Excretion (4 items)
Excretion (4 items)
Urinary Incontinence: Interventions for Client who has Dementia (RM AMS RN 9.0 Chp 44, Active Learning
Template
System Disorder)
• Providing a regular toileting schedule, managing fluid intake, modifying the environment,
avoiding indwelling catheters, providing high-quality skin care and assessment, and avoiding
medications that contribute to incontinence are nursing actions that will promote urinary
continence. Personal absorbent pads or bed-protecting pads may be used to catch episodes of
incontinence in both mobile and immobile individuals.
• Biofeedback may be used to assist the person in gaining improved control over the muscles of
elimination. Biofeedback involves placement of sensors onto the affected area of bowel so that
the person can receive feedback regarding which muscles are being used to control bowel
function.
• Among those with dementia, toilet assistance (including timed voiding and prompted voiding)
along with protective pads, and skin care are standard interventions.
Urinary Incontinence: Irrigating an Indwelling Urinary Catheter (RM Fundamentals 8.0 Chp 44, Active Learning
Template – Nursing Skill)
• If a catheter becomes plugged with pus or sediment, it is best to change it rather than irrigate
because irrigation washes the pus and sediment back into the bladder, creating a worse
infection. Change the catheter as needed.
• It is appropriate to use irrigation after surgery for blood clots and short-term catheter use; but
for long-term use irrigation can create a chronic sediment and pus problem, requiring lifelong
irrigation in long-term indwelling catheters.
• For patients with bladder infections, a health care provider often orders antiseptic or antibiotic
bladder irrigations to wash out the bladder or treat local infection. In both irrigations follow
sterile aseptic technique.
Nutrition/Digestion/Elimination (4 items)
Nutrition/Digestion/Elimination (4 items)
Bowel Incontinence: Low-Residue Diet (RM Nutrition 5.0 Chp 13, Active Learning Template – System Disorder)
• Bowel incontinence is the involuntary passage of stool. Loss of sphincter control is the main problem that
contributes to bowel incontinence.
• Loss of sphincter control can occur as a result of traumatic injury or pathologic changes to the rectum, or
from neurologic injury.
• Bowel incontinence also can occur with diarrhea, particularly when it is associated with forceful intestinal
peristalsis (cramping).
Bowel Incontinence: Skin Care (RM Fundamentals 8.0 Chp 43, Active Learning Template – System Disorder
• In the presence of tissue integrity, the skin functions to maintain fluid and electrolyte balance and
thermoregulation. Production of sweat, which includes both water and electrolytes, serves to cool
the excessive body temperatures that could lead to organ damage and to remove wastes.
• The skin and mucous membranes provide a barrier to most organisms and many toxic substances in
the environment. The nerves of the skin provide feedback about temperature and pressure that serve
as a safety mechanism for the person negotiating the environment.
• Unrelieved pressure on a body tissue eventually causes injury. Urinary or bowel incontinence can
also contribute to impairment of tissue integrity through skin contact with caustic excretions. Finally,
a loss of tissue integrity often results in pain because the skin is laden with sensory nerve endings
reactive to the irritation of the local damage.
Regulation and Metabolism (3 items)
Regulation and Metabolism (3 items)
Regulation & Metabolism Expected Findings: Recognizing Hypoglycemia (RM AMS RN 9.0 Chp 83, Active Learning
Template – System Disorder)
• hypoglycemia refers to a state of insufficient or low blood glucose levels, defined as less than 70
mg/dl.
• Shakiness Nervousness or anxiety Sweating, chills and clamminess Irritability or impatience
Confusion, including delirium Rapid/fast heartbeat Lightheadedness or dizziness Hunger and nausea
Sleepiness Blurred/impaired vision Tingling or numbness in the lips or tongue Headaches
• Weakness or fatigue Anger, stubbornness, or sadness Lack of coordination Nightmares or crying out
during sleep Seizures Unconsciousness
• many people have blood glucose readings below this level and feel no symptoms. This is called
hypoglycemia unawareness.
Sensory Perceptual (5 items)
Sensory Perceptual (5 items)
Reduced Vision: Assessing for Homonymous Hemianopsia (RM AMS RN 9.0 Chp 15, Active Learning Template –
System
Disorder)
• A homonymous hemianopsia is the loss of half of the field of view on the same side in both eyes.
• It is also referred to as ahomonymous hemianopia.
• It occurs frequently in stroke and traumatic brain injuries due to the way part of the optic nerve fibers
from each eye crossover as they pass to the back of the brain.
Mobility (5 items)
Mobility (5 items)
Arthroplasty: Laboratory Findings to Report (RM AMS RN 9.0 Chp 69, Active Learning Template – Diagnostic
Procedure)
• Arthroplasty is a surgical procedure to restore the integrity and function of a joint. A joint can be restored
by resurfacing the bones. An artificial joint (called a prosthesis) may also be used.
• Various types of arthritis may affect the joints. Osteoarthritis, or degenerative joint disease, is a loss of the
cartilage or cushion in a joint, and is the most common reason for arthroplasty.
