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FUNDAMENTALS OF NURSING Modular Review Nursing: A humanistic combination of scientific knowledge and holistic nursing practice Concern for

or the ART OF CARE and the SCIENCE OF HEALTH Is the diagnosis and treatment of human responses to actual or potential health problems (ANA,1980) Nursing as a Profession: Education- requires an extended education of its members, as well as basic liberal foundation. Theory has a theoretical body of knowledge leading to defined skills, abilities and norms. Service provides basic service Autonomy have autonomy in decision-making and in practice Code of ethics possesses a code of ethics for practice Caring The most unique characteristic of nursing as a profession is that, it is a CARING profession. SCOPE OF NURSING PRACTICE (Per R.A. 9173, the Philippine Nursing Act of 2002) A person shall be deemed to be practicing nursing within the meaning of this Act when she/he singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to nursing care during conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As a member of the health team, nurses shall collaborate with other health care providers for the curative, preventive and rehabilitative aspects of care, restoration of health, alleviation of suffering and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to: a. provide nursing care through the utilization of the nursing process b. establish linkages with community resources and coordination with the health team c. provide health education to individuals, families and communities d. teach, guide and supervise students in nursing education program including the administration of nursing services in varied settings, undertake consultation services, engage in such activities that require the utilization of knowledge and decision making skills of a registered nurse e. undertake nursing and health human resource development training and research, which shall include but not limited to the development of advance nursing practice. Provided that this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty. Provided further, that in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization. The Roles and Functions of Nurses: Care Provider concerned with the clients needs Communicator central role of nurses. Nurse uses active listening as part of an effective communication Teacher/Educator Health promotion is the primary nursing concern. The nurse uses health teaching to effect behavioral changes. Counselor The nurse helps client to recognize and cope with psychological or social problems, to develop improved personal relationships and to promote personal growth. Manager/Coordinator The nurse directly manages and coordinates care, delegates nursing activities, supervises and evaluates performance of other nurses and support workers. Change Agent The nurse assists clients to modify behavior and to cope with changes.

Leader The nurse through the process of interpersonal influence influences others to work together towards a mutually envisioned goal. Client Advocate The nurse intercedes for or works on behalf of the patient. Explains, interprets and defends the patients rights. Researcher The nurse participates in scientific investigation and uses research findings in practice. Collaborator As a member of the health team, the nurse works in a combined effort for a mutually acceptable care plan for the client. Types of Nursing Interventions: Independent or nurse-initiated interventions Are autonomous actions based on scientific rationale that is executed to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals. Dependent or physician-initiated interventions Are based on the physicians response to a medical diagnosis. The nurse intervenes by carrying out physicians written orders, but requires nursing judgment or decision making. Interdependent or collaborative interventions Are therapies that require the knowledge, skill and expertise of multiple health care professionals. The Nursing Process: Is a deliberate way of thinking by nurses, using an organized systematic framework or structure of interrelated activities that is a scientific problem-solving approach towards an individualized, dynamic and continuing interpersonal care for the clients changing responses and needs. Components of the Nursing Process: 1. Assessment Observation, interview/interaction, examination/measurement 2. Diagnosis Analysis, synthesis, problem identification 3. Planning Setting priorities, establishing goals, outcomes, objectives and planning interventions 4. Implementation/Intervention Validating care plan, giving/documenting care and continuing data collection 5. Evaluation Re-assessment, comparison of clients current status with expected outcomes ASSEMENT: COVR C collecting data O organizing data V validating data R recording data DIAGNOSIS: SCAN S sorting C cluster A analysis of data N nursing diagnosis NANDA- nursing diagnoses approved by the North American Nursing Association. It is a diagnostic system which is organized around 9 human response patterns, namely; exchanging e.g. Risk for Infection, communicating e.g. Impaired Verbal Communication, relating e.g. Parental Role Conflict, valuing e.g. Spiritual Distress, choosing e.g. Ineffective Individual Coping, moving e.g. Impaired Physical Mobility, perceiving e.g. Body Image Disturbance, knowing e.g. Knowledge Deficit and feeling e.g. Acute Pain. Actual Nursing Diagnosis- based on clinical judgment of the nurse on review of validated data Risk Nursing Diagnosis based on clinical judgment of the clients degree of vulnerability to the development of a specific problem Wellness Nursing Diagnosis focuses on clinical judgment about an individual, group or community transitioning from a specific level to a higher level of wellness Syndrome Nursing Diagnosis cluster of actual or high-risk diagnosis that are predicted to be present because of a certain situation PLANNING: SNIPED S set priority N nursing goals and outcome I intervention selection P plan writing E establish communication D document the quality care

INTERVENTION: DDD D doing D delegation D documentation EVALUATION: ANG A analysis N nursing care plan G goal achievement Concepts and Theories of Nursing and Caring 4 Major Concepts in nursing theories are the ff: PERSON ENVIRONMENT NURSING HEALTH FLORENCE NIGHTINGALE: THE ENVIRONMENTAL THEORY To place the individual in the best condition for nature to act upon him. The act of utilizing the environment of the patient to assist him in his recovery. VIRGINIA HENDERSON: THE COMPLIMENTARYSUPPLEMENTARY MODEL To assist the individual, sick or well, in the performance of those activities contributing to the health or recovery or even a peaceful death that he would perform unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible. DOROTHEA E. OREM: THE SELF- CARE MODEL Assisting or helping clients who are wholly or partly dependent in the achievement of optimal self-care so they can achieve and maintain an optimal health state. MARTHA E. ROGERS: THE SCIENCE OF UNITARY HUMAN BEINGS A humanistic and humanitarian science. It is directed towards humans increasingly complex and expanding interactions with their environment. Nursing role is to help humans in their interactions with their environment. SISTER CALLISTA ROY: THE ADAPTATION MODEL Viewed humans as BIOPSYCHOSOCIAL beings who constantly interact with their environment and who cope with their environment through biopsychosocial adaptation mechanisms. Nursing interactions are aimed to remove, increase, decrease or alter stimuli to the individual. The resulting behavior then becomes adaptive and fosters health. FAYE G. ABDELLAH: PATIENT-CENTERED APPROACHES TO NURSING MODEL Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people. Developed a list of the 21 nursing problem areas. Two examples are to maintain good hygiene and personal comfort and to facilitate the maintenance of elimination. LYDIA E. HALL: TOTAL PATIENT APPROACH Involves 3 interlocking circles, each representing one aspect of nursing: Care aspect represents intimate bodily care of the patient Core aspect- deals with the innermost feelings and motivations of the patient Cure aspect- tells how the nurse helps the patient and family through the medical aspect of care. IMOGENE M. KING: THE GOAL ATTAINMENT THEORY/SYSTEMS INTERACTION MODEL Identified humans as reacting, time-oriented, social beings. Defined nursing as a process of action, reaction, interaction and transaction whereby nurses assist individuals in meeting basic needs in activities of daily living and in coping with health and illness. Important concepts of humans include each persons social system, perceptions, interpersonal relationships, and health.

DOROTHY E. JOHNSON: THE BEHAVIORAL SYSTEM MODEL Viewed the patients behavior as a system, that is, a whole with interacting parts. Believed that a disturbance in one is likely to affect others. A person as a behavioral system is composed of 7 subsystems (e.g. ingestive, eliminative) Nursing goal is to restore, maintain or attain balance and stability of a patients behavioral system at the highest possible level. MYRA E. LEVINE: FOUR CONSERVATION PRINCIPLES Described nursing as being supportive or therapeutic to help the individual in the four conservation areas, namely: conservation of energy, conservation of the structural integrity of the body, conservation of personal integrity and the conservation of social integrity. BETTY NEUMAN: THE HEALTH CARE SYSTEM MODEL Viewed the client as an open system consisting of a basic structure or central core of energy resources. Nursing goal is to prevent stress invasion, to protect the clients basic structure and to obtain or maintain a maximum level of wellness. The nurse helps the client through primary, secondary and tertiary prevention modes, to adjust to environmental stressors and maintain client stability. HILDEGARD PEPLAU: THE INTERPERSONAL MODEL/ THERAPEUTIC RELATIONSHIP Defined nursing as a significant, therapeutic, interpersonal process that functions to help in the reduction of tension and frustration. Viewed nursing as an educative instrument that aims to provide creative, constructive, productive, and personal and community living. Identified the 4 phases of the nurse-client relationship, namely: orientation, identification, exploitation and resolution. IDA JEAN ORLANDO: THE DYNAMIC NURSE- PATIENT RELATIONSHIP MODEL Defined nursing as the process involved in interacting with an ill individual to meet an immediate need. Identified 4 practices basic to nursing, namely: observation, reporting, recording, and actions carried out with or for the patient. MADELEINE LEININGER: THE TRANSCULTURAL NURSING MODEL Nursing care is based on the belief that different cultures perceive, know and practice care in different ways, yet there are some commonalities about care, among all cultures of the world. Nursing goal is to deliver nursing care that best fit with the clients cultural values, beliefs and practices to improve or maintain a health condition. JEAN WATSON: HUMAN CARING MODEL Believed that main focus in nursing is on curative factors, which are derived from humanistic perspective combined with a scientific knowledge base. Nursing goal is to help people achieve a high degree of harmony within self in order to promote self-knowledge, self-control, self-care and self-healing. BRIEF HISTORY OF NURSING Early Beliefs and Practices Beliefs that disease was caused by another person, an enemy or a witch Evil spirits could be driven away by persons with powers to expel demons. Believed in special gods of healing, e.g. herbolarios. Subscribed to superstitions and practices such as witchcraft, sorcery, among others. In the Philippines: Among the earliest hospitals built were: Hospital Real de Manila (1577) San Lazaro Hospital (1578) Hospital de Indio (1586) Hospitals and Schools of Nursing: Iloilo Mission Hospital School of Nursing(1906) St. Pauls Hospital School of Nursing(1907) Philippine General Hospital School of Nursing(1907)

