Midwife Licensure Exam Fundamentals of Care & the Health-Care Process — Basic Oxygenation, Elimination & NutritionDetailed Explanation

Oxygenation: Physiology, Assessment, and Nursing Interventions

Oxygenation is the process by which the body delivers oxygen (O₂) to tissues and removes carbon dioxide (CO₂). Three essential components must work together: (1) a patent airway, (2) effective ventilation and gas exchange, and (3) intact cardiovascular circulation. When any component fails, tissue hypoxia results — cells cannot produce enough ATP and begin to die. Normal oxygen saturation (SpO₂) measured by pulse oximetry is 95–100%. A reading below 90% indicates hypoxemia and requires immediate nursing action. It is important to understand that pulse oximetry has limitations — it may be falsely normal in carbon monoxide poisoning and falsely low in poor peripheral perfusion or nail polish. SIGNS OF HYPOXIA — Early vs. Late: Early signs reflect the body's compensatory response: restlessness and anxiety (the earliest and most critical sign — never dismiss an anxious patient), tachypnea (increased respiratory rate), tachycardia, nasal flaring, and use of accessory muscles (sternocleidomastoid, scalene). Late signs indicate decompensation: cyanosis (bluish discoloration of lips and fingertips — a LATE sign, meaning significant hypoxia already exists), bradycardia (heart is failing), confusion, decreased level of consciousness, and apnea. POSITIONING FOR DYSPNEA: The single most important non-pharmacologic nursing intervention for a dyspneic patient is positioning. Place the patient in High-Fowler's position (head of bed 60–90°) or the orthopneic position (patient sits upright and leans forward on an overbed table). Both positions lower the diaphragm by gravity, allow greater lung expansion, and reduce the work of breathing. Never place a dyspneic patient flat (supine) as this compresses the diaphragm and worsens breathing. OXYGEN DELIVERY DEVICES — Know the flow rates and FiO₂: • Nasal Cannula: 1–6 L/min → delivers approximately 24–44% FiO₂. Each additional 1 L/min adds roughly 4% FiO₂. It is comfortable and allows eating and talking. At flows above 6 L/min, the mucosa dries without significant added oxygen benefit — humidification is needed at higher flows. • Simple Face Mask: 5–10 L/min → approximately 40–60% FiO₂. Must maintain a minimum flow of 5 L/min to flush exhaled CO₂ from the mask; below this, rebreathing of CO₂ occurs. • Partial Rebreather Mask: 10–12 L/min → approximately 60–75% FiO₂. Has a reservoir bag; one-way valve allows some exhaled air into the bag (hence 'partial' rebreathing). • Non-Rebreather Mask (NRM): 10–15 L/min → up to 80–95% FiO₂ (approaching 100%) — used in emergencies (e.g., carbon monoxide poisoning, respiratory distress). One-way valves prevent exhaled air from entering the reservoir bag. Ensure the reservoir bag remains inflated (at least 2/3 full during inhalation) — if it completely deflates, increase flow. • Venturi Mask: delivers a precise, fixed FiO₂ (24%, 28%, 31%, 35%, 40%, 60%) using color-coded adapters/diluters. This is the PREFERRED device for COPD patients because it delivers controlled, consistent oxygen concentration without risk of suppressing the hypoxic drive. OXYGEN SAFETY RULES: • Oxygen is not flammable itself but supports and accelerates combustion. • Post 'Oxygen in Use / No Smoking' signs on the door. • Remove open flames, avoid petroleum-based products (e.g., Vaseline) on the face — use water-based lubricants instead. • Keep electrical equipment away from oxygen sources. COPD CONSIDERATION — A Critical NLE Topic: Patients with chronic COPD retain CO₂ chronically and may rely on hypoxemia (low O₂) as their primary stimulus to breathe — called the 'hypoxic drive.' Giving high-flow oxygen can blunt this drive and cause respiratory depression. Therefore, in COPD patients, target SpO₂ of 88–92% using the lowest effective flow, typically via Venturi mask. HOWEVER — never withhold oxygen from a hypoxic COPD patient. Treat hypoxia first, then titrate carefully. SUCTIONING TECHNIQUE: Suction only when clinically indicated (e.g., patient cannot clear secretions independently). Key steps: (1) Explain the procedure; (2) Hyperoxygenate before and after (give 100% O₂ for 30–60 seconds or have patient deep breathe); (3) Insert catheter without applying suction; (4) Apply suction only during withdrawal using a rotating motion; (5) Limit each suctioning pass to 10–15 seconds to prevent hypoxia; (6) Allow recovery between passes. Use sterile technique (surgical asepsis).

