A NCM 103 Lecture 2013

Intermediate Competency
Content I. INTRODUCTORY CONCEPTS A. STRESS A. Stress 1. Stress and Function: - Dynamic Balance: The Steady State 2. Stress and Adaptation - Selyes General Adaptation Syndrome Model - Fight-Flight Model 4. Stress Appraisal Model B. Stress: Threats to the Steady Sate 1. Types of Stress and Stressors 2. Stress as a stimulus for disease 3. Physiological and Psychological Responses to Stress 4. Maladaptive responses to stress 5. Indications of Stress C. Stress at the Cellular levels i. Control of steady state ii. Cellular adaptation to stress iii. Cellular Injury iv. Cellular response to injury: Inflammation v. Cellular Healing D. Stress Management D1. Promoting healthy lifestyle D2. Enhancing coping strategies D3. Biobehavioral Interventions for stress 1. Biofeedback 2. Progressive Muscle Relaxation 3. Meditation 4. Guided Imagery
Teaching-Learning Activities
No. of Hours Lec RLE
Evaluation
Parameters for evaluation 1. The following are used as evaluation tools throughout the entire course - Class participation in group discussions, role play, simulation exercises; presentation of a care study - Progress Test this activity will either be announced or not announced and the student is expected to read and prepare for the assigned lesson.
Given reading materials on Stress, the students will be able to: 1. Discuss different Stress Models 2. Identify Various Stressors
Skills/Lab Demonstration and Return Demonstration 1. Relaxation techniques a. biofeedback b. progressive muscle relaxation c. meditation d. guided imagery 2. Shibashi 3. Floor Mat Exercises a. Pilates b. Stretching
Given a client, the student will be able to provide appropriate Bio-behavioral interventions for stress
Intermediate Competencies
Content B. ILLNESS B1. Concept of Illness 1. Cell Injury and Inflammation 1.1 Cell adaptation to injury 1.2 Body defenses against injury 1.3 Monocular phagocyte system 1.4 Inflammatory Response B2. Chronic Illness 1. Chronicity of Illness or Disease 1.1 Definition of Chronic Conditions 1.2 Prevalence and Causes of Chronic Illness 1.3 Characteristics of Chronic Conditions 1.4 Phases of Chronic Conditions 1.5 Management of Chronic Conditions C. HEALTHCARE OF THE OLDER ADULT (Geriatric Nursing) 1. Overview of the Aging Process a. Demographics of aging b. Health status of the older adult c. Nursing care of the older adult d. Theories of aging 2. Age-related changes a. Psychosocial aspects of aging b. Physical aspects of aging c. Cognitive aspects of aging d. Pharmacologic considerations for The older adult. 3. Mental health problems in the Older adult a. Depression b. Delirium c. Dementia 4. Common health issues of the older adult a. Impaired mobility b. Dizziness c. Falls and Falling d. Urinary Incontinence e. Increased susceptibility to Infection f. Altered pain and febrile responses g. Altered emotional responses h. Altered Systemic Response
Teaching-Learning Activities Classroom RLE
Lec
No. of Hours RLE
Evaluation
Intermediate Competencies C. Pain
Content
Evaluation
Given Relevant questions; the student will be able to discus the pathophysiological process of 1. Pain
Given a client with simple health needs/problems, the student will be able to 1. Identify appropriate pain assessment tool for a given age group.
1. Types of Pain a. Acute b. Chronic c. Cancer-related Pain 2. Classifications of Pain a. Classification by location b. Classification by etiology 3. Harmful effects of Pain a. Effects of Acute Pain b. Effects of Chronic Pain 4. Pain Theories 5. Pathophysiology i. Neurophysiological transmission of Pain ii. Factors Affecting Pain 6. Nursing Care of a Client Experiencing Pain ASSESSMENT 1. Pain experience inventory 2. Cries Neonatal Post-operative Pain Measurement Scale 3. FLACC Pain assessment tool 4. Faces Pain Rating Scale 5. Poker Chip tool 6. Oucher Pain Rating Scale 7. Numerical or Visual analog Scale 8. Adolescent Pediatric Pain Tool 9. Logs and Diaries
2. States relevant priority nursing diagnosis with a given set of cues
Content PLAN / IMPLEMENTATION Pain Management Strategies 1. Establish therapeutic relationship 2. Teach patient about pain relief 3. Reduce anxiety and fears 4. Provide comfort measure 5. Non-Pharmacologic 5.1.1 Guided Imagery 5.1.2 Thought Stopping 5.1.3 Hypnosis 5.1.4 Aromatherapy, Essential Oils 5.1.5 Magnet Therapy 5.1.6 Music Therapy 5.1.7 Yoga and Meditation 5.1.8 Acupuncture 5.1.9 Crystal or Gem stone Therapy 5.1.10 Herbal Therapies 5.1.11 Biofeedback 5.1.12 Therapeutic touch and massage 5.1.13 TENS 5.1.14 Heat and Cold Application o Pharmacologic Interventions for Pain o Medications for Pain Management o Routes of Administration 7. Neurologic and Neurosurgical Approaches to Pain Management 7.1.Surgical destruction of painful stimuli Rhizotomy Nerve Block Continuous Extravascular Infusion Neurectomy Sympathectomy
Evaluation
2. Utilize appropriate nonpharmacologic interventions to reduce clients pain
Bring students to the floor and observe nurses preparing narcotics to familiarize them with S2 prescription and the narcotic sheet.
EVALUATION
Intermediate Competencies D. PERIOPERATIVE NURSING 1.
Content
Evaluation
Given an actual client for surgery, the student will be able to utilize the nursing process in the peri-operative care. State priority nursing diagnosis for a client requiring surgery during the preoperative phase.
PREOPERATIVE NURSING CARE Perioperative and Perianesthesia Nursing Surgical Classifications General Considerations - Conditions Requiring Surgery - Categories for surgical procedure as to; Purpose Degree of Risk to patient Urgency Effects of surgery on the person Factors in the estimation of surgical risks -Preparation for Surgery -Preoperative Nursing Considerations
ASSESSMENT 1. Nursing History 2. Health History - development consideration - medical history - medications - occupation 3. Life-style - nutrition - use of alcohol - elicit drugs or nicotine - ADL - occupation 4. Coping patterns and support system 5. Pre-operative physical assessment 6. Pre-surgical screening tests - chest x-ray - ECG - CBC - Electrolyte levels and urinalysis
Intermediate Competencies Utilizes appropriate interventions for a surgical client during the pre-operative phase
Content
Teaching-Learning Activities Classroom RLE * Assign students to complete a preoperative; intraoperative; and post-operative care at least (1) surgical client: A. Pre-operative period 1. Psychological preparation 2. Physiological preparation 3. Physical preparation - shaving - enema 4. Spiritual preparation
Evaluation
Demonstrates preoperative teaching Accomplishes preoperative teaching
ANALYSIS - Potential Nursing Diagnosis - Anticipatory Grieving related to perceived loss of normal body image - Anxiety related to the effects of surgical procedure - Fear related to surgery - Risk for infection - Ineffective Airway Clearance - Ineffective Individual Coping PLAN / IMPLEMENTATION 1. Physiological / spiritual preparation for surgery 2. Legal aspects of the informed consent 3. Instructional and Preventive aspects 3.1 Deep breathing exercises 3.2 Coughing exercises 3.3 Turning exercises 3.4 Extremity exercises 4. Physical Preparations 4.1 On the night of the surgery a. Hygiene and skin care b. Elimination c. Nutrition and fluid d. Rest and sleep 4.2 On the day of the surgery a. Pre-operative checklist b. Pre-operative medications
Evaluates patient based on expected outcomes
EVALUATION
Intermediate Competencies Given an actual client for surgery, the student: Utilize assessment technique during the intra-operative phase
Content
Teaching-Learning Activities Classroom RLE Filmstrip: Surgical Asepsis 2. Principles and practice 3. Sterile glove technique 4. Sterile Dressing 5. Sterile Gown Technique 6. Draping 7. Open wound drainage 8. Drains - penrose - t-tube - J-pratt - Hemovac - Gomco suction
Evaluation
2. INTRAOPERATIVE NURSING CARE ASSESSMENT 1. Identify surgical client 2. Assess the emotional and physical status 3. Verify information in the pre-operative checklist ANALYSIS 1. Impaired Skin Integrity related to Incision 2. Risk of Fluid Volume deficit 3. Risk for Injury related to position PLAN / IMPLEMENTATION 1. The surgical team Duties and responsibilities of the circulating nurse; scrub nurse; RN first assistants 2. The surgical environment A. Principles of surgical asepsis B. Environmental controls C. Maintaining surgical asepsis D. The surgical Experience a. Positioning b. draping c. types of anesthesia and sedation d. stages of anesthesia E. Potential Intra-operative complication - Bleeding - Nausea and vomiting - Anaphylaxis - Hypoxia and other respiratory complications - Hyperthermia - DIC 3. Documentation 4. Transferring to the PCU EVALUATION
States priority nursing diagnosis during the intra-operative phase
Discuss the roles and responsibilities of a nurse during intraoperative phase
Demonstrates skills in OR nursing Evaluate outcomes during intra-operative phase.
Intermediate Competencies Given a poet-operative client, student ; 1. Provides appropriate nursing intervention during the immediate post-operative period.
Content
Evaluation
3. POSTOPERATIVE NURSING CARE A. Immediate Post-operative Care in the PACU B. Nursing responsibilities in the PACU a. assessing the post-operative client b. maintenance of pulmonary ventilation c. maintenance of circulation d. protection from injury e. promotion of comfort C. Aldrete post-anesthesia recovery scoring system D. Ongoing post-operative Care E. Immediate post-operative care in the PACU ASSESSMENT a. Vital signs b. Color and temperature of the skin c. Level of Consciousness d. Comfort e. Time of Arrival ANALYSIS Postoperative nursing diagnosis b. risk for surgical site diagnosis c. pain d. altered family processes related to loss of economic stability e. impaired physical mobility f. potential complication: Hemorrhage PLAN / IMPLEMENTATION 1. Preventing Post-operative Complications 1.1 Respiratory Complications 1.2 Circulatory Complications 1.3 Fluid and Electrolytes Imbalance 1.4 Gastrointestinal Complications 1.5 Urinary Complications 1.6 Wound Complications 2. Post-operative Discomforts
Assess a client during the immediate postoperative period.
Given set of cues, states priority nursing diagnosis during immediate post operative period.
Evaluates patient based on outcome criteria
EVALUATION
Intermediate Competencies Given an adult client(young, middle, old, old-old adult)with alteration in fluid, electrolyte and balance, the students will be able to; 1. Apply knowledge of normal fluid ad electrolyte balance and assessment techniques. 2. Assess the health status of the client. a. Conduct a health history and functional health status of clients having or at-risk for altered fluid, electrolyte and acid base balance. b. Systematic and comprehensive physical assessment to validate assessed dat. c. Interpret deviations from normal findings in the physical assessment, diagnostic and laboratory examinations.
E. Fluid and Electrolyte: Balance and Disturbances 1. Fundamental concepts of fluid and electrolyte balance Fluid: The main constituent of the body and is comprised of water and dissolved substances in the form of electrolytes, gases and nonelectrolytes. Therefore, the bodys fluid balance is extremely important. Homeostasis of water accounts for approximately 50% to 60% of a persons body weight. Water: The most important nutrient of life. Humans can survive only few days without water. Functions of water: o Provide a medium for transporting nutrients to cells and wastes from cells, and for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells. o Facilitate cellular metabolism and proper cellular chemical functioning. o Act as solvent for electrolytes and nonelectrolytes. o Help maintain normal body temperature. o Facilitate digestion and promote elimination. o Act as a tissue lubricant. Body Fluid Compartments: Two main compartments or spaces: 1. Intracellular Fluid Fluid within the cells, constituting about 40% of an adults body weight or 70% of TBW. 2. Extracellular Fluid The fluid outside the cells, constituting about 20% of an adults body weight or 30% of TBW. Includes intravascular and interstitial fluids. Intravascular fluid or plasma is the liquid component of the blood. Interstitial fluid is the fluid that surrounds tissue cells and includes lymph. It acts as a transport vehicle for gases, nutrients, wastes, and other materials that move
Teaching-Learning Activities Classroom RLE Teaching materials Bedside clinic on the patient receiving the appropriate tot eh following: topic to be discussed Therapeutics 1. IVF therapy - LCD - Isotonic solutions - Video - Hypotonic solutions - Hypertonic solutions Different types of - Blood expanders tubes, gadgets used for clients 2. Oral / Parenteral electrolyte with disorders of - administration fluid and electrolyte - Computations and acid base - Nursing precautions imbalance 3. Blood transfusions 1. IV sets - Initiating blood therapy and - monitoring adverse effects periphera l lines 4. Dialysis 2. central - peritoneal lines -hemodialysis 3. peritoneal dialysis 5. Maintenance of Peripheral and set Central lines 4. blood - routine care transfusio - complications n sets 6. Diet and Nutrition Therapy - oral - enteral - parenteral
