1. Nutrition and Fluids Chapter 24
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2. Dietary Practices
The person’s diet affects physical and mental well-being.
A poor diet and poor eating habits:
Increase the risk for infection
Increase the risk of acute and chronic diseases
Cause chronic illnesses to become worse
Cause healing problems
Affect physical and mental function, increasing the risk for accidents and injuries
Culture, finances, and personal choice affect dietary practices.
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3. Basic Nutrition
Nutrition is the processes involved in the ingestion, digestion, absorption, and use of foods and fluids by the body.
Good nutrition is needed for growth, healing, and body functions.
A well-balanced diet and correct calorie intake are needed.
Foods and fluids contain nutrients.
Nutrients are grouped into fats, proteins, carbohydrates, vitamins, minerals, and water.
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4. Basic Nutrition (cont’d)
The Dietary Guidelines for Americans, 2010 is for persons 2 years of age and older.
The Dietary Guidelines help people:
Attain and maintain a healthy weight.
Reduce the risk of chronic disease.
Promote overall health.
The Guidelines focus on:
Consuming fewer calories
Making informed food choices
Being physically active
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5. Basic Nutrition (cont’d)
The MyPtate symbol encourages healthy eating from 5 food groups.
MyPlate, issued by the United States Department of Agriculture (USDA), helps you make wise food choices by:
Balancing calories
Increasing certain foods
Reducing certain foods
The USDA recommends that adults do at least one of the following:
2 hours and 30 minutes each week of moderate physical activity
1 hour and 15 minutes each week of vigorous physical activity
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6. Basic Nutrition (cont’d)
Nutrients
Protein is the most important nutrient.
It is needed for tissue growth and repair.
Carbohydrates provide energy and fiber for bowel elimination.
Fats provide energy.
They provide and help the body use certain vitamins.
Vitamins are needed for certain body functions.
Minerals are used for many body processes.
Water is needed for all body processes.
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7. MEETING NUTRITIONAL NEEDS
A team approach is needed to meet a person’s nutritional needs.
The nutritional care plan involves the person’s:
Likes and dislikes
Lifelong habits
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8. Special Diets Doctors may order special diets:
For a nutritional deficiency or a disease
For weight control (gain or loss)
To eliminate or decrease certain substances in the diet
The health team considers the need for dietary changes, personal choices, religion, culture, and eating problems.
Regular diet, general diet, and house diet mean no dietary limits or restrictions.
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9. Special Diets (cont’d)
The sodium-controlled diet
Sodium causes the body to retain water.
The heart has to work harder. The extra workload can cause serious problems or death.
Sodium control decreases the amount of sodium in the body.
The doctor orders the amount of sodium allowed.
Sodium-controlled diets involve:
Omitting high-sodium foods
Not adding salt to food at the table
Limiting the amount of salt used in cooking
Diet planning
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10. Special Diets (cont’d)
Diabetes meal plan
A meal plan for health eating is developed.
Consistency is key.
The meal plan involves:
The person’s food preferences
Calories needed
Eating meals and snacks at regular times
You need to:
Serve meals and snacks on time.
Always check what was eaten.
Report what the person did and did not eat.
Report changes in the person’s eating habits.
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11. Special Diets (cont’d)
The dysphagia diet
Dysphagia means difficulty swallowing.
Food thickness is changed to meet the person’s needs.
Doctor, speech-language pathologist, occupational therapist, dietitian, and nurse choose food thickness.
When feeding the person with dysphagia, you must:
Know the signs and symptoms of dysphagia.
Feed the person according to the care plan.
Follow aspiration precautions and the care plan.
Report changes in how the person eats.
Observe for signs and symptoms of aspiration: choking, coughing, or difficulty breathing during or after meals, and abnormal breathing or respiratory sounds.
Report these observations at once.
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12. Fluid Balance Death can result from too much or too little water.
Fluid balance is needed for health.
The amount of fluid taken in (intake) and the amount of fluid lost (output) must be equal.
If fluid intake exceeds fluid output, body tissues swell with water. This is called edema.
If fluid output exceeds intake, dehydration occurs.
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13. Fluid Balance (cont’d)
Normal fluid requirements
An adult needs 1500 mL (milliliters) of water daily to survive.
About 2000 to 2500 mL are needed for normal fluid balance.
The water requirement increases with:
Hot weather
Exercise
Fever and illness
Excess fluid losses
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14. Fluid Balance (cont’d)
Common special fluid orders are:
Encourage fluids: the person drinks an increased amount of fluids.