Bowel Elimination: Assessment, Constipation, Diarrhea, Enemas, and Ostomy Care

Bowel elimination is a fundamental physiologic need. Normal bowel patterns vary widely among individuals — from several times daily to three times per week — and both extremes can be normal depending on the person's baseline. The nurse's role is to assess the patient's USUAL pattern and identify deviations. Assessment parameters include: frequency, consistency (use the Bristol Stool Scale mentally — hard/lumpy = constipated, watery = diarrhea), color, odor, presence of blood or mucus, and associated symptoms like pain or straining. CONSTIPATION: Defined as infrequent, difficult, or incomplete passage of hard, dry stool. Common causes include: inadequate fiber or fluid intake, immobility, opioid analgesics (a major cause in hospitalized patients), anticholinergic medications, and ignoring the urge to defecate. Nursing management (non-pharmacologic first): • Increase dietary fiber (25–35 g/day) — fruits, vegetables, whole grains • Increase fluid intake (at least 2,000–2,500 mL/day unless contraindicated) • Encourage ambulation and physical activity — movement stimulates peristalsis • Establish a regular toileting routine (e.g., after meals — gastrocolic reflex) • Provide privacy and a normal position (sitting on commode, not bedpan if possible) Pharmacologic options (as ordered by physician): • Stool softeners: docusate sodium (Colace) — softens stool by drawing water in • Bulk-forming laxatives: psyllium (Metamucil) — must be taken with plenty of water • Osmotic agents: lactulose, MOM (Milk of Magnesia) • Stimulant laxatives: bisacodyl — stimulates peristalsis • Lubricants: mineral oil FECAL IMPACTION — a serious complication: A hard, immovable mass of stool in the rectum. Classic paradoxical sign: liquid stool leaking around the impaction (patients may be misdiagnosed with diarrhea). Assessment: patient has urge to defecate but cannot, rectal fullness, and liquid stool leaking. Digital examination confirms a hard mass. Digital removal requires a physician's order. Enemas and suppositories may be used first. DIARRHEA: Frequent passage of loose, watery, unformed stool. The PRIORITY nursing concern is DEHYDRATION and ELECTROLYTE IMBALANCE — especially dangerous in infants, young children, and the elderly. In the Philippine context: The DOH national program for acute diarrhea in children uses ORAL REHYDRATION SOLUTION (ORS) + ZINC supplementation (20 mg/day for 10–14 days for children >6 months). Nurses in RHUs and barangay health centers are trained in this protocol. ORS replaces the sodium, potassium, and water lost in stool. Nursing management for diarrhea: • Monitor fluid/electrolyte status (skin turgor, mucous membranes, urine output, lab values) • Administer ORS or IV fluids as ordered • Provide meticulous perianal skin care — diarrhea is highly irritating; use barrier cream • Identify and address the cause (infection, medications, dietary intolerance) • Send stool specimen for culture if infectious cause suspected • Implement contact precautions if infectious diarrhea (e.g., Clostridium difficile) ENEMAS: An enema introduces fluid into the rectum and colon to stimulate evacuation, soften stool, cleanse the bowel, or administer medications. POSITION — KEY NLE FACT: Always position the patient in LEFT LATERAL (Sims') position. This position follows the natural anatomical curve of the sigmoid colon and descending colon (on the left side), allowing gravity and anatomy to facilitate fluid flow upward into the colon. Procedure highlights: • Lubricate the rectal tube tip • Insert the tubing 7–10 cm (adults), 5–7.5 cm (children) • Raise the solution container 30–45 cm (12–18 inches) above the anus — higher = faster flow and more cramping; lower = gentler instillation • Instill slowly; if the patient reports cramping, LOWER the container or briefly clamp the tubing and ask them to breathe deeply • Retain the solution as long as possible (at least 5–10 minutes for cleansing enemas) Types of enemas: • Cleansing enema (tap water, normal saline, soapsuds solution): stimulates evacuation by distension • Retention enema (oil-based, e.g., mineral oil): retained for 30–60 minutes to soften and lubricate impacted stool • Medicated enema: delivers medication (e.g., lactulose for hepatic encephalopathy, corticosteroids for IBD) • Return-flow (Harris flush): alternately instills and withdraws fluid — used to relieve flatus OSTOMY CARE: An ostomy is a surgically created opening (stoma) on the abdominal wall for bowel or urinary diversion. Common types: colostomy (colon), ileostomy (ileum — high output, liquid stool), urostomy (urinary diversion). Assessing stoma health — CRITICAL for NLE: • HEALTHY stoma: PINK to RED in color, MOIST, and slightly raised. Think of it like the inside of your cheek — it should look like living tissue. • UNHEALTHY stoma: DUSKY, DARK PURPLE, or BLACK = indicates ischemia/necrosis — REPORT IMMEDIATELY to the physician. This is an emergency. • Peristomal skin (skin around the stoma) should be intact, without redness, rash, or breakdown. Ostomy appliance management: • Empty the pouch when it is 1/3 to 1/2 full (to prevent weight from loosening the seal) • Change the entire appliance every 3–7 days or when leaking • Measure the stoma and cut the wafer opening to fit (1/8 inch larger than the stoma diameter) to protect peristomal skin • Provide psychosocial support — ostomy affects body image significantly; nursing diagnosis: Disturbed Body Image (NANDA)