No. of Hours Lec RLE Parameters for evaluation 1. The following are used as evaluation tools throughout the entire course - Class participation in group discussions, role play, simulation exercises; presentation of a care study - Progress Test this activity will either be announced or not announced and the student is expected to read and prepare for the assigned lesson.
between the vascular compartment and body cells. A tissue gel which is spongelike material composed of large quantities of mucopolysaccharides, fills the tissue spaces and aids in even distribution of interstitial fluid. Normally most of the fluid in the interstitium is in gel form. The tissue gel, which has a firmer consistency than water, opposes the outflow of water from the capillaries and prevents the accumulation of free water in the interstitial spaces. Transcellular Compartment (usually minor) includes the CSF and fluid contained in the various body spaces, such as the peritoneal, pleural, and pericardial cavities, and joint spaces. o Normally only about 1% of ECF is in the transcellular space. o This amount can increase considerably in conditions such as ascites, in which large amounts of fluid are sequestered in the peritoneal cavity. o When the transcellular fluid compartment becomes considerably enlarged, it is referred to as a third space, because this fluid is not readily available for exchange with the rest of the ECF.
Electrolytes Dissociation of Electrolytes: Body fluids contain water and electrolytes.
Electrolytes are substances that dissociate in solution to form charged particles, or ions. For example Sodium chloride dissociates to form a positively charged Na and negatively charged Cl ion. Particles that do not dissociate into ions such as glucose and urea are called nonelectrolytes. The distribution of electrolytes between body compartment is influenced by their electrical charge. For example, a positively charged H ion may be exchanged for a positively charged K and a negatively charged bicarbonate ion may be exchanged for another negatively charged Cl ion.
Diffusion and Osmosis Diffusion is the movement of charged or uncharged particles along a concentration gradient. Because there are more molecules in constant motion in a concentrated solution, particles move from an area of higher concentration to one of lower concentration. The concentrations of electrolytes and solutes can be expressed in several ways, for example mg/dL, mEq/L, or millimoles/L (mmol/L). Osmosis is the movement of water across a semipermeable membrane (one that is permeable to water but impermeable to most solutes.) As with solute particles, water diffuses down its concentration gradient, moving from the side of the membrane with the lesser number of particles and greater concentration of water to the side with the greater number of particles and lesser concentration of water. As water moves across the semipermeable membrane, it generates a pressure called osmotic pressure, which represents the pressure needed to oppose the movement of water across the membrane. Osmolality and Osmolarity The osmotic activity of a solution may be expressed in terms of either its osmolarity or osmolality. Osmolarity refers to the osmolar concentration in 1L of solution (mOsm/L); usually used when referring to fluids outside the body. Osmolality refers to the osmolar concentration in 1 kg of water (mOsm/kg of H2O); used for describing fluids inside the body. Because 1kg is equal to 1L, both are used interchangeably. Serum osmolality which is largely determined by sodium and its attendant anions (CL and HCO3) normally ranges
from 280 to 295 mOsm/L/ Tonicity Refers to the tension or effect that the effective osmotic pressure of a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane. Solutions to which body cells are exposed can be classified as isotonic, hypotonic, or hypertonic, depending on whether they cause cells to swell or shrink. Isotonic Solutions Cells placed in isotonic solution (e.g. 0.9% sodium chloride or 5% Dextrose in water), which has the same effective osmolality as the ICF(i.e 280 mOsm/L, neither shrink nor swell. These solutions are important in the clinical setting because they can be infused into the blood without danger of upsetting the osmotic equilibrium between the ICF and ECF. Hypotonic Solutions When cells are placed in a hypotonic solution (i.e. distilled water), which has a lower effective osmolality than the ICF, they swell as water moves into the cell. Hypertonic Solutions When cells are placed in a hypertonic solution (e.g. 3% normal saline or 10% glucose), which has a greater effective osmolality than ICF, they shrink as water is pulled out of the cell. Capillary / Interstitial Fluid Exchange The transfer of water between the vascular and interstitial compartment occurs at the capillary level. Four Forces Control the Movement of Water Between the Capillary and Insterstitial Spaces: Capillary Filtration Pressure/Capillary Hydrostatic pressure, which pushes water out of the capillary into the interstitial spaces through mechanical rather than an osmotic pressure. It is about 30-40 mmHg at the arterial end, 10-15 at the venous end and 25 mmHg at the middle. A rise in arterial or venous pressure increases capillary pressure. The force of gravity increases capillary pressure in the dependent parts of the body. Capillary Colloidal Osmotic Pressure/Plasma
Oncotic Pressure , which pulls water back into the capillary (about 28 mmHg). It is the osmotic pressure generated by the plasma proteins that are too large to pass through the pores of the capillary wall. This is different from the osmotic pressure that develops at the cell membrane from the presence of electrolytes and nonelectrolytes. Because plasma proteins do not normally penetrate the capillary pores and because their concentration is greater than in the interstitial fluids, it is capillary osmotic pressure that pulls fluids back Insterstitial Hydrostatic Pressure, which opposes the movement of water out of the capillary Tissue Colloidal Osmotic Pressure, which pulls water out of the capillary into the interstitial spaces. Combination of these forces is such that only a small excess fluid remains in the interstitium. This excess fluid is removed from the insterstitium by the lymphatic system and returned to the systemic circulation.
Edema Defined as palpable swelling produced by expansion of the interstitial fluid volume. Edema does not become evident until the interstitial fluid volume has been increased by 2.5 to 3 L. Causes of Edema: o Increased capillary pressure: Decreased arteriolar resistance: e.g. Calcium channel-blocking drug responses. Venous obstruction: e.g. liver disease with portal vein obstruction; acute pulmonary edema; venous thrombosis (thrombophlebitis) Increased vascular volume: heart failure, kidney diseases, premenstrual sodium retention, pregnancy, environmental heat stress. o Decreased capillary colloidal osmotic pressure: Increased loss of plasma proteins (albumin): protein-losing kidney diseases, extensive burns. Decreased production of plasma proteins: liver disease, starvation, malnutrition o Increase capillary permeability Inflammation
Allergic reactions Malignancy: ascites, pleural effusion Tissue injury and burns Obstruction to lymphatic flow Malignant obstruction of lymphatic structures Surgical removal of lymph nodes
Routes of Gains and Losses 1. Kidneys: The usual daily urine volume in the adult is 1 to 2L. A general rule is that the output is approximately 1mL of urine per kilogram of body weight per hour in all age groups. 2. Skin: Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from ) to 1,000 mL or more every hour, depending on the environmental temperature. Continuous water loss by evaporation (approximately 600 ml/day) occurs through the skin as insensible perspiration, a nonvisible form of water loss. Fever greatly increases insensible water loss through the lungs and the skin, as does loss of the natural skin barrier (through major burns, for example). 3. Lungs: Eliminates water vapor (insensible loss) at a rate of approximately 400 ml every day. The loss is much greater with increased respiratory rate or depth, or in a dry climate. 4. GI Tract: Only 100 to 200 ml daily though 8L of fluid circulates in GIT every 24 hours. Because the bulk of fluid is reabsorbed in the small intestine, diarrhea and fistulas cause large losses. In healthy people, the daily average intake and output of water are approximately equal .
Average Daily I and O in an Adult. Intake Oral Liquids Water in Food Water produced by metabolism Total Gain Output Urine Stool Insensible Lungs Skin Total loss
1, 300 ml 1, 000 ml 300 ml 2, 600 ml
1, 500 ml 200 ml 300 ml 600 ml 2, 600 ml
Homeostatic Mechanisms 1. Kidneys Normally filter 170 L of plasma every day in the adult, while excreting only 1.5 L of urine. They act both autonomously and in response to blood-borne messengers such as aldosterone and ADH. Major Functions to Regulate Fluid and Electrolytes: o Regulation of ECF volume and osmolality by selective retention and excretion of body fluids. o Regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances. o Regulation of pH of the ECF by retention of hydrogen ions o Excretion of metabolic wastes and toxic substances. 2. Heart and Blood Vessels Distribution of blood to the kidneys to allow for urine formation. Failure of this pump would interfere with renal perfusion and thus with water and electrolyte regulation. 3. Lungs Through exhalation the lungs remove approximately 300 ml of water daily in the normal adult Role in acid-base balance through hyper and hypoventilation
4. Pituitary Gland ADH stored in PPG as manufactured by hypothalamus Controlling retention and excretion of water by kidneys 5. Adrenal Gland Aldosterone which causes sodium retention and water retention and potassium loss. Cortisol in large amount would also cause sodium and water retention. 6. Parathyroid Glands Parathormone regulates calcium and phosphate balance by influencing bone resorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules. 7. Baroreceptors Detect blood pressure changes and transmit impulse to CNS Monitoring the circulating blood volume, regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation and depression of parasympathetic if there is decrease in arterial pressure. Sympathetic stimulation also constricts renal arterioles; this increases the release of aldosterone, decreases glomerular filtration and increases sodium and water retention. 8. RAAS 9. ADH and Thirst Increased osmolality of body fluids and decrease of blood volume stimulate the sensory neurons/osmoreceptors of hypothalamus through intracellular dehydration thirst occurs fluid intake ADH controls urination Thirst is a conscious sensation of the need to obtain and drink fluids high in water content It is controlled by the thirst center in the hypothalamus. Diabetes Insipidus: is caused by a deficiency or a decreased response to ADH. Persons with DI are unable to concentrate their urine during periods of water restriction; they excrete large volume of urine, usually 3 to 20 L/day. Danger arises when there is inability to secure the needed water. Inadequate water intake leads to hypertonic dehydration and increased serum osmolality. Syndrome of Inappropriate Secretion of ADH: results from the failure of the negative feedback system that regulates the release and inhibition of ADH. ADH secretion continues even
when serum osmolality is decreased, causing marked water retention and dilutional hyponatremia 10. Osmoreceptors Increase of osmotic pressure neurons dehydrated impulse toward pituitary gland increased release of ADH 11. Release of Atrial Natriuretic Peptide Increased BV and BPIncrease atrial pressure/atrial stretch increased ANP release from cardiac cells in atria ANP decreases vascular resistance by causing vasodilation decrease in BP suppression of renin levels**decrease in vascular volume, BP and preload and after load. ANP decreased ADH release from PPG ** ANP increase glomerular filtration rate which increases urinary excretion of sodium and water **
