Fundamentals in Nursing (July 31, 2017)

BASIC HUMAN NEEDS

BOWEL ELIMINATION
Normal characteristic of stool:
Color: yellow or golden brown
Melena: upper GI bleeding
Hematochezia: Lower GI bleeding
Barium swallow: Upper
Barium Enema: Lower
Increase fluid intake to eliminate/remove barium
Color:
Acolic: bile obstruction (gray colored)
Steatorrhea: bulky, oily and foul smelling (malabsorption), CELIAC disease
Frequency: 3 times a day/ every 2-3 days
Odor: Aromatic
Maladorous/ foul smelling -Hirschprung disease
Shape: Cyndrical
Intussusception- Currant jelly stool
Hirschprung- Ribbon-like stool
Weight of stool: 150-300 grams

Fecal elimination problem:

1. Constipation: hard fecal material
Adequate fluid intake, High fiber, respond the urge to defecate, minimize stress, laxative as ordered
Sympathetic and Parasympathetic: All bodily system constrict except pupil or bronchus
- All hormones increase except GUT and GIT
2. Fecal Impaction: fluid secretion coming from anal area/ watery secretions
Putty-like feces at the folds of the rectum (inside)
hardened fecal mass palpated during digital rectal exam (clean tech.) (perform Left side (follows contour of
sigmoid/Sims or knee chest) valsalva but avoid with bradycardia and hypotension
Management:
Manual extraction
Increase fluid intake
Adequate exercise/ ambulation
Digital removal of stool:
Wear gloves and other protective gear
Gently loosen the hardened mass by massaging around it and working the feces downward
3. Diarrhea: Watery and chance to develop F/E imblance. Hyperkal (Peak T wave), Hypoka (U wave)
Loss of Potassium, watch out of dysrhythmias
Encourage to eat banana (latundan), rice, apple(skin contain pectin- astringent effect cleanse), toast (adsorbent
effect- bind)
BRAT diet, Coffee (black)- adsorbent effect
Replace fluid and electrolyte imbalance
Good perineal hygiene
Promote rest
Small frequent feeding, NO large meal
Medication: antidiarrheal
IMCI: increase fluid, increase feeding, fast referral and zinc, low fiber, BRAT diet
4. Flatulence
Avoid gas forming food
Early ambulation
Limit carbonated beverage
Cholinergic: Prostagmine
Methods to promote Elimination:
ENEMA:
Purpose
To relieve constipation
To administer medication
To relieve flatulence
TO evacuate the feces
SIMS position (to follow contour)
Warm water used
Gloves needed
Lubricate to avoid trauma
Watch out for valsalva maneuver (hypotensionand bradycardia)
Prepare clamp to stop the flow of fluid
 Height: 12-18 inches from the anal area
Choose appropriate fluid
If abdominal cramping: clamp and go to bathroom and eliminate but do not fush, observe the characteristics of
stool
NOTE: if order is until clear, do the procedure 3 times only. If not clear report to Doctor
Doctors order
provide privacy
SIMS left position Size of tube: French 22-32
insert 3-4 inches
temp: 105 F- 40 degree C
Clean technique
Appropriate size
Adult: 22-30 Fr
Child: 12-18 Fr
Volume
Adult: 750-1000 ml
Child:150-250ml/350-500 ml/ 500-700 ml
Lubricated tube
Adult: 3-4 inches
Child: 2-3 inches
Infant: 1-1.5 inch
Enema container: raised slowly
High: 12-18 inches, Regular: 12 inches, Low: 3 inches
Fluid used:
TAP WATER- hypotonic and exerts a lower osmotic pressure(pull pressure than fluid in interstitial spaces
-Prone to water toxicity/ overload
NORMAL SALINE- the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial
spaces around the bowel
HYPERTONIC SOLUTION: infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces
(distends colon)
FLEET enema- 120-180 ml (4-6 oz), readily available
SOAP SOLUTION- soften the stool, may be added to tap water to create the addtional effect of interstitial
irritation
Only pure castile soap is safe
Retention enema
solution: 90-120 ml of mineral oil
Carminative Solution
Height: 12 inches
40-44 degree C
Non- retention enema
a
