Each individual has unique characteristics, but certain needs are
common to all people. A need is something that is desirable, useful or necessary. Human needs are physiologic and psychologic conditions that an individual must meet to achieve a state of health or well-being. Maslows Hierarchy of Basic Human Needs Physiologic 1. Oygen !. "luids #. $utrition %. &ody temperature '. Elimination (. )est and sleep *. +e Safety and Security 1. ,hysical safety !. ,sychological safety #. -he need for shelter and freedom from harm and danger Love and belonging 1. -he need to love and be loved !. -he need to care and to be cared for. #. -he need for affection. to associate or to belong %. -he need to establish fruitful and meaningful relationships with people, institution, or organi/ation Self-steem Needs 1. +elf-worth !. +elf-identity #. +elf-respect %. &ody image Self-!ctuali"ation Needs 1. -he need to learn, create and understand or comprehend !. -he need for harmonious relationships #. -he need for beauty or aesthetics %. -he need for spiritual fulfillment #haracteristics of Basic Human Needs 1. $eeds are universal. !. $eeds may be met in different ways #. $eeds may be stimulated by eternal and internal factor %. ,riorities may be deferred '. $eeds are interrelated #once$ts of health and %llness HEA0-H 1. is the fundamental right of every human being. 1t is the state of integration of the body and mind !. Health and illness are highly individuali/ed perception. 2eanings and descriptions of health and illness vary among people in relation to geography and to culture. #. Health - is the state of complete physical, mental, and social well- being, and not merely the absence of disease or infirmity. 34HO5 %. Health is the ability to maintain the internal milieu. 1llness is the result of failure to maintain the internal environment.36laude &ernard5 '. Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by the negative feedbac7 mechanism.34alter 6annon5 (. Health 8 is being well and using ones9s power to the fullest etent. Health is maintained through prevention of diseases via environmental health factors.3"lorence $ightingale5 *. Health 8 is viewed in terms of the individual9s ability to perform 1% components of nursing care unaided. 3Henderson5 :. Positive Health symboli/es wellness. 1t is value term defined by the culture or individual. 3)ogers5 ;. Health 8 is a state of a process of being becoming an integrated and whole as a person.3)oy5 1<. Health 8 is a state the characteri/ed by soundness or wholeness of developed human structures and of bodily and mental functioning. 3Orem5 11. Health- is a dynamic state in the life cycle=illness is an interference in the life cycle. 3>ing5 1!.&ellness 8 is the condition in which all parts and subparts of an individual are in harmony with the whole system. 3$euman5 1#. Health 8 is an elusive, dynamic state influenced by biologic,psychologic, and social factors.Health is reflected by the organi/ation, interaction, interdependence and integration of the subsystems of the behavioral system.3?ohnson5 %llness and 'isease %llness is a personal state in which the person feels unhealthy. 1llness is a state in which a person9s physical, emotional, intellectual, social, developmental,or spiritual functioning is diminished or impaired compared with previous eperience. 1llness is not synonymous with disease. 'isease An alteration in body function resulting in reduction of capacities or a shortening of the normal life span. #ommon #auses of 'isease 1. &iologic agent 8 e.g. microorganism !. 1nherited genetic defects 8 e.g. cleft palate #. @evelopmental defects 8 e.g. imperforate anus %. ,hysical agents 8 e.g. radiation, hot and cold substances, ultraviolet rays '. 6hemical agents 8 e.g. lead, asbestos, carbon monoide (. -issue response to irritationsAinBury 8 e.g. inflammation, fever *. "aulty chemicalAmetabolic process 8 e.g. inadequate insulin in diabetes :. EmotionalAphysical reaction to stress 8 e.g. fear, aniety Stages of %llness 1. +ymptoms Eperience- eperience some symptoms, person believes something is wrong # aspects 8physical, cognitive, emotional !. Assumption of +ic7 )ole 8 acceptance of illness, see7s advice #. 2edical 6are 6ontact +ee7s advice to professionals for validation of real illness,eplanation of symptoms, reassurance or predict of outcome %. @ependent ,atient )ole -he person becomes a client dependent on the health professional for help. AcceptsAreBects health professional9s suggestions. &ecomes more passive and accepting. '. )ecoveryA)ehabilitation Cives up the sic7 role and returns to former roles and functions. (is) *actors of a 'isease +, -enetic and Physiological *actors "or eample, a person with a family history of diabetes mellitus, is at ris7 in developing the disease later in life. ., !ge Age increases and decreases susceptibility 3 ris7 of heart diseases increases with age for both sees /, nvironment -he physical environment in which a person wor7s or lives can increase the li7elihood that certain illnesses will occur. 0, Lifestyle 0ifestyle practices and behaviors can also have positive or negative effects on health. #lassification of 'iseases +, !ccording to tiologic *actors a. Hereditary 8 due to defect in the genes of one or other parent which is transmitted to the i. offspring b. #ongenital 8 due to a defect in the development, hereditary factors, or prenatal infection c. Metabolic 8 due to disturbances or abnormality in the intricate processes of metabolism. d. 'eficiency 8 results from inadequate inta7e or absorption of essential dietary factor. e. Traumatic- due to inBury f. !llergic 8 due to abnormal response of the body to chemical and protein substances or to physical stimuli. g. Neo$lastic 8 due to abnormal or uncontrolled growth of cell. h. %dio$athic 86ause is un7nown= self-originated= of spontaneous origin i. 'egenerative 8)esults from the degenerative changes that occur in the tissue and organs. B. %atrogenic 1 result from the treatment of the disease ., !ccording to 'uration or 2nset a. a,!cute %llness 8 An acute illness usually has a short duration and is severe. +igns and symptoms appears abruptly, intense and often subside after a relatively short period. b. #hronic %llness 8 chronic illness usually longer than ( months, and can also affects functioning in any dimension. -he client may fluctuate between maimal functioning and serious relapses and may be life threatening. 1s is characteri/ed by remission and eacerbation. (emission- periods during which the disease is controlled and symptoms are not obvious. 3acerbations 8 -he disease becomes more active given again at a future time, with recurrence of pronounced symptoms. c. Sub-!cute 8 +ymptoms are pronounced but more prolonged than the acute disease. /, 'isease may also be 'escribed as4 a. 2rganic 1 results from changes in the normal structure, from recogni/able anatomical changes in an organ or tissue of the body. b. *unctional 1 no anatomical changes are observed to account from the symptoms present, may result from abnormal response to stimuli. c. 2ccu$ational 8 )esults from factors associated with the occupation engage in by the patient. d. 5enereal 8 usually acquired through seual relation e. *amilial 8 occurs in several individuals of the same family f. $idemic 1 attac7s a large number of individuals in the community at the same time. 3e.g. +A)+5 g. ndemic 8 ,resents more or less continuously or recurs in a community. 3e.g. malaria, goiter5 h. Pandemic 8An epidemic which is etremely widespread involving an entire country or continent. i. S$oradic 1 a disease in which only occasional cases occur. 3e.g. dengue, leptospirosis5 Leavell and #lar)s Three Levels of Prevention a. Primary Prevention 8 see7s to prevent a disease or condition at a prepathologic state = to stop something from ever happening. Health Promotion -health education -marriage counseling -genetic screening -good standard of nutrition adBusted to developmental phase of life S$ecific Protection -use of specific immuni/ation -attention to personal hygiene -use of environmental sanitation -protection against occupational ha/ards -protection from accidents -use of specific nutrients -protections from carcinogens -avoidance to allergens b, Secondary Prevention 8 also 7nown as DHealth 2aintenanceE.+ee7s to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability= to prevent catastrophic effects that could occur if proper attention and treatment are not provided arly 'iagnosis and Prom$t Treatment -case finding measures -individual and mass screening survey -prevent spread of communicable disease -prevent complication and sequelae -shorten period of disability 'isability Limitations - adequate treatment to arrest disease process and prevent further complication and sequelae. -provision of facilities to limit disability and prevent death. c, Tertiary Prevention 8 occurs after a disease or disability has occurred and the recovery process has begun= 1ntent is to halt the disease or inBury process and assist the person in obtaining an optimal health status.-o establish a high-level wellness. D-o maimi/e use of remaining capacitiesEs (estoration and (ehabilitation -wor7 therapy in hospital - use of shelter colony N6(S%N- As defined by the %NT(N!T%2N!L #26N#%L 2* N6(SS as written by Firginia Henderson. the unique function of the nurse is to assist the individual, sic7 or well, in the performance of those activities contributing to health, it9s recovery, or to a peaceful death the client would perform unaided if he had the necessary strength, will or 7nowledge. Help the client gain independence as rapidly as possible. #2N#PT6!L !N' TH2(T%#!L M2'LS 2* N6(S%N- P(!#T%# !, N%-HT!N-LS TH2(7 8 mid-+9::; "ocuses on the patient and his environment . @eveloped the described the first theory of nursing. $otes on $ursing. 4hat 1t 1s, 4hat 1t 1s $ot. +he focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. +he believed that in the nurturing environment, the body could repair itself. 6lient9s environment is manipulated to include appropriate noise, nutrition, hygiene, sociali/ation and hope. B, PPL!6< H%L'-!(' 8+=>+; @efined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient relationship in which the nurse serves as a resource person, counselor and surrogate. %ntroduced the %nter$ersonal Model, +he defined nursing as an interpersonal process of therapeutic between an individual who is sic7 or in need of health services and a nurse especially educated to recogni/e and respond to the need for help . She identified four $hases of the nurse client relationshi$ namely4 1. 2rientation4 the nurse and the client initially do not )now each others goals and testing the role each will assume. -he client attempts to identify difficulties and the amount of nursing help that is needed= !. %dentification4 the client responds to help professionals or the significant others who can meet the identified needs. Both the client and the nurse $lan together an a$$ro$riate $rogram to foster health? #. 3$loitation4 the clients utili"e all available resources to move toward a goal of ma3imum health functionality? %. (esolution4 refers to the termination $hase of the nurse- client relationshi$, it occurs when the clients needs are met and he@she can move toward a new goal. ,eplau further assumed that nurse-client relationship fosters growth in both the client and the nurse. #, !B'LL!H< *!7 -, 8+=A:; @efined nursing as having a problem-solving approach, with 7ey nursing problems related to health needs of people= develo$ed list of .