
- Medications 1-2 days 15 to 60
o Diuretics 3-10 days 100 to 300
- Muscle Tone and Activity 10 days – 2 months 250 to 450
2 months – 1 year 400 to 500
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injury to the bladder and/or the urethra.

o Described as a burning
1 to 3 years 500 to 600 sensation during voiding
3 to 5 years 500 to 700 o Burning during micturition is
5 to 8 years 700 to 1000 often due to an irritated
8 to 14 years 800 to 1400 urethra.
14 years to 1500 o Burning following urination may
adulthood be a result of bladder infection
Older adulthood 1500 or less o Often associated with urinary
hesitancy (delay and difficulty in
Altered Urinary Elimination initiating voiding)
• Urinary Frequency • Enuresis
o Voiding at frequent intervals that o Repeated involuntary urination in
is more often than usual (4 to 6 children beyond the age when
times a day) voluntary bladder control in
o Total amount of urine voided normally acquired (4-5 years)
may be normal, but amount of o Nocturnal enuresis
each voiding is small (50 to o Diurnal enuresis – pathologic in
100mL) origin
o May result from increased fluid • Urinary Retention
intake, cystitis, stress, or pressure o When emptying of the bladder is
on the bladder (pregnancy) impaired, urine accumulates, and
• Nocturia the bladder becomes
o Increased frequency at night that overdistended
is not a result of increased fluid o Common caused prostatic
intake (2 or more times a night) hypertrophy, surgery,
o Expressed in terms number of medications, paralysis
times the person gets out of o Eliminate 25 to 50 mL of urine at
bed to void. frequent intervals
• Urgency o Urinary retention with overflow
o Feeling that the person must – dribbling incontinence that
void results when the bladder is
o Sudden, strong desire to void greatly distended with urine
o Usually accompanies psychologic because of an obstruction.
stress, and irritation of the urethra, o Accumulation of urine in the
poor external sphincter control, bladder (as much as 3L) with
and unstable bladder contractions. associated inability of the
o Common in young children who bladder to empty itself.
have poor external sphincter • Adult
control. o Can hold 250-450 mL of urine in
• Dysuria the bladder before micturition
o Voiding that is either painful or reflex is triggered.
difficult o Prolonged retention leads to
o May result from structure of the stasis (slowing of the flow of
urethra, urinary infections, urine) and stagnation of urine
which increases the possibility of
UTI.
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7. Blood in the urine