Ileostomy liquid to semi- formed stool, dependent upon amount of bowel removed
may skew fluid and electrolyte, especially potassium and sodium
Digestive enzyme in stool irritate skin
DO not give laxatives
Ileostomy lavage
COLOSTOMY
on large intestine
Dr order
privacy
LEFT LATERAL
Size of tube: 22-23 Fr
STOMA- stoma should be painless, feeling of fullness, do not use immediately 5-6 days
Normal color: Pinkish to reddish
Abnormal: Dusky, pale (no circulation), Purplish, Greenish to black
Watch out for bleeding
1/2 to 2/3 full drain
URINE
normal color: amber or straw color
Odor: aromatic
pH: 4.6-8 slightly acidic and alkaline
Specific gravity: 1.010-1.025
long period of 1.010- renal failure
Urine amount: 30-60 ml/hr
Polyuria: more than 2000 ml/24 hours
Anuria: 100 ml/24 hours
Oligura: less than 500 ml/ 24 hours
 Kidney site of urine production
Bladder site of storage
Ureter for transport or urine
Urethra for elimination
Process of urination: micturation
Dysuria: painful urination
Hematuria: blood in urine
How to stimulate urination:
Provide privacy
Turn on the water (sensory stimulation)
Warm and cold alternating
Normal voiding habit: establish urinary pattern of the patient
Incontinence:
Stress incontinence: Sudden leakage of urine/ increase intra abdominal pressure
Urge incontinence: Involuntary passage occurring soon after a strong urge
Reflex incontinence: Involuntary loss or urine, at predictable interval when you reach the volume
Functional incontinence: Inability of the person to reach the toilet that causes unintentional loss
Intervention:
Reestablish or urinary retraining
Initiate individualized schedule-- gradually increase interval ( on awakening, every 2-3 hours, avoid nocturia, then
every 4-6 hours
Teach the pt. pelvic muscle exercise/ keggels exercise (10 seconds), at 1st 10 times --3 times a day to regular
interval ( sitting or lying position)-- to promote muscle tone at perineal area
Urinary catheterization:
Select what type of catheter:
Change PLASTIC (weekly, prone to infection), RUBBER/ Silastic/Latex (watch out for allergy, 2-3 weeks), PVC
(soften within the body temperature, 4-6 weeks), SILICONE (2-3 months)
Identify the length and size of catheter
Male: 40 cm, Fr 14-16
Female: 22 cm, Fr 16-18
Check balloon for patency, use sterile water 5-10 ml (PNSS cause crystallization)
Child: Fr 8-10, 3 ml water
Type:
Strain catheter: single use, Single lumen
Indwelling Catheter: retention, Double lumen
Clean intermittent Catheter: Medical asepsis, Aseptic tech
Male: 6-8 inches(catheter) 4-6(tip), SUPINE, STERILE tech. Prone to UTI
Female: 2-3 inches(catheter) 1-2 (tip), DORSAL
When inserting instruct to do slow deep breathing and exhale purse lip
Location of anchor:
Female: inner thigh
Male: lower abdomen, lateral part of thigh to prevent Penous scrotal pain
NOTE: when inserting, initially advance 2 inches and continue until you see urine flow
Collect 20-30 ml from urine bag
How to remove the catheter:
Deflate the balloon
Slowly remove the catheter and instruct to inhale slowly and remove exhale slowly
Urinary/Bladder retraining
CONDOM catheterization
Non-invasive procedure for male clients
To decrease UTI risk
Reduces urinary incontinence
Can be used ambulatory
Must be erected before inserting to know the maximum size
insert at the tip and unroll , must have 1 inch space/ allowance tip
A special tape is utilized, it should be SNUGLY (not too tight not too loose)
Ordinary tape is contraindicated
Apply the condom catheter followed by tape
Apply the tape around the base belt
Double sided tape- apply overlapping spiral motion, 2-3 turns
Apply the tape first before the condom
Frequency of changing: 24 hours
Frequency of emptying: every 8 hours, 1/3 to 1/2 full
Bedridden: Bed frame
Ambulatory: lower leg
INFECTION
invasion and multiplication of microbes in the body
