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o Humanistic science dedicated to compassionate concern with

FUNDAMENTALS OF NURSING maintaining and promoting health and preventing illness and
caring for and rehabilitating the sick and disabled (Rogers)
4 Major concepts central in nursing: Levels of prevention:
1. Person/Client – recipient of care; first foundational concept in  Primary
nursing  Secondary – disease prevention
2. Health  Tertiary
3. Environment o Helping or assisting service to persons who are wholly or
4. Nursing – attributes, characteristics, actions of the nurse partly dependent, when they, their parents and guardians, or
other adults responsible for their care are no longer able to
CONCEPTS OF MAN AND HIS BASIC HUMAN NEEDS give or supervise their care (Orem)
Concepts of man o Protection, promotion and optimization of health and abilities,
 Man is a biopyschosocial and spiritual being who is in prevention of illness and injury, alleviation of suffering
constant contact with the environment through the diagnosis and tx of individual, families,
o Biological: Man is like all other man (Callista Roy) communities (ANA)
o Spiritual: Man is like all other man; there is a supreme
higher being (Callista Roy) Historical Development of Nursing
o Social: Man is like some other man (Callista Roy)  Intuitive – nursing is by instinct
o Psychological: Man is like no other man (Callista Roy)  Apprentice – nursing is without formal education but directed
 Man is an open system in constant interaction with a changing by more experienced person
environment  Educated – Florence nightingale; 1860
 Man is a unified whole composed of parts which are  Contemporary – end of World War II up to the present time
interdependent and interrelated with each other
o All body parts, systems functions collaboratively Current trends in Nursing
 Man is composed of parts which are greater than and  Evidence-based practice
different from the sum of all his parts  Community-based nursing – primary prevention
 Man is composed of subsystems and suprasystems  Decreased length of hospital stay
o Subsystem: within; systems in the body  Aging population
o Suprasystem: outside; “ang tao ay parte ng isang  Increased in chronic care conditions
pamilya”; family, friends etc  Independent nursing practice
 Culturally competent care
Characteristics of basic human needs
 Universal Nursing theories
 Met in different ways JOHHNN PARROLL
 Stimulated by external and internal factors J-ohnson: Behavioral Systems Model
 Priorities may be altered O-rem: Self Care Deficit Theory
H-all: Core, Care, Cure
 May be deferred
H- enderson: 14 Fundamental Needs of Man
 May be interrelated N- ightingale: Environmental Theory
 Unmet human need results in disruption of normal body N- ewman: Help System Model
activities and frequently leads to eventual illness P- eplau: Interpersonal Relations Model/ Psychodynamic Model of
Nursing
*Maslow’s hierarchy of human needs A- bdellah: 21 Nursing Problems
Physiologic – base of the pyramid R- oy: Adaptation Model
 High priority needs – life threatening needs R- ogers: Science of Unitary Human Being
O- rlando: Dynamic Nurse-Patient Relationship model/ Nursing Process
 Medium priority needs– help threatening needs
Model
 Low priority needs– developmental needs L- eininger: Transcultural Nursing
L- evine: Four Principles of Conservation/ Conservation model
Safety and Security
 Physical safety and security – e.g. keep sharp objects, bedrails,  Dorothy Johnson
etc. o Behavioral systems model
 Psychological safety and security – e.g. explain before doing any o Man is composed of subsystems and these systems exist in
procedure (observe verbal/nonverbal communication) dynamic stability
o 7 subsystems
Love and belonging  Dorothea Orem
Self-esteem o Self care and self care deficit theory of nursing
 Self – promote independence; self-control o Based on the concepts of:
 Others – recognition/praises from others  Self care – activities that a person must perform
 Self care agency
Self actualization
 Self care agent
Concepts of Nursing
 Nursing  Dependent care agent – nurse is totally doing the
o act of utilizing the environment of the patient to assist him in care for the patient
his recovery (Nightingale)  Self care requisites: demands for self care
o Theoretical system of knowledge that prescribes a process of  Universal
analysis and action related to the care of the ill person (Roy)  Developmental
 Health deviation: mother doesn’t know how to
properly care for baby
 Therapeutic self care demand: needs of the person
 Lydia Hall o Total Person Model
o Core, Care, Cure o Also known as health systems model
o Three aspects of nursing: o Attainment and maintenance of maximal level of total
