FUNDAMENTALS OF NURSING Man Forms the Nursing foundation of 'ita$ Reparati(e )rocess By Florence Nightingale !

!an is passive in influencing the nurse or the environment Man is a *#o$e+ Man is comp$ete By Virginia %enderson !an has fourteen &'() fundamental needs ,uman Nee%s Needs are physiologic and psychologic Both these needs must be met in order to maintain "ell* being+ -e" Concept: Basic %uman Needs are e,uivalent to C-!!-N NEE.S C#aracteristics of ,uman Nee%s /niversal 0nterrelated -ne need is related to another need !ay be stimulated by internal or e#ternal factors !ay be deferred &but not indefinitely) Mas$o*.s ,ierarc#" of Nee%s &#" %o *e stu%" t#is/ 0n order to prioriti1e nursing actions '+ 2hysiologic needs Food3 maintenance homeostasis 4+ Safety and security 5+ Love and belongingness (+ Self*Esteem of

Four Components or Attributes of Man Capacity to think on an Abstract Level Establish a family Establish a territory Ability to use verbal symbols as language Concept: Animals form a family by instinct Via hormonal scents Nursin Concepts of Man !iops"c#osocia$ Spiritua$ !ein By Sister Calista oy !an interacts "ith the environment Open S"stem By !artha ogers !an interacts "ith the environment E#changes matter "ith energy E#changes energy "ith environment Unifie% &#o$e By !artha ogers !an is composed of certain parts $otal of those parts is more than the sum of all parts $his is because man has attributes

 Feeling good about one6s self $"o factors affecting Self* esteem o 7ourself Sense of ade,uacy Accomplishment o -thers Appreciation ecognition Admiration Belongingness 8+ Self*Actuali1ation Able to fulfill needs and ambitions !a#imi1ing one6s full potential 9+ Aesthetics Beauty T*o A%%itiona$ Nee%s b" Mas$o* Need to kno" Need to understand Ric#ar% -a$is# !an needs stimulation Needs to e#plore o Se# o Activity o Novelty Stimulator .esire to come up "ith something of your o"n C#aracteristics of Se$f0Actua$i1e% )ersons :udges people correctly Superior perception .ecisive o Capable of making decisions Clear notion as to "hat is right and "rong

-pen to ne" ideas o Not adopts ne" ideas o Not one track mind %ighly creative and fle#ible .oes not need fame 2roblem*centered rather than self*centered Concept: Self*Actuali1ation is very difficult to attain 0t is impossible to attain Ne" needs come after getting one need I$$ness %ighly sub;ective feeling of being sick or ill T*o t"pes of I$$ness: Acute I$$ness Sudden in onset &most of the time3 but not al"ays) Less than si# &9) months C#ronic I$$ness <radual in onset &most of the time3 but not al"ays) $ypes of Chronic 0llness o E#acerbation 2eriod characteri1ed by active signs and symptoms of the illness o emission 2eriods "here no signs and symptoms are present Disease -b;ective pathologic process Concepts: 2

 0llness "ithout disease is possible .isease "ithout illness is possible 0llness may or may not be related to a disease -ne can have a disease "ithout necessarily feeling ill De(iance Any behavior that goes against social norms Shortens life span esults to disrupted family and community Concept: .eviant behavior can considered a disease be

&a$ter Cannon Ability to maintain homeostasis A dynamic e,uilibrium A state of balance of the internal environment "hile e#ternal environment is changing F$orence Ni #tin a$e %ealth is using one6s po"er to the fullest Being "ell Can be maintained by manipulating the environment 'ir inia ,en%erson Vie"ed in terms of ability to perform the fourteen &'() fundamental needs or components of nursing care /NA0.E. Mart#a Ro ers 2ositive health symboli1es "ellness %ealth is a value term defined by a certain culture Sister Ca$ista Ro" A state and process of being and becoming an 0N$E< A$E. 2E S-N Dorot#ea Orem Characteri1ed by soundness and "holeness of .EVEL-2E. %/!AN S$ /C$/ ES and F/NC$0-NS Imo ene -in A dynamic state in the life cycle &contrasted "ith illness)

Rationa$e: Because it also shortens the life span like a disease E2amp$e: Alcoholism o A disease rather than a social problem &e$$ness Feeling of being "ell Definitions of ,ea$t# &or$% ,ea$t# Or ani1ation %ealth is the complete physical3 mental3 social &totality) "ell*being and not merely the absence of disease or infirmity A high*level "ellness= C$au%e !arnar% Ability to maintain internal milieu

 0llness is interference in the life cycle !ett" Neuman >ellness is that all parts and subparts are in harmony "ith each other and the "hole system Dorot#" 3o#nson Elusive dynamic state influenced by biologic3 psychologic and social factors Mo%e$s of ,ea$t# an% I$$ness ,ea$t#0I$$ness Continuum Dunn.s ,i # Le(e$ &e$$ness an% Gri% Mo%e$ ?*a#is is %EAL$% 7*a#is is environment 4ua%rant 5 %igh*level "ellness in favorable environment 4ua%rant 6 2rotected poor health in favorable environment 4ua%rant 7 2oor health in unfavorable environment 4ua%rant 8 Emergent high*level "ellness in unfavorable environment ,ea$t# !e$ief Mo%e$ By osentock Based on a motivational theory 0t assumed that good health is an ob;ective common to all people Consider perceptions &influences individuals motivation to"ard results) o 2erceived susceptibility

o 2erceived seriousness o 2erceived threat Likelihood of Action influenced by@ o 2erceived benefit out of the action o 2erceived barriers

Smit#.s Four Le(e$s of ,ea$t# 5+ C$inica$ Mo%e$ !an is vie"ed as a 2hysiologic Being 0f there are no signs and symptoms of a disease3 then you are healthy Against >%- definition of health $his is the NA ->ES$ concept of health 6+ Ro$e )erformance Mo%e$ As long as you are able to perform S-C0E$AL functions and -LES you are healthy 7+ A%apti(e Mo%e$ %ealth is vie"ed in terms of capacity to A.A2$+ $herefore3 goal of treatment is to restore capacity to adapt+ Failure to adapt is disease 8+ Eu%aemonistic Mo%e$ $his is the B -A.ES$ concept of health Because health is vie"ed in terms of Actuali1ation Lea(e$$ an% C$ar9.s A ent: ,ost: En(ironment Mo%e$ Also kno"n as the Ecologic !odel E#pands to the !/L$0* CA/SA$0-N of a .0SEASE .efinitions of a disease as to its cause is e#panded to a

multi*causation of a disease &i+e+ cancer is a multi*factorial disease) $riad is composed of the agent3 host and susceptible host Based on the interplay of three components of the model Concept of ,ea$t# an% I$$ness Stress By %ans Selye 0s a non*specific response of the body to any demand placed upon it+ <eneral Adaptation Syndrome &<AS) Local Adaptation Syndrome &LAS) Genera$ A%aptation S"n%rome 0nvolves t"o &4) body systems@ Nervous System Endocrine System Ner(ous S"stem in(o$(es: Sympathetic Nervous System 2arasympathetic Nervous system En%ocrine S"stem in(o$(es: Adrenal <lands T#e A%rena$ G$an% is compose% of: Adrenal !edulla Adrenal Corte# A%rena$ Me%u$$a A%rena$ins or Fi #t ,ormones: Epinephrine Norepinephrine re$eases or F$i #t

Effects of A%rena$ins 0ncreases Cardiac ate esponse to increased metabolic rate and o#ygen demand 0ncreases espiratory ate esponse to increased metabolic rate and o#ygen demand Bronchodilation Vasoconstriction 0ncreased 2eripheral esistance 0ncreased Cardiac >orkload 0ncreased Blood 2ressure .ecreased enal 2erfusion .ecreased enal -utput 2ale3 Cool3 Clammy Skin A%rena$ G$an% is compose% of: '+ Adrenal !edulla eleases adrenalins 4+ Adrenal Corte# eleases the follo"ing@ !ineralocorticoids o Aldosterone <lucocorticoids Cortisol o A potent vasoconstrictor Minera$ocorticoi%s 0ncreased Aldosterone levels 0ncreases sodium retention and "ater retention 0ncreases circulating blood volume 0ncreases cardiac "orkload &due to vasoconstriction) G$ucocorticoi%s 0ncreased &transient) hyperglycemia

0ncreased glycogenolysis 0ncreased neogenesis 0ncreases blood sugar 0ncreases osmotic pressure 0ncreases fluid retention &glucose is a colloid "hich attracts "ater and adheres to it) 0ncreases cardiac "orkload Concept: Comp$ications of Stress: Cerebrovascular Attack 0ncreased .iabetic Aetoacidosis &if patient is diabetic) %ypertension leading to cardiac arrest Loca$ A%aptation S"n%rome Also kno"n as non*specific inflammatory response Bradykinin o Activates inflammatory response o Activates histamine %istamine o Activates the follo"ing@ 2rostaglandin Serotonin Concept: Bradykinin3 %istamine3 2rostaglandin3 and Serotonin all increase s"elling -e" Concept; %ans Selye o Author of 2hysiologic esponse to Stress La1arus Stress is a transaction

Stress resulted from interaction of man "ith his environment and fello"man $herefore3 La1arus describes the S-C0AL AS2EC$ -F S$ ESS Also an adopted 2%7S0-L-<0C ES2-NSE -e" Concept; $he most comprehensive concept of stress is the stress concept of LABA /S as it combines 2hysiologic and Social aspects of stress+ Statements about Stress Stress is N-$ a nervous energy !an3 "henever he encounters stress3 tends to adopt Are you going around all stressC ANS>E 0S N-=== because stress is not al"ays to be avoided and stress is not al"ays undesirable Stress may lead to another stress A single stress does not lead to a disease Concepts: Adaptation to stress comprises of ad;ustments made in order to cope "ith a stressor !an is holistic in his adaptation to stress 0t involves the totality of man@ o 2hysiologic o 2sychologic o Social

I$$ness !e#a(ior an% Sta es of I$$ness I$$ness !e#a(ior 2ertains to any activity undertaken by a person "ho feels ill in order to .efine his state of health .iscover a suitable remedy IGUN < E$e(en sta es of I$$ness an% ,ea$t#0see9in !e#a(iors '+ Symptom E#perience Client reali1es there is a problem Client responds emotionally 4+ Self*medication D Self*treatment &if not effective) 5+ Communication to others (+ Assessment of symptoms 2urpose is to verify the veracity of the complaint 8+ Sick* ole Assumption 9+ Concern Stage E+ Efficacy of treatment Assess sources of treatment Assess potential effectiveness of treatment F+ Selection of $reatment Stage Availability Cost of $reatment G+ $reatment 2roper 'H+ Assessment of Effectiveness of $reatment !ay go back to stage E &Efficacy of $reatment) if treatment is not effective !ay go to ne#t stage if treatment is effective ''+ ecovery and ehabilitation Comp$iance Adherence to professional6s advice

Factors Affectin Comp$iance Client motivation .egree of re,uired change in lifestyle 2erceived severity of health problem .ifficulty of understanding instructions Belief about the effectiveness of the therapy Nature of the therapy itself o Adverse effects o Cost Cultural influences .egree of satisfaction "ith the relationship "ith health care providers Su este% Nursin Actions in case of Non0comp$iance Assess the reasons Correct the misconception .emonstrate a caring attitude Encourage and provide positive reinforcement o Focusing on the positive rather than on the negative o Focus on things patient can still do and not on "hat the patient can no longer do Establish a therapeutic relationship of freedom and mutual responsibility o !ake patient reali1e he is also responsible for his recovery o %e is a partner "ith the health care team o %e is an active participant Gui%e$ines Comp$iance 7 to En#ance