 Communicable Disease: transmitted from one person to another
Contagious: easily transmitted
Infectious: not easily transmitted
person interact with organism, both are communicable
Infection period: entrance of microorganism to the appearance of s/sx
Isolation: Segregate the person during the time of communicability
Quarantine: segregate the person during the time of incubation
EPIDEMIOLOGY- study of disease occurrence and distribution(pattern of disease
Epidemic- increase the cases beyond expected, occurs in greater number in specific area over specific time
Endemic- present in community at all times
Sporadic- Habitual, disease is common, seasonal(on and off), occurs occasionally no specific pattern
Pandemic- World-wide, multicontinental (Hepa, HIV)
Incubation period- invasion of m.o until appearance of signs and symptoms (quarantine)
Prodromal Period- Signs and symptom until the time the pathognomonic sign is evident
Active/clinical period- time the patient is sick, treated and properly managed (most evident pathognomonic
Convalescent period- Sign and symptom diminishes until disappear
Resolution- complete recovery
CHAIN OF INFECTION
>Causative agent: any microbe capable of causing disease
Virulence: ability to cause a disease
>Reservoir: environment in which a microbe can survive and multiply (human, animals, food,wate, insects,
inanimate objects
Case: infected with s/sx
Carrier: infected but asymptomatic
Factors that are favorable: Food or nourishment of microorganism
Oxygen: aerobic favorable
Water: moisture can cause reproduction of M.O
Temperature: 20-43 degree C favorable for pathogen
pH- 5-7 favorable
Light- favorable to dark areas
>Portal of exit: path by which infectious agent leaves the reservoir (blood, skin, mucus membrane, respiratory
tract, GUT, trans placental
Mode of transmission: means by which the infectious agent passes from portal of exit to susceptible host
(airborne, droplet)
-Easiest break
1. Airborne transmission- less than 5 microdes, very easy to be transmitted, put patient in private room, extreme
isolation, use N95 mask, high efficiency particulate air (HEPA)-ventilation system that need to employ (reneola,
varicella, PTB)
2. Droplet Transmission- more than 5 microdes, travel until 3 feet (from sneezing, coughing, talking)
use surgical mask (diptheria, rubella,
3. Contact transmission- bodily fluids
Direct contact- handle contaminated fluids
Indirect contact- inanimate object (needles, sharps, dressings)
4. Vehicle transmission- contaminated items, (blood, water, food raw or cooked)
5. Vector-borne transmission- external mechanical transfer- flies, mosquito, flea, tick, lice
>Portal of entry invades by infectious agent
Susceptible Host- weakened host
1st line of defense- external,chemical and mechanical brriers
2nd line of disease- inflammation, cell mediated and humoral immunity
rubor- redness, dullor- pain, callor- temp, tumor- swelling, pallor- change of color
IMMUNITY
condition of being secured against particular disease
Natural
Natural active: disease process and production of antibody
Natural passive: transplacental, (igG) breastmilk (IgM,
Artificial
Active artificial: vaccines, before exposure
Oh
My
Dodong
Have
Been
TT
Active passive: Immunoglobulins post exposure
ASEPSIS
Absence of pathogenic M.O
Medical-clean, reduce M.O , handwashing(3-5 minutes), barrier technique
 Surgical-Sterile, Reduce and kill M.O in preparation for a operative procedure, IV insertion, catheter, suctioning of
tracheo bronchial secretion
Nosochomial infection: sterile, most common (UTI), Post Op (pneumonia)
Procedure
Cleaning: remove soiled materials
Disinfection: kill the M.O but not the spores
Sterilization: kill M.O and spores
Nosocomial Infection
Hospital acquires infection
Precaution
1. Standard Precaution
a. Universal/Handwashing: before and after procedures
