BASIC INTERVENTIONS TO MAINTAIN
fruits.
HEALTHY LIFESTYLE
CONCEPT: NUTRITION
NUTRITION
Sum of all interactions between an organism
& the food it consumes
What a person eats & how the body uses it
NUTRIENTS- organic/inorganic substances found in
foods required for body functioning- water,
carbohydrates, proteins, fats, vitamins & minerals.
Three major functions:
a. Provide energy for body processes & movement
b. Provide structural material for body tissues
c. Regulates body processes
ESSENTIAL NUTRIENTS:
1. CARBOHYDRATES- composed of elements
carbon [C], HYDROGEN [H]. & oxygen [O].2
types:
a. Sugars- simple carbohydrates, water
soluble, produced by plants[fruits, sugar
cane, sugar beets] & animals [lactose
found in animal milk].Processed / refined
sugars [table sugar, corn syrup ] are
extracted /concentrated from natural
sources. Sugars maybe
MONOSACCHARIDES [single molecules]
or DISACCHARIDES [double molecules]
.Of the 3 monosaccharides [glucose,
fructose & galactose] glucose is the most
abundant simple sugar.
b. Starches insoluble, nonsweet forms of
carbohydrate, called POLYSACCHARIDES
[composed of dozens of glucose
molecules].Found in plants- grains,
legumes, potatoes, breads, flour,
puddings.
FIBER complex carbohydrate derived from
plants supplies roughage or bulk to the diet, cannot
be digested by humans. It satisfies the appetite &
helps digestive tract to function effectively &
eliminate waste. Fiber is present in outer layer of
grains, bran, & skin, seeds & pulp of vegetables &
Carbohydrate Digestion- Major enzyme includes
PTYALIN [salivary amylase], pancreatic amylase &
disaccharides. Enzymes are biologic catalysts that
speed up chemical reactions. The desired end
products of carbohydrate digestion are
monosaccharides. Some simple sugars are already
monosaccharides & require no digestion. All
monosaccharides are absorbed by small intestine in
healthy people.
Carbohydrate metabolism after the body breaks
carbohydrates down into glucose, some glucose
continues to circulate in the blood to maintain blood
levels 7 to provide readily available source of energy.
The remainder is either used as energy or stored.
Insulin, a hormone secreted by pancreas, enhances
transport of glucose into cells.
2. PROTEINS- amino acids, organic molecules
made up of carbon, hydrogen, oxygen &
nitrogen combine to form protein. Essential
amino acids- are those that cannot be
manufactured in the body & must be supplied
as part of protein ingested in the diet.
Nonessential amino acids are those that the
body can manufacture. Proteins maybe:
a. Complete proteins- contain essential &
nonessential amino acids including- meats,
poultry, fish, dairy products, eggs.
b. Incomplete proteins- lack one or more essential
amino acids, derived from vegetables.
Protein Digestion:
Begins in the mouth, where the enzyme PEPSIN
breaks protein down into smaller units. Most proteins
are digested in small intestine. Pancreas secretes
trypsin, chymotrypsin, & carboxypeptidase: glands in
intestinal wall secrete aminopeptidase & dipeptides.
These enzymes break protein down into smaller
molecules & amino acids.
3. LIPIDS [FATS] - organic substances that are
greasy & insoluble in water but soluble in
alcohol & ether. Lipids have the same
elements [carbon, hydrogen & oxygen] as
carbohydrates, but they contain high
proportion of hydrogen.
 a. Saturated fatty acids- are those in which sodium, potassium, magnesium,
all carbon atoms are filled to capacity chloride, & sulfur.
with hydrogen: an example is butyric acid
found in butter. Microminerals - people require daily
amounts less than 100 mg. include-
b. Unsaturated fatty acids- can iron, zinc, manganese, iodine,
accommodate more hydrogen atoms fluoride, copper, cobalt, chromium, &
than it currently does. selenium. Common problems include
iron deficiency anemia &
c. Glycerides- simple lipids, most common osteoporosis resulting from loss of
form of lipids. calcium.

