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FUNDAMENTALS IN NURSING

EVOLUTION OF NURSING NURSING IN THE PAST (TRADITIONAL NURSING) FOCUS WAS TAKING CARE OF SICK PEOPLE CONTEMPORARY NURSING EMPHASIZES CARE OF THE WHOLE PERSON, OR HOLISTIC HEALTH CARE

HISTORICAL PERSPECTIVES 1. INTUITIVE WOMEN WHO TOOK CARE OF THEIR CHILDREN, ELDERLY AND SICK MEMBERS OF THE FAMILY SHAMANS INCANTATIONS, TREPHININGS CONTRIBUTIONS TO MEDICINE AND NURSING 1. BABYLONIA CODE OF HAMMURABI 2. EGYPT ART OF EMBALMING; ID 250 RECOGNIZED DISEASES 3. ISRAEL MOSES FATHER OF SANITATION 4. CHINA MATERIA MEDICA (PHARMACOLOGY) 2. PERIOD OF APPRENTICE NURSING EXTENDS FROM THE FOUNDING OF RELIGIOUS ORDERS IN THE 11TH CENTURY AND ENDED IN 1836 ON THE-JOB TRAINING HOSPITALS WERE ESTABLISHED IN THE 16TH CENTURY BUT WERE UNSANITARY, CHEERLESS, GLOOMY AND AIRLESS 3. DARK PERIOD OF NURSING 17TH TO 19TH CENTURY NURSING CARE GIVEN BY CRIMINALS AND WOMEN OF LOW MORAL STANDARDS ENDED IN 1836 WITH THE ESTABLISHMENT OF THE KAISERWERTH INSTITUTE FOR THE DEACONESSES IN GERMANY BY PASTOR FLIEDNER 4. EDUCATIVE PERIOD ESTABLISHMENT OF NIGHTINGALE SCHOOL OF NURSING AT ST. THOMAS HOSPITAL IN LONDON ON JUNE 15, 1860 GUARDIAN ANGEL OR ANGEL OF MERCY IMAGE DOCTORS HANDMAIDEN FLORENCE NIGHTINGALE (May 12, 1820 - Aug. 13, 1920) MOTHER OF MODERN NURSING LADY WITH THE LAMP ANGEL OF CRIMEA NOTES ON NURSING NOTES ON HOSPITAL

NURSING LEADERS CLARA BARTON (1812-1912) AMERICAN RED CROSS LILLIAN WALD (1867-1940) FOUNDER OF PUBLIC HEALTH NURSING MARY ADELAIDE NUTTING, ISABEL HAMPTON ROBB AND LAVINIA DOCKAMERICAN SOCIETY OF SUPERINTENDENTS OF TRAINING SCHOOLS FOR NURSES IN THE US & CANADA CONTEMPORARY DEFINITION OF NURSING BY FLORENCE NIGHTINGALE AND VIRGINIA HENDERSON NIGHTINGALE, 1860 NURSING IS THE ACT OF UTILIZING THE ENVIRONMENT VIRGINIA HENDERSON, 1960 TO ASSIST THE INDIVIDUAL, SICK OR WELL Events and Trends Establishment of WHO by UN Atomic/ nuclear energy for dx and tx Use of computers Aerospace nursing Laws amended perceiving health as a fundamental right Disposable supplies and equipments Development of the expanded roles of nurses. Community health nursing intensified ROLES AND FUNCTIONS OF THE NURSES I. Caregiver (Care Provider) it includes those activities, which usually carried out by a professional, that assist the client physically and psychologically while preserving clients dignity. It if often referred to as Mothering Actions II. Communicator nurses identify client problems and then communicate these verbally or in writing to other members of the health team through coordination. III. Client Advocate one who expresses and defends the cause of another. The nurse promotes what is best for the client, ensuring that the clients needs are met and protects their rights. IV. Counselor Helps a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships and to promote personal growth. Counseling requires therapeutic communication skills, and the nurse should be prepared to provide emotional, psychological and intellectual support appropriately. V. Leader

Nursing leadership is defined as a mutual process of interpersonal influence through which the nurse helps a client make decision in establishing and achieving goals to improve the clients well being VI. Manager Ability to handle or control something successfully, which in this case applies on the nursing care of individuals, families and communities. Roles in nursing management includes planning, organizing, staffing, leading, communicating, decision making and controlling. VII. Nurse Administrator manages client care, including the delivery of nursing services, making sure that the nursing services are organized, coordinated, and dispensed, to meet the patients needs. VIII. Nurse Educators help to coordinate and assess the education needs of nurses in the institution. They coordinate internship and orientation programs to prepare newly hired function in special areas. IX. Role Model Nurses serve as good models when they observe healthful practices of daily living. EXPANDED ROLES 1. NURSE-PRACTIONER GRADUATE OF A NURSE-PRACTIONER PROGRAM 2. CLINICAL NURSE SPECIALIST ADVANCED DEGREE, CONSIDERED AN EXPERT IN A SPECIALIZED AREA OF PRACTICE 3. NURSE-ANESTHETIST 4. NURSE-MIDWIFE 5. NURSE-RESEARCHER DOCTORAL LEVEL 6. NURSE-ADMINISTRATOR-HEAD NURSES, SUPERVISORS 7. NURSE EDUCATORS 8. NURSE-ENTREPRENEUR 9. Nursing Informatics the science of using computer information system in the practice of nursing. - a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information to support patients, nurses and other health professionals in their roles. - this is designed to enhance client care, education, management and nursing research. SCOPE OF NURSING R.A. 9173 Article VI Section 28 of the Philippine Nursing act of 2002 cites the Scope of Nursing. FOUR AREAS OF NURSING PRACTICE: 1. Promotion of Health & Wellness w Nurses promote wellness in clients who are both healthy & ill.

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w This may involve individual & community activities to enhance healthy lifestyles, such as nutrition & physical fitness, preventing drug & alcohol misuse, restricting smoking & preventing accidents & injury in the home & workplace. w The nursing process is the best tool for the nurse in the health promotion role. w As the nurse moves towards greater autonomy in providing client care, a thorough assessment of the clients health status is essential to provide a meaningful data. Prevention of Illness w The goal of illness prevention programs is to maintain optional health by preventing disease. w Prevention, in a narrow sense, means avoiding the development of disease in the future, & in broader sense, consists of all interventions to limit progression of a disease. w Nursing activities that prevent illness include immunizations, prenatal & infant care, Umbilical cord care, prevention of sexually transmitted disease (use of condom), use of first aid, pap smears, mammograms, routine physical examination, & safety. 3 LEVELS OF PREVENTION 1. PRIMARY PREVENTION FOCUS IS ON HEALTH PROMOTION EX. NUTRITION, IMMUNIZATION, FAMILY PLANNING SERVICES, STRESS MANAGEMENT 2. SECONDARY PREVENTION EMPHASIZES EARLY DETECTION, EARLY INTERVENTIONS (EX. SCREENING SURVEYS, TSE, BSE) 3. TERTIARY PREVENTION FOCUS IS TO HELP REHABILITATE INDIVIDUALS (EX. TEACHING CLIENTS WITH DM ABOUT SELF-MEDICATION & PREVETION OF COMPLICATIONS) 3. Restoration of Health w focuses on the ill client & it extends from early detection of disease through helping the client during the recovery period. w Nursing activities include the following: Providing direct care to ill person such as administering medications, baths, & specific procedures & treatment. Performing diagnostic & assessment procedures. (such as measuring BP) Consulting with other health care professionals about client problems Teaching client about recovery activities, such as exercises that will accelerate recovery after a stroke. Rehabilitating clients to their optimal level following physical or mental illness, injury, or addiction. 4. Alleviation of Suffering / Care of Dying it involves comforting & caring for people of all ages who are suffering & dying. It aims to restore maximum functional health pattern.