b. PPE- gloves, gown, mask, goggles
2. Transmission-based Precaution
Airborne, droplet, Contact
Operating Room:
Unrestricted: wear street clothes, scrub suit,
Doctors lounges, dressing room
Semi-restricted: should wear shoe cover and cap, OR complex
Corridors that contains both clean and sterile items
Restricted: always wear mask
operative suite, OR table, wash area, all items stored are sterile
Specimen collection
1. Wound specimen- clean the site with saline solution, apply gloves, use cotton swab, clean test tube, after
swabbing, will not touch the lid of container
2. Stool specimen: Wear gloves, Urinate first before collecting stool, Do not use tissue after defecate/urinate
Solid stool: 1-2 inches (tongue blade)
Liquid stool: 10-15 ml
3. Urine specimen:
Apply gloves
Sterile cup and get 1-5 ml
ENTERAL PRECAUTION
consider all items as infectious
dispose waste on designated area and properly label the specimen
STERILE FIELD
Area free of M.O receive a sterile items only
Principles
1. A sterile object remains sterile only when touch by another sterile object
Sterile items touches by a sterile personnel
2. Only sterile object may be placed on a sterile field
objects dry and stored properly and intact
3. A sterile object or field out of range of vision or an object held below a persons waist id contaminated
Ex. Dangling clothing are considered to be contaminated, falling hair, unknown touching
Nurse never turn back on the sterile field
4. A sterile object becomes contaminated by prolonged exposure to air.
Avoid activities that create air current such as excessive movement/ rearranging linens
5. when sterile surface comes to contact with WET, contaminated
6. Fluid flows in a direction of gravity
water flowing of gravity is also a reason for drying from the fingers and elbow
7. The edges of the sterile field or container are considered contaminated.
2.5 cm or 1 inch border around the drape is contaminated
WASTE MANAGEMENT
RA 9003- Ecological waste management
Solid waste
Components:
Garbage: Biodegradable
Rubbish: Recyclable
WASTE CLASSIFICATION
Municipal waste: household or commercial waste (construction materials,etc)
Industrial waste: form production from factories or mining
Health care waste: biomedical waste and used for diagnosis, treatment and immunizations
Hazardous waste: Toxic substances
Biomedical waste
Infectious waste- suspect to contain bacteria, virus, fungi, parasites
Pathologic waste: contains tissues, organs or body parts of humans that contains blood and body fluids,
anatomical waste
Pharmaceutical waste: Drugs, vaccines (bottles, vials, gloves, mask, tubes)
 Chemical waste: used in the laboratory or used by housekeeping to clean the surroundings
Sharps: Items that can cause puncturing (needles, scalpells, blades)
Radioactive: Chemotherapeutic agents
Hazardous waste
Properties:
Toxic
Corrosive (pH less than 2 or more than 12
Flammable
Reactive/explosion
Genotoxic
COLORS
RED: sharps
INFECTIOUS: yellow
NON-INFECTIOUS
biodegradable: green
non-biodegradable: black
Radioactive: orange
Heavy metal: black and yellow
BASIC HUMAN NEEDS ON ACTIVITY, MOBILITY AND EXERCISES
Mobility: persons ability to perform actions and respond to a particular stimuli taht requires change in position or
even use MSK/Nervous System(balance and coordination)
Body Mechanics: efficient, safe and coordinated
Concept:
Alignment and balance:
Gravity and friction
Advantage:
Reduce energy requirements
Fatigue
Risk of injury

Closer the center of gravity to base of support, bend with knees,

Line of gravity should be closer when you carry
Do not carry more than body weigh/ more than 51 pounds
When carrying object must be closer to body
If you carry an object beyond the base of support, risk of falling
Health promotion
1. Prevent of work related MSK injuries
Lifting
Do not carry more than 51 lbs.