St. Lukes Hospital School of Nursing(1907) Mary Johnston Hospital and School of Nursing(1907) First Colleges of Nursing in the Philippines: University of Santo Tomas College of Nursing(1946) Manila Central University College of Nursing(1947) University of the Philippines College of Nursing(1948) PERIOD OF INTUITIVE NURSING: Was practiced since prehistoric times among primitive tribes and lasted through the early Christian era Nursing was untaught and instinctive and was performed out of compassion for others. Man at this time was a nomad Nursing during this period was a function that belonged to women PERIOD OF APPRENTICE NURSING: This period extends from the founding of religious nursing orders in the Crusades, which began in the 11th century and ended in 1836, when Pastor Fliedner and his wife established the Kaiserworth Institute for the training of Deaconesses ( a training school for nurses in Germany) It is called the period of on the job training. Nursing care was performed without any formal education Religious orders of the Christian Church were responsible for the development of this kind of nursing THE DARK PERIOD OF NURSING: This extends from the 17th to the 19th century, from the period of reformation until the U.S. Civil War. There was religious upheaval between Catholicism and Protestantism. This led to the closure of catholic schools, orphanages and hospitals. During this period, nursing became the work of the least desirable of women women who took bribes from patients, stole patients food and medicines and who used alcohol as a tranquilizer. PERIOD OF EDUCATED NURSING: This period began on June 15, 1860 when the Florence Nightingale School of Nursing opened at St. Thomas Hospital in London (St. Thomas Hospital School of Nursing). The development of nursing during this period was strongly influenced by trends resulting from wars, from social consciousness, from the emancipation of women and from the increased educational opportunities offered to women. PERIOD OF CONTEMPORARY NURSING: This covers the period after World War II to the present. Scientific and technological developments as well as social changes mark this period. The World Health Organization (WHO) was established by the United Nations during this period. Health is perceived as a fundamental human right and laws were legislated to provide such right. Nursing involvement in community health is greatly intensified and the development of the expanded role of the nurse. MAN AND HIS BASIC HUMAN NEEDS Nursing Concepts of Man: Biopsychosocial and Spiritual being ( Roy ) A Unified Whole (Rogers) An individual with vital reparative processes Nightingale) Is a whole, complete and independent being with 14 fundamental needs Henderson) A unity who is functioning biologically, symbolically and socially Orem) The Basic Human Needs: Each individual is unique but certain needs are common to all people. Desirable, useful or necessary Physiologic or Psychologic Abraham Maslows Hierarchy of Basic Human Needs: Physiologic Needs Safety and Security Love and Belongingness Needs Self-esteem Needs Self-actualization Characteristics of Basic Human Needs: Universal

May be met in different ways May be stimulated by external and internal factors Priorities may be altered May be deferred Are interrelated

CONCEPTS OF HEALTH AND ILLNESS Health (WHO): Is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. WALTER CANNON: Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by the negative feedback mechanism. MODELS OF HEALTH AND ILLNESS HALPERT DUNNS THEORY ON HEALTH-ILLNESS CONTINUUM: describes the interaction of the environment with well-being and illness. High Level Wellness (HLW): An integrated method of functioning that is oriented towards maximizing ones potentialities within the limitations of his environment. This concept connotes ability to perform ADL or to function independently. HEALTH BELIEF MODEL (HBM): Suggests that a persons susceptibility to a health threat and its seriousness influences decision to engage in a preventive health behavior. SMITHS MODELS OF HEALTH Clinical Model: views people as physiologic systems Role Performance Model: defines health in terms of the individuals ability to perform certain roles. Adaptive Model: focuses on adaptation. The aim of treatment is to restore the ability of the person to adapt or to cope. Eudaemonistic Model: Health is a condition of actualization or realization of a persons potential. The highest aspiration of a person is fulfillment and complete development- ACTUALIZATION. Leavell and Clarks Agent-Host-Environment Model/Ecologic Model 3 factors that affect health and illness, namely: 1. Agent- Any factor or stressor that can lead to illness or disease. 2. Host- Persons who may or may not be affected by a disease 3. Environment- Any factor external to the host that may or may not predispose the person to a certain disease. ILLNESS- is a state of disturbance in the normal functioning of the human individual including both the state of the organism as a biologic system and of his personal and social adjustment. ILLNESS BEHAVIOR-any activity undertaken by a person who seeks to define the state of his health and to discover a suitable remedy. 5 Stages of Illness: 1. Symptom experience stage- physical, cognitive, emotional 2. Assumption of the sick role-seeks advice and support 3. Medical contact stage-seeks professional medical advice 4. Dependent patient role- becomes dependent on health professional for help 5. Recovery/Rehabilitation stage- gives up the sick role and returns to normal ADL DISEASE- is a medical term that is an alteration in body functions resulting in a reduction of capacities or a shortening of the normal life span Health behaviors- are the actions people take to understand their health state, maintain an optimal state of health, prevent illness or injury, and reach their maximum physical and mental potentials. Leavell and Clarks Three Levels of Prevention: 1. Primary Prevention to prevent or delay the actual occurrence of a specific illness or disease e.g. quit smoking, avoid/limit alcohol intake, exercise regularly, immunizations

2. Secondary Prevention promote early detection(through case finding and screening) and early treatment of the disease e.g. SBE, TB screening, Pap smear, newborn screening 3. Tertiary Prevention directed toward prevention of complication and rehabilitation after the disease e.g. physical therapy after a stroke, speech therapy after laryngectomy STRESS AND ADAPTATION Hans Selye: Modern Stress Theory Stress is the nonspecific response of the body to any demand made upon it. Adaptation: are the adjustments that a person makes in different situations. Types of Adaptation: A. General Adaptation Syndrome (GAS) A general event The entire body is involved All systems involved, primarily the Autonomic Nervous System and The Endocrine System Under the Autonomic Nervous System: Sympathetic (SNS): Fight or Flight Increased heart rate and blood pressure Increased RR Decreased peristalsis Pupils dilate Dilates pulmonary bronchioles Parasympathetic (PNS): Maintains normal body functioning Normalizes heart rate and blood pressure Normalizes RR Increased peristalsis Constricts pulmonary bronchioles Stages of GAS: 1. Stage of Alarm (SA) The person becomes aware of the presence of threat or danger Adaptive mechanisms are mobilized 2. Stage of Resistance (SR) Characterized by adaptation Levels of resistance are increased 3.Stage of Exhaustion Results from prolonged exposure to stress and adaptive mechanisms can no longer persist. Unless other adaptive mechanisms will be mobilized, death may ensue Local Adaptation Syndrome (LAS) Respond to stress through a particular body part or body organ. E.g. inflammatory response B. Local Adaptation Syndrome (LAS) Respond to stress through a particular body part or body organ. E.g. inflammatory response

This is directed towards helping a client heal, cope and manage his condition both physically and emotionally. A professional relationship between a nurse, physician or therapist and a client. A means to smoothly implement the 5 steps of the nursing process The foundation of a therapeutic nurse-patient relationship is the use of the therapeutic communication. Phases of the Therapeutic Nurse-Patient Relationship: 1. Pre-interaction phase- initial assessment of clients records and history, note clients complaints, inquiry into the clients cultural background and emotional state 2. Orientation phase perform thorough extensive/comprehensive assessment, establish trust and rapport with the client, set time frame for the relationship 3. Working phase establish contract with the client regarding expectations and responsibilities, agree on plan of action, set limits 4. Termination phase end of relationship due to discharge, change of service or clients goals are met HEALTH AND ASSESSMENT Tools of Physical Assessment: Inspection visual examination/use of the sense of sight Palpation tactile examination/ use of hands or fingers to through touch Percussion striking certain body surface to elicit sounds or vibration called sound waves. These sound waves are interpreted as air , fluid or solid material in an underlying structure Auscultation auditory examination/ listening to sounds produced by the organs and tissues of the body. These sounds are characterized according to pitch, intensity, quality and duration. Types of Data: 1. Objective Data can be determined through the use of the tools of physical assessment 2. Subjective Data what the client is feeling, sensing, experiencing and perceiving. Vital or Cardinal Signs: Body Temperature: The balance between heat produced by the body and the heat lost from the body. Hypothalamus is the temperature-regulating center of the body. Body heat is primarily produced by metabolism. Types of Body Temperature: Core Temperature temperature from the deep tissues of the body. Measured by taking the oral and rectal temperature. Surface Temperature temperature of the skin, subcutaneous tissues and fat. Measured by taking the axillary temperature Types of Fever: Intermittent Fever temperature fluctuates between periods of fever and periods of normal/subnormal temperature Remittent Fever temperature fluctuates within a wide range over a 24-hr period but remains above normal range Relapsing Fever temperature is elevated for few days, alternated with 1 or 2 days of normal temperature Constant Fever temperature is consistently high and fluctuates minimally Factors Affecting Heat Loss: Radiation transfer of heat from surface to surface without contact e.g. warmth from a crowded room Conduction transfer of heat from surface to surface through contact e.g. TSB Convection dispersion of heat by air currents e.g. from exposure of the skin from an electric fan Evaporation the continuous vaporization of moisture from the skin or mucous membranes(insensible water loss) Methods of Temperature Taking: Oral wait 15 to 30 minutes before taking after a clients intake of hot or cold food or smoking. Ranges from 36.5C to 37.5 C. Take for about 2-3 minutes

Behavioral Responses to Stress/Crisis Anxiety- a feeling of dread or uneasiness from an unrecognized cause Levels of Anxiety: 1. 2. 3. 4. Mild increased alertness/ awareness Moderate decreased awareness Severe disturbances in thought patterns, perceptual field is greatly narrowed Panic distorted perceptions of the environment

General Nursing Intervention Strategies for Stress: 1. Supporting protective mechanisms encourage rest, comfort measures, massage, relief of pain 2. Providing structure or explanations 3. Exploration of feelings 4. Facilitating problem solving 5. Regular pattern of exercise 6. Relaxation techniques 7. Anti-anxiety medications as ordered by M.D. 8. Suggest suitable therapies e.g. music, art Therapeutic Relationship:

Axillary safest and most non-invasive method. Place between 8 to 10 minutes for accurate measurement. Ranges from 35.8C to 37.0C Tympanic careful for injury perforation. Ranges from 36.8C to 37.9C Rectal considered the most accurate measurement of temperature. Ranges from 37.0C to 38.1C. Contraindications are anal/rectal conditions or surgeries, diarrhea, quadriplegic clients. Hold in place for 2 minutes (adult), for neonates about 5 minutes. PULSE: It is the wave of blood created by contraction of the left ventricle of the heart. Regulated by the autonomic nervous system

Isometric Exercise (Static or Setting): There is change in muscle tension but no change in muscle length and no muscle or joint movement. Isokinetic Exercise (Resistive): Maximum force is exerted by a muscle at each point throughout the active range of motion as the muscle contracts. The effort of the client to resist the movement is noted or measured. Can either be isotonic or isometric. Body Mechanics: This is the efficient, coordinated and safe use of the body to move objects and carry out activities of daily living. How to Use Proper Body Mechanics: Balance body parts appropriately Reduce friction Push or pull rather than lift Use rhythmic movements at normal speed Bend from the knees rather than from the waist Hold objects close to the body Breath normally (exhale through the mouth on exertion) Use mechanical devise For stability, broaden the base of support Adjust height of work area For Safety/To Avoid Injury: Ask for assistance/help when needed Face the direction of work to avoid injury Use smooth and continuous movements rather than sharp, sudden and uncontrolled movements Contract abdominal and gluteal muscles to stabilize pelvis. Assume a good starting position(for proper movement, direction and position) Use strong leg muscle when lifting, pushing or pulling Examine the surroundings for potential obstacles to the desired movement POSITIONING Position Prone-client lies face down When Used Contraindications

Pulse Sites: Temporal Carotid Apical- point of maximal impulse(PMI) left 5th ICS midclavicular line Brachial Radial Femoral Posterior Tibial Popliteal Pedal ( Dorsalis Pedis) Assessment of the Pulse: Rate Normal adult =60-100bpm, neonates=80180bpm, 1yr=80-140bpm, toddler(2-4)=80-130bpm, child(6-10)=75-100bpm Rhythm the regularity with which the pulsation occurs Volume/Quality- the strength of the palpated pulse Pulse Deficit = apical pulse - peripheral pulse (radial) RESPIRATION: The act of breathing Ventilation: the movement of gases in and out of the lungs. Inhalation(inspiration) the process of the use of O2, production of CO2 and exchange of these gases between the cells and the blood Exhalation(expiration) the process of taking O2 into and eliminating CO2 from the body Types of Breathing: Costal (Thoracic)- involves movement of the chest Diaphragmatic(Abdominal)-involves movement of the abdomen Assessing Respiration: Rate Normal adult is 12-20cpm, neonate=30-40cpm, toddler(2-4)20-30cpm, child(6-10)10-20cpm Depth/Volume may be normal, deep or shallow Rhythm the regularity of exhalations and inhalations Quality or character- refers to the respiratory effort e.g. dyspnea and sound of breathing e.g. stridor, wheezing BLOOD PRESSURE: Is the measure of the pressure exerted by the blood as it pulsates through the arteries Systolic Pressure- is the pressure of blood as a result of the contraction of the ventricles (100-140mmHg) Diastolic Pressure- is the pressure when the ventricles are at rest(60-90mmHg) Pulse Pressure- is the difference between the systolic and diastolic pressures. Normal is 30-40mmHG Exercises: Aerobic Exercise: activity during which the amount of oxygen taken in the body is greater than what was used to perform the activity. This kind of activity uses large muscle groups In performing continuous and rhythmical movement. Anaerobic Exercise: The muscle cannot extract enough oxygen from the blood and anaerobic pathways provide additional energy for a short period of time. This is useful in athletic endurance training. Isotonic Exercise (Dynamic): Those that shorten muscle to produce contraction and active movement. Such exercise greatly enhances joint mobility and helps improve muscle strength and tone.

Alternate position Post-abdominal for immobilized surgery and clients respiratory and spinal problems Supine-client lies flat on Clients on bed Clients with the back rest, post-spinal dyspnea or at risk surgery and post- for aspiration anesthesia Side-lying/lateral- client A choice position Clients post-hip lies on the side with for clients with replacement and weight on the hip and pressure sore on other orthopedic shoulder, pillows support bony surgery the legs, arm, head and prominences of neck back and sacrum Sims-In this semi prone Same as above Clients with spine or position, the client lies orthopedic on the side with weight conditions distributed toward the anterior ileum, humerus and clavicle, pillows support the flexed arms and legs Fowlers- sitting position Clients with Post-spine or brain raises clients head 80- difficulty of surgery 90 degrees(high), pillows breathing, also support the head, arms for eating, and legs improvement of cardiac output and watching TV Semi-fowlers- semi Same as above Same as above sitting with head elevated 15-45 deg Dorsal recumbent- client For vaginal lies supine with knees examination flexed and hips externally rotated Knee Anal/Rectal Arthritis and other Chest/Genupectoralprocedures and joint deformity client lies prone with examination buttocks elevated and knees drawn to the chest Lithotomy-client lies supine with feet supported in stirrups For vaginal, anal/rectal examinations and

procedures

Positive guaiac stool exam indicates peptic ulcer disease and gastric cancer Increased intracranial pressure, hypotension may result from this position Sputum Specimen Collection 1. Gross appearance of the sputum Collect early morning specimen Use sterile container Rinse mouth only with plain water before collection of the specimen. No eating, brushing or gargling with astringent mouthwash because its alcohol content may destroy the microorganism present in the sputum Instruct client to expectorate sputum by breathing deeply and then coughing out to ensure that it comes from the lungs and lower airways 2. Sputum Culture and Sensitivity Test To assess the specific etiologic agent causing respiratory tract infection and bacterial sensitivity to various antibiotics Use sterile container Collect sputum specimen before the first dose of antibiotic 3. Acid-Fast Bacilli (AFB) Staining To assess the presence of active pulmonary tuberculosis Collect sputum specimen for three consecutive mornings 4. Cytologic/Papanicolaou Examination of Sputum To assess for the presence of abnormal or cancer cells Blood Specimen Collection The medical technologist collects the blood specimen but the nurse must ascertain whether the test will require fasting or not as a preparation No fasting for the following tests: CBC(Complete Blood Count) Hemoglobin Hematocrit level Clotting studies Enzyme studies Serum electrolytes Fasting is required for the following tests: Fasting Blood Sugar(FBS), BUN, Serum Creatinine Serum Lipids (Serum Cholesterol, Triglycerides) The nurse collects the blood specimen for capillary blood glucose (CBG) through finger pinprick/needle stick before meals. Insulin injection is administered before meals. Lumbar Puncture/Spinal Tap This is the withdrawal of cerebrospinal fluid(CSF) through a needle inserted in the subarachnoid space of the spinal canal between the 3rd and 4th or the 4th or 5th lumbar vertebrae Secure written consent Empty bladder and bowel before the procedure Prepare three(3) sterile specimen bottles(label sequence for comparative studies Assist client to a fetal position for full exposure of the lumbar spine. Instruct to keep still with normal breathing Send specimens immediately to the laboratory Vital signs and neurological monitoring every 15 minutes until stable Check puncture site for bleeding or leakage Keep client flat on bed for 4 to 12 hours, to avoid spinal headache Oral analgesics as ordered for spinal headache Bronchoscopy Direct visualization of the trachea and mainstream bronchi. Also to obtain specimen for biopsy Informed consent/permit needed Atropine and valium pre-procedure, topical anesthesia sprayed followed by local anesthesia injected into the larynx, client will experience sore throat post procedure NPO for at least 6 hours prior to test and keep NPO until the gag reflex returns Remove dentures, prostheses, contact lenses Place in side-lying position post examination. Observe for cyanosis, hypotension, tachycardia, arrhythmias, hemoptysis and dyspnea. These are signs and symptoms that indicate perforation of bronchial tree. Angiography Evaluates specific areas of the arterial system by injecting a radio opaque dye and series of radiologic procedures Assess clients history of allergies particularly to seafoods since the dye has iodine content

Trendelenburgs- client For postural lies supine with head 30- drainage and 40 degrees lower than promotion of the feet venous return

Urine Specimen Collection: 1. Clean-catch, midstream urine specimen for routine urinalysis, culture and sensitivity test (C&S) The best time to collect urine specimen is early morning, first voided specimen. This is concentrated form of urine and can reveal the composition of the urine. Provide sterile container. This is to ensure that the specimen is uncontaminated. Do perineal care before collection of urine specimen to reduce microorganisms at the external genitals. Discard the first flow of urine to ensure that the specimen is uncontaminated. Collect the midstream urine: 30-50 ml. for routine urinalysis; 5-10 ml. for urine C&S. Discard the last flow of urine, especially among males( may be contaminated with semen) Label the specimen properly Send the specimen immediately to the laboratory 2. 24-Hour Urine Collection Discard first voided specimen. This was formed hours before time of collection Collect all specimens thereafter, until the same time the following day. Soak specimen in a container with ice. This is for preservation 3. Second-voided Urine Collection This specimen is required to assess glucose levels and for the presence of albumin in the urine Ask the client to void, discard this first urine specimen. This urine may be formed a few hours ago, and may not reveal accurate levels of glucose or presence of albumin at the time of the collection Give the client one glass of water to drink After a few minutes, ask the client to void again and collect this urine specimen. This urine will reveal accurate results. 4. Catheterized Urine Specimen Clamp the catheter for 30 minutes to 1 hour. To allow urine to accumulate in the bladder and adequate specimen can be collected. Cleanse the drainage port of the 2-way Foley catheter with alcohol swab/cotton ball. To remove microorganisms in the area Use sterile needle and syringe to aspirate the urine specimen from the drainage port. This ensures sterility of the specimen. Stool Specimen Collection 1. Routine Fecalysis To assess the gross appearance of stool and the presence of ova or parasites Secure sterile specimen container Instruct client to defecate in a bedpan. If desired, allow the client to void first. Discard the urine and wash the bedpan Use tongue depressor to collect stool specimen Collect one teaspoonful or 1 inch of well formed stool Label the specimen immediately to the laboratory. Fresh warm specimen help detect ova and parasites 2. Stool Culture and Sensitivity Test To assess the specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotic Use sterile test tube and sterile cotton-tipped applicator Label the specimen properly Send the specimen to the laboratory 3. Guaiac Stool Examination (Occult Blood Determination) Microscopic study for the presence of bleeding in the gastrointestinal tract Provide hemoglobin free diet for 3 days (Meatless diet) Avoid red or dark colored foods since these may be mistaken as blood Temporarily discontinue iron therapy because it causes black or greenish discoloration of the stool