 Be sure patient understand procedure by giving information !ake sure patient is capable of performing activity o Set realistic goals Ensure that he is a >0LL0N< participant o Look for buying signals Looking at "ound Looking at materials needed Definitions of Nursin : American Nurses Association Nursing is the diagnosis and treatment of human responses to illness &to actual and potential health problems) Cana%ian Nurses Association $he same definition plusI I includes the supervision of functions and services in collaboration "ith others to promote health F$orence Ni #tin a$e Nursing is the act of utili1ing the ENV0 -N!EN$ for the follo"ing purposes@ o ecovery o eparative process 'ir inia ,en%erson $he uni,ue function of the nurse is to assist individuals3 sick or "ell3 "ith the activities to"ards health that he "ould do unaided3 if "ith strength and kno"ledge+ 0f that is not possible3 to"ards a 2EACEF/L .EA$%

Mart#a Ro ers Nursing is a %/!AN0S$0C SC0ENCE dedicated to compassionate concern for the promotion of health3 prevention of illness and rehabilitation of the sick Sister Ca$ista Ro" Nursing is a $%E- E$0CAL S7S$E! -F AN->LE.<E that prescribes analysis and action related to the care of the sick or ill 0t is a set of kno"ledge Dorot#ea Orem Nursing is a helping service to any individual "ho is sick 0t comprises of "holly dependent or partly dependent care "hen the person is unable to do so+ .efines nursing in terms of a NEE.= Imo ene -in Nursing is a helping profession that assists a person &same "ith %enderson) to"ards a .0<N0F0E. .EA$% !ett" Neuman Nursing is a profession that is concerned "ith 0N$ A2E S-NAL3 0N$E 2E S-NAL3 and E?$ A2E S-NAL VA 0ABLES affecting a person6s response to stressors

Dorot#" 3o#nson Nursing is an E?$E NAL E</LA$- 7 F- CE that regulates the AC$0-N or BE%AV0- of a person "hen such behavior constitutes a threat3 in order to preserve his organi1ation E#ample@ o 0n a C-2. patient "ho remains a smoker3 the nurse "ho encourages the patient not to smoke3 serves as an e#ternal regulatory force Fa"e Ab%e$$a Nursing is a service to individuals3 familiesI and therefore3 to society Conceptuali1ed nursing as an A $ and SC0ENCE of !-L.0N< $%E 0N$ELLEC$3 A$$0$/.E and SA0LLS of the nurse Nursing in terms of providing education ,i$%e ar% )ep$au Nursing is the 0N$E 2E S-NAL process of $%E A2E/$0C 0N$E AC$0-N bet"een the nurse and the patient+ NURSING T,EORIES Concept: First Nursing School Florence Nightingale J

6+ Dorot#" 3o#nson Behavioral Systems !odel Seven Subsystems o Attachment and Affiliative o .ependency o 0ngestive o Eliminative o Se#ual Achievement o Aggressive 7+ 'ir inia ,en%erson Fourteen &'() Fundamental Needs focusing on 2%7S0-L-<0C S-C0AL EC EA$0-N 8+ Fa"e Ab%e$$a 2roblem Solving Approach to $"enty*-ne &4') Nursing 2roblems Focus is on 2 -2E 0.EN$0F0CA$0-N of the problem 2articularly about the proper nursing diagnosis =+ Mar>orie Gor%on 2roposed the %uman Functional %ealth 2atterns used as a systematic frame"ork for data collection Focus is on Eleven &'') %ealth 2atterns Advantage to the nurse@ o 0t enables the nurse to determine the client6s response as functional or dysfunctional Eleven Functional %ealth 2atterns o %ealth perception o Nutritional D !etabolic o Elimination

5+ F$orence Ni #tin a$e Environmental Nursing $heory

o Activity and E#ercise 2attern o Cognitive 2erceptual 2attern o ole elationship 2attern o Se#uality D eproductive o Coping*Stress* $olerance o Value Belief 2atterns ?+ Imo ene -in <oal Attainment $heory 2atient has three &5) interacting systems@ o 0ndividuals D 2ersonal systems o <roup systems D 0nterpersonal systems fraternity o Social systems @+ Ma%e$eine Le#nin er $ranscultural Nursing $heory D !odel Nursing is a %/!AN0S$0C and SC0EN$0F0C mode of helping through C/L$/ E* S2EC0F0C 2 -CESS A+ M"ra Le(ine Four &() Conservation 2rinciples of Nursing '+ Conservation of Energy o E#ample@ complete bed rest "ithout bathroom privileges 4+ Conservation of Structural 0ntegrity o E#ample@ turn patient from side to side every t"o hours to avoid bed sores

5+ Conservation of 2ersonal 0ntegrity o E#ample@ maintain patient6s privacy (+ Conservation of Social 0ntegrity o E#ample@ maintenance of patient6s relationships B+ !ett" Neuman %ealth Care Systems !odel $he concern of nursing is to 2 EVEN$ S$ ESS 0NVAS0-N 5C+ Dorot#ea Orem Self*care and Self*care .eficit $heory $hree &5) Nursing Systems based on Art of Care of 2atient Needs '+ 2artial Compensatory o 2atient performs some of nursing care needs 4+ >holly Compensatory or $otal Compensatory o For paraly1ed patients3 for 0C/ patients 5+ Supportive*Educative o For up and about patient 55+ ,i$%e ar% )ep$au 0nterpersonal !odel Four &() 2hases of Nurse* 2atient 0nteraction '+ -rientation o Nurse and patient test the role each one assumes o 2repares patient for termination o 2atient identifies areas of difficulty 10

 4+ 0dentification 2hase o 2atient identifies "ith the personnel "ho can satisfy his needs 5+ E#ploitation 2hase o Nurse ma#imi1es all the resources to benefit the patient (+ esolution 2hase or $ermination 2hase o -ccurs "hen patient6s needs have been met Concepts: Various settings for application of@ o 2re*0nteraction 2hase 0n psychiatric setting3 this consists of gathering data o 2re*Entry 2hase 0n community health nursing3 this consists of a courtesy call 56+ Mart#a Ro ers Science of /nitary %uman Beings !an is composed of energy fields3 "hich are in constant interaction "ith the environment Concept: $he most reliable method of identification is the Energy Field+ $his is better than the fingerprints as a person6s energy field is absolutely uni,ue= 57+ Sister Ca$ista Ro" Adaptation !odel

!an is a B0-2S7C%-S-C0AL BE0N< Four &() modes of Adaptation o 2hysiologic !ode Compatible "ith %ans Selye o Self Consent o ole Function o 0nterdependence 58+ L"%ia ,a$$ CA E3 C- E3 C/ E Care o Comfort measures given by the nurse to a patient o Nurturance aspect of Nursing Core o $herapeutic use of self Cure o Activities in relation to doctors6 orders o .ependent orders 5=+ 3ean &atson %uman Caring !odel Nursing involves the application of A $ and %/!AN SC0ENCE through $ ANS2E S-NAL $ ANSAC$0-NS in order to help the person achieve mind3 body and soul harmony 5?+ Rosemarie Ri11o )arse $heory of %uman Becoming Emphasis is a F EE C%-0CE &"ith personal meaning) Actions of patients may either be@ o evealing or concealing o Enabling or limiting

11

 $herefore3 there is a conse,uence o $his pertains to behavior and action 5@+ 3osep#ine )atterson an% Loretta D%era% %umanistic Nursing 2ractice $heory Nursing is an E?0S$EN$0AL E?2E 0ENCE bet"een the nurse and the patient &nagkataon*nagkatagpo=) Nursing is a L0VE .0AL-</E bet"een the patient "ho "ants to be nursed and the nurse "ho has the skill to nurse 5A+ ,e$en Tom$in: E(e$"n Tom$"n an% Mar" Ann S*ain !odeling and emodeling $heory Focus is on the 2E S-N Emphasis is on the /NC-N.0$0-NAL ACCE2$ANCE of the 2A$0EN$ 5B+ Ann !o"9in an% Sa(ina Sc#oen#ofer <rand $heory of Nursing as Caring $heory Nursing is N-$ BASE. on a .EF0C0$ but rather it is an E<AL0$A 0AN !-.E of helping $his theory is against the theory of - E! Nursing is an obligation to"ards humanity3 "hether there is a need or N-$=

6C+ Mar aret Ne*man %ealth as E#panding Consciousness %umans are /nitary %uman Beings $he nurse is a N-$ A <-AL* SE$$E or an -/$C-!E 2 E.0C$- 3 rather is a 2A $NE -F $%E 2A$0EN$ 65+ 3o"ce Tra(e$bee 0nterpersonal 2rocess $heory Nurse needs to go beyond nursing roles to establish therapeutic relationship $ ANS2E S-NAL C-!!/N0CA$0-N as the means to establish therapeutic relationship $his implies that the nurse should not be rigid in the nursing role 66+ I%a 3ean Or$an%o .ynamic Nurse*2atient elationship !odel $here is movement3 the relationship is not static 0f the patient6s condition improved3 then the intervention is effective and the patient moves on to ne" problems 67+ No$a )en%er %ealth 2romotion !odel !otivation to participate in health care activities is influenced by C-<N0$0VE and 2E CE2$/AL FAC$- S3 "hich are@ o 0mportance of health to the person o 2erceived control of health

12

o o o o

Self*efficiency 2erceived health status .efinition of health 2erceived barriers to action

68+ )opp" !uc#anan: !ar9er an% )#i$ !ar9er $idal !odel &2sychiatric Nursing) %elping patients recall their o"n personal stories of .0S$ ESS is the F0 S$ S$E2 in helping them regain control of their lives again= 6=+ Corbin an% Strauss $ra;ectory !odel $he patient moves in a $ A:EC$0-N of Eight &F) 2hases Nurse needs to follo" the patient along the eight phases of tra;ection@ '+ 2re*$ra;ectory 2hase o 2atient sho"s no signs and symptoms of illness o No sickness

o 2atient6s illness is controlled o 2atient may still be in the hospital 9+ /nstable 2hase o 2atient is on a critical period o Signs and symptoms are present o 2atient is N-$ in the hospital o 2atient is N-$ under control o 2atient is -/$ of the hospital E+ .o"n"ard 2hase o 2atient is in a deteriorating phase F+ .eath 6?+ !onnie &ea(er an% Du$%t !atte" %umanistic Nursing Communication $heory Emphasis is on the interpersonal relationship bet"een the nurse3 the patient3 the peers and colleagues 6@+ McGi$$ Mo%e$ of Nursin Emphasis is to encourage and engage the patient and the family to actively participate in learning about health 6A+ -at#r"n !arnar% 2arent*Child 0nteraction !odel &2ediatric Nursing) 0n order to produce a healthy person3 the baby6s need should be A.. ESSE. A$ -NCE= Application@ Bonding

4+ $ra;ectory -nset 2hase o 2atient no" has signs and symptoms of illness 5+ Crisis 2hase o 2atient is unstable o 2atient is in a life* threatening situation o 2atient is critical (+ Acute 2hase o 2atient is in a state of active illness 8+ Stable 2hase 13