+ nursing-$roblem areas, %ntroduced Patient 1 #entered !$$roaches to Nursing Model +he defined nursing as service to individual and families= therefore the society. "urthermore, she conceptuali/ed nursing as an art and a science that molds the attitudes, intellectual competencies and technical s7ills of the individual nurse into the desire and ability to help people, sic7 or well, and cope with their health needs. ', 2(L!N'2< %'! +he conceptuali/ed -he @ynamic $urse 8 ,atient )elationship 2odel. , L5%N< M7(! 8+=B/; &elieves nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing. conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity. @escribed the *our #onversation Princi$les. +he Advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual. -he four conservation principles are as follows. 1. #onservation of energy , -he human body functions by utili/ing energy. -he human body needs energy $roducing in$ut 8food< o3ygen< fluids; to allow energy utili"ation out$ut, !. #onservation of Structural %ntegrity . -he human body has physical boundaries 8s)in and mucous membrane5 that must be maintained to facilitate health and prevent harmful agents from entering the body. #. #onservation of Personal %ntegrity . -he nursing interventions are based on the conservation of the individual client9s personality. Every individual has sense of identity< self worth and self esteem, which must be preserved and enhanced by nurses. %. #onservation of Social integrity . The social integrity of the client reflects the family and the community in which the client functions. Health care institutions may separate individuals from their family. 1t is important for nurses to consider the individual in the contet of the family. *, C2HNS2N< '2(2TH7 8+=A:< +=9:; "ocuses on how the client adapts to illness= the goal of nursing is to reduce stress so that the client can move more easily through recovery. Fiewed the patient9s behavior as a system, which is a whole with interacting parts. The nursing $rocess is viewed as a maDor tool, 6onceptuali/ed the &ehavioral +ystem 2odel. According to ?ohnson, each person as a behavioral system is composed of seven subsystems namely. 1. %ngestive, -a7ing in nourishment in socially and culturally acceptable ways. !. liminated, )iddling the body of waste in socially and culturally acceptable ways, #. !ffiliative, +ecurity see7ing behavior, %. !ggressive, +elf 1 protective behavior, '. 'e$endence, $urturance 8 see7ing behavior. (. !chievement, 2aster of oneself and one9s environment according to internali/ed standards of ecellence. B, Se3ual role identity behavior -, (2-(S< M!(TH! 6onsiders man as a unitary human being co-eisting with in the universe, views nursing primarily as a science and is committed to nursing research. H, 2(M< '2(2TH! 8+=B:< +=9>; Emphasi/es the client9s self-care needs, nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. @eveloped the Self-#are 'eficit Theory. +he defined self-care as Dthe practice of activities that individuals initiate to perform on their own behalf in maintaining life, health well-being.E +he conceptuali/ed three systems as follows. 1. &holly #om$ensatory . when the nurse is epected to accomplish all the patient9s therapeutic self-care or to compensate for the patient9s inability to engage in self care or when the patient needs continuous guidance in self care= !. Partially #om$ensatory4 when both nurse patient engage in meeting self care needs= #. Su$$ortive-ducative . the system that requires assistance decision ma7ing, behavior control and acquisition 7nowledge and s7ills. %, %M2-N E%N- 8+=B+< +=9+; $ursing process is defined as dynamic interpersonal process between nurse, client and health care system. Postulated the -oal !ttainment Theory . +he described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. 1f is this not possible, nurses help individuals die with dignity. 1n addition, >ing viewed nursing as an interaction process between client and nurse whereby during perceiving, setting goals, and acting on them transactions occurred and goals are achieved. C, BTT7 N6M!N +tress reduction is a goal of system model of nursing practice. $ursing actions are in primary, secondary or tertiary level of prevention. E, S%S #!LL%ST! (27 8!da$tation Theory; 8+=B=< +=90; Fiews the client as an adaptive system. -he goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. Presented the !da$tation Model, She viewed each $erson as a unified bio$sychosocial system in constant interaction with a changing environment. +he contented that the person as an adaptive system, functions as a whole through interdependence of its part. -he system consist of input, control processes, output feedbac7. L,L7'%! H!LL 8+=A.; -he client is composed of the ff. overlapping parts. person 3core5, pathologic state and treatment 3cure5 and body 3care5. 1ntroduced the model of $ursing. 4hat 1s 1tG, focusing on the notion that centers around three components of #!(< #2( and #6(, 6are represents nurturance and is eclusive to nursing. 6ore involves the therapeutic use of self and emphasi/es the use of reflection. 6ure focuses on nursing related to the physician9s orders. 6ore and cure are shared with the other health care providers. M, 5irginia Henderson 8+=>>; 1ntroduced The Nature of Nursing Model, She identified fourteen basic needs, +he postulated that the unique function of the nurse is to assist the clients, sic7 or well, in the performance of those activities contributing to health or its recovery, the clients would perform unaided if they had the necessary strength, will or 7nowledge. +he further believed that nursing involves assisting the client in gaining independence as rapidly as possible, or assisting him achieves peaceful death if recovery is no longer possible. N, Madaleine Leininger 8+=B9< +=90; @eveloped the Transcultural Nursing Model. +he advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes 3cultural values, beliefs and practices5 to improve or maintain a health condition. 2, %da Cean 2rlando 8+=A+; 6onceptuali/ed The 'ynamic Nurse 1 Patient (elationshi$ Model, +he believed that the nurse helps patients meet a perceived need that the patient cannot meet for themselves. Orlando observed that the nurse provides direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. +he emphasi/ed the importance of validating the need and evaluating care based on observable outcomes. P, rnestine &eidanbach 8+=A0; @eveloped the Clinical Nursing A Helping Art Model. +he advocated that the nurse9s individual philosophy or central purpose lends credence to nursing care. +he believed that nurses meet the individual9s need for help through the identification of the needs, administration of help, and validation that actions were helpful. 6omponents of clinical practice. ,hilosophy, purpose, practice and an art. F, Cean &atson 8+=B=-+==.; 1ntroduced the theory of Human Becoming. +he emphasi/ed free choice of personal meaning in relating value priorities, co 8 creating the rhythmical patterns, in echange with the environment, and co transcending in many dimensions as possibilities unfold. (, Coyce Travelbee 8+=AA<+=B+; +he postulated the %nter$ersonal !s$ects of Nursing Model, +he advocated that the goal of nursing individual or family in preventing or coping with illness, regaining health finding meaning in illness, or maintaining maimal degree of health. +he further viewed that interpersonal process is a human-to-human relationship formed during illness and Deperience of sufferingE +he believed that a person is a unique, irreplaceable individual who is in a continuous process of becoming, evolving and changing. S, Cose$hine Peterson and Loretta Gderad 8+=BA; ,rovided the Humanistic Nursing Practice Theory. -his is based on their belief that nursing is an eistential eperience. $ursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to be nursed. -he essential characteristic of nursing is nurturance. Humanistic care cannot ta7e place without the authentic commitment of the nurse to being with and the doing with the client. Humanistic nursing also presupposes responsible choices. T, Helen ric)son< velyn Tomlin< and Mary !nn Swain 8+=9/; @eveloped Modeling and (ole Modeling Theory . -he focus of this theory is on the person. -he nurse models 3assesses5, role models 3plans5, and intervenes in this interpersonal and interactive theory. -hey asserted that each individual unique, has some self-care 7nowledge, needs simultaneously to be attached to the separate from others, and has adaptive potential. $urses in this theory, facilitate, nurture and accept the person unconditionally. 6, Margaret Newman "ocused on health as e3$anding consciousness. +he believed that human are unitary in whom disease is a manifestation of the pattern of health. +he defined consciousness as the information capability of the system which is influenced by time, space movement and is ever 8 epanding. 5, Patricia Benner and Cudith &rude l 31;:;5 ,roposed the Primacy and #aring Model, -hey believed that caring central to the essence of nursing. 6aring creates the possibilities for coping and creates the possibilities for connecting with and concern for others. &, !nne Boy)in and Savina Schoenhofer ,resented the grand theory of Nursing as #aring. -hey believed that all person are caring, and nursing is a response to a unique social call. -he focus of nursing is on nurturing person living and growing in caring in a manner that is specific to each nurse-nursed relationship or nursing situation. Each nursing situation is original. -hey support that caring is a moral imperative. $ursing as 6aring is not based on need or deficit but is egalitarian model helping. Moral Theories +, *reud 8+=A+; &elieved that the mechanism for right and wrong within the individua l is the su$erego< or conscience . He hypnoti/ed that a child internali/es and adopts the moral standards and character or character traits of the model parent through the process of identification. -he strength of the superego depends on the intensity of the child9s feeling of aggression or attachment toward the model parent rather than on the actual standards of the parent. ., ri)son 8+=A0; Eri7son9s theory on the develo$ment of virtues or unifying strengths of the Dgood manE suggest that moral development continuous throughout life. He believed that if the conflicts of each psychosocial developmental stages favorably resolved, then an HegostrengthE or virtue emerges. /, Eohlberg +uggested three levels of moral development. He focused on the reason for the ma7ing of a decision, not on the morality of the decision itself. 1. !t first level called the $remolar or the $reconventional level< children are responsive to cultural rules and labels of good and bad, right and wrong. However children interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. !. !t the second level< the conventional level< the individual is concerned about maintaining the epectations of the family, groups or nation and sees this as right. #. !t the third level< people ma7e postconventiona l, autonomous, or principal level. At this level, people ma7e an effort to define valid values and principles without regard to outside authority or to the epectations of others. -hese involve respect for other human and belief that relationshi$ are based on mutual trust, Peter 8+=9+; ,roposed a concept of rational morality based on $rinci$les, 2oral development is usually considered to involve three separate components. moral emotion 3what one feels5, moral Budgment 3how one reasons5, and moral behavior 3how one acts5. 