It includes helping clients adapt to altered health & function, live as comfortably as possible until death & helping support persons cope with death. Nursing activities involve problem solving skills, adaptation to changing health status & lifestyle, Strategies to deal with current (e.g. medications, diets, activity limitations, prosthesis) & future ( e.g. fear of pain) problems, facilitation of strong self-image, or grief & bereavement counseling. Nurses carrying out these activities work in homes, hospitals, & extended care facilities. THEORY - a supposition or systems of ideas that is proposed to explain a given phenomenon. - used to describe, predict, and control a phenomena. CONCEPT - the building blocks of theories - easier to understand by example - something thought or imagined or perceived CONCEPTUAL FRAMEWORK - a group of related ideas, statements, or concepts. PARADIGM - a pattern of shared understandings and assumptions about reality and the world. METAPARADIGM - meta meaning with - articulating relationships among major concepts Four major concepts in nursing: 1. Client the recipient of nursing care. 2. Environment the internal or external surroundings that affect the client. 3. Health the degree of wellness or well-being that the client experiences. 4. Nursing the attributes, characteristics, and actions of the nurse providing care. GRAND THEORY - articulate a broad range of the significant relationships among the concepts of discipline. MIDLEVEL THEORY - focus on the exploration of concepts. Purposes of Nursing Theories : - directs links among theory, education, research and clinical practice. - guides knowledge development and directs education, research and practice. - experts in each area helps to ensure that work in other areas remains relevant, current, useful, and ultimately influences health. Theory that focus on environment: 1. Florence Nightingale Environmental theory

- to facilitate the bodys reparative - Process by manipulation of envt. Theories that focus on the client as an Individual / Holistic Approach: 1. Virginia Henderson- 14 Basic/ Fundamental Needs - focus on the independent satisfaction of human needs. - nurse is concerned with both healthy and ill individuals. - nurses interact with clients even when recovery may not be feasible. - to work interdependently with other health caregivers. 2. Faye Abdellah- the typology of 21 nursing problems - holistic delivery of health care to meet the social, physical, intellectual, emotional and spiritual needs of the client and family. 3. DOROTHY E. JOHNSON BEHAVIORAL SYSTEM MODEL - focus on how the client adapts to illness and how actual or potential stress can affect ability to adapt. - the goal of nursing is to stress. - clients basic needs are categorized according to behavioral subsystems. 3. DOROTHEA OREM SELF CARE & SELF-CARE DEFICIT THEORY - nursing care is necessary only if the client is unstable to fulfill biological, psychological, developmental or social needs. - 3 NURSING SYSTEMS 1. WHOLLY COMPENSATORY 100% CARE GIVEN TO THE CLIENT 2. PARTIALLY COMPENSATORY NURSE/CL ENGAGE IN MEETING SELFCARE NEEDS 3. SUPPORTIVE-EDUCATIVE ASSISTS IN DECISION-MAKING AND ACQUISITION OF KNOWLEDGE AND SKILLS 4. SIS. CALLISTA ROY ADAPTATION MODEL - A PERSON IS A UNIFIED BIOPSYCHOSOCIAL SYSTEM IN CONSTANT INTERACTION WITH A CHANGING ENVIRONMENT. - the goal of nursing is to help the person adapt to this changes in physiological needs, self-concept, role function during health and illness. 5. LYDIA HALL - the client is composed of overlapping parts ; person (core), pathologic state and treatment (cure) and body (care) 6. Ida Jean Orlando - client is an individual with a need that when met diminishes distress, increase adequacy and enhances well-being. Theories that focus on the inter-relationship between client and nurse: 1. IMOGENE KING GOAL ATTAINMENT THEORY - to identify problems and identify goals. - ASSISTS INDIVIDUALS AND GROUPS IN SOCIETY TO ATTAIN, MAINTAIN, AND RESTORE HEALTH. - IF THIS IS NOT POSSIBLE, NURSES HELP INDIVIDUALS DIE WITH DIGNITY 2. BETTY NEUMAN

HEALTHCARE SYSTEM MODEL - based on the individual relationship to stress, the reaction to it and reconstitution factors. - views client as an open system consisting of a basic structure or central core of energy resources. - categories of stress: a. Intrapersonal stressors those that occur within the individual b. Interpersonal stressors those that occur between individuals c. extrapersonal stressors those that occur outside the person. 3. JEAN WATSON Human Caring Model - Caring is central to nursing - Caring promotes health more than does curing - promotes health & growth 4. HILDEGARD PEPLAU INTERPERSONAL MODEL - use of therapeutic relationship between the nurse and the client - nurse enters into a personal relationship with an individual when a need is present - 4 PHASES OF THE NURSE-CLIENT RELATIONSHIP: 1. ORIENTATION THE NURSE AND THE CL DO NOT KNOW EACH OTHERS GOALS; PHASE WHERE CL TESTS THE NURSE; CL TRIES TO SEEK HELP, NURSE ASSISTS CL TO UNDERSTAND THE PAST & EXTENT OF NEEDS) 2. IDENTIFICATION THE CLIENT RESPONDS TO THE PROFESSIONALS ; ASSUMES THE POSITION OF DEPENDENCE, INDEPENDENCE AND INTERDEPENDENCE 3. EXPLOITATION CL UTILIZES ALL AVAILABLE RESOURCES TO MOVE TOWARD A GOAL OF MAXIMAL HEALTH 4. RESOLUTION TERMINATION PHASE 5. MADELEINE LEININGER TRANSCULTURAL NURSING MODEL HUMANISTIC & SCIENTIFIC MODE OF HELPING A CLIENT THROUGH SPECIFIC CARING PROCESSES (CULTURAL VALUES, BELIEFS AND PRACTICES) TO IMPROVE OR MAINTAIN A HEALTH CONDITION Theories that focus on the inter- relationship between client and environment : 4. MARTHA ROGERS SCIENCE OF UNITARY HUMAN BEINGS - MAN IS AN ENERGY FIELD IN CONSTANT INTERACTION WITH THE ENVIRONMENT. - focus on the persons wholeness - use of non-therapeutic touch to enhance the healing process 2. MYRA LEVINE FOUR CONSERVATION PRINCIPLES (CONSERVATION OF ENERGY, STRUCTURAL INTEGRITY, PERSONAL INTEGRITY AND SOCIAL INTEGRITY) LEGAL ASPECTS OF NURSING