8. Urinating at night (nocturia)
o Retention if distinguished from
9. Dribbling urine
oliguria or anuria by the
10. Bearing down to start the urine stream
distention of the bladder.
(straining)
o Characterized by small, frequent,
voiding or absence of urine
Nursing Process
output
Assessment
• Urinary Incontinence
Nursing History
o Involuntary leakage of urine or
a. Data about voiding pattens
loss or bladder control.
and habits, any problems
o Is considered a symptom, not a
voiding, and past or present
disease.
problems involving the urinary
Types
system.
1. Stress urinary incontinence
b. Data about any problems
o loss of urine of less than 50cc
that may affect urination
occurring with increased intra-
c. Ask about hydration status
abdominal pressure – due to
weak pelvic floor and it occurs
Physical Assessment:
during laughing, coughing,
o Inspection of the urethral meatus
sneezing.
of both male and female for
2. Urge urinary incontinence
swelling, discharge, and
o Described as urgent need to
inflammation, examination of the
void and the inability to stop
urine.
micturition (passage of urine)
o Palpation and percussion of the
3. Mixed urinary incontinence
bladder
o Is diagnosed when symptoms of
o Percussion of the kidneys to
both stress II and urgency UI is
detect areas of tenderness.
present
4. Overflow incontinence
o Continuous involuntary leakage or
dribbling of urine that occurs with
Assessment of Urine
incomplete bladder emptying
o Volume of urine 1200 – 1500 mL
(enlarged prostate and neurologic
in 24 hours or 60mL/hr/day
disorders – neurogenic bladder)
o Comparing the output to the
*Neurogenic bladder – describes any
intake
voiding problem related to neurologic
o Color – straw, amber
impairment of dysfunction.
o Clarity – clear
o Odor – faint aromatic
Symptoms of Urinary Incontinence Include:
o Specific Gravity – 1:010 – 1.025
1. Uncontrollable leakage of urine
o Glucose – not present
2. Feeling a strong need to urinate
o Blood – not present
immediately (urgency)
o pH – 4.5 to 8
3. Difficulty starting the urine stream
o Ketone bodies (acetone) -not
(hesitancy)
present
4. Urinating more than usual (frequency)
o Sterility – no microorganism
5. Leaking urine without warning
present
6. Inability to reach the toilet in time
7. Pain or burning with urination (may be
associated with infection)
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• Stress
o Are you experiencing any major
stress? If so, what are the
stressors?
o Do you think these affect your
urinary pattern?
• Disease
○ Hypertension, heart disease, neurologic
disease, cancer, prostatic enlargement or
diabetes?
• Diagnostic Procedures and Surgery
o Have you recently had a
cystoscopy or anesthetic?
Assessment Interview
Voiding Pattern
Diagnostic Tests
• How many times do you urinate during a
• Urinalysis
24-hour period?
• Blood tests: (BUN and Creatinine
• Has this pattern changed recently?
Clearance)
• Do you need to get out of bed to void at
• Cystoscopy
night? How often?
• Intravenous pyelogram (IVP/excretory
pyelogram
Description of Urine and any Changes
• Retrograde pyelogram
• How would you describe your urine in
• Computed axial tomography OR CT scan
terms of color, clarity (clear, transparent,
• UTZ
or cloudy) and odor (faint or strong?)
US US Other SI
Test
Urinary Elimination Problems Units Units
• What problems have you had, or do you BUN (mg/dL) U (mmol/L)
now have with passing your urine? Urea 7-30 mg/dL 2.5-10.7
mmol/L
Factors Influencing Urinary Elimination Cr (mg/dL) Cr (μmol/L)
• Medications Creatinine 0.7-1.2 62-106
o What medications are you md/dL μmol/L
taking?
o Do you know if any of your Diagnosing
medications increase urine General Diagnostic Labels for urinary
output or cause retention of Elimination
urine? • Impaired urinary Elimination:
o Note specific medication and • Readiness for Enhanced Urinary
dosage. Elimination:
• Fluid Intake
o How much and what kind of Possible Nursing Diagnoses:
fluid do you drink each day? • Incontinence
(e.g., 6 glasses of water, two o Overflow Urinary Incontinence
cups of coffee) o Stress Urinary Incontinence
• Environmental Factors o Urge Urinary Incontinence
o Do you have any problems with o Risk for Urge Urinary
toileting (mobility, removing Incontinence
clothing, toilet seat too low, o Urinary Retention
facility without grab bar)? • Risk for Infection
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• Situational Low Self-esteem or Social • Toileting Self-care Deficit

Isolation
• Risk for Impaired Skin Integrity
Diagnosing:
• Risk for Deficient Fluid Volume or Excess
Fluid Volume
• Disturbed Body Image
• Deficient Knowledge
• Risk for Caregiver Role Strain
• Risk for Social Isolation

Cutaneous Urinary Diversions

A. Conventional Ileal Conduit
B. Cutaneous Ureterostomy
C. Vesicostomy
D. Nephrostomy

insert image

Planning
• Maintain or restore a normal voiding
pattern
• Regain normal urine output
• Prevent associated risks such as infection,
skin breakdown, fluid and electrolyte
imbalance, and lowered self- esteem.
• Perform toileting activities independently
with or without assistive devices
• Contain urine with the appropriate
device, catheter, ostomy applicance or
absorbent product.
Videos to Watch
1. Formation of Urine - Nephron Function,
Animation.
[Link]
x1lFw
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CONCEPTS OF DEATH - It may still hold concepts

