Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Stoma Care ppt.

Restraints ppt.

Respiratory System ppt.

Planning ppt.

Post Natal Exercises ppt.

Pain During Pregnancy ppt.

Obesity Prevention and Education for School Nurses ppt.

Oxygen Inhalation ppt.

Neonatal Infections ppt.

Nasogastric Feeding or Gavage Feeding

Multi Organ Dysfunction Syndrome ppt.

Bladder Cancer ppt.

Augmentation of Labour ppt.

Alendronate sodium (Drug Study)

Drug Name

Generic name: alendronate sodium
(ah len‘ dro nate)

Brand name: Fosamax

Pregnancy Category CDrug classes
  • Bisphosphonate
  • Calcium regulator

Therapeutic actions
Slows normal and abnormal bone resorption without inhibiting bone formation and mineralization.

  • Treatment and prevention of osteoporosis in postmenopausal women
  • Treatment of men with osteoporosis
  • Treatment of glucocorticoid-induced osteoporosis
  • Treatment of Paget’s disease of bone in patients with alkaline phosphatase at least two times upper limit of normal, those who are symptomatic, those at risk for future complications

Contraindications and cautions
  • Contraindicated with allergy to biphosphonates; hypocalcemia.
  • Use cautiously with renal dysfunction, upper GI disease, pregnancy, lactation.

Available forms
Tablets—5, 10, 35, 40, 70 mg

  • Postmenopausal osteoporosis: 10 mg/day PO in AM with full glass of water, at least 30 min before the first beverage, food, or medication of the day, or 70 mg PO once a week. Avoid lying down for 30 min after taking drug.
  • Males with osteoporosis: 10 mg/day PO.
  • Prevention of osteoporosis: 5 mg/day PO or 35 mg PO once a week.
  • Paget’s disease: 40 mg/day PO in AM with full glass of water, at least 30 min before the first beverage, food, or medication of the day for 6 mo; may retreat after 6-mo treatment-free period.
  • Glucocorticoid-induced osteoporosis: 5 mg/day PO with calcium and vitamin D.
Safety and efficacy not established.
Dosage adjustment not necessary for creatinine clearance 35–60 mL/min; not recommended if creatinine clearance < 35 mL/min.
Route Onset Duration
PO Slow Days
Metabolism: Not metabolized; T1/2: More than 10 yr
Distribution: Crosses placenta; may enter breast milk
Excretion: Urine

Adverse effects
  • CNS: Headache
  • GI: Nausea, diarrhea, GI irritation, pain, esophageal erosion
  • Skeletal: Increased or recurrent bone pain, focal osteomalacia

  • Increased risk of GI distress with aspirin
  • Decreased absorption if taken with antacids, calcium, iron, multivalent cations; separate dosing by at least 30 min
  • Significantly decreased absorption and serum levels if taken with food; separate dosing from food and beverage by at least 30 min

Nursing considerations
CLINICAL ALERT! Name confusion has occurred between Fosamax (alendronate) and Flomax (tamsulosin); use caution.
  • History: Allergy to bisphosphonates, renal failure, upper GI disease, lactation, pregnancy
  • Physical: Muscle tone, bone pain; bowel sounds; urinalysis, serum calcium
  • WARNING: Give in AM with full glass of water at least 30 min before the first beverage, food, or medication of the day. Patient must stay upright for 30 min.
  • Monitor serum calcium levels before, during, and after therapy.
  • Ensure 6-mo rest period after treatment for Paget’s disease if retreatment is required.
  • Ensure adequate vitamin D and calcium intake.
  • Provide comfort measures if bone pain returns.
Teaching points
  • Take drug in morning with a full glass of plain water (not mineral water), at least 30 min before any beverage, food, or medication, and stay upright for 30 min and until after the first food of the day.
  • You may experience these side effects: Nausea, diarrhea; bone pain, headache (analgesic may help).
  • Report twitching, muscle spasms, dark-colored urine, severe diarrhea.

albuterol sulfate (Drug Study)

