FUNDAMENTALS OF NURSING

The Earliest Hospitals Established were the followin!

a. Hospital Real de Manila (1577). It was established mainly to care for the Spanish Kin!s
soldiers" b#t also admitted Spanish ci$ilians.%o#nded by &o$. %rancisco de Sande
b. San 'a(aro Hospital (157)) * b#ilt e+cl#si$ely for patients with leprosy. %o#nded by ,rother
-#an .lemente
The Earliest Hospitals Established
a. Hospital de Indio (15)/) *0stablished by the %ranciscan 1rder2 Ser$ice was in eneral
s#pported by alms and contrib#tion from charitable persons.
b. Hospital de 3#as Santas (1545). 0stablished in 'a#na" near a medicinal sprin" %o#nded by
,rother -. ,a#tista of the %ranciscan 1rder.
c. San -#an de 6ios Hospital (154/) %o#nded by the ,rotherhood de Misericordia and s#pport
was deri$ed from alms and rents. Rendered eneral health ser$ice to the p#blic.
N"rsin D"rin the #hilippine Re$ol"tion
The pro%inent persons in$ol$ed in the n"rsin wor&s were!
a. 'osephine (ra)&en * wife of -ose Ri(al. Installed a field hospital in an estate ho#se in
7e8eros. 9ro$ided n#rsin care to thw wo#nded niht and day.
b. b+Rosa Se$illa De Al$ero * con$erted their ho#se into :#arters for the filipino soldier"d#rin
the 9hilippine;3merican war that bro<e o#t in 1)44.
c. Dona Hilaria de A"inaldo * =ife of 0milio 3#inaldo2 1rani(ed the %ilipino Red .ross
#nder the inspiration of 3polinario Mabini.
d. Dona Maria de A"inaldo; second wife of 0milio 3#inaldo.9ro$ided n#rsin care for the
%ilipino soldier d#rin the re$ol#tion. 9resident of the %ilipino Red .ross branch in
,atanas.
e. Mel)hora A,"ino -Tandan Sora. * >#rse the wo#nded %ilipino soldiers and a$e them
shelter and food.
f. /aptain Salo%e * 3 re$ol#tionary leader in >#e$a 0ci8a2 pro$ided n#rsin care to the
wo#nded when not in combat.
. A"eda 0ahabaan * Re$ol#tionary leader in 'a#na" also pro$ided n#rsin ser$ices to her
troop.
h. Trinidad Te)son * ?Ina n ,iac na ,ato@" stayed in the hospital at ,iac na ,ato to care for
the wo#nded soldier.
Hospitals and N"rsin S)hools
1+Iloilo Mission Hospital S)hool of N"rsin (Iloilo .ity" 145/)
It was ran by the ,aptist %orein Mission Society of 3merica.
Miss Rose Ni)olet" a rad#ate of >ew 0nland Hospital for woman and children in
,oston" Massech#settes" was the first s#perintendent.
Miss Flora Ernst" an 3merican n#rse" too< chare of the school in 14AB.
B. St+ #a"l2s Hospital S)hool of N"rsin -Manila3 1456.
7he hospital was established by the 3rchbishop of Manila" 7he Most Re$erend -eremiah
Harty" #nder the s#per$ision of the Sisters of St. 9a#l de .hartres.
It was located in Intram#ros and it pro$ided eneral hospital ser$ices.
C. #hilippine eneral Hospital S)hool of N"rsin -1456.
In 1457" with the s#pport of the &o$ernor &eneral %orbes and the 6irector of Health and
amon others" she opened classes in n#rsin #nder the a#spices of the ,#rea# of
0d#cation.
Anasta)ia Giron7T"pas3 was the first %ilipino to occ#py the position of chief n#rse and
s#perintendent in the 9hilippines" s#cceded her.
A.St+ L"&e2s Hospital S)hool of N"rsin -8"e9on /it:3 1456.
7he Hospital is an 0piscopalian Instit#tion. It bean as a small dispensary in 145C. In
1457" the school opened with three %ilipino irls admitted.
Mrs+ ;itiliana (eltran was the first %ilipino s#perintendent of n#rses.
5. Mar: 'ohnston Hospital and S)hool of N"rsin -Manila3 1456.
It started as a small dispensary on .alle .er$antes (now 3$enida)
It was called ,ethany 6ispensary and was fo#nded by the Methodist Mission.
Miss 'ibrada -a$elera was the first %ilipino director of the school.
/. #hilippine /hristian %ission Instit"te S)hool of N"rsin+
7he Dnited .hristian Missionary of Indianapolis" operated 7hree schools of >#rsinE
1. Sallie 'on Read Memorial Hospital School of >#rsin ('aoa" Ilocos >orte"145C)
B. Mary .hiles Hospital school of >#rsin (Manila" 1411)
C. %ran< 6#nn Memorial hospital
6+ San '"an de Dios hospital S)hool of N"rsin -Manila3 141<.
=+ E%%an"el Hospital S)hool of N"rsin -/api93141<.
4+ So"thern Island Hospital S)hool of N"rsin -/eb"3141=.
7he hospital was established #nder the ,#rea# of Health with Anasta)ia Giron7T"pas as the
orani(er.
The First /ollees of N"rsin in the #hilippines
Dni$ersity of Santo 7omas ..ollee of >#rsin (14A/)
Manila .entral Dni$ersity .ollee of >#rsin (14A))
Dni$ersity of the 9hilippines .ollee of >#rsin (14A)). Ms.-#lita Sote8o was its first 6ean
The (asi) H"%an Needs
0ach indi$id#al has #ni:#e characteristics" b#t certain needs are common to all people.
3 need is somethin that is desirable"#sef#l or necessary.
H#man needs are physioloic and psycholoic conditions that an indi$id#al m#st meet to
achie$e a state of health or well;bein.
Maslow2s Hierar)h: of (asi) H"%an Needs
#h:sioloi)
1. 1+yen
B. %l#ids
C. >#trition
A. ,ody temperat#re
5. 0limination
/. Rest and sleep
7. Se+
Safet: and Se)"rit:
1. 9hysical safety
B. 9sycholoical safety
C. 7he need for shelter and freedom from harm and daner
Lo$e and belonin
1. 7he need to lo$e and be lo$ed
B. 7he need to care and to be cared for.
C. 7he need for affectionE to associate or to belon
A. 7he need to establish fr#itf#l and meaninf#l relationships with people"instit#tion" or
orani(ation
Self7Estee% Needs
1. Self;worth
B. Self;identity
C. Self;respect
A. ,ody imae
Self7A)t"ali9ation Needs
1. 7he need to learn" create and #nderstand or comprehend
B. 7he need for harmonio#s relationships
C. 7he need for bea#ty or aesthetics
A. 7he need for spirit#al f#lfillment
/hara)teristi)s of (asi) H"%an Needs
1. >eeds are #ni$ersal.
B. >eeds may be met in different ways
C. >eeds may be stim#lated by e+ternal and internal factor
A. 9riorities may be deferred
5. >eeds are interrelated
/on)epts of health and Illness
H03'7H
1. is the f#ndamental riht of e$ery h#man bein. It is the state of interation of the body and mind
B. Health and illness are hihly indi$id#ali(ed perception. Meanins and descriptions of health and
illness $ary amon people in relation to eoraphy and to c#lt#re.
C. Health ; is the state of complete physical" mental" and social well;bein" and not merely the
absence of disease or infirmity. (=H1)
A. Health is the ability to maintain the internal milie#. Illness is the res#lt of fail#re to maintain
the internal en$ironment.(.la#de ,ernard)
5. Health is the ability to maintain homeostasis or dynamic e:#ilibri#m. Homeostasis is re#lated
by the neati$e feedbac< mechanism.(=alter .annon)
/. Health * is bein well and #sin ones!s power to the f#llest e+tent. Health is maintained thro#h
pre$ention of diseases $ia en$ironmental health factors.(%lorence >ihtinale)
7. Health * is $iewed in terms of the indi$id#al!s ability to perform 1A components of n#rsin care
#naided. (Henderson)
). #ositi$e Health symboli(es wellness. It is $al#e term defined by the c#lt#re or indi$id#al.
(Roers)
4. Health * is a state of a process of bein becomin an interated and whole as a person.(Roy)
15. Health * is a state the characteri(ed by so#ndness or wholeness of de$eloped h#man str#ct#res
and of bodily and mental f#nctionin.(1rem)
11. Health- is a dynamic state in the life cycle2illness is an interference in the life cycle. (Kin)
1B. >ellness * is the condition in which all parts and s#bparts of an indi$id#al are in harmony with
the whole system. (>e#man)
1C. Health * is an el#si$e" dynamic state infl#enced by bioloic"psycholoic" and social
factors.Health is reflected by the orani(ation" interaction" interdependence and interation of the
s#bsystems of the beha$ioral system.(-ohnson)
Illness and Disease
Illness
is a personal state in which the person feels #nhealthy.
Illness is a state in which a person!s physical" emotional" intellect#al" social" de$elopmental"or
spirit#al f#nctionin is diminished or impaired compared with pre$io#s e+perience.
Illness is not synonymo#s with disease.
Disease
3n alteration in body f#nction res#ltin in red#ction of capacities or a shortenin of the normal
life span.
/o%%on /a"ses of Disease
1. ,ioloic aent * e.. microoranism
B. Inherited enetic defects * e.. cleft palate
C. 6e$elopmental defects * e.. imperforate an#s
A. 9hysical aents * e.. radiation" hot and cold s#bstances" #ltra$iolet rays
5. .hemical aents * e.. lead" asbestos" carbon mono+ide
/. 7iss#e response to irritationsFin8#ry * e.. inflammation" fe$er
7. %a#lty chemicalFmetabolic process * e.. inade:#ate ins#lin in diabetes
). 0motionalFphysical reaction to stress * e.. fear" an+iety
Staes of Illness
1. Symptoms 0+perience; e+perience some symptoms" person belie$es somethin is wron
C aspects *physical" coniti$e" emotional
B. 3ss#mption of Sic< Role * acceptance of illness" see<s ad$ice
C. Medical .are .ontact
See<s ad$ice to professionals for $alidation of real illness"e+planation of symptoms" reass#rance
or predict of o#tcome
A. 6ependent 9atient Role
7he person becomes a client dependent on the health professional for help.
3cceptsFre8ects health professional!s s#estions.
,ecomes more passi$e and acceptin.
5. Reco$eryFRehabilitation
&i$es #p the sic< role and ret#rns to former roles and f#nctions.
Ris& Fa)tors of a Disease
1+ Geneti) and #h:sioloi)al Fa)tors
%or e+ample" a person with a family history of diabetes mellit#s" is at ris< in de$elopin the
disease later in life.
?+ Ae
3e increases and decreases s#sceptibility ( ris< of heart diseases increases with ae for both
se+es
<+ En$iron%ent
7he physical en$ironment in which a person wor<s or li$es can increase the li<elihood that
certain illnesses will occ#r.
@+ Lifest:le
'ifestyle practices and beha$iors can also ha$e positi$e or neati$e effects on health.
/lassifi)ation of Diseases
1+ A))ordin to Etioloi) Fa)tors
a. Hereditar: * d#e to defect in the enes of one or other parent which is transmitted to the
i. offsprin
b. /onenital * d#e to a defect in the de$elopment" hereditary factors" or prenatal infection
c. Metaboli) * d#e to dist#rbances or abnormality in the intricate processes of metabolism.
d. Defi)ien): * res#lts from inade:#ate inta<e or absorption of essential dietary factor.
e. Tra"%ati)7 d#e to in8#ry
f. Alleri) * d#e to abnormal response of the body to chemical and protein s#bstances or to
physical stim#li.
. Neoplasti) * d#e to abnormal or #ncontrolled rowth of cell.
h. Idiopathi) *.a#se is #n<nown2 self;oriinated2 of spontaneo#s oriin
i. Deenerati$e *Res#lts from the deenerati$e chanes that occ#r in the tiss#e and orans.
8. Iatroeni) * res#lt from the treatment of the disease
?+ A))ordin to D"ration or Onset
a. a+A)"te Illness * 3n ac#te illness #s#ally has a short d#ration and is se$ere. Sins and
symptoms appears abr#ptly" intense and often s#bside after a relati$ely short period.
b. /hroni) Illness * chronic illness #s#ally loner than / months" and can also affects
f#nctionin in any dimension. 7he client may fl#ct#ate between ma+imal f#nctionin and
serio#s relapses and may be life threatenin. Is is characteri(ed by remission and
e+acerbation.
Re%ission; periods d#rin which the disease is controlled and symptoms are not
ob$io#s.
EAa)erbations * 7he disease becomes more acti$e i$en aain at a f#t#re time" with
rec#rrence of prono#nced symptoms.
c. S"b7A)"te * Symptoms are prono#nced b#t more proloned than the ac#te disease.
<+ Disease %a: also be Des)ribed as!
a. Orani) * res#lts from chanes in the normal str#ct#re" from reconi(able anatomical
chanes in an oran or tiss#e of the body.
b. F"n)tional * no anatomical chanes are obser$ed to acco#nt from the symptoms present"
may res#lt from abnormal response to stim#li.
c. O))"pational * Res#lts from factors associated with the occ#pation enae in by the patient.
d. ;enereal * #s#ally ac:#ired thro#h se+#al relation
e. Fa%ilial * occ#rs in se$eral indi$id#als of the same family
f. Epide%i) * attac<s a lare n#mber of indi$id#als in the comm#nity at the same time. (e..
S3RS)
. Ende%i) * 9resents more or less contin#o#sly or rec#rs in a comm#nity. (e.. malaria"
oiter)
h. #ande%i) *3n epidemic which is e+tremely widespread in$ol$in an entire co#ntry or
continent.
i. Sporadi) * a disease in which only occasional cases occ#r. (e.. den#e" leptospirosis)
Lea$ell and /lar&2s Three Le$els of #re$ention
a. #ri%ar: #re$ention * see<s to pre$ent a disease or condition at a prepatholoic state 2 to
stop somethin from e$er happenin.