 Therapeutic use of self: motivation of pt to recover and wellness by purposeful interventions
energy to promote healing  Patricia Benner
 Bodily care: nurses o Novice to Expert theory
 Cure: doctors Expert
Proficient
 Virginia Henderson Competent
o The Nature of Nursing Model Advanced beginner
Novice
o 14 fundamental needs of the person
Nursing Functions
 Florence Nightingale  Independent
o Environmental theory  Dependent
o Linked health with 5 environmental factors
 Interdependent/Collaborative
 Hildegard Peplau
o Interpersonal Relations Model/ Psychodynamic Model Health, Disease and Illness
o Rel bet the nurse and pt must be significant and Health
therapeutic  A state of complete physical, mental and social well-being, and
o Identified 4 phases of nurse-client rel: not merely the absence of disease or infirmity (WHO, 1948)
 Orientation  Smith’s 4 Models of Health:
 Identification o Clinical model: healthy if with/without signs and
 Exploitation symptoms; narrowest definition
 Resolution o Role performance model: healthy if able to perform ADLs
 Faye Abdellah and roles
o 21 Nursing problems o Adaptive model: health is a very dynamic; healthy if able to
o It is from the client’s needs that the our nursing problems adapt and adjust to env’t
originated from o Eudaemonistic model: healthy if able to reach the apex of
o Patient-centered approaches to Nursing Model Maslow’s hierarchy of needs; very comprehensive view
o Nursing as having a problem-solving approach, with key about health
nursing prob –solving approach  Leavell and Clark Model
 Sister Callista Roy o Agent-host Environment model: absence of (-) agent and
o Adaptation Model presence of (+) agent; (-) microorganisms; (+) health
o Viewed humans as biopsychosocial beings who o Ecologic Model
constantly interact with their env’t  Dunn’s high level Wellness grid (copy from Raj)
 Martha Rogers  Travis’s Illness/Wellness Continuum (copy)
o Science of Unitary Human beings
o Unitary man is an energy field in constant interaction
with the env’t
o Human beings are more than diff from the sum of their
parts Premature High level
 Ida Jean Orlando death Neutral point wellness
o Dynamic Nurse-patient relationship model
o Nursing process theory Illness
o Nursing as a process involved in interacting with an ill  Personal state wherein the physical, mental and social aspects
individual to meet an intermediate need of well-being is thought to be diminished
o 4 practices basic to nursing o Acute: sudden, short period of time; may or may not
o Dynamic: forever changing relationship require intervention
 Madeleine Leininger o Chronic: remission & exacerbation; more on the
o Transcultural Nursing Model rehabilitation
o Cultural care diversity  Suchman Five stages of illness:
 Myra Levine o Symptoms experience
o 4 Conservation Principles: o Assumption of sick role
 Conservation of energy o Medical care contact
 Conservation of structural integrity of the body o Dependent client role
 Conservation of personal integrity o Recovery or rehabilitation
 Conservation of social integrity
 Jean Watson Disease
o Human Caring theory  Alteration in body functions that may result in a reduction of
o 10 Carative factors capacities or a shortening of the normal life span
o Nursing is an innate personality of the nurse; something
Stages of Health behaviour change:
personal or within
 Pre-contemplation: patient is without the intention to change; it
 Imogene King
could be that the patient is misinformed or under informed
o Goal attainment theory
 Contemplation: patient acknowledge that there is a problem and
o Nurses purposefully interact with patient and mutually
there’s an intention to change but may take him/her months or
set, explore and agree to means to achieve goals
years to change
 Betty Newman
 Preparation: patient is planning to have a behavioural change 2. Validation of data
 Action: there is an observable behavioural modification 3. Organization of data
 Maintenance: patient is able to integrate the new behaviour into 4. Categorizing or identifying patterns of data
his/her lifestyle but needs to prevent relapses 5. Making influences or impressions
 Termination : it’s as if the unhealthy behaviour did not exist and 6. Recording/reporting of data
there is no possibility for relapse
Diagnosis
Nursing Process Medical diagnosis Nursing diagnosis
Characteristics: Focuses on illness, injury and Focuses on response to actual
 Cyclic and dynamic nature dse process or potential health prob
 Critical-thinking skills Remains constant until cure is Changes as the client’s
effected response or health prob
 Decision making change
 Client-centered Indentifies condition that Identifies situation
 Interpersonal and collaborative practitioners is licensed and
 Universally applicable qualified to treat