Fluid Regulation see p. 255. Regulation of Water and Sodium Balance It is the amount of water and its effect on sodium concentration in the ECF that serves to regulate the distribution of fluid between the ICF and the ECF compartments. Most of the bodys sodium (135 to 145 mEq/L) is in the ECF with only small amount (10-14 mEq/L) located in the ICF compartment. Sodium functions mainly in regulating extracellular fluid volume, including that in the vascular compartment. Sodium normally enters the body through the GIT and is eliminated by the kidneys or lost through GIT or skin. Kidney is efficient in sodium regulation and when sodium intake is limited or conservation of sodium is needed, it is able to reabsorb almost all the sodium that has been filtered by the glomerulus, which will produce essentially sodiumfree urine. The sympathetic nervous system respond to changes in arterial pressure and blood volume by adjusting the glomerular filtration rate and the rate at which sodium is filtered from the blood (see also RAAS). Regulation of Potassium Balance Potassium is the second most abundant cation in the body and major cation in the ICF compartment.
98% of body K is contained within the body cells (ICF K:140-150 mEq/L) ECF K: 3.5 to 5.0 mEq/L Because potassium is an intracellular ion, total body stores of potassium are related to body size and muscle mass. Thus, total body potassium declines with age, mainly as a result of a decrease in muscle mass. Potassium intake is normally derived from dietary sources. Potassium balance can be maintained by a daily intake of 50 to 100 mEq. The kidneys are the main potassium losses occur in the urine, with the remainder being lost in stools or sweat. Two Mechanisms that regulate serum potassium levels: o Renal mechanisms that conserve or eliminate potassium o Transcellular shift of potassium between the ICF and ECF compartments.
Renal Regulation Kidney provides the major route for potassium. Potassium is filtered in the glomerulus, reabsorbed along with sodium and water in the proximal tubule and with sodium and chloride in the ascending loop of Henle, and then secreted into the late distal and cortical collecting tubules for elimination in the urine. Aldosterone plays an essential role in regulating potassium elimination by the kidney. In the presence of aldosterone, sodium is transported back into the blood and potassium is secreted into the tubular filtrate for elimination in the urine. There is also a potassium-hydrogen exchange system in the collecting tubules of the kidney. When serum potassium levels are increased, potassium is secreted into the urine and hydrogen is reabsorbed into the blood, producing a decrease in pH and metabolic acidosis. When potassium levels are low, potassium is reabsorbed and hydrogen is secreted into the urine, leading to metabolic alkalosis. Extracellular-Intracellular Shifts Normally, it takes 6-8 hours to eliminate 50% of potassium intake. To avoid rise in extracellular potassium levels during this time, excess potassium is temporarily shifted into RBC and other cells such as those of muscle, liver and bone. This is controlled by the Na/K adenosine triphosphatase (ATPase)
membrane pump and the permeability of the ion channels in the cell membrane. Factors that alter Intracellular/Extracelllular distribution of potassium: o Acid-Base disorders The hydrogen and potassium ions, which are positively charged, can be exchanged between the ICF and ECF in a cation shift. In metabolic acidosis, for example, hydrogen ions move into body cells for buffering, causing potassium to leave the cells and move into the ECF. o Serum osmolality Acute increases in serum osmolality cause water to leave the cell. The loss of cell water produces an increase in intracellular potassium, causing it to move out of the cell into the ECF. Insulin Both insulin and catecholamines (e.g.epinephrine) increase cellular uptake of potassium by increasing the activity of the Na/K ATPase membrane pump. Beta-adrenergic stimulation Exercise: repeated muscle contraction causes potassium to be released into the ECF.
o o
Regulation of Calcium and Magnesium 99% of body calcium is found in bone, where it provides the strength and stability for the skeletal system and serves as an exchangeable source to maintain extracellular calcium levels. Most of the remaining calcium (approx. 0.7%) is located inside the cells and only 0.1% to 0.3% is present in the ECF. Extracellular calcium exists in three forms: o Protein bound: with albumin o Complexed: with substances such as citrate, phosphate, and sulfate. o Ionized: free to leave intravascular and participate in cellular functions; participates in enzyme reactions, membrane potentials and neuronal excitability , contraction in skeletal, cardiac, smooth muscle, etc. Factors that Regulate Calcium
1.
Vitamin D: influential in the absorption of calcium from the intestine. It is then stored in the bone then excreted by the kidneys. Only 30-50% is absorbed from the duodenum and upper jejunum, he remainder is eliminated in the stool. Calcium is filtered in the glomerulus of the kidney and then selectively reabsorbed back into the blood. 60-65% of filtered calcium is passively reabsorbed in the proximal tubule, driven by the reabsorption of sodium chloride; 15-20% is reabsorbed in the thick ascending loop of Henle, driven by the Na/K/2Clcotransport system; 5-10% is reabsorbed in the distal convoluted tubule.Thiazide diuretics enhances reabsorption of calcium. PTH: maintain the calcium concentration of the ECF by promoting the release of calcium from bone, increasing the activation of vitamin D and stimulating calcium conservation by the kidney while increasing phosphate excretion. Calcitonin: acts on kidney and bone to remove calcium from the circulation. Serum phosphate level: calcium and phosphate are reciprocally regulated. Calcium levels fall when phosphate levels are high.
2.
3. 4.
Regulation of Magnesium It is the second most abundant intracellular cation. 50-60% is stored in the bone; 39-49% contained in body cells; 2% is dispersed in the ECF. 20-30% of ECF magnesium is protein bound and only 1530% is exchangeable in the ECF. The normal serum magnesium is 1.8 to 2.7 mg/dL Cofactor in many intracellular enzyme reactions; all reactions that require ATP, replication and transcription of DNA; cellular energy metabolism; nerve conduction, etc. Ingested in the diet, absorbed from the intestine and excreted by kidneys. Contained in all green vegetables, grains, nuts, meats, and seafood. 30-40% of filtered Magnesium is reabsorbed in the proximal tubule.
50-37% is reabsorbed in the ascending loop of Henle. The distal tubule is the major site of magnesium regulation. Increased serum levels of Magnesium decreases reabsorption, PTH increases reabsorption and increased calcium levels inhibits reabsorption. The major driving force for magnesium reabsorption is the Na/K/2Cl-cotransport system in the thick ascending loop of Henle. Since this is site of loop diuretics action, this diuretic lowers magnesium reabsorption.
IV Fluid Administration Purpose: 1. 2. 3. to provide water, electrolytes, and nutrients to meet daily requirements ; to replace water and correct electrolyte deficits; to administer medications and blood products.
Types of IV Solutions 1. Isotonic solution: a. Total electrolyte content is approximately 310 mEq/L, which is closer to that of the ECF (i.e. 280295 mEq/L). b. Expands the ECF volume by 1L; however, it expands the plasma by only 0.25 L because it is a crystalloid fluid and diffuses quickly into the ECF compartment. c. For the same reason, 3L of isotonic solution is needed to replace 1L of blood loss. Because thes fluids expand the intravascular space, patients with hypertension and heart failure should be carefully monitored for signs of overload. d. D5W (252 m,Eq/L) initially isotonic but disperses as hypotonic, 1/3 ECF, 2/3 intracellular. Good is the patient is at risk of increased in intracranial pressure. D5W is not used in fluid resuscitation because it can cause hyperglycemia. It is used mainly to supply water and to correct an increased serum osmolality. e. NSS (0.9% sodium chloride) has a total osmolality of 308. Since composed mainly of electrolytes, it remains within ECF. Therefore normally to correct Extracellular volume deficit. Used with administration of blood transfusions and to replace large sodium losses, as in burn injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium retention.
f. 2.
Lactated Ringers has potassium and calcium in addition to NaCl.
Hypotonic solutions a. Total electrolyte content is less than 250 mEq/L. b. Purpose of hypotonic solution is to replace cellular fluid because its hypotonic compared to plasma. Another is to provide water for excretion of body wastes. c. Half strength saline (0.45 NaCl with an osmolality of 154 mEq/L is frequently used. d. Excessive infusion could lead to intravascular fluid depletion, decreased blood pressure, cellular edema, and cell damage. Hypertonic solutions a. Total electrolyte count is more than 375 mEq/L. b. When normal saline solution or lactated ringers contain 5% dextrose, the total osmolality exceeds that of the ECF. c. 50% Dextrose, d. They draw water from the ICF to the ECF and cause cells to shrink
3.
Choosing an IV Site: Factors to consider: 1. Condition of the vein 2. type of fluid or medication to be infused 3. Duration of therapy 4. Patients age and size 5. Whether the patient is right or left-handed. 6. Patients age and size 7. Patients medical history and current health status 8. Skill of the person performing the venipuncture. Systemic Complications 1. Fluid Overload: a. Increased BP and CVP, moist crackles on auscultation of the lungs, edema, weight gain, dyspnea, and respirations that are shallow and have an increased rate. b. Causes: rapid infusion, hepatic, cardiac or renal disease. Common in elderly c. Mgt: decreasing the IV rate, monitoring vital signs, assessing breath sounds, place patient in high Fowlers position. Contact physician. d. Complication: Heart failure and pulmonary edema.
2.
Air Embolism: a. Associated with cannulation of central veins. b. Manifestations: dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; chest, shoulder, and low back pain. c. Treatment: Clamping of cannula, place patient on the left side in the Trendelenburg position, assess vital signs and breath sounds; administer oxygen. d. Complications: shock and death Septicemia and Other Infection a. Pyrogenic substances can induce a febrile reaction and septicemia. b. Signs and Symptoms: abrupt temperature elevation shortly after infusion, backache, headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise
3.
Local Complications: 1. Infiltration and Extravasation a. Infiltration is the unintentional administration of a nonvesicant solution or medication into surrounding tissue. It is characterized by edema around insertion site, leakage of IV fluids from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate b. Infiltration Scale: i. 0 no symptoms ii. 1 skin blanched, edema less than 1 inch in any direction, cool to touch, with or without pain. iii. 2 skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without pain. iv. 3 skin blanched, translucent, gross edema greater than 6 inches in any direction, cool to touch, mild to moderate pain, possible numbness v. 4 skin blanched, translucent, skin tight , leaking, skin discolored, bruised, swollen, gross edema greater than 6 inches in any direction, deep pitting tissue edema, circulatory impairment, moderate to severe pain, infiltration of any amount of blood products, irritant, or vesicant. c. Extravasation:
i. Is similar to infiltration with an inadvertent administration of vesicant or irritant solution or medication into the surrounding tissue. ii. Medications such as dopamine, calcium preparations and chemotherapeutic agents can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. iii. Infusion must be stopped and physician notified. 2. Phlebitis a. Characterized by reddened, warm area around site or along path of vein, pain or tenderness at the site or along the vein. Grade 0 1 2 3 Clinical Criteria no clinical symptoms erythema at access site with or without pain pain at access site. Erythema, edema or both pain at access site, erythema, edema or both, streak formation, palpable venous cord )1 inch or shorter) pain at access site with erythema, streak formation, palpable venous cord (longer than 1 inch), purulent drainage.
3.
hrombophlebitis a. Presence of clot plus inflammation in the vein. b. Localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis. c. Discontinue infusion, cold compress, followed by warm compress, elevate extremity, restarting the line in opposite extremity. NO Flushing .
4. 5.