CRIME ACT COMMITTED IN VIOLATION OF PUBLIC LAW; FELONIES OR MISDEAMENOR FELONY A SERIOUS CRIME SUCH AS MURDER; 2ND DEGREE MURDER MISDEAMENOR AN OFFENSE OF A LESS SERIOUS NATURE TORTS CIVIL WRONG COMMITTED AGAINST A PERSON OR A PERSONS PROPERTY; INTENTIONAL, Intentional Torts Fraud false presentation of some facts with the intention that it will be acted upon to another person. Invasion of Privacy Defamation false communication > Libel print, writing, pictures > Slander spoken word Assault attempt or threat to touch another person unjustifiably Battery willful touching of a person (or clothing) that may or may not cause harm False Imprisonment unlawful restraint or detention of another person against his/her will Unintentional torts NEGLIGENCE COMMISSION OR OMISSION TO DO SOMETHING THAT A REASONABLE PERSON WOULD DO or would not do which cause injury MALPRACTICE A PROFESSIONAL NEGLIGENCE Improper or unskillful care of a patient MOST COMMON NURSING ERRORS THAT RESULT IN NEGLIGENCE MEDICATION ERRORS BURNING A CLIENT FALLS IGNORING A CLIENTS COMPLAINTS OR FAILURE TO OBSERVE AND TAKE APPROPRIATE ACTION MISTAKEN IDENTITY LEGAL DOCTRINES R/T NEGLIGENCE RESPONDEAT SUPERIOR LET THE MASTER ANSWER RES IPSA LOQUITOR THE THING SPEAKS FOR ITSELF No proof is needed. ETHICAL ASPECT OF NURSING ETHICS RULES OR PRINCIPLES THAT GOVERN RIGHT CONDUCT BIOETHICS THE ETHICS CONCERNING LIFE MORALITY CONCERNS BEHAVIOR WHICH INVOLVES JUDGEMENTS, ACTIONS AND ATTITUDES BASED ON NORMS CODE OF ETHICS PROVIDES A MEANS BY WHICH PROFESSIONAL STANDARDS OF PRACTICE ARE ESTABLISHED, MAINTAINED AND IMPROVED

ETHICAL ISSUES IN NURSING CARING FOR AIDS PATIENTS ABORTION CONFIDENTIALITY TERMINATION OF LIFE-SUSTAINING TREATMENT DNR NURSING PROCESS SYSTEMATIC, RATIONAL METHOD OF PLANNING AND PROVIDING INDIVIDUALIZED NURSING CARE; IT PROVIDES A FRAMEWORK FOR ACCOUNTABILITY AND RESPONSIBILITY IN NURSING AND IT MAXIMIZES RESPONSIBILITY FOR STANDARDS OF CARE. GAINED LEGITIMACY IN 1973 WHEN ANA PUBLISHED STANDARDS OF NURSING PRACTICE, DESCRIBING THE 5 STEPS OF THE NURSING PROCESS CHARACTERISTICS OF THE NURSING PROCESS: CYCLICAL AND DYNAMIC, RATHER THAN STATIC CLIENT CENTERED OPEN AND FLEXIBLE INTERPERSONAL AND COLLABORATIVE IT IS PLANNED GOAL DIRECTED PERMITS CREATIVITY OF THE NURSE EMPHASIZES FEEDBACK UNIVERSALLY APPLICABLE BENEFITS FOR THE CLIENT QUALITY OF CARE CONTINUITY OF CARE CLIENT PARTICIPATION IN THEIR HEALTH CARE BENEFITS FOR THE NURSE CONSISTENT AND SYSTEMATIC NURSING EDUCATION JOB SATISFACTION PROFESSIONAL GROWTH AVOIDANCE OF LEGAL ACTION NURSING PROCESS It was popularized by Lydia Hall in 1955 It is both a problem solving process and a framework in which nurses can apply their knowledge and skills. It is a GOSH approach G oal oriented O rganize S ystematic H umanistic Care

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Phases / Steps in Nursing Process: Assessment Get the facts. Collect, organize, validate, and record client data. Types of Data: 1. Subjective (symptoms) apparent only to the client (e.g. Pain, dizziness) 2. Objective (signs) can be observed (by the use of senses) and measured Sources of data: 1. Primary Data provided by the client 2. Secondary Data provided by a source other than the patient. Methods of collecting Data: 1. Interview a planned communication with the client. 2. Observation use of 5 sense and instruments 3. Physical Assessment- to validate and confirm subjective and objective data. 2. Diagnosis identify the clients status and health care needs. Uses the PES format P- roblem E- tiology S- igns and symtoms Prioritizing nursing diagnosis is based on what endangers life. Types of Nursing Diagnosis: 1. Actual problem is present 2. Potential problems may arise 3. Possible problem may be present 4. Wellness transition from a specific level of wellness to a higher level. 3. Planning Determine goals and outcomes. Identifying the specific actions to be done. Formulation of NCP which is used mainly as a guide to individualize care. Characteristics of a well stated goal: S- pecific M- easurable A- ttainable R- ealistic T- ime framed 4. Implementing- putting the NCP into action Requirement for implementation : TUOS - technical skills knowledge - communication skills 5. Evaluating measuring the clients health achievements based on the goals specified. VITAL SIGNS 1. TEMPERATURE- the balance between heat produce by the body and heat loss from the body. (normal- 36C 37.5C)

Types of Body Temperature: a. Core temperature- deep tissue temperature of the body. Normal ranges from 36.7C -37C b. Surface temp.- temperature of the skin, subcutaneous tissue, and fats. Routes of temperature- taking Route oral Rectal Axilla Tympanic membrane No. of minutes 2 - 3 mins. 2 mins. 7 10 mins Automatic results Normal value 37o C 98.6o F 37.7o C 99.6oF 36.4 o C 97.5 o F 37.7 o C 99.9 o F Description Most convenient and accessible Most accurate and invasive Least invasive and least accurate Directly reflects core temperature

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FACTORS AFFECTING BODY TEMPERATURE AGE Infants Elderly hypothermia (lack of SC) Diurnal variables Highest temp 8pm-12am, lowest 4-6am Exercise Hormones progesterone Stress Environment elderly cl susceptible to heat stroke Four common types of fever INTERMITTENT ALTERNATES BETWEEN PERIODS OF FEVER AND PERIODS OF NORMAL TEMP REMITTENT WIDE RANGE OF TEMP FLUCTUATION OCCURRING OVER THE 24HOUR PERIOD, ALL OF WHICH ARE ABOVE NORMAL RELAPSING FEVER TEMP IS ELEVATED FOR A FEW DAYS ALTERNATED WITH 1 OR 2 DAYS OF NORMAL TEMPERATURE CONSTANT FEVER BODY TEMP IS CONSISTENTLY HIGH CONVERSION: Fahrenheit to Celsius = (o F-32) x 5/9 Celsius to Fahrenheit = (o C x 9/5) + 32 PULSE - it is the wave of blood created by the contraction of the left ventricle. it is regulated by the autonomic nervous sys. Normal PR for adult 60-100 bpm

Pulse Site Temporal Carotid Apical Brachial Radial Femoral

Purposes Used when radial pulse is not accessible Used for infants and in cardiac arrest Used for infants and children up to 3 y/o. To determine discrepancies with radial pulse Used to measure blood pressure Readily accessible and routinely use Determine the circulation of the legs