Drug Name
Generic Name : albuterol sulfate

Brand Name:  AccuNeb, Novo-Salmol (CAN), Proventil, Proventil HFA, Salbutamol (CAN), Ventodisk (CAN), Ventolin HFA

Classification: Sympathomimetic, Beta2-selective adrenergic agonist, Bronchodilator, Antasthmatic

Pregnancy Category C


  • Initially, 2 or 4 mg (1–2 tsp syrup) tid–qid PO; may cautiously increase dosage if necessary to 4 or 8 mg qid, not to exceed 32 mg/day.
  • Each actuation of aerosol dispenser delivers 90 mcg albuterol; 2 inhalations q 4–6 hr; some patients may require only 1 inhalation q 4 hr; more frequent administration or larger number of inhalations not recommended.
    • Prevention of exercise-induced bronchospasm: 2 inhalations 15 min prior to exercise.
Solution for inhalation
  • 2.5 mg tid to qid by nebulization.
Inhalation capsules
  • One 200 mcg capsule q 4–6 hr up to two 200 mcg capsules q 4–6 hr.
    • Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise.
Oral, tablets
  • 6–12 yr: 2 mg tid–qid. Do not exceed 24 mg/day.
  • > 12 yr: Use adult dosage.
Oral, syrup
  • < 2 yr: Safety and efficacy not established.
  • 2–6 yr: Initially 0.1 mg/kg tid, not to exceed 2 mg (1 tsp) tid; if necessary, cautiously increase stepwise to 0.2 mg/kg tid. Do not exceed 4 mg (2 tsp) tid.
  • 6–14 yr: 2 mg (1 tsp) tid–qid; if necessary, cautiously increase dosage. Do not exceed 24 mg/day in divided doses.
  • 14 yr: Use adult dosage.
  • 2–12 yr: For child 10–15 kg, use 1.25 mg; for child > 15 kg, use 2.5 mg.
  • 12 yr: Use adult dosage.
Solution for inhalation
  • 10–15 kg: 1.25 mg bid or tid by nebulization.
  • 15 kg: 2.5 mg bid or tid by nebulization.
Inhalation capsules
  • > 4 yr: One 200 mcg capsule inhaled q 4–6 hr.
    • Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise.

Therapeutic actions
  • In low doses, acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic cardiac effects.

  • Relief and prevention of bronchospasm in patients with reversible obstructive airway disease
  • Inhalation: Treatment of acute attacks of bronchospasm
  • Prevention of exercise-induced bronchospasm
  • Unlabeled use: Adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentrations when inhaled by patients on hemodialysis

Adverse effects
  • CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache
  • CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain
  • Dermatologic: Sweating, pallor, flushing
  • GI: Nausea, vomiting, heartburn, unusual or bad taste in mouth
  • GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies
  • Respiratory: Respiratory difficulties, pulmonary edema, coughing, bronchospasm, paradoxical airway resistance with repeated, excessive use of inhalation preparations

Contraindications and cautions
  • Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of CVA; COPD patients with degenerative heart disease.
  • Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis); hyperthyroidism; history of seizure disorders; psychoneurotic individuals; labor and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic agonists can accelerate fetal heart beat and cause hypoglycemia, hypokalemia, pulmonary edema in the mother and hypoglycemia in the neonate); lactation; the elderly (more sensitive to CNS effects).

Nursing considerations
  • History: Hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane; unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of CVA; COPD patients who have developed degenerative heart disease; diabetes mellitus; hyperthyroidism; history of seizure disorders; psychoneurotic individuals; lactation
  • Physical: Weight; skin color, T, turgor; orientation, reflexes, affect; P, BP; R, adventitious sounds; blood and urine glucose, serum electrolytes, thyroid function tests, ECG
  • Use minimal doses for minimal periods; drug tolerance can occur with prolonged use.
  • Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur.
  • Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization.
  • Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive.
Teaching points
  • Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant.
  • You may experience these side effects: Dizziness, drowsiness, fatigue, headache (use caution if driving or performing tasks that require alertness); nausea, vomiting, change in taste (eat frequent small meals); rapid heart rate, anxiety, sweating, flushing, insomnia.
  • Report chest pain, dizziness, insomnia, weakness, tremors or irregular heart beat, difficulty breathing, productive cough, failure to respond to usual dosage.