Hematoma: apply pressure with a dressing, ice for 24 hours, warm compress Clotting and Obstruction 2. Nursing Process a. Assessment A1. Subjective Data i. ECF volume deficits loss of body weight; changes in I and O; changes in Vital Signs ii. Other manifestations drying of the mouth and mucous membrane; tenting of the skin; changes in urine output and urination; muscle weakness, change in consistency of the stool; cerebral changes A2. Objective Data 1. Physical Assessment there is no specific physical examination to assess fluid, electrolyte, and acid-base balance. Skin poor skin turgor; cold, clammy skin, pitting edema; flushed dry skin Pulse bounding; rapid, weak, thready, irregular, slow pulse BP hypotension, hypertension Respirations deep, rapid breathing; shallow; slow, irregular breathing; shortness of breath, moist crackles, restricted airways Skeletal Muscles cramping of exercised muscle; carpal spasms (Trousseaus), flabby muscles, positive Chvosteks sign
Intermediate Competencies 1. Perform systematic and comprehensive physical assessment to validate assessed data. 2. Interpret deviations from normal findings in the physical assessment, diagnostic, and laboratory examinations
Content B. ANALYSIS / NURSING DIAGNOSIS B1. Common Problems of Fluid and Electrolyte Imbalance 1. Fluid Volume Disturbances: - Hypovolemia - Hypervolemia 2. Electrolyte Imbalances a. Sodium imbalances b. Potassium imbalances c. Calcium imbalances d. Magnesium imbalances e. Phosphorus imbalances f. Chloride imbalances 3. Acid-Base Imbalances a. Acute and Chronic Metabolic Acidosis (Base Bicarbonate Deficit) b. Acute and Chronic Metabolic Alkalosis (Base Bicarbonate Excess) c. Acute and Chronic Respiratory Acidosis (Carbonic Acid Excess) d. Acute and Chronic Respiratory Alkalosis (Carbonic Acid Deficit) 4. Mixed Acid-Base Disorders B2. Potential Nursing Diagnosis 1. Deficient fluid volume, related to insufficient fluid intake, diarrhea, hemorrhage or third-space fluid shift such as ascites or burns 2. Excess fluid volume related to fluid retention secondary to heart, renal, or lives failure, or excess consumption 3. Impaired Oral Mucous membrane 4. Risk for Injury 5. Risk for Activity Intolerance 6. Risk for Decreased Cardiac Output 7. Risk for impaired skin integrity 8. Imbalanced Nutrition; Less than body requirements related to insufficient intake of foods rich in potassium
No. of Hours Lec
Evaluation RLE 1. Performance evaluation checklist 2. Progress Test Final Examination
Intermediate Competencies Implement individualized nursing care; 1. safely and knowledgeably administers prescribed medications and treatments 2. actively participates in planning and coordinating culturally sensitive interdisciplinary care. 3. provide appropriate client education and health maintenance and community based care of clients 4. efficiently and effectively, utilize available resources in the care of clients to achieve outcomes 5. evaluate the effectiveness of nursing care, revising care as needed to promote, maintain, or restore functional health status of the clients 6. maintain confidentiality and protect clients privacy
Content C. PLANNING 1. Planning for Health Promotion Preventing fluid and electrolyte loss Planning for client hydration Reducing risk for injury 2. Planning for Health Restoration and Maintenance Fluid and electrolyte Management Oral and Intravenous fluid and electrolyte replacement D. IMPLEMENTATION 1. Pharmacological Therapy a. IV Additives - KCl - CaCL - MgSO4 - HCO3 b. Plasma Expanders - Colloids - Dextran - Hexastarch 2. Nutrition and Diet Therapy a. Food Sources of - Sodium - Potassium - Calcium - Phosphate - Magnesium 3. Client Education EVALUATION
Teaching-Learning Activities Classroom RLE Demonstration and return demonstration of appropriate and specific nursing procedures pertinent to the care of fluid, electrolyte and acid base disturbances Medication Administration 1. Diuretics 2. Antidotes
No. of Hours Lec
Evaluation RLE
7. accurately records and reports findings in clinical practice Intermediate Competencies Content Alterations in the Respiratory System I. CONCEPT REVIEW A. Anatomy and Physiology of the Respiratory System II. APPLICATION OF THE NURSING PROCESS I. Assessment of Respiratory Function A. History a. Biographical and Demographic Data b. Present Health b.1 Chief Complaint 1. Dyspnea - Onset: Sudden onset indicates pneumothorax, acute respiratory obstruction or ARDS. 2. Cough a. Results as a reaction to the irritants of the mucous membrane lining the respiratory tract. b. Chief protection of the client from the accumulation of secretions in the bronchi and the bronchioles. c. May indicate serious lung disease d. Evaluate the type, character and time. 1) Dry, irritative cough: URT infection of viral origin. 2) Irritative, high-pitched cough: Laryngotracheitis 3) Brassy cough: tracheal lesions. 4) Severe changing cough: Bronchogenic carcinoma 5) Cough accompanied by pleuritic chest pain: Pleural or chest wall involvement. 6) Cough that worsens in supine position: Sinusitis 7) Coughing at night may indicate left-sided heart failure or bronchial asthma. 8) Coughing after food intake may indicate Teaching-Learning Activities Classroom RLE Reading Comprehension on the assigned concept on alteration in respiratory function. No. of Hours Lec RLE Evaluation
Teacher-Student Discussion
Round Table Discussion
Concept Mapping
aspiration. 3. Sputum Production a. Discharge formation which serves as the lungs reaction to recurring irritant or may be associated with nasal discharge. b. The presence of an infection or disease entity and its causative organism can be determined by its amount, color, and consistency. c. Great amount of purulent sputum (thick and yellow, green or rust colored: Bacterial infection. d. Increase in amount over time: chronic bronchitis or bronchiectasis. e. Pink- tinged mucoid sputum: Lung tumor f. Profuse, frothy, pink-tinged discharge: Pulmonary edema g. Foul-smelling sputum with halitosis: Lung abscess, bronchiectasis, or infection. 4. Chest Pain a. Discomfort associated with pulmonary or cardiac disease. b. Pain related to pulmonary conditions may be sharp, stabbing, intermittent, or it may be dull, aching and persistent. c. May occur with pneumonia, pulmonary embolism with lung infarction, and pleurisy. d. Late symptom of bronchogenic carcinoma. 5. Wheezing a. High-pitched, musical sound heard mainly on expiration. b. Indicates obstruction or increased resistance of the air passages. 6. Clubbing of the Fingers a. Manifested as sponginess of the nailbed and loss of the nailbed angle. b. Observed in clients with chronic hypoxic conditions, infections, and malignancies. 7. Hemoptysis a. Expectoration of blood from the respiratory tract. b. Signifies lung or cardiac disorder. 8. Cyanosis a. A very late indicator of hypoxia b. Central cyanosis is typified by bluish discoloration of the lips and tongue .
c. Peripheral cyanosis results from decreased blood flow to distal structures (i.e. nail beds and ear lobes) c. d. Past Health History: clients previous hospitalization, illnesses, childhood diseases, medications, and allergies. Family Health History: previous health history and present health status of every member of the family.
B. Physical Examination a. Upper and Lower Respiratory Structures Use penlight for a routine examination and a nasal speculum for a thorough examination. 1. Nose and Sinuses a. Inspect the external nose for lesions, asymmetry, or inflammation. b. Examine the internal structures for any signs of swelling, exudates, bleeding or change in color of the nasal mucosa. c. Check nasal septum for deviation, perforation, or bleeding. d. Inspect the inferior and middle turbinates for presence of polyps. e. Palpate the frontal and maxillary sinuses for tenderness. 2. 3. 4. Pharynx and Mouth a. Inspect the color, symmetry, and evidence of exudates, ulceration or enlargement. Trachea a. Palpate the position and mobility. Thorax a. Observe the skin over the thorax for color and turgor and evidence of loss of subcutaneous tissue. b. Check for asymmetry.
b. Chest configuration - Assess shape and dimensions of the chest 1. Funnel chest (Pectus excavatum): depressed lower portion of the sternum with the lower ribs flaring outward. 2. Pigeon chest (Pectus carinatum): sternum protrudes anteriorly. 3. Barrel chest: increased anteroposterior diameter of the thorax due to overinflation of the lungs. 4. Kyphoscoliosis: characterized by elevation of the scapula and S-shaped spine.
c. Breathing Pattern: - Observe the rate, regularity, depth and location of respiration. d. Palpation 1. Upper Lobe Place the tips of thumbs at the midsternal line at the sternal notch. Extend fingers above the clavicles. Ask client to fully exhale then inhale deeply. 2. Middle Lobe Place tips of thumbs at the xiphoid process. Extend fingers laterally around the ribs. Ask client to breathe in deeply. 3. Lower Lobe Place the tips of thumbs along the clients back at the spinous processes of the lower thoracic level. Extend fingers around the ribs. Ask the client to breathe in deeply. 4. Depth of excursion Measure the girth of the chest at three levels (axilla, xiphoid, and subcostal) during inspiration and expiration. Fremitus Vocal (tactile) fremitus: vibration felt over the chest wall as the client speaks; used to assess the quality of underlying tissues. o Place the palms of hands lightly on the chest wall o Ask the client to speak a few words or repeat 99 several times. Chest wall pain Ask the client to take a deep breath and identify any painful areas of the chest wall. Position of Trachea Determine whether the trachea is palpable at midline or has shifted to the right or left.
5.
6.
7.
e. Thoracic Percussion Used to determine whether underlying tissues are filled with air, fluid, or solid material. Estimates the size and location of certain structures
within the thorax (heart, liver, diaphragm). Dull and flat sounds: greater than normal amount of solid matter (tumor, consolidation) is present than air. Hyperresonance: presence of greater than normal amount of air in the area (emphysema, asthma)
f. Auscultation Evaluates the presence of fluid or solid obstruction in the lung structures by listening to the breath sounds with the use of stethosocope. C. Diagnostic Evaluation a. Tests to Evaluate Respiratory Function 1. Pulmonary Function Test: includes measurements of lung volumes and capacities, ventilatory functions, mechanics of breathing, and diffusion and gas exchange. 2. Pulse Oximetry: non-invasive method of monitoring subtle or sudden changes in oxygen saturation of hemoglobin. 3. Capnography: non-invasive procedure used to measure carbon dioxide concentration exhaled by the client who are receiving mechanical ventilation. 4. Arterial Blood Gas Analysis: measures the degree of oxygenation of the blood and adequacy of alveolar ventilation. 5. Ventilation-Perfusion Lung Scan: painless procedure used to measure adequacy of lung ventilation and perfusion. b. Tests to Evaluate Anatomic Structures 1. Radiography (Chest X-Ray) 2. Magnetic Resonance Imaging 3. Ultrasonography 4. Gallium Scan 5. Bronchoscopy 6. Laryngoscopy 7. Alveolar Lavage 8. Endoscopic Thoracotomy 9. Pulmonary Angiography c. Specimen Recovery and Analysis 1. Sputum culture: to identify organisms responsible for infection of the respiratory tract.
2. Nose and Throat Culture: to identify specific pathogenic organisms present in the nose and throat 3. Thoracentesis: to remove fluid and air in the pleural cavity. 4. Biopsy: examination of cells through excision of small amount of tissues obtained from target structures.
Content B. ANALYSIS 1. Common Health Problems of the Respiratory System A. Upper Airway Infection i. Rhinitis ii. Acute and Chronic Sinusitis iii. Acute and Chronic Pharyngitis iv. Tonsillitis and Adenoiditis v. Peritonsillar Abscess vi. Laryngitis B. Obstruction and Trauma of the Upper Respiratory Airway i. Obstruction during Sleep ii. Epistaxis iii. Nasal Obstruction iv. Fractures of the Nose v. Laryngeal Obstruction vi. Cancer of the Larynx C. Chest and Lower Respiratory Tract Disorders i. Atelectasis ii. Respiratory Infections Acute Tracheobronchitis Pneumonia Severe Acute Respiratory Disorders Pulmonary Tuberculosis Lung Abscess D. Pleural Conditions i. Pleurisy ii. Pleural Effusion iii. Empyema E. Pulmonary Edema F. Severe Acute Respiratory Distress Syndrome G. Pulmonary Hypertension H. Pulmonary Heart Disease (Cor Pulmonale) I. Pulmonary Embolism
Evaluation
J. K.
L.
Sarcoidosis Occupational Lung Disease i. Silicosis ii. Asbestosis iii. Coal Workers Disease Chest Tumors
Content K. Chest Trauma i. Blunt Trauma ii. Penetrating Trauma iii. Pneumothorax iv. Cardiac Tamponade v. Subcutaneous Emphysema vi. Aspiration 2. Clients with Chronic Obstructive Disease a. Bronchiectasis b. Asthma Status Asthmaticus c. Chronic Obstructive Pulmonary Disorders Emphysema Chronic Bronchitis d. Cystic Fibrosis 3. Potential Nursing Diagnosis a. Ineffective Airway Clearance as evidenced by shortness of breath, dyspnea, orthopnea, retractions, nasal flaring, altered chest excursion b. Ineffective Breathing Pattern as evidenced by ineffective cough, diminished or abnormal breath sounds, cyanosis, restlessness c. Impaired Gas Exchange as evidenced by cyanosis, abnormal respiratory rate, and rhythm, nasal flaring, tachycardia, diaphoresis and confusion d. Impaired Spontaneous Ventilation as evidenced by dyspnea, use of accessory muscles, tachycardia, and apprehension e. Disturbed Sleep pattern (Sleep-Rest) f. Anxiety 4. PLANNING a. Planning for promotion b. Planning for Heath Restoration and Maintenance i. Maintain Airway Patency