Urinary Elimination: Assessment, Catheterization, and Promoting Normal Voiding

Urinary elimination is critical for fluid balance, waste removal, and kidney function assessment. The nurse monitors urinary output as a direct indicator of renal perfusion and hemodynamic stability. NORMAL PARAMETERS: • Normal adult urine output: approximately 1,500 mL/day (range: 1,000–2,000 mL) • Minimum acceptable hourly output: 30 mL/hour (key clinical benchmark — below this indicates inadequate renal perfusion) • Normal urine: pale to amber yellow, clear, slight ammonia odor, pH 4.5–8.0, specific gravity 1.001–1.035 IMPORTANT URINARY TERMS (all potential NLE vocabulary items): • Oliguria: urine output <400 mL/day or <30 mL/hr — REPORT IMMEDIATELY • Anuria: urine output <100 mL/day or essentially absent — indicates severe renal failure • Polyuria: excessive urine output >2,500 mL/day — seen in diabetes insipidus, DM, diuretic use • Dysuria: painful or burning urination — sign of urinary tract infection (UTI) • Nocturia: awakening at night to urinate — can indicate BPH, heart failure, poor bladder control • Frequency: urinating more often than usual without increased total volume — UTI, anxiety • Urgency: sudden, compelling urge to urinate — urgency incontinence • Urinary retention: inability to empty the bladder despite urge — post-operative, BPH, neurogenic bladder • Urinary incontinence: involuntary leakage of urine — stress, urge, overflow, functional types URINARY CATHETERIZATION: A urinary catheter is inserted to drain urine from the bladder. Indications include: urinary retention, surgery, accurate I&O monitoring in critically ill patients, and urinary diversion after surgery. INSERTION TECHNIQUE — Sterile (Surgical Asepsis): Urinary catheterization uses STERILE TECHNIQUE because the urinary tract is normally sterile. Any break in technique can introduce bacteria and cause a catheter-associated urinary tract infection (CAUTI). Key insertion steps: 1. Explain the procedure and provide privacy 2. Position: female — dorsal recumbent (lithotomy); male — supine with thighs slightly apart 3. Open catheter kit using sterile technique; set up sterile field 4. Clean the urinary meatus: female — clean labia minora and urethral meatus with antiseptic swabs using downward strokes (front to back), using each swab only once; male — retract foreskin, clean glans in circular motion from meatus outward 5. Lubricate the catheter tip 6. Insert catheter: female — 5–7.5 cm (2–3 inches); male — 17–20 cm (6–8 inches) until urine flows 7. INFLATE THE BALLOON ONLY AFTER URINE FLOWS — this confirms the catheter tip is in the bladder, not the urethra 8. Gently pull back to seat the balloon at the bladder neck 9. Secure the catheter to the inner thigh (female) or upper thigh/lower abdomen (male) to prevent tension and urethral trauma ONGOING CATHETER CARE: • Keep the DRAINAGE BAG BELOW BLADDER LEVEL at all times — gravity drainage; if the bag is above the bladder, urine flows back = retrograde contamination = infection risk • Maintain a CLOSED DRAINAGE SYSTEM — never disconnect unless absolutely necessary • Perform routine catheter care (perineal hygiene with soap and water twice daily and after bowel movements) • Empty the drainage bag every 8 hours or when 2/3 full • Never allow the drainage port to touch the collection container when emptying • Document urine color, clarity, amount, and any abnormalities CAUTI PREVENTION — The #1 CAUTI risk factor is DURATION of catheterization: • Remove the catheter as early as clinically possible • Question the need for the catheter daily (catheter necessity review) • Never insert a catheter for convenience or routine — only when clinically indicated PROMOTING NORMAL VOIDING: Before resorting to catheterization for urinary retention, try these non-invasive nursing interventions: • Provide PRIVACY — many patients cannot void with someone watching • Allow normal POSITION — sitting for females; standing at the bedside for males if safe • Run WATER IN THE SINK or use a warm washcloth over the perineum (triggers voiding reflex) • Provide adequate TIME — do not rush the patient • BLADDER TRAINING for incontinence: schedule toileting every 2 hours, gradually extending intervals • KEGEL EXERCISES (pelvic floor exercises) for stress incontinence — contract the pelvic floor muscles for 5–10 seconds, 10–15 repetitions, 3× daily