1n addition, ,eters believed that the development of character traits or virtues is an essential as$ect or moral develo$ment, And that virtues or character traits can be learned from others and encouraged by the eample of others. Also, ,eters believed that some can be described as habits because they are in some sense automatic and therefore are performed habitually, such as politeness, chastity, tidiness, thrift and honesty. -illigan 8+=9.; 1ncluded the conce$ts of caring and res$onsibility, +he described three stages in the process of developing an DEthic of 6areE which are as follows. 1. 6aring for oneself. !. 6aring for others. #. 6aring for self and others. +he believed the human see morality in the integrity of relationshi$s and caring, "or women, what is right is ta7ing responsibility for others as self-chosen decision. On the other hand, men consider what is right to be what is Dust, S$iritual Theories *owler 8+=B=; @escribed the development of faith. He believed that faith, or the spiritual dimension is a force that gives meaning to a person9s life. He used the term DfaithE as a form of 7nowing a way of being in relation Dto an ultimate environment.E -o "owler, faith is a relational phenomenon. it is Dan active made-of-being-in-relation to others in which we invest commitment, belief, love, ris7 and hope.E (2LS !N' *6N#T%2NS 2* TH N6(S #are giver 'ecision-ma)er Protector #lient !dvocate Manager (ehabilitator #omforter #ommunicator Teacher #ounselor #oordinator Leader (ole Model !dministrator Selected 3$anded #areer (oles of Nurses +, Nurse Practitioner A nurse who has an advanced education and is a graduate of a nurse practitioner program. -hese nurses are in areas as adult nurse practitioner, family nurse practitioner, school nurse practitioner, pediatric nurse practitioner, or gerontology nurse practitioner. -hey are employed in health care agencies or community based settings. -hey usually deal with non-emergency acute or chronic illness and provide primary ambulatory care. ., #linical Nurse S$ecialist A nurse who has an advanced degree or epertise and is considered to be an epert in a speciali/ed area of practice 3e.g., gerontology, oncology5. -he nurse provides direct client care, educates others, consults, conducts research, and manages care. -he American $urses 6redentialing 6enter provides national certification of clinical specialists. /, Nurse !nesthetist A nurse who has completed advanced education in an accredited program in anesthesiology. -he nurse anesthetist carries out pre-operative visits and assessments, and Administers general anesthetics for surgery under the supervision of a physician prepared in anesthesiology. -he nurse anesthetist also assesses the postoperative of clients 0, Nurse Midwife An )$ who has completed a program in midwifery. -he nurse gives pre-natal and post-natal care and manages deliveries in normal pregnancies. -he midwife practices the association with a health care agency and can obtain medical services if complication occurs. -he nurse midwife may also conduct routine ,apanicolaou smears, family planning, and routine breast eamination. >, Nurse ducator $urse educator is employed in nursing programs, at educational institutions, and in hospital staff education. -he nurse educator usually ha a baccalaureate degree or more advanced preparation and frequently has epertise in a particular area of practice. The nurse educator is res$onsible for classroom and of ten clinical teaching, A, Nurse ntre$reneur A nurse who usually has an advanced degree and manages a health-related business. -he nurse may be involved in education, consultation, or research, for eample. #2MM6N%#!T%2N %N N6(S%N- #2MM6N%#!T%2N 1. 1s the means to establish a helping-healing relationships. All behavior communication influences behavior. !. 6ommunication is essential to the nurse-patient relationship for the following reasons. #. 1s the vehicle for establishing a therapeutic relationship. %. 1t the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention. Basic lements of the #ommunication Process 1. +E$@E) 8 is the person who encodes and delivers the message !. 2E++ACE+ 8 is the content of the communication. 1t may contain verbal, nonverbal, and symbolic language. #. )E6E1FE) 8 is the person who receives the decodes the message. %. "EE@&A6> 8 is the message returned by the receiver. 1t indicates whether the meaning of the sender9s message was understood. Modes of #ommunication 1. 5erbal #ommunication 8 use of spo7en or written words. !. Nonverbal #ommunication 8 use of gestures, facial epressions, postureAgait, body movements, physical appearance and body language #haracteristics of -ood #ommunication 1. Sim$licity 1 includes uses of commonly understood, brevity, and completeness. !. #larity 8 involves saying what is meant. -he nurse should also need to spea7 slowly and enunciate words well. #. Timing and (elevance 8 requires choice of appropriate time and consideration of the client9s interest and concerns. As7 one question at a time and wait for an answer before ma7ing another comment. %. 6haracteristics of Cood 6ommunication '. !da$tability 8 1nvolves adBustments on what the nurse says and how it is said depending on the moods and behavior of the client. (. #redibility 8 2eans worthiness of belief. -o become credible, the nurse requires adequate 7nowledge about the topic being discussed. -he nurse should be able to provide accurate information, to convey confidence and certainly in what she says. #ommunicating &ith #lients &ho Have S$ecial Needs +,#lients who cannot s$ea) clearly 8a$hasia< dysarthria< muteness; 1. 0isten attentively, be patient, and do not interrupt. !. As7 simple question that require DyesE and DnoE answers. #. Allow time for understanding and response. %. Ise visual cues 3e.g., words, pictures, and obBects5 '. Allow only one person to spea7 at a time. (. @o not shout or spea7 too loudly. *. Ise communication aid. -pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm. ., #lients who are cognitively im$aired 1. )educe environmental distractions while conversing. !. Cet client9s attention prior to spea7ing #. Ise simple sentences and avoid long eplanation. %. As7 one question at a time '. Allow time for client to respond (. &e an attentive listener *. 1nclude family and friends in conversations, especially in subBects 7nown to client. #. #lient who are unres$onsive 1. 6all client by name during interactions !. 6ommunicate both verbally and by touch #. +pea7 to client as though he or she could hear %. Eplain all procedures and sensations '. ,rovide orientation to person, place, and time (. Avoid tal7ing about client to others in his or her presence *. Avoid saying things client should not hear %. #ommunicating with hearing im$aired client 1. Establish a method of communication 3penApencil and paper, sign- language5 !. ,ay attention to client9s non-verbal cues #. @ecrease bac7ground noise such as television %. Always face the client when spea7ing '. 1t is also important to chec7 the family as to how to communicate with the client (. 1t may be necessary to contact the appropriate department resource person for this type of disability 0, #lient who do not s$ea) nglish 1. +pea7 to client in normal tone of voice 3shouting may be interpreted as anger5 !. Establish method for client o signal desire to communicate 3call light or bell5 #. ,rovide an interpreter 3translator5 as needed %. Avoid using family members, especially children, as interpreters. '. @evelop communication board, pictures or cards. (. Have dictionary 3EnglishA+panish5 available if client can read. (e$orts Are oral ,written, or audiotaped echanges of information between caregivers. #ommon re$orts4 1. 6hange-in-shift report !. -elephone report #. -elephone or verbal order 8 only )$9s are allowed to accept telephone orders. %. -ransfer report '. 1ncident report 'ocumentation 1. 1s anything written or printed that is relied on as record or proof for authori/ed person. !. $ursing documentation must be. #. accurate %. comprehensive '. fleible enough to retrieve critical data, maintain continuity of care, trac7 client outcomes, and reflects current standards of nursing practice (. Effective documentation ensures continuity of care, saves time and minimi/es the ris7 of error. *. As members of the health care team, nurses need to communicate information about clients accurately and in timely manner :. 1f the care plan is not communicated to all members of the health care team, care can become fragmented, repetition of tas7s occurs, and therapies may be delayed or omitted. ;. @ata recorded, reported, or c<mmunicated to other health care professionals are 6O$"1@E$-1A0 and must be protected. #2N*%'NT%!L%T7 1. nurses are legally and ethically obligated to 7eep information about clients confidential. !. $urses may not discuss a client9s eamination, observation, conversation, or treatment with other clients or staff not involved in the client9s care. #. 2nly staff directly involved in a s$ecific clients care have legitimate access to the record, %. 6O$"1@E$-1A01-J '. 6lients frequently request copies of their medical record, and they have the right to read those records. (. $urses are responsible for protecting records from all unauthori/ed readers. *. when nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, appropriate authori/ation must be obtained according to agency policy. :. 6onfidentiality ;. 2aintaining confidentiality is an important aspect of profession behavior. 1<.1t is essential that the nurse safe-guard the client9 right to privacy by carefully protecting information of a sensitive, private nature. 11.+haring personal information or gossiping about others violates nursing ethical codes and practice standards. 1!.1t sends the message that the nurse cannot be trusted and damages the interpersonal relationships. -uidelines of Fuality 'ocumentation and (e$orting +,*actual 1. a record must contain descriptive, obBective information about what a nurse sees, hears, feels, and smells. !. -he use of vague terms, such as appears, seems, and apparently , is not acceptable because these words suggests that the nurse is stating an opinion. Eample. D the client seems aniousE 3the phrase seems anious is a conclusion without supported facts.5 ., !ccurate 1. -he use of eact measurements establishes accuracy. 3eample. D1nta7e of #'< ml of waterE is more accurate than D the client dran7 an adequate amount of fluidE !. @ocumentation of concise data is clear and easy to understand. #. 1t is essential to avoid the use of unnecessary words and irrelevant details /, #om$lete 1. -he information within a recorded entry or a report needs to be complete, containing appropriate and essential information. Eample. -he client verbali/es sharp, throbbing pain locali/ed along lateral side of right an7le, beginning approimately 1' minutes ago after twisting his foot on the stair. 6lient rates pain as : on a scale of <-1<. 