d. Triglycerides- have 3 fatty acids, account Factors Affecting Nutrition:

for more than 90 % of lipids in food & in
the body. Saturated triglycerides are 1. Development- infants./ adolescence increase
found in animal products such as butter need for nutrients: elderly need few calories
& are usually solid at room temperature.
Unsaturated triglycerides are usually 2. Gender- muscle mass of men need greater
liquid at room temperature, found in calories
plant products such as olive oil & corn oil.
3. Ethnicity & culture- Asians rice: Italians-
e. Cholesterol- fatlike substance produced pasta
by the body & found in foods of animal
origin & synthesized by the liver. 4. Beliefs about food- reducing animal fat to
avoid heart attack
Lipid Metabolism- Converting fat into
usable energy occurs through the use of 5. Personal Preference- likes & dislikes
enzyme hormone sensitive LIPASE that
6. Religious practices- Islam prohibits pork
breaks down triglycerides in adipose
cells, releasing glycerol &fatty acids into 7. Lifestyle- cooking skills, fast foods
the blood.
8. Economics- financial resources
4. MICRONUTRIENTS
9. Medications & therapy- drugs may alter
a. Vitamin- organic compound that appetite
cannot be manufactured by the body
& is needed in small quantities. 10. Health- lack of teeth, dysphagia
Water soluble vitamins include C &
B complex vitamins- B1 [Thiamine]: 11. Alcohol consumption- lead to weight gain
B2 [Riboflavin]: B3 [Niacin or nicotinic
acid]: B6 [Pyridoxine]: B9 [Folic acid]: 12. Advertising- media, TV
B12 [Cobalamin]: pantothenic acid &
biotin. The body cannot store water- 13. Psychologic factors- depression, stress,
soluble vitamins, thus people must anorexia nervosa, bulimia
get daily supply in the diet.
NURSING DIAGNOSES [NANDA]
Fat soluble vitamins include A, D, E,
1. Imbalanced Nutrition : More Than Body
and K. The body can store these
Requirements
vitamins. Vitamin content is highest
in fresh foods that are consumed as 2. Imbalanced Nutrition: Less Than Body
soon as possible after harvest. Requirements

b. Minerals- are found in organic 3. Readiness for Enhanced Nutrition

compound. Macrominerals - people
require daily in amounts over 100 4. Risk for Imbalanced Nutrition: More Than Body
mg; include calcium, phosphorus, Requirements
 5. Constipation related to inadequate fluid intake & pulse decreases, growth hormone levels
fiber intake peak, BMR decreases

6. Low Self Esteem related to obesity b. REM sleep [Rapid Eye Movement]-recurs
every 90 minutes & lasts 5 to 30 minutes, &
IMPROVING APPETITE/ PROVIDING CLIENT most dreams take place.
MEALS-INTERVENTIONS:
Functions of Sleep:
1. Provide familiar food that the person likes.
a. Restore normal level of activity / balance of
2. Select small portions so as not to discourage nervous system
anorexic client.
b. Necessary for protein synthesis, allows repair
3. Avoid unpleasant / uncomfortable treatment processes
immediately before or after a meal
c. Psychological wellbeing-
4. Provide tidy, clean environment
Factors Affecting Sleep:
5. Encourage / provide oral hygiene
1. Illness
6. Relieve illness symptoms that depress
appetite] 2. Environment

7. Reduce stress 3. Lifestyle

8. Assist client to a comfortable position 4. Emotional stress

9. Clear over bed table so that there is space for 5. Stimulants /Alcohol
food tray
6. Diet
10. Check each tray for clients name, type of
diet, completeness 7. Smoking

11. Assist client as required 8. Motivation

12. For a blind person, identify the placement of 9. Medications

food as you would describe the time on a
clock Common Sleep Disorders:

13. If a client is on special diet, record amount of
food eaten& any pain, fatigue or nausea
experienced
14. If the client is not eating, document this
CONCEPT:REST AND SLEEP
1. Insomnia- inability to fall asleep or remain
asleep: awaken not feeling rested.
2. Hypersomnia- obtain sufficient sleep at night
but still cannot stay awake during the day:
caused by CNS damage, kidney, liver or
metabolic disease- DM

SLEEP- a basic human need, a universal biological
process common to all people.
Circadian Rhythms- Biological rhythm exist in plants,
animals & humans. In humans, these are controlled
from within the body & synchronized with
environmental factors such as light & darkness.
Types of sleep:
a. NREM[ Non Rapid Eye Movement] sleep
physiologic changes include arterial BP falls,
3. Narcolepsy- excessive daytime sleepiness
caused by lack of chemical HYPOCRETIN in
Central Nervous System that regulates sleep.
4. Sleep apnea- characterized by frequent short
breathing pauses during sleep. All individuals
have occasional apnea during sleep. More
than 5 apneic episodes or 5 breathing pauses
longer than 10 seconds/ hour is abnormal &
should be evaluated.
 5. Insufficient sleep- 6.8 hours of sleep is
average. Sleep deprivation may result to
fatigue, attention /concentration deficits,
malaise, diplopia, dry mouth.
6. Parasomnia- behavior that interfere with
sleep & may even occur during sleep.
Sleepwalking [ somnambulism ] &
sleeptalking
CONCEPT:RESPIRATION/OXYGENATION
RESPIRATION
Process of gas exchange between individual
& environment.
Upper respiratory system mouth, nose,
pharynx & larynx

NURSING DIAGNOSIS: Lower respiratory system trachea & lungs-

bronchi, bronchioles, alveoli, pulmonary
1. Insomnia related to overstimulation prior to capillary network & pleural membranes
bedtime
Pulmonary ventilation act of breathing:
2. Risk for Injury related to somnambulism] inspiration [inhalation] & expiration
[exhalation] Factors: clear airways: intact
3. Fatigue related to insufficient sleep
CNS / respiratory center [medulla & pons]:
intact thoracic cavity: adequate lung
4. Risk for Impaired Gas Exchange related to
compliance & recoil
apnea

5. Deficient Knowledge [nonprescription remedies Factors affecting respiratory function

for sleep] related to misinformation [oxygenation]:

PROMOTING SLEEP 1. Age

1. Establish regular bedtime & wake- up time 2. Environment

for all days of the week
3. Lifestyle
2. Regular, relaxing bedtime routine before
4. Health status
sleep- listening to soft music, warm bath,
doing quite activity 5. Medications
3. Avoid dealing with office work/ family 6. Stress
problems before bedtime
Hypoxia- insufficient oxygen in the body-
4. Adequate exercise during daytime
rapid pulse, rapid shallow respiration,
dyspnea, restless, light headedness, flaring
5. Use bed for sleep or sexual activity, take
of nares
computers, TV out of bedroom

6. Create sleep conducive environment- dark, Hypoxemia- low oxygen in the blood: low
quiet, comfortable, cool hemoglobin saturation

7. Keep noise to a minimum Cyanosis- bluish discoloration of skin,

nailbeds, mucous membrane due to reduce
8. Sleep on comfortable mattress / pillows hemoglobin- oxygen saturation