Enteral (Tube) Feeding: Safety, Technique, and Complications

Enteral nutrition (EN) delivers nutrients directly into the gastrointestinal tract via a feeding tube in patients who cannot eat orally but have a functioning GI tract. The principle is: 'If the gut works, use it.' Enteral feeding preserves gut integrity, maintains the intestinal mucosa barrier, and is safer and more physiologic than parenteral (intravenous) nutrition. COMMON FEEDING TUBES: • Nasogastric (NG) tube: inserted through the nose into the stomach — most common, used for short-term feeding and drainage • Orogastric (OG) tube: through the mouth into the stomach — used in neonates (obligate nasal breathers) and when nasal insertion is contraindicated • Gastrostomy/PEG tube (Percutaneous Endoscopic Gastrostomy): surgically placed directly into the stomach through the abdominal wall — for long-term feeding • Jejunostomy tube: placed into the jejunum — used when gastric feeding is contraindicated (e.g., gastroparesis, aspiration risk) NG TUBE INSERTION — Key Steps: 1. Measure the tube length using the NEX method: tip of the NOSE → EARLOBE → XIPHOID PROCESS. Mark this length on the tube before insertion. 2. Position patient in HIGH-FOWLER'S (sitting upright) to reduce aspiration risk during insertion. 3. Lubricate the tube tip with water-soluble lubricant (never petroleum-based). 4. Insert through the nose (select the more patent nostril). Advance toward the back of the throat. 5. When the tube reaches the oropharynx, ask the patient to FLEX THE HEAD FORWARD (chin to chest) — this closes the epiglottis over the trachea and guides the tube into the esophagus rather than the airway. 6. Ask the patient to SIP WATER or SWALLOW as the tube advances — swallowing promotes esophageal entry. 7. WARNING SIGNS of airway misplacement: COUGHING, CHOKING, CYANOSIS, voice changes, inability to speak → STOP and WITHDRAW the tube immediately. 8. After insertion, CONFIRM PLACEMENT before use. TUBE PLACEMENT VERIFICATION — Critical Safety Procedure: This is the SINGLE MOST IMPORTANT safety step in tube feeding — confirmed by the NLE and professional standards. METHODS (in order of reliability): 1. GOLD STANDARD: Radiographic (X-ray) confirmation after INITIAL insertion — mandatory before first use 2. BEDSIDE BEST PRACTICE: Aspirate gastric content and check pH — GASTRIC ASPIRATE pH ≤5 confirms gastric placement (gastric acid is acidic). pH >6 suggests respiratory or intestinal placement — do NOT feed. 3. Check external tube length against the marked insertion point — tube should not have migrated in or out. 4. Auscultation (the 'whoosh' test): AIR INSUFFLATION — UNRELIABLE ALONE. This test (injecting 30 mL air via syringe and auscultating the abdomen) is no longer recommended as the sole verification method because it cannot reliably differentiate gastric from pulmonary placement. It can be used TOGETHER with other methods but never alone. Verify placement BEFORE every feeding, every medication administration, and after any episode of coughing, vomiting, or patient repositioning. SAFE TUBE FEEDING PRACTICES: • Elevate the HOB 30–45° during the feeding AND for 30–60 minutes AFTER completion — prevents aspiration • Aspirate and check GASTRIC RESIDUAL VOLUME (GRV) before each feeding per facility protocol; hold and reassess if GRV is high (specific threshold varies by protocol — often 200–500 mL) • Administer formula at ROOM TEMPERATURE — cold formula causes GI cramping and diarrhea • Flush the tube with water: before and after each feeding, before and after each medication, and every 4–8 hours during continuous feedings • Give medications in LIQUID FORM when possible; if crushing tablets is necessary, crush each tablet separately and dissolve fully — NEVER crush enteric-coated or sustained-release formulations • Flush with 5–15 mL of water BETWEEN each medication when multiple drugs are given — prevents drug interactions in the tube COMPLICATIONS TO MONITOR: • Aspiration pneumonia — MOST SERIOUS complication; prevented by HOB elevation and checking GRV • Diarrhea — most common complication; caused by hyperosmolar formula, rapid infusion, or bacterial contamination • Constipation — inadequate water, insufficient fiber • Dehydration — insufficient free water flushes • Hyperglycemia — especially in diabetic patients; monitor blood glucose • Refeeding syndrome — in severely malnourished patients; rapid refeeding causes dangerous shifts in phosphate, potassium, and magnesium — can be life-threatening; start feedings slowly and monitor electrolytes • Tube displacement or clogging — prevent by flushing regularly; do not administer crushed medications through small-bore tubes without checking compatibility • Nausea, vomiting, abdominal distension — signs of intolerance; reduce rate or volume