Evaluation
ii. iii. iv.
Relieving Apprehension and Fear Reducing Metabolic Demand Preventing and Controlling Infection
Content 5. IMPLEMENTATION a. Pharmacologic Therapeutics i. Decongestants and Antihistamines ii. Anti-tubercular Drugs iii. Broad Spectrum Antibiotics iv. Adrenergic Stimulants v. Methylxanthines vi. Anticholinergics vii. Corticosteroids viii. Mast Cell Stabilizers ix. Leukotriene Modifiers b. Complementary and Alternative Therapies i. Echinacea ii. Golden Seal iii. Zinc c. Nutritional Diet Therapy i. Tube feedings ii. Fluid Therapy iii. High Protein, high Calorie supplements d. Respiratory Care Modalities I. Non-invasive Respiratory Therapies i. Oxygenation Therapy ii. Incentive Spirometry iii. Nebulization Therapy iv. Intermittent Positive Pressure Breathing v. Chest Physiotherapy II. Airway Management i. Endotracheal Intubation ii. Tracheostomy iii. Mechanical Ventilation iv. Chest Drainage e. Thoracic Surgery i. Pneumonectomy ii. Lobectomy iii. Segmentectomy (Segmental Resection) iv. Wedge Resection
Evaluation
v. Bronchoplastic or Sleeve Resection vi. Lung Volume Reduction g. Client Health Teaching 6. EVALUATION
Intermediate Competencies Given an adult client (young, middle, old, old-old) with altered responses to cardiac and peripheral tissue perfusion/transport, the students will be able to; a. Apply knowledge of normal anatomy and physiology and assessment techniques in caring for clients. Assess the health status of a client 1. Conduct a health history and functional health pattern interview of clients with alterations in cardiac and tissue perfusion and transport.
Content Altered Oxygenation: Cardiac and Tissue Peripheral Perfusion and Transport I. II. Review of Anatomy and Physiology of the Cardiovascular and Hemato-lymphatic System The Nursing Process A. ASSESSMENT i. Subjective Data Nursing Health History Demographic Information regarding age, gender, and ethnic origin Presence of signs and symptom related to cardiovascular and hemato-lymphatic problems. - Chest pain or discomfort - Shortness of breath or dyspnea - Fluid retention, peripheral edema or weight gain - Palpitations - Fatigue or changes in level of consciousness - Syncope - Irregular heartbeat - Pain extremities - Tenderness on calf or leg - Altered neurologic function 11 Functional Patterns ii. Objective Data Physical Assessment - Non-invasive tests ECG Echocardiogram Ultrasound Chest X-ray Radionuclide studies
Teaching-Learning Activities Classroom RLE Video clips on : Anatomy and physiology, physical assessment of the cardiovascular system.
Evaluation
Classroom: a. Paper and pencil test b. Case study c. Nursing Care Plans RLE: a. b. Nursing Care Plans Performance Checklist
b.
CT scan CVP monitoring Invasive tests Cardiac Catheterization Arteriogram Angiocardiogram Venogram Lymphography Bone marrow aspiration Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
Intermediate Competencies III. 2. Perform systematic and comprehensive physical assessment to validate assessed date 3. Interprets deviations from normal findings in the physical assessment, diagnostics and laboratory examinations. 4. Utilize assessed data in order to; a. Prioritize nursing diagnosis b. Plan the care of clients utilizing evidenced based nursing research 5. Discuss the pathophysiologic responses to altered cardiac and peripheral tissue perfusion/transport 6. Plan effective care 7. Implement individualized nursing care
The Nursing Process B. ASSESSMENT -Diagnostic Tests and Laboratory Procedures Cardiac Biomarker Analysis Blood Chemistry Hematology Coagulation studies Lipid Profiles Cholesterol levels Triglycerides C. ANALYSIS 1. Common Problems of the Cardiovascular and Hemato-lymphatic Systems Cardiovascular System a. Conduction problems of the heart Dysrhythmias b. Coronary vascular disorders 1. Coronary Artery Disease Coronary Atherosclerosis Angina Pectoris Myocardial Infarction c. Structural, Infectious and Inflammatory cardiac problems 1. Valvular Disorders Mitral Valve Prolapse Mitral Regurgitation Mitral Stenosis Aortic Regurgitation Aortic Stenosis 2. Cardiomyopathy
8. Safely and knowledgeably administers prescribed medications and treatment/alternative complementary medicine.
3. Infectious Disorders of the heart Rheumatic Endocarditis Infective Endocarditis Myocarditis Pericarditis d. Complications of Heart Disease 1. Cardiac Hemodynamics a. Heart Failure A1. Chronic Heart Failure A2. Acute Heart Failure
9. Actively participates in planning and coordinating culturally sensitive interdisciplinary care. 10. Provide appropriate and effectively utilize available resources in the care of clients to achieve positive outcome. 11. Evaluate the effectiveness of nursing care, revising the nursing care plan as needed to promote, maintain, or restore functional health status of clients with altered cardiac and peripheral tissue perfusion/transport. 12. Maintain confidentiality and protect clients privacy 13. Accurately reports and documents findings in clinical practice.
Content 2. Other Complications a. Cardiogenic shock b. Thromboembolism c. Pericardial Infusion and Cardiac Tamponade d. Cardiac arrest e. Hypertension 1. Types of hypertension 2. Hypertensive Crisis f. Vascular Disorders: Problems of Peripheral Circulation 1. Arterial Disorders Arteriosclerosis and Atherosclerosis Peripheral Arterial Occlusive Disease Thromboangiitis Obliterans (Buergers Disease) Aortitis Aortoiliac disorders Dissecting Aorta Arterial embolism and Arterial thrombosis Raynauds Disease 2. Venous Disorders Venous thrombosis - Deep vein thrombosis - Thrombophlebitis - Phlebothrombosis Chronic Venous Insufficiency Leg ulcers Varicose veins 3. Lymphatic Disorders
Evaluation
Lymphangitis and Lymphadenitis Lymphedema and Elephantiasis 4. Cellulitis
Content Hematologic Problems a. Anemia Hypoproliferative Hemolytic b. Polycythemia Polycythemia Vera Secondary Polycythemia c. Leukopenia Neutropenia Lymphopenia d. Leukemia Acute Myeloid Leukemia Chronic Myeloid Leukemia Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia e. Agnogenic Myeloid Metaplasia (Lymphoma) Hodgkins Disease Non-Hodgkins disease f. Multiple Myeloma g. Bleeding Disorders Primary Thrombocytopenia Secondary Thrombosis Thrombocytopenia Idiopathic Thrombocytopenic Purpura Platelet Defects Hemophilia Von Willebrands Disease h. Acquired Coagulation Disorders Vitamin K deficiency Disseminated Intravascular
Evaluation
Coagulopathy Thrombotic Disorders Hyperhomocysteinemia Anti-thrombin Deficiency Acquired Thrombophilia
Content
Evaluation
2. Gerontologic Considerations 3. Probable Nursing Diagnosis Decreased Cardiac Output as evidenced by increased heart rate, fatigue, shortness of breath, decreased urine output, impaired mental processing, decreased level of consciousness Activity intolerance as evidenced by weakness, fatigue, vital signs, changes with activity. Fatigue as evidenced by difficulty completing usual daily activities, frequent desire to rest. Impaired home maintenance as evidenced by inability to maintain family roles Risk for peripheral neurovascular dysfunction as evidenced by changes in color, temperature, sensation of extremities Impaired Tissue Integrity Ineffective Therapeutic Regimen Management Ineffective Tissue Perfusion as evidenced by cool, dusky skin, decreased urine output and chest pain Acute pain D. PLANNING 1. Planning for Health Promotion
a. b. c. d. e.
Risk factor and risk management Promotion of circulation Prevention of infection Genetic Counseling Role of Nutrition
2. Planning for Health Maintenance and Restoration a. Planning for basic life support: CPR b. Planning for advanced life support : ACLS c. Planning for Care of clients to have Cardiac Surgery
Intermediate Competencies E.
Content IMPLEMENTATION
Evaluation
1. Pharmacologic Management a. Cholesterol lowering medications - Statins - Bile Sequestrants - Nicotinic Acid - Fibric acid derivatives b. Antianginal Medication - Nitroglycerin - Beta-blockers - Calcium Channel Blockers c. Antidysrhythmics - Class I Sodium Channel Blockers - Class II Beta-Adrenergic Blockers - Class III Prolong Repolarization - Class IV Calcium Channel Blockers d. Antiplatelets e. Diuretics f. Medications for Heart Failure - ACE Inhibitors - Angiotensin Receptor Blockers - Diuretics - Positive Inotropic Agents - Sympathomimetic - Phosphodiesterase Inhibitors g. Medications for Anemia - Iron supplement - Vitamin B12 - Folic Acid supplement h. Antihypertensives - Alpha adrenergic blockers
- ACE Inhibitors - Angiotensin Receptor Blockers - Beta Adrenergic lockers - Calcium Channel; Blockers - Centrally acting sympatholytics - Vasodilators i. Anticoagulants - Heparin - Warfarin
Content 2. Surgical Management a. Invasive Coronary Artery Procedures Percutaneous Coronary Interventions Percutaneous Transluminal Coronary Angioplasty (PTCA) Coronary Artery Stents Atherectomy Brachytherapy Coronary Artery Revascularization Coronary Artery Bypass Graft (CABG) b. Heart Transplantation c. Valvular Replacement Procedures Valvuloplasty Valve Replacement Therapy Septal Repair 3. Complementary and Alternative Therapies a. Fish oil / Omega 3 fatty acids b. Hawthorn c. Herbs that may affect clotting d. Natural Lipid lowering agents 4. Management for Blood disorders a. Blood Transfusion b. Stem Cell Transfusion - Bone marrow transplantation - Peripheral blood stem cell transfusion 5. Adjunctive Modalities for Cardiovascular Problems a. Cardioversion and Defibrillation - Electrical Cardioversion - Pacemaker Insertion
Evaluation
6. Nutrition and Diet Therapy H. EVALUATION
Content NUTRITIONAL-METABOLIC PATTERNS
Evaluation
Responses to Altered Nutrition Functions I. Anatomy and Physiology of the Gastrointestinal System II. The Nursing Process a) Assessment i) Nursing History (1) Subjective Data (a) Demographic Data (b) Presence of signs and symptoms related to Gastrointestinal Problems Abdominal pain Dyspepsia Intestinal gas Nausea and vomiting Change in bowel habits or stool characteristics (2) Objective Data (a) 11 functional pattern (b) Physical Assessment (i) Anthropometric Measurement (ii) Inspection (iii) Auscultation
(iv)Percussion (v) Palpation
Content
Evaluation
(c) Diagnostic Assessment (i) Non-invasive Diagnostic Procedures 1. Radiological Studies 2. Upper GI Barium Swallow 3. Lower GI or Barium Enema 4. Flat Plate of the Abdomen 5. Ultrasound 6. Magnetic Resonance Imaging 7. Computed Tomography (ii) Invasive Diagnostic Procedures 1. Scintigraphy (Molecular Imaging Scan) 2. Anoscopy 3. Proctoscopy 4. Sigmoidoscopy (ii) Other GI tests 1. Bernstein Tests (Esophageal Acidity, Manometry, Acid Perfusion) 2. Esophageal Manometry 3. Ambulatory Esophageal pH monitoring 4. Exfoliative Cytologic Analysis 5. Gastric Analysis
(d) Laboratory Procedures (i) Blood Chemistries (ii) Total Lymphocyte Count (iii) Fecal Analysis 1. Occult Blood 2. Ova and Parasite 3. Quantitative fat Studies 4. Fecal Leukocytes 5. Stool electrolyte tests
Intermediate Competencies Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
b) Analysis i) Common Health Problems of the Gastrointestinal Systems (1) Disorders of the Salivary (a) Parotitis (b) Sialadenitis (c) Salivary Calculus (2) Cancer of the Oral Cavity (3) Disorders of the esophagus (a) Achalasia (b) Diffuse Spasm (c) Hiatal Hernia (d) Diverticulum (e) Perforation (f) Foreign Bodies (g) Chemical Burns (h) Gastroesophageal reflux (i) Barretts esophagus (j) Benign tumors of the esophagus (k) Cancer of the esophagus (4) Gastric and Duodenal Disorders (a) Gastritis (b) Peptic Ulcer Disease
(c) Morbid Obesity (d) Gastric Acid (e) Duodenal Tumors (5) Intestinal and Rectal Disorders (a) Abnormalities of Fecal Elimination (i) Constipation (ii) Diarrhea (iii) Fecal Incontinence (iv)Irritable Bowel Syndrome
Intermediate Competencies Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
(b) Conditions of the Malabsorption, Acute Inflammatory and Intestinal Disorders (i) Appendicitis (ii) Diverticular disease (iii) Peritonitis (c) Inflammatory Bowel Disease (i) Regional Enteritis (Crohns Disease) (ii) Ulcerative Colitis (iii) Diverticulosis and Diverticulitis (iv)Hemorrhoids (6) Intestinal Obstructions (a) Small bowel obstruction (b) Colorectal Cancer (c) Polyps of the Colon and Rectum (7) Diseases of the Anorectum (a) Anorectal Abscess (b) Anal Fistula (c) Anal Fissure (d) Hemorrhoids (e) Sexually Transmitted Anorectal Disease