0, #urrent 1. -imely entries are essential in the clients ongoing care. -o increase accuracy and decrease unnecessary duplication, many healthcare agencies use records 7ept near the client9s bedside, which facilitate immediate documentation of information as it is collected from a client >, 2rgani"ed 1. -he nurse communicates information in a logical order. "or eample, an organi/ed note describes the client9s pain, nurse9s assessment, nurse9s interventions, and the client9s response Legal -uidelines for recording +. @raw single line through error, write word error above it and sign your name or initials. -hen record note correctly. !. @o not write retaliatory or critical comments about the client or care by other health care professionals. Enter only obBective descriptions of client9s behavior= client9s comments should be quoted. #. 6orrect all errors promptly errors in recording can lead to errors in treatment Avoid rushing to complete charting, be sure information is accurate. %. @o not leave blan7 spaces in nurse9s notes. 6hart consecutively, line by line= if space is left, draw line hori/ontally through it and sign your name at end. '. )ecord all entries legibly and in blan7 in7 $ever use pencil, felt pen. &lan7 in7 is more legible when records are photocopied or transferred to microfilm. 0egal Cuidelines for )ecording (. 1f order is questioned, record that clarification was sought. 1f you perform orders 7nown to be incorrect, you are Bust as liable for prosecution as the physician is. *. 6hart only for yourself $ever chart for someone else. Jou are accountable for information you enter into chart. :. Avoid using generali/ed, empty phrases such as Dstatus unchangedE or Dhad good dayE. &egin each entry with time, and end with your signature and title. @o not wait until end of shift to record important changes that occurred several hours earlier. &e sure to sign each entry. ;. "or computer documentation 7eep your password to yourself. maintain security and confidentiality. Once logged into the computer do not leave the computer screen unattended. !ssessing 5ital Signs Fital +igns or 6ardinal +igns are. &ody temperature ,ulse )espiration &lood pressure ,ain %, Body Tem$erature -he balance between the heat produced by the body and the heat loss from the body. -ypes of &ody -emperature 6ore temperature 8temperature of the deep tissues of the body. +urface body temperature !lteration in body Tem$erature Pyrexia 8 &ody temperature above normal range3 hyperthermia5 Hy$er$yre3ia 8 Fery high fever, %1K631<'.: "5 and above Hy$othermia 8 +ubnormal temperature. Normal !dult Tem$erature (anges 2ral #(.' 8#*.' K6 !3illary #'.: 8 #*.< K6 (ectal #*.< 8 #:.1 K6 Tym$anic #(.: 8 #*.;K6 Methods of Tem$erature-Ta)ing 1. 2ra l 8 most accessible and convenient method. a. ,ut on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far bac7 as possible. 1t promotes contact to the superficial blood vessels and ensure a more accurate reading. b. 4ash thermometer before use. c. -a7e oral temp !-# minutes. d. Allow 1' min to elapse between client9s food inta7e of hot or cold food, smo7ing. e. 1nstruct the patient to close his lips but not to bite down with his teeth to avoid brea7ing the thermometer in his mouth. #ontraindications Joung children an infants ,atients who are unconscious or disoriented 4ho must breath through the mouth +ei/ure prone ,atient with $AF ,atients with oral lesionsAsurgeries ., (ectal- most accurate measurement of tem$erature a. ,osition- lateral position with his top legs fleed and drape him to provide privacy. b. +quee/e the lubricant onto a facial tissue to avoid contaminating the lubricant supply. c. 1nsert thermometer by <.' 8 1.' inches d. Hold in place in !minutes e. @o not force to insert the thermometer #ontraindications ,atient with diarrhea )ecent rectal or prostatic surgery or inBury because it may inBure inflamed tissue )ecent myocardial infarction ,atient post head inBury /, !3illary 8 safest and non-invasive a. ,at the ailla dry b. As7 the patient to reach across his chest and grasp his opposite shoulder. -his promote s7in contact with the thermometer c. Hold it in place for ; minutes because the thermometer isn9t close in a body cavity Note4 Ise the same thermometer for repeat temperature ta7ing to ensure more consistent result +tore chemical-dot thermometer in a cool area because eposure to heat activates the dye dots. 0, Tym$anic thermometer a. 2a7e sure the lens under the probe is clean and shiny b. +tabili/ed the patient9s head= gently pull the ear straight bac7 3for children up to age 15 or up and bac7 3for children 1 and older to adults5 c. 1nsert the thermometer until the entire ear canal is sealed d. ,lace the activation button, and hold it in place for 1 second >, #hemical-dot thermometer a. 0eave the chemical-dot thermometer in place for %' seconds b. )ead the temperature as the last dye dot that has change color, or fired. Nursing %nterventions in #lients with *ever a. 2onitor F.+ b. Assess s7in color and temperature c. 2onitor 4&6, Hct and other pertinent lab records d. ,rovide adequate foods and fluids. e. ,romote rest f. 2onitor 1 L O g. ,rovide -+& h. ,rovide dry clothing and linens i. Cive antipyretic as ordered by 2@ %%, Pulse 1 1t9s the wave of blood created by contractions of the left ventricles of the heart. Normal Pulse rate 1 year :<-1%< beatsAmin ! years :<- 1#< beatsAmin ( years *'- 1!< beatsAmin 1< years (<-;< beatsAmin Adult (<-1<< beatsAmin Tachycardia 8 pulse rate of above 1<< beatsAmin Bradycardia- pulse rate below (< beatsAmin %rregular 1 uneven time interval between beats, 4hat you need. a. 4atch with second hand b. +tethoscope 3for apical pulse5 c. @oppler ultrasound blood flow detector if necessary )adial ,ulse a. 4ash your hand and tell your client that you are going to ta7e his pulse b. ,lace the client in sitting or supine position with his arm on his side or across his chest c. Cently press your inde, middle, and ring fingers on the radial artery, inside the patient9s wrist. d. Ecessive pressure may obstruct blood flow distal to the pulse site e. 6ounting for a full minute provides a more accurate picture of irregularities 'o$$ler device a. Apply small amount of transmission gel to the ultrasound probe b. ,osition the probe on the s7in directly over a selected artery c. +et the volume to the lowest setting d. -o obtain best signals, put gel between the s7in and the probe and tilt the probe %' degrees from the artery. e. After you have measure the pulse rate, clean the probe with soft cloth soa7ed in antiseptic. @o not immerse the probe %%%, (es$iration - is the echange of oygen and carbon dioide between the atmosphere and the body !ssessing (es$iration )ate 8 $ormal 1%-!<A min in adult -he best time to assess respiration is immediately after ta7ing client9s pulse 6ount respiration for (< second As you count the respiration, assess and record breath sound as stridor, whee/ing, or stertor. )espiratory rates of less than 1< or more than %< are usually considered abnormal and should be reported immediately to the physician. %5, Blood Pressure Adult 8 ;<- 1#! systolic (<- :' diastolic Elderly 1%<-1(< systolic *<-;< diastolic a. Ensure that the client is rested b. Ise appropriate si/e of &, cuff. c. 1f too tight and narrow- false high &, d. 1f too lose and wide-false low &, e. ,osition the patient on sitting or supine position f. ,osition the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading g. Ise the bell of the stethoscope since the blood pressure is a low frequency sound. h. 1f the client is crying or anious, delay measuring his blood pressure to avoid false-high &, lectronic 5ital Sign Monitor a. An electronic vital signs monitor allows you to continually tract a patient9s vital sign without having to reapply a blood pressure cuff each time. b. Eample. @inamap F+ monitor :1<< c. 0ightweight, battery operated and can be attached to an 1F pole d. &efore using the device, chec7 the client*s pulse and &, manually using the same arm you9ll using for the monitor cuff. e. 6ompare the result with the initial reading from the monitor. 1f the results differ call the supply department or the manufacturer9s representative. 5, Pain How to assess ,ain a. Jou must consider both the patient9s description and your observations on his behavioral responses. b. "irst, as7 the client to ran7 his pain on a scale of <-1<, with < denoting lac7 of pain and 1< denoting the worst pain imaginable. c. As7. d. 4here is the pain locatedG e. How long does the pain lastG f. How often does it occurG g. 6an you describe the painG h. 4hat ma7es the pain worse i. Observe the patient9s behavioral response to pain 3body language, moaning, grimacing, withdrawal, crying, restlessness muscle twitching and immobility5 B. Also note physiological response, which may be sympathetic or parasympathetic Managing Pain 1. Civing medication as per 2@9s order !. Civing emotional support #. ,erforming comfort measures %. Ise cognitive therapy Height and weight a. Height and weight are routinely measured when a patient is admitted to a health care facility. b. 1t is essential in calculating drug dosage, contrast agents, assessing nutritional status and determining the height-weight ratio. c. 4eight is the best overall indicator of fluid status, daily monitoring is important for clients receiving a diuretics or a medication that causes sodium retention. d. 4eight can be measured with a standing scale, chair scale and bed scale. e. Height can be measured with the measuring bar, standing scale or tape measure if the client is confine in a supine position. Pointers4 a. )eassure and steady patient who are at ris7 for losing their balance on a scale. b. 4eight the patient at the same time each day. 3usually before brea7fast5, in similar clothing and using the same scale. c. 1f the patient uses crutches, weigh the client with the crutches or heavy clothing and subtract their weight from the total determined patient9 weight. Laboratory and 'iagnostic e3amination %, 6rine S$ecimen +,#lean-#atch mid-stream urine specimen for routine urinalysis, culture and sensitivity test a. &est time to collect is in the morning, first voided urine b. ,rovide sterile container c. @o perineal care before collection of the urine d. @iscard the first flow of urine e. 0abel the specimen properly f. +end the specimen immediately to the laboratory g. @ocument the time of specimen collection and transport to the lab. h. @ocument the appearance, odor, and usual characteristics of the specimen. ., .0-hour urine s$ecimen a. @iscard the first voided urine. b. 6ollect all specimen thereafter until the following day c. +oa7 the specimen in a container with ice d. Add preservative as ordered according to hospital policy /, Second-5oided urine 8 required to assess glucose level and for the presence of albumen in the urine. a. @iscard the first urine b. Cive the patient a glass of water to drin7 c. After few minutes, as7 the patient to void 0, #atheteri"ed urine s$ecimen a. 6lamp the catheter for #< min to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected. b. 6lamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary surgery. %%, Stool S$ecimen +, *ecalysis 1 to assess gross appearance of stool and presence of ova or parasite a. +ecure a sterile specimen container b. As7 the pt. to defecate into a clean , dry bed pan or a portable commode. c. 1nstruct client not to contaminate the specimen with urine or toilet paper3 urine inhibits bacterial growth and paper towel contain bismuth which interfere with the test result. ., Stool culture and sensitivity test -o assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics. /, *ecal 2ccult blood test are valuable test for detecting occult blood 3hidden5 which may be present in colo-rectal cancer, detecting melena stool a. Hematest- 3an Orthotolidin reagent tablet5 b. Hemoccult slide- 3filter paper impregnated with guaiac5 &oth test produces blue reaction id occult blood lost eceeds ' ml in !