Fluid Intake and Output (I&O) Monitoring and Fluid Balance

Accurate monitoring of fluid intake and output (I&O) is one of the most fundamental and frequently performed nursing skills. It enables the nurse to detect fluid imbalances early — before they become life-threatening. INTAKE INCLUDES: • All oral fluids: water, juice, broth, ice chips (count as 50% of their volume), gelatin, ice cream • Tube feeding formula and flush water • Intravenous fluids (crystalloids, colloids, blood products) • Irrigants that are not fully withdrawn (e.g., bladder irrigation) OUTPUT INCLUDES: • Urine (measured precisely — never estimated) • Emesis/vomiting • Diarrhea (estimated) • Wound drainage (from surgical drains — e.g., Jackson-Pratt, Penrose) • Nasogastric tube drainage • Blood loss (significant amounts) 'Insensible losses' (perspiration, respiration) are typically estimated at 500–1,000 mL/day but are not directly measured. NORMAL FLUID BALANCE: A healthy adult takes in approximately 2,000–2,500 mL/day and loses approximately the same. Intake and output should roughly balance ('euvolemia'). A consistent daily surplus or deficit indicates a fluid imbalance. FLUID VOLUME DEFICIT (Dehydration/Hypovolemia): Occurs when fluid output exceeds intake. Causes include: diarrhea, vomiting, fever (sweating), hemorrhage, burns, inadequate oral intake, and diuretic use. Clinical signs: • Thirst (early sign) • Dry mucous membranes and lips • Decreased skin turgor (the skin 'tents' when pinched — takes more than 2–3 seconds to return to normal; not reliable in the elderly due to natural skin laxity) • Sunken eyes and fontanelle (in infants) • Concentrated, dark amber urine with high specific gravity (>1.030) • Decreased urine output (oliguria) • Weight loss (acute) • Tachycardia (early compensatory mechanism) • Hypotension/orthostatic hypotension (late sign — hemodynamic compromise) • Weak, thready pulse Nursing interventions: Encourage oral fluids, administer IV fluids as ordered, monitor I&O and daily weight, assess vital signs and electrolytes. FLUID VOLUME EXCESS (Overhydration/Hypervolemia): Occurs when fluid intake exceeds output. Causes include: excessive IV fluids, renal failure (inability to excrete), heart failure, liver cirrhosis, corticosteroid use. Clinical signs: • Edema (peripheral — ankles, feet; pitting edema presses and leaves an indentation) • Weight gain (acute — most reliable indicator) • Crackles (rales) in lung bases — fluid in alveoli = pulmonary edema • Distended neck veins (jugular venous distension — JVD) • Hypertension • Bounding pulse • Shortness of breath, orthopnea (difficulty breathing while lying flat) • Decreased hemoglobin/hematocrit (dilutional effect) Nursing interventions: Fluid restriction, sodium restriction, monitor I&O strictly, elevate head of bed, administer diuretics as ordered (e.g., furosemide), weigh daily. DAILY WEIGHT — The Most Accurate Indicator of Fluid Status: Fluid changes reflect directly on body weight BEFORE they appear visually as edema or in I&O measurements. The rule: 1 kg of body weight change = approximately 1 liter of fluid change. Weight must be measured under consistent conditions to be valid: • Same time each day (typically early morning before breakfast, after voiding) • Same scale • Same amount of clothing (hospital gown ideally) • Document the scale used (bedside vs. standing scale) Clinically: A patient gaining 1 kg overnight has retained approximately 1 liter of fluid — a significant finding that warrants assessment and possible physician notification.