6B+ A$fre% A%$er $he personality of an individual is affected by the B0 $% - .E 7C+ G$a%"s ,uste% an% 3ames ,uste% Symphonological Bioethical $heory Symphono* means harmony and agreement <overned by ethical standards3 "hich influence nursing actions+ LE'ELS OF )RE'ENTION: 5+ )rimar" )re(ention Emphasis on@ o <enerali1ed health promotion and specific protection o ecipients are <ENE ALL7 %EAL$%7 2E-2LE >hen given@ o Before onset of illness or before onset of disease E#amples@ o <enerali1ed health education 2revention of accidents Standards of nutrition o 0mmuni1ations Specific preventions o isk Assessment for specific disease o Family 2lanning Services and !arriage Counseling

o Environmental Sanitation o ecreation %ousing

and

6+ Secon%ar" )re(ention Emphasis placed on@ o Early detection D diagnosis o 2rompt treatment o %ealth maintenance of persons already having health problems o 2revention of complications >hen given@ o .uring illness E#amples@ o Screening survey o Encouraging regular check*ups o Complying "ith regular check*ups o $eaching Breast*self* e#amination o $eaching $esticular* self*e#amination Concept: o !ost effective method of teaching is .E!-NS$ A$0-N Additional E#amples of Secondary 2revention o Assessment of gro"th and development o <eneral nursing assessment and care at the hospital3 community and the home 7+ Tertiar" )re(ention Emphasis placed on@ 14

o Support of the client to achieve the follo"ing@ Successful re* adaptation -ptimal reconstitution egain high* level "ellness $herefore3 the purpose is more of E%AB0L0$A$0-N >hen given@ o Begins after the illness or "hen a defect or disability is fi#ed or irreversible E#amples@ o eferring a client to support groups o $eaching a diabetic client ho" to in;ect insulin ROLES OF A NURSE 5+ Care i(er E Care )ro(i%er $o convey understanding and support Activities@ o Support and comfort measures &mothering aspect of nursing D nurturance aspect of nursing)

o %elping develop skills

the ne"

patient coping

Concept: .o not give advice= o $his is meant to facilitate decision* making on the part of the client o $his is observed so that the client "ould not develop .E2EN.ENC7 7+ C$ient A%(ocate 2rotects rights of patients Activity@ o Speaking on behalf of the patient 8+ C#an e A ent Brings change or ad;ustments Nurse only influences a patient Nurse does not change the patient =+ Teac#er $eaching 0mparting of kno"ledge ?+ Lea%er Application of interpersonal influence to bring out desired behavior &leadership) @+ Mana er .ecision*making 2lanning <iving directions !onitoring operations Facilitating staff development

6+ Counse$or 0nvolves helping patient identify and avoid stressful and psychological problems Focuses on@ o %elping client establish capacity for successful interpersonal relations

15

 $herefore3 this is done on the supervisory level of organi1ation A+ Researc#er After graduation3 nurse cannot yet be a researcher %e can only be a researcher after he receives his !aster of Arts in Nursing &!+A+N) degree TEAC,ING AND STRATEGIES LEARNING

Addresses affective cognitive learning 7+ Ans*erin 4uestions Cognitive 8+ Demonstration !otor =+ Disco(er" Cognitive and Affective

and

!asic Gui%e$ines .evelop a "ell*defined ob;ective Assess client6s readiness to learn Start "ith "hat the client is concerned about Assess and start "ith "hat the client already kno"sK proceed from the kno"n to the unkno"n Start "ith the simple proceeding to the comple# Schedule a revie" of the content Concept: Areas of Learning .omain o Ano"ledge J cognitive o Skills J motor o Attitude J emotional TEAC,ING STRATEGIES 5+ E2p$anation an% Description Address cognitive aspect of learning 6+ One0to0one Discussion

Concept: Learning is more effective if the learner discovers the content for himself+ &$hat is3 through e#perience=) ?+ Group Discussion Affective and Cognitive Sharing feelings during group dynamics @+ )ractice !otor A+)rinte% an% Au%io(isua$ Materia$ B+ Ro$e0p$a"in For pediatric and psychiatric nursing settings 5C+ Mo%e$in >hat you say is "hat you do 55+ Computer Assiste% Learnin )ro rams -nline revie" T,E NURSING )ROCESS Concept: $he Nursing 2rocess "as introduced by LFDIA ,ALL= Definition: 16

 $he Nursing 2rocess is a systematic3 organi1ed3 rational method of planning and providing individuali1ed3 humanistic nursing care )urposes of t#e Nursin )rocess: $o identify health status o Actual health problems o 2otential health problems $o establish plans $o deliver specific nursing care C#aracteristics of Nursin )rocess GMEMORIDE T,IS;;;H '+ <oal*oriented and client* centered 4+ Cyclical &no absolute beginning and end)3 dynamic &moving) rather than static 5+ 2lan of care organi1ed according to client problems rather than nursing goals (+ Basis of prioriti1ing nursing activities "ould be the problems and not the goals 8+ Follo"s a logical se,uence 9+ /niversally applicable &to any type of patient) E+ 0nterpersonal and collaborative >ork "ith patients and relatives >ork "ith colleagues and other members of the health team F+ Adaptation of problem*solving techni,ues and principles G+ 2roblem*oriented3 fle#ible3 open to ne" information 'H+ Allo"s creativity of nurse and patient

!ENEFITS DERI'ED FROM T,E NURSING )ROCESS Concepts: Both the nurse and the patient benefit from the nursing process 2atient obtains greater benefit emember@ Nursing process is CL0EN$* CEN$E E. or 2A$0EN$* CEN$E E. and N-$ N/ SE*CEN$E E. !enefits from Nursin )rocess: 0mproves ,uality of care Ensures continuity and appropriate level of care Facilitates client participation through planning "ith patient Enables nurse to ma#imi1e resources Feedback allo"s nurse to evaluate care Serves as a frame"ork for accountability through documentation 2romotes a positive "orking atmosphere through collaboration %elps the nurse define roles to those outside the profession For ;ob satisfaction Facilitates professional gro"th Avoidance of legal action !eeting standards of accredited hospitals

)ARTS OR COM)ONENTS T,E NURSING )ROCESS

OF

17

ASSESSMENT ),ASE OF T,E NURSING )ROCESS Nursin Acti(ities Assessment )#ase .ata collection .ata -rgani1ation .ata Validation .ata ecording in t#e

IM)ORTANT CONCE)T; No conclusion is developed in the assessment phase )urposes of t#e Assessment )#ase $o create a data base of the client6s response to health and illness $o determine the nursing care needs of the patient Four G8H t"pes of Assessment: 5+ Initia$ Assessment >hen performed@ o At specified time after admission >here done@ o .one at the "ard >here Admitted@ o At the "ard 2urpose of 0nitial Assessment@ o $o create a data base for problem identification o For reference and future comparison

>hen performed@ o 0ntegrated throughout the nursing process 2urpose of -n*going Assessment@ o $o identify problems overlooked earlier o $o determine the status of a health problem &i+e+ hydration status every fifteen minutes) 7+ Emer enc" Assessment >hen done@ o .uring acute physiologic and psychologic crisis >here done@ o Emergency oom o Comfort oom o Any"here=== o -n site=== 2urpose of Emergency Assessment o $o identify life* threatening condition Frame"ork or 2rinciple in Emergency Assessment o A J Air"ay o B J Breathing o C J Circulation o /tili1e either !aslo"6s %ierarchy of Needs or ABC principle 8+ Time0Lapse% Assessment >hen done@ o Several months after initial assessment 2urpose of $ime*Lapsed Assessment o $o compare current status of patient "ith base line data &initial assessment) 18

6+ Focus Assessment or On0 oin Assessment

ASSESSMENT )ROCESS Concepts: .ata is information e,uivalent to

$he person "ho brought the patient to the hospital 7+ En(ironment of t#e )atient E#ample@ o 2atient "ith diabetes mellitus e#hibits acetone breath Assess for diabetic ketoacidosis Met#o%s of Data Co$$ection -bserving 0ntervie"ing E#amining 5+ Obser(in 0t should be deliberate E#ert effort T*o G6H aspects of obser(ation process: Noticing the stimuli .o an interpretation of the stimuli 6+ Inter(ie*in T*o G6H t"pes of Inter(ie*: Directi(e T"pe of Inter(ie* Structured /ses closed*ended ,uestions calling for specific data >hen used@ o >hen you need to elicit specific data o >hen there is little time available Concept: Characteristics of Closed*ended ,uestions@ 7es or No ,uestions

&#at is t#e initia$ output of t#e Assessment )#ase/ .ata or ecorded .ata Never validated data=== T"pes of Data: 5+ Sub>ecti(e or Co(ert Data Felt by the patient .uring the recording of data3 this should be stated using the patient6s o"n "ords $hese are the symptoms felt by the patient 6+ Ob>ecti(e or O(ert Data Capable of being observed by use of senses J sight3 touch3 smell3 taste3 hearing $hese are the signs "hich are observable Sources of Data: 5+ )rimar" Source 2atient himself e#cept "hen@ o %e is unconscious o 2atient is a baby o 2atient is insane 6+ Secon%ar" Source 2atient6s record %ealth care members elated literature or ;ournals Significant others &they become primary source "hen patient is unconscious Family or relatives

19

 Asks "hen or asks for the time "hen event happened Asks ho" many 2oint "ith finger "hen asking to provide clarity $herefore3 they call for highly specific ans"ers Non0Directi(e T"pe or Rapport0 !ui$%in Inter(ie* /ses more open*ended ,uestions Advantage is that it allo"s the patient to volunteer information T"pes of Inter(ie* 4uestions: 5+ Open0En%e% 4uestions Luestions not ans"erable by MyesN or MnoN Luestions that elicit information or e#planation 6+ C$ose%0En%e% 4uestions Luestions ans"erable by MyesN or MnoN Leading Luestions 2hrasing of ,uestion suggests "hat ans"er the intervie"er is e#pecting 7+ Neutra$ 4uestions 2hrasing allo"s patient to ans"er "ith least pressure /sually N-$ addressed to patient personally &i+e+ "hat is your opinion aboutI) aised as a general topic )$annin t#e Inter(ie* Settin Concepts: Before the determine "hat intervie"3 information

you already kno" or "hat information is available An intervie" is a planned conversation "ith a purpose An intervie" is a t"o*"ay process >hen is it doneC o >hen patient available o >hen patient comfortable is is

ecommended distance from the patient is three &5) to four &() feet+

Sta es of t#e Inter(ie* 5+ Openin Sta e -e" Concept;;; $his is the most important part of the intervie" Rationa$e >hat "as said and done during the opening stage sets the tone all throughout the intervie" 6+ !o%" of t#e Inter(ie* -ccurs "hen patient responds to ,uestioning 7+ C$osin Sta e %o" to close the intervie"@ o Summari1ing $echni,ue 'a$i%ation of Data Act of double*checking the data 2urposes of .ata Validation o $o ensure the@ Correctness Completeness

20

Accuracy of the data

2roblem present at the time the statement "as made 6+ ,i #0Ris9 Nursin Dia nosis A diagnosis that a patient is more vulnerable or susceptible compared "ith others in the same situation 7+ )ossib$e Nursin Dia nosis $here is an evidence of a health problem but the causes are N-$ fully understood 8+ &e$$ness Nursin Dia nosis A positive statement 0ndicates a healthy response E#amples@ o 2otential for increased compliance related to increased level of kno"ledge o 2otential for enhanced body image related to regular e#ercise o 2otential for effective coping related to ade,uate support systems Domains of Nursin Dia nosis -e" Concept; 0t only includes health problems that a nurse is capable and licensed to treat )arts of a Nursin Dia nosis 5+ )rob$em Statement E#ample@ o Fluid Volume .eficit 6+ )resume% Etio$o " E#ample@ o Irelated to fre,uent loss of bo"el movement

Gui%e$ines in 'a$i%atin Data Compare sub;ective and ob;ective data Be familiar "ith "ord usage &particularly if the patient is a child) eassess D double*check data "hich are e#tremely abnormal Be sure that your data contains C/ES and not 0NFE ENCES Be sure that your data is F EE -F B0ASES Avoid ;umping to conclusions Data Recor%in Concepts: .ata ecording C-!2LE$ES the Assessment 2hase 0nitial -utput of the Assessment 2hase is .A$A Final -utput of the Assessment 2hase is EC- .E. .A$A DIAGNOSING ),ASE NURSING )ROCESS OF T,E

Acti(ities %urin t#e Dia nosin )#ase: $his involves sorting3 clustering3 analy1ing and interpreting data Concept: $he final output in the .iagnosing 2hase is a N/ S0N< .0A<N-S0S=== Different T"pes of Nursin Dia noses: 5+ Actua$ Nursin Dia nosis