% hours. c. 6olocare 8 a newer test, requires no smear %nstructions4 a. Advise client to avoid ingestion of red meat for # days b. ,atient is advise on a high residue diet c. avoid dar7 food and bismuth compound d. 1f client is on iron therapy, inform the 2@ e. 2a7e sure the stool in not contaminated with urine, soap solution or toilet paper f. -est sample from several portion of the stool. 5eni$uncture Pointers a. $ever collect a venous sample from the arm or a leg that is already being use d for 1.F therapy or blood administration because it mat affect the result. b. $ever collect venous sample from an infectious site because it may introduce pathogens into the vascular system c. $ever collect blood from an edematous area, AF shunt, site of previous hematoma, or vascular inBury. d. @on9t wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine. e. 1f the patient has a clotting disorder or is receiving anticoagulant therapy , maintain pressure on the site for at least ' min after withdrawing the needle. !rterial $uncture for !B- test a. &efore arterial puncture, perform Allen9s test first. b. 1f the patient is receiving oygen, ma7e sure that the patient9s therapy has been underway for at least 1' min before collecting arterial sample c. &e sure to indicate on the laboratory request slip the amount and type pf oygen therapy the patient is having. d. 1f the patient has Bust receive a nebuli/er treatment, wait about !< minutes before collecting the sample. %5, Blood s$ecimen a. $o fasting for the following tests. - 6&6, Hgb, Hct, clotting studies, en/yme studies, serum electrolytes b. "asting is required. - "&+, &I$, 6reatinine, serum lipid 3 cholesterol, triglyceride5 5, S$utum S$ecimen +,-ross a$$earance of the s$utum a. 6ollect early in the morning b. Ise sterile container c. )inse the mount with plain water before collection of the specimen d. 1nstruct the patient to hac7-up sputum !. S$utum culture and sensitivity test a. Ise sterile container b. 6ollect specimen before the first dose of antibiotic /, !cid-*ast Bacilli a. -o assess presence of active pulmonary tuberculosis b. 6ollect sputum in three consecutive morning 0, #ytologic s$utum e3am- -to assess for presence of abnormal or cancer cells. 'iagnostic Test +, PP' test a. read result %: 8 *! hours after inBection. b. "or H1F positive clients, induration of ' mm is considered positive ., Bronchogra$hy a. +ecure consent b. 6hec7 for allergies to seafood or iodine or anesthesia c. $,O (-: hours before the test d. $,O until gag refle return to prevent aspiration /, Thoracentesis 8 aspiration of fluid in the pleural space. a. +ecure consent, ta7e FA+ b. ,osition upright leaning on overbed table c. Avoid cough during insertion to prevent pleural perforation d. -urn to unaffected side after the procedure to prevent lea7age of fluid in the thoracic cavity e. 6hec7 for epectoration of blood. -his indicate trauma and should be reported to 2@ immediately. 0,Holter Monitor a. it is continuous E6C monitoring, over !% hours period b. -he portable monitoring is called telemetry unit >, chocardiogram 8 a. ultrasound to assess cardiac structure and mobility b. 6lient should remain still, in supine position slightly turned to the left side, with HO& elevated 1'-!< degrees A, lectrocardiogra$hya. 1f the patient9s s7in is oily, scaly, or diaphoretic, rub the electrode with a dry %% gau/e to enhance electrode contact. b. 1f the area is ecessively hairy, clip it c. )emove clientMs Bewelry, coins, belt or any metal d. -ell client to remain still during the procedure B, #ardiac #atheteri"ation a. +ecure consent b. Assess allergy to iodine, shelfish c. FA+, weight for baseline information d. Have client void before the procedure e. 2onitor ,-, ,--, E6C prior to test f. $,O for %-( hours before the test g. +have the groin or brachial area h. After the procedure . bed rest to prevent bleeding on the site, do not fle etremity i. Elevate the affected etremities on etended position to promote blood supply bac7 to the heart and prevent thrombplebities B. 2onitor FA+ especially peripheral pulses 7. Apply pressure dressing over the puncture site l. 2onitor etremity for color, temperature, tingling to assess for impaired circulation. 9, M(% m. secure consent, n. the procedure will last %'-(< minute o. Assess client for claustrophobia p. )emove all metal items q. 6lient should remain still r. -ell client that he will feel nothing but may hear noises s. 6lient with pacema7er, prosthetic valves, implanted clips, wires are not eligible for 2)1. t. 6lient with cardiac and respiratory complication may be ecluded u. 1nstruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedure =,6-%S 1 Barium Swallow a. instruct client on low-residue diet 1-# days before the procedure b. administer laative evening before the procedure c. $,O after midnight d. instruct client to drin7 a cup of flavored barium e. -rays are ta7en every #< minutes until barium advances through the small bowel f. film can be ta7en as long as !% hours later g. force fluid after the test to prevent constipationAbarium impaction +:,L-%S 1 Barium nema a. instruct client on low-residue diet 1-# days before the procedure b. administer laative evening before the procedure c. $,O after midnight d. administer suppository in A2 e. Enema until clear f. force fluid after the test to prevent constipationAbarium impaction ++, Liver Bio$sy a. +ecure consent, b. $,O !-% hrs before the test c. 2onitor ,-, Fit > at bedside d. ,lace the client in supine at the right side of the bed e. 1nstruct client to inhale and ehale deeply for several times and then ehale and hold breath while the 2@ insert the needle f. )ight lateral post procedure for % hours to apply pressure and prevent bleeding g. &ed rest for !% hours h. Observe for +A+ of peritonitis +., Paracentesis a. +ecure consent, chec7 FA+ b. 0et the patient void before the procedure to prevent puncture of the bladder c. 6hec7 for serum protein. ecessive loss of plasma protein may lead to hypovolemic shoc7. +/, Lumbar Puncture a. obtain consent b. instruct client to empty the bladder and bowel c. position the client in lateral recumbemt with bac7 at the edge of the eamining table d. instruct client to remain still e. obtain specimen per 2@s order N6(S%N- P(2#'6(S +, Steam %nhalation a. 1t is dependent nursing function. b. Heat application requires physician9s order. c. ,lace the spout 1!-1: inches away from the client9s nose or adBust the distance as necessary. ., Suctioning a. Assess the lungs before the procedure for baseline information. b. ,osition. conscious 8 semi-"owler9s c. Inconscious 8 lateral position d. +i/e of suction catheter- adult- fr 1!-1: e. Hyper oygenate before and after procedure f. Observe sterile technique g. Apply suction during withdrawal of the catheter h. 2aimum time per suctioning 81' sec /, Nasogastric *eeding 8gastric gavage; 1nsertion. a. "owler9s position b. -ip of the nose to tip of the earlobe to the yphoid Tube *eeding a. +emi-"owler9s position b. Assess tube placement c. Assess residual feeding d. Height of feeding is 1! inches above the tube9s point of insertion e. As7 client to remain upright position for at least #< min. f. 2ost common problem of tube feeding is @iarrhea due to lactose intolerance 0, nema a. 6hec7 2@9s order b. ,rovide privacy c. ,osition left lateral d. +i/e of tube "r. !!-#! e. 1nsert #-% inches of rectal tube f. 1f abdominal cramps occur, temporarily stop the flow until cramps are gone. g. Height of enema can 8 1: inches >, 6rinary #atheteri"ation a. Ferify 2@9s order b. ,ractice strict asepsis c. ,erineal care before the procedure d. 6atheter si/e. male-1%-1( , female 8 1! 8 1% e. 0ength of catheter insertion male 8 (-; inches ,female 8 #-% inches *or retention catheter4 2ale 8anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure "emale- inner aspect of the thigh A, Bed Bath a. ,rovide privacy b. Epose, wash and dry one body part a time c. Ise warm water 311<-11' "5 d. 4ash from cleanest to dirtiest e. 4ash, rinse, and dry the arms and leg using 0ong, firm stro7es from distal to proimal area 8 to increase venous return. B, *oot #are a. +oa7ing the feet of diabetic client is no longer recommended b. 6ut nail straight across 9, Mouth #are a. Eat coarse, fibrous foods 3cleansing foods5 such as fresh fruits and raw vegetables b. @ental chec7 every ( mounts =, 2ral care for unconscious client a. ,lace in side lying position b. Have the suction apparatus readily available +:, Hair Sham$oo c. ,lace client diagonally in bed d. 6over the eyes with wash cloth e. ,lug the ears with cotton balls f. 2assage the scalp with the fatpads of the fingers to promote circulation in the scalp. ++, (estraints g. +ecure 2@9s order for each episode of restraints application. h. 6hec7 circulation every 1' min i. )emove restraints at least every ! hours for #< minutes Normal 5alues Bleeding time +-= min Prothrombin time +:-+/ sec Hematocrit Male 0.->.H *emale /A-09H Hemoglobin male +/,>-+A g@dl female +.-+A g@dl Platelet +>:<::- 0::<::: (B# male 0,>-A,. million@L female 0,.->,0 million@L !mylase 9:-+9: %6@L Bilirubin8serum; direct :-:,0 mg@dl indirect :,.-:,9 mg@dl total :,/-+,: mg@dl $H B,/>- B,0> Pa#o. />-0> H#2/ ..-.A mI@L Pa 2. 9:-+:: mmHg Sa2. =0-+::H Sodium +/>- +0> mI@L Potassium /,>- >,: mI@L #alcium 0,.- >,> mg@dL #hloride =9-+:9 mI@L Magnesium +,>-.,> mg@dl B6N + :-.: mg@dl #reatinine :,0- +,. #PE-MB male >: 1/.> mu@ml female >:-.>: mu@ml *ibrinogen .::-0:: mg@dl *BS 9:-+.: mg@dl -lycosylated Hgb 0,:-B,:H 8Hb!+c; 6ric !cid .,> 19 mg@dl S( male +>-.: mm@hr *emale .:-/: mm@hr #holesterol +>:- .:: mg@dl Triglyceride +0:-.:: mg@dl Lactic 'ehydrogenase +::-..> mu@ml !l)aline $hos$o)inase /.-=. 6@L !lbumin /,.- >,> mg@dl #2MM2N TH(!P6T%# '%TS +, #L!(-L%F6%' '%T ,urpose. relieve thirst and help maintain fluid balance. Ise. post-surgically and following acute vomiting or diarrhea. "oods Allowed. carbonated beverages= coffee 3caffeinated and decaff.5= tea= fruit- flavored drin7s= strained fruit Buices= clear, flavored gelatins= broth, consomme= sugar= popsicles= commercially prepared clear liquids= and hard candy. "oods Avoided. mil7 and mil7 products, fruit Buices with pulp, and fruit. ., *6LL-L%F6%' '%T ,urpose. provide an adequately nutritious diet for patients who cannot chew or who are too ill to do so. Ise. acute infection with fever, C1 upsets, after surgery as a progression from clear liquids. "oods Allowed. clear liquids, mil7 drin7s, coo7ed cereals, custards, ice cream, sherbets, eggnog, all strained fruit Buices, creamed vegetable soups, puddings, mashed potatoes, instant brea7fast drin7s, yogurt, mild cheese sauce or pureed meat, and seasoning. "oods Avoided. nuts, seeds, coconut, fruit, Bam, and marmalade S2*T '%T ,urpose. provide adequate nutrition for those who have troubled chewing. Ise. patient with no teeth or ill-fitting dentures= transition from full-liquid to general diet= and for those who cannot tolerate highly seasoned, fried or raw foods following acute infections or gastrointestinal disturbances such as gastric ulcer or cholelithiasis. "oods Allowed. very tender minced, ground, ba7ed broiled, roasted, stewed, or creamed beef, lamb, veal, liver, poultry, or fish= crisp bacon or sweet bread= coo7ed vegetables= pasta= all fruit Buices= soft raw fruits= soft bread and cereals= all desserts that are soft= and cheeses. "oods Avoided. coarse whole-grain cereals and bread= nuts= raisins= coconut= fruits with small seeds= fried foods= high fat gravies or sauces= spicy salad dressings= pic7led meat, fish, or poultry= strong cheeses= brown or wild rice= raw vegetables, as well as lima beans and corn= spices such as horseradish, mustard, and catsup= and popcorn. S2'%6M-(ST(%#T' '%T ,urpose. reduce sodium content in the tissue and promote ecretion of water. Ise. heart failure, hypertension, renal disease, cirrhosis, toemia of pregnancy, and cortisone therapy. 