acyclovir (Drug Study)

Drug  Name
Generic Name :  acyclovir (acycloguanosine)

Brand Name:
  Alti-Acyclovir (CAN), Avirax (CAN), Zovirax
Classification: Antiviral, Purine nucleoside analogue

Pregnancy Category B

Dosages & Route

  • 5–10 mg/kg infused IV over 1 hr, q 8 hr (15 mg/kg/day) for 7–10 days.
  • Initial genital herpes: 200 mg q 4 hr (1,000 mg/day) for 10 days.
  • Long-term suppressive therapy: 400 mg bid for up to 12 mo.
  • Acute herpes zoster: 800 mg q 4 hr five times daily for 7–10 days.
  • Chickenpox: 800 mg qid for 5 days.
  • HSV infections < 12 yr: 10 mg/kg infused IV over 1 hr q 8 hr for 7 days.
  • Shingles, HSV encephalitis: 20 mg/kg IV over 1 hr q 8 hr for 10 days.
  • Neonatal HSV: 10 mg/kg infused over 1 hr q 8 hr for 10 days.
  • < 2 yr: Safety not established.
  • 2 yr and < 40 kg: 20 mg/kg per dose qid (80 mg/kg/day) for 5 days.
  • 40 kg: Use adult dosage.
  • 12 yr: Use adult dosage.

Therapeutic actions
  • Antiviral activity; inhibits viral DNA replication.

  • Initial and recurrent mucosal and cutaneous HSV-1 and HSV-2 and varicella zoster infections in immunocompromised patients
  • Severe initial and recurrent genital herpes infections in selected patients
  • Herpes simplex encephalitis
  • Treatment of neonatal herpes simplex virus infections
  • Acute treatment of herpes zoster (shingles) and chickenpox
  • Ointment: Initial HSV genital infections; limited mucocutaneous HSV infections in immunocompromised patients
  • Cream: Recurrent herpes labialis (cold sores) in patients > 12 yr
  • Unlabeled uses: Cytomegalovirus and HSV infection following transplant, herpes simplex infections, varicella pneumonia, disseminated primary eczema herpeticum

Adverse effects
Systemic administration
  • CNS: Headache, vertigo, depression, tremors, encephalopathic changes
  • Dermatologic: Inflammation or phlebitis at injection sites, rash, hair loss
  • GI: Nausea, vomiting, diarrhea, anorexia
  • GU: Crystalluria with rapid IV administration, hematuria
Topical administration
  • Dermatologic: Transient burning at site of application

  • Contraindicated with allergy to acyclovir, seizures, CHF, renal disease, lactation.
  • Use cautiously with pregnancy.

Nursing considerations
  • History: Allergy to acyclovir, seizures, CHF, renal disease, lactation, pregnancy
  • Physical: Skin color, lesions; orientation; BP, P, auscultation, perfusion, edema; R, adventitious sounds; urinary output; BUN, creatinine clearance
Systemic administration
  • Ensure that the patient is well hydrated.
Topical administration
  • Start treatment as soon as possible after onset of signs and symptoms.
  • Wear a rubber glove or finger cot when applying drug.
Teaching points
Systemic administration
  • Complete the full course of oral therapy, and do not exceed the prescribed dose.
  • Oral acyclovir is not a cure for your disease but should make you feel better.
  • Avoid sexual intercourse while visible lesions are present.
  • You may experience these side effects: Nausea, vomiting, loss of appetite, diarrhea; headache, dizziness.
  • Report difficulty urinating, rash, increased severity or frequency of recurrences.
Topical administration
  • Wear rubber gloves or finger cots when applying the drug to prevent autoinoculation of other sites and transmission to others.
  • This drug does not cure the disease; application during symptom-free periods will not prevent recurrences.
  • Avoid sexual intercourse while visible lesions are present.
  • This drug may cause burning, stinging, itching, rash; notify your physician if these are pronounced.