Health #ro%otion
7health ed#cation
;marriae co#nselin
7enetic screenin
7ood standard of n#trition ad8#sted to
de$elopmental phase of life
Spe)ifi) #rote)tion
7#se of specific imm#ni(ation
;attention to personal hyiene
;#se of en$ironmental sanitation
;protection aainst occ#pational ha(ards
;protection from accidents
;#se of specific n#trients
7protections from carcinoens
;a$oidance to allerens
b+ Se)ondar: #re$ention * also <nown as ?Health Maintenance@.See<s to identify specific
illnesses or conditions at an early stae with prompt inter$ention to pre$ent or limit disability2
to pre$ent catastrophic effects that co#ld occ#r if proper attention and treatment are not
pro$ided
Earl: Dianosis and #ro%pt Treat%ent
;case findin meas#res
;indi$id#al and mass screenin s#r$ey
;pre$ent spread of comm#nicable disease
;pre$ent complication and se:#elae
;shorten period of disability
Disabilit: Li%itations
7 ade:#ate treatment to arrest disease process and pre$ent f#rther complication and
se:#elae.
;pro$ision of facilities to limit disability and pre$ent death.
)+ Tertiar: #re$ention * occ#rs after a disease or disability has occ#rred and the reco$ery
process has be#n2 Intent is to halt the disease or in8#ry process and assist the person in
obtainin an optimal health stat#s.7o establish a hih;le$el wellness.
?7o ma+imi(e #se of remainin capacities@s
Restoration and Rehabilitation
;wor< therapy in hospital
; #se of shelter colony
NURSING
3s defined by the INTERNATIONAL /OUN/IL OF NURSES as written by Girinia Henderson.
the #ni:#e f#nction of the n#rse is to assist the indi$id#al" sic< or well" in the performance of
those acti$ities contrib#tin to health" it!s reco$ery" or to a peacef#l death the client wo#ld
perform #naided if he had the necessary strenth" will or <nowlede.
Help the client ain independence as rapidly as possible.
/ON/E#TUAL AND THEORETI/AL MODELS OF NURSING #RA/TI/E
A+ NIGHTANGLE2S THEORB - %id71=55.
%oc#ses on the patient and his en$ironment.
6e$eloped the described the first theory of n#rsin. >otes on >#rsinE =hat It Is" =hat It Is >ot.
She foc#sed on chanin and manip#latin the en$ironment in order to p#t the patient in the best
possible conditions for nat#re to act.
She belie$ed that in the n#rt#rin en$ironment" the body co#ld repair itself. .lient!s en$ironment
is manip#lated to incl#de appropriate noise" n#trition" hyiene" sociali(ation and hope.
(+ #E#LAU3 HILDEGARD -14C1.
6efined n#rsin as a therape#tic" interpersonal process which stri$es to de$elop a n#rse; patient
relationship in which the n#rse ser$es as a reso#rce person" co#nselor and s#rroate.
Introd")ed the Interpersonal Model+ She defined n#rsin as an interpersonal process of
therape#tic between an indi$id#al who is sic< or in need of health ser$ices and a n#rse especially
ed#cated to reconi(e and respond to the need for help. She identified fo"r phases of the n"rse )lient
relationship na%el:!
1+ Orientation! the n#rse and the )lient initiall: do not &now ea)h other2s oals and testin the role
ea)h will ass"%e. 7he client attempts to identify diffic#lties and the amo#nt of n#rsin help that is
needed2
?+ Identifi)ation! the client responds to help professionals or the sinificant others who can meet the
identified needs. (oth the )lient and the n"rse plan toether an appropriate prora% to foster
healthD
<+ EAploitation! the )lients "tili9e all a$ailable reso"r)es to %o$e toward a oal of %aAi%"%
health f"n)tionalit:D
@+ Resol"tion! refers to the ter%ination phase of the n"rse7)lient relationship+ it o))"rs when the
)lient2s needs are %et and heEshe )an %o$e toward a new oal. 9epla# f#rther ass#med that
n#rse;client relationship fosters rowth in both the client and the n#rse.
/+ A(DELLAH3 FABE G+ -14F5.
6efined n#rsin as ha$in a problem;sol$in approach" with <ey n#rsin problems related to
health needs of people2 de$eloped list of ?1 n"rsin7proble% areas+
Introd")ed #atient * /entered Approa)hes to N"rsin Model She defined n#rsin as
ser$ice to indi$id#al and families2 therefore the society. %#rthermore" she concept#ali(ed
n#rsin as an art and a science that molds the attit#des" intellect#al competencies and
technical s<ills of the indi$id#al n#rse into the desire and ability to help people" sic< or well"
and cope with their health needs.
D+ ORLANDO3 IDA
She concept#ali(ed 7he 6ynamic >#rse * 9atient Relationship Model.
E+ LE;INE3 MBRA -146<.
,elie$es n#rsin inter$ention is a )onser$ation a)ti$it:" with conser$ation of enery as a
primary concern" fo#r conser$ation principles of n#rsinE conser$ation of client enery"
conser$ation of str#ct#red interity" conser$ation of personal interity" conser$ation of social
interity.
6escribed the Fo"r /on$ersation #rin)iples. She 3d$ocated that n#rsin is a h#man
interaction and proposed fo#r conser$ation principles of n#rsin which are concerned with
the #nity and interity of the indi$id#al. 7he fo#r conser$ation principles are as followsE
1+ /onser$ation of ener:+ 7he h#man body f#nctions by #tili(in enery. 7he h"%an bod: needs
ener: prod")in inp"t -food3 oA:en3 fl"ids. to allow ener: "tili9ation o"tp"t+
?+ /onser$ation of Str")t"ral Interit:. 7he h#man body has physical bo#ndaries -s&in and %")o"s
%e%brane) that m#st be maintained to facilitate health and pre$ent harmf#l aents from enterin
the body.
<+ /onser$ation of #ersonal Interit:. 7he n#rsin inter$entions are based on the conser$ation of the
indi$id#al client!s personality. 0$ery indi$id#al has sense of identit:3 self worth and self estee%"
which m#st be preser$ed and enhanced by n#rses.
@+ /onser$ation of So)ial interit: . The so)ial interit: of the )lient refle)ts the fa%il: and the
)o%%"nit: in which the client f#nctions. Health care instit#tions may separate indi$id#als from
their family. It is important for n#rses to consider the indi$id#al in the conte+t of the family.
F+ 'OHNSON3 DOROTHB -14F53 14=5.
%oc#ses on how the client adapts to illness2 the oal of n#rsin is to red#ce stress so that the
client can mo$e more easily thro#h reco$ery.
Giewed the patient!s beha$ior as a system" which is a whole with interactin parts.
The n"rsin pro)ess is $iewed as a %aGor tool+
.oncept#ali(ed the ,eha$ioral System Model. 3ccordin to -ohnson" each person as a beha$ioral
system is composed of se$en s#bsystems namelyE
1+ Inesti$e+ 7a<in in no#rishment in socially and c#lt#rally acceptable ways.
?+ Eli%inated+ Riddlin the body of waste in socially and c#lt#rally acceptable ways+
<+ Affiliati$e+ Sec#rity see<in beha$ior+
@+ Aressi$e+ Self * protecti$e beha$ior+
C+ Dependen)e+ >#rt#rance * see<in beha$ior.
F+ A)hie$e%ent+ Master of oneself and one!s en$ironment accordin to internali(ed standards of
e+cellence.
6+ SeA"al role identit: beha$ior
G+ ROGERS3 MARTHA
.onsiders man as a #nitary h#man bein co;e+istin with in the #ni$erse" $iews n#rsin
primarily as a science and is committed to n#rsin research.
H+ OREM3 DOROTHEA -14653 14=C.
0mphasi(es the client!s self7)are needs" n#rsin care becomes necessary when client is #nable to
f#lfill bioloical" psycholoical" de$elopmental or social needs.
6e$eloped the Self7/are Defi)it Theor:. She defined self;care as ?the practice of acti$ities that
indi$id#als initiate to perform on their own behalf in maintainin life" health well;bein.@ She
concept#ali(ed three systems as followsE
1. >holl: /o%pensator:E when the n#rse is e+pected to accomplish all the patient!s
therape#tic self;care or to compensate for the patient!s inability to enae in self care or
when the patient needs contin#o#s #idance in self care2
B. #artiall: /o%pensator:! when both n#rse patient enae in meetin self care needs2
C. S"pporti$e7Ed")ati$eE the system that re:#ires assistance decision ma<in" beha$ior
control and ac:#isition <nowlede and s<ills.
I+ IMOGENE 0ING -14613 14=1.
>#rsin process is defined as dynamic interpersonal process between n#rse" client and
health care system.
#ost"lated the Goal Attain%ent Theor:. She described n#rsin as a helpin profession
that assists indi$id#als and ro#ps in society to attain" maintain" and restore health. If is
this not possible" n#rses help indi$id#als die with dinity.
In addition" Kin $iewed n#rsin as an interaction process between client and n#rse
whereby d#rin percei$in" settin oals" and actin on them transactions occ#rred and
oals are achie$ed.
'+ (ETTB NEUMAN
Stress red#ction is a oal of system model of n#rsin practice. >#rsin actions are in
primary" secondary or tertiary le$el of pre$ention.
0+ SIS /ALLISTA ROB -Adaptation Theor:. -14643 14=@.
Giews the client as an adapti$e system. 7he oal of n#rsin is to help the person adapt to
chanes in physioloical needs" self;concept" role f#nction and interdependent relations
d#rin health and illness.
#resented the Adaptation Model+ She $iewed ea)h person as a "nified
biops:)hoso)ial s:ste% in constant interaction with a chanin en$ironment. She
contented that the person as an adapti$e system" f#nctions as a whole thro#h
interdependence of its part. 7he system consist of inp#t" control processes" o#tp#t
feedbac<.
L+LBDIA HALL -14F?.
7he client is composed of the ff. o$erlappin partsE person (core)" patholoic state and
treatment (c#re) and body (care).
Introd#ced the model of >#rsinE =hat Is ItH" foc#sin on the notion that centers aro#nd
three components of /ARE3 /ORE and /URE+ .are represents n#rt#rance and is
e+cl#si$e to n#rsin. .ore in$ol$es the therape#tic #se of self and emphasi(es the #se of
reflection. .#re foc#ses on n#rsin related to the physician!s orders. .ore and c#re are
shared with the other health care pro$iders.
M+ ;irinia Henderson -14CC.
Introd#ced The Nat"re of N"rsin Model+ She identified fo"rteen basi) needs+
She post#lated that the #ni:#e f#nction of the n#rse is to assist the clients" sic< or well" in the
performance of those acti$ities contrib#tin to health or its reco$ery" the clients wo#ld perform
#naided if they had the necessary strenth" will or <nowlede.
She f#rther belie$ed that n#rsin in$ol$es assistin the client in ainin independence as rapidly
as possible" or assistin him achie$es peacef#l death if reco$ery is no loner possible.
N+ Madaleine Leininer -146=3 14=@.
6e$eloped the Trans)"lt"ral N"rsin Model. She ad$ocated that n#rsin is a h#manistic and
scientific mode of helpin a client thro#h specific c#lt#ral carin processes (c#lt#ral $al#es"
beliefs and practices) to impro$e or maintain a health condition.
O+ Ida 'ean Orlando -14F1.
.oncept#ali(ed The D:na%i) N"rse * #atient Relationship Model+
She belie$ed that the n#rse helps patients meet a percei$ed need that the patient cannot meet for
themsel$es. 1rlando obser$ed that the n#rse pro$ides direct assistance to meet an immediate
need for help in order to a$oid or to alle$iate distress or helplessness.
She emphasi(ed the importance of $alidatin the need and e$al#atin care based on obser$able
o#tcomes.
#+ Ernestine >eidanba)h -14F@.
6e$eloped the Clinical Nursing A Helping Art Model.
She ad$ocated that the n#rse!s indi$id#al philosophy or central p#rpose lends credence to
n#rsin care.
She belie$ed that n#rses meet the indi$id#al!s need for help thro#h the identification of the
needs" administration of help" and $alidation that actions were helpf#l. .omponents of clinical
practiceE 9hilosophy" p#rpose" practice and an art.
8+ 'ean >atson -14647144?.
Introd#ced the theory of Human Becoming. She emphasi(ed free choice of personal meanin in
relatin $al#e priorities" co * creatin the rhythmical patterns" in e+chane with the en$ironment"
and co transcendin in many dimensions as possibilities #nfold.
R+ 'o:)e Tra$elbee -14FF31461.
She post#lated the Interpersonal Aspe)ts of N"rsin Model+ She ad$ocated that the oal of
n#rsin indi$id#al or family in pre$entin or copin with illness" reainin health findin
meanin in illness" or maintainin ma+imal deree of health.
She f#rther $iewed that interpersonal process is a h#man;to;h#man relationship formed d#rin
illness and ?e+perience of s#fferin@
She belie$ed that a person is a #ni:#e" irreplaceable indi$id#al who is in a contin#o#s process of
becomin" e$ol$in and chanin.
S+ 'osephine #eterson and Loretta Hderad -146F.
9ro$ided the H"%anisti) N"rsin #ra)ti)e Theor:. 7his is based on their belief that n#rsin is
an e+istential e+perience.
>#rsin is $iewed as a li$ed dialo#e that in$ol$es the comin toether of the n#rse and the
person to be n#rsed.
7he essential characteristic of n#rsin is n#rt#rance. H#manistic care cannot ta<e place witho#t
the a#thentic commitment of the n#rse to bein with and the doin with the client. H#manistic
n#rsin also pres#pposes responsible choices.
T+ Helen Eri)&son3 E$el:n To%lin3 and Mar: Ann Swain -14=<.