Gastroscopy The direct visualization of the esophagus and the stomach using a lighted fexible tube Secure written consent NPO from midnight or at least 8 hours prior to the procedure and maintain NPO until gag reflex returns Local anesthesia by spray or gargle may lead to sore throat for about 4 days after the procedure Observe for hematemesis and respiratory distress Colonoscopy The direct visualization of the entire colon with the use of fiberoptic endoscope Clear liquid diet 1 to 3 days prior to the procedure Laxatives for 2 nights prior to the procedure Enema in the morning of the examination Position on the left side with knees flexed Observe stool and vital signs Upper GI Series (UGIS/Barium Swallow) This is to visualize the esophagus, stomach, duodenum and jejunum NPO for 6-8 hours Barium Sulfate per orem as ordered Post Procedure: Give laxative as ordered, since barium sulfate is constipating Increase fluid intake to further enhance excretion of barium sulfate Inform client that stool is light (white/gray) for about 24-72 hours Lower GI Series (LGIS/Barium Enema) Low residue diet for 2 days before the procedure Barium Sulfate per rectum as ordered Laxative the evening prior to the procedure Increase fluid intake Ultrasound of the Kidneys, Ureters and Bladder Detects tumors, cysts obstruction, abscesses Cleanse the bowel. Laxative as ordered Give 2 to 3 glasses of water to distend the bladder. This permits better imaging. Withhold voiding Inform client that this is a painless procedure Skin Test: Mantoux test PPD ( Purified Protein Derivative ) is used Intradermal route of injection Read result 48-72 hours after injection Positive Mantoux test is induration of 10mm or more For HIV positive clients, induration of 5mm is considered positive A positive Mantoux test signifies exposure to mycobacterium bacilli Chest X-ray Instruct the client on how to hold his breath and to do deep breathing Metals should be removed from the chest since metals are radio opaque, these may be mistaken as lesions Arterial Blood Gas Studies This is to assess ventilation and acid base balance Radial artery is the common site for withdrawal of blood specimen Allens test is done to assess for adequacy of collateral circulation of the hand, if ABG is to be monitored 10ml pre-heparinized syringe is used to prevent clotting of the specimen Have a container with ice to prevent hemolysis of the specimen Complete Blood Count (CBC) For evaluation of general health status RBC=4.5-5.5M/cu.mm;WBC=5,00010,000/cu.mm; platelets=150,000450,000/cu.mm Hemoglobin=12-17g/dl Hematocrit: Male = 42-50% Female = 40-48% Differential Count (Leukocytes) Neutrophils = 60-70% Eosinophils = 1-4% Basophils = 0-.5% Lymphocytes = 20-30% Monocytes = 2-6% Erythrocyte Sedimentation Rate (ESR) It is a measurement of the rate at which red blood cells settle out of coagulated blood in an hour Elevated in inflammatory conditions e.g. infectious heart disorders or MI

Normal Range is ; Male = 15-20 mm/hr, Female = 20-30 mm/hr Blood Urea Nitrogen (BUN) It is an indicator of renal function Normal range is 10-20 mg/dl Serum Electrolytes These electrolytes affect the cardiac contractility, namely; Na(Sodium)=135-145 mEq/L, K(Potassium)=3.5-5.5 mEq/L, Ca(Calcium)=4.5-5.5 mEq/L or 8.5-10 mg/dl Blood Lipids Cholesterol The client should be on NPO for 10-12 hours Normal range is 150-200 mg/dl Triglycerides The client should observe fasting for 10-12 hours Normal range is 140-200 mg/dl Components of Nursing Health History 1. Biographic Data Name, address, age, race, sex, marital status, occupation and religion 2. Chief complaint or reason for the visit The primary reason given by the client as to why he sought consultation or hospitalization 3. History of Present Illness Includes the following; usual health status, elaboration of the chief complaint, relevant family history and disability assessment 4. Past health history Includes childhood illness, childhood immunizations, allergies, accidents and injuries, hospitalization and medications 5. Family history of illness Includes ages of siblings, parents and grandparents and their current state of health or the cause of death. Reveals risk factors for certain diseases e.g. diabetes mellitus, hypertension, cancer, obesity,etc. 6. Review of systems Review of all health problems by body system. It is a tool in which the major organ system can be assessed 7. Lifestyle/Usual patterns of daily life Includes personal habits, diet, sleep/rest patterns, activities of daily living and recreation/hobbies. These data provide the basis for planning health promotion, health maintenance and restoration 8. Social data Includes family relationships, ethnic affiliation, educational history, occupational history and economic status 9. Psychological data Includes general survey of appearance and behavior, major stresses, usual coping pattern, communication style, self-concept and mood 10. Patterns of Health Care Includes health care resources Asepsis and Infection Control Infection The invasion of the body tissue by microorganisms and their proliferation Asepsis The absence of disease-producing microorganisms Medical asepsis- These are practices designed to reduce the number and transfer of pathogens. Clean Technique Surgical asepsis These are practices that render and keep objects and areas free from microorganisms. Sterile technique Pathogen A disease-producing microorganism Sepsis The presence of infection Infectious Disease- Results from the invasion and multiplication of microorganisms in a host. Stages of Infectious Process 1. Incubation Period Extends from the entry of microorganisms into the body to the onset of signs and symptoms 2. Prodromal Period Extends from the onset of non-specific signs and symptoms to the appearance of specific signs and symptoms. Generally considered to be the most infectious period 3. Illness Period Specific signs and symptoms develop and become evident 4. Convalescent Period Signs and symptoms start to diminish until the client returns to normal state of health The Chain of Infection 1. Etiologic/Infectious Agent Bacteria, virus, fungi or parasites. The ability of the infectious agent to cause a disease depends on its pathogenecity, virulence, invasiveness and specificity. 2. Reservoir(Source) Humans, animals, plants and the general environment

Portal of Exit from Reservoir Respiratory tract: droplets, sputum GI tract: vomitus: feces, saliva, drainage tubes Urinary tract: urine, urethral catheters Reproductive tract: semen, vaginal discharges Blood: open wound, needle puncture sites 4. Mode of Transmission a. Contact transmission May be direct or indirect contact Direct contact- immediate, direct transfer from person to person(body surface to body surface) Indirect contact occurs when a susceptible host is exposed to a contaminated object e.g. needle b. Droplet transmission a type of contact transmission Occurs when the mucous membrane of the nose, mouth or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, talking or laughing, usually within a distance of 3 feet. c. Vehicle transmission this involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens E.g. Food, water, milk, eating utensils, bed sheets d. Airborne transmission Occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens Air current disperses microorganisms, which can be inhaled or deposited on the skin of a susceptible host e. Vector Borne transmission vectors can be biologic or mechanical Biologic vectors are animals like rats, snails mosquitoes Mechanical vectors are inanimate objects contaminated with infected body fluids 5. Portal of Entry- Pathogens can enter susceptible hosts through body orifices such as the mouth, nose, ears, eyes, vagina, rectum or urethra Breaks in the skin or mucous membranes from wounds or abrasions increase the chance for organisms to enter the host. 6. Susceptible Host is at risk for infection, whose own body defense mechanisms, when exposed are unable to withstand the invasion of pathogens. E.g. malnourished children, infants, the elderly, clients who are immune compromised. They have the propensity to develop numerous types of infection Immunization, natural or acquired, acts to resist infection Breaking the Chain of Infection: Aseptic Practices 1. HANDWASHING Hand washing is the single most important infection control practice. Everyone should learn and practice proper hand washing techniques. Wash hands before and after every client care, even before and after eating, before and after performing a procedure. Soap, water and alcohol-based hand rubs are effective preparations for removing transient microorganisms. Effectiveness of hand washing is greatly influenced by adequate friction and thoroughness of surfaces cleansed. In medical asepsis, hand washing is done by holding hands lower than the elbow. Hands are more contaminated than the lower arms. Wash hands using running water, soap and friction for about 15to 30 seconds on each hand. Clean under fingernails Keep fingernails short and avoid nail polish to prevent harboring microorganisms. Ideally, turn off the faucet with clean paper towel. 2. Cleaning, Disinfection and Sterilization Cleaning- the physical removal of visible dirt and debris by washing, dusting or mopping surfaces that are contaminated. Disinfection the chemical or physical processes used to reduce the number of potential pathogens on an objects surface. But

3.