acetaminophen (N-acetyl-p-aminophenol) Drug Study

Drug Name

Generic Name: acetaminophen (N-acetyl-p-aminophenol)

Brand Name:

  • Suppositories: Abenol (CAN), Acephen
  • Oral: Aceta, Apacet, Atasol (CAN), Genapap, Genebs, Liquiprin, Mapap, Panadol, Tapanol, Tempra,Tylenol
Classification: Antipyretic, Analgesic (nonopioid)

Pregnancy Category B

  • PO or PR
  • By suppository, 325–650 mg q 4–6 hr or PO, 1,000 mg tid to qid. Do not exceed 4 g/day.
  • PO or PR
  • Doses may be repeated 4–5 times/day; do not exceed five doses in 24 hr; give PO or by suppository.
 Age  Dosage (mg)
 0–3 mo  40
 4–11 mo  80
 12–23 mo  120
 2–3 yr  160
 4–5 yr  240
 6–8 yr  320
 9–10 yr  400
 11 yr  480

Therapeutic actions
  • Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.
  • Analgesic: Site and mechanism of action unclear.

  • Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis
  • Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects)
  • Common cold, flu, other viral and bacterial infections with pain and fever
  • Unlabeled use: Prophylactic for children receiving DPT vaccination to reduce incidence of fever and pain

Adverse effects
  • CNS: Headache
  • CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr
  • GI: Hepatic toxicity and failure, jaundice
  • GU: Acute kidney failure, renal tubular necrosis
  • Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia
  • Hypersensitivity: Rash, fever

  • Contraindicated with allergy to acetaminophen.
  • Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

Nursing considerations
  • History: Allergy to acetaminophen, impaired hepatic function, chronic alcoholism, pregnancy, lactation
  • Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs, renal function tests
  • Do not exceed the recommended dosage.
  • Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness).
  • Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products.
  • Give drug with food if GI upset occurs.
  • Discontinue drug if hypersensitivity reactions occur.
  • Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should be available as a specific antidote; basic life support measures may be necessary.
Teaching points
  • Do not exceed recommended dose; do not take for longer than 10 days.
  • Take the drug only for complaints indicated; it is not an anti-inflammatory agent.
  • Avoid the use of other over-the-counter preparations. They may contain acetaminophen, and serious overdosage can occur. If you need an over-the-counter preparation, consult your health care provider.
  • Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns.

Bowel Elimination

The Large Intestine
  • Primary organ of bowel elimination
  • Extends from the ileocecal valve to the anus
  • Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L)
  • Manufacture of some vitamins
  • Formation of feces
  • Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis
  • Peristalsis is under control of nervous system
  • Contractions occur every 3 to 12 minutes
  • Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
  • One-third to one-half of food waste is excreted in stool within 24 hours
Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination
  1. Age
  2. Diet
  3. Position
  4. Pregnancy
  5. Fluid Intake
  6. Activity
  7. Psychological
  8. Personal Habits
  9. Pain
  10. Medications
  11. Surgery/Anesthesia

Developmental Considerations
  • Infants—characteristics of stool and frequency depend on formula or breast feedings
  • Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs)
  • Child, adolescent, adult—defecation patterns vary in quantity, frequency, and rhythmicity
  • Older adult—constipation is often a chronic problem

Foods Affecting Bowel Elimination
  • Constipating foods cheese, lean meat, eggs, & pasta
  • Foods with laxative effect—fruits and vegetables, bran, chocolate, alcohol, coffee
  • Gas-producing foods—onions, cabbage, beans, cauliflower

Effect of Medications on Stool
  • Aspirin, anticoagulants pink, red, or black stool
  • Iron salts—black stool
  • Antacids white discoloration or speckling in stool
  • Antibiotics—green-gray color