Restrict fluids: fluids are limited to a certain amount.
Nothing by mouth (NPO): the person cannot eat or drink anything.
Thickened liquids: all fluids are thickened, including water.
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15. Fluid Balance (cont’d)
Intake and output (I&O) records
The doctor or nurse may order (I&O) measurements.
I&O records are kept:
To evaluate fluid balance and kidney function
To help in planning medical treatment
When the person has special fluid orders
The following fluids are measured and recorded:
All fluids taken by mouth
Foods that melt at room temperature
IV fluids and tube feedings
Output includes urine, vomitus, diarrhea, and wound drainage.
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16. Fluid Balance (cont’d)
Measuring intake and output
Intake and output are measured in milliliters (mL).
A measuring container for fluid is called a graduate.
The measuring device is held at eye level to read the amount.
An I&O record is kept at the bedside.
Amounts are totaled at the end of the shift.
The purpose of measuring I&O and how to help are explained to the person.
The urinal, commode, bedpan, or specimen pan is used for voiding.
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17. Meeting Food and Fluid Needs
The following can affect appetite and ability to eat:
Weakness, illness, and confusion
Unpleasant odors, sights, and sounds
An uncomfortable position
The need for oral hygiene
The need to eliminate
Pain
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18. Meeting Food and Fluid Needs (cont’d)
Preparing for meals
To promote comfort when preparing patients and residents for meals:
Assist with elimination needs.
Provide oral hygiene.
Make sure needed dentures are in place.
Make sure eyeglasses and hearing aids are in place (if worn).
Make sure incontinent persons are clean and dry.
Position the person in a comfortable position.
Assist the person with hand washing.
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19. Meeting Food and Fluid Needs (cont’d)
Serving meals
You serve meals after preparing patients and residents for meals.
Some agencies have “room service” meal programs.
Serve meals in the assigned order.
If food is not served within 15 minutes, re-check food temperatures.
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20. Meeting Food and Fluid Needs (cont’d)
When feeding the person:
Serve food and fluids in the order the person prefers.
Offer fluids during the meal.
Use teaspoons to feed the person.
Let the person do as much as possible.
Always tell the visually impaired person what is on the tray.
When feeding visually impaired persons, describe what you are offering.
For persons who feed themselves, describe foods and fluids and their places on the tray.
Use the numbers on a clock for the location of foods.
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21. Meeting Food and Fluid Needs (cont’d)
Allow time and privacy for prayer.
Engage the person in pleasant conversation.
Allow time for chewing and swallowing.
Sit facing the person.
You can see how well the person is eating.
You can also see if the person has problems swallowing.
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22. Meeting Food and Fluid Needs (cont’d)
Between-meal nourishments
Snacks are served upon arrival on the nursing unit.
Follow the same considerations and procedures as for serving meals and feeding persons.
Calorie counts
On a flow sheet, note what the person ate and how much.
A nurse or dietitian converts the portions into calories.
Providing drinking water
Patients and residents need fresh drinking water each shift and whenever the pitcher is empty.
Follow the agency’s procedure for providing fresh drinking water.
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23. Chapter 22
Urinary Elimination

24. Urinary Elimination Eliminating waste is a physical need.
The urinary system:
Removes waste products from the blood
Maintains the body’s water balance
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25. Normal Urination
The healthy adult produces about 1500 mL (milliliters), or 3 pints, of urine a day.
Factors affecting urine production include:
Age
Disease
Amount and kinds of fluid ingested
Dietary salt
Body temperature and perspiration
Drugs
Frequency of urination is affected by:
Amount of fluid intake, habits, and available toilet facilities
Activity, work, and illness
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26. Normal Urination (cont’d)
Observations
Normal urine:
Is pale yellow, straw-colored, or amber
Is clear with no particles
Has a faint odor
Observe urine for color, clarity, odor, amount, particles, and blood.
Report complaints of urgency, burning on urination, or painful or difficult urination.
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27. Normal Urination (cont’d)
Bedpans are used by:
Persons who cannot be out of bed
Women for voiding and bowel movements
Men for bowel movements
Standard bedpans and fracture pans are used.
Fracture pans are used:
By persons with casts
By persons in traction
By persons with limited back motion
After spinal cord injury or surgery
After a hip fracture
After hip replacement surgery
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28. Normal Urination (cont’d)
Men use urinals to void.
The man stands if possible.
Some sit on the side of the bed or lie in bed.
Some men need support when standing.
You may have to place and hold the urinal for some men.
