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Communication: The nurse-patient relationship • Working- in this phase the nurse and patient participate in nursing care activities. The
Effective communication within the nurse-patient relationship is not so much a natural process as a patient “uses” the nurses expertise and abilities on his/her behalf.
learned skill. In the nurse-patient relationship, the client and his or her experiences and problems are
• Termination- is the closure of relationship phase. The nurse reviews with the client aspects
the main subject of communication. The results are directed towards improving coping skills related
of care and how they have dealt with physical and emotional responses.
to the clients’ health status and well-being.
Ingredients of therapeutic communication
Therapeutic communication-facilitates interactions focused on the client and the clients concerns
1. Empathy
Types of communication:
2. Positive regard
a) Verbal
3. Comfortable sense of self
b) Non-verbal
Causes of non-therapeutic responses
c) Meta communication- i.e. a message about a message. It includes anything taken into
Non-therapeutic responses prevent nurses from functioning as professionals and therapeutic agents in
account when interpreting what is happening.
the care of clients.
Relationships among types of communication
• Rescue feelings-theses occur when a nurse feels essential to the clients welfare.
1. Congruent relationships- the way nurse-patient communicate fit together i.e. good fit between
• False re-assurance means giving reassurance that is not based on the real situation
verbal non verbal and meta communication e.g. nurse rounds indicate “I am your professional

nurse. We will work together to meet your nursing care needs.” • Giving advice-i.e. Nurse focuses exclusively on own experiences and opinions

• Changing the subject-this usually indicates anxiety on the nurses’ part.

2. Incongruent relationships- the way nurse-patient communicate does not fit in recognizing
• Being moralistic- means seeing a situation as good or bad or right or wrong.
incongruence between kinds of communication informs the nurse about the clients experience.

Within the nurse-patient relationship the nurse assumes the roles of a professional and a helper. • Non-professional involvement-means being overly social and trying to be the clients’ friend

The client is the one seeking help. The relationship focuses on the client is goal directed and has or buddy.

defined parameters. The nurse also assesses how his/her own role communication skills; Client education

personal history and values may be affecting the interactions. 1. Qualities of a teaching-learning relationship.

In nursing, the relationship between teacher and learner is special, characterised by mutual sharing,
Phases
advocacy and negotiation. Effective learning occurs when clients and healthcare professionals are
• Orientation-this phase consists of introductions and an agreement between nurse and client
equal are equal participants in the teaching-learning process. At times teaching must be delayed until
about their mutual roles and responsibilities.
clients desire to participate actively. Positive qualities of a teaching relationship include:
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• Client focus- client education is a therapeutic relationship focusing on the client’s specific 4. Assessing learning

needs. • Motivation- provides drive and is a powerful determinant of success in client education. It

• Holism-the teaching-learning relationship considers the whole person. is related to compliance to treatment plan.

• Negotiation- nurse and client determine what is already known and what is important to • Compliance-assessing history of client’s compliance or non-compliance.

learn. • Sensory and physical state-these affect learning readiness and the teaching plan must be

• Interactive- the teaching-learning relationship is a dynamic, interactive process that modified accordingly.

involves active participation from nurse and client. • Literacy level- illiteracy is found in every walk of life, among all races and at all socio-

2. Purpose of client education: economic levels. Educational level gives only a rough estimate of literacy. Direct testing is

• Promote wellness the most accurate way to assess literacy, but it is not practical in the clinical setting.

• Prevent disease Care management

The management of health care needs in the home setting involves the client and also family
• Restore optimal health or function
members, friends and other sources of support. The nurse collaborates with people to manage their
• Assist clients and families to cope with alterations in health status.
health care needs in the home setting and uses community resources to support clients in this effort.
3. Assessment for learning

The educational assessment begins with determining what the client needs to know or to do function As a client moves or is moved from one environment to another, nurse must consider the clients’

independently. ability to carry put activities of daily living (ADLs). Understanding the client in relation to the living

i. Baseline knowledge- many times, clients articulate specifically what learning is important environment is important in developing plans for care that maximise the persons ability to maintain

to them and why. Other times requests for knowledge are less direct. independence safely.

Home healthcare
ii. Cultural and language needs- religion, health beliefs, language and sex roles beliefs are
A range of health issues and related services characterizes home healthcare. Such services are
important factors to consider when planning education.
delivered to persons at home who are recovering from illness, the disabled or chronically ill and need
iii. Priorities-clients usually have many learning needs, so nurses must set priorities to help
various services to progress, maintain function or perform their ADLs. These services can involve
ensure that teaching will be effective.
multi professionals.
iv. Realistic approach-realistic approach enables nurses to set priorities and try not to teach
Def; home care nursing is the provision of nursing care to acute, chronically ill and well clients of all
too much in any one teaching session. Consider client’s energy level, age and emotional
ages, in their homes while integrating community health nursing principles that focus on health
state.
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promotion and on environmental psychological, economic, cultural and personal health factors • The nurse as facilitator of self-determination of self-care in the roles of educator, advocate,
affecting an individual and families health status. spiritual communer and case manager.