Physical Assessment of the Abdomen
  • Inspection—observe contour, any masses, scars, or distension
  • Auscultation—listen for bowel sounds in all quadrants
  • Note frequency and character, audible clicks, and flatus
  • Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussion—expect resonant sound or tympany
  • Areas of increased dullness may be caused by fluid, a mass, or tumor
  • Palpation—note any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum
  • Inspection and palpation
  • Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass
  • Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining
  • Inspect perineal area for skin irritation secondary to diarrhea
Stool Collection
  • Medical aseptic technique is imperative
  • Wear disposable gloves
  • Wash hands before and after glove use
  • Do not contaminate outside of container with stool
  • Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection
  • Void first so urine is not in stool sample
  • Defecate into the container rather than toilet bowl
  • Do not place toilet tissue in bedpan or specimen container
  • Notify nurse when specimen is available
  • get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies
  • Esophagogastroduodenoscopy (EGD)
  • Colonoscopy
  • Sigmoidoscopy
  • Wireless capsule endoscopy

Indirect Visualization Studies
  • Upper gastrointestinal (UGI)
  • Small bowel series
  • Barium enema

Scheduling Diagnostic Tests
  • 1 — fecal occult blood test
  • 2 — barium studies (should precede UGI) make sure ALL barium is removed*
  • 3 — endoscopic examinations
Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination
  • Patient has a soft-formed bowel movement every 1-3 days without discomfort
  • The relationship between bowel elimination and diet, fluid, and exercise is explained
  • Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits
  • Timing -attend to urges promptly
  • Positioning – have pt. sit up, gravity aids in BM
  • Privacy – close door & pull curtain
  • Nutrition
  • Exercise – abdominal muscles & thighs
  • Abdominal settings
  • Thigh strengthening

Individuals at High Risk for Constipation
  • Patients on bed rest taking constipating medications
  • Patients with reduced fluids or bulk in their diet
  • Patients who are depressed
  • Patients with central nervous system disease or local lesions that cause pain
*Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injury

Nursing Measures for the Patient With Diarrhea
  • Answer call lights immediately
  • Remove the cause of diarrhea whenever possible (e.g., medication)
  • If there is impaction, obtain physician order for rectal examination
  • Give special care to the region around the anus
  • After diarrhea stops, suggest the intake of fermented dairy products
  • Fecal seepage may indicate impaction

Preventing Food Poisoning
  • Never buy food with damaged packaging
  • Never use raw eggs in any form
  • Do not eat ground meat uncooked
  • Never cut meat on a wooden surface
  • Do not eat seafood that is raw or has unpleasant odor
  • Clean all vegetables and fruits before eating
  • Refrigerate leftovers within 2 hours of eating them
  • Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces
  • Enemas
  • Rectal suppositories
  • Rectal catheters
  • Digital removal of stool

Types of Enemas
  • Cleansing – high volume
  • Retention - oil
  • Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas
Retention Enemas
  • Oil-retention—lubricate the stool and intestinal mucosa easing defecation
  • Carminative—help expel flatus from rectum
  • Medicated—provide medications absorbed through rectal mucosa
  • Anthelmintic—destroy intestinal parasites
  • Nutritive—administer fluids and nutrition rectally

Bowel Training Programs
  • Manipulate factors within the patient's control
  • Food and fluid intake, exercise, time for defecation
  • Eliminate a soft, formed stool at regular intervals without laxatives
  • When achieved, discontinue use of suppository if one was used

Types of Colostomies – each has different stool consistency
  • Sigmoid colostomy
  • Descending colostomy
  • Transverse colostomy
  • Ascending colostomy
  • Ileostomy
Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care
  • Keep patient as free of odors as possible; empty appliance frequently
  • Inspect the patient's stoma regularly
  • Note the size, which should stabilize within 6 to 8 weeks
  • Keep the skin around the stoma site clean and dry
  • Measure the patient's fluid intake & output
  • Explain each aspect of care to the patient and self-care role
  • Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies
  • Community resources are available for assistance
  • Initially encourage patients to avoid foods high in fiber
  • Avoid foods that cause diarrhea or flatus
  • Drink two quarts of water daily
  • Teach about medications
  • Teach about odor control (intake of dark green vegetables helps control odor)
  • Resume normal activity including work and sexual relations
Comfort Measures
  • Encourage recommended diet and exercise
  • Use medications only as needed
  • Apply ointments or astringent (witch hazel)
  • Use suppositories that contain anesthetics