6e$eloped Modelin and Role Modelin Theor: . 7he foc#s of this theory is on the person. 7he
n#rse models (assesses)" role models (plans)" and inter$enes in this interpersonal and interacti$e
theory.
7hey asserted that each indi$id#al #ni:#e" has some self;care <nowlede" needs sim#ltaneo#sly
to be attached to the separate from others" and has adapti$e potential. >#rses in this theory"
facilitate" n#rt#re and accept the person #nconditionally.
U+ Mararet New%an
%oc#sed on health as eApandin )ons)io"sness. She belie$ed that h#man are #nitary in whom
disease is a manifestation of the pattern of health.
She defined conscio#sness as the information capability of the system which is infl#enced by
time" space mo$ement and is e$er * e+pandin.
;+ #atri)ia (enner and '"dith >r"del (14)4)
9roposed the #ri%a): and /arin Model+ 7hey belie$ed that carin central to the essence of
n#rsin. .arin creates the possibilities for copin and creates the possibilities for connectin
with and concern for others.
>+ Anne (o:&in and Sa$ina S)hoenhofer
9resented the rand theor: of N"rsin as /arin. 7hey belie$ed that all person are carin" and
n#rsin is a response to a #ni:#e social call. 7he foc#s of n#rsin is on n#rt#rin person li$in
and rowin in carin in a manner that is specific to each n#rse;n#rsed relationship or n#rsin
sit#ation. 0ach n#rsin sit#ation is oriinal.
7hey s#pport that carin is a moral imperati$e. >#rsin as .arin is not based on need or deficit
b#t is ealitarian model helpin.
Moral Theories
1+ Fre"d -14F1.
,elie$ed that the mechanism for riht and wron within the indi$id#al is the s"pereo3
or )ons)ien)e . He hypnoti(ed that a child internali(es and adopts the moral standards and
character or character traits of the model parent thro#h the process of identification.
7he strenth of the s#pereo depends on the intensity of the child!s feelin of aression
or attachment toward the model parent rather than on the act#al standards of the parent.
?+ Eri&son -14F@.
0ri<son!s theory on the de$elop%ent of $irt"es or #nifyin strenths of the ?ood man@
s#est that moral de$elopment contin#o#s thro#ho#t life. He belie$ed that if the
conflicts of each psychosocial de$elopmental staes fa$orably resol$ed" then an Ieo;
strenth@ or $irt#e emeres.
<+ 0ohlber
S#ested three le$els of moral de$elopment. He foc#sed on the reason for the ma<in of
a decision" not on the morality of the decision itself.
1+ At first le$el )alled the pre%olar or the pre)on$entional le$el3 children are responsi$e to
c#lt#ral r#les and labels of ood and bad" riht and wron. Howe$er children interpret these in
terms of the physical conse:#ences of the actions" i.e." p#nishment or reward.
?+ At the se)ond le$el3 the )on$entional le$el3 the indi$id#al is concerned abo#t maintainin the
e+pectations of the family" ro#ps or nation and sees this as riht.
<+ At the third le$el3 people ma<e postcon$entional" a#tonomo#s" or principal le$el. 3t this le$el"
people ma<e an effort to define $alid $al#es and principles witho#t reard to o#tside a#thority or
to the e+pectations of others. 7hese in$ol$e respect for other h#man and belief that relationship
are based on %"t"al tr"st+
#eter -14=1.
9roposed a concept of rational %oralit: based on prin)iples+ Moral de$elopment is
#s#ally considered to in$ol$e three separate componentsE moral emotion (what one feels)"
moral 8#dment (how one reasons)" and moral beha$ior (how one acts).
In addition" 9eters belie$ed that the de$elopment of )hara)ter traits or $irt"es is an
essential aspe)t or %oral de$elop%ent+ 3nd that $irt#es or character traits can be
learned from others and enco#raed by the e+ample of others.
3lso" 9eters belie$ed that some can be described as habits beca#se they are in some sense
a#tomatic and therefore are performed habit#ally" s#ch as politeness" chastity" tidiness"
thrift and honesty.
Gillian -14=?.
Incl#ded the )on)epts of )arin and responsibilit:+ She described three staes in the process of
de$elopin an ?0thic of .are@ which are as follows.
1. .arin for oneself.
B. .arin for others.
C. .arin for self and others.
She belie$ed the h"%an see %oralit: in the interit: of relationships and )arin+ %or women"
what is riht is ta<in responsibility for others as self;chosen decision. 1n the other hand" %en
)onsider what is riht to be what is G"st+
Spirit"al Theories
Fowler -1464.
6escribed the de$elopment of faith. He belie$ed that faith" or the spirit#al dimension is a force
that i$es meanin to a person!s life.
He #sed the term ?faith@ as a form of <nowin a way of bein in relation ?to an #ltimate
en$ironment.@ 7o %owler" faith is a relational phenomenonE it is ?an acti$e made;of;bein;in;
relation to others in which we in$est commitment" belief" lo$e" ris< and hope.@
ROLES AND FUN/TIONS OF THE NURSE
/are i$er
De)ision7%a&er
#rote)tor
/lient Ad$o)ate
Manaer
Rehabilitator
/o%forter
/o%%"ni)ator
Tea)her
/o"nselor
/oordinator
Leader
Role Model
Ad%inistrator
Sele)ted EApanded /areer Roles of N"rses
1+ N"rse #ra)titioner
3 n#rse who has an ad$anced ed#cation and is a rad#ate of a n#rse practitioner proram.
7hese n#rses are in areas as ad#lt n#rse practitioner" family n#rse practitioner" school
n#rse practitioner" pediatric n#rse practitioner" or erontoloy n#rse practitioner.
7hey are employed in health care aencies or comm#nity based settins. 7hey #s#ally
deal with non;emerency ac#te or chronic illness and pro$ide primary amb#latory care.
?+ /lini)al N"rse Spe)ialist
3 n#rse who has an ad$anced deree or e+pertise and is considered to be an e+pert in a
speciali(ed area of practice (e.." erontoloy" oncoloy).
7he n#rse pro$ides direct client care" ed#cates others" cons#lts" cond#cts research" and manaes
care.
7he 3merican >#rses .redentialin .enter pro$ides national certification of clinical specialists.
<+ N"rse Anesthetist
3 n#rse who has completed ad$anced ed#cation in an accredited proram in anesthesioloy.
7he n#rse anesthetist carries o#t pre;operati$e $isits and assessments" and 3dministers eneral
anesthetics for s#rery #nder the s#per$ision of a physician prepared in anesthesioloy.
7he n#rse anesthetist also assesses the postoperati$e of clients
@+ N"rse Midwife
3n R> who has completed a proram in midwifery.
7he n#rse i$es pre;natal and post;natal care and manaes deli$eries in normal prenancies.
7he midwife practices the association with a health care aency and can obtain medical ser$ices
if complication occ#rs.
7he n#rse midwife may also cond#ct ro#tine 9apanicolao# smears" family plannin" and ro#tine
breast e+amination.
C+ N"rse Ed")ator
>#rse ed#cator is employed in n#rsin prorams" at ed#cational instit#tions" and in hospital staff
ed#cation.
7he n#rse ed#cator #s#ally ha a baccala#reate deree or more ad$anced preparation and
fre:#ently has e+pertise in a partic#lar area of practice. The n"rse ed")ator is responsible for
)lassroo% and of ten )lini)al tea)hin+
F+ N"rse Entreprene"r
3 n#rse who #s#ally has an ad$anced deree and manaes a health;related b#siness.
7he n#rse may be in$ol$ed in ed#cation" cons#ltation" or research" for e+ample.
/OMMUNI/ATION IN NURSING
/OMMUNI/ATION
1. Is the means to establish a helpin;healin relationships. 3ll beha$ior comm#nication infl#ences
beha$ior.
B. .omm#nication is essential to the n#rse;patient relationship for the followin reasonsE
C. Is the $ehicle for establishin a therape#tic relationship.
A. It the means by which an indi$id#al infl#ences the beha$ior of another" which leads to the
s#ccessf#l o#tcome of n#rsin inter$ention.
(asi) Ele%ents of the /o%%"ni)ation #ro)ess
1. S0>60R * is the person who encodes and deli$ers the messae
B. M0SS3&0S * is the content of the comm#nication. It may contain $erbal" non$erbal" and
symbolic lan#ae.
C. R0.0IG0R * is the person who recei$es the decodes the messae.
A. %006,3.K * is the messae ret#rned by the recei$er. It indicates whether the meanin of the
sender!s messae was #nderstood.
Modes of /o%%"ni)ation
1. ;erbal /o%%"ni)ation * #se of spo<en or written words.
B. Non$erbal /o%%"ni)ation * #se of est#res" facial e+pressions" post#reFait" body
mo$ements" physical appearance and body lan#ae
/hara)teristi)s of Good /o%%"ni)ation
1. Si%pli)it: * incl#des #ses of commonly #nderstood" bre$ity" and completeness.
B. /larit: * in$ol$es sayin what is meant. 7he n#rse sho#ld also need to spea< slowly and
en#nciate words well.
C. Ti%in and Rele$an)e * re:#ires choice of appropriate time and consideration of the client!s
interest and concerns. 3s< one :#estion at a time and wait for an answer before ma<in another
comment.
A. .haracteristics of &ood .omm#nication
5. Adaptabilit: * In$ol$es ad8#stments on what the n#rse says and how it is said dependin on the
moods and beha$ior of the client.
/. /redibilit: * Means worthiness of belief. 7o become credible" the n#rse re:#ires ade:#ate
<nowlede abo#t the topic bein disc#ssed. 7he n#rse sho#ld be able to pro$ide acc#rate
information" to con$ey confidence and certainly in what she says.
/o%%"ni)atin >ith /lients >ho Ha$e Spe)ial Needs
1+/lients who )annot spea& )learl: -aphasia3 d:sarthria3 %"teness.
1. 'isten attenti$ely" be patient" and do not interr#pt.
B. 3s< simple :#estion that re:#ire ?yes@ and ?no@ answers.
C. 3llow time for #nderstandin and response.
A. Dse $is#al c#es (e.." words" pict#res" and ob8ects)
5. 3llow only one person to spea< at a time.
/. 6o not sho#t or spea< too lo#dly.
7. Dse comm#nication aidE
;pad and felt;tipped pen" maic slate" pict#res denotin basic needs" call bells or alarm.
?+ /lients who are )oniti$el: i%paired
1. Red#ce en$ironmental distractions while con$ersin.
B. &et client!s attention prior to spea<in
C. Dse simple sentences and a$oid lon e+planation.
A. 3s< one :#estion at a time
5. 3llow time for client to respond
/. ,e an attenti$e listener
7. Incl#de family and friends in con$ersations" especially in s#b8ects <nown to client.
C. /lient who are "nresponsi$e
1. .all client by name d#rin interactions
B. .omm#nicate both $erbally and by to#ch
C. Spea< to client as tho#h he or she co#ld hear
A. 0+plain all proced#res and sensations
5. 9ro$ide orientation to person" place" and time
/. 3$oid tal<in abo#t client to others in his or her presence
7. 3$oid sayin thins client sho#ld not hear
A. /o%%"ni)atin with hearin i%paired )lient
1. 0stablish a method of comm#nication (penFpencil and paper" sin;lan#ae)
B. 9ay attention to client!s non;$erbal c#es
C. 6ecrease bac<ro#nd noise s#ch as tele$ision
A. 3lways face the client when spea<in
5. It is also important to chec< the family as to how to comm#nicate with the client
/. It may be necessary to contact the appropriate department reso#rce person for this type of
disability
@+ /lient who do not spea& Enlish
1. Spea< to client in normal tone of $oice (sho#tin may be interpreted as aner)
B. 0stablish method for client o sinal desire to comm#nicate (call liht or bell)
C. 9ro$ide an interpreter (translator) as needed
A. 3$oid #sin family members" especially children" as interpreters.
5. 6e$elop comm#nication board" pict#res or cards.
/. Ha$e dictionary (0nlishFSpanish) a$ailable if client can read.
Reports
3re oral "written" or a#diotaped e+chanes of information between carei$ers.
/o%%on reports!
1. .hane;in;shift report
B. 7elephone report
C. 7elephone or $erbal order * only R>!s are allowed to accept telephone orders.
A. 7ransfer report
5. Incident report
Do)"%entation
1. Is anythin written or printed that is relied on as record or proof for a#thori(ed person.
B. >#rsin doc#mentation m#st beE
C. acc#rate
A. comprehensi$e
5. fle+ible eno#h to retrie$e critical data" maintain contin#ity of care" trac< client o#tcomes" and
reflects c#rrent standards of n#rsin practice
/. 0ffecti$e doc#mentation ens#res contin#ity of care" sa$es time and minimi(es the ris< of error.
7. 3s members of the health care team" n#rses need to comm#nicate information abo#t clients
acc#rately and in timely manner
). If the care plan is not comm#nicated to all members of the health care team" care can become
framented" repetition of tas<s occ#rs" and therapies may be delayed or omitted.
4. 6ata recorded" reported" or c5mm#nicated to other health care professionals are
.1>%I60>7I3' and m#st be protected.
/ONFIDENTIALITB
1. n#rses are leally and ethically obliated to <eep information abo#t clients confidential.
B. >#rses may not disc#ss a client!s e+amination" obser$ation" con$ersation" or treatment with other
clients or staff not in$ol$ed in the client!s care.
C. Onl: staff dire)tl: in$ol$ed in a spe)ifi) )lient2s )are ha$e leiti%ate a))ess to the re)ord+
A. .1>%I60>7I3'I7J
5. .lients fre:#ently re:#est copies of their medical record" and they ha$e the riht to read those
records.
/. >#rses are responsible for protectin records from all #na#thori(ed readers.
7. when n#rses and other health care professionals ha$e a leitimate reason to #se records for data
atherin" research" or contin#in ed#cation" appropriate a#thori(ation m#st be obtained
accordin to aency policy.