(f) Pilonidal Sinus or Cysts (i) Cholelithiasis (ii) Gall Bladder Cancer
Content
Evaluation
(8) Disturbances of the Accessory Organs (a) Disorders of the liver (i) Hepatitis (ii) Cirrhosis (iii) Liver Cancer (b) Disorders of the Pancreas (i) Acute and Chronic pancreatitis (ii) Pancreatic Cancer (c) Disorders of the Biliary Tract ii) Gerontologic Assessment iii) Potential Nursing Diagnosis (1) Imbalanced Nutrition less than body requirements as evidenced by decreased food intake, weight loss 20% or more of ideal body weight, dry or brittle hair, weakness, impaired tissue healing. (2) Deficient Fluid and Volume as evidenced by complaints of stomach discomfort, increased salivation, tachycardia and cold clammy skin. (3) Impaired skin integrity as evidenced by disruption of skin integrity as evidenced by disruption of skin surface, pain and itching (4) Acute pain
(5) Diarrhea c) Planning
Content
Evaluation
d) Implementation i) Pharmacologic Management (1) Antiemetics (2) Anticoagulants (3) Histamine agents (4) Laxatives (a) Bulk forming (b) Stool softeners (c) Saline and osmotic solutions (d) Stimulants (e) Selective chloride channel activator (f) Serotonin type 4 receptor partial agonists (5) Antipruritis (6) Vitamin Supplement (7) Antacids (8) Antihyperlipidemics (9) Antispasmodics (10) Antidiarrheal (11) Antisecretory agents H2 Receptor Blockers (12) Vasopressin (13) Epinephrine (14) Cholinergics (15) Antibiotics for H. Pylori and Antiinfectives
(16) Alpha-interferon and ribavirin (17) Pancreatic Enzyme Replacement ii) Complimentary Therapy (1) Ginger (2) Milk thistle (Silymarin)
Content
Evaluation
iii) Surgical Management (1) Neck Dissection (2) Esophagectomy (3) Vagotomy (4) Pyloroplasty (5) Gastrostomy (6) Gastrectomy (7) Colostomy (8) Hemorrhoidectomy (9) Gastrointestinal Bypass (10) Ileostomy (11) Vagotomy (12) Pyloroplasty (13) Antrectomy (a) Billroth I (Gastroduodenostomy) (b) Billroth II (Gastrojejunostomy) (14) Bariatric Surgery (15) Fistulectomy iv) Modalities of Care of the Gastrointestinal System (1) Parenteral Hyperalimentation Feeding via Nasogastric, Jejunostomy and Gastrostomy Tubes (2) Colostomy
Content
Evaluation
v) Special Procedures (1) Colostomy care and Irrigation (2) Hot Sitz Bath vi) Nutrition and Diet Therapy (1) Regular Diets (2) Special; Diets high fiber, gluten free, low-protein, high calorie, high protein diets vii) Client Education e) Evaluation
Content
Evaluation
Responses to Altered Metabolic and Endocrine Function I. Anatomy and Physiology of the Endocrine System
II. The Nursing Process I. Assessment a. Subjective Data i. Demographic Data ii. Presence of Signs and Symptoms b. Objective Data i. 11 functional pattern ii. Physical assessment iii. Diagnostic Assessment 1. Invasive Procedures 2. Non-invasive Procedures 3. Laboratory II. Analysis a. Common Health Problems b. Gerontologic Considerations c. Potential Nursing diagnosis III. Planning IV. Implementation a. Pharmacologic Management b. Complimentary Therapy
c. Surgical Management d. Modalities of Care e. Special Procedures f. Nutrition and Diet g. Client Education V. Evaluation
Content
Evaluation
Intermediate Competencies Given an adult client (young, middle, old, old-old adult) with response4s to altered endocrine function; the student should be to; Apply knowledge of normal anatomy and physiology, and assessment techniques in caring for clients. 1. Conduct a health history and functional health status of clients having at risk for alterations for endocrine function 2. Perform systemic and comprehensive physical
Endocrine and Metabolic Problems I. Anatomy and Physiology of the Metabolic, Hepatic and Endocrine Systems II. The Nursing Process b. Assessment i. Subjective Data 1. Demographic Data 2. Presence of Signs and Symptoms related to the Endocrine and Metabolic Systems Jaundice Malaise Weakness Fatigue Pruritus Abdominal Pain Increasing abdominal girth (ascites) Melena Hematochezia ii. Objective Data 1. 11 functional pattern 2. Physical assessment
assessment to validate assessed data.
Abdominal Girth Measurement Inspection Percussion Palpation Auscultation
Content
Evaluation
3. Interpret deviations from normal findings in the physical assessment, diagnostic and laboratory examinations 4. Utilize the assessed data in order to; Prioritize nursing diagnosis Discuss the physiological processes Plan the care of clients utilizing evidence-based nursing research Achieve the best clinical outcomes utilizing ethicomoral and legal principles. Plan effective care.
5.
Diagnostic Assessment Invasive Procedures a. Angiography b. Adrenal Venogram c. Portal Pressure Measurement d. Biopsy e. Paracentesis f. Endoscopic Retrograde Cholangiopancreatography Non-invasive Procedures a. Test of anatomic system structure and function b. MRI c. Electroencephalogram d. Ultrasonography e. CT scan f. Radionuclide Imaging g. Fine needle aspiration h. Achilles tendon reflex tests i. Radioiodine re-uptake tests
Content
Evaluation
6. Implement individualized nursing care; Safely and knowledgeably administers prescribed medications and treatments Actively participates in planning, coordinating, culturally sensitive interdisciplinary care Provide appropriate client eduction, health maintenance instructions and community
Laboratory a. Pigment Studies b. Protein Studies c. Serum Aminotransferase Studies d. Prothrombin Time e. Serum Aminotransferase Studies f. Ammonia g. Cholesterol c. Analysis i. Common Health Problems 1. Common Problems of the Endocrine System Disorders of the Thyroid Gland a. Hyperthyroidism i. Graves disease ii. Toxic Nodular Goiter iii. Thyroiditis iv. Thyroid Tumors
based-care
Hypothyroidism i. Iodine Insufficiency ii. Hashimotos Disease iii. Myxedema Disorders of the Parathyroid Gland a. Hyperparathyroidism b. Hypoparathyroidism Disorders of the Adrenal Gland a. Addisons Disease b. Pheochromocytoma c. Cushings Syndrome Disorders of the Pituitary Gland a. Anterior Pituitary Gland Disorders i. Gigantism b. Posterior Pituitary Gland Disorders i. SIADH ii. Diabetes Insipidus
Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
b.
2.
Common Problems of the Biliary System Cholecystitis Cholelithiasis Pancreatitis a. Acute b. Chronic Pancreatic Cysts Hyperinsulinism Diabetes Mellitus a. Types of Diabetes Mellitus b. Acute complications of Diabetes Mellitus i. Hypoglycemia (Insulin Reactions) ii. Diabetic Ketoacidosis
iii. c. i. ii. iii. d. 3.
(DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Long Term complications of Diabetes Mellitus Macrovascular complications Microvascular complications Foot and leg problems Special Issues in Diabetic Care
Common Problems of the Hepatic System Viral Hepatitis a. Hepatitis A, B, C, D,E and G Non-viral Hepatitis a. Toxic Hepatitis b. Drug Induced Hepatitis Fulminant Hepatic Failure Hepatic Cirrhosis Cancer of the Liver
Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
ii. Gerontologic Considerations iii. Potential Nursing diagnosis 1. Activity Intolerance related to fatigue and depressed cognitive process 2. Risk for imbalance body temperature 3. Constipation related to depressed gastrointestinal function 4. Ineffective Breathing Pattern related to depressed ventilation 5. Disturbed thought process related to depressed metabolism
6. 7. 8. 9. 10.
Imbalanced Nutrition: Less / More than Body requirements Deficient fluid volume as evidenced by dry mucus membranes, thirst and decreased urine output Impaired skin integrity as evidenced by dry, rough, reddened, and edematous skin. Disturbed body image Ineffective therapeutic management
d. Planning i. Planning for Health Restoration and Health Maintenance e. Implementation i. Pharmacologic Management 1. Iodine Resources 2. Antithyroid 3. Thyroid Replacement 4. Cortisol Replacement 5. Insulin 6. Oral Hypoglycemics 7. Hormone therapy
Content
Evaluation
ii. Complimentary Therapy 1. Aloe vera 2. Bilberry 3. Biter Melon 4. Fish Oil 5. Fenugreek 6. Garlic 7. Ginseng 8. Gymema 9. Horse Chestnut Seed Extract 10. Prickly pear
iii. Surgical Management 1. Thyroidectomy 2. Parathyroidectomy 3. Unilateral and Bilateral Adrenalectomy 4. TranssphenoidalHypophysectomy 5. AK//BK Amputation 6. Pacreatic Transplantation 7. Liver Transplantation 8. Surgical Bypass Procedures 9. Revascularization and Transition 10. Lobectomy 11. Cryosurgery
Content
Evaluation
iv. Modalities of Care/Special Procedures 1. Balloon Tamponade 2. Endoscopic Therapy 3. Esophageal Intrahepatic Portosystemic Shunting 4. Radiation Therapy 5. Chemotherapy 6. Percutaneous Biliary Drainage 7. Laser Hyperthermia
v. Nutrition and Diet vi. Client Education f. Evaluation
Intermediate Competencies Given a client with simple health needs/problems, the student will be able to 1. Identify appropriate pain assessment tool for a given age group.
Content E. Concept of Pain E1. Types of Pain a. acute pain b. chronic pain c. Cancer related pain d. Pain classified by location e. Pain classified by etiology E2. Harmful effects of Pain a. Effects of Acute pain b. Effects of Chronic pain E3. Pain Assessment Tools a. Pain experience inventory
Evaluation
2. States relevant priority nursing diagnosis with a given set of cues
b. Cries Neonatal Postoperative Pain measurement scale c. FLACC Pain assessment tool d. Poker chip tool e. Faces Pain rating Scale f. Oucher Pain Rating Scale g. Numerical or Visual Analog Scale h. Adolescent Pediatric Pain tool i. Logs and Diaries E4. Neurophysiological transmission of pain E5. Pain theories E6. Factors influencing Pain response E7. Characteristics of pain E8. Pain Management Strategies a. Nurses role in Pain Management b. Pharmacologic Interventions for Pain c. Routes of Administration d. Non-pharmacologic Interventions - Guided Imagery - Thought Stopping - Hypnosis - Aromatherapy, Essential Oils - Magnet therapy - Music therapy - Yoga and Meditation - Acupuncture - Crystal or Gemstone therapy - Herbal therapies/Hot and Cold application - Biofeedback - Therapeutic touch and massage - TENS
Intermediate Competencies 3. Utilize appropriate nonpharmacologic interventions to reduce clients pain
Content
PLAN/IMPLEMENTATION 5.2. Pharmacologic Pain Relief 5.2.1 Analgesics a. Narcotic b. Non-narcotic analgesics 5.2.2 Method of Administration a. Topical
Teaching-Learning Activities Classroom RLE Bring students to the floor and observe nurses preparing narcotics to familiarize them with S2 prescription and the narcotic sheet.
Evaluation
b. Oral c. IM d. IV e. PCA f. Conscious Sedation g. Intranasal h. Local Injection i. Epidural 5.2.3 Surgical destruction of painful stimuli a. Rhizotomy b. Nerve Block c. Continuous Extravascular Infusion d. Neurectomy e. Sympathectomy
EVALUATION
Intermediate Competencies Given an actual client for surgery, the student will be able to utilize the nursing process in the peri-operative care.
Content
Evaluation
D.
Care of Patients Requiring Surgery 1. General Considerations 1.1 Conditions Requiring Surgery 1.2 Categories for surgical procedure as to; a. Purpose b. Degree of Risk to patient c. Urgency d. Effects of surgery on the person e. Factors in the estimation of surgical risks 2. The Surgical Experience
2.1
Pre-operative Nursing Care
State priority nursing diagnosis for a client requiring surgery during the preoperative phase.
ASSESSMENT 7. Nursing History 8. Health History - development consideration - medical history - medications - occupation 9. Life-style - nutrition - use of alcohol - elicit drugs or nicotine - ADL - occupation 10. Coping patterns and support system 11. Pre-operative physical assessment 12. Pre-surgical screening tests - chest x-ray - ECG - CBC - Electrolyte levels and urinalysis
Intermediate Competencies Utilizes appropriate interventions for a surgical client during the pre-operative phase
Content
Demonstrates preoperative teaching
ANALYSIS - Potential Nursing Diagnosis - Anticipatory Grieving related to perceived loss of normal body image - Anxiety related to the effects of surgical procedure - Fear related to surgery - Risk for infection - Ineffective Airway Clearance - Ineffective Individual Coping PLAN / IMPLEMENTATION 1. Physiological / spiritual preparation for surgery
Teaching-Learning Activities Classroom RLE * Assign students to complete a pre-operative; intra-operative; and postoperative care at least (1) surgical client: A. Pre-operative period 1. Psychological preparation
Evaluation
Accomplishes preoperative teaching
2. Legal aspects of the informed consent 3. Instructional and Preventive aspects 3.1 Deep breathing exercises 3.2 Coughing exercises 3.3 Turning exercises 3.4 Extremity exercises 4. Physical Preparations 4.1 On the night of the surgery a. Hygiene and skin care b. Elimination c. Nutrition and fluid d. Rest and sleep 4.3 On the day of the surgery c. Pre-operative checklist d. Pre-operative medications
2. Physiological preparation 3. Physical preparation - shaving - enema 4. Spiritual preparation