spores of the pathogens are not necessarily destroyed. Sterilization the complete destruction of all microorganisms, including spores, leaving no viable forms of organisms. Any item introduced into sterile tissues or the vascular system, such as surgical instruments, cardiac and urinary catheters, vaginal speculum, implants, IV fluids and needles must be sterile. Methods of Sterilization: a. Steam sterilization- Autoclaving is sterilization using supersaturated steam under pressure. This method is non-toxic, inexpensive, sporicidal and able to penetrate fabrics rapidly. It is used to sterilize surgical dressings, surgical linens, parenteral solutions, metals and glass objects. Color indicator strips change color, indicating that sterilization has occurred. Check packaging for integrity and always check the expiration date to ensure sterility of the object. b. Gas sterilization Ethylene oxide is a colorless gas that can penetrate plastic, rubber, cotton and other substances. This is used to sterilize oxygen or suction gauges, Bp apparatus, stethoscope and catheters. This type of sterilization is expensive and requires 2 to 5 hours to be accomplished. Ethylene oxide is toxic to humans. c. Radiation Ionizing radiation penetrates deeply into objects. This is used in sterilizing drugs, food and other heat-sensitive items. d. Chemicals These are effective disinfectants. These attack all types of microorganisms, act rapidly, work with water, are inexpensive, stable in light and heat, are not harmful to body tissues and do not destroy articles. These are used for instruments and equipment such as glass thermometer. Chlorine is used for disinfecting water. e. Boiling Water This is the least expensive for use at home. Items like glass baby bottles should be boiled for at least 15 minutes. Types of Disinfection: Concurrent Disinfection: These are ongoing practices that are observed in the care of the client, Including his supplies, his immediate environment, to limit/control the spread Of microorganisms. Terminal Disinfection: These are practices to remove pathogens from the clients belongings and his immediate environment after his illness is no longer communicable. 3. Use of Barriers These are techniques that prevent the transfer of pathogens from one person to another. The most commonly used barriers are the following; masks, caps and shoe coverings, gloves, private rooms, waterproof disposable bags for linen and trash, labeling and bagging of contaminated equipment and specimens, control of airflow into the sterile areas and out of contaminated areas, and goggles or face shields Masks should fit tightly to the face, covering the nose and the mouth. Disposable particulate respirators look like masks but fit the face more tightly and are able to filter out particles or organisms as small as 1 micromillimeter. These are indicated whenever a care provider is working with a client who has, or is suspected of having contagious, airborne diseases such as TB. Gowns: Should be worn when a care providers clothing is likely to be soiled by infected material. Gowns are used only once and should be changed when soiled. Caps and shoe coverings: These are used to cover the hair and special covers are available for shoes. These shield body parts from accidental exposure to contaminated body secretions. Gloves: These protect the hands from acquiring infective microorganisms. Gloves should be changed and discarded when soiled or torn, and between care of clients. Never touch with bare hands anything that is wet coming from a body surface. Hands should be washed and dried before and after removing gloves.

Private Rooms: Separation of clients into private rooms decreases the chance of transmission of infection by all routes. Equipment and Refuse Handling: Articles and linens soiled by any body fluid should be placed in water proof bags before these are removed from the clients bedside. The outside part of the bag should not be contaminated when placing articles inside it, if the outside portion becomes contaminated; placing that bag in another bag (double bagging) is required. 4. Isolation Systems These are techniques used to prevent or to limit the spread of infection. These are classified as standard precautions, transmission-based precautions and protective isolation. Standard Precautions A.Wear gloves when touching blood and body fluids, mucous membranes and non-intact skin B.Perform hand washing immediately when there is direct contact with blood and body fluids, mucous membranes and non-intact skin; after removing gloves and in between client contact. C. Wear a mask, eye protection and face shield during procedures and client care activities that are likely to generate splashes or sprays of blood, body fluids and secretions. D. Wear a gown during procedures and client care activities that are likely to generate splashes or sprays that cause soiling of clothing. E.Remove soiled protective items promptly when the potential for contact with pathogens is no longer present. F. Clean and reprocess all equipment before reuse by another client. G. Discard all single use items promptly in appropriate containers. H. Prevent injuries with used needles, scalpels and other sharp devices by: 1. Never removing, recapping, bending or breaking used needles 2. Never pointing the needle toward a body part 3. Using syringes with a retractable protective guard or shield for enclosing a needle or blunt point needles. 4. Depositing disposable and reusable syringes and needles in puncture resistant containers. - Use a private room or consult with an infection control professional for the care of clients who contaminate the environment or who cannot or do not assist with appropriate hygiene or environmental cleanliness measures. Transmission-based Precaution 1. Airborne Precaution These are used for microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents, e.g. TB, varicella, measles. The client should be cared for in a private, negative airflow room, to contain the air within the clients unit. Care providers wear masks and the client should wear mask when transported out of the room. 2. Droplet Precaution These are used for microorganisms transmitted by larger particle droplets (through coughing, sneezing, laughing or talking) which disperse into air currents, e.g. haemophilus influenzae, diphtheria, rubella, mycoplasma pneumoniae. Client should be placed in a private room. Care providers wear masks and the client should wear a mask when outside the room. 3. Contact Precautions These are used with microorganisms that can be transmitted by hand, skin or skin contact, such as during client care activities or when touching the clients environmental surfaces or care items. E.g. clostridium difficile, shigella, impetigo. The client is cared for in a private room or has a roommate who is infected with the same organism.

Personnel use gloves before entering the room and change gloves when exposed to potentially infected material during care activities. Remove gloves before leaving the clients room. Gowns and other protective barriers are to be used when contamination is likely either from the client, the environmental surfaces or the clients room. This is implemented to prevent infection for people whose resistance to infection/body defenses are lowered or compromised. E.g. clients with low WBC count, on immunosuppressive medications like cancer chemotherapy, extensive burns. Meticulous hand washing is strictly practiced by the client, the clients family, all caregivers. Visitors are restricted. Persons with signs and symptoms of infection are not allowed to visit the client. E.g. those with cough and colds, diarrhea, skin infections. No fresh fruits or vegetables, raw food, fresh flowers and potted plants are allowed. Only cooked or canned fruits are allowed.

Protective Isolation

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Surgical Asepsis Surgical asepsis is required in the following situations, namely; surgical procedures all procedures that invade the bloodstream procedures that cause a break in skin or mucous membranes. E.g. intramuscular injections complex dressing changes and wound care insertion of tubes, catheters or devices into sterile body cavities. E.g. urinary bladder care for high risk groups E.g. transplant recipients, burn clients, clients with cancer

Principles of Surgical Asepsis: 1. Moisture causes contamination. 2. Never assume that an object is sterile. Always face the sterile field. 4. Sterile articles may touch only sterile articles or surfaces if they are to maintain their sterility. 5. Sterile equipment or areas must be kept above the waist and on top of the sterile field. 6. Prevent unnecessary traffic and air currents around the sterile field. 7. pen, unused sterile articles are no longer sterile after the procedure. 8. A person who is considered sterile who becomes contaminated must reestablish sterility. 9. Surgical technique is a team effort. Communication, Documentation and Reporting Characteristics of Communication 1. Simplicity includes use of commonly understood words, brevity and completeness. 2. Clarity Say exactly what is meant. One needs to speak slowly and enunciate words well. Repeat the message when needed 3. Timing and Relevance Requires choice of appropriate time and consideration of the clients interests and concerns. Ask one question at a time and wait for an answer before making another comment. 4. Adaptability Involves adjustment on what one should say and how it is said depending on the mood and behavior of the client.

5. Credibility What one is saying should be worth believing. For a nurse to be credible, she should have adequate knowledge and accurate information to convey confidence. She should be a good role model for what she teaches. Components of Communication 1. Sender (Encoder) 2. Message 3. Receiver (Decoder) 4. Response (Feedback) Documentation: serves as a permanent record of client information and care.

Reporting: takes place when two or more people share information about client care, either face to face or by telephone. Purposes of Clients Record/Chart 1. Communication provides efficient and effective method of sharing information. It contains meaningful data about the client. 2. Legal Documentation it is admissible as evidence in a court of law. 3. Research provides valuable health-related data for research. 4. Statistics provides statistical information that can be utilized for planning peoples future needs. 5. Education serves as an educational tool for students in health discipline. 6. Audit and Quality Assurance monitors the quality of care received by the client and the competence of health care providers. 7. Planning Client Care provides data which the entire health team uses to plan care for the client. 1. Reimbursement provides the basis for decisions regarding care to be provided and subsequent reimbursement to the agency, to cover health-related expenses. Types of Records A. Source Oriented medical record (Traditional client record) - Each person or department makes notations in a separate section/s of the clients chart. B. Problem-oriented medical record (POMR or POR) - Data about the client are recorded and arranged according to the source of the information. - The record integrates all data about the problem, gathered by the members of the health team. 4 Basic Components of the POMR/POR 1. Database contains all the initial information about the client. 2. Problem List contains all the aspects of the persons life requiring health care. 3. Initial list of orders or care plans. 4. Progress Notes: Nurses or narrative notes (SOAPIE Format) S Subjective data O Objective data A Assessment P Planning I Intervention E Evaluation Flow sheets ( data that are monitored ) Discharge notes or referral summaries Kardex Provides a concise method of organizing and recording data about a client, making information readily accessible to all members of the health team. It is a series of flip cards usually kept in a portable file. It is a way to ensure continuity of care from one shift to another and from one day to the next. It is a tool for change of shift report but endorsement is not simply

reciting content of the kardex. The health care needs of the client are still the primary basis for endorsement. The kardex usually includes the following data: Personal data ( demographic data ) Basic needs Allergies Diagnostic tests Daily nursing procedures Medications and intravenous (IV) therapy, blood transfusions Treatments like O2 therapy, steam inhalation, suctioning, change of dressing, mechanical ventilation.