Lift object close to the body
Pulling/Pushing
Enlarge the base of support in the direction in which the movement is to be produced or opposed
Pivoting
Technique in which the body is turned in a way that avoids twisting the spine
Logrolling
2-3 nurses should assist in logrolling
Use draw sheet
Above the shoulder to below the hips
Hand hygiene
Privacy
Explain
Bed at comfortable position
Patient cross to chest
Pillows between the knees, dorsiflex foot
Have 2 nurses stand on the side of the bed opposite the direction
Third person on the other side
Roll the draw sheet tightly the patient
Face the patient
Turn as a unit simultaneously
in side-lying support the back, buttocks and legs
raise the side rails, lower the bed, place call light
Reassess and Document
Moving turning in bed
Perform every 1-2 hours to prevent decubitus ulcer
Raise the height of bed close to Center of gravity
when bedmaking with a patient- higher
When bedmaking without a patient- lower
 Lock the wheels on the bed
Rails the rails on the side of the bed opposite you
Face in a direction (prevent twisting)
Broad stance
Lean your trunk forward and flex hips, knees and ankles
Tighten your gluteal muscle, abdominal, leg and arm muscle
When pulling: Rock from the front leg to the back
When pushing: Rock from the back leg to the front leg
Exercises (Physical Activity)
Planned
Structures
Repetitive endurance, adaptation, flexibility and adaptability
Train the body not strain the body
Active ROM
Passive ROM
Active-resistance ROM- done by the client against a weight or force
Active-assistance ROM- Done by the stronger arm and leg to the weaker arm and leg
Isotonic (Dynamic)- change of muscle length and tension (running, walking,swimming, cycling, ADL)
Active movement Increase muscle tone, mass and strength
Isometric (Static)- Change in muscle tension only, muscle length does not change (keggels exercise, abdominal
tightening)
Isokinetic (resistive)- muscle contraction or tension against resistance
Transfer technique
Wheelchair safety
Always lock the brakes on the wheel
Raise footplates before transferring
Client positioned well back
Use seatbelts
Back the wheelchair into or out of the elevator rear large wheels first
Place body between the wheelchair
Bed and Chair
Place the wheelchair on the side of the bed that allows the client to move toward his/her stronger side-lying
Lock the wheel, raise the footplate
Wheelchair is place parallel to the bed as close as possible
Stand directly in front of the client
lean the trunk forward from the hips
Flex the knees, hips, ankles (assume a broad stance)
Placing one foot forward, other at the back, (mirroring the client)
Getting into a chair:
Stand with the back of the unaffected leg centered against the chair
Place both crutches to the hand on the affected
Push down on the hand piece while raising the body standing
Getting out of the chair:
Grasp the crutches at the hand piece for control, and bend forward slightly while assuming a sitting position
Ambulation
1st time after surgery
Have an assist following you and client with wheelchair
Moderately weak/ unstable
Walk on client weaker side and interlock your forearm with the clients closest forearm
Very weak and unstable
Place your near arm around the clients waist, with your other arm (support the client near arm at the elbow)
Walk on the stronger side
Going upstairs
.