9. Avoid heavy meal 2- 3 hours before bedtime Eupnea- normal respiration

10. Avoid alcohol/ caffeine food/ beverages Tachypnea- rapid respiratory rate- fever, pain

11. Use sleep medications as last resort
12. Consult physician for medications that cause
insomnia
Bradypnea- slow respiratory rate- persons
taking morphine, increase intracranial
pressure
Apnea- cessation of breathing
 Orthopnea- inability to breath except in 5. Sleep pattern disturbance related to:
upright or standing position
Ineffective breathing pattern [ orthopnea]
Dyspnea- difficult breathing
Measures that Promote Adequate
Nursing Diagnosis [NANDA] Ineffective Airway Respiratory Function:
Clearance r/t inability to clear secretions from
respiratory tract: Ineffective Breathing 1. Adequate oxygen supply from the
Pattern: Impaired Gas Exchange: Activity environment. Man requires 21 % of
Intolerance oxygen from the environment in order to
survive. The higher the altitude, the
Oxygen Therapy-for clients with dyspnea to lower is the oxygen concentration.
prevent hypoxia. Oxygen is colorless,
2. Deep breathing & coughing exercises- to
odorless & tasteless. Precautions: place a
promote maximum lung expansion&
sign NO SMOKING : instruct clients/ visitors
loosen mucous secretions. Inhale deeply
about hazards: avoid materials that generate
through the nose, and then exhale
static electricity [wool blanket]: avoid
passively through the mouth.
flammable materials- oil, alcohol, acetone
near clients: Fire extinguishers should be
3. Positioning. Semi- fowlers or high
available
fowlers position promotes maximum
lung expansion. By gravity, the
Oxygen delivery systems- cannula, face
diaphragm moves down & abdominal
mask, face tent
organs do not compress diaphragm.
Nursing Diagnoses of Clients with Oxygenation
4. Patent airway- to promote gaseous
Problems:
exchange between person & environment
1. Ineffective airway clearance related to:
5. Adequate hydration to maintain
moisture of mucous membrane lining &
Tracheobronchial infection. Obstruction ,
respiratory tract[6-8 glasses of water
secretions
daily]
Decreased energy and fatigue
6. Avoid environmental pollutants, alcohol,
2. Ineffective breathing pattern related to : smoking- these factors inhibit
mucuciliary function
Neuromuscular/ musculoskeletal impairment

Pain
CONCEPT: FLUIDS AND ELECTROLYTES

Inflammatory process Homeostasis- tendency of the body to maintain a

state of balance or equilibrium while continually
Tracheobronchial obstruction
changing; a mechanism in which deviations from
normal state are sensed & counteracted.
3. Impaired gas exchange related to:
Water is vital to health & normal cellular
Altered oxygen- carrying capacity of the
function, serving as;
blood
1. Medium for metabolic reactions within cells
Altered blood flow
2. Transporter for nutrients, waste products, &
Altered oxygen supply other substances