PULSE SCALE SCALE FOR MEASURING PULSE STRENGTH 0 ABSENT 1+ PULSE IS DIMINISHED, BARELY PALPABLE 2+NORMAL 3+FULL PULSE 4+STRONG, BOUNDING PULSE Pulse rate vary in different age levels 1 y/o 80 100 bpm 10 y/o 50 90 bpm 2 y/o 80 140 bpm adult 60 100 bpm 6 y/o 75 120 bpm 3. RESPIRATION it is the act of breathing. Medulla Oblongata is the primary respiratory center of the body. Normal Adult breathes 16-20 times per min. Characteristics : a. Normal breathing quiet, regular, rhythmic b. Cheyne Stoke alternate waxing and waning with temporary period of apnea. c. Biots irregular respiration with period of apnea. d. KAUSSMAULS INCREASED RR, DEPTH (SEEN IN METABOLIC ACIDOSIS, RENAL FAILURE 4. BLOOD PRESSURE BLOOD PRESSURE it is the pressure exerted by the blood in the arteries. Normal Adults BP is 120/80 Systolic Pressure pressure resulting from the contraction of ventricles. Diastolic Pressure pressure when the ventricles are at rest. Pulse Pressure the difference between the systolic and diastolic pressure the series of sounds during BP reading is called Korotkoff sounds. PULSE PRESSURE DIFFERENCE BETWEEN SYSTOLIC AND DIASTOLIC WIDENED PULSE PRESSURE WITH INCREASED ICP BP130/60 NARROWED PULSE PRESSURE HYPOVOLEMIC SHOCK BP 70/60 If the BP cuff is too small for the patient, the BP reading may result to false high measurement; if the cuff is too big for the patient, the BP reading may result to false measurement.

ASEPSIS AND INFECTION CONTROL Six Links in the Chain of infection: (SHARE ME) S-usceptible H-ost A-gent R-eservoir E-ntry M-ode of transmission E-xit

1. Infectious Agent also known as pathogens Types of Infection-producing microorganism Virus HIV, influenza, hepetitis Bacteria- E. Coli, S. Aureus Fungi Candida Albicans Parasites ticks, protozoa, worms 2. Reservoir sources or places for growth of pathogens 3. Portal of Entry and exit provides the way for the pathogen to leave one host and enter another host. 4. Modes of Transmission Direct Transmission person to person Droplet Transmission if the source and host are within 3 feet Vehicle-borne any object or substance that provides a means of transport and introduce pathogen into a host. Vector borne - any animal or insect 5. Susceptible Host a carrier Body Defenses Against Infection:

1. Anatomic and physiologic barriers- such as cilia, tears, acidity of the stomach, saliva, intact skin and mucous membrane. 2. Inflammatory Response 3. Immune Response immunity is the resistance of the body to a specific infection NOSOCOMIAL INFECTION occurs when the client is in the hospital. Handwashing one of the most effective measures for preventing nosocomial infection. Nosocomial infection can be: 1. Exogenous infection acquired from the environment or other people. 2. Endogenous infection acquired by microorganisms that the client himself harbors. 3. Iatrogenic infection receives as the direct result of a treatment or diagnostic procedure. Manifestations of Infection: General (LATENT) Loss of energy, Anoxia, Tachycardia and tachypnea, Enlarged lymph nodes, Nausea and vomiting, Temperature is high. Local (RED Heat) Redness, Edema, Discomfort, Heat Medical Asepsis Terminologies: Clean implies the absence of nearly all microorganism Dirty presence of microorganism Sepsis it is the state of being infected Disinfectant chem. prep. Used to inanimate obj. Bactericidal preparations that destroy bacteria Bacteriostatic- preparations Prevents growth and reproduction of some bacteria. Remember: 1. Hand washing 2. Keep fingernails short 3. Remove all jewelries 4. Wear latex gloves for dirty procedure Surgical Asepsis Sterile Technique practice to keep an object or area free from all microorganism Principles: 1. Sterile objects become unsterile when touched by unsterile objects 2. Sterile items are considered unsterile if it is out of vision or below waist level 3. All objects used in a sterile field must be sterile 4. The edges of the sterile field are considered unsterile 5. Skin is unsterile and cannot be sterilized 6. When sterile objects become unsterile, it does not necessarily change appearance. 7. Alertness, conscientiousness, and honesty are essential in maintaining sterile asepsis

Isolation Precaution Isolation describes measures taken to prevent the spread of microorganism to client, visitors and health care workers Standard Precaution also known as universal precaution. Isolation Practices:

1. Strict Isolation indicated to highly transmissible diseases by direct contact and airborne routes of transmission such as Herpes Zoster, Varicella, Pneumonia. 2. Respiratory Isolation indicated if the mode of transmission is droplet transmission. Examples : measles, mumps, influenza 3. Contact Isolation indicated for infectious diseases or multiple resistant microorganism that are spread by direct or close contact. Example : Herpes Simplex, Scabies, Syphilis 4. Enteric Precaution infectious diseases transmitted through direct or indirect contact with infected feces. Example: diarrhea, typhoid fever 5. Drainage / Secretion Precaution patients with wound drainage or infected wounds. Example: Burns 6. Universal / Blood and body fluids precaution blood borne, body fluids pathogens (blood, semen, vaginal secretion, pleural fld.) Ex: AIDS, Hepa B, STDs 7. Reverse Isolation patient is protected from pathogens and nosocomial infections. Ex: Burns and open wounds, immunocompromised patient MEDICATION ADMINISTRATION Terminologies: Desired Effect therapeutic effect Adverse Effect a harmful reaction; unexpected Toxic Effect plasma concentration of the drug reaches threatening level Side Effect a response that is unrelated to the desired action of the drug; expected Drug dependence the physical or psychological reliance on a chemical agent resulting from addiction. Hypersensitivity abnormal, excessive response Paradoxical reaction - opposite reaction Drug Allergy a hypersensitive response to an allergen which the individual has been exposed and developed antibodies. 1. Route of administration Oral Medication most common method of drug administration and generally the safest route. Onset is slower. Sublingual drugs are placed under the tongue. Buccal drugs are placed in the inner cheek * Rule: Never swallow the drug and do not follow with water might cause aspiration and choking Assess for gag reflex, dysphagia or altered LOC Do not give if the client is on NPO. If the drug has an offensive taste, offer oral hygiene. Eye Medication (optic) Effects: pupil constriction (miotics), pupil dilation(mydriatic) Types: Liquid 2gtts (conjunctival sac) Ointment lower conjunctiva (inner to outer canthus) Note: 1. no to cornea 2. press the nasolacrimal gland 3. dont let the tip of canister touch any part of the eye.

Ear Medication (otic) Position: lateral for 5mins. Age: <3y/o pull the pinna down and back; > 3y/o pull the pinna up and back Solution: side of the ear and warm temp. Press the tragus of the ear 3x for absorption ROUTE : Intradermal Amount : < 1 cc Needle Gauge # 26-27 Angle of Insertion : 5 -15 Sites : Anterior aspect of lower arm Lateral aspect of upper arm Upper aspect of the chest Others Used for mantoux test and allergy test Do not massage the bleb Bevel up No red ink Subcutaneous Sites outer aspect of the upper arm abdomen thigh Amount : > 1 cc Needle Gauge # 25-26 Angle of Insertion : 45 < Used for: Insulin Heparin Do not massage Do not aspirate Intramuscular Amount : 1-3cc Needle Gauge Child: # 24 25 Adult: # 23 - 24 Angle of Insertion: 90 Sites 1. Deltoid- 1 ml, non-irritating drug 2. Vastus Lateralis- Below 7 months of age 3. Ventro Gluteal 7 months and above 4. Dorso-gluteal children 3 yrs and above used for large amounts of drug or highly irritating drug such as Dextran