Trends affecting home health care. The client and family and family move along a continuum from dependence to interdependence to
• Earlier discharges from hospital due to technological advances in medical equipment. independence. The nurse does initial assessment in order to collaboratively identify needs of the

• Increased demand for cost-effective healthcare option (homecare) client and family for education, advocacy, spiritual communion/aesthetic and case management. The

• Managed care plans-at home. rice model emphasizes the importance of shared responsibility among the nurse, client and caregiver

• Changes in family status to promote the whole persons health and optimal self care capacities

• Increased self-care responsibilities Phases of home nursing visits

• Initiation-includes clarifying the source of referral and the purpose of the visit and initial
• Increased expectations of lay care givers.
contact with the family.
• Tele-home health-use of interactive television and transmitted of data.
• Pre-visit- includes establishing an understanding with the family for the purpose of the
Home care versus acute care
visit, scheduling the visit and reviewing pertinent records and information.
In home care the nurse is “guest” in the clients home. The clients and families retain the power and
• In home phase-involves establishing the professional therapeutic relationship and
control. The opposite is true in acute care setting.
implementing the nursing process

• Termination phase-the nurse and family summarize accomplishments of the visits and make
Factors affecting home healthcare management
plans for future visits.
• Decreased functional abilities
• Post visit phase- includes recording findings and carrying out activities necessary to plan
• Insufficient family or social support
for the next visit.
• Insufficient community resources

A framework for home care

The rice model (2001) dynamic self-determination for self-care

The purpose of home care is to provide patients (care givers) with the understanding, support,

treatment, information and caring they need to successfully manage their health care needs at home.

• Motivational factors of the client and family (care giver)

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Assessment of home management and home conditions • Care/case management-components of this include: assessment, planning coordinating,

Assessment should encompass the functional abilities, strengths and assets of the client, family, home making referrals, monitoring medical progress, filing and completing paperwork,

and community. The nurse collects subjective information to assess how the person normally monitoring outcomes and the plans’ effectiveness, determining case closure and

manages at home, what the home is like and what family and community support is available; the transferring the case at closure.

nurse explores the clients beliefs and culture, competences, capabilities, concerns, deficits and • Coordination-nurse works collaboratively with other healthcare professionals in planning

limitations to understand how the client manages at home and what he/she desires. Assessment implementing and evaluating the client’s care.

includes; • Accessing community resources-home care nurse may need to access and coordinate the

• The individual procurement of needed equipment for clients.

• The family Hospice

Nurses play a major role in hospice care and work with multi professional’s team. Nurses focus on
• Risk-include unsafe neighbourhoods, inadequate housing, difficult clients, long waiting
managing pain, treating symptoms and helping clients live life to the fullest until death. Nurses work
lists, lack of volunteer programmes, inadequate home health services.
with family members to assist in bereavement and reorganizing their lives.
• The home- includes safety, sanitation mobility, temperature and personal space
Skin integrity and wound healing
• Community resources-economic stability, neighbourhood, social and health resources, and
Adequate blood flow to the skin is necessary for healthy viable tissues. Alterations in adequate blood
community’s cultural norms.
circulation can lead to skin that has abnormal colour, texture, thickness, moisture or temperature or

that becomes ulcerated.

Leg ulceration

Leg and foot ulcers occur from venous disease, arterial disease and diabetes mellitus. Impaired
Care management and responsibilities in home care.
circulation in the lower extremities produce ulcerations that are difficult to heal unless the underlying
• Patient education-nurses assess for readiness of client and family to learn; they negotiate
disordered treated. Stasis dermatitis result for impaired venous return. Pooling of blood leads to
the learning objectives and collaboratively with client and family develop and implement a
oedema, vasodilatation and plasma extravasations all of which result in dermatitis by increasing the
teaching plan.
disdance between the blood vessel and the skin they nourish.
• Advocacy- protecting rights of clients to promote client autonomy and self-actualisation.

• Aesthetic/communion-entering the “caring moment” by acknowledging the holistic nature

of clients and caregiver.

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Pressure ulcers 2nd phase- regeneration follows inflammatory phase in healing of partial-thickness wounds.

Bed sores result when capillary blood flow to the skin or underlying tissue is impeded. These ulcers Epidermal cells reproduce and migrate across the surface of partial- thickness wound a process called

result from unequal distribution of pressure over bony prominences and decreased blood flow to re-epithelialization. When cells have been covered the base of the wound, cells continue to replicate,

these areas. increasing the number of cellular layers in the epidermis to assimilate the thickness of healthy

Pressure ulcer staging epidermis.

Stage1: non blanchable erythmea of skin over a bony prominence or area of pressure. Most stage 1 In full thickness wound healing, proliferation occurs after inflammation. Granulation tissues

ulcers are reversible if pressure is relieved. Assessment is difficult in dark-skinned individuals. consisting of a matrix of collagen embedded with macrophages, fibroblasts and capillary buds is