Remind men:
To hang urinals on bed rails and signal after use
Not to place urinals on overbed tables and bedside stands
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29. Normal Urination (cont’d)
Persons unable to walk to the bathroom often use commodes.
The commode allows a normal position for elimination.
The commode arms and back provide support and help prevent falls.
Some commodes are wheeled into bathrooms and placed over toilets. They are useful for persons who need support when sitting.
The container is removed if the commode is used with the toilet.
Wheels are locked after the commode is positioned over the toilet.
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30. Urinary Incontinence The basic types of incontinence are:
Stress
Urge
Overflow
Functional
Reflex
Mixed incontinence
Transient incontinence
If incontinence is a new problem, tell the nurse at once.
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31. Urinary Incontinence (cont’d)
The following may be needed:
Good skin care and dry garments and linens
Promoting normal urinary elimination
Bladder training
Catheters
Incontinence is linked to abuse, mistreatment, and neglect.
Remember, incontinence is beyond the person’s control.
If you are becoming short-tempered and impatient, talk to the nurse at once.
The person has the right to be free from abuse, mistreatment, and neglect.
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32. Catheters
Inserted through the urethra into the bladder, a urinary catheter drains urine into a drainage bag.
A straight catheter drains the bladder and then is removed.
An indwelling catheter (retention or Foley catheter) is left in the bladder.
Catheterization is the process of inserting a catheter.
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33. Catheters (cont’d) Catheters are used:
Before, during, and after surgery
For people who are too weak or disabled to use the bedpan, urinal, commode, or toilet
To protect wounds and pressure ulcers from contact with urine
To allow hourly urinary output measurements
As a last resort for incontinence
To collect sterile urine specimens
For measuring residual urine
When caring for persons with indwelling catheters, the risk of infection is high.
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34. Catheters (cont’d) Drainage systems
A closed drainage system is used for indwelling catheters.
Nothing can enter the system from the catheter to the drainage bag.
Some people wear leg bags that attach to the thigh or calf when standing up.
The drainage bag is always kept lower than the bladder to prevent urinary tract infections (UTIs).
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35. Catheters (cont’d)
If the drainage system is disconnected accidentally, tell the nurse at once.
Do not touch the ends of the catheter or tubing.
Practice hand hygiene and put on gloves.
Wipe the end of the tube with an antiseptic wipe.
Wipe the end of the catheter with another antiseptic wipe.
Do not put the ends down.
Do not touch the ends after you clean them.
Connect the tubing to the catheter.
Discard the wipes into a biohazard bag.
Remove the gloves and practice hand hygiene.
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36. Catheters (cont’d)
Leg bags are changed to drainage bags when the person is in bed.
You open the closed drainage system.
Prevents microbes from entering the system.
Drainage bags are emptied and urine is measured:
At the end of every shift
When changing from a leg bag to a drainage bag
When changing from a drainage bag to a leg bag
When the bag is becoming full
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37. Catheters (cont’d) Removing indwelling catheters
An indwelling catheter has two lumens (passage-ways).
Sterile water is injected through one lumen to inflate the balloon.
Urine drains from the bladder through the other lumen.
A physician’s order is needed to remove a catheter.
Most people need bladder training first.
Dysuria and urinary frequency are common after removing catheters.
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38. Catheters (cont’d)
Condom catheters (external catheters, Texas catheters, urinary sheaths) are often used for incontinent men.
A condom catheter is a soft sheath that slides over the penis.
To apply a condom catheter:
Follow the manufacturer’s instructions.
Thoroughly wash the penis with soap and water.
Dry the penis before applying the catheter.
Condom catheters are self-adhering or applied with elastic tape.
Never use adhesive tape to secure catheters.
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39. Bladder Training Control of urination is the goal.
The person uses the toilet, commode, bedpan, or urinal at certain times.
The rules for normal elimination are followed.
The normal position for urination is assumed if possible.
Privacy is important.
Four methods are:
Bladder retraining
Prompted voiding
Habit training/scheduled voiding
Catheter clamping
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40. Bowel Elimination Chapter 23
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41. Bowel Elimination
Bowel elimination is the excretion of wastes from the gastro-intestinal (GI) system.
Factors affecting bowel elimination include:
Privacy
Habits
Age
Diet
Exercise and activity
Fluids
Drugs
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42. Normal Bowel Elimination
Time and frequency of bowel movements vary.