Z-TRACK METHOD Do not massage the site after injection to prevent tissue irritation. Used to administer IM medication that are highly irritating to subcutaneous and skin tissues Attach a new sterile needle to the syringe after drawing up the medication Retract the skin to the side before piercing the skin with the needle to prevent tracking. Intravenous Medications IV meds enter the clients bloodstream directly by the way of a vein, they are appropriate when a rapid effect is required Medications are administered intravenously by the following methods: 1. Large volume infusion the safest and easiest way to administer IV meds. The drugs are diluted in volumes of 1,000ml or 500 ml of compatible fld. Normal Saline or LR are frequently used. 2. Intermittent IV infusions a method of administering a medication mixed in a small amount of IV solution such as 50 or 100ml. Secondary IV setups are the tandem and piggyback. 3. Volume- control Infusions intermittent meds may also be administered by a volume-control infusion set such as Soluset, Volutrol and Pediatrol. They are small fluid containers (100-150ml) attached below the primary infusion container. Frequently used to infuse solutions into children. 4. IV Push (bolus)- the IV administration of an undiluted drug directly into the systemic circulation. It is used in emergency cases, introduced directly into a vein by venipuncture. 5. Intermittent Infusion Devices- may be affixed to an IV catheter or needle to allow medications to be administered intravenously. Intermittent injection ports have either a resealable latex injection site for needle access.

Type of Fluid Isotonic -SHOCK Hypotonic -Dehydration Hypertonic -Use to treat metabolic acidosis

IV Fluid 0.9% NaCl, Ringers Solution ,Lactated Ringers 5% dextrose in water

0.45 NaCl

10-15% Dextrose in water 3% NaCl Sodium Bicarbonate

FORMULA FOR DOSAGE COMPUTATION ORAL MEDICATIONS: Solids (D/S=Q) Desired dose = quantity of Stock dose drug ORAL/PARENTERAL MEDICATIONS: Liquids (D/S X DILUTION = Q) Desired dose x dilution = quantity of Stock dose drug IV FLUID FLOW RATE: gtts/min = volume in cc x gtt factor no. of hours x 60 min. cc/hr = volume in cc or gtts/min x 4 no. of hours duration in hours = volume in cc cc/hr The following is a method to calculate drops per minute: Volume to be infused (cc/hour) X gtt/ml 60 minutes 10 Rights in giving medications: 1. Right Drug 2. Right Dosage 3. Right Route 4. Right Time 5. Right Patient 6. Right Approach 7. Right Documentation 8. Right Frequency 9. Right Action 1O.Right Preparation PROCEDURES 1. Blood Glucose Screening The glucose value measures the effectiveness of the treatment of the client with diabetes. Capillary blood glucose is monitored by using commercial glucose meter such as Glucometer. Protect test tips from exposure to light. Measurement is done 30 minutes before meal. Normal Blood Glucose is 60-120 mg/dl Signs and Symptoms of Abnormal Blood Glucose Level Hypoglycemia- Bld glucose < 60 mg/dL Shakiness

Hunger Rapid Pulse Irritability Loss of concentration Seizure Hyperglycemia Bld glucose > 120 mg/dL Weakness Polydipsia Dry skin and mouth Nausea and Vomiting Glucosuria Thirst Kussmaul breathing (late) 2. Insertion of NGT NGT is inserted through the nose and into the stomach . Purposes: a. Gavage gastric feeding b. Lavage stomach irrigation c. For decompression d. Medication and supplemental fld. Adm. Principles: Position: High Fowlers Position Length of tube to inserted: (NEX) from the tip of the nose to the earlobe down to the xiphoid process. Remember to stop and remove if the client cannot talk, is coughing, or becomes cyanotic. Fr 12 (36 inches) for adult Enema act by distending the intestine, and sometimes by irritating the intestinal mucosa; increases peristalsis and expulsion of the feces and flatus. Purpose : Bowel training program to establish bowel fxn Eliminate feces and flatus Avoid contamination of the sterile field Treat constipation and impaction Support visualization of intestine Principles: lubricate tube 3 -4 inches Position: left lateral position or sims position Administration: deliver slowly to minimize discomfort Height of container: 12 above the rectum Temperature: not more than 42C Solutions commonly used: 1. Hypertonic solution increased osmotic pressure will draw fluid from the interstitial space into the colon (e.g. Saline) 90-120 ml. Solution. Draws water into the colon

3.

2. Hypotonic solution lower osmotic pressure will cause water to move from the colon to the interstitial space (e.g. Tap water). 500-1,000 ml. Stimulates peristalsis and soften feces * watch out for circulatory overload 3. Isotonic solution - no movement of fluid in or out of the colon. The volume of solution stimulates peristalsis (e.g. Normal saline) Types of Enemas : 1. Cleansing used to cleanse the bowel * instruct the client to hold the fluid for 10 -15 mins. * If client complains of cramping, clamp the tube for 30 secs. 2. Carminative release gas; it distends the rectum and colon and stimulates peristalsis. 60-80 ml. Of fluid is instilled 3. Oil retention given to soften feces and lubricate the rectum and anal canal. . Introduce oil or meds into the rectum and sigmoid colon. The fluid is retained for 1-3 hrs. the force of the solution is controlled by REST Resistance of the rectum Elevation of the solution container Size of the tubing Thickness of the fluid 4. Urinary Catheterization introduction of a catheter into the urethra towards the urinary bladder. Principles : (sterile technique is a must) Size : children- #8 or #10, female adult - #14 or #16, male adult #18 do not allow the catheter bag to lie on the floor. Do not allow the drainage spout to touch the collection receptacle. Client should void within 4 6 hrs after an indwelling catheter is removed Acidify the urine offer food such as cranberries, plums and prunes Increase fluid intake to 3L/day to prevent urinary stasis Types of catheter : a. Indwelling catheter (foley, retention) for long period catheterization, usually with 2 lumens b. Straight Catheter for short-period catheterization, single lumen c. Suprapubic catheter small insertion is made above the pubic area and the tube is directly inserted into the baldder. d. External Urine Drainage Device (condom cath)
MALE Position Length Length to be inserted FEMALE

Supine / flaccid penis at 90 Dorsal Recumbent angle 22 cm catheter 40 cm catheter 2 3 inches 6 9 inches

5. Suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction outlet. Principles : (sterile technique is a must) Suction Catheter size : Adult: #12-#18 Children: #8-#10 Infant: #5-#8. performed to clear the airways irritates mucosa and removes oxygen from the resp. Tract it is normal for suctioning to cause coughing, sneezing and gagging Manifestations of the need for suctioning: 4D a. Dyspnea, pallor and cyanosis b. Drooling; bubbling breath sound c. Decreased oxygen saturation d. Decreased breath sound ROUTE Position ORO PHARYNGEAL Conscious- semifowlers Unconscious side lying 110-150 mmHg NASO PHARYNGEAL Semi fowlers with neck hyperextended TRACHEOSTOMYENDOTRACHEAL Semi fowlers unless contraIndicated

Pressure

Depends upon the age 90 110 mmHg and type of suction apparatus 3 5 inches Water-soluble 5 15 secs. 20 30 secs 2 3 inches Saline solution 5 10 secs. 2 3 minutes