Stage2: superficial ulcer that manifests as an abrasion, shallow crater or blister. Partial thickness skin produced and fills the wound with connective tissue. Open wounds undergo contracture during this

loss involves the epidermis, dermis or both. The ulcer is painful. phase of healing. Contracture can be seen by its effect of pulling the wounds inward, leading to a

decrease in depth and dimension of the wound. This phase lasts from day 4 after injury to about day
Stage3: full thickness skin loss involving damage or loss of subcutaneous tissue that may extend
21 in a normally healing full-thickness wound.
down to, but not through underlying faslia. These ulcers requires months to heal.
3rd phase- maturation is the final stage of full thickness wound healing. It begins about 3 weeks after
Stage4: full thickness skin loss with extensive destruction, tissue narcosis or damage to muscle, bone
injury and may last up to 2 years. The number of fibroblasts decrease, collagen fibrils become
or supporting structures (e.g. tendons, joint capsule); it may have underlying or sinus tracts.
increasingly organized, resulting in greater tensile strengths of the wound. The tissue reaches
Wound healing
maximum strength in 10-12 weeks, but even after healing, only 70-80% of original strength can be
When a wound is present, a type of healing by replacement occurs. The nature of this healing is
expected.
similar for wounds of similar depth, but the time frame for healing depends on the wounds location

and extent; the regenerative capacity of the injured cells and the clients overall health. Types of wound healing

Phases of wound healing Wounds heal differently depending on whether tissue loss has occurred.

Wounded skin is repaired by regeneration or connective tissue repair. Many cells are involved in this 1. Primary intention- wounds with minimal tissue loss e.g. surgical incisions, heal by this intention.

healing and a number produce and release chemical messengers called growth factors, which play an The edges are approximated or lightly pulled together. Granulation tissue is not visible and scarring is

important role in the healing process. minimal. Infection risk is lower when a clean surgical wound heals by primary intention.

1st phase is inflammation. Injury to tissue prompts the responses of homeostasis, oedema and 2. Secondary intention- wound with full-thickness tissue loss, such as lacerations, burns and pressure

attraction of leokocytes to the wound bed. This phase lasts 3 days. ulcers have edges that do not readily approximate. The open wound gradually fills with soft, pinkish-

red buds that bleed easily (granulation tissue). Eventually, epithelial cells grow over these
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granulations completing the cycle. Scarring is more prevalent: because the wounded is open for a 4. Intramuscular injection- injections placed into muscular tissue sites commonly used are the
longer time, it becomes colonized with microorganisms that lead to infection. ventrogluteal, vastus laleralis, deltoid and dorsogluteal muscles.

3. Tertiary intention- healing by this intention occurs when a delay ensues between injury and wound 5. Intravenous route- route to administer medications directly into the vein or venous system,
closure. This type of healing is also referred to as delayed primary closure. This happens when a deep the most dangerous route of medication administration.
wound is not sutured immediately or is purposely left open until there is no sign of infection and then
6. Subcutaneous injection- injection placed between the epidermis and muscles, into the
closed with sutures. When a wound heals by secondary or tertiary intention, a deeper and wider scar
subcutaneous tissue, sites commonly used are the outer aspect of the upper arm, the
is common.
abdomen, the anterior aspects of the thigh, the upper back and the upper ventral or
Factors affecting wound healing.
dorsogluteal area.
1. Systemic factors like: nutrition, circulation and oxygenation obesity, smoking
7. Sublingually- under the tongue
2. Local factors like: nature of injury, presence of infection.
8. Vial- a glass bottle with a self-seal stopper through which medication is removed.
Complications of wound healing.
9. A drug- is any substance that alters physiologic function, with the potential for affecting
1. Haemorrhage and interstitial fluid loos health.
2. Haematoma 10. A medication is a drug administered for its therapeutic effects
3. Infection Systems of medication distribution
4. Dehiscence- total or partial disruption in wound edges i.e. wound separation 1. Stock supply limited- large quantities of frequently prescribed medications are stored in
5. Evisceration- protrusion of viscera through an abdominal wound opening locked cupboards in a store. Individual doses are dispensed and administered by nurses.
6. Fistula 2. Unit-dose system: this involves the pharmacy or manufacturer in packaging and Para
Medication administration labelling an individual client dose.
Key terms: 3. Automated medication-dispensary system-this is common in healthcare facilities.
1. Ampoule- a glass flask that contains a single medication for intravenous administration. 4. Self-administered medication system- supplies each client with his or her prescribed doses
2. Inhalation-route to administer medication into the lungs or airway passages. and quantities for a given period.

3. Intradermal injection- injection placed just below the epidermis; sites commonly used are 5. Bar code medication administration- this system uses lightweight hand-held laser scanner

the inner+- and bar codes.

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Non-prescription and prescription medications Medication name: the name can be written using generic or trade name. The name should be written

1. Non-prescription medications: these are obtained without a written order from a healthcare clearly because many medications are similar in spelling but different in drugs action.

provider. Medication dosage: dosage can be written using metric, apothecary or household

2. Prescription medications: a prescription is a legal order for the preparation and Measurement system: the strength and frequency of the dose are also indicated e.g. digoxin 0.25mg

administration of a medication. once a day

Route of administration: this is commonly abbreviated as a part of the written order- e.g. (PO)-orally
3. Herbs and other botanicals: unlike other medications, herbs and botanicals lack quality
standards and regulation; their ingredients or quantities may or may not be as stated on the Signature: because a written order is a legal (document) request, the prescribers signature must follow

label. Herbal preparations doses vary depending on how it was prepared and the plant the written order.

source used. The preparations are classified are classified by “food and drug act” as Types of orders

“dietary supplements.” 1. Routine or standing order: this is one that should be carried out for a specified number of

days e.g. antibiotics or until another order cancels it e.g. diabetic medication.

2. PRN orders: this does not indicate a specific time for administration of a medication. It

Medication order states guidelines so that medication can be administered as needed.