Nutrition: Assessment, Therapeutic Diets, and Wound Healing

Nutrition is a fundamental physiologic need (Maslow's first tier) that directly affects every body system. Adequate nutrition supports wound healing, immune function, muscle strength, medication metabolism, and recovery from illness. Nurses play a critical role in nutritional assessment, assistance with feeding, diet teaching, and collaboration with dietitians. MACRONUTRIENTS — the energy-providing nutrients: • Carbohydrates: primary energy source; 4 kcal/gram. Classified as simple (sugars — quick energy) and complex (starches, fiber — sustained energy). Complex carbohydrates are preferred for sustained energy and GI health. In the Philippines, rice (kanin) is the primary carbohydrate source. • Proteins: essential for tissue building, repair, enzyme and hormone production, immune function; 4 kcal/gram. Complete proteins (contain all essential amino acids): meat, fish (isda), poultry, eggs, dairy. Incomplete proteins: beans (monggo, patani), legumes — combine plant proteins to get complete amino acid profiles. • Fats (Lipids): most concentrated energy source; 9 kcal/gram. Types: saturated (solid at room temp — animal fats, coconut oil — raises LDL cholesterol), unsaturated (liquid at room temp — vegetable oils — protective), trans fats (most harmful — avoid). Fats are essential for fat-soluble vitamin absorption (A, D, E, K). MICRONUTRIENTS: • Vitamins: fat-soluble (A, D, E, K — stored in fatty tissues) and water-soluble (B complex, C — not stored, must be consumed daily). Vitamin C is essential for collagen synthesis (wound healing). Vitamin A promotes epithelial healing. • Minerals: calcium, phosphorus (bone health); iron (oxygen-carrying hemoglobin); zinc (enzyme function, wound healing, immune support); sodium, potassium (fluid and electrolyte balance). NUTRITIONAL ASSESSMENT: • Anthropometric measurements: height, weight, BMI (Body Mass Index = weight in kg ÷ height in m²). Normal BMI: 18.5–24.9. Overweight: 25–29.9. Obese: ≥30. Underweight: <18.5. • Biochemical markers: serum albumin (normal: 3.5–5.0 g/dL; <3.5 indicates malnutrition; half-life ~20 days — reflects long-term nutrition status). Prealbumin (half-life 2–3 days — more sensitive indicator of recent nutritional changes). Total lymphocyte count (immune response to malnutrition). • Clinical assessment: observe for signs of malnutrition — muscle wasting, edema, hair loss, poor wound healing, glossitis (inflamed tongue), angular cheilitis (cracked lip corners). • Dietary history: 24-hour dietary recall, food frequency questionnaire. THERAPEUTIC DIETS — Commonly Tested in NLE: • Low-sodium diet (2–4 g/day): for hypertension, heart failure, renal disease, and cirrhosis. Avoid canned foods, processed meats (tocino, hotdog), soy sauce, and patis (fish sauce). • Diabetic/Carbohydrate-controlled diet: consistent carbohydrate intake per meal; low glycemic index foods; avoid simple sugars; monitor carbohydrate counting. • Renal diet (renal failure): restrict potassium (avoid bananas, oranges, camote), phosphorus (avoid dairy, nuts, dark colas), protein (moderated), sodium, and fluid. Specific restrictions depend on whether the patient is on dialysis or not. • Low-fat/Cardiac diet: for hypercholesterolemia and cardiovascular disease; limit saturated and trans fats, increase dietary fiber. • High-fiber diet: for constipation, diverticular disease, and diabetes management; increase fruits, vegetables, whole grains. • Clear liquid diet: used post-surgery or during acute GI illness — broth, water, gelatin, juice without pulp, ice pops. Not nutritionally complete. • Full liquid diet: all clear liquids plus milk, cream soups, ice cream, pudding. • NPO (Nothing per Oral): no food or water — typically for procedures, surgery, or acute GI conditions. PHILIPPINE CONTEXT — PINGGANG PINOY: The DOH and FNRI (Food and Nutrition Research Institute) recommend 'Pinggang Pinoy' — the Filipino food plate guide. It recommends: half the plate = go foods (carbohydrates: kanin, pan de sal), one-quarter = grow foods (protein: isda, itlog, karne), one-quarter = glow foods (fruits and vegetables: gulay, prutas), plus a glass of water. Nurses use this model for community nutrition teaching. NUTRITION FOR WOUND HEALING — HIGH-YIELD NLE TOPIC: Three nutrients are ESSENTIAL and commonly asked about: 1. PROTEIN: Required for tissue synthesis, immune response, and cellular repair. Protein deficiency impairs ALL phases of wound healing. Sources: fish, chicken, eggs, beans. 2. VITAMIN C (Ascorbic acid): Essential for COLLAGEN SYNTHESIS. Collagen is the structural protein forming the wound matrix. Deficiency causes poor wound healing (scurvy symptoms in extreme cases). Sources: calamansi, dalandan, pineapple, guava, green leafy vegetables. 3. ZINC: Acts as a cofactor for enzymes involved in protein synthesis and cell proliferation; boosts immune function. Deficiency impairs wound healing and immunity. Sources: meat, shellfish, legumes. Additional supportive nutrients: Vitamin A (epithelial regeneration), iron (oxygen delivery to wound via hemoglobin), adequate hydration.