• Arthroplasty may be used when medical treatments no longer provide adequate relief from joint pain
and/or disability . Some medical treatments for osteoarthritis that may be used prior to arthroplasty
include, but are not limited to, the following:
▪ Anti-inflammatory medications
▪ Pain medications
▪ Limiting painful activities
▪ Assistive devices for walking (such as a cane)
▪ Physical therapy
▪ Cortisone injections into a knee joint
▪ Viscosupplementation injections (to add lubrication into the joint to make joint
movement less painful)
▪ Weight loss (for obese people)
▪ Glucosamine and chondroitin sulfate
▪ Exercise and conditioning
Arthroplasty: Reporting Medication History to Provider (RM AMS RN 9.0 Chp 96, Active Learning Template –
Medication)
• Pain control is very important after knee replacement surgery. If your pain isn’t managed well, you may
have difficulty beginning rehabilitation and moving around after surgery.
• These often include opioid pain medicines, such as:
o morphine
o hydromorphone (Dilaudid)
o hydrocodone, which is found in Norco and Vicodin
o oxycodone, which is found in Percocet
o meperidine (Demerol)
• These are commonly used as medicines to manage moderate to severe pain after surgery. However,
taking too many opioid medications can cause:
o constipation
o drowsiness
o nausea
o slowed breathing
o confusion
o a loss of balance
o an unsteady gait
• Patient-controlled analgesia (PCA) pumps
o Patient-controlled (PCA) pumps usually contain opioid pain medications. This machine will allow
you to control the dose of your medication. Whenever you press the button, more medication is
released. However, the pump is programmed so that it cannot deliver an excess of pain
medicine. The dose is controlled over time. For example, a pump may be programmed so that
you can’t receive more than a certain amount of morphine per hour.
• Nerve blocks
o A nerve block is administered by inserting an intravenous (IV) catheter into areas of the body
near nerves that would transmit pain messages to the brain. This is also known as regional
anesthesia. Nerve blocks are an alternative to PCA pumps. After one to two days, your doctor will
remove the catheter and you can begin taking pain medicines by mouth if they’re needed.
o People who’ve received nerve blocks report higher satisfaction and fewer adverse events than
those who’ve used a PCA pump. However, nerve blocks still have risks that include infection,
allergic reaction, and bleeding. The nerve block also causes you to lose control of the muscles of
the lower leg. This may slow your physical therapy and ability to walk.
• Liposomal bupivacaine
• This is a newer medication for pain relief that a doctor injects into the surgical site. Also
known as Exparel, this medicine releases a continuous analgesic to relieve pain for up to 72
hours after your procedure. This medication may be prescribed along with other pain
medications.
Fractures: Monitoring for Complications (RM AMS RN 9.0 Chp 72, Active Learning Template – Therapeutic
Procedure)
• Fractures are at risk of developing infection and a variety of other non-infective complications.
• Fractures are associated with a range of potential complications. Acute complications occur as a direct
result of the trauma sustained and can include damage to vascular structures, nerves, or soft tissue.
Delayed complications may occur after initial treatment or in response to treatment. Therefore,
reevaluation at regular intervals during healing is prudent in most cases.
• Certain fractures can cause severe hemorrhage or predispose to other life-threatening complications.
Femur fractures that disrupt the femoral artery or its branches are potentially fatal Pelvic fractures can
damage pelvic arteries or veins causing life-threatening hemorrhage; the more displaced the pelvic
fracture, the greater the potential blood loss
• Hip fractures, particularly in the elderly, may prevent ambulation, resulting in potentially life-threatening
complications, such as pneumonia, thromboembolic disease, and possibly rhabdomyolysis, if there is a
prolonged period of immobility. Patients with multiple rib fractures are at substantial risk for pulmonary
contusion and related complications.
Osteoarthritis: Client Teaching Regarding Exercise (RM AMS RN 9.0 Chp 73, Active Learning Template – System
Disorder)
• Three kinds of exercise are important for people with osteoarthritis: exercises involving range of motion,
also called flexibility exercises; endurance or aerobic exercises; and strengthening exercises. Each one
plays a role in maintaining and improving your ability to move and function
• Range of motion/flexibility: Range of motion refers to the ability to move your joints through the full
motion they were designed to achieve. When you have osteoarthritis, pain and stiffness make it very
difficult to move certain joints more than just a little bit, which can make even the simplest tasks
challenging.
Range-of-motion exercises include gentle stretching and movements that take joints through their full
span. Doing these exercises regularly – ideally every day – can help maintain and even improve the
flexibility in your joints.
Aerobic/endurance: These exercises strengthen your heart and make your lungs more efficient. This
conditioning has the added benefit of reducing fatigue, so you have more stamina throughout the day.
Aerobic exercise also helps control your weight by increasing the amount of calories your body uses.
Furthermore, this type of exercise can help you sleep better and improve your mood.
• Strengthening: Strengthening exercises help maintain and improve your muscle strength. Strong muscles
can support and protect joints that are affected by arthritis.
• Having a chronic disease like osteoarthritis can be stressful. Stress, in turn, can make dealing with a
disease like osteoarthritis more difficult – and painful. That’s because when you feel stressed, your body
becomes tense. This muscle tension can increase pain, making you feel helpless and frustrated because
the added pain may limit your abilities. This, in turn, can depress you. Stress, depression and limited and
lost abilities can all contribute to pain, which then perpetuates the cycle. If you understand how your
body reacts physically and emotionally to stress and learn how to manage stress, you can break the
destructive cycle.
Oxygenation (3 items)
Oxygenation (3 items)