2odifications. mildly restrictive ! g sodium diet to etremely restricted !<< mg sodium diet. "oods Avoided. table salt= all commercial soups, including bouillon= gravy, catsup, mustard, meat sauces, and soy sauce= buttermil7, ice cream, and sherbet= sodas= beet greens, carrots, celery, chard, sauer7raut, and spinach= all canned vegetables= fro/en peas= all ba7ed products containing salt, ba7ing powder, or ba7ing soda= potato chips and popcorn= fresh or canned shellfish= all cheeses= smo7ed or commercially prepared meats= salted butter or margarine= bacon, olives= and commercially prepared salad dressings. (N!L '%T ,urpose. control protein, potassium, sodium, and fluid levels in the body. Ise. acute and chronic renal failure, hemodialysis. "oods Allowed. high-biological proteins such as meat, fowl, fish, cheese, and dairy productsrange between !< and (< mgAday. ,otassium is usually limited to 1'<< mgAday. Fegetables such as cabbage, cucumber, and peas are lowest in potassium. +odium is restricted to '<< mgAday. "luid inta7e is restricted to the daily volume plus '<< m0, which represents insensible water loss. "luid inta7e measures water in fruit, vegetables, mil7 and meat. "oods Avoided. 6ereals, bread, macaroni, noodles, spaghetti, avocados, 7idney beans, potato chips, raw fruit, yams, soybeans, nuts, gingerbread, apricots, bananas, figs, grapefruit, oranges, percolated coffee, 6oca-6ola, orange crush, sport drin7s, and brea7fast drin7s such as -ang or Awa7e H1CH-,)O-E1$, H1CH 6A)&OHJ@)A-E @1E- ,urpose. to correct large protein losses and raises the level of blood albumin. 2ay be modified to include lowfat, low-sodium, and low-cholesterol diets. Ise. burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis, protein deficiency due to poor eating habits, geriatric patient with poor inta7e= nephritis, nephrosis, and liver and gall bladder disorder. "oods Allowed. general diet with added protein. "oods Avoided. restrictions depend on modifications added to the diet. -he modifications are determined by the patient9s condition. P6(%N-(ST(%#T' '%T ,urpose. designed to reduce inta7e of uric acid-producing foods. Ise. high uric acid retention, uric acid renal stones, and gout. "oods Allowed. general diet plus !-# quarts of liquid daily. "oods Avoided. cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils, dried peas and beans, broth, bouillon, gravies, oatmeal and whole wheat, pasta, noodles, and alcoholic beverages. 0imited quantities of meat, fish, and seafood allowed. BL!N' '%T ,urpose. provision of a diet low in fiber, roughage, mechanical irritants, and chemical stimulants. Ise. Castritis, hyperchlorhydria 3ecess hydrochloric acid5, functional C1 disorders, gastric atony, diarhhea, spastic constipation, biliary indigestion, and hiatus hernia. "oods Allowed. varied to meet individual needs and food tolerances. "oods Avoided. fried foods, including eggs, meat, fish, and sea food= cheese with added nuts or spices= commercially prepared luncheon meats= cured meats such as ham= gravies and sauces= raw vegetables= potato s7ins= fruit Buices with pulp= figs= raisins= fresh fruits= whole wheats= rye bread= bran cereals= rich pastries= pies= chocolate= Bams with seeds= nuts= seasoned dressings= caffeinated coffee= strong tea= cocoa= alcoholic and carbonated beverages= and pepper. L2&-*!T< #H2LST(2L-(ST(%#T' '%T ,urpose. reduce hyperlipedimia, provide dietary treatment for malabsorption syndromes and patients having acute intolerance for fats. Ise. hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue 3disease of intestinal tract characteri/ed by malabsorption5, gastrectomy, massive resection of small intestine, and cholecystitis. "oods Allowed. nonfat mil7= low-carbohydrate, low-fat vegetables= most fruits= breads= pastas= cornmeal= lean meats= nsaturated fats "oods Avoided. remember to avoid the five 69s of cholesterol- coo7ies, cream, ca7e, coconut, chocolate= whole mil7 and whole-mil7 or cream products, avocados, olives, commercially prepared ba7ed goods such as donuts and muffins, poultry s7in, highly marbled meats butter, ordinary margarines, olive oil, lard, pudding made with whole mil7, ice cream, candies with chocolate, cream, sauces, gravies and commercially fried foods. '%!BT%# '%T ,urpose. maintain blood glucose as near as normal as possible= prevent or delay onset of diabetic complications. Ise. diabetes mellitus "oods Allowed. choose foods with low glycemic inde compose of. a. %'-''N carbohydrates b. #<-#'N fats c. 1<-!'N protein coffee, tea, broth, spices and flavoring can be used as desired. echange groups include. mil7, vegetable, fruits, starchAbread, meat 3divided in lean, medium fat, and high fat5, and fat echanges. the number of echanges allowed from each group is dependent on the total number of calories allowed. non-nutritive sweeteners 3sorbitol5 in moderation with controlled, normal weight diabetics. "oods Avoided. concentrated sweets or regular soft drin7s. !#%' !N' !LE!L%N '%T ,urpose. "urnish a well balance diet in which the total acid ash is greater than the total al7aline ash each day. Ise. )etard the formation of renal calculi. -he type of diet chosen depends on laboratory analysis of the stone. Acid and al7aline ash food groups. a. Acid ash. meat, whole grains, eggs, cheese, cranberries, prunes, plums b. Al7aline ash. mil7, vegetables, fruits 3ecept cranberries, prunes and plums.5 c. $eutral. sugar, fats, beverages 3coffee, tea5 "oods allowed. &reads. any, preferably whole grain= crac7ers= rolls 6ereals. any, preferable whole grains @esserts. angel food or sunshine ca7e= coo7ies made without ba7ing powder or soda= cornstarch, pudding, cranberry desserts, ice cream, sherbet, plum or prune desserts= rice or tapioca pudding. "ats. any, such as butter, margarine, salad dressings, 6risco, +pry, lard, salad oil, olive oil, ect. fruits. cranberry, plums, prunes 2eat, eggs, cheese. any meat, fish or fowl, two serving daily= at least one egg daily ,otato substitutes. corn, hominy, lentils, macaroni, noodles, rice, spaghetti, vermicelli. +oup. broth as desired= other soups from food allowed +weets. cranberry and plum Belly= plain sugar candy 2iscellaneous. cream sauce, gravy, peanut butter, peanuts, popcorn, salt, spices, vinegar, walnuts. )estricted foods. no more than the amount allowed each day 1. 2il7. 1 pint daily 3may be used in other ways than as beverage5 !. 6ream. 1A# cup or less daily #. "ruits. one serving of fruits daily3 in addition to the prunes, plums and cranberries5 %. Fegetable. including potatoes. two servings daily '. +weets. 6hocolate or candies, syrups. (. 2iscellaneous. other nuts, olives, pic7les. H%-H-*%B( '%T ,urpose. +often the stool eercise digestive tract muscles speed passage of food through digestive tract to prevent eposure to cancercausing agents in food lower blood lipids prevent sharp rise in glucose after eating. Ise. diabetes, hyperlipedemia, constipation, diverticulitis, anticarcinogenics 3colon5 "oods Allowed. recommended inta7e about ( g crude fiber daily All bran cereal 4atermelon, prunes, dried peaches, apple with s7in= parsnip, peas, brussels sprout, sunflower seeds. L2& (S%'6 '%T ,urpose. )educe stool bul7 and slow transit time Ise. &owel inflammation during acute diverticulitis, or ulcerative colitis, preparation for bowel surgery, esophageal and intestinal stenosis. "ood Allowed. eggs= ground or well-coo7ed tender meat, fish, poultry= mil7, cheeses= strained fruit Buice 3ecept prune5. coo7ed or canned apples, apricots, peaches, pears= ripe banana= strained vegetable Buice. canned, coo7ed, or strained asparagus, beets, green beans, pump7in, squash, spinach= white bread= refined cereals 36ream of 4heat5 P(%N#%PLS 2* M'%#!T%2N !'M%N%ST(!T%2N % - DSi3 (ightsJ of drug administration +, The (ight Medication 8 when administering medications, the nurse compares the label of the medication container with medication form. -he nurse does this # times. a. &efore removing the container from the drawer or shelf b. As the amount of medication ordered is removed from the container c. &efore returning the container to the storage ., (ight 'ose 8when performing medication calculation or conversions, the nurse should have another qualified nurse chec7 the calculated dose /, (ight #lient 8 an important step in administering medication safely is being sure the medication is given to the right client. a. -o identify the client correctly. b. -he nurse chec7 the medication administration form against the clients identification bracelet and as)s the client to state his or her name to ensure the client9s identification bracelet has the correct information. 0, (%-HT (26T 8 if a prescriber9s order does nor designate a route of administration, the nurse consult the prescriber. 0i7ewise, if the specified route is not recommended, the nurse should alert the prescriber immediately. >, (%-HT T%M a. the nurse must 7now why a medication is ordered for certain times of the day and whether the time schedule can be altered b. each institution has are commended time schedule for medications ordered at frequent interval c. 2edication that must act at certain times are given priority 3e.g insulin should be given at a precise interval before a meal 5 A, (%-HT '2#6MNT!T%2N 8@ocumentation is an important part of safe medication administration a. -he documentation for the medication should clearly reflect the client9s name, the name of the ordered medication,the time, dose, route and frequency b. +ign medication sheet immediately after administration of the drug #L%NTS (%-HT (L!T' T2 M'%#!T%2N !'M%N%ST(!T%2N A client has the following rights. a. -o be informed of the medication9s name, purpose, action, and potential undesired effects. b. -o refuse a medication regardless of the consequences c. -o have a qualified nurses or physicians assess medication history, including allergies d. -o be properly advised of the eperimental nature of medication therapy and to give written consent for its use e. -o received labeled medications safely without discomfort in accordance with the si rights of medication administration f. -o receive appropriate supportive therapy in relation to medication therapy g. -o not receive unnecessary medications %% 1 Practice !se$sis 8 wash hand before and after preparing the medication to reduce transfer of microorganisms. %%% 1 $urse who administer the medications are responsible for their own action. Ouestion any order that you considered incorrect 3may be unclear or appropriate5 %5 8 &e 7nowledgeable about the medication that you administer K! *6N'!MNT!L (6L 2* S!* '(6- !'M%N%ST(!T%2N %S4 KN5( !'M%N%ST( !N 6N*!M%L%!( M'%#!T%2NE 5 8 >eep the $arcotics in loc7ed place. 5%8 Ise only medications that are in clearly labeled containers. )elabelling of drugs are the responsibility of the pharmacist. 5%% 8 )eturn liquid that are cloudy in color to the pharmacy. 