). .onfidentiality
4. Maintainin confidentiality is an important aspect of profession beha$ior.
15. It is essential that the n#rse safe;#ard the client! riht to pri$acy by caref#lly protectin
information of a sensiti$e" pri$ate nat#re.
11. Sharin personal information or ossipin abo#t others $iolates n#rsin ethical codes and
practice standards.
1B. It sends the messae that the n#rse cannot be tr#sted and damaes the interpersonal relationships.
G"idelines of 8"alit: Do)"%entation and Reportin
1+Fa)t"al
1. a record m#st contain descripti$e" ob8ecti$e information abo#t what a n#rse sees" hears" feels"
and smells.
B. 7he #se of $a#e terms" s#ch as appears, seems, and apparently " is not acceptable beca#se these
words s#ests that the n#rse is statin an opinion.
0+ampleE ? the client seems an+io#s@ (the phrase seems an+io#s is a concl#sion witho#t
s#pported facts.)
?+ A))"rate
1. 7he #se of e+act meas#rements establishes acc#racy. (e+ampleE ?Inta<e of C55 ml of water@ is
more acc#rate than ? the client dran< an ade:#ate amo#nt of fl#id@
B. 6oc#mentation of concise data is clear and easy to #nderstand.
C. It is essential to a$oid the #se of #nnecessary words and irrele$ant details
<+ /o%plete
1. 7he information within a recorded entry or a report needs to be complete" containin appropriate
and essential information.
0+ampleE
7he client $erbali(es sharp" throbbin pain locali(ed alon lateral side of riht an<le"
beinnin appro+imately 15 min#tes ao after twistin his foot on the stair. .lient rates
pain as ) on a scale of 5;15.
@+ /"rrent
1. 7imely entries are essential in the clients onoin care. 7o increase acc#racy and decrease
#nnecessary d#plication" many healthcare aencies #se records <ept near the client!s bedside" which
facilitate immediate doc#mentation of information as it is collected from a client
C+ Orani9ed
1. 7he n#rse comm#nicates information in a loical order.
%or e+ample" an orani(ed note describes the client!s pain" n#rse!s assessment" n#rse!s
inter$entions" and the client!s response
Leal G"idelines for re)ordin
1. 6raw sinle line thro#h error" write word error abo$e it and sin yo#r name or initials. 7hen
record note correctly.
B. 6o not write retaliatory or critical comments abo#t the client or care by other health care
professionals.
0nter only ob8ecti$e descriptions of client!s beha$ior2 client!s comments sho#ld be :#oted.
C. .orrect all errors promptly
errors in recordin can lead to errors in treatment
3$oid r#shin to complete chartin" be s#re information is acc#rate.
A. 6o not lea$e blan< spaces in n#rse!s notes.
.hart consec#ti$ely" line by line2 if space is left" draw line hori(ontally thro#h it and sin
yo#r name at end.
5. Record all entries leibly and in blan< in<
>e$er #se pencil" felt pen.
,lan< in< is more leible when records are photocopied or transferred to microfilm.
'eal &#idelines for Recordin
/. If order is :#estioned" record that clarification was so#ht.
If yo# perform orders <nown to be incorrect" yo# are 8#st as liable for prosec#tion as the
physician is.
7. .hart only for yo#rself
>e$er chart for someone else.
Jo# are acco#ntable for information yo# enter into chart.
). 3$oid #sin enerali(ed" empty phrases s#ch as ?stat#s #nchaned@ or ?had ood day@.
,ein each entry with time" and end with yo#r sinat#re and title.
6o not wait #ntil end of shift to record important chanes that occ#rred se$eral ho#rs earlier.
,e s#re to sin each entry.
4. %or comp#ter doc#mentation <eep yo#r password to yo#rself.
maintain sec#rity and confidentiality.
1nce loed into the comp#ter do not lea$e the comp#ter screen #nattended.
Assessin ;ital Sins
Gital Sins or .ardinal Sins areE
,ody temperat#re
9#lse
Respiration
,lood press#re
9ain
I+ (od: Te%perat"re
7he balance between the heat prod#ced by the body and the heat loss from the body.
7ypes of ,ody 7emperat#re
.ore temperat#re *temperat#re of the deep tiss#es of the body.
S#rface body temperat#re
Alteration in bod: Te%perat"re
Pyrexia * ,ody temperat#re abo$e normal rane( hyperthermia)
H:perp:reAia * Gery hih fe$er" A1K.(155.) %) and abo$e
H:pother%ia * S#bnormal temperat#re.
Nor%al Ad"lt Te%perat"re Ranes
Oral C/.5 *C7.5 K.
AAillar: C5.) * C7.5 K.
Re)tal C7.5 * C).1 K.
T:%pani) C/.) * C7.4K.
Methods of Te%perat"re7Ta&in
1. Oral * most accessible and con$enient method.
a. 9#t on lo$es" and position the tip of the thermometer #nder the patients ton#e on either
of the fren#l#n as far bac< as possible. It promotes contact to the s#perficial blood
$essels and ens#re a more acc#rate readin.
b. =ash thermometer before #se.
c. 7a<e oral temp B;C min#tes.
d. 3llow 15 min to elapse between client!s food inta<e of hot or cold food" smo<in.
e. Instr#ct the patient to close his lips b#t not to bite down with his teeth to a$oid brea<in
the thermometer in his mo#th.
/ontraindi)ations
Jo#n children an infants
9atients who are #nconscio#s or disoriented
=ho m#st breath thro#h the mo#th
Sei(#re prone
9atient with >FG
9atients with oral lesionsFs#reries
?+ Re)tal; %ost a))"rate %eas"re%ent of te%perat"re
a. 9osition; lateral position with his top les fle+ed and drape him to pro$ide pri$acy.
b. S:#ee(e the l#bricant onto a facial tiss#e to a$oid contaminatin the l#bricant s#pply.
c. Insert thermometer by 5.5 * 1.5 inches
d. Hold in place in Bmin#tes
e. 6o not force to insert the thermometer
/ontraindi)ations
9atient with diarrhea
Recent rectal or prostatic s#rery or in8#ry beca#se it may in8#re inflamed tiss#e
Recent myocardial infarction
9atient post head in8#ry
<+ AAillar: * safest and non;in$asi$e
a. 9at the a+illa dry
b. 3s< the patient to reach across his chest and rasp his opposite sho#lder. 7his promote s<in
contact with the thermometer
c. Hold it in place for 4 min#tes beca#se the thermometer isn!t close in a body ca$ity
Note!
Dse the same thermometer for repeat temperat#re ta<in to ens#re more consistent res#lt
Store chemical;dot thermometer in a cool area beca#se e+pos#re to heat acti$ates the dye dots.
@+ T:%pani) ther%o%eter
a. Ma<e s#re the lens #nder the probe is clean and shiny
b. Stabili(ed the patient!s head2 ently p#ll the ear straiht bac< (for children #p to ae 1) or #p
and bac< (for children 1 and older to ad#lts)
c. Insert the thermometer #ntil the entire ear canal is sealed
d. 9lace the acti$ation b#tton" and hold it in place for 1 second
C+ /he%i)al7dot ther%o%eter
a. 'ea$e the chemical;dot thermometer in place for A5 seconds
b. Read the temperat#re as the last dye dot that has chane color" or fired.
N"rsin Inter$entions in /lients with Fe$er
a. Monitor G.S
b. 3ssess s<in color and temperat#re
c. Monitor =,." Hct and other pertinent lab records
d. 9ro$ide ade:#ate foods and fl#ids.
e. 9romote rest
f. Monitor I L 1
. 9ro$ide 7S,
h. 9ro$ide dry clothin and linens
i. &i$e antipyretic as ordered by M6
II+ #"lse * It!s the wa$e of blood created by contractions of the left $entricles of the
heart.
Nor%al #"lse rate
1 year )5;1A5 beatsFmin
B years )5; 1C5 beatsFmin
/ years 75; 1B5 beatsFmin
15 years /5;45 beatsFmin
3d#lt /5;155 beatsFmin
Ta)h:)ardia * p#lse rate of abo$e 155 beatsFmin
(rad:)ardia7 p#lse rate below /5 beatsFmin
Irre"lar * "ne$en ti%e inter$al between beats+
=hat yo# needE
a. =atch with second hand
b. Stethoscope (for apical p#lse)
c. 6oppler #ltraso#nd blood flow detector if necessary
Radial 9#lse
a. =ash yo#r hand and tell yo#r client that yo# are oin to ta<e his p#lse
b. 9lace the client in sittin or s#pine position with his arm on his side or across his
chest
c. &ently press yo#r inde+" middle" and rin finers on the radial artery" inside the patient!s wrist.
d. 0+cessi$e press#re may obstr#ct blood flow distal to the p#lse site
e. .o#ntin for a f#ll min#te pro$ides a more acc#rate pict#re of irre#larities
Doppler de$i)e
a. 3pply small amo#nt of transmission el to the #ltraso#nd probe
b. 9osition the probe on the s<in directly o$er a selected artery
c. Set the $ol#me to the lowest settin
d. 7o obtain best sinals" p#t el between the s<in and the probe and tilt the probe A5 derees from
the artery.
e. 3fter yo# ha$e meas#re the p#lse rate" clean the probe with soft cloth soa<ed in antiseptic. 6o
not immerse the probe
III+ Respiration 7 is the e+chane of o+yen and carbon dio+ide between the atmosphere
and the body
Assessin Respiration
Rate * >ormal 1A;B5F min in ad#lt
7he best time to assess respiration is immediately after ta<in client!s p#lse
.o#nt respiration for /5 second
3s yo# co#nt the respiration" assess and record breath so#nd as stridor" whee(in" or stertor.
Respiratory rates of less than 15 or more than A5 are #s#ally considered abnormal and sho#ld be
reported immediately to the physician.
I;+ (lood #ress"re
3d#lt * 45; 1CB systolic
/5; )5 diastolic
0lderly 1A5;1/5 systolic
75;45 diastolic
a. 0ns#re that the client is rested
b. Dse appropriate si(e of ,9 c#ff.
c. If too tiht and narrow; false hih ,9
d. If too lose and wide;false low ,9
e. 9osition the patient on sittin or s#pine position
f. 9osition the arm at the le$el of the heart" if the artery is below the heart le$el" yo# may et a false
hih readin
. Dse the bell of the stethoscope since the blood press#re is a low fre:#ency so#nd.
h. If the client is cryin or an+io#s" delay meas#rin his blood press#re to a$oid false;hih ,9
Ele)troni) ;ital Sin Monitor
a. 3n electronic $ital sins monitor allows yo# to contin#ally tract a patient!s $ital
sin witho#t ha$in to reapply a blood press#re c#ff each time.
b. 0+ampleE 6inamap GS monitor )155
c. 'ihtweiht" battery operated and can be attached to an IG pole
d. ,efore #sin the de$ice" chec< the client7s p#lse and ,9 man#ally #sin the same arm yo#!ll
#sin for the monitor c#ff.
e. .ompare the res#lt with the initial readin from the monitor. If the res#lts differ call the s#pply
department or the man#fact#rer!s representati$e.
;+ #ain
How to assess 9ain
a. Jo# m#st consider both the patient!s description and yo#r obser$ations on his beha$ioral
responses.
b. %irst" as< the client to ran< his pain on a scale of 5;15" with 5 denotin lac< of pain and 15
denotin the worst pain imainable.
c. 3s<E
d. =here is the pain locatedH
e. How lon does the pain lastH
f. How often does it occ#rH
. .an yo# describe the painH
h. =hat ma<es the pain worse
i. 1bser$e the patient!s beha$ioral response to pain (body lan#ae" moanin" rimacin"
withdrawal" cryin" restlessness m#scle twitchin and immobility)
8. 3lso note physioloical response" which may be sympathetic or parasympathetic
Manain #ain
1. &i$in medication as per M6!s order
B. &i$in emotional s#pport
C. 9erformin comfort meas#res
A. Dse coniti$e therapy
Heiht and weiht
a. Heiht and weiht are ro#tinely meas#red when a patient is admitted to a health care facility.
b. It is essential in calc#latin dr# dosae" contrast aents" assessin n#tritional stat#s and
determinin the heiht;weiht ratio.
c. =eiht is the best o$erall indicator of fl#id stat#s" daily monitorin is important for clients
recei$in a di#retics or a medication that ca#ses sodi#m retention.
d. =eiht can be meas#red with a standin scale" chair scale and bed scale.
e. Heiht can be meas#red with the meas#rin bar" standin scale or tape meas#re if the client is
confine in a s#pine position.
#ointers!
a. Reass#re and steady patient who are at ris< for losin their balance on a scale.
b. =eiht the patient at the same time each day. (#s#ally before brea<fast)" in similar clothin and
#sin the same scale.
c. If the patient #ses cr#tches" weih the client with the cr#tches or hea$y clothin and s#btract
their weiht from the total determined patient! weiht.
Laborator: and Dianosti) eAa%ination
I+ Urine Spe)i%en
1+/lean7/at)h %id7strea% #rine specimen for ro#tine #rinalysis" c#lt#re and sensiti$ity test
a. ,est time to collect is in the mornin" first $oided #rine
b. 9ro$ide sterile container
c. 6o perineal care before collection of the #rine
d. 6iscard the first flow of #rine
e. 'abel the specimen properly
f. Send the specimen immediately to the laboratory
. 6oc#ment the time of specimen collection and transport to the lab.
h. 6oc#ment the appearance" odor" and #s#al characteristics of the specimen.
?+ ?@7ho"r "rine spe)i%en
a. 6iscard the first $oided #rine.
b. .ollect all specimen thereafter #ntil the followin day
c. Soa< the specimen in a container with ice
d. 3dd preser$ati$e as ordered accordin to hospital policy
<+ Se)ond7;oided "rine * re:#ired to assess l#cose le$el and for the presence of alb#men in the #rine.
a. 6iscard the first #rine
b. &i$e the patient a lass of water to drin<
c. 3fter few min#tes" as< the patient to $oid
@+ /atheteri9ed "rine spe)i%en
a. .lamp the catheter for C5 min to 1 ho#r to allow #rine to acc#m#late in the bladder and ade:#ate
specimen can be collected.
b. .lampin the drainae t#be and emptyin the #rine into a container are contraindicated after a
enito#rinary s#rery.