Components: 3. Standing protocols: these are written for medications to be administered in specific

The prescriber conveys an order by specifying the clients name, the medication name, amount and situations with criteria for administration outlined clearly for clients on a specific unit or

frequency of the dose and route of administration. Included with this directive are the date and time services.

the prescription was written and the signature of the prescribing healthcare provider. The clients first 4. One-time order or single order is written for a medication that will be given only e.g. pre-

and last name must be written with the medication order to avoid confusion between two clients with medication order.

same last names. The client’s medical number must also be written as further identification. 5. Stat order- is a single order for a medication that must be given immediately e.g. IV stat
Abbreviations are commonly used in the medication order- they indicate the amount and frequency of frusemide 20 mgs

a dosage. These abbreviations are legal and are written in the client’s chart. Commonly used are:
6. Telephone, verbal and fax orders- the nurse and prescribers may discuss a client’s condition
TDS-every eight hours; BD every 12 hours; QDS-every 6 hours; OD-once every 24 hours; Liq-
over the phone and decide to change the clients medication regimen. Because the prescriber
liquid; IM-intramasclar; IV-intravenously; tab-tablet; tsp-teaspoon; P.R.N-when required.
is not available to write and sign the order, the nurse may write the order on a physician
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order sheet. The order is designated on the sheet as a telephone order and signed by the Interpretation of the orders

nurse. The nurse is responsible for safe interpretation for safe interpretation of the medication order. If the

Legal aspects of medication administration order is illegible, the order can easily be misinterpreted. Confirm unclear order or unusual

1. Food and drug administration. This is controlled by the pharmacy and poisons board of abbreviations. Evaluate if the route and dose are safe for the client.

Kenya- ministry of health. Calculating adult medication dosages.

2. Controlled substance. As a result of rising drug abuse and increasing public concern Expertise in medication calculation and administration is essential for safe medication administration.

controlled substance act was established by parliament. Controlled substances are drugs Dose on hand = dose desired

that are considered to have either limited medical use or high potential for abuse or Quantity on hand x
addiction.
Where x is the quantity desired
3. Nurses practice act. Nursing legislation controls the administration of medication by nurses.
e.g. 400mgs of an antibiotic is ordered and you have 200mg tablets on hand
4. Institutional medication policies. Nurses work in various settings, including schools,
200mg/1 tablet = 400mgs/x
hospital, nursing homes, home healthcare agencies and private industries. Each institution
200x=400
develops and oversees its own medication administration policies and these rules can vary
x=2 tablets
widely.
e.g. you have 0.25mg of digoxin ordered IV. The vicil the pharmacy sent says 0.125mgs=ICC
5. Client’s rights. The client has the right to expect safe and appropriate drug administration
0.125/ICC = 0.25/x
by the nurse.
0.125x=0.25
6. Substance abuse. The illegal use of drugs by any health professional jeopardizes client
X=2 CC
welfare and professional credibility. Stringent rules and procedures help to prevent
Administering medication according to the “five rights”
diversion of client medications to healthcare personnel.
After validating the order and calculating the proper drug dose, the following can ensure accurate
Safe medication administration
administration:
To administer medication safely, the following actions are necessary:
• The right client: the first “right” of administration of medication means the right medication
• Accurately interpret the prescribers order.
is given to the right client for whom it is intended.
• Accurately calculate the amount of drug to give for the prescribed dose.
• The right medication: the second “right” means the medication given is the medication that
• Develop a systematic and safe procedure, using the “five rights” for drug administration.
was ordered and is appropriate for the client.
• Document medication administration according to agency policy.
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• The right dosage: the “third right” means the medication is given in the dose ordered and An important aspect of accurate home medication administration is ensuring a schedule or regimen

the dose is appropriate for the client. that is easy to remember and suits the clients lifestyle. Nurses arrange administration by linking it

• The right route: the “fourth right” means the medication is given by the ordered route and with normal events in clients life e.g. meals, bedtime; which promotes compliance and accuracy.

that route is safe and appropriate for the client. Oral medications

• The right time: the fifth ”right” means the medication is given with the correct frequency Oral medications are designed to be swallowed or held under the tongue until they dissolve or held in

the side of the mouth until they dissolve (buccal route). Oral medications can also be given into
and time ordered according to policy.
feeding tubes.
Documentation of medication administration
If the client cannot swallow water or fluids or is nauseated or vomiting, oral medications are usually
Medication policies define the time and type of medication documentation required. This includes:
discontinued or given by another route. If a client is “NIL per oral” before a test or surgery, selected
time, route, dosage, site of administration and the nurses initials and signature. Specific
oral medications are given with sips of water. If nil per oral after major surgery, oral medication are
documentation is required if a nurse does not give a medication administered.
withheld or administered by another route until intestinal function resumes. If client is treated with
Medication errors
gastric suction, oral medication are withheld or given by another route.
Medication errors include when a medication is not administered as ordered; when the order is unsafe
Tropical medications
or inappropriate for the client or when the documentation in a clients chart does not reflect that a
These medications are placed on the skin surface or mucous membranes. They may also be placed in
medication was administered as ordered or iv medication administered at the wrong rate and charting
body cavities.
medication that was not given. Nurse must ensure the name of the medication supplied is the same as
Lotions, cream and ointment
not just similar to the name of the medication ordered. This error occurs with increased use of generic

medications. These are used to treat skin or wound infection or skin disease or to decrease symptoms of skin

Medication administration in the home disorders. Lotion moisturizers prevent complications with excessive dry skin. Lotion are rubbed into

Types of medication the skin until no longer visible. Creams are applied to skin surfaces with a sterile swab or sterile

tongue depressor or gloved fingers. Clean and dry skin ointments are applied to protect skin against
Oral medications like antibiotics and analgesics have always been prescribed for clients to take at
chafing or maceration associated with bowel and bladder incontinence. Clean and dry skin first.
home. Long term antibiotics or antinoeplastics medication are administered in the home via portable

IV infusion devices.