5%%% 8 &efore administering medication, identify the client correctly %L 8 @o not leave the medication at the bedside. +tay with the client until he actually ta7es the medications, L 8 -he nurse who prepares the drug administers it.. Only the nurse prepares the drug 7nows what the drug is. @o not accept endorsement of medication. L% 8 1f the client vomits after ta7ing the medication, report this to the nurse incharge or physician. L%% 8 ,reoperative medications are usually discontinued during the postoperative period unless ordered to be continued. L%%%- 4hen a medication is omitted for any reason, record the fact together with the reason. L%5 8 4hen the medication error is made, report it immediately to the nurse incharge or physician. -o implement necessary measures immediately. -his may prevent any adverse effects of the drug. Medication !dministration +, 2ral administration !dvantages a. -he easiest and most desirable way to administer medication b. 2ost convenient c. +afe, does nor brea7 s7in barrier d. Isually less epensive 'isadvantages a. 1nappropriate if client cannot swallow and if C1- has reduced motility b. 1nappropriate for client with nausea and vomiting c. @rug may have unpleasant taste d. @rug may discolor the teeth e. @rug may irritate the gastric mucosa f. @rug may be aspirated by seriously ill patient. 'rug *orms for 2ral !dministration a. +olid. tablet, capsule, pill, powder b. 0iquid. syrup, suspension, emulsion, eliir, mil7, or other al7aline substances. c. +yrup. sugar-based liquid medication d. +uspension . water-based liquid medication. +ha7e bottle before use of medication to properly mi it. e. Emulsion. oil-based liquid medication f. Eliir. alcohol-based liquid medication. After administration of eliir, allow #< minutes to elapse before giving water. -his allows maimum absorption of the medication. KN5( #(6SH NT(%#-#2!T' 2( S6ST!%N' (L!S T!BLTJ #rushing enteric-coated tablets 8 allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation. #rushing sustained-released medication 8 allows all the medication to be absorbed at the same time, resulting in a higher than epected initial level of medication and a shorter than epected duration of action ., S6BL%N-6!L a. A drug that is placed under the tongue, where it dissolves. b. 4hen the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue. c. A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved Advantages. a. +ame as oral b. @rug is rapidly absorbed in the bloodstream @isadvantages a. 1f swallowed, drug may be inactivated by gastric Buices. b. @rug must remain under the tongue until dissolved and absorbed /, B6##!L a. A medication is held in the mouth against the mucous membranes of the chee7 until the drug dissolves. b. -he medication should not be chewed, swallowed, or placed under the tongue 3e.g sustained release nitroglycerine, opiates,antiemetics, tranquili/er, sedatives5 c. 6lient should be taught to alternate the chee7s with each subsequent dose to avoid mucosal irritation !dvantages4 a. +ame as oral b. @rug can be administered for local effect c. Ensures greater potency because drug directly enters the blood and bypass the liver 'isadvantages4 1f swallowed, drug may be inactivated by gastric Buice 0, T2P%#!L 8 Application of medication to a circumscribed area of the body. +, 'ermatologic 8 includes lotions, liniment and ointments, powder. a. &efore application, clean the s7in thoroughly by washing the area gently with soap and water, soa7ing an involved site, or locally debriding tissue. b. Ise surgical asepsis when open wound is present c. )emove previous application before the net application d. Ise gloves when applying the medication over a large surface. 3e.g large area of burns5 e. Apply only thin layer of medication to prevent systemic absorption. !. 2$thalmic - includes instillation and irrigation a. 1nstillation 8 to provide an eye medication that the client requires. b. 1rrigation 8 -o clear the eye of noious or other foreign materials. c. ,osition the client either sitting or lying. d. Ise sterile technique e. 6lean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus f. 1nstill eye drops into lower conBunctival sac. g. 1nstill a maimum of ! drops at a time. 4ait for ' minutes if additional drops need to be administered. -his is for proper absorption of the medication. h. Avoid dropping a solution onto the cornea directly, because it causes discomfort. i. 1nstruct the client to close the eyes gently. +hutting the eyes tightly causes spillage of the medication. B. "or liquid eye medication, press firmly on the nasolacrimal duct 3inner cantus5 for at least #< seconds to prevent systemic absorption of the medication. /, 2tic %nstillation 1 to remove cerumen or pus or to remove foreign body a. 4arm the solution at room temperature or body temperature, failure to do so may cause vertigo, di//iness, nausea and pain. b. Have the client assume a side-lying position 3 if not contraindicated5 with ear to be treated facing up. c. ,erform hand hygiene. Apply gloves if drainage is present. d. +traighten the ear canal. <-# years old. pull the pinna downward and bac7ward Older than # years old. pull the pinna upward and bac7ward e. 1nstill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adBust to body temperature f. ,ress gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal. g. As7 the client to remain in side lying position for about ' minutes h. At times the 2@ will order insertion of cotton puff into outermost part of the canal.@o not press cotton into the canal. )emove cotton after 1' minutes. 0, Nasal 1 $asal instillations usually are instilled for their astringent effects 3to shrin7 swollen mucous membrane5, to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. @econgestants, steroids, calcitonin. a. Have the client blow the nose prior to nasal instillation b. Assume a bac7 lying position, or sit up and lean head bac7. c. Elevate the nares slightly by pressing the thumb against the client9s tip of the nose. 4hile the client inhales, squee/e the bottle. d. >eep head tilted bac7ward for ' minutes after instillation of nasal drops. e. 4hen the medication is used on a daily basis, alternate nares to prevent irritations >, %nhalation 8 use of nebuli/er, metered-dose inhaler a. +imi or high-fowler9s position or standing position. -o enhance full chest epansion allowing deeper inhalation of the medication b. +ha7e the canister several times. -o mi the medication and ensure uniform dosage delivery c. ,osition the mouthpiece 1 to ! inches from the client9s open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. -his allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharyn then swallowed d. 1nstruct the client to hold breath for 1< seconds. -o enhance complete absorption of the medication. e. 1f bronchodilator, administer a maimum of ! puffs, for at least #< second interval. Administer bronchodilator before other inhaled medication. -his opens airway and promotes greater absorption of the medication. f. 4ait at least 1 minute before administration of the second dose or inhalation of a different medication by 2@1 g. 1nstruct client to rinse mouth, if steroid had been administered. -his is to prevent fungal infection. A, 5agina l 1 drug forms. tablet liquid 3douches5. ?elly, foam and suppository. a. 6lose room or curtain to provide privacy. b. Assist client to lie in dorsal recumbent position to provide easy access and good eposure of vaginal canal, also allows suppository to dissolve without escaping through orifice. c. Ise applicator or sterile gloves for vaginal administration of medications. 5aginal %rrigation 8 is the washing of the vagina by a liquid at low pressure. 1t is also called douche. a. Empty the bladder before the procedure b. ,osition the client on her bac7 with the hips higher than the shoulder 3use bedpan5 c. 1rrigating container should be #< cm 31! inches5 above d. As7 the client to remain in bed for '-1< minute following administration of vaginal suppository, cream, foam, Belly or irrigation. B, (#T!L 8 can be use when the drug has obBectionable taste or odor. a. $eed to be refrigerated so as not to soften. b. Apply disposable gloves. c. Have the client lie on left side and as7 to ta7e slow deep breaths through mouth and rela anal sphincter. d. )etract buttoc7s gently through the anus, past internal sphincter and against rectal wall, 1< cm 3% inches5 in adults, ' cm 3! in5 in children and infants. 2ay need to apply gentle pressure to hold buttoc7s together momentarily. e. @iscard gloves to proper receptacle and perform hand washing. f. 6lient must remain on side for !< minute after insertion to promote adequate absorption of the medication. 9, P!(NT(!L- administration of medication by needle. %ntradermal 8 under the epidermis. a. -he site are the inner lower arm, upper chest and bac7, and beneath the scapula. b. 1ndicated for allergy and tuberculin testing and for vaccinations. c. Ise the needle gauge !', !(, !*. needle length #A:E, 'A:E or PE d. $eedle at 1<81' degree angle= bevel up. e. 1nBect a small amount of drug slowly over # to ' seconds to form a wheal or bleb. f. @o not massage the site of inBection. -o prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous. Subcutaneous 8 vaccines, heparin, preoperative medication, insulin, narcotics. -he site. outer aspect of the upper arms anterior aspect of the thighs Abdomen +capular areas of the upper bac7 Fentrogluteal @orsogluteal a. Only small doses of medication should be inBected via +6 route. b. )otate site of inBection to minimi/e tissue damage. c. $eedle length and gauge are the same as for 1@ inBections d. Ise 'A: needle for adults when the inBection is to administer at %' degree angle= P is use at a ;< degree angle. e. "or thin patients. %' degree angle of needle f. "or obese patient. ;< degree angle of needle g. "or heparin inBection . h. do not aspirate. i. @o not massage the inBection site to prevent hematoma formation B. "or insulin inBection. 7. @o not massage to prevent rapid absorption which may result to hypoglycemic reaction. l. Always inBect insulin at ;< degrees angle to administer the medication in the poc7et between the subcutaneous and muscle layer. AdBust the length of the needle depending on the si/e of the client. m. "or other medications, aspirate before inBection of medication to chec7 if the blood vessel had been hit. 1f blood appears on pulling bac7 of the plunger of the syringe, remove the needle and discard the medication and equipment. %ntramuscular a. $eedle length is 1E, 1 PE, !E to reach the muscle layer b. 6lean the inBection site with alcoholi/ed cotton ball to reduce microorganisms in the area. c. 1nBect the medication slowly to allow the tissue to accommodate volume. Sites4 5entrogluteal site a. -he area contains no large nerves, or blood vessels and less fat. 1t is farther from the rectal area, so it less contaminated. b. ,osition the client in prone or side-lying. c. 4hen in prone position, curl the toes inward. d. 4hen side-lying position, fle the 7nee and hip. -hese ensure relaation of gluteus muscles and minimi/e discomfort during inBection. e. -o locate the site, place the heel of the hand over the greater trochanter, point the inde finger toward the anterior superior iliac spine, then abduct the middle 3third5 finger. -he triangle formed by the inde finger, the third finger and the crest of the ilium is the site. 