from previous
AND DYING developmental stages.
5. 18-45 years - has an attitude
THEORY OF THE DEVELOPMENT OF toward death influenced by
THE CONCEPT OF DEATH religious and cultural beliefs
1. Infancy - 5 years - does not 6. 45-65 years - accepts own
understand the concept of death mortality
- An infant’s sense of - Encounters death of
separation forms the basis parents and some peers
for later understanding of - Experiences peaks of
loss and death death anxiety
- Believes death is reversible, - Death anxiety diminishes
a temporary departure, or with emotional well-being
sleep 7. 65+ years- fears prolonged illness
- Emphasized immobility and - Encounters death of family
inactivity as attributes of members and peers
death. - Sees death as having
2. 5-9 years - understands that death multiple meanings
is final
- Believes own death can be DEFINITIONS AND SIGNS OF DEATH
avoided. The traditional clinical signs of death were
- Associates death with the cessation of the apical pulse, respirations,
aggression of violence and blood pressure, also referred to as
- Believes wishes or heart-lung death.
unrelated actions can be
responsible for the death In 1968, the World Medical Assembly
3. 9-12 years - understands death as (Gilder, 1968) adopted the following
the inevitable end of life guidelines for physicians as indications of
- Begins to understand their death:
mortality, expressed as a. Total lack of response to external
interest in the afterlife or as stimuli
fear of death b. No muscular movement, especially
4. 12-18 years - fears a lingering breathing
death c. No reflexes
- May fantasize that death d. Flat encephalogram (brain waves).
can be defied, acting out In instances of artificial support,
defiances through reckless the absence of brain waves for at
behaviors (e.g. dangerous least 24 hours indicates death
driving, substance abuse)
- He seldom thinks about Another definition of death is cerebral
death, but views it in death—
religious and philosophic
terms
- They may seem to reach
an “adult” perception of
death but be emotionally
unable to accept it
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Death-Related Religious and Cultural - In cases of terminal illness,

Practices the state of awareness
- Knowledge of the client’s religious shared by the crying
and cultural heritage helps provide person and the family
individualized care to clients and affects the nurse’s ability to
their families communicate freely with
- Beliefs and attitudes about death, clients and other health
its cause, and the soul also vary care team members and to
among cultures assist in the grieving
- Beliefs about the preparation of the process.
body, autopsy, organ donation,
cremation, and prolonging life are Three types of awareness:
closely allied to the person’s 1. Closed Awareness - the client is
religion. not made aware of impending
death.
Buddhist - believes in reincarnation 2. Mutual Pretense - the client,
family, and health care personnel
- Nurses also need to be know that the prognosis is terminal
knowledgeable about the client’s but do not talk about it and make
death-related rituals, such as last an effort not ot raise the subject
rites, chanting at the bedside, and 3. Open Awareness - the client and
other practices, such as special others know about the impending
procedures for washing, dressing, death and feel comfortable
positioning, shrouding, attending discussing it, even though it is
the dead. difficult.
- Nurses need to ask family
members about their preference 2. Nursing care and support for the dying
and verify who will carry out these client and family include making an
activities. accurate assessment of the physiological
- The nurse must ensure that any signs of approaching death.
ritual items present in the health - Besides signs related to the
care agency are returned to the client’s specific disease, certian
family or to the funeral home. (e.g. other physical signs indicate
insence) impending death

NURSING MANAGEMENT 3. As death approaches, the nurse assists

Assessment the family and other significant people to
1. The nurse first needs to recognize prepare.
the states of awareness
manifested by the client and family 4. The nurse needs to know what the
members. family expects to happen when the
- To gather a complete person dies so asscurate
database that allows information can be given at the
accurate analysis and appropriate depth.
identification of appropriate
nursing diagnoses for dying Diagnosis
clients and their families Should address both physiological and
psychosocial needs, can apply to the
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dying client, depending on the Specific responsibilities include the

assessment data. following:
- Diagnosis that may be particularly a. To minimize loneliness, fear, and
appropriate for the dying client are depression
Fear, Hopelessness, and b. To mintain the client’s sense of
Powerlessness. In addition, Risk security, self-confidence, dignity,
for Caregiver Role Strain and and self-worth
Interrupted Family Processes. c. To help the clientele accept
losses-
Planning
Major goals for dying clients are: CARING FOR TERMINALLY ILL
(a) Maintainig physiological and CLIENTS AND THEIR FAMILY
psychological comfort 1. Helping clients Die with Dignity
(b) Achieving a dignified and peaceful - Nurses need to ensure that the
death, which includes maintaining client is treated with dignity, that is,
a personal control and accepting with honor and respect
declining health status. - Helping clients die with dignity
involves maintaining their humanity,
THE DYING PERSON’S BILL OF consistent with their values, beliefs,
RIGHTS (Fundamentals Book) and culture.
1. I have the right to be treated as a - Allow clients to choose: the
living location of care, times of
appointments with health
Planning for Home Care professionals —
- People facing death may need
help accepting that they have to STRATEGIES TO HELP YOU MAKE
depend on others. DISCUSSIONS ON DEATH EASIER
- They need to consider what will 1. Identify your personal feelings
happen and how and where they about death and how they may
would like to die. influence interactions with clients.
- A major factor in determining 2. Focus on the client’s needs.
whether a person will die in a 3. Talk to the client or family
health care facility or at home is members about how the client
the availability of willing and able usually copes with stress
caregivers. 4. Establish a communication
- If the dying person wishes to be at relationship that shows concer
home, and family or others can
provide care to maintain symptom HOSPICE AN PALLIATIVE CARE
control, the nurse should facilitate The hospice movement was founded by
a referral to outpatient hospice the physician Cecily Saunders in London,
services. England, in 1967.