Organizing medication regimes in the home

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Transdermal medication Nasal medications

These are medications designed to be absorbed through skin for systemic effects. They are prepared Solutions are usually sprayed into the nose to treat nasal congestion. Frequent use can cause systemic

in patches. Patches have special membranes that allow medication to be absorbed slowly over 24-72- effects e.g. tachycardia or hypertension. When administering nasal spray, client sits up and leans

hour period his/her head back. Holding the medication bottle in one hand, place top of bottle just inside the nostril

Application guidelines aiming the spray applicator top toward the midline of the nose while the client inhales, squeeze the

• Remove previous patch bottle.

• Fold the patch in half and avoid touching the inner surface continuing medication Rectal medications

• Apply the new patch to a clean, dry, hairless intact area of skin. Medication in suppository form is placed in the rectum to treat systemic complaints or as laxative to

• Rotate sites encourage bowel movements or as antemetics. Liquid enemas or resin enemas to remove potassium

• Apply the patch immediately after removing the protective liner from the bowel if level is high.

• Wash hands before and after applying the patch. Vaginal medications

• Dispose used patch carefully into a sharps bin. Vaginal medications come in various forms like: foams, jellics, liquids (douches), creams, tablets or

• Note date, time and your initials on the patch. suppositories. These are used for contraception, infection, pre-gynaecological operation preparation

Ophthalmic medications or to induce labour

Ophthalmic solutions and ointments are used to treat eye irritation, infections or glaucoma. The lower Inhaled medications

eyelid is gently retracted and the solution or ointment is placed in the conjuctival sac. Do not touch Inhaled medications may be used to induce anaesthesia during surgery and to treat respiratory

client’s eyelid or eye with tip of tube or dropper. Instruct client not to rub the eye after application of disorders. Nurses administer inhaled medications through mechanical ventilator, a hand held

medication. nebulizer or a metered dose inhaler. Liquid medication are added to a receptable in the ventilator or

Otic medications nebulizer and changed into a gas form when air or oxygen flows over them. Nurse anaesthetics

administer anaesthetic medications. Assess the clients respiratory status before and after
Solutions may be dropped into the ear to treat external ear infections or to soften and remove earwax.
administering an inhalable bronchodilator.
Use solutions at room temperature, because using hot or cold solutions can cause vertigo, nausea and

pain. Parentral medications

The parentral route refers to medication given by injections or infusions. Parentral medications may

be injected into: intradermal (ID), subcutaneous (SC), intramuscular (IM) or intralesional tissue; Into
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intravenous (IV), intra-arterial circulation; or into intraspinal, intra-articular spaces. Parentral • Complexity of administering IV medication outside healthcare settings

medications are absorbed more completely and begin acting more quickly than medications given by
• Difficulty of maintaining patency of peripheral IV cannulae
oral or topical routes. This route requires aseptic technique in preparation and administration to
• Risk of phlebitis and generalised infection
prevent infection.
Medication prepared in an oil base and insoluble substances cannot be administered by IV route e.g.
Subcutaneous injections (SC)
penicillin G.benzathine, which contain large particles suspended in a solution; the large medication
Medication administered through the abdomen are absorbed more rapidly, those administered into the
particles might act as emboli and lodge in small veins.
arm are absorbed intermiately and into the thigh and upper buttocks slowly. Avoid areas like;
Types of IV access
underneath burns, birthmarks, inflamed tissue or scars because of unpredictable medication
• Vein access (peripheral) for short term intermittent therapy
absorption. Absorption is slow or incomplete in oedematous areas, severe peripheral vascular disease

or in cardiogenic shock. Medication may be absorbed faster than expected if client has little S/C • Central vein access for orbolus doses long term, continuous or intermittent therapy

tissue e.g. premature babies or cachectic adults.

Techniques:
Intramuscular injections (IM) • IV push (bolus) – rapid administration of medication

Medication given by IM route are absorbed immediately, but slower than IV administration. • Intermittent infusion- commonly used- 20-60 minutes (intermediate length). Volumes

Intravenous administration 50mls-500mls. Volumetric or syringe drivers are used.