Entries are usually in pencil so that it can be changed as the clients condition changes. The kardex is for planning and communication purposes only. Characteristics of Good Recording 1. Brevity Entries are concise. Complete sentences are not required. Start each entry with a capital letter and end the entry with a period even if the entry can be used is a single word or phrase. 2. Use of ink/Permanence Avoid felt pen or pencil for permanence of the data, because the clients chart can be used as evidence in a legal court. 3. Accuracy Chart objective facts, not your own interpretations or opinions. E.g. Correct: Refused medications, Incorrect: Uncooperative Place complaint of the client in quotation marks to indicate that it is the clients statement. E.g. complained of chest pain radiating down the left arm. Objective data are also to be charted. E.g. skin cold and clammy Describe behaviors rather than feelings to allow other health team members to determine the actual problems of the client. Refusal of medications and treatments must be documented. 4. Appropriateness Only information that pertain to the clients health problems and care are recorded. Any other personal information that is conveyed to the nurse is inappropriate for the record. 5. Completeness and Chronology/Organization/Sequencing/Timing Notes should appear on each succeeding line. Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new idea or entry. Date and time are entered in their respective column Avoid double charting. If something appears on a particular sheet, it does not need to appear on the nurses notes, unless there is an alteration from the normal. Avoid squeezing information into a space because it was not charted earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information. The following information should be charted: Physicians visits

Times the client leaves and returns to the unit, mode of transportation and destination. Medications should be charted immediately after it was given. Treatments should be charted immediately after it was done. 6. Use of standard terminology Use only those abbreviations and symbols approved by the institution, spell correctly and use proper grammar. 7. Affix signature Signature should be placed at the end of the charting, at the right hand margin of the nurses notes. Sign each entry with your full name and status. 8. In case of ERROR Correct errors by drawing a single horizontal line across the error. Write the word error above the line, and then affix your signature. Erasures, ink eradications or the use of occlusive materials are not allowed. 9. Confidentiality Only the health personnel included in the care of the client are allowed to read the chart. 10. Legal awareness Chart only what you personally have done, observed, heard, smelled or felt. What was done is charted, what was not done is not charted. Do not discard any part of the client record. 11. Legible Writing must be clear and can be read easily by others. If writing is not legible, then print. 12. It is not necessary to use the word patient or pt. in the chart, the chart belongs to the patient. The information in the chart is all about the patient. 13. A horizontal line is drawn to fill a partial line. This is to prevent other persons from adding information the nurses notes. Types of Reporting 1. Change of shift reports or endorsement For continuity of care. Based on health care needs of the client. 2. Telephone reports Provide clear, accurate and concise information. Document the telephone report by including the following information: when the call was made; who made the call/report who was called; to whom the information was given what information was given; what information was received

2. Deep breathing and coughing exercises. This is to promote maximum lung expansion and to loosen mucous secretions. 3. Positioning. The semi-fowlers or high fowlers position promotes maximum lung expansion. By gravity, the diaphragm moves down and abdominal organs do not compress the diaphragm. 1. Patent airway. To promote gaseous exchange between the person and the environment. Causes of Airway Obstruction Tongue among unconscious clients, the tongue tends to fall back Mucous secretions Edema of the airways (rhinitis, laryngitis, bronchitis) Spasm of the airways (laryngospasm, bronchospasm) Foreign bodies (aspirated food, fluids) 5. Adequate hydration. Fluids liquefy mucus secretions. Ideally 6 to 8 glasses of fluid, preferably water, is needed everyday. 6. Avoid environmental pollutants, alcohol and smoking. These factors affect mucociliary function. 1. Chest Physiotherapy (CPT) Percussion, Vibration and Postural Drainage (PVD) These procedures are dependent nursing functions. Percussion (clapping) is the forceful striking of the skin with cupped hands. It can mechanically dislodge tenacious secretions from bronchial walls. Vibration is a series of vigorous quivering produced by the hands that are placed flat against the clients chest wall as the client exhales. Postural Drainage This is the use of gravity to assist in the movement of secretions (mucus-filled segment of the lungs should be higher to allow movement out of the lungs) Each position during postural drainage will be assumed by the client for about 10-15 minutes. The entire treatment should last for only 30 minutes. Provide good oral hygiene after the procedure. Do postural drainage before meals, in the morning upon awakening and at bedtime. Gradual change of position should be observed to prevent exhaustion and postural hypotension 8. Bronchial Hygiene Measures a. Steam Inhalation Purposes of steam inhalation: - To liquefy mucous secretions - To warm and humidify inspired air - To relieve edema of the airways - To soothe irritated airways - To administer medications It is a dependent nursing function. To be effective, render steam inhalation therapy for about 15-20 minutes. Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate expectoration of secretions. Provide good oral hygiene after the procedure. b. Aerosol Inhalation done among pediatric clients to administer bronchodilators or mucolytic expectorants. 9. Suctioning this is done to clear airways from mucus secretions. 10. Incentive Spirometry this is a method of encouraging voluntary deep breathing by providing visual feedback about inspiratory volume.

3. Telephone orders - Only RNs may receive telephone orders. - The order needs to be verified by reporting it clearly and precisely. - The order should be countersigned by the physician who made the order within the prescribed period of time (within 24 hours). 4. Transfer reports - This is done when the client is to be transferred from one unit to another. Oxygenation MANS PHYSIOLOGIC NEEDS Measures that Promote Adequate Respiratory Function 1. Adequate oxygen supply from the environment. Atmospheric oxygen is about 21%. We need this to survive. The higher the altitude, the lower the oxygen concentration.

11. Intermittent Positive Pressure Breathing (IPPB) this is a method of administering oxygen at pressures higher than the atmospheric pressure. 12. Administration of Supplemental O2 Indicated for Hypoxemia Signs of Hypoxemia

Decreased rate and depth of respiration It causes retention of carbon dioxide.

- Restlessness (initial) - Increased pulse rate - Rapid, shallow respiration and dyspnea - Light-headedness - Flaring of the nares - Cyanosis (late sign) Oxygen Systems 1. Low Flow Administration devices Nasal Cannula (24-45% at 2-6 LPM) May be used in clients with COPD at 2-3LPM if venture mask is not available Simple face mask (40-605 at 5-8 LPM) Partial Rebreathing mask (60-90% at 6-10 LPM) Non-rebreathing mask (95100% at 6-15 LPM) Croupette Oxygen Tent 2. High Flow Administration devices - Venturi mask Low concentration venture type mask is preferred for clients with COPD because it provides accurate amount of O2. They require about 2-3LPM or 28% oxygen. - Face mask - Oxygen hood. This is used for low and high flow concentration. - Incubator/Isolette. This is used for low and high flow concentration. Alterations in Respiratory Function 1. Hypoxia insufficient oxygenation of tissues

c. Rhythm - Cheyne-stokes marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea. - Kussmauls respirations (Hyperventilation) increased rate and depth of respirations, usually seen in metabolic acidosis and renal failure. - Apneustic prolonged gasping inspiration followed by a very short, usually inefficient expiration. - Biots respirations shallow breaths interrupted by apnea. d. Ease of Effort - Dyspnea difficult or labored breathing. - Orthopnea inability to breathe except in upright or sitting position. Nutrition Is the sum of all interactions between an organism and the food it consumes. It is also the study nutrients and the processes by which these are used by the body. Nutrients are the organic and inorganic chemicals found in food required for proper body functioning. These are water, carbohydrates, proteins, fats, vitamins and minerals Calorie (kilocalorie) is a unit of heat energy. Variables Affecting an Individuals Calorie Needs 1. Age and Growth - E.g. the first 2 years of life, adolescence, pregnancy require more calories. 2. Gender - Men have higher BMR than women. 3. Climate - Cold climate causes higher BMR. This is due to increased thyroxine level in people who live in cold places. 4. Sleep Less energy is required during sleep, the metabolic rate drops to about 10% to 15%. Thus, dinner should ideally be the lightest meal of the day. 5. Activity Increased muscular activity increases BMR. Greater energy expenditure requires more calories. 6. Fever Increases metabolic rate. 1. Illness Increases energy requirements due to increased metabolic rate. Food and fluid Intake Regulating Mechanisms: 1. Thirst triggered by the loss of body fluid of more than 2% 2. Hunger triggered by low blood glucose level 3. Appetite triggered by sight, smell and thought of food 4. Satiety triggered by gastric distention Vitamins A. Water-Soluble Vitamins C (Ascorbic Acid) Scurvy, poor wound healing - Guava, citrus fruits, tomatoes B1 (Thiamine) Beriberi - Legumes, eggs, milk B2 (Riboflavin) Skin lesions, cheilosis, glossitis - enriched grains, green leafy vegetables B3 (Niacin/Nicotinic Acid) - Pellagra, dermatitis, diarrhea - Fish, dried peas, lean meat B6 (Pyridoxine) Peripheral neuritis - Oats, yeast, chicken, corn B9 (Folacin/Folic Acid) - Megaloblastic anemia - Green leafy vegetables, kidney beans B12 (Cyanocobalamin) Pernicious anemia - Oyster, liver, cheese, shrimp Pantothenic Acid - Fatigue, sleep disturbances, nausea - Fruits, whole grain cereals, meat Biotin - Depression, dermatitis, muscular pain - Egg yolk, organ meats, milk, yeast B. Fat-Soluble Vitamins

Clinical Signs of Hypoxia Early Signs: Tachycardia Increased rate and depth of respiration Slight increase in systolic BP Late Signs: Bradycardia Dyspnea Decreased systolic BP Cough Hemoptysis Other Clinical Signs of Acute Hypoxia: 1. Nausea and Vomiting 2. Oliguria and Anuria 3. Headache 4. Apathy 5. Dizziness 6. Irritability 7. Memory Loss Other Clinical Signs of Chronic Hypoxia 1. Fatigue and Lethargy 2. Pulmonary ventilation increases 3. RBC count increases 4. Hemoglobin concentration increases 5. Clubbing of fingers 2. Altered Breathing Patterns a. Rate - Tachypnea (rapid respiratory rate) - Bradypnea (slow respiratory rate) - Apnea (Cessation of breathing) b. Volume - Hyperventilation Excessive amount of air in the lungs It results from deep rapid respirations - Hypoventilation

A (Retinol) of the lens squash

- Night blindness, xeropthalmia, opacity - Liver, milk and dairy products, carrots,