21

7+ Definin C#aracteristics E#ample@ o Ias manifested by decreased skin turgor A%(anta es of Usin Stan%ar%i1e% Dia nostic Termino$o " 2rovides professional accountability and autonomy by defining and describing the independent areas of practice 2rovides effective vehicle of communication 2rovides an organi1ing principle for meaningful research Facilitates continuity and individuali1ed care )LANNING ),ASE NURSING )ROCESS OF T,E

o At specified time upon or after admission of the patient 6+ On0 oin )$annin >ho are involved@ o .one by all nurses "ho "orked "ith the patient o $he patient himself o $he family o But primarily3 the N/ SE 2urposes of -n*going 2lanning o $o determine if the client6s health status has changed o $o decide "hich problems to focus on during the shift o $o set priorities for client care during the shift o $o coordinate the patient care and activities so that more than one problem can be addressed at the same time 7+ Disc#ar e )$annin 2urpose of .ischarge 2lanning o $o ensure continuity of care C#aracteristics or t#e )$annin )rocess S J Specific ! J !easurable A J Attainable J ealistic $ J $ime bound Acti(ities %urin )$annin )rocess

Concept: 2lanning means@ .etermining ahead of time Forecasting a course of action -e" Concept;;; For your plans to be effective3 involve the patient and the family IM)ORTANT CONCE)T;;; Final output of the 2lanning 2hase is a N/ S0N< CA E 2LAN or a > 0$$EN CA E 2LAN T"pes of )$annin 5+ Initia$ )$annin .one by the nurse >hen done@

22

 Set priorities Set goals 0dentify alternatives of nursing care Select nursing measures >rite nursing orders &supervisors do this) >rite the nursing care plan )urposes of Goa$0settin $o set direction $o provide a time span $o have a criteria for evaluation $o enable the nurse and the patient to determine "hether the problem has been resolved or not $o help motivate the client and the patient by providing a sense of accomplishment -e" Concept;;; For your goal to be useful during evaluation3 it should be stated in BE%AV0- AL $E !S IM)LEMENTING ),ASE OF T,E NURSING )ROCESS Imp$ementation 2utting the care plan into action )urpose of Imp$ementation $o carry out planned activities $o help the client Concept;;; $he implementation phase ends upon recording of the care given and the response of the patient to that procedure

ReIuirements for Imp$ementation Ade,uate kno"ledge $echnical Skills Communication skills $herapeutic use of self ight attitude as a re,uirement Nursin Acti(ities %urin t#e Imp$ementation )#ase eassess the patient o ationale $o determine if the procedure is still needed .etermine the need for nursing assistance 0mplement the nursing strategies Communicate the procedure performed by documenting the procedure /nderstand orders o Clarify D verify doctors6 orders Encourage patient to participate actively Gui%e$ines for Imp$ementation of t#e Nursin Strate ies -e" Concept;;; 0t should be based on scientific kno"ledge3 research3 professional standards of practice &care) o ationale@ $his is done to ensure safe nursing care 0t should be adapted to the individual patient 0t should al"ays be safe+ .o not compromise 23

 0t should be holistic 0t should be accompanied by support3 comfort and teaching

o Allo"s the nurse to decide and make on* the*spot modificationDs in an intervention

E'ALUATION ),ASE NURSING )ROCESS

OF

T,E 6+ Intermittent E(a$uation >hen done@ o At a specified time 2urpose@ o 0t sho"s the e#tent of progress of the patient 0mportance@ o Enables the nurse to correct deficiencies and modify the nursing care plan 7+Termina$ E(a$uation >hen done@ o At or immediately before discharge 0mportance@ States the status of a health problem at the time of discharge 0t determines "hether the goals are@ o !et o 2artially met o /nmet DOCUMENTATION 0t is a "ritten3 formal document A record of client6s progress )urposes of Documentation 2lanning Care Communication For legal documentation purposes For research 24

)urpose of t#e E(a$uation )#ase $o determine client6s progress $o determine the effectiveness of the care plan $o determine as to "hat e#tent the nursing goals have been met Importance of %oin an E(a$uation 0t determines if the care plan "ill be@ o Continued o !odified o .iscontinued Acti(ities %urin t#e E(a$uation )#ase 0dentify the -/$C-!E C 0$E 0A to be used as measurement <ather information &data) relevant to the outcome criteria Compare outcome &data) "ith the criteria Assess the reasons for the outcome evise the nursing care plan as needed T"pes of E(a$uation 5+ On0 oin E(a$uation >hen done@ o .uring or immediately after the intervention 0mportance@

 For education eimbursements For statistics3 reporting3 epidemiology Accreditation3 licensing Gui%e$ines on Documentation $iming o .ocument patient care as soon as possible -bserve confidentiality -bserve permanence o /se non*erasable ink o .o not use sign pen Signature o Sign full name and append +N+ Accuracy o Ensure that data is correct o Avoid biases o Avoid ambiguous terms Appropriateness o >rite only appropriate information Completeness /se standard terminology Brevity o !ake it concise yet meaningful Legal A"areness o Cross out erroneous entry o >rite MErrorN o Countersign TF)ES OF RECORDS Source Oriente% C$inica$ Recor% Accumulation of chronological3 variative notations that are difficult to follo" because they are not

assembled into an orderly or scientific manner Classification of information is based on S-/ CE Each person or department maintains a different section on chart Components of a Source Oriente% C$inica$ Recor% Admission Sheet Face Sheet !edical %istory and 2hysical E#amination Sheet .iagnostic Findings Sheet $2 <raphic Sheet .octor6s $reatment and -rder Sheet $herapeutic Sheet )rob$em Oriente% C$inica$ Recor% Same as 2roblem -riented !edical ecord Entry of data is based on CL0EN$6S 2 -BLE! E#ample@ o 2roblem No+ '@ constipation 0ncrease fluid intake@ doctor .iatabs@ pharmacist N2-@ 0ncludes observations about the patient E#ample@ o adiologist6s notes are "ith doctor6s notes under one problem )rob$em List Contains problems information problem) 25 only AC$0VE &and relevant about the

 No potential problems &these are contained only in the progress notes) Four G8H !asic Components of )rob$em Oriente% C$inica$ Recor% 5+ !ase$ine Data All information gathered from a patient "hen he first entered the agency 6+ )rob$em List 7+ Initia$ $ist of or%ers or Care )$ans 8+ )ro ress Notes 0ncludes@ o Nurses6 narrative notes &S-A20E) o Flo" sheets o .ischarge Notes and eferral Summaries Formats: S-A20E J for revisions COMMON MET,ODS OF COMMUNICATION AMONG NURSES 5+ Referrin $o endorse patient6s special concern to a higher authority or a speciali1ed department or personnel 6+ Confer Verifying information 7+ Reportin <iving information concerned person -ARDEJ 26 to a

0s the Aarde# a part of the patient6s recordC No3 it is not=== 0t is ;ust a bulletin board )urpose of t#e -ar%e2 $o make valuable information readily available Allergies are "ritten in red ink 0t is a reminder 0t is not a record Concept: A Nursing Care 2lan is not a record COMMUNICATION IN NURSING TEC,NI4UES

Communication E#change of ideas3 information3 feelings3 data bet"een t"o communicators Concept: Communication is the basic component of %uman elationships E$ements of Communication '+ !essage .ata 4+ Sender Encoder 5+ eceiver .ecoder (+ Feedback 8+ Conte#t Setting -verall environment "here the communication takes place Mo%es of Communication '+ Verbal

-ral Spoken >ritten communication $e#ted communication Cable communication $ele# communication Facsimile communication

o -ne person believes that the space and all the things in that space belongs to him o .o not enter abruptlyK this may result in breach of privacy oles and relationships

4+ Non*verbal communication Facial e#pression <rimacing 2osture <ait Adornment !ake*up <estures Factors Affectin Communication Ability of the communicator 2erceptions 2ro#emics o .istances bet"een communicators 0ntimate .istance Actual physical contact to '+8 feet 2ersonal .istance '+8 feet to ( feet 5 feet to ( feet for intervie" Social .istance ( feet to '4 feet 2ublic .istance '4 feet and beyond $erritoriality

T#erapeutic Communication in Nursin /sing Silence o Supplement "ith non* verbal communication 2rovide <eneral Leads o E#amples@ MIgo onN MItell me moreN -pen*ended ,uestions /se $ouch o But assess the culture of the patient o 0f the patient is a child3 touch the patient on the top of the head o 0f the patient is an elderly3 touch the patient on the hand o 0f the patient is of the same age level3 touch the patient on the shoulder -ffering yourself o For autistic child Stay nearby or stay beside the patient 2resenting eality o E#ample@ M7ou are in the hospitalN eflecting o E#ample@

27

M>hat do you think "ill make you happyN o Never agree nor disagree o eflect it back or thro" it back Non0t#erapeutic Communication Stumbling blocks to effective communication Stereotyping <enerali1ing Agreeing and .isagreeing No confrontation No argument Being defensive !orali1ing or 2assing :udgment <iving Common Advise E#amples@ M0f 0 "ere youIN M7ou should have done itIN )ROMOTING REST AND SLEE) Circa%ian R#"t#m A biological rhythm A biological clock egulated from outside the person6s body T"pes of S$eep 5+ Rapi% E"e Mo(ement S$eep GREM s$eepH 0ncreased brain metabolism and activity Also called 2A A.-?0CAL SLEE2 Characteri1ed by@ o Vivid dreams o Easily recalled upon a"akening Concepts; 28

E! sleep is N-$ AS ES$F/L as N-N* E! sleep %o"ever3 E! sleep is NEE.E. .reaming is a psychological outlet of pent up emotions Nursin A$ert; .eprivation of E! sleep results to@ o 0rritability o estlessness o 2oor concentration 6+ Non0Rapi% E"e Mo(ement S$eep GNon0REM S$eepH .eep restful sleep Benefit is that it restores the body physically and psychologically &especially for post*operative patients) Concept; .eprivation of Non* E! sleep causes@ o 2hysical e#haustion o .ecreased resistance against infection &e$$ness Teac#in s to En#ance or )romote S$eep Establish a regular routine %ave ade,uate e#ercise at daytime o Avoid stimulating activity by bedtime Avoid all types of stimulants o Caffeine*containing foods Coffee Cocoa Chocolate $ea Cola

o Nicotine o Alcohol 2rolongs the E! stage of sleep 0t e#cites the patient like an anesthetic Not a stimulant Avoid shabu /se the bed mainly for sleep 0f unable to sleep3 get up and pursue satisfying activity .rink something "arm or hot &e#cept stimulants) o !ilk contains L* tryptophan o L*tryptophan is an amino acid "ith a natural sedative effect that induces one to sleep .o something %-$= o $"ice*a*"eek masturbation is ideal o Facilitates release of tension of the day Side*to*side turning every t"o hours "ith back tapping Support bedtime rituals emove all music in order to sleep

Fats Concepts: <lucose is a ready source of energy for metabolic processes Carbo#"%rates >hen eaten are metaboli1ed to glucose for energy E#cess carbohydrates are converted to glycogen and stored in the liver -ther e#cess carbohydrates go to the fat cells -e" Concept; .uring starvation3 stored glycogen is converted to glucose via a process called glycogenolysis 0f glycogen is used up3 fat resources are converted to glucose via a process called gluconeogenesis Nursin A$ert; Fat conversion to glucose produces "aste products called AE$-NE B-.0ES $hese give rise to metabolic acidosis as in .iabetic Aetoacidosis A%%itiona$ concepts; .uring starvation protein reserves are converted to glucose via process called gluconeogenesis G$uconeo enesis 2roduction of glucose out of non*carbohydrate products Lipoproteins 29

)ROMOTING NUTRITION )roteins !acromolecules composed of o Carbon o %ydrogen o -#ygen o Nitrogen !asic !o%" Nee%s: Carbohydrates 2roteins

