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Older age (delayed gastric emptying and weakenedLES tone) Sleep apneaNG TubeoReview bowel assessment, constipation, diarrheaoBowel assessment: Inspect → Auscultate → Percuss → Palpate oConstipationMonitor forAbdominal bloatingAbdominal crampingStraining at defecation
Presence of dry, hard feces at defecation.Irregular bowel movements, or reduced frequency from client’s normal pattern.hypoactive bowel soundsNursing CareIncrease fiber and water consumption (unless contraindicated) before more invasive interventionsGive bulk-forming products before stool softeners, stimulants, or suppositoriesEnemas are last resort for stimulating defecation. oDiarrheaMonitor forFrequent loose stoolsAbdominal crampingStool of water consistencyhyperactive bowel soundsNursing CareHelp determine and treat the causeAdminister medications to slow peristalsisProvide perineal care after each stool, and apply moisture barrierAfter diarrhea stops, suggest eating yogurt to help re-establish an intestinal balance of beneficial bacteria Review acid-base imbalances, signs/symptoms (see chart)oNormal ValuespH = 7.35 - 7.45PaCO2 = 35 - 45HCO3 = 21- 28oRespiratory Acidosis : HYPOventilation Results from:Brain tumors, cerebral aneurysm, stroke, or overhydration, trauma, or neurologic diseasesInadequate chest expansion due to muscle weakness, pneumothorax/ hemothorax, flail chest, obesity, sleep apnea, tumors, or deformities.Airway obstruction from neck edema, localized lymph node enlargement, foreign bodies or mucusAlveolar-capillary blockage secondary to a pulmonary embolus, thrombus, acute respiratory distress
syndrome, chest trauma, drowning, or pulmonary edema Inadequate mechanical ventilation Results inIncrease CO2Decreased pHS&SVitals: Tachycardia, tachypnea, increased blood pressureDysrhythmiasAnxiety, Irritability, confusionIneffective shallow, rapid breathingPale or cyanoticSeen in clients with COPD, pulmonary disease, sleep apnea, and obesity.oRespiratory Alkalosis: HYPERrventilationResults From:Hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilationResults in:Decreased CO2Increased pHS&SVitals: TachypneaInability to concentrate, numbness, tingling, tinnitus, andpossible loss of consciousnessTachycardia, ventricular and atrial dysrhythmiasRapid, deep respirations oMetabolic AcidosisResults From:Excess production of hydrogen ionsDiabetic Ketoacidosis (DKA)Lactic AcidosisHeavy exerciseSeizure Activity HypoxiaExcess intake of acidsEthyl alcoholMethyl alcohol
Acetylsalicylic acid (Aspirin)Inadequate elimination of hydrogen ionsKidney FailureSevere Lung problems Inadequate production of bicarbonate HCO3Kidney FailurePancreatitis Results in:Decreased HCO3Decreased pHS&S:DysrhythmiasVitals: Bradycardia, weak peripheral pulses, hypotension, tachypneaHeadache, drowsiness, confusion