II+ Stool Spe)i%en
1+ Fe)al:sis * to assess ross appearance of stool and presence of o$a or parasite
a. Sec#re a sterile specimen container
b. 3s< the pt. to defecate into a clean " dry bed pan or a portable commode.
c. Instr#ct client not to contaminate the specimen with #rine or toilet paper( #rine inhibits bacterial
rowth and paper towel contain bism#th which interfere with the test res#lt.
?+ Stool )"lt"re and sensiti$it: test
7o assess specific etioloic aent ca#sin astroenteritis and bacterial sensiti$ity to $ario#s
antibiotics.
<+ Fe)al O))"lt blood test
are $al#able test for detectin occ#lt blood (hidden) which may be present in colo;rectal cancer"
detectin melena stool
a. Hematest; (an 1rthotolidin reaent tablet)
b. Hemocc#lt slide; (filter paper imprenated with #aiac)
,oth test prod#ces bl#e reaction id occ#lt blood lost e+ceeds 5 ml in BA ho#rs.
c. .olocare * a newer test" re:#ires no smear
Instr")tions!
a. 3d$ise client to a$oid inestion of red meat for C days
b. 9atient is ad$ise on a hih resid#e diet
c. a$oid dar< food and bism#th compo#nd
d. If client is on iron therapy" inform the M6
e. Ma<e s#re the stool in not contaminated with #rine" soap sol#tion or toilet paper
f. 7est sample from se$eral portion of the stool.
;enip"n)t"re
#ointers
a. >e$er collect a $eno#s sample from the arm or a le that is already bein #se d for I.G therapy or
blood administration beca#se it mat affect the res#lt.
b. >e$er collect $eno#s sample from an infectio#s site beca#se it may introd#ce pathoens into the
$asc#lar system
c. >e$er collect blood from an edemato#s area" 3G sh#nt" site of pre$io#s hematoma" or $asc#lar
in8#ry.
d. 6on!t wipe off the po$idine;iodine with alcohol beca#se alcohol cancels the effect of po$idine
iodine.
e. If the patient has a clottin disorder or is recei$in anticoa#lant therapy" maintain press#re on
the site for at least 5 min after withdrawin the needle.
Arterial p"n)t"re for A(G test
a. ,efore arterial p#nct#re" perform 3llen!s test first.
b. If the patient is recei$in o+yen" ma<e s#re that the patient!s therapy has been #nderway for at
least 15 min before collectin arterial sample
c. ,e s#re to indicate on the laboratory re:#est slip the amo#nt and type pf o+yen therapy the
patient is ha$in.
d. If the patient has 8#st recei$e a neb#li(er treatment" wait abo#t B5 min#tes before collectin the
sample.
I;+ (lood spe)i%en
a. >o fastin for the followin testsE
; .,." Hb" Hct" clottin st#dies" en(yme st#dies" ser#m electrolytes
b. %astin is re:#iredE
; %,S" ,D>" .reatinine" ser#m lipid ( cholesterol" trilyceride)
;+ Sp"t"% Spe)i%en
1+Gross appearan)e of the sp"t"%
a. .ollect early in the mornin
b. Dse sterile container
c. Rinse the mo#nt with plain water before collection of the specimen
d. Instr#ct the patient to hac<;#p sp#t#m
B. Sp"t"% )"lt"re and sensiti$it: test
a. Dse sterile container
b. .ollect specimen before the first dose of antibiotic
<+ A)id7Fast (a)illi
a. 7o assess presence of acti$e p#lmonary t#berc#losis
b. .ollect sp#t#m in three consec#ti$e mornin
@+ /:toloi) sp"t"% eAa%7
;to assess for presence of abnormal or cancer cells.
Dianosti) Test
1+ ##D test
a. read res#lt A) * 7B ho#rs after in8ection.
b. %or HIG positi$e clients" ind#ration of 5 mm is considered positi$e
?+ (ron)horaph:
a. Sec#re consent
b. .hec< for alleries to seafood or iodine or anesthesia
c. >91 /;) ho#rs before the test
d. >91 #ntil a refle+ ret#rn to pre$ent aspiration
<+ Thora)entesis * aspiration of fl#id in the ple#ral space.
a. Sec#re consent" ta<e GFS
b. 9osition #priht leanin on o$erbed table
c. 3$oid co#h d#rin insertion to pre$ent ple#ral perforation
d. 7#rn to #naffected side after the proced#re to pre$ent lea<ae of fl#id in the thoracic ca$ity
e. .hec< for e+pectoration of blood. 7his indicate tra#ma and sho#ld be reported to M6
immediately.
@+Holter Monitor
a. it is contin#o#s 0.& monitorin" o$er BA ho#rs period
b. 7he portable monitorin is called telemetry #nit
C+ E)ho)ardiora% *
a. #ltraso#nd to assess cardiac str#ct#re and mobility
b. .lient sho#ld remain still" in s#pine position slihtly t#rned to the left side" with H1, ele$ated
15;B5 derees
F+ Ele)tro)ardioraph:7
a. If the patient!s s<in is oily" scaly" or diaphoretic" r#b the electrode with a dry A+A a#(e to
enhance electrode contact.
b. If the area is e+cessi$ely hairy" clip it
c. Remo$e clientMs 8ewelry" coins" belt or any metal
d. 7ell client to remain still d#rin the proced#re
6+ /ardia) /atheteri9ation
a. Sec#re consent
b. 3ssess allery to iodine" shelfish
c. GFS" weiht for baseline information
d. Ha$e client $oid before the proced#re
e. Monitor 97" 977" 0.& prior to test
f. >91 for A;/ ho#rs before the test
. Sha$e the roin or brachial area
h. 3fter the proced#reE bed rest to pre$ent bleedin on the site" do not fle+ e+tremity
i. 0le$ate the affected e+tremities on e+tended position to promote blood s#pply bac< to the heart
and pre$ent thrombplebities
8. Monitor GFS especially peripheral p#lses
<. 3pply press#re dressin o$er the p#nct#re site
l. Monitor e+tremity for color" temperat#re" tinlin to assess for impaired circ#lation.
=+ MRI
m. sec#re consent"
n. the proced#re will last A5;/5 min#te
o. 3ssess client for cla#strophobia
p. Remo$e all metal items
:. .lient sho#ld remain still
r. 7ell client that he will feel nothin b#t may hear noises
s. .lient with pacema<er" prosthetic $al$es" implanted clips" wires are not eliible for MRI.
t. .lient with cardiac and respiratory complication may be e+cl#ded
#. Instr#ct client on feelin of warmth or shortness of breath if contrast medi#m is #sed d#rin the
proced#re
4+UGIS * (ari"% Swallow
a. instr#ct client on low;resid#e diet 1;C days before the proced#re
b. administer la+ati$e e$enin before the proced#re
c. >91 after midniht
d. instr#ct client to drin< a c#p of fla$ored bari#m
e. +;rays are ta<en e$ery C5 min#tes #ntil bari#m ad$ances thro#h the small bowel
f. film can be ta<en as lon as BA ho#rs later
. force fl#id after the test to pre$ent constipationFbari#m impaction
15+LGIS * (ari"% Ene%a
a. instr#ct client on low;resid#e diet 1;C days before the proced#re
b. administer la+ati$e e$enin before the proced#re
c. >91 after midniht
d. administer s#ppository in 3M
e. 0nema #ntil clear
f. force fl#id after the test to pre$ent constipationFbari#m impaction
11+ Li$er (iops:
a. Sec#re consent"
b. >91 B;A hrs before the test
c. Monitor 97" Git K at bedside
d. 9lace the client in s#pine at the riht side of the bed
e. Instr#ct client to inhale and e+hale deeply for se$eral times and then e+hale and hold breath
while the M6 insert the needle
f. Riht lateral post proced#re for A ho#rs to apply press#re and pre$ent bleedin
. ,ed rest for BA ho#rs
h. 1bser$e for SFS of peritonitis
1?+ #ara)entesis
a. Sec#re consent" chec< GFS
b. 'et the patient $oid before the proced#re to pre$ent p#nct#re of the bladder
c. .hec< for ser#m protein. e+cessi$e loss of plasma protein may lead to hypo$olemic shoc<.
1<+ L"%bar #"n)t"re
a. obtain consent
b. instr#ct client to empty the bladder and bowel
c. position the client in lateral rec#mbemt with bac< at the ede of the e+aminin table
d. instr#ct client to remain still
e. obtain specimen per M6s order
NURSING #RO/EDURES
1+ Stea% Inhalation
a. It is dependent n#rsin f#nction.
b. Heat application re:#ires physician!s order.
c. 9lace the spo#t 1B;1) inches away from the client!s nose or ad8#st the distance as necessary.
?+ S")tionin
a. 3ssess the l#ns before the proced#re for baseline information.
b. 9ositionE conscio#s * semi;%owler!s
c. Dnconscio#s * lateral position
d. Si(e of s#ction catheter; ad#lt; fr 1B;1)
e. Hyper o+yenate before and after proced#re
f. 1bser$e sterile techni:#e
. 3pply s#ction d#rin withdrawal of the catheter
h. Ma+im#m time per s#ctionin *15 sec
<+ Nasoastri) Feedin -astri) a$ae.
InsertionE
a. %owler!s position
b. 7ip of the nose to tip of the earlobe to the +yphoid
T"be Feedin
a. Semi;%owler!s position
b. 3ssess t#be placement
c. 3ssess resid#al feedin
d. Heiht of feedin is 1B inches abo$e the t#be!s point of insertion
e. 3s< client to remain #priht position for at least C5 min.
f. Most common problem of t#be feedin is 6iarrhea d#e to lactose intolerance
@+ Ene%a
a. .hec< M6!s order
b. 9ro$ide pri$acy
c. 9osition left lateral
d. Si(e of t#be %r. BB;CB
e. Insert C;A inches of rectal t#be
f. If abdominal cramps occ#r" temporarily stop the flow #ntil cramps are one.
. Heiht of enema can * 1) inches
C+ Urinar: /atheteri9ation
a. Gerify M6!s order
b. 9ractice strict asepsis
c. 9erineal care before the proced#re
d. .atheter si(eE male;1A;1/ " female * 1B * 1A
e. 'enth of catheter insertion
male * /;4 inches "female * C;A inches
For retention )atheter!
Male *anchor laterally or #pward o$er the lower abdomen to pre$ent penoscrotal press#re
%emale; inner aspect of the thih
F+ (ed (ath
a. 9ro$ide pri$acy
b. 0+pose" wash and dry one body part a time
c. Dse warm water (115;115 %)
d. =ash from cleanest to dirtiest
e. =ash" rinse" and dry the arms and le #sin 'on" firm stro<es from distal to pro+imal area * to
increase $eno#s ret#rn.
6+ Foot /are
a. Soa<in the feet of diabetic client is no loner recommended
b. .#t nail straiht across
=+ Mo"th /are
a. 0at coarse" fibro#s foods (cleansin foods) s#ch as fresh fr#its and raw $eetables
b. 6ental chec< e$ery / mo#nts
4+ Oral )are for "n)ons)io"s )lient
a. 9lace in side lyin position
b. Ha$e the s#ction apparat#s readily a$ailable
15+ Hair Sha%poo
c. 9lace client diaonally in bed
d. .o$er the eyes with wash cloth
e. 9l# the ears with cotton balls
f. Massae the scalp with the fatpads of the finers to promote circ#lation in the scalp.
11+ Restraints
. Sec#re M6!s order for each episode of restraints application.
h. .hec< circ#lation e$ery 15 min
i. Remo$e restraints at least e$ery B ho#rs for C5 min#tes
Nor%al ;al"es
(leedin ti%e 174 %in
#rothro%bin ti%e 1571< se)
He%ato)rit Male @?7C?I
Fe%ale <F7@=I
He%olobin %ale 1<+C71F Edl
fe%ale 1?71F Edl
#latelet 1C53557 @553555
R(/ %ale @+C7F+? %illionEL
fe%ale @+?7C+@ %illionEL
A%:lase =571=5 IUEL
(ilir"bin-ser"%. dire)t 575+@ %Edl
indire)t 5+?75+= %Edl
total 5+<71+5 %Edl
pH 6+<C7 6+@C
#a/o? <C7@C
H/O< ??7?F %E,EL
#a O? =57155 %%H
SaO? 4@7155I
Sodi"% 1<C7 1@C %E,EL
#otassi"% <+C7 C+5 %E,EL
/al)i"% @+?7 C+C %EdL
/hloride 4=715= %E,EL
Manesi"% 1+C7?+C %Edl
(UN 1 57?5 %Edl
/reatinine 5+@7 1+?
/#07M( %ale C5 *<?C %"E%l
fe%ale C57?C5 %"E%l
Fibrinoen ?557@55 %Edl
F(S =571?5 %Edl
Gl:)os:lated Hb @+576+5I
-HbA1).
Uri) A)id ?+C *= %Edl
ESR %ale 1C7?5 %%Ehr
Fe%ale ?57<5 %%Ehr
/holesterol 1C57 ?55 %Edl
Tril:)eride 1@57?55 %Edl
La)ti) Deh:droenase 1557??C %"E%l
Al&aline phospo&inase <?74? UEL
Alb"%in <+?7 C+C %Edl
/OMMON THERA#EUTI/ DIETS
1+ /LEAR7LI8UID DIET
9#rposeE
relie$e thirst and help maintain fl#id balance.
DseE
post;s#rically and followin ac#te $omitin or diarrhea.