Length of tube to be inserted Lubricant Duration Resting pd bet. suctioning

3 5 inches water 5 15 secs. 20 30 secs

6. Oxygenation Oxygen is a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for all living cells. 3 - 5 mins. absence of oxygen in the brain may cause permanent damage. Therapeutic Nursing Intervention for Oxygenation : a. Facilitate ventilation

position in semi or high fowlers Incentive spirometer provides an incentive to breath deeply. b. Ensure adequate hydration. c. Promote patent airway d. Administer oxygen Oxygen Delivery Devices : a. Cannula tubes with two prongs for insertion into the nostrils. Oxygen flow rate1-6L/min, b. Face Masks the mask covers the clients nose and mouth 1. Simple face mask delivers oxygen concentration 60 90%. Flows- 5-8L/min. 2. partial rebreather delivers oxygen concentration; flows : 6-10 L/min 3. Non-rebreather 95 -100 %, flow 10-15 L/min. 4. Venturi mask - 25-50%, flow 4-10L/min. Preferably used for patient with COPD. Safety Precaution 1. No smoking sign on the door 2. No objects that cause static electricity 3. No volatile subs. near the patient

PHYSICAL ASSESSMENT Methods of Assessment: 1. Inspection is the visual examination, that is assessing by using the sense of sight. 2. Palpation examination of the body using the sense of touch. The pads of the fingers are used 3. Percussion the act of striking a body surface to elicit sounds that can be heard or vibrations that can be felt. flatness produced by very dense tissue such as muscle or bone dullness produced by dense tissue such as liver, heart. Resonance produced by lung filled with air Hyperresonance booming sound that can be heard over an emphysematous lung. Tympany sound produced from an air-filled stomach. 4. Auscultation is the process of listening to sounds produced within the body. Palpation:

percussion

ASSESSMENT

NORMAL FINDINGS Varies from light to deep brown No edema

DEVIATION FROM NORMAL Pallor, cyanosis, jaundice, erythema +1 barely detectable +2 indentation of 2-4mm +3 indentation of 5-7mm +4 indentation >7mm Papule, nodule, vesicle, pustule Excessive moisture (hyperthermia) Excessive dryness (dehydration) Localized hyperthermia (infection) ; generalized hypothermia (shock) Skin stays pinched or tented or moves back slowly Alopecia

1.
b. c.

Skin a. color b. Edema

c. Skin lessions d. moisture

Freckles, some birthmarks Moisture in skin folds Uniform ; within normal

e. Temperature f. Skin turgor 2. HAIR a. Distribution b. Thickness or thinness c. Amount of body hair 3. NAILS a. Curvature and angle b. Nail bed color b. Perform blanche test ASSESSMENT 4. SKULL AND FACE a. Size, shape and symmetry b. Facial features and movement 5. EYES a. Pupil size When pinched skin springs back to previous state Evenly distributed thick variable

Very thin hair (hypothyroidism) Hirsutism in women

Convex; angle of nail plate - 160 Highly vascular and pink Prompt return of pink or usual color (1-2 secs.) NORMAL FINDINGS

180 or greater (clubbing), spoon nail Bluish (cyanosis), pallor (poor arterial circulation) Delayed return of color (circulatory impairment)

DEVIATION FROM NORMAL

Normocephalic and symmetrical Slightly asymmetric facial feature, symmetric facial movement

Lack of symmetry: increased skull size; Longer mandible (may indicate excessive growth hormone) Exophthalmos, myxedema Mydriasis, miosis, anisocoria Absent response Strabismus, nystagmus

3 7mm in dm Illuminated pupils constrict and when looking at near objects

ABDOMEN SUPINE INSPECT,AUSCULTATE,PERCUSS AND PALPATE BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 20 SECOND INTERVALS( 5-25/MIN NORMAL) IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS MORE. SEQUENCE IS CLOCKWISE FROM RLQ HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT TINKLING SOUND BOWEL OBSTRUCTION

RUQ RLQ o o o o o o o LUQ

Liver and Gall Bladder Pylorus Duodenum Head of the Pancreas Right Adrenal Gland Portion of the Right Kidney Hepatic Flexure of Colon Portions of Ascending and Transverse Colon Cecum and Appendix Portion of Ascending Colon Bladder (usually if distended) Lower pole of Right Kidney Right Ovary Right Spermatic Cord Right Ureter Left lobe of Liver Spleen Stomach

LLQ

Body of Pancreas Left Adrenal Gland Portion of the Left Kidney Splenic portion of Colon Portions of transverse and descending colon Lower pole of Left Kidney Sigmoid Colon Portion of Descending Colon Bladder (usually if distended) Left Ovary Uterus (if enlarged) Left Spermatic Cord Left Ureter

9 Regions of the Abdomen Right Hypochondriac R Lumbar Right Iliac Epigastric Umbilical Hypogastric Left Hypochondriac Left Lumbar Left Lumbar

NEUROLOGIC TESTS MENTAL STATUS LANGUAGE-CEREBRAL CORTEX-APHASIA ORIENTATION(TIME,PLACE,PERSON)(CONFUSION) MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY ATTENTION SPAN AND CALCULATION (SERIAL 7S/3S TESTS) CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING MOVEMENTS,GAIT SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSE- ROMBERGS TEST) CRANIAL NERVE FUNCTIONS Cranial Nerves CN I Olfactory sense of smell CN II Optic visual field testing CN III Oculomotor, IV (Trochlear), VI ( Abducens) visual pathways pupil size, papillary reactions, extraocular movements CN V Trigeminal mm of mastication, facial sensation CN VIII Vestibulocochlear/ Auditory nystagmus, hearing capacity CN VII Facial, IX Glossopharyngeal, X Vagus, XII- Hypoglossal - ARTICULATION > TASTE CN VII Ant. 2/3 CN IX Post. 1/3 CN X region of epiglottis

> SWALLOWING CN IX, X, XII > FACIAL EXPRESSION CN VII CN XI - Spinal Accessory SCM and Trapezius mm Glasgow Coma Scale > Eye Opening >Best Motor Response Spontaneous ---- 4 Obeys ------------------ 6 To Speech ----- 3 Localizes ------------- 5 To Pain ----------- 2 Withdraws ------------ 4 Nil ------------------- 1 Abnormal Flexion --- 3 Extensor response ---2 Nil ------------------- 1 >Verbal Response Oriented -------------------------- 5 Coma score: Confused conversation ------- 4 (E + M + V) = 3 to 15 Inappropriate Words ---------- 3 GCS : 13-15 = Normal Incomprehensible sounds --- 2 GCS : 9-12 = Moderately Nil ---------------------------------- 1 depressed GCS : 3-8 = Severely depressed/comatose DEEP TENDON REFLEX 0 - NO REFLEX +1 MINIMAL ACTIVITY(HYPOACTIVE) +2 NORMAL RESPONSE +3 MORE ACTIVE THAN NORMAL +4 MAXIMUM ACTIVITY ( HYPERACTIVE) PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY

LABORATORY AND DIAGNOSTIC EXAMINATIONS 1. URINE A. CLEAN-CATCH, MIDSTREAM URINE SPECIMEN B. 24-HR URINE SPECIMEN C. SECOND-VOIDED URINE SPECIMEN D. CATHETERIZED URINE SPECIMEN 2. STOOL ROUTINE FECALYSIS TO ASSESS GROSS APPEARANCE OF STOOL & PRESENCE OF OVA/PARASITES STOOL CULTURE & SENSITIVITY TEST GUIAIC STOOL EXAM BLEEDING IN THE GIT 3.SPUTUM SPECIMEN GROSS APPEARANCE OF THE SPUTUM SPUTUM CULTURE & SENSITIVITY TEST ACID-FAST BACILLI STAINING 4. SERUM CREATININE (0.5-1.5 mg/100 ml) Most accurate measure of GFR. If GFR fails, the serum creatinine rises; reflects the degree

of renal impairment

KEY INFO ABOUT VITAMIN WATER-SOLUBLE NOT STORED IN THE BODY, NEEDS DAILY SUPPLY IN THE DIET VITAMIN C DEF WILL RESULT IN SCURVY, SKIN SPOTS, BLEEDING, DELAYED WOUND HEALING, IMPAIRED IMMUNE RESPONSE (FOUND IN CITRUS FRUITS, TOMATO, BROCCOLI, POTATOES) VITAMIN B1 (THIAMINE) BERIBERI (NERVE CHANGES, EDEMA, HEART FAILURE, MUSCLE WEAKNESS); FOUND IN PORK, LIVER, PEAS, EGGS, MILK; COMMONLY SEEN IN ALCOHOLICS VIT B2 (RIBOFLAVIN) SKIN LESIONS, CHEILOSIS; FOUND IN MILK AND MILK PRODUCTS, EGGS, CHEESE, ORGAN MEATS VIT B3 (NIACIN) PELLAGRA (DIARRHEA, DERMATITIS, DEMENTIA); FOUND IN BEEF, PORK, FISH, LIVER, WHOLE GRAINS VIT B6 (PYRIDOXINE) NERVOUS AND MUSCULAR PROBLEMS; SEEN IN PATIENTS TAKING INH; FOUND IN MEAT, LIVER, TUNA, POULTRY, NUTS, GREEN BEANS C/I TO PX TAKING L-DOPA VIT B9 (FOLIC ACID) MEGALOBLASTIC ANEMIA; NTDs; FOUND IN GREEN, LEAFY VEG, MEATS, NUTS, COTTAGE CHEESE VIT B12 (COBALAMIN) PERNICIOUS ANEMIA; FOUND IN ANIMAL PRODUCTS FAT-SOLUBLE VITAMINS A (RETINOL) NIGHT BLINDNESS, FOUND IN DEEP ORANGE FRUITS AND VEG D (CHOLECALCIFEROL) RICKETS, OSTEOMALACIA, FOUND IN MILK AND DAIRY PRODUCTS E (TOCOPHEROLS) ANTIOXIDANT; PREVENTS CELL MEMBRANE DAMAGE; FOUND IN VEG OILS K - ESSENTIAL FOR BLOOD CLOTTING; FOUND IN GREEN LEAFY VEG

SPECIAL DIET CLEAR LIQUID PROVIDED FOR CL POST-OP, OR IN THE ACUTE STAGES OF INFX, PARTICULARLY GI (EX. WATER, TEA, COFFEE, CLEAR BROTHS, GINGER ALE, APPLE JUICE) FULL-LIQUID DIET LIQUIDS OR FOODS THAT TURN TO LIQUID AT ROOM TEMP (EX. MILK) SOFT DIET FOR CL WHO HAVE DIFFICULTY CHEWING AND SWALLOWING; LIGHTLY SEASONED, LOW-RESIDUE (LOW-FIBER DIET); EX. SPAG SAUCE, PUDDING, CUSTARD PUREED DIET MODIFICATION OF THE SOFT DIET IN WHICH LIQUID IS ADDED AND BLENDED TO A SEMISOLID CONSISTENCY Normal values: RBC (Erythrocytes) 5,000,000 / mm WBC (Leukocytes) 5,000 10,0000 / mm Platelets 150,000 450,000 mm Hct male: 38-54 vol%, female: 35-45

Hgb 12-17 g/ dl Bld. Prothrombin 10-15 mg/100 ml plasma Bld. Fibrinogen 350 mg/ 100 ml plasma Prothrombin time 11 -16 sec PTT 60 70 secs APTT 30 45 sec Bleeding time 3- 5 mins Clotting time 8 15 mins GFR 125 ml/ min MAP- 80- 120 mmHg ESR male : 15-20 ml/hr, female: 20-30 Differential counts: > Neutrophils: 60 100% > Eosinophils : 0 5 % > Basophils : 0- 3 % > Lymphocytes: 30 40% > Monocytes : 0 -5 % Blood Studies: > BUN : 10 -20 mg/dl > Serum Creatinine: .4 1.2 mg/ dl > Serum uric acid : 2.5 8 mg/dl > Albumin : 3.2 5.5 mg/ dl > Cholesterol : 150 250 mg/dl > Triglycerides 140 200 mg/dl Genito- urinary Color amber/ straw Ph 4.5 8.0 Spe. Gr. 1.010 1.025 Protein Absent RBC 0-5 hpf WBC 0-5 hpf Pus absent Glucose absent Ketones absent Cast 0-4 Serum Electrolytes: Sodium 135- 145 mEq / L Chloride 98- 108 mEq / L Calcium 4.5 5.5 mEq / L Potassium 3.5 5 mEq / L Phosphorus 3.5 5.5 mEq / L

Magnesium 1.5 2.5 Laboratory Test Total Cholesterol: Overnight Fast Result: Optimal: <200mg/dL; High: >239mg/dL LDL/ HDL Fast for 12-14 hrs BUN/ Creatinine Test To determine renal functioning BUN 8-25 mg/dl Values affected by protein intake, tissue breakdown, fluid volume changes High Renal Disease Excessive protein intake/catabolism Low Severe liver damage Creatinine Normal Values: 0.6-1.5 g/day (NPO 8 hrs)

High Hypothyroidism Low Renal disease/ shock Sputum Examinations Sputum Culture and Sensitivity Culture- to determine the type of bacteria Sensitivity- to determine what type of antibiotics will be used Stool Guaiac Test to determine the presence of occult blood and bleeding in the GI tract Ova and parasite tests to determine the presence of parasitic infection of the intestine

BLOOD TRANSFUSIONS PURPOSES: To restore circulating blood volume To stop bleeding due to platelet deficiencies/ defects and coagulation factor deficiencies To increase oxygen carrying capacity of the blood To combat infection due to decreased and defective white cells or antibodies TERMINOLOGIES: ANTIGENS- complex proteins on the red cells surface may stimulate the formation of antibodies if antigen is present in the red cell, the immune system recognizes it as self and not produce antibody