IV medications are given through cannulae inserted into veins. • Continuous infusion- used for medication that must be given continuously to achieve the

Advantages desired effect e.g. heparin; and for medications that are toxic if given over a short period

• Rapid action of medication e.g. cisplatin, potassium

• Predictable, therapeutic blood levels of medications can be obtained. Machines used for continuous infusions can be programmed to deliver a set volume of IV fluids over

• The route can be used when absorption in other route is unpredictable a specific time frame, usually a number of millilitres per hour. This prevents overdose. The machines

• The route is used for medication that cannot be used by other routes have audible alarms that temporarily stop the infusion while simultaneously alerting the nurse to

• Large doses can be administered by using this route. check the system. Problems that set off the alarm:

Disadvantage • Air in the tubing

• High cost of treatment • Occlusion (kinking of tube, dot formation at cannulae tip)
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• Infusion complete effort are general indicators of the effectiveness of oxygen therapy. Arterial blood gas

• Empty bag. monitoring and pulse oximetry provide more specific information concerning client response to

Patient-controlled analgesia (PCA) oxygen therapy. For most clients, the aim of oxygen therapy should be to maintain the PaO2

PCA devices permit clients to administer opiates intravenously as needed for pain control. PCA above 60mmHg or the SaO2 above 93%. It is rarely necessary to exceed a PaO2 of 90mmHg or

device is programmed electronically to deliver a set amount of medication (a controlled substance) an SaO2 greater than 97%. Most often, clients use oxygen continuously for a short time as

through a pre filled syringe connected to IV tubing. Specific dosages and time intervals can be possible until they can maintain satisfactory blood oxygenation without it.

programmed into the machine to prevent over dosage. Medication is delivered when the client pushes Selection of oxygen systems

a control button. The clients’ oxygenation status determines which oxygen delivery device is most appropriate- that

Oxygenation can deliver his/her oxygen needs e.g.

Oxygen therapy
• Nasal cannula for small amount of oxygen
Some clients need oxygen therapy to maintain adequate arterial blood oxygen levels. Oxygen therapy
• Simple face mask for moderate amount of oxygen
is used to reverse hypoxemia
• A reservoir mask for high concentration of oxygen.
Purposes
Safety considerations
• To improve tissue oxygenation
Because oxygen is a drug, a prescription is required for its use. Potential risks include harm with
• To decrease work of breathing in dyspenic clients
misuse e.g. lung damage with high concentrations. No smoking sign to be put up on client’s bedside

• To decrease work of the heart in clients with cardiac disease to prevent risk of fire from cigarettes.

General principles of oxygen administration Oxygenation: cardiovascular function.

1. Oxygen is prescribed either in terms of flow or concentration depending on the client’s needs Factors affecting cardiovascular function

and the delivery devices capabilities. Oxygen flow is expressed in litres per minute. 1. Cigarette smoking-it increases the heart rate and blood pressure, constricts arterioles and cause

Concentration is expressed as a percentage or as a fraction of inspired oxygen. A general rule for irregular cardiac rhythm, atherosclerosis and peripheral vascular disease. Smoking limits the blood

safe oxygen therapy is to use the lowest oxygen concentration or flow possible to achieve an oxygen carrying capacity by displacing oxygen with carbon monoxide.

acceptable blood oxygen level. 2. High blood pressure- is a manifestation of cardiovascular dysfunction and in turn cause of further

dysfunction, resulting in severe tissue and organ damage.

2. When administering oxygen, assess the client’s response regularly to determine the need for
3. Nutrition- diet high in total fat is strongly associated with the risk of heart disease.
continuation or adjustment of therapy. The clients’ colour, alertness heart rate and breathing
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4. Lack of exercise – improves heart’s pumping efficiency. Nursing diagnosis

5. Diabetes- an independent risk factor for M1 and stroke. Diagnosing human responses to actual or potential health problems is the second phase of the nursing

6. Obesity- places excessive demands on the cardiovascular system. process. After collecting relevant information about a client, nurses need to analyse and interpret the

7. Medical and family history- genetics play a role in certain cardiovascular disorders. data. The results of this interpretation are the nursing diagnosis.

8. Stress- cause hypertension, angina and M1, elevates serum lipids and blood coagulation. Definition: nursing diagnosis is a clinical judgement about individual, family or community response
Altered cardiovascular function to actual or potential health/life processes. The nursing diagnosis provides the basis for selection of
Tissue oxygenation requires that all portions of the cardiovascular system work properly. nursing interventions to achieve outcomes for which the nurse is accountable. The term nursing
1. Changes in vital signs diagnosis serves as both the label and the action of describing a client’s functional problems.

Blood pressure- BP fluate with changes in cardiac output and fluid volume. Purpose: its purpose is to identify problems and synthesize the information gathered during the

Pulse character- diminished or absent pulses indicate inadequate blood flow to an area. nursing assessment by:

Heart rate- it increases in response to increased oxygen demand. A resting heart rate of 100 beat/min • Analysing collected data

indicate problems with cardiac output. An increase in heart rate of more than 20 beats/minute during • Identifying the client’s strengths
mild activity indicate decreased cardiac output is contributing to activity intolerance. Conversely, a
• Identifying the clients normal functional level and indicators of actual or potential
heart rate that does not increase with exercise may indicate that the heart is unable to adjust to
dysfunction
changing oxygen demands.
• Formulating a diagnostic statement in relation to this synthesis.
Respiration- this increases with effort in cardiovascular dysfunction. With increased activity, tissues In the diagnosis phase, the nurse does the following:
demand more oxygen thus respiration increases to supplement and blood oxygenation.
• Identifies patterns

2. Changes in the skin- skin colour is an indicator of the level of blood oxygenation and • Validates the diagnosis

adequacy of local blood flow. Skin temperature rises with increased blood flow to the skin, • Formulates the nursing diagnosis statement.
vascular constriction or poor perfusion cools the skin. Historical development

3. Decreased cardiac output- muscle damage, value dysfunction or conduction problems can 1926- Harmer suggested nurses should include problem statements when documenting care.

decrease the hearts ability to pump blood effectively resulting in cardiogenic shock. 1947- Lesnich and Anderson argued that diagnosis was within the scope of nursing practice.