 Substances composed of fats and proteins T"pes of Lipoproteins 5+ ,i # Densit" Lipoproteins G,DLH %igh*grade lipoprotein <ood grade lipoprotein <ood cholesterol Function of %.Ls o $ransports the bad cholesterol from systemic circulation to the liver for metabolism and eventual elimination 6+ Lo* Densit" Lipoproteins GLDLH Lo"*grade lipoprotein Bad cholesterol Function of L.Ls $hey clog the blood vessels 7+ 'er" Lo* Densit" Lipoproteins G'LDLH Very bad cholesterol Functions of Fats 0nsulation %eat Conservation Source of Energy )roteins $"o &4) types in terms of needs of the body@ '+ Essential 2roteins 2roteins that cannot be produced by the body itself $o be sourced out from food eaten Animal protein is complete protein 2lant protein is considered as incomplete protein

4+ Non*essential 2roteins 2roteins that can be produced by the body Functions of )rotein !ain element of our cells+ o Building blocks of the cells are proteins esistance against infection o Formation of 0mmunoglobulins &globular proteins) !aintenance of normal intravascular fluid volume o >orks "ith glucose and sodium o Albumin !ain protein of blood Acts as a colloid Attracts "ater around it Concepts;;; 0f protein levels are decreased3 sodium and glucose "ill not be enough to hold plasma inside blood vessel resulting into edema 0n liver cirrhosis3 hypoalbuminemia results to edema 'ITAMINS T*o G6H t"pes of 'itamins Fat Soluble Vitamins >ater Soluble Vitamins Fat So$ub$e 'itamins 5+ 'itamin A Essential for normal vision For transmission of light stimulus via the optic nerve

30

6+ 'itamin D Source is food 2recursor is in the skin Sunlight is needed for Vitamin . to be converted to its active form Function@ o 0nfluences calcium metabolism o $o metaboli1e calcium Concept; >ithout Vitamin .3 there "ould be decreased calcium levels 0ncreased levels of Vitamin . leads to increased calcium levels 'itamin E Anti*o#idant 2romotes cell membrane integrity &like Vitamin C) Vitamin for the heart and skin Sources are meats and in vegetables .eficiency results to Vitamin E deficiency hemolytic anemia 'itamin Synthesis of clotting factors Synthesis of prothrombin Concept; .ecreased levels of Vitamin A leads to prothrombin deficiency .eficiency in prothrombin leads to bleeding MICRONUTRIENTS Ferrous su$fate GFeSO8H

Forms@ o $ablet o Li,uid o 0n;ectable -ral &tablet and li,uid forms) o $ake on an empty stomach o 0f there is <0 distress &i+e+ diarrhea)3 take "ith food o 0f <0 distress subsides3 take on an empty stomach $o#ic effects@ o Constipation &first option) -ral Li,uid 0ron o /se dropper and apply at the back of the tongue or use a stra" ationale@ $o avoid staining the teeth %ealth $eaching=== o $o enhance iron absorption3 advice taking orange ;uice o Vitamin C in orange ;uice enhances iron absorption o .o not take milk o !ilk inhibits absorption of iron o $oo much fiber prevents absorption of iron o $hus3 do not take oats "hen taking iron+ 0n;ectable 0ron o oute is deep 0+!+ o /se B*track techni,ue o

31

o <auge of Needle is at least 'F o Length of Needle is '+8N to 4+HN o Site of administration is the <L/$EAL !/SCLE -NL7=== o ationale@ $o avoid staining the skin Concept@ o /se an airlock o 2lace H+8 ml of air in syringe so that medication "ould not leak into the subcutaneous tissues Nursing Alert= o Apply firm pressure for at least five &8) minutes after in;ection .o N-$ massage S)ECIAL DIETS 5+ Li #t Diet <iven for post*operative patients 2lainly cooked No spices Large amounts of FA$ omitted Avoid bran and high fiber 6+ Soft Diet For people "ith difficulty "ith s"allo"ing and che"ing <enerally lo" residue diet Nursing Alert= o Avoid the follo"ing@ Nuts Seeds &tomato3 guava3 berry) a" fruits and vegetables Fried Foods 32

>hole grains and cereals

7+ )uree% Diet -steori1ed diet 8+ Fu$$ LiIui% Diet Foods that melt or li,uefy at body temperature =+ C$ear LiIui% Diet <iven to surgical patients Limited to@ o >ater o Coffee o $ea o Cola o Clear stained broth o <elatin o %ard candies Nursing Alert= o .airy products are avoided ?+ ,i # Fiber Diet For patients constipation at risk for

@+ Can%i%iasis Diet Free of the follo"ing@ o Fruits o Sugar o 7east o Fermented foods A+ Lo* Resi%ue Diet educed fiber $o decrease <0 irritation For patients "ith bo"el inflammatory diseases@ o Chron6s disease o /lcerative colitis Aci%0As# Diet

 $o alkalini1e urine $o soothe an irritated bladder and urethra <ive citrus fruits <ive vegetables E#ceptions are@ o 2rune :uice o Cranberry :uice o Both produce AC0.0C / 0NE As#0Aci% Diet <iven to acidify urine $o minimi1e or help control /rinary $ract 0nfections <ive the follo"ing@ o 2rotein o !eat o 2oultry ASSESSMENT OF NUTRITIONAL STATUS Ant#ropometric Measurements S9in Fo$% Test .erived from reserved fat of the body Mi%0upper arm Circumference Measurement -btains the muscle mass of the body $his reflects the protein reserves of the body Laboratory diagnostic procedure for albumin SU))ORTING NUTRITION OF )ATIENT: ENTERAL AND )ARENTERAL FEEDING ENTERAL FEEDING

5+ NASOGASTRIC TU!E FEEDING GNGTH 2urpose of N<$ insertion o For gastric gavage and lavage o For administration of food and medication o $o keep the stomach empty o $o prevent aspiration from regurgitation of gastric contents o For gastric decompression %o" to 0nsert N<$ o .epth of 0nsertion !easure length from the tip of the nose to the ears to the tip of the #iphoid process 0nsertion@ o 2osition the patient in semi*Fo"ler6s or Fo"ler6s position o >hile inserting to NAS-2%A 7N? 2osition the head in a hypere#tended manner o >hen glottis3 epiglottis are approached Fle# the head o ationale@ $o prevent entry of the tube into the trachea Nursing Alert= o >atch for signs and symptoms of ES20 A$- 7 .0FF0C/L$7

33

o 0f there are signs3 >0$%. A> $/BE o >hile inserting tube3 observe for coughing or difficulty of breathing After inserting3 ascertain proper placement on the stomach Concept; o !ost accurate method to test for proper placement of the N<$ is via ?* A7 -ther "ays to test proper placement@ o '+ Let patient hum 0f positive for humming3 tube is in the esophagus and stomach 0f negative for humming3 tube is in the trachea Nursing Alert= o Small*bore tube allo"s patient to hum o $herefore3 this method is N-$ EL0ABLE o 4+ .etermine the p% of the aspirate /se litmus paper Change of color from BL/E to E. indicates that the aspirate is acidic and3 therefore3 from stomach contents Change of color from E. to BL/E indicates that the aspirate is basic and3

therefore3 from lung contents 0!2- $AN$ C-NCE2$S=== o $o insure safety of the patient prior to feeding3 C%ECA $%E F-LL->0N<@ 2lacement of the tube For patient safety $o prevent L/N< aspiration of food 2atency of the tube $o insure successful introduction or administration of food o 5+ By auscultating the epigastric region "hile insufflating 8H ml of air %ear gurgling sound TU!E FEEDING Never try to submerge the free end of the N<$ to "ater o $his is potentially dangerous o 0f in trachea and submerging of free end to "ater coincides "ith inspiration3 it "ill suck the "ater and lead to pulmonary aspiration 2osition during feeding@ o Fo"ler6s 2osition !easure gastric residual volume

34

o Subtract this from total feeding to introduce o 0f aspirate is greater than 8H ml for adult or 'H ml for infant3 then >0$%%-L. FEE.0N< for 4 J 5 hours+ o ationale@ 2atient is not yet ready for ne#t feeding+ o 0f same occurs after 4 J 5 hours3 N-$0F7 .-C$- + $here is a problem "ith gastric emptying >atch out for C-/<%0N< o Leakage to trachea 0f "ith .0FF0C/L$7 -F B EA$%0N< o Stop the procedure Flush "ith "ater after feeding to avoid clogging of the tube After the procedure o .o not place the patient on bed before 5H minutes have lapsed o ationale@ $o prevent aspiration and regurgitation Average volume of feeding@ o 5HH ml to (HH ml

0mportant Concept=== o $ube must reach t"o &4) centimeters before or above the 0<%$ A$ 0/! Nursing esponsibilities@ o >atch out for signs and symptoms of embolism Care of 0nsertion Site o Application of sterile dressing "ith anti* bacterial ointment as ordered by doctor &prn) GASTROSTOMF TU!E FEEDING GEntera$H No auscultation needed Assess for the patency of the tube /se "ater to do this )ROMOTING OJFGENATION DEE) !REAT,ING $"o &4) types of .eep Breathing@ 5+ A)ICAL DEE) !REAT,ING .one to e#pand the upper portion of the lungs Let the patient place palms on the upper chest Concentrate on that area $ake a slo" deep breath at a count of '3435 elease it slo"ly through the nose or a pursed lip at a count of (38393E $herefore3 e#piration is longer than inspiration ationale@ o $o prevent respiratory alkalosis $aught to patients "ho "ill undergo@ o /pper abdominal surgery 35

TOTAL )ARENTERAL NUTRITION 0ntroduced directly to the bloodstream $ube is inserted via the@ o Subclavian vein o 0nternal ;ugular vein of the neck o E#ternal ;ugular vein of the neck

o Cholecystectomy 0ncision site on diaphragm 2atient does not "ant to breathe 2redisposed to hypostatic pneumonia 6+ !ASAL DEE) !REAT,ING Same procedure Area of concentration is the lo"er ribcage >hen to teach patient@ o Before surgery o Before pain is present ationale@ o 0f pain is already present3 it "ould be difficult for patient to follo" >hen done@ o .one ,4 hours together "ith turning COUG,ING EJERCISES 2urpose o $o e#pand the lungs o $o facilitate e#pectoration of secretions %o" often done@ o At least every t"o &4) hours 2rocedure o $each the patient to inhale and e#hale o $ell the patient to inhale and e#hale a second time o $ell the patient to inhale and cough out NURSING ALERT;;;

o Coughing is contraindicated in the follo"ing patients@ >ith increased intracranial pressure &0C2) >ith increased intraoptical pressure &0-2) >ith cardiac arrhythmias &but are allo"ed to do deep breathing) Concepts;;; .eep Breathing and Coughing o 2urpose is to stimulate surfactant production 7a"ning and snee1ing also stimulate surfactant production OJFGEN IN,ALATION ADMINISTRATION AND

)ractica$ App$ication Concept; >hen administering o#ygen3 be sure to open the valve of the o#ygen tank first+ Be certain that the valve on the regulator is closed so that the flo" meter "ould not break= Concept; %umidifier moistens the o#ygen administered 2urpose o $o avoid drying and irritation of the mucosal lining o Also traps particulates from the tank

36

0ron o#ide may be present in the tank &iron plus o#ygen produces iron o#ide or rust)

6+ ,i # F$o* A%ministration /ses a venturi mask NE!ULIDATION >ith sodium chloride and salbutamol A physiologic solution >ater li,uefies secretions Sodium chloride stimulates coughing Salbutamol is a bronchodilator 2urpose@ o For e#pectoration of secretions Nursin )re0t#erap" Assessment )rior to Nebu$i1ation %ave baseline data of patient6s breath sounds Assess again after nebuli1ation to assess effectiveness of the procedure S)IROMETRF 2urpose is to e#pand the lungs .one "hen inhaling 0nstruction to the patient@ o 0nhale from the spirometer and N-$ blo" to the spirometer 2rocedure@ o 0nhale J e#hale o 0nhale J e#hale fully o 2lace mouthpiece bet"een teeth o %old breath for four &() seconds o $hen inhale3 fully rising the ball /pon inhalation3 the ball rises C,EST ),FSIOT,ERA)F $his is a dependent procedure