4. Powerlessness related to: 3. Lubricant

Impaired verbal communication associated 4. Insulator & shock absorber

with endotracheal tube
 5. Regulating & maintaining body temperature
Distribution of Body Fluids- 2 major
components:
1. Intracellular fluid [ICF]- found within the cells
of the body, approximately 2/3 of total body
fluids in adult. Contains solutes- oxygen,
electrolytes & glucose ; and provides a
medium for metabolic processes of cells.
2. Extracellular fluid [ ECF] found outside cells
& accounts for 1/3 of total body fluid.It is the
transport system that carries nutrients to &
waste products from cells. Subdivided into 2
compartments:
a. Intravascular fluid or plasma- accounts
for 20% of ECF, found within vascular
system
b. Interstitial fluid- accounts for 75% of ECF,
surround the cell.
c. Other compartments are Lymph &
transcellular fluid- cerebrospinal ,
pericardial, pancreatic , pleura ,
intraocular, biliary , peritoneal & synovial
fluids
Average Daily Fluid Intake :
Source : oral fluids 1,200 ml- 1500 ml
Water in foods- 1000 ml
Water as by product of food metabolism- 200 ml
Total= 2,400- 2700 ml
Factors Affecting Body Fluid, Electrolyte &
Acid- base Balance:
1. Age- Infants lose more fluid through kidneys
because of immature kidneys , less able to
conserve water than adults; elderly people
are affected also because of aging process
2. Gender & body size- fat cells contain little no
water, hence people with higher body fats
have less body water
3. Environmental temperature- people with
illness & those with strenuous activity are at
risk for fluid / electrolytes imbalances.
4. Lifestyle- diet, exercise, stress. Conditions
such as anorexia nervosa, bulimia[ induced
vomiting, uses of diuretics, laxatives]
Nursing Diagnoses of clients with problems in
fluid & electrolytes imbalance:
1. Deficient Fluid Volume related to decreased
intravascular, interstitial & /or intracellular
fluid
2. Excess Fluid Volume related to increased
isotonic fluid retention
3. Risk for imbalanced Fluid Volume
4. Risk for Deficient Fluid Volume
5. Impaired Oral Mucous Membrane r/t fluid
volume deficit
6. Impaired Skin Integrity r/t dehydration & / or
edema
7. Acute Confusion r/t electrolyte imbalance
Promoting Fluid & Electrolyte Balance:
1. Consume 6- 8 glasses of water daily
2. Eat well- balanced diet including milk
3. Limit alcohol intake- diuretic
4. Increase fluid intake before, during & after
exercise
5. Maintain normal body weight
6. Monitor side effects of medications
[ diuretics]
7. Recognize risk factors of fluid/electrolytes
imbalance- vomiting, watery stools,
8. Prompt professional health care for signs of
fluid imbalance- weight gain or loss, decrease
urine, swollen ankles, dyspnea, dizziness,
confusion
CONCEPT :FECAL ELIMINATION
Defecation is the expulsion of feces from the
rectum. It has an involuntary phase. When
the feces enters the rectum, local distention
& the pressure gives rise to sensory impulses
that initiate reflex impulses to the internal
anal sphincter & to the muscle tissue of
sigmoid colon & the rectum.
 The sphincter relaxes & the muscle tissue
contracts, moving feces into the anal canal.
The external anal canal sphincter is under
voluntary control & must also relax for
evacuation of the rectum.
Change in routine [diet intake]
Abuse of laxatives
Delaying defecation when urge is present

Normal characteristics of stool: 2. Diarrhea related to:

Color- yellow / golden brown[due to bile Dietary alteration

stercobilin/fecal urobilinogen]
Stress/ anxiety
Odor- aromatic [due to indole/ scatole-
Inflammation / irritation of bowel
products of fermentation/ putrefaction in
large intestine]
Drug side effects
Amount- depends on bulk of food intake:
Spoiled food
150- 300 grams /day
Allergy
Consistency- soft, formed
Tube feeding
Shape- cylindrical
3. Potential fluid volume deficit related to
Frequency- variable: range 1-2 per day to
diarrhea
every 2- 3 days
Nursing Interventions to prevent/
Acholic stool- gray, pale or clay- colored stool
relieve constipation:
due to absence of stercobilin/ biliary
obstruction 1. Adequate fluid intake

Hematochezia- passage of stool with bright 2. High fiber diet

red blood, due to lower gastrointestinal
bleeding 3. Establish regular pattern of defecation

Melena- passage of black, tarry stool due to 4. Respond immediately to the urge to
upper GI bleeding defecate