%oods 3llowedE
carbonated be$eraes2 coffee (caffeinated and decaff.)2 tea2 fr#it;fla$ored drin<s2 strained fr#it
8#ices2 clear" fla$ored elatins2 broth" consomme2 s#ar2 popsicles2 commercially prepared clear
li:#ids2 and hard candy.
%oods 3$oidedE
mil< and mil< prod#cts" fr#it 8#ices with p#lp" and fr#it.
?+ FULL7LI8UID DIET
9#rposeE
pro$ide an ade:#ately n#tritio#s diet for patients who cannot chew or who are too ill to do so.
DseE
ac#te infection with fe$er" &I #psets" after s#rery as a proression from clear li:#ids.
%oods 3llowedE
clear li:#ids" mil< drin<s" coo<ed cereals" c#stards" ice cream" sherbets" eno" all strained fr#it
8#ices" creamed $eetable so#ps" p#ddins" mashed potatoes" instant brea<fast drin<s" yo#rt"
mild cheese sa#ce or p#reed meat" and seasonin.
%oods 3$oidedE
n#ts" seeds" cocon#t" fr#it" 8am" and marmalade
SOFT DIET
9#rposeE
pro$ide ade:#ate n#trition for those who ha$e tro#bled chewin.
DseE
patient with no teeth or ill;fittin dent#res2 transition from f#ll;li:#id to eneral diet2 and for
those
who cannot tolerate hihly seasoned" fried or raw foods followin ac#te infections or astrointestinal
dist#rbances s#ch as astric #lcer or cholelithiasis.
%oods 3llowedE
$ery tender minced" ro#nd" ba<ed broiled" roasted" stewed" or creamed beef" lamb" $eal" li$er"
po#ltry" or fish2 crisp bacon or sweet bread2 coo<ed $eetables2 pasta2 all fr#it 8#ices2 soft raw fr#its2
soft bread and cereals2 all desserts that are soft2 and cheeses.
%oods 3$oidedE
coarse whole;rain cereals and bread2 n#ts2 raisins2 cocon#t2 fr#its with small seeds2 fried foods2
hih
fat ra$ies or sa#ces2 spicy salad dressins2 pic<led meat" fish" or po#ltry2 stron cheeses2 brown or
wild rice2 raw $eetables" as well as lima beans and corn2 spices s#ch as horseradish" m#stard" and
cats#p2 and popcorn.
SODIUM7RESTRI/TED DIET
9#rposeE
red#ce sodi#m content in the tiss#e and promote e+cretion of water.
DseE
heart fail#re" hypertension" renal disease" cirrhosis" to+emia of prenancy" and cortisone therapy.
ModificationsE
mildly restricti$e B sodi#m diet to e+tremely restricted B55 m sodi#m diet.
%oods 3$oidedE
table salt2 all commercial so#ps" incl#din bo#illon2 ra$y" cats#p" m#stard" meat sa#ces" and
soy
sa#ce2 b#ttermil<" ice cream" and sherbet2 sodas2 beet reens" carrots" celery" chard" sa#er<ra#t" and
spinach2 all canned $eetables2 fro(en peas2
all ba<ed prod#cts containin salt" ba<in powder" or ba<in soda2 potato chips and popcorn2
fresh or
canned shellfish2 all cheeses2 smo<ed or commercially prepared meats2 salted b#tter or mararine2
bacon" oli$es2 and commercially prepared salad dressins.
RENAL DIET
9#rposeE
control protein" potassi#m" sodi#m" and fl#id le$els in the body.
DseE
ac#te and chronic renal fail#re" hemodialysis.
%oods 3llowedE
hih;bioloical proteins s#ch as meat" fowl" fish" cheese" and dairy prod#cts; rane between B5
and
/5 mFday.
9otassi#m is #s#ally limited to 1555 mFday.
Geetables s#ch as cabbae" c#c#mber" and peas are lowest in potassi#m.
Sodi#m is restricted to 555 mFday.
%l#id inta<e is restricted to the daily $ol#me pl#s 555 m'" which represents insensible water
loss.
%l#id inta<e meas#res water in fr#it" $eetables" mil< and meat.
%oods 3$oidedE
.ereals" bread" macaroni" noodles" spahetti" a$ocados" <idney beans" potato chips" raw fr#it"
yams" soybeans" n#ts" inerbread" apricots" bananas" fis" rapefr#it" oranes" percolated coffee" .oca;
.ola" orane cr#sh" sport drin<s" and brea<fast drin<s s#ch as 7an or 3wa<e
HI&H;9R170I>" HI&H .3R,1HJ6R370 6I07
9#rposeE
to correct lare protein losses and raises the le$el of blood alb#min. May be modified to incl#de
low;
fat" low;sodi#m" and low;cholesterol diets.
DseE
b#rns" hepatitis" cirrhosis" prenancy" hyperthyroidism" monon#cleosis" protein deficiency d#e to
poor
eatin habits" eriatric patient with poor inta<e2 nephritis" nephrosis" and li$er and all bladder
disorder.
%oods 3llowedE
eneral diet with added protein.
%oods 3$oidedE
restrictions depend on modifications added to the diet. 7he modifications are determined by the
patient!s condition.
#URINE7RESTRI/TED DIET
9#rposeE
desined to red#ce inta<e of #ric acid;prod#cin foods.
DseE
hih #ric acid retention" #ric acid renal stones" and o#t.
%oods 3llowedE
eneral diet pl#s B;C :#arts of li:#id daily.
%oods 3$oidedE
cheese containin spices or n#ts" fried es" meat" li$er" seafood" lentils" dried peas and beans"
broth"
bo#illon" ra$ies" oatmeal and whole wheat" pasta" noodles" and alcoholic be$eraes. 'imited
:#antities of meat" fish" and seafood allowed.
(LAND DIET
9#rposeE
pro$ision of a diet low in fiber" ro#hae" mechanical irritants" and chemical stim#lants.
DseE
&astritis" hyperchlorhydria (e+cess hydrochloric acid)" f#nctional &I disorders" astric atony"
diarhhea" spastic constipation" biliary indiestion" and hiat#s hernia.
%oods 3llowedE
$aried to meet indi$id#al needs and food tolerances.
%oods 3$oidedE
fried foods" incl#din es" meat" fish" and sea food2 cheese with added n#ts or spices2
commercially
prepared l#ncheon meats2 c#red meats s#ch as ham2 ra$ies and sa#ces2 raw $eetables2
potato s<ins2 fr#it 8#ices with p#lp2 fis2 raisins2 fresh fr#its2 whole wheats2 rye bread2 bran
cereals2
rich pastries2 pies2 chocolate2 8ams with seeds2 n#ts2 seasoned dressins2 caffeinated coffee2 stron tea2
cocoa2 alcoholic and carbonated be$eraes2 and pepper.
LO>7FAT3 /HOLESTEROL7RESTRI/TED DIET
9#rposeE
red#ce hyperlipedimia" pro$ide dietary treatment for malabsorption syndromes and patients
ha$in
ac#te intolerance for fats.
DseE
hyperlipedimia" atherosclerosis" pancreatitis" cystic fibrosis" spr#e (disease of intestinal tract
characteri(ed by malabsorption)" astrectomy" massi$e resection of small intestine" and cholecystitis.
%oods 3llowedE
nonfat mil<2 low;carbohydrate" low;fat $eetables2 most fr#its2 breads2 pastas2 cornmeal2 lean
meats2
nsat#rated fats
%oods 3$oidedE
remember to a$oid the fi$e .!s of cholesterol; coo<ies" cream" ca<e" cocon#t" chocolate2 whole
mil<
and whole;mil< or cream prod#cts" a$ocados" oli$es" commercially prepared ba<ed oods s#ch as
don#ts and m#ffins" po#ltry s<in" hihly marbled meats
b#tter" ordinary mararines" oli$e oil" lard" p#ddin made with whole mil<" ice cream" candies
with
chocolate" cream" sa#ces" ra$ies and commercially fried foods.
DIA(ETI/ DIET
9#rposeE
maintain blood l#cose as near as normal as possible2 pre$ent or delay onset of diabetic
complications.
DseE
diabetes mellit#s
%oods 3llowedE
choose foods with low lycemic inde+ compose ofE
a. A5;55N carbohydrates
b. C5;C5N fats
c. 15;B5N protein
coffee" tea" broth" spices and fla$orin can be #sed as desired.
e+chane ro#ps incl#deE mil<" $eetable" fr#its" starchFbread" meat (di$ided in lean" medi#m fat"
and
hih fat)" and fat e+chanes.
the n#mber of e+chanes allowed from each ro#p is dependent on the total n#mber of calories
allowed.
non;n#triti$e sweeteners (sorbitol) in moderation with controlled" normal weiht diabetics.
%oods 3$oidedE
concentrated sweets or re#lar soft drin<s.
A/ID AND AL0ALINE DIET
9#rposeE
%#rnish a well balance diet in which the total acid ash is reater than the total al<aline ash each
day.
DseE
Retard the formation of renal calc#li. 7he type of diet chosen depends on laboratory analysis of
the stone.
3cid and al<aline ash food ro#psE
a. 3cid ashE meat" whole rains" es" cheese" cranberries" pr#nes" pl#ms
b. 3l<aline ashE mil<" $eetables" fr#its (e+cept cranberries" pr#nes and pl#ms.)
c. >e#tralE s#ar" fats" be$eraes (coffee" tea)
%oods allowedE
,readsE any" preferably whole rain2 crac<ers2 rolls
.erealsE any" preferable whole rains
6essertsE anel food or s#nshine ca<e2 coo<ies made witho#t ba<in powder or soda2 cornstarch"
p#ddin" cranberry desserts" ice cream" sherbet" pl#m or pr#ne desserts2 rice or tapioca p#ddin.
%atsE any" s#ch as b#tter" mararine" salad dressins" .risco" Spry" lard" salad oil" oli$e oil" ect.
fr#itsE cranberry" pl#ms" pr#nes
Meat" es" cheeseE any meat" fish or fowl" two ser$in daily2 at least one e daily
9otato s#bstit#tesE corn" hominy" lentils" macaroni" noodles" rice" spahetti" $ermicelli.
So#pE broth as desired2 other so#ps from food allowed
SweetsE cranberry and pl#m 8elly2 plain s#ar candy
Miscellaneo#sE cream sa#ce" ra$y" pean#t b#tter" pean#ts" popcorn" salt" spices" $inear"
waln#ts.
Restricted foodsE
no more than the amo#nt allowed each day
1. Mil<E 1 pint daily (may be #sed in other ways than as be$erae)
B. .reamE 1FC c#p or less daily
C. %r#itsE one ser$in of fr#its daily( in addition to the pr#nes" pl#ms and cranberries)
A. GeetableE incl#din potatoesE two ser$ins daily
5. SweetsE .hocolate or candies" syr#ps.
/. Miscellaneo#sE other n#ts" oli$es" pic<les.
HIGH7FI(ER DIET
9#rposeE
Soften the stool
e+ercise diesti$e tract m#scles
speed passae of food thro#h diesti$e tract to pre$ent e+pos#re to cancer;ca#sin aents in
food
lower blood lipids
pre$ent sharp rise in l#cose after eatin.
DseE diabetes" hyperlipedemia" constipation" di$ertic#litis" anticarcinoenics (colon)
%oods 3llowedE
recommended inta<e abo#t / cr#de fiber daily
3ll bran cereal
=atermelon" pr#nes" dried peaches" apple with s<in2 parsnip" peas" br#ssels spro#t" s#nflower
seeds.
LO> RESIDUE DIET
9#rposeE
Red#ce stool b#l< and slow transit time
DseE
,owel inflammation d#rin ac#te di$ertic#litis" or #lcerati$e colitis" preparation for bowel
s#rery"
esophaeal and intestinal stenosis.
%ood 3llowedE
es2 ro#nd or well;coo<ed tender meat" fish" po#ltry2 mil<" cheeses2 strained fr#it 8#ice (e+cept
pr#ne)E coo<ed or canned apples" apricots" peaches" pears2 ripe banana2 strained $eetable 8#iceE
canned" coo<ed" or strained aspara#s" beets" reen beans" p#mp<in" s:#ash" spinach2 white bread2
refined cereals (.ream of =heat)
#RIN/I#LES OF MEDI/ATION ADMINISTRATION
I 7 ?SiA RihtsJ of dr" ad%inistration
1+ The Riht Medi)ation * when administerin medications" the n#rse compares the label of the
medication container with medication form.
7he n#rse does this C timesE
a. ,efore remo$in the container from the drawer or shelf
b. 3s the amo#nt of medication ordered is remo$ed from the container
c. ,efore ret#rnin the container to the storae
?+ Riht Dose *when performin medication calc#lation or con$ersions" the n#rse sho#ld ha$e another
:#alified n#rse chec< the calc#lated dose
<+ Riht /lient * an important step in administerin medication safely is bein s#re the medication is
i$en to the riht client.
a. 7o identify the client correctlyE
b. 7he n#rse chec< the medication administration form aainst the )lient2s identifi)ation bra)elet
and as&s the )lient to state his or her na%e to ens#re the client!s identification bracelet has the
correct information.
@+ RIGHT ROUTE * if a prescriber!s order does nor desinate a ro#te of administration" the n#rse
cons#lt the prescriber. 'i<ewise" if the specified ro#te is not recommended" the n#rse sho#ld alert the
prescriber immediately.