Concept; Fire 2recaution o 2lace ON- S!-A0N<6 sign at the door or at the head part of the patient $ank and o#ygen do not e#plode $hey merely support combustion Ot#er Concepts; .o not use volatile substances Acetone and alcohol can react "ith o#ygen and lead to to#icity of patient .o not use oil based or grease on any part of the o#ygen set .o not allo" the patient to use an electric ra1or as sparks may trigger combustion Nursin A$ert; etrolental Fibroplasia occurs if there is e#cess o#ygen administration in infants+ E#cess o#ygen leads to destruction of the retina and blindness Mo%es of A%ministration 5+ Lo* F$o* A%ministration /tili1es nasal cannula or nasal prongs or nasal catheters <iven to C-2. patients

37

 $here are no absolute contraindications to this procedure Contraindicated for the follo"ing patients "ith@ o 2acemakers o Lung abscess o %emoptysis o .angerous Arrhythmias o Active 2$B &"hich goes to the other lobe) o Lung CA &malignancy goes to other lung) T#ree components of )#"siot#erap" Vibration 2ercussion 2ostural .rainage C#est

Assess breath sounds to kno" "hich lung fields have secretions $hen assess again after procedure to check effectiveness of the procedure+ Concepts;;; Vibration and percussion are done to mechanically dislodge secretions Nebuli1ation is done to li,uefy secretions Suctioning is done to clear secretions 2ostural .rainage is done to drain secretions using gravity )ostura$ Draina e >hen done@ o Before meals o $"o &4) hours after meals Before doing the procedure3 the follo"ing baseline data are needed@ o Breath sounds o Vital signs o Continuous EC< monitoring .uring the procedure@ o Ensure the comfort of the patient o 2rovide a kidney basin and tissue paper Nursin A$ert; o >atch out for signs of symptoms "hich may re,uire stopping of the procedure@ Sudden dyspnea Cyanosis E#treme diaphoresis 38

'ibration 2alms of your hand are placed on chest or back of patient giving ,uivering motions 2alms remain in contact "ith the chest or back )ercussion /se cupped hands %ands alternate in rising and coming into contact "ith chest or back of patient )ostura$ Draina e .rain secretions by gravity Change positions 0!2- $AN$ C-NCE2$=== o ule out contraindications before performing chest physiotherapy )re0t#erap" Assessment 'ibration an% )ercussion for

Sudden alteration of blood pressure3 respiratory rate3 pulse rate Appearance of arrhythmias %emoptysis <eneral intolerance of the procedure

SUCTIONING 2urpose is secretions

to

seek

out

Important Concept; 0f any of the above occurs3 S$-2 $%E 2 -CE./ E and inform the physician Concepts; After the procedure assess the follo"ing@ o Breath sounds o Vital signs o Luantity and ,uality of sputum o -verall response of the patient to the procedure <ive oral hygiene o ationale@ $o eliminate phlegm from the mouth Important Concept;;; 2atients "ith cystic fibrosis benefit much from postural drainage TF)ES OF SUCTIONING T"pe of )osition of Suctionin t#e )atient *#i$e Suctionin Orop#ar"n ea$

Concepts;;; Luestion@ o 0f you have only one &') suction catheter3 "hich "ill you suction first3 the nose or the mouthC Ans"er@ o 0f the patient is an infant or a ne"born@ Start on the mouth then proceed to the nose ationale@ o 0f you start on the nose3 you "ill trigger the snee1ing refle# and this "ould result into aspiration Ans"er@ o 0f the patient is an adult3 suction the mouth first3 then proceed to the nose ationale@ o $his is done for aesthetic reasons

Dept#

Duration

Inter(a$ *it# eac# )ass of Suction

Tota$ Time

39

Suctionin 0f patient conscious is Fo"ler6s &high 'H J '8 or moderate)K centimeters %ead turned to one side &to"ards the nurse) Not more 4H J 5H than 'H J seconds '8 seconds Not more than 8 minutes

0f the patient is 2lace on one 'H J '8 unconscious side &facing the centimeters nurse)K $ilt neck to move head slightly for"ard to"ards the basin to avoid aspiration during suctioning Nasop#ar"n ea$ Suctionin 0f the patient is Neck should be conscious hypere#tendedK Fo"ler6s position 0f the patient is Flat on bed unconscious "ith head turned to the nurse Lateral position may be assumed TF)ES OF SUCTIONING T"pe of )osition of Suctionin t#e )atient *#i$e Suctionin Orotrac#ea$ Suctionin From tip of the nose to tip of the earlobe From tip of the nose to the tip of the earlobe

Not more 4H J 5H than 'H J seconds '8 seconds

Not more than 8 minutes

Not more 4H J 5H than 'H J seconds '8 seconds Not more 4H J 5H than 'H J seconds '8 seconds

Not more than 8 minutes Not more than 8 minutes

Dept#

Duration

Inter(a$ *it# eac# )ass of Suction

Tota$ Time

40

0f patient is Lo" to !easure Not more 4H J 5H Not more conscious semi* from mouth than 'H seconds than 8 fo"ler6s to mid* seconds minutes position sternum 0f the patient Flat on !easure Not more 4H J 5H Not more is bedK from mouth than 'H seconds than 8 unconscious Suction to mid* seconds minutes trachea sternum through the mouth Nasotrac#ea$ Suctionin 0f the patient Lo" to From tip of Not more 4H J 5H Not more is conscious semi* the nose to than 'H seconds than 8 fo"ler6s earlobe to seconds minutes position dominating side of neck to the thyroid cartilage 0f the patient Flat on From tip of is bedK the nose to unconscious Suction earlobe to trachea dominating through the side of nose neck to the thyroid cartilage Not more 4H J 5H Not more than 'H J seconds than 8 '8 minutes seconds

41

TF)ES OF SUCTIONING T"pe of )osition of Suctionin t#e )atient *#i$e Suctionin En%otrac#ea$ Tube Suctionin

Inter(a$ Tota$ *it# Time eac# )ass of Suction Semi*Fo"ler6s '4+8 8 J 'H 4 J 5 Not if not centimeters seconds minutes more contraindicated or 9 inchesK than 8 0nsert as minutes far as it goes until you meet resistance or until patient coughs

Dept#

Duration

42

Trac#eostom" Tube Suctionin

Semi*Fo"ler6s 0nsert as 8 J 'H 4 J 5 if not far as it seconds minutes contraindicated gets until you meet resistance or until the patient coughs

Not more than 8 minutes

Important Concepts;;; For Endotracheal Suctioning o N- $/BE 0S /SE. %E E o $his is suctioning of the trachea through the mouth or through the nose $"o &4) types of Endotracheal Suctioning o -rotracheal Suctioning -ral approach o Nasotracheal Suctioning Nasal approach Genera$ Con%itions for Suctionin

For Endotracheal and $racheostomy &Naso and -ral and $ube) o Before suctioning3 %72E -?7<ENA$E the patient o .uring intervals3 %72E -?7<ENA$E the patient For E$3 $racheostomy3 E$ $ube o Nursing Alert= .uring insertion3 if you encounter resistance3 "ithdra" the catheter about one centimeter 43

o o o

&' cm) before applying suction ationale@ $o avoid trauma on the mucous membrane .o suctioning intermittently Suctioning should not be continuous otate the catheter &bet"een the thumb and the inde# finger) as you "ithdra" Apply suction only "hen you are ready to "ithdra" &i+e+ keep finger a"ay from suction port if you are still not ready)

o 0nstill 4+8 ml to 8+H ml Normal Saline Solution for adults to li,uefy the mucous plug o 0nstill 4+H ml Normal Saline Solution for children to li,uefy the mucous plug 0nstill H+8 ml to '+H ml Normal Saline Solution for infants to li,uefy the mucous plug 'ITAL SIGNS TEM)ERATURE -ral A#illary ectal Ora$ Met#o% !ost convenient !ost accessible Nursing Alert= o Applicability is for children aged si# &9) years and above o Not applicable for children belo" si# &9) years old Contraindicated in patients "ith@ o -ral surgery o !outh breathers o %istory of convulsive sei1ures o /nconscious o 0ncoherent o 0rrational o !entally disrupted o 0nsane 2rocedure o Nothing 2er -rem for about thirty &5H) minutes before taking temperature 44

,o* to ,"pero2" enate t#e )atient <ive t"o &4) to three &5) blo"s by ambubag 0ncrease flo" rate and concentration of o#ygen Nursing Alert= o 0f the patient has thick3 tenacious secretions3 .- N-$ /SE AN A!B/BA< o /se an -?7<EN 0NS/FFLA$0-N S/C$0-N CA$%E$E instead=== o $his is a t"o*lumen catheter &one lumen brings o#ygen to the patient3 the other lumen brings out secretions from the patient) 0n the event of encrustations3 2E F- ! $ AC%EAL LAVA<E

o No food intake o No drinks o No smoking o No che"ing gum o No "histling o No gargling ationale@ o Any of the above "ould alter the result 2lacement@ o /nder the tongue3 beside the frenulum &right or left) $otal $ime@ o $"o &4) to three &5) minutes A2i$$ar" Met#o% Least realiable Safest method Nursing Alert= o .uring application3 be sure that a#illa is dry o .ry using a patting motion Nursing Alert= o .o N-$ /B=== ationale@ o $his increases heat due to friction o ubbing increases blood supply to the area o $herefore3 there "ill be increase in temperature reading o ubbing provides a false*positive elevation of temperature reading .uration@ o 0n adults J nine &G) minutes o 0n children J five &8) minutes

Recta$ Met#o% !ost reliable &e#cept for tympanic thermometer) !ost accurate &e#cept for tympanic thermometer) Concept; o 0f tympanic method is used using a tympanic thermometer3 the rectal method is only second most reliable and second most accurate .isadvantage@ o 2lacement on a different site yields a different reading o $herefore3 ensure that the bulb of the rectal thermometer rests on the mucous membrane Contraindications@ o %emorrhoids o ectal Surgery o Certain Cardiac ailments due to stimulation of the vagus nerveK valsalva maneuver leads to arrhythmias 2osition of 2atient "hen taking the reading@ o Sim6s left position o Sim6s right position o For Ne"born3 lift up ankles to keep buttocks up o 0n $oddlers3 set on prone position on adult6s lap .uration@ o $"o &4) minutes Con(ersion Fa#ren#eit of Centi ra%e to

45

 Centigrade P &8DG)F J 54 Centigrade P &FD'+F) J 54 Con(ersion of Fa#ren#eit Centi ra%e Fahrenheit P &GD8)C Q 54 Fahrenheit P &'+F)C Q 54 to

Concepts;;; 2eak body temperature occurs at '4NN to 52! or (2! Lo"est body temperature occurs in the early morning hours of the day FE'ER Normally3 the hypothalamus is able to ad;ust body temperatures bet"een 5EC to (HRC But due to the presence of pyrogenic materials like the follo"ing@ o 2athogenic microorganisms o $o#ins o Foreign substances o Any substance capable of increasing body temperature Creates a deficiency of *5RC3 making a person enter the F0 S$ S$A<E -F FEVE First Sta e of Fe(er $ypical signs and symptoms indicate the body6s compliance mechanism to increase and conserve heat@ o Chills o Shivering o <ooseflesh Contraction of arectores