1953- Fry was credited with the first use of the term nursing diagnosis in the nursing literature.
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1996- joint commission on the accreditation of health care organization mandated that each clients Only healthcare problems within the scope of nursing practice can be identified as nursing diagnosis.

nursing care be based on identified nursing diagnosis or client care needs. A nurse cannot diagnose a medical disease and is not licensed to treat such a problem. Registered

Interest in the nursing diagnosis movement has been stimulated by the contribution that nursing nurses must take care to identify client problems within their scope, practice abilities and education.

vocabularies can make in: This enables them to determine whether such problems can be addressed legally and independently in

a) Documenting care such a case the problems can receive a nursing diagnoses.

b) Linking nursing contributions to quality outcomes Collaborative health problems:

c) Costing out nursing care services. Collaborative problems refer to actual or potential physiologic complications that can result from
Nursing diagnosis taxonomy disease, trauma, treatment or diagnostic studies for which nurses intervene in collaboration with
Professionals require a sound scientific base; the nursing process is nursling’s scientific base. To personnel of other healthcare members. (see handout)
achieve this scientific foundation, nursing requires a taxonomy or classification system to provide a
Procedures, medical terminology, symptoms client needs and treatment are often confused with
structure for nursing practice. The purposes of taxonomy are:
nursing diagnosis. For example if the nurse write “Foley catheter,” this is treatment, not the response
I. To provide vocabulary for classifying phenomena in a discipline
the client may have to the treatment. Other examples include “need for oxygen” or “dyspnoea” terms
II.Provide new ways of looking at the discipline
that describe symptoms and do not provide enough information to validate the presence of a nursing
III.Play a part in concept derivation
diagnosis. Another mistake is to write “lack of adequate nutrition” as the nursing diagnosis. This
Nursing diagnosis and other healthcare problems
phrase describes a client need, but it is not a nursing diagnosis. The nursing diagnosis in this case
Nursing diagnosis must be distinguished from medical diagnosis.
would be “imbalanced nutrition less than body requirements”
Medical diagnosis-describes a disease or pathology of specific organs or body systems. Medical
The following lists shows the proper use of a variety of terms for a client with a specific breathing
diagnosis conveys information about the signs and symptoms of disease processes and provide a
problem.
convenient means for communicating treatment requirements. The physician’s focuses on treating the
• Medical diagnosis: pneumonia
underlying pathology.
• Nursing diagnosis: ineffective airway clearance related to tracheobronchial secretions.
In contrast, a nursing diagnosis describes an actual, risk, or wellness human response to a health

problem that nurses are responsible for treating independently. Nursing diagnoses describe the clients • Client need: oxygenation

responses to the disease process, developmental stage or life process and provide a convement way to
• Procedure: bronchoscopy
communicate nursing therapies or interventions.
• Treatment: oxygen therapy
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Formulating an accurate nursing diagnosis is a clinical judgement but nursing diagnosis should not be 6. Related factors: related factors describe conditions, circumstances or etiologies that
written judgmentally. For example it is incorrect to write “failure to carry out medical regimen contribute to the problem. Terms that can be used are associated with, related to and
related to drug use.” The reasons for the clients non compliance with the regimen should be explored contributing to. Identifying related factors helps nurses to develop specific interventions to
and analysed to avoid labelling or stereotyping a clients’ behaviour based on insufficient evidence. resolve the health problem. For example nurses would use different nursing interventions

Components of a nursing diagnosis when caring for a client with stress incontinence related to high intra-abdominal pressure

1. Diagnostic label: this is the name of the nursing diagnosis as listed in the taxonomy. It than for a client with stress incontinence related to over distension between voidings.

describes the essence of the problem using as few words as possible. Some examples Diagnostic activities
include: stress urinary incontinence, anxiety, and feeding self-care deficit.
1. Identify pattern: the nursing assessment data, both objective signs and subjective symptoms
2. Descriptors: this word used to give additional meaning to a nursing diagnosis. They
from cues. Several cues form a cluster, which is then interpreted and validated. The result is
describe changes in condition state of the client or some specific nursing diagnosis.
nursing diagnostic label that accurately reflects the specific client problem. As nurses
Examples include: ability, balance, compromised, perceived etc.
develop skill in making clinical judgements, they evaluate individual pieces of data,
3. Definition: each nursing diagnosis that NANDA approves for clinical use and testing has a
examine trends and view the client as a whole. The major problems in cue clustering are
definition that describes the characteristics of the human response under consideration. For
insufficient, inaccurate and inconsistent cues. Skill in cue clustering comes with experience
example the definition of the diagnostic label Hypothermia is “body temperature below
and practice. The lack of adequate cues can also cause premature closure i.e. selecting a
normal range.”
diagnosis before analysing pertinent information. Intellectual activity of cluster
4. Defining characteristics: defining characteristics are the “observable cue (pt
interpretation requires nurses to see the whole picture and to attach meaning to the cluster.
information)”/inferences that cluster as manifestations of an actual or wellness nursing
Looking at the pattern the cluster suggest. Analysis of cue clusters can be impeded by
diagnosis. Each piece of client information is considered a clinical cue; a set of clinical
incorrect clustering of data and misinterpretation of cue clusters.
issues from a cluster that is present if the diagnosis is accurate.
2. Validate diagnosis: after selecting a nursing diagnosis (e.g. ineffective role performance),
5. Risk factors: the term risk factor is used to describe clinical cues in risk nursing diagnosis.
the nurse should validate if with the client. This legitimises the diagnosis and helps to
They are “environmental factors and physiological, psychological, genetic or chemical
discover its significance for the client. Problems can occur in diagnostic validation because
elements that increase the vulnerability of an individual family or community to an
of a nurses limited experience, lack of a knowledge base about the nursing diagnosis or
unhealthy event.” Example: risk factors for the nursing diagnosis “risk for deficient fluid
insufficient characteristics of a diagnosis.
volume” include extremes of ages, physical immobility and medication (diuretics). If risk