Clinical Signs Dietary History

D (Ergocalciferol) Rickets, osteomalacia - Salmon, tuna, sardines, butter, liver E (Tocopherol) Anemia, skin lesions - Soybeans, vegetable oils, leafy vegetables K (Menadione) Bleeding - Cabbage, cauliflower, green leafy vegetables Minerals Macrominerals: Calcium, Phosphorus, Potassium, Sulfur, Sodium, Chloride and Magnesium Microminerals: Iron, Zinc, Selenium, Manganese, Tin, Copper, Iodine, Cobalt, Fluoride, Chromium, Nickel, Silicon Common Minerals: 1. Calcium Necessary for bone and teeth formation, promotes muscular contraction, blood coagulation and collagen formation. Facilitates nerve transmission, activates enzymes and serves as catalyst for biological reactions. A deficiency results in retarded growth, rickets, osteomalacia and tetany. While an excess will result in tonic contraction (calcium rigor). Good sources are; milk and dairy products, green leafy vegetables, whole grains, nuts and legumes, carrots, seafood 2. Potassium Promotes fluid and electrolyte balance. It is the major cation in the intracellular fluids. It influences the acidbase balance and affects the activity of the skeletal and cardiac muscles. Hypokalemia is manifested by the following signs and symptoms: apathy, muscular weakness, mental confusion, and abdominal distention, and nausea, lack of appetite, nervous irritability and life threatening dysrythmias. Hyperkalemia is manifested by weakening of cardiac contraction, mental confusion, poor respirations and numbness of extremities. Good sources are; avocado, banana and cantaloupe (ABC), oranges, strawberries, raisins, raw tomatoes, carrots, mushroom, pork, beef and fish 3. Sodium Is responsible for maintaining fluid balance. It is the major cation in the extracellular fluid. It is also responsible for maintaining the acid-base balance It allows the passage of glucose through the cell wall. It also maintains normal muscle excitability. Hyponatremia causes reduction in the ECF and blood volume. The veins collapse, BP is low and the pulse is rapid. While an excess will result in edema and a high blood pressure. 4. Iron Is the most abundant trace element in the body. It is a constituent of hemoglobin and myoglobin, thus plays a role as a carrier of oxygen. It is necessary for hemoglobin formation. It is an active component of tissue enzymes involved in the conversion of betacarotene to vitamin A, the synthesis of purine, antibody production, collagen synthesis and for the oxidation of glucose to produce energy. - Pork liver is the richest source of iron. Lean meat is secondary richest source. Other sources include; enriched rice, kamote leaves, soybeans and clams. - Iron deficiency leads to anemia. - Iron overload is known as hemosiderosis. 5. Iodine Participates in the synthesis of thyroxine, a hormone in the thyroid gland. Iodine deficiency causes goiter. Cretenism results if a pregnant woman does not have adequate supply of iodine in the diet. Myxedema may be experienced by adults who had low iodine intake throughout their childhood and adolescence. - Good Sources are; iodized salt, seafood, milk, eggS Biochemical Data

Hemoglobin and Hematocrit indices Serum Albumin Transferrin (Blood protein that binds with iron) Total Lymphocyte Count Nitrogen Balance Creatinine Excretion Assess hair, skin, eyes, tongue, mucous membranes 24-hour diet recall, 72-hour diet recall. To determine adequacy of food intake of the client.

Common Problems of Nutrition 1. Anorexia loss of appetite 2. Nausea and Vomiting 3. Malnutrition Over nutrition : overweight and obesity Under nutrition : Kwashiorkor is protein deficiency while marasmus is calorie deficiency Over weight: weight is 10% greater than IBW(ideal body weight) Obesity: 20% greater than IBW Measures to Stimulate the Appetite 1. Serve food in a pleasant and attractive manner. 2. Place client in a comfortable eating position. 3. Provide good hygiene measures. 4. Promote comfort Relieve pain Adequate ventilation and humidity Remove unsightly articles Check very tight or very loose dressing Provide good lighting 5. Color affects the appetite. Include red, yellow, green-colored food. 6. Engage in pleasant conversation. 7. Assist weak client in feeding. General Nursing Management for the Client with N and V: 1. Position properly; for conscious clients, place in semi-fowler, for unconscious clients, side-lying or lateral position. This is to prevent aspiration. 2. Provide good oral care measures. 3. Suction the mouth as needed if the client is unable to expel vomitus. 4. Relieve sensation of nausea by providing any of the following: Ice chips Hot tea with lemon/calamansi Hot ginger ale Dry toast or crackers Cold cola beverages Hard candy 5. Replace fluid-electrolyte losses as ordered through oral or intravenous fluid infusions. 6. Observe for potential complications, namely; a. Dehydration Thirst (first sign) Dry mouth and mucous membrane Warm, flushed, dry skin Fever, tachycardia, low BP Weight loss, sunken eyeballs, oliguria Dark, concentrated urine/high specific gravity of urine Poor skin turgor Altered LOC (level of consciousness) Elevated BUN, serum Creatinine Elevated hemocrit b. Acid-base Balance Initially, metabolic alkalosis due to excessive loss of gastric acids. In

prolonged vomiting, metabolic acidosis occurs due to excessive loss of bicarbonate from the duodenum. c. Hypokalemia Initial manifestation is muscle weakness in the legs or leg cramps. Provide potassium rich food such as ABC, raw tomatoes, raw carrots, baked potatoes, citrus fruits and dried fruits. 7. Administer antiemetic medications as ordered by the AP E.g. Plasil(Metochlopramide), Phenergan (Promethazine), Compazine ( Prochlorperazine maleate) Special Diets 1. Clear liquid diet includes only liquids that lack residue E.g. water, bouillon, clear broth, gelatin, popsicles, lemonade, hard candy, carbonated beverages 2. Full liquid diet includes all fluids and foods that become liquid at room temperature. E.g. plain ice cream, sherbet, milk, strainedsoups, pudding/custard, strained vegetable juices 3. Soft diet includes soft foods and those with reduced fiber content which require less energy for digestion. E.g. chopped or pureed foods 4. Diet as tolerated (DAT)- those foods that the client can tolerate after surgery or after GI distress. Bowel and Bladder Elimination Normal Characteristics of the Stool Color: yellow or golden brown (due to the bile pigment derivative known as stercobilin or fecal urobilinogen). Odor: aromatic upon defecation (due to the indole and scatole, which are products of fermentation and putrefaction in the large intestine). Amount: depends on the bulk of the food intake, approximately 150 to 300g. per day. Consistency: soft, formed Shape: cylindrical Frequency: Variable usually ranges from 1-2 per day to 1 every 2-3 days. Alteration on the Characteristics of Stool 1. Acholic Stool gray, pale or clay-colored stool due to the absence of stercobilin caused by biliary obstruction. 2. Hematochezia passage of stool with bright red blood. It is due to lower gastrointestinal bleeding. 3. Melena passage of black, tarry stool due to upper GI bleeding. 4. Steatorrhea greasy, bulky, foul-smelling stool. It is due to the presence of undigested fats such as in hepatobiliarypancreatic obstructions/disorders. Common Fecal Elimination Problems A. Constipation it is the passage of small, dry, hard stools or passage of no stool for a period of time. Nursing Interventions to Prevent and Relieve Constipation 1. Adequate fluid intake, between 1,500 to 2,000 ml/day. This is the most effective measure to relieve constipation. 2. High-fiber diet. This type of diet provides bulk to the stool. High fiber foods include fresh or cooked fruits and vegetables, whole grain breads and cereals, fruits and vegetable juices. 3. Establish regular pattern of defecation. 4. Respond immediately to the urge to defecate. The defecation reflex and the urge to defecate subside after a few

minutes if the initial urge is ignored. The feces then remain in the rectum until another mass colonic movement propels more stool into the rectum, which may not be for several hours or longer. 5. Minimize stress. Stress triggers the sympathetic nervous system, causing decreased peristalsis. 6. Adequate activity and exercise promotes muscle tone and facilitates peristalsis. 7. Assume sitting or semi squatting position. This position allows gravity to assist the elimination of feces and also makes it easier for the client to contract the abdominal and pelvic muscles, thereby applying external pressure to the large intestine and encouraging evacuation. 8. Administer laxatives as ordered. Laxatives stimulate peristalsis and promote defecation. Avoid overuse of laxatives because natural defecation reflexes are inhibited, rebound constipation occurs. Types of Laxatives 1. Chemical Irritants these provide chemical stimulation to intestinal wall, thereby increasing peristalsis. E.g. Dulcolax (Bisacodyl), castor oil, Senokot(Senna) 2. Stool Lubricants these lubricate feces and facilitate its expulsion. E.g. mineral oil 3. Stool Softeners these soften the stool and its expulsion. E.g. Colace 4. Bulk Formers these increase the bulk of the feces, increasing mechanical pressure and distention of the intestine, thereby increasing peristalsis. E.g. Metamucil 1. Osmotic Agents These attract fluids from the intestinal capillaries to the stool. E.g. Milk of Magnesia (Magnesium Hydroxide), Duphalac (Lactulose) A. Fecal Impaction is the mass or collection of hardened, putty-like feces in the folds of the rectum. The stool is lodged or stuck in the rectum; the person is unable to voluntarily evacuate the stool.

Assessment: Absence of bowel movement for 3 to 5 days. Passage of liquid fecal seepage. Hardened fecal mass is palpated during digital examination of the rectum. Nonproductive desire to defecate Rectal pain Anorexia, body malaise Subjective feeling of abdominal fullness or bloating; apparent abdominal distention. Nausea and vomiting Nursing Interventions to Relieve Fecal Impaction 1. Manual extraction or fecal disimpaction as ordered. 2. Increase fluid intake. 3. Sufficient bulk in the diet. 4. Adequate activity and exercise. C. Diarrhea this is the frequent evacuation of watery stools. It is associated with increased GI motility, and a rapid passage of fecal contents through the lower GI tract. Nursing Interventions to Relieve Diarrhea 1. Replace fluid and electrolyte losses. 2. Provide good perineal care. Diarrheal stool is oftentimes highly acidic. This causes anal soreness and irritation in the perineal area 3. Promote rest. This is to reduce peristalsis. 4. Diet: Small amounts of bland foods Low fiber diet BRAT Diet (Banana, Rice am, Apple, Toast) Avoid excessively hot or cold fluids. These are stimulants. Potassium rich foods and fluids ( e.g. banana, Gatorade ) 5. Anti-diarrheal medications as ordered. Demulcents mechanically coat the irritated bowel and act as protectives. Absorbents absorbs gas or toxic substances from the bowel.

Astringents shrink swollen or inflamed tissues in the bowel.