46

pilorum or pilo arecti muscles o Vasoconstriction .ecreases blood supply to the skin 2allid Skin o Cyanotic nail beds -e" Concept;;; o 2atient complains of feeling cold o S"eating "ill stop because body "ill minimi1es heat loss Also called@ o -nset Stage o Chill Stage o Cold Stage $his stage is characteri1ed by lo" febrile temperatures Nursin Mana ement o -e" Concept Aim is to minimi1e heat loss o -e" Concept .o N-$ apply $E20. S2-N<E BA$% because this "ould make patient progress to S%-CA 2rovide additional clothing as necessary 2rovide additional blankets as necessary 2rovide something "arm to drink $hese measures "ould result to a gradual increase in body temperature Luestion@ o >hen "ill you start application of $SBC Ans"er@

o 0f there is a 'RC to 4RC increase in body temperature Secon% Sta e of Fe(er Also called@ o Coarse Stage of Fever o 2eak Stage of Fever -e" Concept; o 2atient does not feel hot or cold o Skin is "arm to touch o Skin is flushed o Fever blisters are present %erpetic lesions o Absence of shivering o 2ossible dehydration Important Concept;;; o For every increase of temperature3 there is a corresponding increase in pulse rate ationale@ o 0ncrease in temperature results in an increase in pulse rate due to increased metabolic rate o 0ncreased metabolic rate increases o#ygen demand o .ue to increased o#ygen demand of susceptible brain cells3 C-NV/LS0VE SE0B/ ES may occur+ $hese may also be due to irritation of nerve cells J FEB 0LE C-NV/LS0-NS 0ncreased o#ygen demand also leads to an increase in respiratory rate 2atient complains of@ 47

o Loss of appetite o !yalgia or muscle pains due to increased catabolism Nursin Mana ement o $epid Sponge Bath o Cooling Bed Bath Tepi% Spon e !at# $emperature of "ater is 54RC o $his temperature is maintained throughout the procedure %o" to apply@ o .one by patting ationale@ o $o avoid friction3 "hich increases temperature Important Concept; o .o N-$ use ALC-%-L "hen applying $SB ationale@ o Alcohol dries the skin and leads to irritation -e" Concept; o $SB should not be done hurriedly ationale@ o >hen done hurriedly3 $SB "ill stimulate shivering o Shivering "ould lead to increased muscle activity o 0ncreased muscle activity "ould lead to increased temperature Coo$in !e% !at#

 >ater temperature "ill start at 54RC 2rocedure "ill go on "ith gradual decrease in "ater temperature until it is maintained at 'FRC $herefore3 to achieve this drop in temperature3 utili1e ice Same procedure of application as in $epid Sponge Bath T"pes of Fe(er 5+ Intermittent Fe(er A fever that is alternated at regular intervals by periods of normal and subnormal temperature 6+ Remittent Fe(er Fever alternated by "ide range of fluctuations in temperature3 all of them are AB-VE N- !AL+ .uration is "ithin a 4(* hour period 7+ Re$apsin Fe(er Short periods of febrile episodes alternated by one &') to t"o &4) days of normal temperature 8+ Constant Fe(er !inimal fluctuations of temperature3 all of "hich are AB-VE N- !AL =+ Staircase or Spi9in Fe(er Common in patients "ith $72%-0. FEVE )ULSE ASSESSMENT Concepts;

0f pulse is regular3 count or monitor pulse for thirty &5H) seconds and multiply by t"o &4)+ $his is legal= 0f pulse is irregular3 count or monitor the pulse for one &') F/LL minute Assessment of t#e )u$se Deficit $his is the most accurate method 0nvolves t"o nurses using one "atch Starts at the same time Ends at the same time Comparison of results ensues Count is done for one &') full minute Sca$e in )u$se Assessment H * Absent or cannot be felt 'Q * >eak or thready 4Q * Normal 5Q * <rounding !LOOD )RESURE S"sto$ic 2roduced by ventricular contraction 2ressure on blood vessels during depolari1ation or ventricular contraction Diasto$ic 2ressure that remains in the "alls of the blood vessels during rela#ation or repolari1ation or resting !roa%$" t*o G6H t"pes: .irect o By insertion catheter

of

48

 0ndirect !ethod o Auscultatory method o 2alpatory method o Flush !ethod Auscu$tator" Met#o% /ses Aorotkoff sound o A popping sound o N-$ the heart beat o 0t is a phenomenon J an unkno"n phenomenon= Determinin Amount of Inf$ation /sing auscultatory method o Ask patient "hat is his last B2 reading and then add 5H J (H mm%g from last systolic reading+ o .eflate gradually J rate is appro#imately 4 J 5 mm%g per second Alternative auscultatory method o Auscultate for the last sound as you go up+ $hen add 5H J (H mm%g o $hen deflate Tripartite !$oo% )ressure .one if patient is an adult+ E#ample@ '(H mm%g systolic J first loudest sound 'HH mm%g 'st diastolic J muffling EH mm%g 4nd diastolic J last sound o $herefore3 the tripartite blood pressure is '(H D 'HH D EH 0f there is no muffling3 an e#ample "ould be@ 49

o '9H D no muffling D ''H Concepts;;; $ake systolic on loudest sound if patient is an adult 0f patient is pediatric or up to ten &'H) years old3 take the first sound3 "hether it is faint or loud 0f3 for e#ample3 first sound is at 'GH mm%g and there is silence up to '(H mm%g and then there is a sound at '5H mm%g do"n to FH mm%g thenI /se the 2AL2A$- 7 !E$%-. in combination "ith the A/SC/L$A$- 7 !E$%-. because there is an auscultatory gap Repeat usin : Auscultatory method 2alpatory method ,o* to %o t#e )a$pator" Met#o% 0nflate o .etermine up to "hat point to inflate o 2alpate pulse o 0f pulse is absent3 add 5H J (H mm%g .eflate o First palpable pulse is true systolic pressure For diastolic pressure3 proceed using the auscultatory method F$us# Met#o% epresents the mean blood pressure epresents the average of the systolic and diastolic pressures

 >hen done@ o >hen you have a B2 apparatus "ithout a stethoscope o /sed for pediatric patients %o" done@ o 0nflate up to the point "here e#tremity becomes pale o .eflate slo"ly and look for a EB-/N. FL/S% J "hen e#tremity becomes red again $his is the true reading== Note that there is only -NE reading=== S-IN INTEGRITF .ecubitus ulcers are caused by@ o /nrelieved3 sustained pressure o Locali1ed ischemia o Shearing force o 2ressure plus friction 2redisposing Factors@ o /nconsciousness o 0ncontinence o Loss of Sensation o %ypoproteinemia .ecreased lean muscle mass 0ncrease in fluid shifting leads to edema .ependent position is the skin attached to or facing the bed o Emaciation Sta es of Formation Decubitus U$cer

Sta e 5 0nvolves the epidermis !anifestation o Non*blanchable erythema of 0N$AC$ SA0N o $his is the first heralding sign of decubitus ulceration Sta e 6 2artial $hickness Skin Loss 0nvolves epidermis and dermis !anifestation o Blister formation o Shallo" craters o Shallo" abrasion and ulceration Sta e 7 Fu$$ T#ic9ness S9in Loss U$ceration $here is skin loss already 0nvolves necrosis of the skin and subcutaneous tissues E?$EN.0N< $- but N-$ $% -/<% the underlying fascia Sta e 8 Formations and manifestations of Stage 5 plusI o 0nvolvement of bones3 supporting structures &tendons)3 ;oint capsules o !assive damage Too$s to Assess Ris9 of U$ceration Norton6s 2ressure Area isk Assessment Form Shannon6s Scoring System

50

 Branden Scale of 2redicting /lceration >aterlo" isk Assessment Cards o !ost important tool o !ost common tool o !ost often used tool EDEMA Caused by shifting of fluid into the interstitial tissues Mana ement of E%ema '+ Elevation of the edematous part Nursin A$ert; 0f edema is due to Congestive %eart Failure & ight Sided)3 NEVE ELEVA$E $%E L->E E?$ E!0$0ES Rationa$e: $his increases the "orkload of the right side of the heart Concept; 0f edema is due to prolonged standing3 .$%E ELEVA$0-N 4+ >ear elastic stockings 5+ /se "arm compress alternated "ith cold compress Rationa$e: Vasoconstriction and vasodilation causes re* circulation of fluid Concept; $his is contraindicated if there is inflammation Assessment of E%ema 0nduration 'Q * ' cm induration 4Q * 4 cm induration

5Q (Q 8Q

* * *

5 cm induration ( cm induration 8 cm induration

)AIN MANAGEMENT )ain A no#ious stimulation of actual or threatened D potential tissue damage Cate ories of )ain accor%in to Ori in Cutaneous o Skin .eep Somatic o $endons3 ligaments o Bones o Blood Vessels Visceral 2ain o -rgans of the body Cate ories of )ain base% on Cause Acute o .ue to trauma or surgery o 2ersists for less than si# &9) months Chronic !alignant 2ain o elated to cancer o -n and off o 2ersists for more than si# &9) months Chronic Non*malignant 2ain o 2ersists for more than si# &9) months Cate ories of )ain accor%in to &#ere It Is E2perience% adiating 2ain o Felt on the source and is e#tending to nearby tissues eferred 2ain 51

o Felt on other parts detached from the source o E#ample@ o 2ain on a lacerated liver may be felt on the right shoulder and not on the right upper ,uadrant 0ntractable 2ain o %ighly resistant to pain* relief methods 2hantom 2ain o 2ain that is felt on a !0SS0N< B-.7 2A $ or a 2A $ $%A$ 0S 2A AL7BE. by S20NAL C- . 0N:/ 7+ )ain T#res#o$% Amount of pain stimulation that is re,uired in order to feel pain )ain To$erance !a#imum amount of pain and duration that a person is "illing to endure Gate Contro$ T#eor" Concept; $his is the most "idely used theory in pain management Concepts; At the dorsal horn of the spinal cord is a gate+ $his gate is called the S/BS$ANC0A <ELA$0N-SA A series of nerves pass through this gate Small diameter nerve fibers pass through the substancia gelatinosa

o 2ain signals are carried to the spinal cord by the small diameter nerve fibers Large diameter nerve fibers also pass through the substancia gelatinosa o Large diameter nerve fibers close the gate J prevents the transmission of impulses through the spinal cord o $herefore3 "hen LA <E .0A!E$E NE VE F0BE S A E S$0!/LA$E.3 $%E <A$E 0S CL-SE. 2ain management operates on the principle of ho" to stimulate the Large .iameter Nerve Fibers to close the gate+ )ain Mana ement Strate ies )#armaco$o ic Met#o%s Narcotics NSA0.s Ad;uvants or Co*analgesics Non0)#armaco$o ic Met#o%s 2hysical 0nterventions Cognitive D Behavioral 0nterventions Non0)#armaco$o ic )#"sica$ Inter(entions '+ Cutaneous Stimulation !assage o Effleurage o Soft massage o <entle stroking 2etrissage o %ard massage

52

o Large and ,uick pinches o Also done by striking Application of Counter*0rritant o Bengay o !enthol o -mega 2ain Ailler o Fla# Seeds o 2oultices %eat and Cold Application o Nursing Alert= o ebound 2henomenon >hen you apply heat &usually done for 4H minutes)3 vasodilation is produced 0f heat is applied for more than 4H minutes3 there is vasoconstriction $his is an inherent defense mechanism from burning of tissues Cold Application o !a#imum vasoconstriction is reached "hen skin reaches '8RC o 0f there is further drom in temperature3 there is vasodilation &skin becomes reddish) o $his is the inherent defense mechanism from being fro1en Accupressure o 2ressure on certain points of the body o Stimulates release of endorphins3 "hich have

natural analgesic effects o $his started in Ancient China Accupuncture o 0nsertion of long slender needles on certain chemical path"ays o -rigin is also Ancient china Contralateral Stimulation o E#ample@ 0n;ury on left side and massage is done on the right side o /seful "hen patient cannot be accessed@ For patients in a cast For patients "ith burns For patients "ith phantom pain 4+ 0mmobili1ation Application of splints 5+$ranscutaneous Electrical Nerve Stimulation Composed of electrodes -perated by battery Electrodes are applied on painful site or over the spinal cord (+Administration of a 2lacebo elieves pain because of its intent and not because of physical or chemical properties Co niti(e or !e#a(iora$ Non0 )#armaco$o ic Inter(entions 2urpose@ o $o alter pain perception