EVALUATION Evaluates patient based on expected outcomes
Intermediate Competencies Given an actual client for surgery, the student: Utilize assessment technique during the intra-operative phase
Content
2.2 Intra-operative Nursing Care ASSESSMENT 1. Identify surgical client 2. Assess the emotional and physical status 3. Verify information in the pre-operative checklist ANALYSIS 1. Impaired Skin Integrity related to Incision 2. Risk of Fluid Volume deficit 3. Risk for Injury related to position PLAN / IMPLEMENTATION
States priority nursing diagnosis during the intra-operative phase
Teaching-Learning Activities Classroom RLE Filmstrip: Surgical Asepsis 9. Principles and practice 10.Sterile glove technique 11.Sterile Dressing 12.Sterile Gown Technique 13.Draping 14.Open wound drainage 15.Drains
Evaluation
1. Discuss the roles and responsibilities of a nurse during intraoperative phase
Demonstrates skills in OR nursing
Duties and responsibilities of the circulating nurse; scrub nurse; RN first assistants 2. The surgical environment - Principles of surgical asepsis - Environmental controls - Maintaining surgical asepsis 3. The surgical Experience a. Positioning b. draping c. types of anesthesia and sedation d. stages of anesthesia 4. Potential Intra-operative complication - Bleeding - Nausea and vomiting - Anaphylaxis - Hypoxia and other respiratory complications - Hyperthermia - DIC 5. Documentation 6. Transferring to the PCU EVALUATION
- Penrose - t-tube - J-pratt - Hemovac - Gomco suction
Evaluate outcomes during intra-operative phase
Intermediate Competencies Given a post-operative client, student ; 1. Provides appropriate nursing intervention during the immediate post-operative period.
Content
Evaluation
2.3 Post-operative Nursing Care 2.3.1 Immediate Post-operative Care in the PACU Nursing responsibilities in the PACU a. assessing the post-operative client b. maintenance of pulmonary ventilation c. maintenance of circulation d. protection from injury e. promotion of comfort 2.3.2 Aldrete post-anesthesia recovery scoring system 2.3.3 Ongoing post-operative Care 2.3.4 Immediate post-operative care in the PACU ASSESSMENT
Assess a client during the immediate postoperative period.
a. b. c. d. e.
Vital signs Color and temperature of the skin Level of Consciousness Comfort Time of Arrival
Given set of cues, states priority nursing diagnosis during immediate post operative period.
ANALYSIS Postoperative nursing diagnosis b. risk for surgical site diagnosis c. pain d. altered family processes related to loss of economic stability e. impaired physical mobility f. potential complication: Hemorrhage PLAN / IMPLEMENTATION 1. Preventing Post-operative Complications 1.1 Respiratory Complications 1.2 Circulatory Complications 1.3 Fluid and Electrolytes Imbalance 1.4 Gastrointestinal Complications 1.5 Urinary Complications 1.6 Wound Complications 2. Post-operative Discomforts EVALUATION
Evaluates patient based on outcome criteria
Content C. HEALTHCARE OF THE OLDER ADULT (Geriatric Nursing) 1. Overview of the Aging Process a. Demographics of aging b. Health status of the older adult c. Nursing care of the older adult d. Theories of aging 2. Age-related changes a. Psychosocial aspects of aging b. Physical aspects of aging c. Cognitive aspects of aging d. Pharmacologic considerations for e. The older adult. 3. Mental health problems in the Older adult a. Depression b. Delirium
Evaluation
4.
c. Dementia Common health issues of the older adult a. Impaired mobility b. Dizziness c. Falls and Falling d. Urinary Incontinence e. Increased susceptibility to f. Infection g. Altered pain and febrile h. responses i. Altered emotional responses j. Altered Systemic Response
Content Responses to Altered Oxygenation : Altered Respiratory Patterns I. Concept Review : Anatomy and Physiology of the Respiratory System II. Application of the Nursing Process A. Assessment 1. Subjective Data a. Nursing health history b. Functional health patterns 2. Objective Data a. Physical Assessment - Inspection - Auscultation - Percussion
Evaluation
- Palpation b. Diagnostics and Laboratory Radiographic Tests - Chest x-ray - Computed Tomography - Magnetic Resonance Imaging - Ventilation Perfusion Scan - Pulmonary Angiography - Positron Emission Tomography Direct Visualizations - Laryngoscopy - Thoracostomy - Bronchoscopy - Mediastinoscopy Biopsies Laboratory Studies - Hematologic Examinations - Cytologic - Bacteriologic - Sputum culture - Nose and Throat Culture - Arterial blood gas analysis - Smoke Analyzer - Fagerstrom Skin tests Pulmonary Function Tests Bronchospirometry Thoracentesis and Pleural fluid
Content B. Analysis 1. Common Problems of the Respiratory System a. Upper Airway Infections - Rhinitis - Viral rhinitis - Acute and Chronic Sinusitis - Acute and Chronic Pharyngitis - Tonsillitis and Adenoiditis - Peritonsillar Abscess - Laryngitis b. Obstruction and Trauma - Obstruction during sleep - Epistaxis - Nasal obstruction
Evaluation
c. -
d. e. f. g. h. i. j. k. l. Intermediate Competencies
Fractures of the nose Laryngeal obstruction Cancer of the Larynx Chest and Lower Respiratory Disorders Atelectasis Respiratory Infections of the Lower Respi. System Acute tracheobronchitis Pneumonia Severe acute respiratory disorders Pulmonary tuberculosis Lung abscess Pleural Conditions Pleurisy - Empyema Pleural Effusion Pulmonary Edema Sever acute respiratory distress syndrome Pulmonary hypertension Pulmonary heart disease Sarcoidosis Occupational lung disease Silicosis (Pneumoconiosis) Asbestosis Coal Miners Disease Chest tumors Chest trauma Blunt trauma Penetrating trauma Pneumothorax Cardiac Tamponade Subcutaneous Emphysema Aspiration Content Teaching-Learning Activities Classroom RLE No. of Hours Lec RLE Evaluation
m. Clients with Chronic Obstructive Pulmonary Disease a. Bronchiectasis b. Asthma - Status Asthmaticus c. Chronic Obstructive Pulmonary Disease - Emphysema - Chronic Bronchitis d. Cystic Fibrosis 2. Potential Nursing Diagnosis a. Ineffective Airway Clearance as evidenced by shortness of breath, dyspnea, orthopnea, retractions, nasal flaring and altered chest
excursions b. Ineffective breathing patter as evidenced by ineffective cough, diminished or abnormal breath sounds, cyanosis and restlessness c. Impaired gas exchange as evidenced by cyanosis, abnormal respiratory rate, rhythm, nasal flaring, tachycardia, diaphoresis, and confusion. d. Impaired spontaneous ventilation as evidenced by dyspnea, use of accessory muscles, tachycardia, and apprehension. e. Disturbed sleep pattern (sleep-rest) f. Anxiety C. Planning/Implementation C1. Planning 1. Planning for Respiratory health promotion 2. Planning for health restoration and maintenance a. Maintain airway patency b. Relieving apprehension c. Reducing metabolic demand d. Maintaining nutrition and hydration e. Maintaining elimination f. Preventing and controlling infection
Content C2. Implementation 1. Pharmacologic Management a. Decongestants and antihistamines b. Anti-tuberculosis Drugs c. Broad Spectrum Antibiotics d. Adrenergic stimulants e. Methylxanthines f. Anticholinergics g. Corticosteroids h. Mast cell stabilizers i. Leukotriene modifiers 2. Complementary and Alternative Management Echinacea Golden seal
Evaluation
Zinc 3. Respiratory Care Modalities A. Non-invasive airway management Oxygen therapy Intensive spirometry Nebulization therapy Intermittent positive pressure breathing Chest physiotherapy B. Invasive airway management Endotracheal intubation Tracheostomy Mechanical ventilation 4. Thoracic Surgery a. Pneumonectomy b. Lobectomy c. Segmentectomy (segmental resection) d. Wedge resection e. Bronchoplastic or sleeve resection f. Lung volume reduction 5. Nutritional and Diet Therapy a. Tube feedings b. Fluid therapy per Orem and IV infusion c. High protein, high calorie and supplements 6. Client Health Education 7. Nursing Considerations and Implementations D. EVALUATION
Content Responses to Altered Oxygenation: Altered Cardiac and Tissue Peripheral Perfusion and Transport I. Review of Anatomy and Physiology of the Cardiovascular and Hemato-lymphatic Systems
Evaluation
II. Application of the Nursing Process A. Assessment 1. Subjective Data a. Nursing health history b. Functional Health Pattern 2. Objective Data a. Physical Assessment - Inspection
1.
2.
3. 4.
- Auscultation - Percussion - Palpation b. Diagnostics / Laboratory Tests Non-invasive Diagnostic Tests a. Electrocardiogram b. Echocardiogram c. Ultrasound d. Chest X-ray e. Radionuclide Studies Invasive Diagnostic Tests a. Cardiac Catheterization b. Arteriogram c. Angiogram d. Venogram e. Lymphography f. Bone Marrow Aspiration Laboratory Tests Gerontologic Considerations
Intermediate Competencies B.
Content Analysis 1. Common Problems of the Cardiovascular System a. Dysrhythmias and conduction problems Dysrhythmias b. Coronary Vascular Disorders Coronary Arthrosclerosis Angina pectoris Myocardial infarction c. Structural, Infectious, and Inflammatory Cardiac Disorders i. Valvular disorders Mitral valve prolapse Mitral regurgitation
Evaluation
Mitral stenosis Aortic regurgitation Aortic stenosis i. Cardiomyopathy ii. Infectious diseases of the heart Rheumatic endocarditis Infective endocarditis Myocarditis Pericarditis d. Complications of cardiac disorders Chronic Heart Failure Acute Heart Failure (pulmonary edema) Cardiogenic shock Thromboembolism Pericardial Effusion and Cardiac Tamponade Cardiac Arrest
Content 2. Arterial Disorders a. Hypertension a. Types of Hypertension b. Hypertensive Crisis b. Arterial Disorders 1. Arteriosclerosis and Atherosclerosis 2. Peripheral Arterial Occlusive Disease 3. Thromboangiitis Obliterans (Buergers Disease) 4. Aortitis 5. Aorta-iliac disorders 6. Aneurysms 7. Dissecting Aorta 8. Arterial Embolism and Arterial thrombosis
Evaluation
9. Raynauds Disease c. Venous Disorders 1. Venous thrombosis, deep vein thrombosis, thrombophlebitis and phlebothrombosis 2. Chronic Venous Insufficiency 3. Leg Ulcers 4. Varicosities d. Lymphatic Disorders Cellulitis 1. lymphangitis and lymphadenitis 2. lymphedema and elephantiasis e. Cellulitis 3. Hematologic Disorders a. Anemia i. Hypoproliferative anemia Iron deficiency anemia Anemias in renal disease Anemias of chronic disease Aplastic anemia Megaloblastic anemia - Folic acid deficiency anemia - Vitamin B12 deficiency anemia - Pernicious anemia - Myelodysplastic syndrome ii. Hemolytic Anemia Sickle cell anemia Thalassemia Glucose-6-phosphatase-dehydrogenase deficiency Hereditary Spherocytosis Immune Hemolytic anemia
Content b. Polycythemia Polycythemia Vera Secondary Polycythemia c. Leukopenia Neutropenia lymphopenia d. Leukemia Acute myeloid leukemia Chronic myeloid leukemia Acute lymphocytic leukemia Chronic lymphocytic leukemia
Evaluation
e. Agnogenic Myeloid Metaplasia Hodgkins lymphoma Non-Hodgkins lymphoma f. Multiple Myeloma g. Bleeding Disorders Primary thrombocytopenia Secondary thrombosis Thrombocytopenia Idiopathic thrombocytopenic purpura Platelet defects Hemophilia Von Willebrands Disease h. Acquired Coagulation Disorders Vitamin K deficiency Disseminated Intravascular Coagulation Thrombotic Disorders Hyperhomocysteinemia Antithrombin (AT) deficiency Acquired thrombophilia
Course Name Course Description
Nursing Care Management 103 (NCM 103) Care of Clients Across the Lifespan with Alterations in Fluid, Electrolyte and AcidBase, Oxygenation, Metabolism, and Endocrine Functions. This course deals with principles and techniques of nursing care management of sick clients across the lifespan in
any setting with alterations / problems in oxygenation, fluid, electrolyte and acid-base balance, metabolism and endocrine functions.
Course Credit Contact Hours / Semester Pre-requisite Placement Terminal Competencies
: : : : :
8 Units lecture; 6 Units Related Learning Experience (RLE) 144 hours lecture and 306 RLE NCM 102 3rd year, 1st Semester Given an actual client with problems in oxygenation, fluid and electrolyte balance, metabolic and endocrine function, the students should be able to;
1. Utilize the nursing process in the care of individuals, families in selected settings a. Assess clients condition / health status through interview, physical e examination, interpretation of laboratory findings b. Identify actual and at-risk nursing diagnosis c. Plan appropriate nursing interventions with client/s and family for identified nursing diagnosis d. Implement plan of care with client/s and family e. Evaluate the progress of his/her clients condition and outcomes of care.
2. 3. 4.
Ensure a well organized and accurate documentation system Observe bioethical concepts/principles, core values and nursing standards in the care of clients and; Promote personal and professional growth of self and others
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A NCM 103 Lecture 2013