Going Downstairs

Upper lobectomy- place in unaffected side

Peumonectomy- affected
Laryngectomy- Semi-fowlers position
Mastectomy-semi fowlers with affected arm elevated
Liver biopsy- During supine (expose the RUQ, after right side lying)
Thoracentesis- Lean to an over bed table, after: towards th unaffected side
Cataract surgery: non operative side
Retinal detachment- Face down toward on unoperative side
PULMONARY EDEMA: upright
Lumbar puncture- Supine 4-12 hours
SLEEP
 naturally occuring, altered state of consiousness
NREM- quiet sleep
REM- Raspid eye movement
Stage 1- Drowsy, RR and PR drops
eyes roll side to side
readily awakes
Stage 2- light sleep
RR and PR decreases slightly
Temp falls
More intense stimuli to be awakened
Eyes generally still
Stage 3and 4
Deep sleep
Snoring
Decreased swallowing and saliva
not disturbed by sensory stimuli
PR and RR 20-30% below
difficult to arouse
restores energy
REM (Rapid eye Movement)
distinct eye movement
voluntary muscle ton decreases
PR and RR irregular
Learning/Thinking/Organized
Info are stimulated
Recur every 90 minutes
Lasts for 5-30 minutes
Dopamine- inc. Cortical activation
Brain- active
20% inc. Metabolism
Paradoxical- EEG
Cycle:
NREM to REM
90-110 minutes
NREM: 20-30
Stage IV- 30
Stage II/II- 20 min
REM: 10 min- first cycle
Geriatrics:
Aging: slow process of growth toward
.
Elderly: classification of age group to any person reaching the mid 70s up to 8 th decade of life
Geriatrics: study of old people
Gerontology: Study of aging process
Gerontologic Nursing: Nursing practice toward the aging person
Vision:
Decrease color discoloration: blue and green (difficult), Yellow and red (better)
Bring to farm and sea
Decreased depth perception:
mark the edges of the stairs
Decreased dark adaptation:
Nightlight
Decreased acuity and visual fields:
Do not move objects around
Increased glare sensitivity
Wear sunglasses
Elevated minimal threshold of light perception
High intensity microspiral telescopes/ magnifying glasses
Note:
Annual check up
Isotonic eye drops
Use large lettering to label medication
Alllow more time to focus and adjust
Presbyopia
decreased visual accomodation from loss of lens elasticity
Arcus senilis-lipi deposits, no impairment
Cataract- lens thinning and decrease permability
 Glaucoa: Increase IOP

HEARING
1. Progression from loss of high to low tone frequency
Do not shout
Consonant (not heard well)
2. Hearing loss increased in men
Face the person- lip read
Touch to get attention
Speak in GOOD EAR
Speak slowly and clearly
3. Increased in sound threshold
Use amplifiers on the telephone
4. Cerumen Impaction
Most common cause of Conductive HL
Note:
Increase of own speech
turning head toward speaker allow repeating
Lack of response to loud noise
inappropriate answers
Presbycusis (aging)
Progressive bilateral loss of high tone perception
SMELL
Changes in smell are
Discrimination of fruity odors seems to persist longest
Smell decreases in men than women
At mealtime- name food and give time to thing and smell
TASTE
Taste BUDS decreases with age (men)
ages 60 or more- loss half of the taste buds
ages 80 or more- 1/6 remains
Serve attractive food, vary food texture
Lost of buds from front to back
Lost first=sweet ans salty
Longer to remain= bitter ans sour
DEATH AND DYING
Denial- shock and disbelief
Anger -outburst of emotions
Bargaining- delays the grieving process
Depression- saddest part of loss, plan to suicide
Acceptance- Focus on the future, perform suicide
Palliative Care- alleviate pain
Hospice care- care for terminally ill
Shock and disbelief- Do not reinforce
Dignified and peaceful death
Prepare the person Physiologically and Psychologically
Provide spiritual support
Care for the body after death
1. Rigor Mortis
stiffening 2-4 hours after death
lack or absence of ATP
Position body and place dentures in mouth, close eyes and mouth
2. Algor Mortis
Gradual loss of body temp (1C/1.8F)
10C/min until room temperature
3. Livor Mortis
discoloration of the skin
Clinical death
loss of muscle tone
Slowing of circulation
Changes in V/S
Sensory impairment
Flat EEG: accurate indicator