Stools normally:
Are brown
Are soft, formed, moist, and shaped like the rectum
Have a normal odor caused by bacterial action in the intestines
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43. Normal Bowel Elimination (cont’d)
Observe and report the following to the nurse. If allowed to chart, also record the following:
Color
Amount
Consistency
Presence of blood or mucus
Odor
Shape
Frequency of BMs
Complaints of pain or discomfort
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44. Factors Affecting Bowel Elimination
Normal, regular elimination is the goal.
Factors affecting stool frequency, consistency, color, and odor
Privacy
Habits
Diet—high-fiber foods
Diet—other foods
Fluids
Activity
Drugs
Disability
Aging
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45. Common Problems Constipation is the passage of a hard, dry stool.
Constipation occurs when feces move slowly through the bowel.
Fecal impaction is the prolonged retention and build-up of feces in the rectum.
Feces are hard or putty-like.
Fecal impaction results in constipation if not relieved.
Symptoms include abdominal discomfort, abdominal distention (swelling), nausea, cramping, and rectal pain. Older persons may have poor appetite, confusion, or even a fever.
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46. Common Problems (cont’d)
The nurse does a digital (finger) exam to check for an impaction.
The digital exam often causes the urge to have a BM.
Sometimes the fecal mass is removed with a gloved finger.
This is called digital removal of an impaction.
Checking for and removing impactions is very dangerous.
The vagus nerve can become stimulated, which slows the heart rate.
Heart rate can slow to unsafe levels in some persons.
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47. Common Problems (cont’d)
Diarrhea is the frequent passage of liquid stools.
Feces move through the intestines rapidly.
Diet and drugs are ordered to reduce peristalsis.
You need to:
Assist with elimination needs promptly.
Dispose of stools promptly.
Give good skin care.
Fluid lost through diarrhea must be replaced.
Otherwise dehydration occurs.
Always follow Standard Precautions and the Bloodborne Pathogen Standard when in contact with stools.
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48. Common Problems (cont’d)
Fecal incontinence is the inability to control the passage of feces and gas through the anus.
Fecal incontinence affects the person emotionally.
The person may need:
Bowel training
Help with elimination after meals and every 2 to 3 hours
Incontinence products to keep garments and linens clean
Good skin care
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49. Common Problems (cont’d)
Flatulence is the excessive formation of gas or air in the stomach and intestines.
Gas or air passed through the anus is called flatus.
If flatus is not expelled, the intestines distend.
The following help produce flatus:
Exercise
Walking
Moving in bed
The left side-lying position
Doctors may order enemas and drugs to relieve flatulence.
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50. Bowel Training Bowel training has two goals, to:
Gain control of bowel movements.
Develop a regular pattern of elimination.
Factors that promote elimination are part of the care plan and the bowel-training program. These include:
High-fiber diet
Increased fluids
Warm fluids
Activity
Privacy
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51. Suppositories
A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature.
A rectal suppository is inserted into the rectum.
A BM occurs about 30 minutes later.
The doctor may order a suppository to stimulate a BM for:
Constipation
Fecal impaction
Bowel training
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52. Enemas
An enema is the introduction of fluid into the rectum and lower colon.
Doctors order enemas to:
Remove feces
Relieve constipation, fecal impaction, or flatulence
Clean the bowel of feces before certain surgeries and diagnostic procedures
A doctor orders the enema solution.
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53. Enemas (cont’d)
The solution depends on the enema’s purpose cleansing, constipation, fecal impaction, or flatulence.
Tap-water enema is obtained from a faucet.
Saline enema is a solution of salt and water.
Soapsuds enema (SSE) is a solution of castile soap and water.
Small-volume enema is commercially prepared.
Oil-retention enema is mineral, olive, or cottonseed oil.
Other enema solutions may be ordered.
Nurses give enemas that contain drugs.
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54. Enemas (cont’d) Cleansing enemas: Tap-water enemas can be dangerous.
Clean the bowel of feces and flatus
Relieve constipation and fecal impaction
Are needed before certain surgeries and diagnostic procedures
Tap-water enemas can be dangerous.
Saline enema solution is similar to body fluid.
Soapsuds enemas irritate the bowel’s mucous lining.
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55. Enemas (cont’d) Small-volume enemas irritate and distend the rectum.
Often ordered for constipation
Also ordered when the bowel does not need complete cleansing
Oil-retention enemas relieve constipation and fecal impactions.
Retaining oil softens feces and lubricates the rectum.
Most oil-retention enemas are commercially prepared.
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56. The Person with an Ostomy
An ostomy is a surgically created opening for the elimination of body wastes.