Characteristics of Normal Stool

  1. Color – varies from light to dark brown foods & medications may affect color
  2. Odor – aromatic, affected by ingested food and person’s bacterial flora
  3. Consistency – formed, soft, semi-solid; moist
  4. Frequency – varies with diet (about 100 to 400 g/day)
  5. Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

  1. Constipation – abnormal frequency of defecation and abnormal hardening of stools
  2. Impaction – accumulated mass of dry feces that cannot be expelled
  3. Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence
  4. Incontinence – involuntary elimination of feces
  5. Flatulence – expulsion of gas from the rectum
  6. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation.

Blood Transfusion Therapy

Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).

Blood components include:
  1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
  2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
  3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
  4. Granulocytes ( basophils, eosinophils, and neutrophils )
  5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
  6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation.
  7. Albumin, a plasma protein.
  8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
  9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
  10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
  11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy
  1. Avoids the risk of sensitizing the patients to other blood components.
  2. Provides optimal therapeutic benefit while reducing risk of volume overload.
  3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy
  1. Whole blood transfusion
    • Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.
  2. Packed RBCs
    • Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.
  3. Platelets
    • Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.
  4. Granulocytes
    • May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.
  5. Plasma
    • Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.
  6. Albumin
    • Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure.
  7. Cryoprecipitate
    • Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.
  8. Factor IX concentrate
    • Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.
  9. Factor VIII concentrate
    • Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.
  10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.


  1. To increase circulating blood volume after surgery, trauma, or hemorrhage
  2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia
  3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

Nursing Interventions

  1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
  2. Check for cross matching and typing. To ensure compatibility
  3. Obtain and record baseline vital signs
  4. Practice strict Asepsis
  5. At least 2 licensed nurse check the label of the blood transfusion
    • Check the following:
      • Serial number
      • Blood component
      • Blood type
      • Rh factor
      • Expiration date
      • Screening test (VDRL, HBsAg, malarial smear) - *this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.
  6. Warm blood at room temperature before transfusion to prevent chills.
  7. Identify client properly. Two Nurses check the client’s identification.
  8. Use needle gauge 18 to 19. This allows easy flow of blood.
  9. Use BT set with special micron mesh filter. To prevent administration of blood clots and particles.
  10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
  11. Monitor vital signs. Altered vital signs indicate adverse reaction.
  12. Do not mix medications with blood transfusion. To prevent adverse effects
    • Do not incorporate medication into the blood transfusion
    • Do not use blood transfusion lines for IV push of medication.
  13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis.
  14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
  15. Observe for potential complications. Notify physician.

Complications of Blood Transfusion

  1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.
    • Assessments:
      • Flushing
      • Rush, hives
      • Pruritus
      • Laryngeal edema, difficulty of breathing
  2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion
    • Assessments:
      • Sudden chills and fever
      • Flushing
      • Headache
      • Anxiety
  3. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria.
    • Assessment:
      • Rapid onset of chills
      • Vomiting
      • Marked Hypotension
      • High fever
  4. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.
    • Assessment:
      • Rise in venous pressure
      • Dyspnea
      • Crackles or rales
      • Distended neck vein
      • Cough
      • Elevated BP
  5. Hemolytic reaction. It is caused by infusion of incompatible blood products.
    • Assessment:
      • Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
      • Chills
      • Feeling of fullness
      • Tachycardia
      • Flushing
      • Tachypnea
      • Hypotension
      • Bleeding
      • Vascular collapse
      • Acute renal failure