Specific gravity: 1.010-1.025 (measured by urinometer) Problems in Urinary Elimination A. Altered Urine Composition RBC Hematuria WBC Pus Pyuria Bacteria Bacteriuria Albumin Albuminuria Protein Proteinuria Casts Cylindriuria Glucose Glycosuria Ketones Ketonuria Urge incontinence follows a sudden strong desire to urinate and leads to involuntary detrusor contraction. Functional incontinence the involuntary, unpredictable passage of urine. Reflex incontinence is the involuntary loss of urine occurring at somewhat predictable intervals when specific bladder volume is reached. 9. Retention the accumulation of urine in the bladder with associated inability of the bladder to empty itself. About 250-450 ml of urine in the bladder triggers voiding reflex. Clinical Signs of Urinary Retention a. Discomfort in the pubic area. b. Bladder distention ( Palpation/Percussion) smooth, firm, ovoid mass at the suprapubic area mass arising out of the pelvis dullness on percussion c. Inability to void or frequent voiding of small volume (25-50ml at a time) d. A disproportionately small amount of output in relation to fluid intake a. Increasing restlessness and feeling of need to void. Nursing Interventions to Induce Voiding 1. Provide privacy. This is considered the most effective nursing measure to induce voiding. 2. Provide fluids to drink. 3. Assist the client in the anatomical position of voiding. 4. Serve clean, warm and dry bedpan (female) or urinal (male). 5. Allow the client to listen to the sound of running water. 6. Dangle fingers warm water. 7. Pour warm water over the perineum. 8. Promote relaxation. 9. Provide adequate time for voiding. 10. Let the client listen to running water. 11. Perform Credes maneuver as ordered. This is done by applying pressure on the suprapubic area. 12. Administer medications as ordered e.g. Urecholine (Bethanecol) 13. Last resort: urinary catheterization (as ordered)

A.

Flatulence this is the presence of excessive gas in the intestines (also called tympanites). This may be due to swallowed air, bacterial action in the large intestines and diffusion from blood.

Common Causes of Flatulence 1. Constipation 2. Codeine, barbiturates and other medications that decrease intestinal motility. 3. Anxiety 4. Eating gas-forming foods e.g. cabbage, onions, legumes 5. Rapid food or fluid ingestion 6. Improper use of drinking straw 7. Excessive drinking of carbonated beverages 8. Gum chewing, candy sucking and smoking 9. Abdominal surgery. This causes decreased peristalsis. Nursing Interventions to Relieve Flatulence 1. Avoid gas-forming foods. 2. Provide warm fluids to drink. This increases peristalsis. 3. Early ambulation among postoperative clients. 4. Adequate activity and exercise. 5. Limit carbonated beverages, use of drinking straws and chewing gums. 6. Rectal tube insertion as ordered. 7. Carminative enema as ordered E. Fecal Incontinence This is the involuntary elimination of bowel contents; it is often associated with neurologic, mental or emotional impairments. Clients with cerebral cortex injury may be unable to perceive distended rectum, or are unable to initiate the motor response required to inhibit defecation voluntarily. People who have sustained sacral and spinal cord injury experience impaired nerve supply to the rectum and anal sphincters. They are unable to inhibit voluntary anal sphincters to postpone defecation. Clients who are disoriented or confused may have lost the social inhibition that prevents immediate fecal evaluation. Diarrhea predisposes a person to fecal incontinence. Sometimes, the volume of feces is so large and the defecation urge so intense that the person cannot maintain sphincter contraction long enough to access toilet facilities and remove the necessary clothing.

Types of Enema 1. Cleansing enema stimulated peristalsis by irritating the colon and rectum and or by distending the intestine with the volume of fluid introduced. High enema Used to clean as much of the colon as possible; 1,000 ml of solution is introduced. Low enema Used to clean the rectum and the sigmoid colon only; 500 ml of solution is introduced. 2. Carminative enema Used to expel flatus; 60-180 ml of solution is introduced. 3. Retention enema introduces oil into the rectum and sigmoid colon; oil is retained in about 1 to 3 hours. The oil acts to soften the feces and to lubricate the rectum and the anal canal, facilitating the passage of feces. 4. Return Flow enema/Harris Flush/Colonic Irrigation This is done to expel flatus. Urinary Elimination Normal Characteristics of Urine Color: amber/straw colored Odor: Aromatic upon voiding Transparency: Clear pH: slightly acidic ( ranges from 4.6 8; average of 6 )

Peripheral parenteral nutrition (PPN)

Total parenteral nutrition (TPN)

designed to increase nutrient intake in mildly reverse starvation and promote stressed patients who are expected to return to PO tissue synthesis, wound healing, and normal or enteral feedings alone within 1 to 2 weeks metabolic function

peripheral line or peripherally inserted central line (PICC)

Central venous catheter

dextrose percentages dextrose (20 to 70 percent), amino acids, of the infusion remain 20 percent with the addition multivitamins, of amino acids and lipids. electrolytes, and trace elements

not adequate for nutritionally depleted patients or those needing to gain weight

nutritionally complete; Insulin is often added to the content as needed to control blood glucose

Test Antigen skin Benedicts test Bentonite Flacculation Test Beutlers test Blanching test Bronsulpthalein test Caloric test CD4 determination Cerebral perfusion test Coombs test CPK BB CPK MB CPK MM Dark field illumination test and kalm test Dick test ELISA test Gram staining and Culture of cervical and urethral smear Gross hearing test Guthrie test Heat and Acetic acid test Immunochromatographic test Jones Criteria Lepronin test

Indication Test to rule-out cancer of the lungs For glucose monitoring Test for filariasis Test for galactosemia Determines the impairment in circulation Liver angiography Test done by placing water in the ear canal causes nystagmus. A test for inner ear Checking the immune status to AIDS patient Test used to check the cerebral function Determines the production of the antibodies. RhoGAM is given (1st 72 hours) Test for brain muscles Test for cardiac muscles: for MI Test for muscle injury Determination for the presence of syphilis Detect scarlet fever Determines presence of HIV Determination for the presence of gonorrhea Test used by whispering words or spoken voice test Test for PKU For protein or albumin detection A rapid assessment method done for filariasis. The antigen test that can be done at daytime One way of diagnosing Rheumatic heart fever A screening test for leprosy

Liver enzyme test Liver profile test Lumbar puncture Malaria smear Mantoux test Menieres test Methylene blue test Moloney test Oxytocin challege test Pandys test Phenosulpthalein test Queckkenstedts test Rectal swab Rinne Test Rombergs test Schick test Schillers test Schilling test Schwabach test Skin test Slit skin smear Specific gravity test Sperm count test Sputum exam Sulkowitch test Sweat chloride test Tensilon (Endophonium) test Tonometer Torniquet test TZANK test Weber test Wedals Test Western blot test

For SGOT and SGPT Determines Hepa-b surface antigen Determines for the presence of meningitis and encephalitis. Position the patient in side lying position Test to confirm malaria; specimen is taken at the height or peak of fever Determination for TB exposure Test for vestibular function For ketone detection Hypersensitivity test for Diphtheria Determines if the fetus can tolerate uterine contraction; (+) CS is necessary Determines the presence of protein in the CSF Kidney angiogram Test that involve the compression of jugular veins Done in patient with cholera, pinworm detection Shifted between mastoid bone and two inches from the ear canal opening Assess gait and station such as ataxia Susceptibility test for diphtheria (+) no immunity (-) with immunity Staining the cervix with an iodine solution. Healthy tissues will turn brown, while cancerous tissue resist the stain Used to patient with severe chilling sensation; for confirmation of pernicious anemia Differentiate between conductive and sensorineural deafness Purpose it to produce antigen reaction A confirmatory test for leprosy For diabetes mellitus and insipidus as well as for dehydration For male infertility (low sperm count-oversex) For defection and sensitivity of causative microorganism, for pneumonia and TB Urine test detection for calcium deficiency and calcium in the urine Used to diagnosed cystic fibrosis For rapid detection of myasthenia gravis Test used to measure ocular tension and helping in detecting early glaucoma N=12-20 mmHg Done to determine presence of petechiae in Dengue Hemorrhagic fever Determination for the presence of herpes simplex Evaluation of bone conduction. Tuning fork is placed on patients forehead or teeth For typhoid fever determination A confirmatory for AIDS

Step/Action Airway Breaths Initial Foreign-body airway obstruction Compressions Compression Landmarks Compression Method Push hard and fast Allow complete recoil

Adult: 8 years Child: 1 to 8 and older years Head tiltchin lift 2 breaths at 1 second/breath Abdominal thrust

Infant: Under 1 year

Back slaps and chest thrusts Just below nipple line 2 fingers

Compression Depth Compression Rate Compression Ventilation 30:2 Ratio Defibrillation

In the center of the chest, between nipples 2 Hands: Heel of 2 Hands: Heel 1 hand, second of 1 hand with hand on top second on top or 1 Hand: Heel of 1 hand only 11/2 to 2 inches About 1/3 to 1/2 the depth of the chest About 100/min

AED

Use adult pads. Do not use child pads/child system.

Use after 5 cycles of CPR. Use child pads/ system for child 1 to 8 years if available. If not, use adult AED and pads.

No recommendation for infants <1 year of age

DRUGS WITH ANTIDOTE Acetaminophen Anticholinergics (Atropine) Anticholinesterase (Neostigmine, Edrophonium) Benzodiazepine Coumadin Cyanide Poisoning Digitalis Heparin Iron Lead Acetylcysteine Physostigmine Atropine So4 Flumazenil Vitamin K Sodium Nitrate Digibind Protamine Sulfate Deferoxamine Mesylate Edetate Disodium (EDTA) Dimercaprol (BAL) Succimer (CHEMET) Calcium Gluconate Naloxone Hydrochloride

Magnesium Sulfate Narcotics (Morphine, Codeine)

*cain *cillin *dine *done *ide *lam/ *pam *micin/ *mycin *mine/ *zide *olol *pril *sone

Local anesthetics Antibiotics Antiulcer agent Opiod analgesics Oral hypoglycemics Antianxiety Antibiotics Diuretics Beta blockers ACE inhibitors Steroids

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