'orsogluteal site a. ,osition the client similar to the ventrogluteal site b. -he site should not be use in infant under # years because the gluteal muscles are not well developed yet. c. -o locate the site, the nursedraw an imaginary line from the greater trochanter to the posterior superior iliac spine. -he inBection site id lateral and superior to this line. d. Another method of locating this site is to imaginary divide the buttoc7 into four quadrants. -he upper most quadrant is the site of inBection. ,alpate the crest of the ilium to ensure that the site is high enough. e. Avoid hitting the sciatic nerve, maBor blood vessel or bone by locating the site properly. 5astus Lateralis a. )ecommended site of inBection for infant b. 0ocated at the middle third of the anterior lateral aspect of the thigh. c. Assume bac7-lying or sitting position. (ectus femoris site 8located at the middle third, anterior aspect of thigh. 'eltoid site a. $ot used often for 12 inBection because it is relatively small muscle and is very close to the radial nerve and radial artery. b. -o locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the ailla. -his is approimately ' cm 3! in5 or ! to # fingerbreadths below the acromion process. %M inDection 1 G tract inDection a. Ised for parenteral iron preparation. -o seal the drug deep into the muscles and prevent permanent staining of the s7in. b. )etract the s7in laterally, inBect the medication slowly. Hold retraction of s7in until the needle is withdrawn c. @o not massage the site of inBection to prevent lea7age into the subcutaneous. -N(!L P(%N#%PLS %N P!(NT(!L !'M%N%ST(!T%2N 2* M'%#!T%2NS 1. 6hec7 doctor9s order. !. 6hec7 the epiration for medication 8 drug potency may increase or decrease if outdated. #. Observe verbal and non-verbal responses toward receiving inBection. 1nBection can be painful.client may have aniety, which can increase the pain. %. ,ractice asepsis to prevent infection. Apply disposable gloves. '. Ise appropriate needle si/e. -o minimi/e tissue inBury. (. ,lot the site of inBection properly. -o prevent hitting nerves, blood vessels, bones. *. Ise separate needles for aspiration and inBection of medications to prevent tissue irritation. :. 1ntroduce air into the vial before aspiration. -o create a positive pressure within the vial and allow easy withdrawal of the medication. ;. Allow a small air bubble 3<.! ml5 in the syringe to push the medication that may remain. 1<.1ntroduce the needle in quic7 thrust to lessen discomfort. 11.Either spread or pinch muscle when introducing the medication. @epending on the si/e of the client. 1!.2inimi/ed discomfort by applying cold compress over the inBection site before introduction of medicati<n to numb nerve endings. 1#.Aspirate before the introduction of medication. -o chec7 if blood vessel had been hit. 1%.+upport the tissue with cotton swabs before withdrawal of needle. -o prevent discomfort of pulling tissues as needle is withdrawn. 1'.2assage the site of inBection to haste absorption. 1(.Apply pressure at the site for few minutes. -o prevent bleeding. 1*.Evaluate effectiveness of the procedure and ma7e relevant documentation. %ntravenous -he nurse administers medication intravenously by the following method. 1. As miture within large volumes of 1F fluids. !. &y inBection of a bolus, or small volume, or medication through an eisting intravenous infusion line or intermittent venous access 3heparin or saline loc75 #. &y Dpiggybac7E infusion of solution containing the prescribed medication and a small volume of 1F fluid through an eisting 1F line. a. 2ost rapid route of absorption of medications. b. ,redictable, therapeutic blood levels of medication can be obtained. c. -he route can be used for clients with compromised gastrointestinal function or peripheral circulation. d. 0arge dose of medications can be administered by this route. e. -he nurse must closely observe the client for symptoms of adverse reactions. f. -he nurse should double-chec7 the si rights of safe medication. g. 1f the medication has an antidote, it must be available during administration. h. 4hen administering potent medications, the nurse assesses vital signs before, during and after infusion. Nursing %nterventions in %5 %nfusion a. Ferify the doctor9s order b. >now the type, amount, and indication of 1F therapy. c. ,ractice strict asepsis. d. 1nform the client and eplain the purpose of 1F therapy to alleviate client9s aniety. e. ,rime 1F tubing to epel air. -his will prevent air embolism. f. 6lean the insertion site of 1F needle from center to the periphery with alcoholi/ed cotton ball to prevent infection. g. +have the area of needle insertion if hairy. h. 6hange the 1F tubing every *! hours. -o prevent contamination. i. 6hange 1F needle insertion site every *! hours to prevent thrombophlebitis. B. )egulate 1F every 1'-!< minutes. -o ensure administration of proper volume of 1F fluid as ordered. 7. Observe for potential complications. Ty$es of %5 *luids 1sotonic solution 8 has the same concentration as the body fluid a. @' 4 b. $a 6l <.;N c. plain)inger9s lactate d. ,lain $ormosol 2 Hypotonic 8 has lower concentration than the body fluids. a. $a6l <.#N Hypertonic 8 has higher concentration than the body fluids. a. @1<4 b. @'<4 c. @'0) d. @'$2 #om$lication of %5 %nfusion +, %nfiltration 8 the needle is out of nein, and fluids accumulate in the subcutaneous tissues. Assessment. ,ain, swelling, s7in is cold at needle site, pallor of the site, flow rate has decreases or stops. $ursing 1ntervention. 6hange the site of needle Apply warm compress. -his will absorb edema fluids and reduce swelling. ., #irculatory 2verload - )esults from administration of ecessive volume of 1F fluids. Assessment. Headache "lushed s7in )apid pulse 1ncrease &, 4eight gain +yncope and faintness ,ulmonary edema 1ncrease volume pressure +O& 6oughing -achypnea shoc7 $ursing 1nterventions. +low infusion to >FO ,lace patient in high fowler9s position. -o enhance breathing Administer diuretic, bronchodilator as ordered #. 'rug 2verload 8 the patient receives an ecessive amount of fluid containing drugs. Assessment. @i//iness +hoc7 "ainting $ursing 1ntervention +low infusion to >FO. -a7e vital signs $otify physician %. Su$erficial Thrombo$hlebitis 1 it is due to o<veruse of a vein, irritating solution or drugs, clot formation, large bore catheters. Assessment. ,ain along the course of vein Fein may feel hard and cordli7e Edema and redness at needle insertion site. Arm feels warmer than the other arm $ursing 1ntervention. 6hange 1F site every *! hours Ise large veins for irritating fluids. +tabili/e venipuncture at area of fleion. Apply cold compress immediately to relieve pain and inflammation= later with warm compress to stimulate circulation and promotion absorption. D@o not irrigate the 1F because this could push clot into the systemic circulation9 '. !ir mbolism 8 Air manages to get into the circulatory system= ' ml of air or more causes air embolism. Assessment. 6hest, shoulder, or bac7pain Hypotension @yspnea 6yanosis -achycardia 1ncrease venous pressure 0oss of consciousness $ursing 1ntervention @o not allow 1F bottle to Drun dryE D,rimeE 1F tubing before starting infusion. -urn patient to left side in the trendelenburg position. -o allow air to rise in the right side of the heart. -his prevent pulmonary embolism. (. Nerve 'amage 8 may result from tying the arm too tightly to the splint. Assessment $umbness of fingers and hands $ursing 1nterventions 2assage the are and move shoulder through its )O2 1nstruct the patient to open and close hand several times each hour. ,hysical therapy may be required $ote. apply splint with the fingers free to move. B, S$eed Shoc) 8 may result from administration of 1F push medication rapidly. -o avoid speed shoc7, and possible cardiac arrest, give most 1F push medication over # to ' minutes. BL22' T(!NS*6S%2N TH(!P7 2bDectives4 1. -o increase circulating blood volume after surgery, trauma, or hemorrhage !. -o increase the number of )&6s and to maintain hemoglobin levels in clients with severe anemia #. -o provide selected cellular components as replacements therapy 3e.g clotting factors, platelets, albumin5 $ursing 1nterventions. a. Ferify doctor9s order. 1nform the client and eplain the purpose of the procedure. b. 6hec7 for cross matching and typing. -o ensure compatibility c. Obtain and record baseline vital signs d. ,ractice strict Asepsis e. At least ! licensed nurse chec7 the label of the blood transfusion 6hec7 the following. +erial number &lood component &lood type )h factor Epiration date +creening test 3F@)0, H&sAg, malarial smear5 - this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion. f. 4arm blood at room temperature before transfusion to prevent chills. g. 1dentify client properly. -wo $urses chec7 the client9s identification. h. Ise needle gauge 1: to 1;. -his allows easy flow of blood. B.Ise &- set with special micron mesh filter. -o prevent administration of blood clots and particles. 7. +tart infusion slowly at 1< gttsAmin. )emain at bedside for 1' to #< minutes. Adverse reaction usually occurs during the first 1' to !< minutes. l. 2onitor vital signs. Altered vital signs indicate adverse reaction. 'o not mi3ed medications with blood transfusion, To $revent adverse effects 'o not incor$orate medication into the blood transfusion 'o not use blood transfusion line for %5 $ush of medication, m. Administer <.;N $a6l before, during or after &-. $ever administer 1F fluids with detrose. @etrose causes hemolysis. n. Administer &- for % hours 3whole blood, pac7ed rbc5. "or plasma, platelets, cryoprecipitate, transfuse quic7ly 3!< minutes5 clotting factor can easily be destroyed. #om$lications of Blood Transfusion +, !llergic (eaction 8 it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen. Assessments "lushing )ush, hives ,ruritus 0aryngeal edema, difficulty of breathing !. *ebrile< Non-Hemolytic 8 it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. -his is the most symptomatic complication of blood transfusion Assessments. +udden chills and fever "lushing Headache Aniety #. Se$tic (eaction 8 it is caused by the transfusion of blood or components contaminated with bacteria. Assessment. )apid onset of chills Fomiting 2ar7ed Hypotension High fever %. #irculatory 2verload 1 it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate. !ssessment )ise in venous pressure @yspnea 6rac7les or rales @istended nec7 vein 6ough Elevated &, >, Hemolytic reaction. 1t is caused by infusion of incompatible blood products. Assessment 0ow bac7 pain 3first sign5. -his is due to inflammatory response of the 7idneys to incompatible blood. 6hills "eeling of fullness -achycardia "lushing -achypnea Hypotension &leeding Fascular collapse Acute renal failure Nursing %nterventions when com$lications occurs in Blood transfusion 1. 1f blood transfusion reaction occurs. +-O, -HE -)A$+"I+1O$. !. +tart 1F line 3<.;N $a 6l5 #. ,lace the client in fowlers position if with +O& and administer O! therapy. %. -he nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every ' minutes. '. $otify the physician immediately. (. -he nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician9s order or protocol. *. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of )&6 hemolysis. :. &lood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis. #om$ilation co$y of4 Lorie Noval- Pacli$an MPH< (N MSH- #2LL-
DC 2019-0436 Moratorium For The Implementation of Selected Sections of AO 2019-0026 - National Policy in The Provision of Birthing Assistance To Primigravid and Grand Multigravid Women PDF