factors are not addressed, a potential problem may become an actual problem.
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3. Formulate the diagnostic statement: this involves writing the label of the actual risk, Functional approach to nursing diagnosis

wellness or possible nursing diagnosis that has been made through the nursing diagnostic Because data collected in nursing assessment is organized in functional health pattern. It is

process. useful to organize nursing diagnosis in the same manner

Types of nursing diagnosis

1. Actual nursing diagnosis: this describes human responses to a health problem that is being Outcome identification

manifested. They are written in three parts: diagnostic label, defining characteristics and Nursing is a practice discipline involving application of theoretical knowledge actual client

related factors. E.g. impaired mobility related to pain (inaccurate-ineffective movement situations. Nurses and clients set realistic foals in what the nursing process calls “outcome

related to arthritis, which causes pain when moving). identification”.

2. Risk nursing diagnosis: the word “risk” is more descriptive of some clients particular Definition: outcome identification is the following of goals and measurable outcomes that

vulnerability to health problems. Risk nursing diagnosis describes human responses to provide the basis for evaluating nursing diagnosis. Outcome identification is the most recent

health conditions/life processes that may develop in a vulnerable individual, family or addition to the nursing process.

community. Risk nursing diagnoses are two part statements because they do not include Seven measurement criteria for outcome identification

defining characteristics. E.g. risk for aspiration related to reduced level of consciousness. This measurement criteria includes specifying intermediate and long term outcomes that focus

3. Wellness nursing diagnosis: this is a diagnostic statement that describes the human response on health promotion, health maintenance or health restoration.

to levels of wellness in a client that have a potential for enhancement to a higher state. E.g. Purpose of outcome identification

readiness for enhanced spiritual well being. • Providing individualised care

4. Possible nursing diagnosis: this is made when not enough evidence supports the presence of • Promoting client participation

the problem but the nurse thinks that it is highly probable and wants to collect more • Planning care that is realistic and measurable

information. E.g. possible impaired adjustment related to unknown aetiology (one of the • Allowing for involvement of support people.
first interventions will be to collect additional assessment data). Activities performed in this phase
Significance of nursing diagnosis
• Establish priorities
Nursing diagnosis provides a means of communicating nursing requirements for clients care to • Establish client goals and outcome criteria.
other nurses, the healthcare team and the public. Making accurate nursing diagnosis helps to

ensure that clients receive quality-nursing care. Acknowledging nursing specific contribution to

resolving health problems advances professional nursing practice.

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Establish priorities evaluation phase of the nursing process. Outcome criteria answer the question ‘who’, ‘what

Nurses’ use experience, clinical expertise, practice, knowledge and assessment data collected from actions’, ‘under what circumstances’, ‘how well’ and ‘when’

clients to determine priorities; Requirements include:

i. Life threatening problems always take precedence over routine care. For example • Subject: who is the person expected to achieve the goal?
maintaining an airway when a client respiratory difficulty takes precedence over client
• Verb: what action must the person do to achieve the goal
teaching
• Condition: under what circumstances is the person to perform the action
ii. Medium priority nursing diagnosis involve problems that could result in unhealthy
consequences such as physical or emotional impairment, but are not likely to threaten life.

E.g. fatigue, stress incontinence, dysfunctional.

iii. Low priority nursing diagnosis involves problems that usually can be resolved easily with

minimal interventions and have little potential to cause significant dysfunction. E.g. pain

might be a nursing diagnosis for a client after minor surgery, but because the pain is

moderate and probably will last only a short time the diagnosis is of low priority.

Establish client goals and outcome criteria

i. Client goals: a client is an educated guess, made as a broad statement about what the

client’s state will be after the nursing intervention is carried out. It directly addresses the

problem stated in the nursing diagnosis. Using clinical knowledge and experience, the

nurse in collaboration with the client, determines appropriate goals. For example, a multiple

sclerosis clients goal may read: “ambutes safely with a quad cane” or “transfers safely to a

chair.” As this clients’ mobility status improves or deteriorates, mobility goals will need to

be revised.

ii. Outcome criteria: outcome criteria are specific, measurable, realistic statements of goal
attainment. They may restate the goal, but they also present information that will guide the