C+ RIGHT TIME
a. the n#rse m#st <now why a medication is ordered for certain times of the day and whether the
time sched#le can be altered
b. each instit#tion has are commended time sched#le for medications ordered at fre:#ent inter$al
c. Medication that m#st act at certain times are i$en priority (e. ins#lin sho#ld be i$en at a
precise inter$al before a meal )
F+ RIGHT DO/UMENTATION *6oc#mentation is an important part of safe medication
administration
a. 7he doc#mentation for the medication sho#ld clearly reflect the client!s name" the name of the
ordered medication"the time" dose" ro#te and fre:#ency
b. Sin medication sheet immediately after administration of the dr#
/LIENT2S RIGHT RELATED TO MEDI/ATION ADMINISTRATION
3 client has the followin rihtsE
a. 7o be informed of the medication!s name" p#rpose" action" and potential #ndesired effects.
b. 7o ref#se a medication reardless of the conse:#ences
c. 7o ha$e a :#alified n#rses or physicians assess medication history" incl#din alleries
d. 7o be properly ad$ised of the e+perimental nat#re of medication therapy and to i$e written
consent for its #se
e. 7o recei$ed labeled medications safely witho#t discomfort in accordance with the si+ rihts of
medication administration
f. 7o recei$e appropriate s#pporti$e therapy in relation to medication therapy
. 7o not recei$e #nnecessary medications
II * #ra)ti)e Asepsis * wash hand before and after preparin the medication to red#ce transfer of
microoranisms.
III * >#rse who administer the medications are responsible for their own action. O#estion any order that
yo# considered incorrect (may be #nclear or appropriate)
I; * ,e <nowledeable abo#t the medication that yo# administer
KA FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS! KNE;ER ADMINISTER
AN UNFAMILIAR MEDI/ATION@
; * Keep the >arcotics in loc<ed place.
;I* Dse only medications that are in clearly labeled containers. Relabellin of dr#s are the
responsibility of the pharmacist.
;II * Ret#rn li:#id that are clo#dy in color to the pharmacy.
;III * ,efore administerin medication" identify the client correctly
IL * 6o not lea$e the medication at the bedside. Stay with the client #ntil he act#ally ta<es the
%edi)ations+
L * 7he n#rse who prepares the dr# administers it.. 1nly the n#rse prepares the dr# <nows what the
dr# is. 6o not accept endorsement of medication.
LI * If the client $omits after ta<in the medication" report this to the n#rse in;chare or physician.
LII * 9reoperati$e medications are #s#ally discontin#ed d#rin the postoperati$e period #nless ordered
to be contin#ed.
LIII; =hen a medication is omitted for any reason" record the fact toether with the reason.
LI; * =hen the medication error is made" report it immediately to the n#rse in;chare or physician. 7o
implement necessary meas#res immediately. 7his may pre$ent any ad$erse effects of the dr#.
Medi)ation Ad%inistration
1+ Oral ad%inistration
Ad$antaes
a. 7he easiest and most desirable way to administer medication
b. Most con$enient
c. Safe" does nor brea< s<in barrier
d. Ds#ally less e+pensi$e
Disad$antaes
a. Inappropriate if client cannot swallow and if &I7 has red#ced motility
b. Inappropriate for client with na#sea and $omitin
c. 6r# may ha$e #npleasant taste
d. 6r# may discolor the teeth
e. 6r# may irritate the astric m#cosa
f. 6r# may be aspirated by serio#sly ill patient.
Dr" For%s for Oral Ad%inistration
a. SolidE tablet" caps#le" pill" powder
b. 'i:#idE syr#p" s#spension" em#lsion" eli+ir" mil<" or other al<aline s#bstances.
c. Syr#pE s#ar;based li:#id medication
d. S#spensionE water;based li:#id medication. Sha<e bottle before #se of medication to properly
mi+ it.
e. 0m#lsionE oil;based li:#id medication
f. 0li+irE alcohol;based li:#id medication. 3fter administration of eli+ir" allow C5 min#tes to elapse
before i$in water. 7his allows ma+im#m absorption of the medication.
KNE;ER /RUSH ENTERI/7/OATED OR SUSTAINED RELEASE TA(LETJ
/r"shin enteri)7)oated tablets * allows the irriatin medication to come in contact with the oral or
astric m#cosa" res#ltin in m#cositis or astric irritation.
/r"shin s"stained7released %edi)ation * allows all the medication to be absorbed at the same time"
res#ltin in a hiher than e+pected initial le$el of medication and a shorter than e+pected d#ration of
action
?+ SU(LINGUAL
a. 3 dr# that is placed #nder the ton#e" where it dissol$es.
b. =hen the medication is in caps#le and ordered s#blin#ally" the fl#id m#st be aspirated from the
caps#le and placed #nder the ton#e.
c. 3 medication i$en by the s#blin#al ro#te sho#ld not be swallowed" or desire effects will not be
achie$ed
3d$antaesE
a. Same as oral
b. 6r# is rapidly absorbed in the bloodstream
6isad$antaes
a. If swallowed" dr# may be inacti$ated by astric 8#ices.
b. 6r# m#st remain #nder the ton#e #ntil dissol$ed and absorbed
<+ (U//AL
a. 3 medication is held in the mo#th aainst the m#co#s membranes of the chee< #ntil the dr#
dissol$es.
b. 7he medication sho#ld not be chewed" swallowed" or placed #nder the ton#e (e. s#stained
release nitrolycerine" opiates"antiemetics" tran:#ili(er" sedati$es)
c. .lient sho#ld be ta#ht to alternate the chee<s with each s#bse:#ent dose to a$oid m#cosal
irritation
Ad$antaes!
a. Same as oral
b. 6r# can be administered for local effect
c. 0ns#res reater potency beca#se dr# directly enters the blood and bypass the li$er
Disad$antaes!
If swallowed" dr# may be inacti$ated by astric 8#ice
@+ TO#I/AL * 3pplication of medication to a circ#mscribed area of the body.
1+ Der%atoloi) * incl#des lotions" liniment and ointments" powder.
a. ,efore application" clean the s<in thoro#hly by washin the area ently with soap and water"
soa<in an in$ol$ed site" or locally debridin tiss#e.
b. Dse s#rical asepsis when open wo#nd is present
c. Remo$e pre$io#s application before the ne+t application
d. Dse lo$es when applyin the medication o$er a lare s#rface. (e. lare area of b#rns)
e. 3pply only thin layer of medication to pre$ent systemic absorption.
B. Opthal%i) ; incl#des instillation and irriation
a. Instillation * to pro$ide an eye medication that the client re:#ires.
b. Irriation * 7o clear the eye of no+io#s or other forein materials.
c. 9osition the client either sittin or lyin.
d. Dse sterile techni:#e
e. .lean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from
the inner to the o#ter canth#s
f. Instill eye drops into lower con8#ncti$al sac.
. Instill a ma+im#m of B drops at a time. =ait for 5 min#tes if additional drops need to be
administered. 7his is for proper absorption of the medication.
h. 3$oid droppin a sol#tion onto the cornea directly" beca#se it ca#ses discomfort.
i. Instr#ct the client to close the eyes ently. Sh#ttin the eyes tihtly ca#ses spillae of the
medication.
8. %or li:#id eye medication" press firmly on the nasolacrimal d#ct (inner cant#s) for at least C5
seconds to pre$ent systemic absorption of the medication.
<+ Oti)
Instillation * to remo$e cer#men or p#s or to remo$e forein body
a. =arm the sol#tion at room temperat#re or body temperat#re" fail#re to do so may ca#se $ertio"
di((iness" na#sea and pain.
b. Ha$e the client ass#me a side;lyin position ( if not contraindicated) with ear to be treated facin
#p.
c. 9erform hand hyiene. 3pply lo$es if drainae is present.
d. Straihten the ear canalE
5;C years oldE p#ll the pinna downward and bac<ward
1lder than C years oldE p#ll the pinna #pward and bac<ward
e. Instill eardrops on the side of the a#ditory canal to allow the drops to flow in and contin#e to
ad8#st to body temperat#re
f. 9ress ently b#r firmly a few times on the tra#s of the ear to assist the flow of medication into
the ear canal.
. 3s< the client to remain in side lyin position for abo#t 5 min#tes
h. 3t times the M6 will order insertion of cotton p#ff into o#termost part of the canal.6o not press
cotton into the canal. Remo$e cotton after 15 min#tes.
@+ Nasal * >asal instillations #s#ally are instilled for their astrinent effects (to shrin< swollen m#co#s
membrane)" to loosen secretions and facilitate drainae or to treat infections of the nasal ca$ity or
sin#ses. 6econestants" steroids" calcitonin.
a. Ha$e the client blow the nose prior to nasal instillation
b. 3ss#me a bac< lyin position" or sit #p and lean head bac<.
c. 0le$ate the nares slihtly by pressin the th#mb aainst the client!s tip of the nose. =hile the
client inhales" s:#ee(e the bottle.
d. Keep head tilted bac<ward for 5 min#tes after instillation of nasal drops.
e. =hen the medication is #sed on a daily basis" alternate nares to pre$ent irritations
C+ Inhalation * #se of neb#li(er" metered;dose inhaler
a. Simi or hih;fowler!s position or standin position. 7o enhance f#ll chest e+pansion allowin
deeper inhalation of the medication
b. Sha<e the canister se$eral times. 7o mi+ the medication and ens#re #niform dosae deli$ery
c. 9osition the mo#thpiece 1 to B inches from the client!s open mo#th. 3s the client starts inhalin"
press the canister down to release one dose of the medication. 7his allows deli$ery of the
medication more acc#rately into the bronchial tree rather than bein trapped in the oropharyn+
then swallowed
d. Instr#ct the client to hold breath for 15 seconds. 7o enhance complete absorption of the
medication.
e. If bronchodilator" administer a ma+im#m of B p#ffs" for at least C5 second inter$al. 3dminister
bronchodilator before other inhaled medication. 7his opens airway and promotes reater
absorption of the medication.
f. =ait at least 1 min#te before administration of the second dose or inhalation of a different
medication by M6I
. Instr#ct client to rinse mo#th" if steroid had been administered. 7his is to pre$ent f#nal
infection.
F+ ;ainal * dr# formsE tablet li:#id (do#ches). -elly" foam and s#ppository.
a. .lose room or c#rtain to pro$ide pri$acy.
b. 3ssist client to lie in dorsal rec#mbent position to pro$ide easy access and ood e+pos#re of
$ainal canal" also allows s#ppository to dissol$e witho#t escapin thro#h orifice.
c. Dse applicator or sterile lo$es for $ainal administration of medications.
;ainal Irriation * is the washin of the $aina by a li:#id at low press#re. It is also called do#che.
a. 0mpty the bladder before the proced#re
b. 9osition the client on her bac< with the hips hiher than the sho#lder (#se bedpan)
c. Irriatin container sho#ld be C5 cm (1B inches) abo$e
d. 3s< the client to remain in bed for 5;15 min#te followin administration of $ainal s#ppository"
cream" foam" 8elly or irriation.
6+ RE/TAL * can be #se when the dr# has ob8ectionable taste or odor.
a. >eed to be refrierated so as not to soften.
b. 3pply disposable lo$es.
c. Ha$e the client lie on left side and as< to ta<e slow deep breaths thro#h mo#th and rela+ anal
sphincter.
d. Retract b#ttoc<s ently thro#h the an#s" past internal sphincter and aainst rectal wall" 15 cm (A
inches) in ad#lts" 5 cm (B in) in children and infants. May need to apply entle press#re to hold
b#ttoc<s toether momentarily.
e. 6iscard lo$es to proper receptacle and perform hand washin.
f. .lient m#st remain on side for B5 min#te after insertion to promote ade:#ate absorption of the
medication.
=+ #ARENTERAL7 administration of medication by needle.
Intrader%al * #nder the epidermis.
a. 7he site are the inner lower arm" #pper chest and bac<" and beneath the scap#la.
b. Indicated for allery and t#berc#lin testin and for $accinations.
c. Dse the needle a#e B5" B/" B7E needle lenth CF)@" 5F)@ or P@
d. >eedle at 15*15 deree anle2 be$el #p.
e. In8ect a small amo#nt of dr# slowly o$er C to 5 seconds to form a wheal or bleb.
f. 6o not massae the site of in8ection. 7o pre$ent irritation of the site" and to pre$ent absorption of
the dr# into the s#bc#taneo#s.
S"b)"taneo"s * $accines" heparin" preoperati$e medication" ins#lin" narcotics.
7he siteE
o#ter aspect of the #pper arms
anterior aspect of the thihs
3bdomen
Scap#lar areas of the #pper bac<
Gentrol#teal
6orsol#teal
a. 1nly small doses of medication sho#ld be in8ected $ia S. ro#te.
b. Rotate site of in8ection to minimi(e tiss#e damae.
c. >eedle lenth and a#e are the same as for I6 in8ections
d. Dse 5F) needle for ad#lts when the in8ection is to administer at A5 deree anle2 P is #se at a 45
deree anle.
e. %or thin patientsE A5 deree anle of needle
f. %or obese patientE 45 deree anle of needle
. %or heparin in8ectionE
h. do not aspirate.
i. 6o not massae the in8ection site to pre$ent hematoma formation
8. %or ins#lin in8ectionE
<. 6o not massae to pre$ent rapid absorption which may res#lt to hypolycemic reaction.
l. 3lways in8ect ins#lin at 45 derees anle to administer the medication in the poc<et between the
s#bc#taneo#s and m#scle layer. 3d8#st the lenth of the needle dependin on the si(e of the
client.
m. %or other medications" aspirate before in8ection of medication to chec< if the blood $essel had
been hit. If blood appears on p#llin bac< of the pl#ner of the syrine" remo$e the needle and
discard the medication and e:#ipment.
Intra%"s)"lar
a. >eedle lenth is 1@" 1 P@" B@ to reach the m#scle layer
b. .lean the in8ection site with alcoholi(ed cotton ball to red#ce microoranisms in the area.
c. In8ect the medication slowly to allow the tiss#e to accommodate $ol#me.
Sites!
;entrol"teal site
a. 7he area contains no lare ner$es" or blood $essels and less fat. It is farther from the rectal area"
so it less contaminated.
b. 9osition the client in prone or side;lyin.
c. =hen in prone position" c#rl the toes inward.
d. =hen side;lyin position" fle+ the <nee and hip. 7hese ens#re rela+ation of l#te#s m#scles and
minimi(e discomfort d#rin in8ection.
e. 7o locate the site" place the heel of the hand o$er the reater trochanter" point the inde+ finer
toward the anterior s#perior iliac spine" then abd#ct the middle (third) finer. 7he trianle formed
by the inde+ finer" the third finer and the crest of the ili#m is the site.