Implementing Hospice care focuses on support and care

The major nursing responsibility for clients of the dying perso and family, with the
who are dying is to assit the client to a goal offacilitating a peaceful and dignified
peaceful death. death.
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Hospice care is based on holistic concepts, slowing of body proceses and to

emphasizes care to improve quality of life homeostatic imbalances
rather than cure, supports the client and - Interventionsin include providing
family through the dying process, and personal hygiene measures;
supports the family through bereavement. controlling pain; relieving
respiratory difficulties; assisting
The principles of hospice care can be with movement, nutrition, hydration,
carried out in a vari—- and elimination; and providing
measures related to sensory
Palliative Care (non-pharmacologic changes.
care) as described by the WHO, is an - Pain control is essential to enable
approach that improves the quality of life clients to maintain some quality in
of clients and their families facing the their life and their daily activities,
problem associated with lifethreatening including eating, moving, and
illness, through the prevention and relief of sleeping
suffering by means of early identification
and impeccable assessment and Providing Spiritual Support
treatment of pain and other problems, Spiritual support is of great importance in
physical, psychosocial and spiritual. dealing with death.

Palliative Care: The nurse has a responsibility to ensure

- Provides relief from pain and other that the client’s spiritual needs are
distressing symptoms attended to.
- Affirms life and regards dying as a
normal process Nurses need to be aware of their own
- Intend neither to hasten nor comfort with spiritual issues and be clear
postpone death about their own ability to interact
- Integrates the psychological and supportively with the client.
spiritual aspects of client care
- Offers a supprt system to help Nurses have an ethical and moral
clients live as actively as possible responsibility to not impose their own
until death religious or spiritual beliefs on a client but
- Offers a support system to help the to repond to the client in relation to the
family cope during the client’s client’s own background and needs.
illness and in their own
bereavement Communication skills are most—
- Uses a team approach to address
the needs of clients and their Supporting the family
families, including bereavement The dying and the family must be allowed
counseling, if indicated; as much privacy as they desire in order to
- Will enhance quality of life, and meet their needs for physical and
may also positive emotional intimacy,

4. Meeting the Physiological Needs of Family members should be encouraged to

the Dying Client participate in the physical care of the
- The physiological needs of people dying person as much as they wish to a
who are dying are related to a and are able.
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They should be shown an appropriate

waiting area if they wish to remain nearby. (a) Providing Presence - Presence is
a term describing the art of being
It may be therapeutic for both the client present, or just being with a client
and the family for the family to verbally during an “existential moment”.
give permission to the client to ‘let go’, to Presencing is a “gift of “self” given
die when he or she is ready. by the nurse who maintains an
attitude of attentiveness toward the
After the client dies, the family should be client.
encouraged to view the body (with or (b) Conversing about Spirituality
without a nurse present), because this has
been shown to facilitate the grieving Nursing Responsibilities:
process. a. Emergency Baptism
b. Confession
Nurses: c. Holy Communion
1. Use therapeutic communication to d. Anointing of the Sick
facilitate their expression of
feelings. EMERGENCY BAPTISM
2. Provide an empathetic and caring - An infant in danger of death is to
presence. be baptized without any delay.
3. Explain what is happening and - An adult in danger of death can be
what the family can expect; may baptized if, having some
need to have information provided knowledge of the principal truths of
repeatedly the faith, has manifested in any
4. Must have a calm and patient wat at all the intention to receive
demeanor baptism and promises to observe
5. Must not have specific the commandments of the
expectations for family members’ Christian Religion
participation
6. Must be prepared to encourage When a priest is not available, in case of
and support the family by saying necessity, any person can be baptized
their last goodbyes. provided that he or she has the following:
- The intention to baptize as the
How do you show spiritual support? church baptizes
1. Use the gifts of presence and - Pour water on the candidate’s
touch head
2. Ask the patient how you can - While saying: “I baptize you in the
support them spiritually name of the Father, and of the Son,
3. Listen to fears and concerns and of the Holy Spirit”
4. Ask if you can pray with them.
The Sacrament of Penance
C. supporting religious practices Nurses can provide spiritual care by
D. Assist clients with prayer: prayer allows arranging a visit to the hospital.
people to connect with each other and/or Chaplain or the patient's own religious
with the divine. leader if requested.
To pray for another is also a way for loving
people to express care. The Sacrament of Holy Communion
D. referring clients for spiritual counseling The Sacrament of Anointing the Sick
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releasing hemoglobin, which