Steatorrhea- greasy, bulky, foul smelling 5. Minimize stress

stool, due to indigested fats like
6. Adequate activity/ exercise promote
hepatobiliary- pancreatic obstructions/
muscle tone /peristalsis
disorders
7. Assume sitting/ semi squatting position
Constipation- passage of small, dry, hard
stools or passage of no stools for a period of 8. Administer laxative as ordered [avoid
time. overuse of laxatives because natural
defecation reflexes are inhibited, rebound
Nursing Diagnosis [NANDA]
constipation occurs].
1. Constipation related to: DIARRHEA
Inadequate fiber in diet
Frequent evacuation of watery stools.
Associated with increased gastrointestinal
Immobility/ inadequate physical activity
motility & rapid passage of fecal contents &
Inadequate fluid intake rapid passage of fecal contents through the
lower gastrointestinal tract.
Pain on defecation
 Nursing interventions to relieve
diarrhea:
1. Replace fluid & electrolytes
2. Provide good perianal care
3. Promote rest- to reduce peristalsis
4. Diet- low fiber diet/ small amount of
bland foods: BRAT diet: avoid excessive
hot/ cold fluids[these are stimulants]:give
potassium rich foods [banana,
Gatorade]
5. Antidiarrheal medications as ordered
[caution- do not administer antidiarrheal
at the start of diarrhea. Diarrhea is the
bodys protective mechanism to rid itself
of bacteria / toxins]
CONCEPT : URINARY ELIMINATION
The major role of urinary system is to
maintain homeostasis by maintaining body
fluid composition & volume.
Components of urinary system kidneys,
ureters, urinary bladder, & urethra
Micturition/ urination/ voiding- expelling urine
from the bladder. Parasympathetic nervous
system initiates voiding, whereas
sympathetic nervous system inhibits voiding.
Micturition reflex is involuntary, but can be
inhibited by higher brain centers.
Normal characteristics of urine:
Color- amber/ straw/ transparent
Odor- aromatic upon voiding
Transparency clear
pH- slightly acidic [range: 4.6 to 8:
average 6]
Specific gravity- 1.010 1. 025
[measured by urinometer]
Problems in urinary elimination:
Hematuria- presence of RBC in urine
Pus presence of pus in urine
Bacteriuria- presence of bacteria in urine
Albuminuria- albumin
Proteinuria- protein
Cylindriuria- casts
Glycosuria0- glucose
Ketonuria- ketones
Polyuria- production of excessive amount
of urine, more than 100ml / hr. or 2500
ml/ day [also diuresis]
Oliguria low urine output, less than 500
ml / day or 30 ml/ hour for adult,
indicates impaired blood flow to the
kidneys / impending renal failure
Anuria absence of production of urine
by the kidneys, 0- 10 ml / hr. [also urinary
suppression]
Frequency- voiding at frequent intervals
Nocturia- increased frequency at night
Urgency- strong feeling that the person
wants to void, may or may not be a great
amount of urine in bladder
Dysuria- voiding that is either painful/
difficult
Hesitancy- difficulty in initiating voiding
Enuresis- repeated involuntary voiding
beyond 4- 5 years of age [ age when
voluntary bladder control is normally
acquired ]
Pollakuria- frequent scanty urination
Retention- accumulation of urine in
bladder with associated inability of
bladder to empty itself. 250 to 450 ml of
urine in the bladder triggers micturition
reflex.
Urinary incontinence:
 a. Total incontinence- continuous /
unpredictable loss of urine
b. Stress incontinence- leakage of less
than 50 ml of urine as a result of
sudden increase in intra- abdominal
pressure: when one cough, sneezes,
laughs or exerts physically
c. Urge incontinence- follows sudden
strong desire to urinate & leads to
involuntary detrusor contraction
d. Functional incontinence- involuntary
unpredictable passage of urine
e. Reflex incontinence- involuntary loss
of urine occurring at predictable
intervals when bladder volume is
reached
Clinical signs of urinary retention:
a. Discomfort in pubic area
b. Bladder distention- [palpation/
percussion] smooth, firm, ovoid mass at
suprapubic area: mass arising out of
pelvis: dullness on percussion
c. Inability to void / frequent voiding of
small volume [25-50 ml at a time]
d. Disproportionately small amount of
output in relation to fluid intake
e. Restlessness / feeling of need to void
Nursing Interventions to Induce Voiding
1. Provide privacy
2. Provide fluids to drink
3. Assist in anatomical position of voiding
4. Serve clean, warm & dry bedpan [female]
or urinal [male]
5. Allow patient to listen to the sound of
running water
6. Dangle fingers in warm water
7. Pour warm water over perineum
8. Promote relaxation
9. Provide adequate time for voiding
10. Perform Credes maneuver as ordered-
applying pressure on suprapubic area
11. Urinary catheterization as ordered - last
resort, common cause of nosocomial
infection
Urine output below 30 ml per hour may
indicate low blood volume or kidney
malfunction & must be reported. To measure
fluid output the nurse follows these steps:
1. Wear clean gloves to prevent contact with
microorganisms/ blood
2. Ask client to void in a clean urinal, bedpan ,
commode or toilet collection device [ hat]
3. Instruct client to keep urine separate from
feces & to avoid putting toilet paper in urine
collection container
4. Pour the voided urine into calibrated container
5. Holding container at eye level, read the
amount [ containers have measuring scale on
the inside]
6. Record the amount on I & O sheet
7. Rinse the urine collection & measuring
containers with water & store appropriately
8. Remove gloves /perform handwashing
9. Calculate & document total output at the end
of shift & at the end of 24 hours on clients
chart
Nursing Diagnoses: Clients with Urinary
Elimination Problems
1. Incontinence related to
Altered environment
Sensory or cognitive deficit
Mobility deficit
Neurologic impairment
Weak pelvic muscles & structural support
associated with age, surgery or multiple
injuries
2. Urinary retention related to:
 Urethral blockage Bereavement subjective response to a loss
through the death of a person with whom
Medication there has been a significant relationship.