Assessment findings
  1. Clinical manifestations of transfusions complications vary depending on the precipitating factor.
  2. Signs and symptoms of hemolytic transfusion reaction include:
    • Fever
    • Chills
    • low back pain
    • flank pain
    • headache
    • nausea
    • flushing
    • tachycardia
    • tachypnea
    • hypotension
    • hemoglobinuria (cola-colored urine)
  3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
    • fever
    • mild jaundice
    • gradual fall of hemoglobin
    • positive Coombs’ test
  4. Febrile non-hemolytic reaction is marked by:
    • Temperature rise during or shortly after transfusion
    • Chills
    • headache
    • flushing
    • anxiety
  5. Signs and symptoms of septic reaction include;
    • Rapid onset of high fever and chills
    • vomiting
    • diarrhea
    • marked hypotension
  6. Allergic reactions may produce:
    • hives
    • generalized pruritus
    • wheezing or anaphylaxis (rarely)
  7. Signs and symptoms of circulatory overload include:
    • Dyspnea
    • cough
    • rales
    • jugular vein distention
  8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
  9. Characteristics of GVH disease include:
    • skin changes (e.g. erythema, ulcerations, scaling)
    • edema
    • hair loss
    • hemolytic anemia
  10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis
  1. Ineffective breathing pattern
  2. Decreased Cardiac Output
  3. Fluid Volume Deficit
  4. Fluid Volume Excess
  5. Impaired Gas Exchange
  6. Hyperthermia
  7. Hypothermia
  8. High Risk for Infection
  9. High Risk for Injury
  10. Pain
  11. Impaired Skin Integrity
  12. Altered Tissue Perfusion

Planning and Implementation
  1. Help prevent transfusion reaction by:
    • Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion.
    • Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
    • Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
    • Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
    • Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
    • Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
    • Preventing hypothermia by warming blood unit to 37 C before transfusion.
    • Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.
  2. On detecting any signs or symptoms of reaction:
    • Stop the transfusion immediately, and notify the physician.
    • Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
    • Send the blood bag and tubing to the blood bank for repeat typing and culture.
    • Draw another blood sample for plasma hemoglobin, culture, and retyping.
    • Collect a urine sample as soon as possible for hemoglobin determination.
  3. Intervene as appropriate to address symptoms of the specific reaction:
    • Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
    • Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
    • In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
    • Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
    • For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions when complications occurs in Blood transfusion
  1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.
  2. Start IV line (0.9% Na Cl)
  3. Place the client in fowler’s position if with SOB and administer O2 therapy.
  4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
  5. Notify the physician immediately.
  6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician’s order or protocol.
  7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
  8. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

  1. The patient maintains normal breathing pattern.
  2. The patient demonstrates adequate cardiac output.
  3. The patient reports minimal or no discomfort.
  4. The patient maintains good fluid balance.
  5. The patient remains normothermic.
  6. The patient remains free of infection.
  7. The patient maintains good skin integrity, with no lesions or pruritus.
  8. The patient maintains or returns to normal electrolyte and blood chemistry values.

Back Care

After bathing and drying the back, it should be massaged or rubbed thoroughly.

I. Purpose

  1. To stimulate the circulation and give general relief.
  2. To prevent bedsore
  3. To give comfort to the patient.

II. Equipment
  • Alcohol 25%
  • Talcum powder
  • Bath towel
III. Procedure
  1. Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. If the supine position is used and the patient is a woman, pillow under the abdomen removes pressure from the breasts and favor relaxation.
  2. Raise the camisa and gown.
  3. Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long strokes and kneading motions. The amount of pressure to exert depends upon the patient’s condition. Begun from neck and shoulders then proceed over the entire back.
  4. Massage with both hands working with a strong stroke. In upward than in downward motions. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be used.)
  5. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes.
  6. Turn patient on his back and put on camisa or gown.
  7. Fix and make patient comfortable.

Movements Used
  1. Effleurage (stroking—is a long sweeping movement with palm of hand conforming to the contour of the surface treated, over small surface (on the neck) the thumb and fingers are used. Strokes should be slow, rhythmical and gentle with pressure constant and in the direction of venous stream.
  2. Kneading—performed with the ulnar side palm resting on the surface and the fingers, and thumble grasping the skin and subcutaneous tissues which move with the hand of the operator.
  3. Friction—is performed with the whole palmar surface of the hand or fingers and thumbs over limited areas. This movement is a circular from of kneading with pressure against the underlying part of tissue which cannot be grasped.


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