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Intermediate Competency

No. of Hours Lec RLE

Teaching-Learning Activities Classroom RLE

No. of Hours RLE

Intermediate Competencies C. Pain

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

2. States relevant priority nursing diagnosis with a given set of cues

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

2. Utilize appropriate nonpharmacologic interventions to reduce clients pain

Intermediate Competencies D. PERIOPERATIVE NURSING 1.

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

No. of Hours Lec RLE

Demonstrates preoperative teaching Accomplishes preoperative teaching

Evaluates patient based on expected outcomes

No. of Hours Lec RLE

States priority nursing diagnosis during the intra-operative phase

Discuss the roles and responsibilities of a nurse during intraoperative phase

Demonstrates skills in OR nursing Evaluate outcomes during intra-operative phase.

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

Assess a client during the immediate postoperative period.

Evaluates patient based on outcome criteria

Electrolytes Dissociation of Electrolytes: Body fluids contain water and electrolytes.

1, 300 ml 1, 000 ml 300 ml 2, 600 ml

1, 500 ml 200 ml 300 ml 600 ml 2, 600 ml

Lactated Ringers has potassium and calcium in addition to NaCl.

Teaching-Learning Activities Classroom RLE

No. of Hours Lec

Evaluation RLE 1. Performance evaluation checklist 2. Progress Test Final Examination

No. of Hours Lec

Round Table Discussion

Teaching-Learning Activities Classroom RLE

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Teaching-Learning Activities Classroom RLE

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ii. iii. iv.

Teaching-Learning Activities Classroom RLE

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Teaching-Learning Activities Classroom RLE

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Lymphangitis and Lymphadenitis Lymphedema and Elephantiasis 4. Cellulitis

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

Coagulopathy Thrombotic Disorders Hyperhomocysteinemia Anti-thrombin Deficiency Acquired Thrombophilia

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

Teaching-Learning Activities Classroom RLE

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Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

6. Nutrition and Diet Therapy H. EVALUATION

Content NUTRITIONAL-METABOLIC PATTERNS

Teaching-Learning Activities Classroom RLE

No. of Hours Lec RLE

(iv)Percussion (v) Palpation

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(5) Diarrhea c) Planning