The opening seen through the abdominal wall is called a stoma.
The person wears a pouch over the stoma to collect stools and flatus.
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57. The Person with an Ostomy (cont’d)
Colostomy
A colostomy is a surgically created opening between the colon and abdominal wall.
With a permanent colostomy, the diseased part of the colon is removed.
A temporary colostomy gives the diseased or injured bowel time to heal.
After healing, surgery is done to reconnect the bowel.
The colostomy site depends on the site of disease or injury.
Ileostomy
An ileostomy is a surgically created opening between the ileum (small intestine) and the abdominal wall.
Liquid stools drain constantly from an ileostomy.

58. The Person with an Ostomy (cont’d)
Ostomy pouches
The pouch has an adhesive backing applied to the skin.
Sometimes pouches are secured to ostomy belts.
Many pouches have a drain at the bottom that close with a clip, clamp, or wire closure.
The drain is opened to empty the pouch.
The pouch is emptied when stools are present.
It is opened when it balloons or bulges with flatus.
Wipe the drain with toilet tissue before it is closed.
The pouch is changed every 3 to 7 days and when it leaks.
Do not flush pouches down the toilet.

59. Collecting and Testing Specimens
Chapter 31
Collecting and Testing Specimens
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60. Specimens
Ordered by doctors, specimens (samples) are collected and tested to prevent, detect, and treat disease.
Most specimens are tested in the laboratory.
All specimens sent to the laboratory require requisition slips.
Some tests are done at the bedside.
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61. Urine Specimens Urine specimens are collected for urine tests.
Random urine specimen is used for a routine urinalysis (UA).
It is collected any time during a 24-hour period.
Many people can collect the specimen themselves.
Weak and very ill persons need help.
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62. Urine Specimens (cont’d)
Midstream specimen (clean-voided specimen or clean-catch specimen)
The perineal area is cleaned before collecting the specimen.
To collect the specimen:
The person starts to void into a device.
The person stops the urine stream.
A sterile specimen container is positioned.
The person voids into the container until the specimen is obtained.
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63. Urine Specimens (cont’d)
The 24-hour urine specimen
All urine voided during a 24-hour period is collected.
Urine is chilled on ice or refrigerated during this time.
A preservative is added to the collection container for some tests.
The person voids to begin the test with an empty bladder.
Discard this voiding.
Save all voidings for the next 24 hours.
The test is restarted if:
A voiding was not saved.
Toilet tissue was discarded into the specimen.
The specimen contains stool.

64. Urine Specimens (cont’d)
To collect a urine specimen from an infant or a child who is not toilet-trained, a collection bag (“wee bag”) is applied over the urethra.
Voiding on request is hard for toilet-trained toddlers and young children.
Potty chairs and specimen pans are useful.
Remember to use terms the child understands.
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65. Urine Specimens (cont’d)
The doctor orders the type and frequency of urine tests. The nurse may ask you to do these simple urine tests.
Testing for pH
Urine pH measures if urine is acidic or alkaline.
A random urine specimen is needed.
Testing for glucose and ketones
The diabetic person may have sugar (glucose) in the urine and ketones in the urine.
Tests for glucose and ketones are usually done 4 times a day—30 minutes before each meal and at bedtime.
The doctor uses the test to make drug and diet decisions.

66. Urine Specimens (cont’d)
Testing for blood
Injury and disease can cause hematuria (blood in the urine).
Sometimes blood is seen in the urine.
At other times, it is unseen (occult).
A random urine specimen is needed.
Using reagent strips
Do not touch the test area on the strip.
Dip the strip into urine.
Compare the strip with the color chart on the bottle.
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67. Urine Specimens (cont’d)
Straining urine
A stone (calculus) can develop in the kidney, ureter, or bladder.
Stones (calculi) vary in size.
Stones causing severe pain and urinary system damage may require removal by medical or surgical procedures.
Some stones pass through urine.
All of the person’s urine is strained.
Passed stones are sent to the laboratory.

68. Stool Specimens
Stools are studied for fat, microbes, worms, blood, and other abnormal contents.
Bleeding may occur in very small amounts
Stools are tested for occult (hidden) blood.
Stools are tested for occult blood to screen for colon cancer and other digestive disorders.
Occult blood test kits vary. Follow manufacturer’s instructions.
Urine must not contaminate the stool specimen.
The person uses one device for voiding and another for a BM.
Some tests require a warm stool.
The specimen is taken at once to the laboratory or storage area.