Evaluating discolors the surrounding tissues.
To evaluate the achievement of client Postmortem care should be carried out
goals, the nurse collects data in according to thepoicy of the hospital or
accordance with the desired outcomes agency
established in the planning phase.
Because care of the body may be
Evaluation activities may include the influenced by religious law, the nurse
following: should check the client’s religion and
a. Listening to the client’s reports of make every attempt to comply.
feeling in control—-
If the deceased’s family or friends wish to
CARE OF THE DEAD BODY view the body, make the environment
Postmortem Care clean and pleasant and to make the body
Rigor Mortis - is the stiffening of the body appear natural and comfortable.
that occurs about 2 to 4 hours after death.
- Starts in the involuntary muscles All equipment, soiled linen, and supplies
(heart, bladder, and so on), then should be removed from the bedside.
progresses to the head, neck, and Some agencies require that all tubes in
trunk, and finally reaches the the body remain i—-
extremities.
- Usually leaves the body about 96 Normally the body is places in a supine
hours after death position with the arms either at the sides,
- Nurses need to place the body in palms down, or across the abdomen.
an anatomic position, place
dentures in the mouth, and close One pillow is placed under the head and
the eyes and mouth before rigor shoulders to prevent blood from
mortis sets in. discoloring the face by settling in it.
—
Algor Mortis - is the gradual decrease of
the body’s temperature after death. Soiled areas of the body are washed.
- When blood circulation terminates - Using a face towel wet in water,
and the hypothalamus ceases to wipe the face and the arms, then
function, body temperature falls the body and the lower extremities.
about 1 degrees celsius (1.8
degrees fahrenheit) per hour until it Absorbent pads are placed under the
reaches room temperature. buttocks to take up any feces and urine
- Simultaneously, the skin loses its releaed because of relaxation of the
elasticity and can easily be broken sphincter muscles.
when removing dressings and
adhesive tape A clean gown is placed on the client, and
the hair is arranged.
Livor Mortis - is the discoloration
- Appears in the lowermost or All jewelry is removed, except a wedding
dependent areas of the body band in some instances, which is taped in
- After blood circulation has ceased, the finger—-
the red blood cells break down,
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In the hospital, after the body has been Losing one’s job, the death of a child, and
viewed by the family, the deceased’s wrist losing functional ability because of acute
identification tag is left on and additional illness or injury.
identification tags are applied. Losses that occur in normal development -
such as the departure of grown children
The body is wrapped in a shroud to from the home, retirement from a career,
enclose a body after death. and the death of aged parents — are
developmental losses that can, to some
Identification is then applied to the outside extent, be anticipated and prepared for.
of the shroud.
There are many sources of loss:
The body is taken to the morgue if (a) Loss of an aspect of oneself - a
arrangements have not been made to body part, a physiological
have a mortician pick it up from the client’s function—
room.
Grief - is the total response to the
Nurses have a duty to handle the emotional experience related to loss
deceased with dignity and to label - Is manifested in thoughts, feelings,
and behaviors associated with
Death is not the opposite—- overwhelming distress or sorrow.
- Is a social process; it is best
LOSS AND GRIEVING shared and carried out with the
Loss is an actual or potential situation in assistance of others
which something that is valued is changed - Grieving permits the individual to
or no longer available. cope with the loss gradually and to
accept it as part of reality.
People can experience the loss of body
image, a significant other, a sense of well- Bereavement - is the subjective response
being, a job, personal possessions, or experienced by the surviving loved ones.
beliefs.
Mourning - is the behavioral process
Illness and hospitalization often produce through which grief is eventually resolved
losses. or altered, it is often influenced by culture,
spiritual beliefs, and customs.
Death is a loss both for the dying—
Grief and mourning are experienced not
TYPES AND SOURCES OF LOSS only by the person who faces the death of
Two General Types of Losses, Actual a loved one but also by the person who
and Perceived suffers other kinds of losses.
1. Actual Loss - can be recognized by
others Types of Grief Responses
2. Perceived Loss - is experienced by 1. Abbreviated Grief - is brief but
one person but cannot— genuinely felt. This can occur
when the lost object is not
Loss can be viewed as situational or significantly important to the
developmental. grieving person or may have been
replaced immediately by another,
equally esteemed object.
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2. Anticipatory Grief - is 5. Even after a prolonged period, the