53

o $o alter pain behavior o $o provide client "ith a greater sense of control over the pain Specific Inter(entions '+.istraction 2urpose is to divert attention from pain Slo" hythmic Breathing o Stare at a certain ob;ect o $ake deep breath slo"ly o elease or e#hale slo"ly o Concentrate on breathing o 2icture a peaceful scene o Establish a rhythmic pattern 4+!assage Breathing and Slo" hythmic

URINARF ELIMINATION O$i uria enal output of less than 8HH ml per day Anuria enal output of less than 'HH ml per day Retention 2ositive for distended bladder !ay also occur in the absence of bladder distention A$tere% Urinar" E$imination Enuresis Common among pediatric patients Age ( J 8 years old child has ade,uate bladder control 2rimary Enuresis o Never had a dry period Secondary Enuresis o Ac,uired enuresis o At age E3 bladder control is present for at least one year o $hen3 enuresis comes back o /rinating could N-$ be controlled again Incontinence 0nvoluntary passage of urine T"pes of Incontinence '+Functional 0ncontinence 0nvoluntary passage /npredictable time

5+ hythmic Singing and $apping -e" Concept; o Faster beat music is more preferable (+<uided 0magery 0magine that you are "alking along a peaceful shore Eyes are closed and suggestions are given 8+%ypnosis $he success of hypnosis depends on the ability of the patient to concentrate and the capacity of the hypnotist to suggest Based on suggestion 2rogressive rela#ation

54

4+ efle# 0ncontinence -ccurs at some"hat predictable times "hen specific bladder volume is reached No a"areness of bladder filling No urge to void 0t may be related to neurologic impairment 5+Stress 0ncontinence Loss of urine is less than 8H ml occurring "ith increased intra*abdominal pressure o -ccurs "hen laughing o -ccurs "hen snee1ing o -ccurs "hen smiling $otal 0ncontinence Continuous flo" of urine No bladder distention No bladder spasm No a"areness of bladder filling /rge 0ncontinence /rine flo"s as soon as a strong sense of feeling to void occurs Strong bladder spasm Mana ement of Incontinence '+Aegel6s E#ercises Also called@ o 2ubococcygeal !uscle E#ercises o 2elvic Floor !uscle E#ercises Applicable for@ o Functional 0ncontinence o Stress 0ncontinence %o" done@

o Advise patient to stand "ith legs slightly apart o Concentrate on perineum o .ra" perineum up"ard slo"ly Alternative "ay@ o >hen urinating3 try to stop in the middle of flo" or try to stop diarrhea from flo"ing o Advantage of Aegel6s E#ercises o 0ncreases muscle tone of the pelvis o 0ncreases muscle control 4+Clean 0ntermittent Self Catheteri1ation Applicable for efle# 0ncontinence %o" done@ o /se a mirror for@ -bese male patients Female patients Concept= o 2ossible Board Luestion@ 0s your Clean 0ntermittent Self Catheteri1ation procedure a sterile procedureC o Ans"er@ No3 it is ;ust a clean procedure+ $herefore3 you can ;ust "ash the catheter for the ne#t use+ 5+Crede6s !aneuver

55

 Application of a steady but gentle pressure on the supra* pubic region to force urine out of the bladder Nursing Alert= o .o not use if there is -BS$ /C$0-N &i+e+ renal obstruction in the form of renal stones) o $his is done only for patients "ho are no longer e#pected to regain control & efle# incontinence and retention) (+2rompted Voiding or Scheduled $oileting For efle# 0ncontinence 8+Application of Adult Catheter and E#ternal Condom Catheter For elderly "ith $otal 0ncontinence 9+Catheteri1ation MIDSTREAM CLEAN CATC, URINE S)ECIMEN %o" is this doneC 0f patient is a !aleI o Clean the penis o .o this from the meatus do"n to the shaft o Let the patient urinate o .iscard the first or the initial urine o Collect midstream urine o 2urpose is to attain sterile specimen for urine culture and sensitivity testing 0f patient is a FemaleI

o Let patient "ash genitals o .ry the genitals o <et to bed 2lace patient in semi*Fo"ler6s position "hen she is ready to void Clean and spread labia "ith t"o fingers emain holding labia $hen let patient urinate Let go of first flo" Collect ne#t flo"

CAT,ETERIDATION Coude Catheter o Elbo"ed catheter for Benign 2rostatic %ypertrophy patients obinson Catheter o Straight catheter !ulti*Lumen etention Catheter o Foley catheter -ne lumen is for inflation -ne lumen is for drainage of urine -ne lumen is for irrigation A three*"ay catheter Aspirate using syringe and needle $his is made "ith a self* sealing rubber Concepts;;; See to it that penis is perpendicular to body to straighten up the urethra to bladder >hile inserting the catheter3 ask the patient to breathe through the mouth Cleanse the penis before insertion 56

 <rasp penis firmly to avoid stimulating erections >here to tape catheter o $ape it up"ard on the abdomen ationale@ o $o avoid scrotal e#coriation o $ape on the inner thigh &"ith penis side"ays either on left or right and follo" the normal contour of the penis Length of Catheter o (H centimeters .epth of 0nsertion o >hile inserting3 the point at "hich urine starts to flo"3 insert further by five &8) centimeters and then inflate the balloon J A-B0E o 0nsert up to a the 7* point3 retract after inflating &this method is more prone to infection For females o 0nsert at female /rethra Length of Catheter o 44 centimeters .epth of 0nsertion o 2oint at "hich urine starts to flo"3 insert further by five &8) centimeter before inflating balloon GIT < FECAL ELIMINATION &e$$ness Teac#in s Fluid intake of at least 43HHH ml per day egular e#ercise %igh fiber diet 57

Avoid ignoring the urge to defecate .o not abuse la#atives Concepts; For Flatulence o Avoid carbonated drinks o .o not use stra" o Avoid che"ing gum o Avoid gas*forming foods@ Camote Cabbage Cauliflo"er -nions For Constipation: 0ncrease fluid intake 2rune ;uice 2apaya 0ncrease fiber in the diet /se !E$A!/C0L &natural fiber) instead of la#atives Specia$ Laborator" )roce%ures '+Guiac Test $o determine the presence of occult blood Concepts;;; o %ave a meat*less diet three &5) days before e#amination o >ithhold oral iron supplements o 0n;ectible iron is allo"ed o Avoid any food that discolors the stool+ 6+GI SERIES Upper GI Series < !arium S*a$$o* Nursing Considerations@

o Elimination of contrast medium %o"@ o 0ncrease fluid intake o 0ncrease fiber in the diet ationale@ o $o offset the risk of constipation o 0nform patient that the color of the stool "ill be >%0$E Lo*er GI Series < !arium Enema .one at the radiology department Nursing Concern@ o Elimination of Barium %o"@ o Cleansing enema may be needed after barium enema Different T"pes of Enema 5+ C$eansin Enema Soap suds enema Alkaline solution Nursin A$ert; o Contraindicated in patients "ith liver cirrhosis and "ith increased ammonia in the blood ationale@ o Alkaline solution facilitates transfer of ammonia from the <0 tract to the bloodstream $herefore3 use lemon ;uice or dilute vinegar instead=== Nursin A$ert; o Also contraindicated in possible appendicitis or appendicitis patients 58

ationale@ o Can lead to rupture of the appendi#

6+ Carminati(e Enema /sed to e#pel out flatus Burned sugar No" commercially available 7+ Oi$ Retention Enema 2urpose@ o $o lubricate the colon and to soften the feces o etention time is one &') to three &5) hours 8+ Retention F$o* Enema Also called %arish Flush Enema Solution is continually administered until "hat comes out of the body is clear+ )ositions in Enema Cleansing Enema %igh Cleansing Enema o Clean as much of the colon as possible o -n introduction3 Sim6s Left position facilitates flo" of enema to sigmoid colon o $hen3 assume .orsal ecumbent position to facilitate flo" of enema to transverse colon o $hen3 ight Side*Lying position to facilitate flo" of enema to the descending colon Lo" Cleansing Enema o For cleaning of rectum and colon only SEJUALITF

,uman Se2ua$ Response E2citement E )#"sica$ Stimu$ation Erotic stimuli causes se#ual stimulation Lasts for a fe" minutes to several hours T"pes of Stimu$ation )#"sica$ Stimu$ation -ral stimulation o Fellatio -ral stimulation of the penis using the mouth o Cunningulus -ral stimulation of the vagina o Anningulus -ral stimulation of the anus 0n homose#ual male3 typhoid fever may be obtained from anningulus !ale and Female oral se# is called S-0?AN$E NE/F )#"sio$o ica$ Se2ua$ Stimu$ation Stimulation by@ o Smell o Sight o %earing o Fantasy o Spoken "ords o !ental imagery Durin stimu$ation or )erio% of E2citement !ales 59

o Erection of the penis Females o edness near the ear o Nipples3 breasts move up o Fourchette retracts o Clitoris becomes visible o 0ncreased vaginal secretion o 0f female is unaroused3 there is backpain as penis hits the cervi# 0f the female is "ell* stimulated3 the cervi# rises )$ateau Sta e Lasts thirty &5H) seconds to three &5) minutes 0n males@ o Scrotum rises up"ard o Shaft of penis increases in length and "idth 0n females@ o Cervi# rises 0n both se#es@ o $here is increased muscle tone o !yotonia Or asmic )#ase or Or asmic Sta e Clima# of se#ual tension 2eak of se#ual e#perience Lasts three &5) to ten &'H) seconds Reso$ution Sta e -e" Concepts; o Females have longer resolution phase o !ales have shorter resolution phase )ERIO)ERATI'E NURSING

Sta es of )erioperati(e Nursin 2re*operative 2hase 0ntra*operative 2hase 2ost*operative 2hase )re0operati(e )#ase Begins upon decision of patient to undergo the operation Ends "hen patient is placed on the operating table Intra0operati(e )#ase Begins "hen patient is placed on the operating table Ends "hen client is admitted to the 2ost*Anesthesia Care /nit or 2AC/ )ost0operati(e )#ase Begins upon admission to the 2AC/ Ends upon the discharge of the patient S9in )reparation 2urpose@ o $o reduce post* operative infection by@ emoving soil and transient microbes educing microbial count to subpathological level in a short period of time "ith minimal skin irritation+ Concepts; %air on the skin should not be shaved if it does not interfere "ith the procedure

0f hair needs to be removed3 the best method "ould be through the use of@ o Clippers o .epilatory cream Shaving is N-$ A.V0SE.+ $his is the last choice >here is shaving doneC o Not at the -perating oom= TF)ES OF &OUNDS 5+ C$ean &oun% /ninfected No inflammation espiratory3 Alimentary and /rinary tracts are not entered 6+ C$ean Contaminate% &oun% A surgical "ound No evidence of infection espiratory3 <03 /rinary tracts are entered

7+ Contaminate% &oun% 0nvolves large spillage of content from the <03 /rinary and espiratory tracts 2ositive for inflammation 2ositive for infection .irty 0nfected >ound -ld "ounds Necrotic3 gangrenous "ound Mo%es Dressin of App$"in Gau1e

5+ Dr" to Dr" A "ide mesh of cotton applied to the surface of the "ound A second layer is applied over it 60

6+ &et to Dr" 0nner layer is saturated "ith NSS or anti*microbial agent -n top is a moist absorbent material 7+ &et to Damp A variation of "et to dry 0t is removed before it is completely dried 8+ &et to &et 0nner layer is saturated "ith NSS or anti*microbial solution Second layer is a "ide mesh 0t is kept moist "ith a "etting agent

61