Basic Wound Care: Assessment, Dressing Changes, and Complications

Wound care is a fundamental nursing skill that bridges physiologic knowledge, aseptic technique, and clinical assessment. A wound is any disruption of the skin and underlying tissue. Nurses assess wounds, perform dressing changes, recognize complications, and support healing through nutritional and environmental interventions. TYPES OF WOUND HEALING — KEY CLASSIFICATION: 1. Primary Intention (First Intention): The wound edges are clean, closely approximated (brought together), and sutured or stapled. Minimal tissue loss, minimal scarring, fastest healing. Example: clean surgical incision (e.g., appendectomy incision with sutures). 2. Secondary Intention: The wound is left open to heal from the base upward through granulation tissue formation. More tissue is lost; healing is slower and produces more scar tissue. Example: pressure ulcer, abscess cavity, infected wound. 3. Tertiary Intention (Delayed Primary Closure): The wound is initially left open (to allow drainage or infection resolution) and then surgically closed later (usually after 3–5 days). Example: contaminated traumatic wounds or wounds with heavy bacterial burden left open to drain, then closed when clean. PHASES OF WOUND HEALING — must know in order: 1. HEMOSTASIS: Immediately after injury. Blood vessels constrict; platelets aggregate and form a clot; fibrin mesh develops. Goal: stop bleeding. 2. INFLAMMATORY PHASE (Days 1–5): Vasodilation and increased permeability bring immune cells (neutrophils, then macrophages) to clean the wound. Signs: redness (rubor), warmth (calor), swelling (tumor), pain (dolor), and loss of function — these are NORMAL and expected. Do not mistake normal inflammation for infection in the early days. Macrophages orchestrate the transition to the next phase. 3. PROLIFERATIVE PHASE (Days 5–21): New blood vessels form (angiogenesis). Fibroblasts deposit collagen (granulation tissue — beefy red, moist, healthy). Epithelial cells migrate across the wound surface (epithelialization). Wound edges contract. This is where nutrition (protein, vitamin C, zinc) is MOST critical. 4. MATURATION/REMODELING PHASE (21 days to 2 years): Collagen fibers reorganize and cross-link; the wound gains tensile strength. The scar matures and may fade. Maximum scar strength is about 80% of original tissue strength. WOUND ASSESSMENT — The Nurse's Systematic Approach: Assess and document ALL of the following: • LOCATION and SIZE: measure length × width × depth in centimeters • WOUND BED COLOR — this is the critical indicator of healing status: - RED: Healthy granulation tissue — healing is progressing. Protect and keep moist. - YELLOW: Slough (fibrinous exudate mixed with dead cells) — indicates the presence of non-viable tissue. Needs debridement or appropriate wound care to promote healing. - BLACK: Eschar (dry, hard, dead tissue/necrosis) — indicates the wound is necrotic. Needs debridement (except in stable, dry heel eschars per some protocols). • EXUDATE: amount, color, consistency, odor. Serous (clear/watery) = normal. Serosanguineous (pink/blood-tinged) = normal early. Purulent (yellow/green/brown/thick, foul-smelling) = INFECTION. • SURROUNDING SKIN (periwound): assess for redness, warmth, induration, maceration (softening from excessive moisture). • WOUND EDGES: approximated (closed), separated (open/dehiscence), undermining (tissue loss under intact skin at wound edges), tunneling. • PAIN: assess wound pain at rest and during dressing change. DRESSING CHANGE TECHNIQUE: The level of asepsis depends on wound type: • Clean technique: for chronic wounds (e.g., pressure ulcers) in community settings • STERILE TECHNIQUE (Surgical Asepsis): for OPEN WOUNDS, SURGICAL WOUNDS, and any wound at high risk of infection CLEANING DIRECTION — KEY NLE FACT: Always clean from LEAST CONTAMINATED to MOST CONTAMINATED (clean to dirty): • For a surgical incision: clean from the incision LINE outward (center to periphery) • For a wound with surrounding contamination: start at the cleanest area and move toward the dirty area • Use each swab/gauze only ONCE — then discard • Never go back over a cleaned area with the same swab WOUND IRRIGATION: Use normal saline (0.9% NaCl) as the preferred irrigation solution — it is isotonic and non-cytotoxic. Avoid hydrogen peroxide and full-strength povidone-iodine on granulation tissue — these are cytotoxic and destroy healthy granulation cells. COMPLICATIONS — Critical for NLE: 1. INFECTION: Signs — increasing redness and warmth beyond the wound edges, purulent exudate (pus), foul odor, increasing pain, fever. A culture and sensitivity (C&S) test of wound drainage guides antibiotic therapy. 2. DEHISCENCE: Separation/splitting open of wound edges (typically suture line). More common 5–12 days post-operatively. Seen in obese patients, malnourished patients, or when excessive tension or early suture removal occurs. Management: cover wound with sterile moist dressing, keep the patient quiet, notify the physician. 3. EVISCERATION: Protrusion/herniation of abdominal organs through the separated wound — a SURGICAL EMERGENCY. EMERGENCY NURSING ACTIONS for evisceration: a. CALL for help — activate emergency response b. Cover the exposed organs IMMEDIATELY with a STERILE SALINE-MOISTENED DRESSING — keep organs moist to prevent necrosis; never push organs back in c. Place the patient in LOW-FOWLER'S POSITION with KNEES FLEXED — relieves abdominal tension d. Keep patient NPO and calm — reassure the patient e. NOTIFY THE SURGEON IMMEDIATELY — operative intervention needed f. Monitor vital signs for signs of shock DRAIN MANAGEMENT: • Jackson-Pratt (JP) drain: bulb-shaped closed suction drain — compress the bulb after emptying and secure to create suction; empty and recompress every 8 hours • Penrose drain: flat, open rubber drain — drains by gravity and capillary action; no suction; secure to prevent it from slipping into the wound • Document drainage volume, color, and consistency every shift