experienced in advance of the client continues to search for the
event lost person
Disenfranchised Grief occurs when a 6. A relatively minor event triggers
person is unable to acknowledge the loss symptoms of—-
to other people.
Many factors contribute to unresolved
3. Complicated Grief - exists when grief after a death:
the strategies to cope with the loss
are maladaptive and out of Ambivalence - (intense feelings, both
proportion or inconsistent with positive and negative) toward the lost
cultural, religious, or age- person
appropriate norms.
- Lasts fro more—- A perceived need to be brave andl in
control; fear of losing control
Complicated grief may take several
forms. Endurance of multiple losses, such as
(a) Unresolved Chronic grief - is losing an entire family, which the
extended in length and severtiy bereaved finds—-

The same signs are expressed as with Stages of Grieving

normal grief, but the bereaved may also 1. Elisabeth Kubler-Ross (1969), who
have difficulty expressing the grief, may described five stages: denial,
deny the loss, or may grieve beyond the anger—-
expected time.
Factors Influencing the Loss and Grief
With Inhibited Grief , many of the normal responses
symptoms of grief are suppressed and a. Age
otther effects, including somatic, are b. Significance of the loss
experienced instead. c. Culture
d. Spiritual beliefs
Delayed Grief occurs when feelings are e. Gender
purposely or subconsciously suppressed f. Socioeconomic status
until a much later time. g. Support systems
h. The cause of the loss or death
A survivor who appears to b—-
Diagnosing—
COMPLICATED GRIEF Other nursing diagnoses may include
1. The client fails to grieve the—-
2. The client avoids visiting the grave
and refuses to participate in Planning
memorial services The overall goals for clients grieving the
3. The client becomes recurrently loss of body function or a body part are to
symptomatic on the anniversary of adjust to the changed ability and to
a loss redirect both physical and emotional—
4. The client develops persistent guilt
and lowered self-esteem Implementing
- Providing physical comfort
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- Maintaining privacy/dignity
- Promoting independence

Review the following concepts:

1. Medical Abbreviations
2. Vital Signs taking
3. Monitoring intake and output
4. Nursing process to creating NCP
5. Documentation
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ENERGY BALANCE
CONCEPT OF NUTRITION
- A person's energy balance is determined by comparing his or her
NUTRITION
energy intake with energy output.
- Is the sum of all the interactions between an organism and the
- Voluntary and involuntary activities.
food it consumes.
- Energy in equals to energy out.
NUTRIENTS

- Are organic and inorganic substances found in food that are

required for body functioning.

NUTRITIVE VALUE

- The nutrient content of a specified amount of food.

NUTRIENTS HAVE THREE MAJOR FUNCTIONS

1. Providing energy for body processes and movement.

2. Providing structural material for body tissues.

3. Regulating body processes.

ESSENTIAL NUTRIENTS

- The body’s most basic nutrient need is water.

- The energy-providing nutrients are carbohydrates, fats, and

proteins.

MACRONUTRIENTS

- Carbohydrates, fats, proteins, minerals, vitamins, and water.

MICRONUTRIENTS

- Are those vitamins and minerals.

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10. Health

11. Alcohol consumption

12. Advertising

13. Psychological factors.

NUTRITIONAL VARIATIONS THROUGHOUT THE LIFE CYCLE

- Neonate to 1 year

- Toddler

- Preschooler

- School-Age Child

- Adolescent

- Young Adult
FACTORS AFFECTING NUTRITION - Middle-Aged Adult
Habits about eating are influenced by: - Older Adults
1. Developmental considerations

2. Gender

3. Ethnicity and culture

4. Beliefs about food

5. Personal preferences

6. Religious practices

7. Lifestyle

8. Economics

9. Medications and therapy

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NURSING MANAGEMENT

ASSESSMENT

- Nutritional Screening

 Nursing History

- Anthropometric Measurements

 MUAC/MAMA

- Biochemical (Laboratory) Data

 Serum Proteins

 Urinary Tests

 Total Lymphocyte Count

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ALTERNATIVE FEEDING METHOD

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Nostril to nasopharynx to alimentary tract

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