3. Altered patterns of urinary elimination Grief total response to emotional

related to: experience of the loss & is manifested in
thoughts, feelings & behaviors
Bladder infection
Mourning- behavioral process through which
Neurologic disorder or injury
grief is eventually resolved / altered: often
influenced by culture/ custom
Renal calculi
Stages of Grieving [Kubler- Ross]:
Loss of perineal tissue tone
1. Denial- refuses to believe that loss is
Medication therapy
happening: unready to deal with practical
4. Potential for infection related to: problems: may assume artificial
cheerfulness
Indwelling urethral catheter
2. Anger- client/ family may direct anger to
Urinary retention a nurse or hospital about matters that
normally would not bother them
5. Potential for impaired skin integrity
related to: 3. Bargaining- seeks bargain to avoid loss:
express feeling of guilt/ fear of
Incontinence punishment for past sins, real or
imagined
Urinary diversion ostomy
4. Depression- grieves over what has
6. Social isolation related to: happened & what cannot be: may talk
freely or withdraw
Incontinence
5. Acceptance- comes to terms with loss:
7. Self- esteem disturbance related to: decreased interest in surroundings/
support persons: may wish to begin
Incontinence making plans

8. Self- care deficit: Toileting related to: Symptoms of Grief:

Functional incontinence 1. Repeated somatic distress

9. Potential fluid volume deficit/ volume 2. Tightness in the chest

excess related to:
3. Choking / shortness of breath
Impaired urinary function associated with
disease process 4. Sighing

10. Body image disturbance related to: 5. Empty feeling in abdomen

Urinary diversion ostomy 6. Loss of muscular power

CONCEPT: COPING WITH LOSS, GRIEVING AND 7. Intense subjective distress

DEATH
Assisting Clients with their Grief
Loss actual /potential situation in which a
valued object, person or the like is 1. Provide opportunity for the person to
inaccessible or changed so that it is no longer tell their story
perceived as valuable.
 2. Recognized/ accept varied emotions that 2. Slowing of circulation
people express in relation to the loss
a. Diminished sensation
3. Provide support for expression of
feelings- anger/ sadness b. Mottling / cyanosis of extremities

4. Include children in grieving process c. Cold skin, first in feet & later in
hands, ears & nose
5. Encourage bereaved to maintain
established relationships 3. Changes in vital signs