Dorsol"teal site
a. 9osition the client similar to the $entrol#teal site
b. 7he site sho#ld not be #se in infant #nder C years beca#se the l#teal m#scles are not well
de$eloped yet.
c. 7o locate the site" the n#rsedraw an imainary line from the reater trochanter to the posterior
s#perior iliac spine. 7he in8ection site id lateral and s#perior to this line.
d. 3nother method of locatin this site is to imainary di$ide the b#ttoc< into fo#r :#adrants. 7he
#pper most :#adrant is the site of in8ection. 9alpate the crest of the ili#m to ens#re that the site is
hih eno#h.
e. 3$oid hittin the sciatic ner$e" ma8or blood $essel or bone by locatin the site properly.
;ast"s Lateralis
a. Recommended site of in8ection for infant
b. 'ocated at the middle third of the anterior lateral aspect of the thih.
c. 3ss#me bac<;lyin or sittin position.
Re)t"s fe%oris site *located at the middle third" anterior aspect of thih.
Deltoid site
a. >ot #sed often for IM in8ection beca#se it is relati$ely small m#scle and is $ery close to the
radial ner$e and radial artery.
b. 7o locate the site" palpate the lower ede of the acromion process and the midpoint on the lateral
aspect of the arm that is in line with the a+illa. 7his is appro+imately 5 cm (B in) or B to C
finerbreadths below the acromion process.
IM inGe)tion * H tra)t inGe)tion
a. Dsed for parenteral iron preparation. 7o seal the dr# deep into the m#scles and pre$ent
permanent stainin of the s<in.
b. Retract the s<in laterally" in8ect the medication slowly. Hold retraction of s<in #ntil the needle is
withdrawn
c. 6o not massae the site of in8ection to pre$ent lea<ae into the s#bc#taneo#s.
GENERAL #RIN/I#LES IN #ARENTERAL ADMINISTRATION OF MEDI/ATIONS
1. .hec< doctor!s order.
B. .hec< the e+piration for medication * dr# potency may increase or decrease if o#tdated.
C. 1bser$e $erbal and non;$erbal responses toward recei$in in8ection. In8ection can be
painf#l.client may ha$e an+iety" which can increase the pain.
A. 9ractice asepsis to pre$ent infection. 3pply disposable lo$es.
5. Dse appropriate needle si(e. 7o minimi(e tiss#e in8#ry.
/. 9lot the site of in8ection properly. 7o pre$ent hittin ner$es" blood $essels" bones.
7. Dse separate needles for aspiration and in8ection of medications to pre$ent tiss#e irritation.
). Introd#ce air into the $ial before aspiration. 7o create a positi$e press#re within the $ial and
allow easy withdrawal of the medication.
4. 3llow a small air b#bble (5.B ml) in the syrine to p#sh the medication that may remain.
15. Introd#ce the needle in :#ic< thr#st to lessen discomfort.
11. 0ither spread or pinch m#scle when introd#cin the medication. 6ependin on the si(e of the
client.
1B. Minimi(ed discomfort by applyin cold compress o$er the in8ection site before introd#ction of
medicati5n to n#mb ner$e endins.
1C. 3spirate before the introd#ction of medication. 7o chec< if blood $essel had been hit.
1A. S#pport the tiss#e with cotton swabs before withdrawal of needle. 7o pre$ent discomfort of
p#llin tiss#es as needle is withdrawn.
15. Massae the site of in8ection to haste absorption.
1/. 3pply press#re at the site for few min#tes. 7o pre$ent bleedin.
17. 0$al#ate effecti$eness of the proced#re and ma<e rele$ant doc#mentation.
Intra$eno"s
7he n#rse administers medication intra$eno#sly by the followin methodE
1. 3s mi+t#re within lare $ol#mes of IG fl#ids.
B. ,y in8ection of a bol#s" or small $ol#me" or medication thro#h an e+istin intra$eno#s inf#sion
line or intermittent $eno#s access (heparin or saline loc<)
C. ,y ?piybac<@ inf#sion of sol#tion containin the prescribed medication and a small $ol#me of
IG fl#id thro#h an e+istin IG line.
a. Most rapid ro#te of absorption of medications.
b. 9redictable" therape#tic blood le$els of medication can be obtained.
c. 7he ro#te can be #sed for clients with compromised astrointestinal f#nction or peripheral
circ#lation.
d. 'are dose of medications can be administered by this ro#te.
e. 7he n#rse m#st closely obser$e the client for symptoms of ad$erse reactions.
f. 7he n#rse sho#ld do#ble;chec< the si+ rihts of safe medication.
. If the medication has an antidote" it m#st be a$ailable d#rin administration.
h. =hen administerin potent medications" the n#rse assesses $ital sins before" d#rin and after
inf#sion.
N"rsin Inter$entions in I; Inf"sion
a. Gerify the doctor!s order
b. Know the type" amo#nt" and indication of IG therapy.
c. 9ractice strict asepsis.
d. Inform the client and e+plain the p#rpose of IG therapy to alle$iate client!s an+iety.
e. 9rime IG t#bin to e+pel air. 7his will pre$ent air embolism.
f. .lean the insertion site of IG needle from center to the periphery with alcoholi(ed cotton ball to
pre$ent infection.
. Sha$e the area of needle insertion if hairy.
h. .hane the IG t#bin e$ery 7B ho#rs. 7o pre$ent contamination.
i. .hane IG needle insertion site e$ery 7B ho#rs to pre$ent thrombophlebitis.
8. Re#late IG e$ery 15;B5 min#tes. 7o ens#re administration of proper $ol#me of IG fl#id as
ordered.
<. 1bser$e for potential complications.
T:pes of I; Fl"ids
Isotonic sol#tion * has the same concentration as the body fl#id
a. 65 =
b. >a .l 5.4N
c. plainRiner!s lactate
d. 9lain >ormosol M
Hypotonic * has lower concentration than the body fl#ids.
a. >a.l 5.CN
Hypertonic * has hiher concentration than the body fl#ids.
a. 615=
b. 655=
c. 65'R
d. 65>M
/o%pli)ation of I; Inf"sion
1+ Infiltration * the needle is o#t of nein" and fl#ids acc#m#late in the s#bc#taneo#s tiss#es.
3ssessmentE
9ain" swellin" s<in is cold at needle site" pallor of the site" flow rate has decreases or
stops.
>#rsin Inter$entionE
.hane the site of needle
3pply warm compress. 7his will absorb edema fl#ids and red#ce swellin.
?+ /ir)"lator: O$erload 7Res#lts from administration of e+cessi$e $ol#me of IG fl#ids.
3ssessmentE
Headache
%l#shed s<in
Rapid p#lse
Increase ,9
=eiht ain
Syncope and faintness
9#lmonary edema
Increase $ol#me press#re
S1,
.o#hin
7achypnea
shoc<
>#rsin Inter$entionsE
Slow inf#sion to KG1
9lace patient in hih fowler!s position. 7o enhance breathin
3dminister di#retic" bronchodilator as ordered
C. Dr" O$erload * the patient recei$es an e+cessi$e amo#nt of fl#id containin dr#s.
3ssessmentE
6i((iness
Shoc<
%aintin
>#rsin Inter$ention
Slow inf#sion to KG1.
7a<e $ital sins
>otify physician
A. S"perfi)ial Thro%bophlebitis * it is d#e to o5$er#se of a $ein" irritatin sol#tion or dr#s" clot
formation" lare bore catheters.
3ssessmentE
9ain alon the co#rse of $ein
Gein may feel hard and cordli<e
0dema and redness at needle insertion site.
3rm feels warmer than the other arm
>#rsin Inter$entionE
.hane IG site e$ery 7B ho#rs
Dse lare $eins for irritatin fl#ids.
Stabili(e $enip#nct#re at area of fle+ion.
3pply cold compress immediately to relie$e pain and inflammation2 later with warm compress to
stim#late circ#lation and promotion absorption.
?6o not irriate the IG beca#se this co#ld p#sh clot into the systemic circ#lation!
5. Air E%bolis% * 3ir manaes to et into the circ#latory system2 5 ml of air or more ca#ses air
embolism.
3ssessmentE
.hest" sho#lder" or bac<pain
Hypotension
6yspnea
.yanosis
7achycardia
Increase $eno#s press#re
'oss of conscio#sness
>#rsin Inter$ention
6o not allow IG bottle to ?r#n dry@
?9rime@ IG t#bin before startin inf#sion.
7#rn patient to left side in the trendelenb#r position. 7o allow air to rise in the riht side of the
heart. 7his pre$ent p#lmonary embolism.
/. Ner$e Da%ae * may res#lt from tyin the arm too tihtly to the splint.
3ssessment
>#mbness of finers and hands
>#rsin Inter$entions
Massae the are and mo$e sho#lder thro#h its R1M
Instr#ct the patient to open and close hand se$eral times each ho#r.
9hysical therapy may be re:#ired
>oteE apply splint with the finers free to mo$e.
6+ Speed Sho)& * may res#lt from administration of IG p#sh medication rapidly.
7o a$oid speed shoc<" and possible cardiac arrest" i$e most IG p#sh medication o$er C to 5
min#tes.
(LOOD TRANSFUSION THERA#B
ObGe)ti$es!
1. 7o increase circ#latin blood $ol#me after s#rery" tra#ma" or hemorrhae
B. 7o increase the n#mber of R,.s and to maintain hemolobin le$els in clients with se$ere anemia
C. 7o pro$ide selected cell#lar components as replacements therapy (e. clottin factors" platelets"
alb#min)
>#rsin Inter$entionsE
a. Gerify doctor!s order. Inform the client and e+plain the p#rpose of the proced#re.
b. .hec< for cross matchin and typin. 7o ens#re compatibility
c. 1btain and record baseline $ital sins
d. 9ractice strict 3sepsis
e. 3t least B licensed n#rse chec< the label of the blood transf#sion
.hec< the followinE
Serial n#mber
,lood component
,lood type
Rh factor
0+piration date
Screenin test (G6R'" H,s3" malarial smear)
; this is to ens#re that the blood is free from blood;carried diseases and therefore" safe from transf#sion.
f. =arm blood at room temperat#re before transf#sion to pre$ent chills.
. Identify client properly. 7wo >#rses chec< the client!s identification.
h. Dse needle a#e 1) to 14. 7his allows easy flow of blood.
8.Dse ,7 set with special micron mesh filter. 7o pre$ent administration of blood clots and particles.
<. Start inf#sion slowly at 15 ttsFmin. Remain at bedside for 15 to C5 min#tes. 3d$erse reaction #s#ally
occ#rs d#rin the first 15 to B5 min#tes.
l. Monitor $ital sins. 3ltered $ital sins indicate ad$erse reaction.
Do not %iAed %edi)ations with blood transf"sion+ To pre$ent ad$erse effe)ts
Do not in)orporate %edi)ation into the blood transf"sion
Do not "se blood transf"sion line for I; p"sh of %edi)ation+
m. 3dminister 5.4N >a.l before" d#rin or after ,7. >e$er administer IG fl#ids with de+trose. 6e+trose
ca#ses hemolysis.
n. 3dminister ,7 for A ho#rs (whole blood" pac<ed rbc). %or plasma" platelets" cryoprecipitate" transf#se
:#ic<ly (B5 min#tes) clottin factor can easily be destroyed.
/o%pli)ations of (lood Transf"sion
1+ Alleri) Rea)tion * it is ca#sed by sensiti$ity to plasma protein of donor antibody" which reacts with
recipient antien.
3ssessments
%l#shin
R#sh" hi$es
9r#rit#s
'aryneal edema" diffic#lty of breathin
B. Febrile3 Non7He%ol:ti) * it is ca#sed by hypersensiti$ity to donor white cells" platelets or plasma
proteins. 7his is the most symptomatic complication of blood transf#sion
3ssessmentsE
S#dden chills and fe$er
%l#shin
Headache
3n+iety
C. Septi) Rea)tion * it is ca#sed by the transf#sion of blood or components contaminated with bacteria.
3ssessmentE
Rapid onset of chills
Gomitin
Mar<ed Hypotension
Hih fe$er
A. /ir)"lator: O$erload * it is ca#sed by administration of blood $ol#me at a rate reater than the
circ#latory system can accommodate.
Assess%ent
Rise in $eno#s press#re
6yspnea
.rac<les or rales
6istended nec< $ein
.o#h
0le$ated ,9
C+ He%ol:ti) rea)tion. It is ca#sed by inf#sion of incompatible blood prod#cts.
3ssessment
'ow bac< pain (first sin). 7his is d#e to inflammatory response of the <idneys to incompatible
blood.
.hills
%eelin of f#llness
7achycardia
%l#shin
7achypnea
Hypotension
,leedin
Gasc#lar collapse
3c#te renal fail#re
N"rsin Inter$entions when )o%pli)ations o))"rs in (lood transf"sion
1. If blood transf#sion reaction occ#rs. S719 7H0 7R3>S%DSI1>.
B. Start IG line (5.4N >a .l)
C. 9lace the client in fowlers position if with S1, and administer 1B therapy.
A. 7he n#rse remains with the client" obser$in sins and symptoms and monitorin $ital sins as
often as e$ery 5 min#tes.
5. >otify the physician immediately.
/. 7he n#rse prepares to administer emerency dr#s s#ch as antihistamines" $asopressor" fl#ids"
and steroids as per physician!s order or protocol.
7. 1btain a #rine specimen and send to the laboratory to determine presence of hemolobin as a
res#lt of R,. hemolysis.
). ,lood container" t#bin" attached label" and transf#sion record are sa$ed and ret#rned to the
laboratory for analysis.