ANTIBODY protein circulating in the plasma produced in response to an antigen that the individual is lacking AGGLUTINATION clumping of blood cells HEMOLYSIS destruction of RBC CROSSMATCHING compatibility testing, accomplished by incubating a sample of the patients plasma with the donor red cell to detect sign of incompatibility. RED BLOOD CELL ( ERYTHROCYTE) the major cellular element of the circulating blood. Its principal function is to transport oxygen. WHITE BLOOD CELL (LEUKOCYTE) its function is to protect the body from invasion of bacteria and other foreign entities. It is divided into 2 general categories, granulocytes (60%) & mononuclear cells (40%). Total leukocyte count is 5,000-10,000 cells/ cubic ml. PLATELETS play an essential role in the control of bleeding. Normal value 150,000-400,000 cubic ml. BLOOD COAGULATION is the process whereby the components of the liquid blood are transformed into a semisolid material TRANSFUSION TECHNIQUE Packed red cells > administer only with 0.9% Na Cl (dextrose hemolyzes RBC and LR causes coagulation) > squeeze bag to mix cells every 20-30 mins. During administration. Adm. 1unit over 1-2 hrs. > If necessary to help cells infuse, add 50-100ml 0.9% NaCl. > If necessary to help cells infuse, add 50-100ml 0.9% NaCl. Platelets > administer as rapidly as tolerated, usually 4 units/hr. to prevent platelets from clumping and sticking to the side of the bag. NURSING INTERVENTION Check and verify doctors order. Inform the client and explain the purpose of the procedure. Check for cross matching and blood typing. To ensure compatibility. obtain and record vital signs as baseline data. Practice strict aseptic technique At least 2 nurses , check the label of the blood, the serial no., blood component, blood type, Rh factor, expiration date, and screening tests ( STDs, Hepatitis B, malaria) Warm blood at room temperature before transfusion to prevent chills. Identify client properly. Use BT set with filter, needle gauge 18 or 19 and NSS as a main line. Start infusion slowly @ 10 gtts/min. Remain at bedside for 15-30 mins. To observe any untoward reaction. Monitor vital signs every 30 mins. Altered VS indicates adverse reaction. Do not mix medications with BT to prevent adverse effects. Blood should be transfused 30 mins. after it is taken from the blood bank. Observe for potential complications or reactions. Notify physician. Documentation. COMPLICATIONS OF BLOOD TRANSFUSION 1. Allergic reaction- sensitive to plasma protein or donor antibody which react with recipients antigen.

(antibody-antigen reaction). Mild- flushing, itching, rashes, urticaria, hives, asthmatic wheezing Severe- laryngeal edema, dyspnea, chest pain, cardiac arrest. Nursing Actions: (1) Stop the infusion, (2) KVO with NSS, (3) give anti-histamine as directed, (4) monitor VS, (5) observe for anaphylaxis or severe reaction. 2. Febrile / Non-hemolytic- hypersensitivity to donor white cells, platelets, or plasma proteins. Signs: (1) sudden chills, (2) headache, (3) flushing, (4) anxiety, (5) muscle pain. Nursing Actions: (1) discontinue transfusion, (2) monitor temp., (3) give antipyretics as ordered . Septic reaction- caused by transfusion of blood contaminated with bacteria. Signs: (1) rapid onset of chills, (2) high fever, (3) vomiting & diarrhea, (4) marked hypotension. Nursing Actions: (1) stop infusion and KVO with NSS, (2) notify the physician & the blood bank, (3) obtain culture of patients blood and return blood bag with administration set for culture, (4) give antibiotics & intravenous fluids. Circulatory Overload- fluid administered at a rate or volume greater than the circulating sys. Can accommodate. Signs: (1) rise in venous pressure, (2) distended neck veins, (3) dyspnea, cough, crackles. Nursing actions: (1) stop infusion & notify the doctor, (2) place the patient in upright with feet in dependent position, (3) administer diuretics and oxygen as prescribed. Hemolytic Reaction- infusion of incompatible blood products. Signs; (1) chills & fever, (2) low back pain, (3) feeling of head fullness, flushing, (4) tachycardia, tachypnea, (5) hypotension, (6) bleeding, acute renal failure, (7) death. Nursing Actions: (1) stop infusion, (2) treat shock if present, (3) maintain BP with IV colloid solution. (3) Give diuretics as prescribed to maintain urine flow, glomerular filtration, renal blood flow, (4) insert indwelling catheter to monitor hourly urine output. Tracheostomy a surgical incision in the trachea just below the larynx. for clients who need long-term airway support. a curved tracheostomy tube is inserted to extend through the stoma into the trachea Outer cannula inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with a tape or ties. Obturator used to insert the outer cannula and then removed. It is kept at the bedside in case the tube becomes dislodged and needs to be reinserted.

Cuffed tracheostomy tubes Surrounded by inflatable cuff that produces an airtight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakage between the tube and trachea. Essential when ventilating a tracheostomy client with a mechanical ventilator. Tracheostomy Care 1. Assist client in semi-fowlers position

2. Pour hydrogen peroxide and normal saline in separate sterile basins 3. Suction the tracheostomy tube 4. Unlock the inner cannula and remove it gently pulling it out toward you. Place the inner cannula in hydrogen peroxide. 5. Remove soiled tracheostomy dressing. Discard the glove and dressing. 6. Clean the inner cannula. Remove from the soaking solution, using a brush or pipe cleaners moistened with sterile normal saline. 7. Rinse the inner cannula thoroughly in the sterile normal saline. 8. After rinsing, gently tap the cannula, using a pipe cleaner folded in half to dry only the inside of the cannula. 9. Suction the outer cannula 10. Insert the inner cannula by grasping the outer flange. Lock the cannula in place. 11. Clean the incision site and tube flange using sterile applications or gauze dressings moistened with NS. 12. Hydrogen peroxide may be used to remove crusty secretion. Thoroughly rinse the cleaned area using gauze moistened with sterile NS. 13. Apply sterile dressing, ensure thatthetracheostomy tube is securely supported. 14. Change the tracheostomy ties. Gastrostomy an opening through the abdominal wall into the stomach. Jejunostomy opens through the abdominal wall into the jejunum. Ileostomy opens into the ileum (small bowel) Colostomy opens into the colon (large bowel) The location of ostomy influences the character and management of the fecal drainage. An ileostomy produces liquid fecal drainage. It contains digestive enzymes, which are damaging to the skin. Odor is minimal because fewer bacteria are present. 2. Transverse colostomy produces a malodorous, mushy drainage because some of the liquid has been reabsorbed. 3. Descending colostomy produces increasingly solid fecal drainage. Stoma an end or terminal colostomy 1. Colostomy First few days: beefy red and swollen Gradually swelling recedes and color is pink or red Notify physician immediately if stoma is dark blue, blackish, or purple- indicates insufficient blood supply BEGINS TO FUNCTION 3-6 DAYS POSTOPERATIVELY Colostomy Care and Irrigation Colostomy is irrigated to empty the feces, gas or mucus, cleanse the lower intestinal tract and establish a regular pattern of evacuation. Suitable time selected: preferably after meal and same time each day Irrigating reservoir: 500-1500 ml of luke warm tapwater, hung 45 to 50 cm (18 to 20 in) Lubricate the catheter/ cone gently insert into the stoma. No more 8 cm or 3 in

Never force the catheter! A slow flow helps to relax the bowel and facilitates passage of the catheter Water should flow in over 5 to 10 minute pd. Allow 10 to 15 mns most of the return and also ambulation stimulates peristalsis and completion of the irrigation. Pouches need to be emptied when they are one-third to one-half full. Empty the contents of the pouch through the bottom opening into a bedpan (prevents spillage of effluent onto the clients skin) Use warm water, mild soap to clean the stoma and skin. In applying appliance, about 0.3 cm (1/8 in) larger than the stoma. (to prevent rubbing, cutting or trauma to the stoma) Use skin barrier to protect skin Cleanse skin gently and pat dry; do not rub The patient can lightly dust nystatin (Mycostatin) powder on the peristomal skin if irritation or yeast growth is present. Patients avoid foods that cause excessive odor and gas such as cabbage family, eggs, fish, beans and high-cellulose products such as peanuts.

Do not lose hope if a door was locked. God holds the key and Hell open it on the right time! If you think YOU CAN DO IT. YOU CAN! Believe in yourself!

GOOD LUCK AND GOD BLESS! Ms. Carmela perez, rn MAN

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