SpO₂ of 88% with accessory muscle use, tachypnea, and restlessness meets the criteria for hypoxemia (SpO₂ <90%) requiring urgent intervention. Restlessness is the earliest sign of hypoxia — the patient's attempt to remove the IV line is a behavioral manifestation of hypoxia-induced agitation, NOT a behavioral problem. Using ABC priority and Maslow's framework: oxygenation (Airway-Breathing) takes precedence over all other concerns. The nurse must recognize this emergency, intervene immediately, and notify the physician. The NANDA nursing diagnosis is Impaired Gas Exchange related to post-operative atelectasis as evidenced by SpO₂ 88%, tachypnea, and restlessness.

The most common error in I&O calculation is counting ice chips at full volume — they must be counted at 50% of their measured volume because half of the cup's volume is ice (which yields only half its volume as liquid when melted). All other fluids are counted at full volume. IV fluids and tube feeding formula and flush water are all counted as intake. This type of calculation question appears frequently in NLE. A total of 2,730 mL is slightly above the normal 2,000–2,500 mL/day range — the nurse should compare this to urine output to determine if the balance is positive or negative.

This problem tests multiple tube feeding concepts simultaneously. The pH of 4.5 (≤5) confirms correct gastric placement — feeding is safe in terms of tube location. However, the HIGH GRV (280 mL) indicates delayed gastric emptying — if feeding is administered despite this, the risk of regurgitation and aspiration is unacceptably high. The HOB being at only 20° is also a problem that must be corrected immediately — standard is 30–45° during and for 30–60 minutes after feeding. Reinstilling the aspirate prevents iatrogenic electrolyte loss (the gastric content contains sodium, potassium, HCl, and digestive enzymes). This scenario requires the nurse to apply multiple simultaneous clinical decisions — a hallmark of higher-level NLE questions.

Stoma color is the single most important assessment criterion for stoma viability. A healthy stoma is PINK to RED (like the inside of the cheek) and moist. Pale or light pink may indicate anemia. DARK PURPLE, BLUE, or BLACK = ischemia/necrosis — the blood supply to the stoma is compromised and the tissue is dying. This requires IMMEDIATE surgical intervention to restore blood flow or revise the stoma. Delayed reporting can result in complete stoma necrosis. This is a knowledge-application question testing whether NLE candidates know the emergency significance of stoma discoloration — a distractor might be 'apply a new appliance and document.'

Dehiscence is a partial or complete separation of wound edges, typically of the suture line. It is most common on post-operative days 5–12, when sutures are most stressed (before adequate collagen strength develops) and is associated with obesity, malnutrition, poor surgical technique, infection, and excessive straining. It is different from evisceration (organ protrusion), which requires the same positioning but an even more urgent response. Both require IMMEDIATE physician notification. Reinforcing the dressing with additional tape is a COMMON ERROR — this does not address the underlying dehiscence and delays proper treatment. Under RA 9173, the nurse must practice within the scope of safe, competent, and accountable care.