6. Acknowledge mutual help groups a. Decelerated/ weak pulse

7. Encourage self- care by family members/ b. Decreased BP

caregivers
c. Rapid, shallow, irregular/ abnormally
8. Acknowledge counseling for difficult slow respirations: Cheyne- stokes
problems respirations: noisy breathing [death
rattle]: mouth breathing
Nursing Diagnoses: Client with Grief and
Loss 4. Sensory impairment

1. Anticipatory grieving related to: a. Blurred vision

Perceived potential loss of loved one b. Impaired sense of taste/ smell

Perceived loss of body part or function Indications of Death

2. Impaired adjustment related to: a. Total lack of response to external stimuli

Disability requiring change in lifestyle b. No muscular movement

Inadequate or unavailable support c. No reflexes

system
d. Flat encephalogram [EEG]- most accurate
indicator of death
3. Social isolation related to

Inadequate personal resources Nursing interventions for the Dying

Client:
Alteration in physical appearance
1. Assist client achieved a dignified &
Care of the Dying Client- signs of peaceful death
impending death:
a. Provide relief from loneliness, fear,
depression
1. Loss of muscle tone
b. Maintain clients sense of security,
a. Relaxation of facial muscles[jaw may
self- confidence, dignity & self- worth
sag]
c. Maintain hope
b. Difficulty in speaking
d. Help client accept his / her loss
c. Difficulty swallowing/ loss of gag
reflex
e. Provide physical comfort
d. Decreased activity of GI tract
2. Maintain physiologic / psychologic
comfort
e. Urinary/ rectal incontinence
a. Personal hygiene measures
f. Diminished body movement
 b. control [highest priority when caring Stiffening of the body that occurs 2- 4
for dying clients] hours after death

c. Relief of respiratory difficulty Results from lack of adenosine

triphosphate [ATP] which is not
d. Assistance with movement, nutrition, synthesized due to lack of oxygen
hydration, elimination
Position the body, place dentures in
e. Measures related to sensory changes mouth & close eyes & mouth before rigor
mortis sets in
3. Provide spiritual support
2. Algor Mortis
a. Search for meaning
Gradual decrease of body temperature
b. Sense of forgiveness
after death
c. Need for love
When blood circulation terminates & the
d. Need for hope. Hospices are health hypothalamus ceases to function, body
care facilities designed to care for temperature falls about 1 degree
terminally ill clients & their families Centigrade per hour until it reaches room
by providing supportive & palliative temperature
services.
3. Livor Mortis
Nursing Diagnoses: Dying Clients
Discoloration of skin after death after
1. Fear related to circulation has ceased. RBCs break down,
releasing hemoglobin which discolors
Knowledge deficit surrounding tissues

Lack of social support in threatening Nursing interventions for the Body After
situation Death:

2. Hopelessness related to: 1. Make environment clean / pleasant

Prolonged restriction of activity resulting 2. Make body appear natural / comfortable

in isolation
3. Remove all equipment/ supplies from
Deteriorating physiologic condition bedside

Terminal illness 4. Remove soiled linens, room free from

odors
Long term stress
5. Place body in supine position, arms at
Perceived significant loss of loved one, sides, palms down
youth, influence
6. Place one pillow under head / shoulders
3. Powerlessness related to to prevent blood from discoloring face

Chronic debilitating disease 7. Close eyelids, insert dentures/ close

mouth
Terminal illness
8. Wash soiled areas of the body
Institutional environment
9. Place absorbent pads under buttocks to
Care of the Body After Death- Body take up feces/ urine released due to
relaxation of sphincter muscles
changes:
10. Provide clean gown/ comb hair
1. Rigor Mortis
11. Remove jewelry[clients valuables are after death]. Apply another Identification
listed & placed in safe storage area for tag to the outside of the shroud.
family to take away
15. Bring the body to the morgue for cooling
12. Allow family to view the patients body [cryonics].

13. Apply ID tags. One to ankle & one to the

wrist

14. Wrap body in shroud [large rectangular

plastic or cotton used to enclose a body