Assessment *2 part statement: Problem, Etiology


Types: *3 part statement: Problem, Etiology, Signs and Symptoms
1. Initial assessment – upon admission; for baseline data Planning
3 phases of planning nursing care:
2. Problem-focused assessment – during the hospitalization
 Initial planning
phase; to be able to identify:
 Ongoing planning
 Overlooked problems
 Discharge planning – planning in anticipation of the needs of the
 New problems
client after discharge
3. Emergency assessment – during psychological/physiological
crisis; to be able to identify life-threatening needs
Steps:
4. Time-lapsed assessment – after a period of time; for evaluation 1. Setting priorities
(compare past & present data) 2. Establishing client goals (SMART)
 Short term
Sources of data:
 Long term
1. Primary
2. Secondary
Parts:
 Subject: client
Types of data:
1. Subjective data/symptoms/covert  Verb: action
2. Objective data/signs/overt  Condition/modifier
 Time
Steps in assessment: 3. Selecting nursing interventions (INDEPENDENT)
1. Collection of data 4. Writing nursing orders
Principal methods Types of nursing orders:
 Observing – to be able to notice if the patient is not in a  Observation order – e.g. monitor VS, I &O
physiological or psychological crisis; notice if  Treatment order – e.g. uterine massage after delivery
patient/area is safe; notice if the assistive devices are  Preventive order –e.g. turn to sides
properly functioning  Health promotive orders – e.g. encourage high fiber diet
 Interviewing – a structured communication bet pt and
nurse; need to observe personal space(preferred Implementation
distance of the patient when communicating with Requirements for effective implementation:
another person) 1. Cognitive skills (intellectual)
o Social phase – to establish rapport; non directive 2. Proficiency with psychomotor skills
o Professional phase – to gather data; directive 3. Interpersonal skills

4 types of personal space: Process:


o Intimate space – body contact to 1 ½ feet of a  Reassess the client
distance; used during procedures (e.g. VS,  Determine nurse’s needs for assistance
enema, catheterization, phy examination)  Implement nursing interventions
o Personal space – 1 ½ feet to 4 feet; used during  Supervising the delegated care
interview  Documenting nursing activities
o Social space – 4 to 12 feet
o Public space – 12 feet Evaluation
 Examining Purposes:
o Inspection  Determine:
o Palpation o Client’s progress or lack of progress
o Percussion o Effectives of nursing care
 Flat – bones, muscles o Overall quality of care provided
 Dull – thud like; spleen, liver, heart  Promote nursing accountability
 Resonance – air filled organs
 Hyperresonance – booming; emphysema Documenting and Reporting
*Report – is oral, written or computer-based information
 Tympany - abdomen
*Record-written
o Auscultation
Purposes of client records: o Core temperature – usually higher than the surface;
 Communication constant; rectal, tympanic, pulmonary artery, bladder
 Planning client care o Surface temperature – varies depending on the
 Audit environmental temp; oral, axillary, skin temperature
 Research  Average: Oral – 36.5 to 37.5 C; Axillary – 36 to 37 C ;
 Education Rectal/Tympanic – 37 to 38 C
 Reimbursement  Thermoregulation process
 Legal documentation o Heat production
o Heat loss
Documentation System:  Factors affecting the body temperature:
 Source-oriented record o Age
 Problem-oriented medical record o Exercise
o Hormones (for girls: progesterone increases temp
Basic components: during ovulation)
 Database o Stress
 Problem list o Environmental temperature
 Plan of care o Medications
 Progress notes o Diurnal variation
 Lowest: 4 am to 6 am
Methods of charting:  Highest: 6 pm to 8 pm or 8 pm to 12 midnight
 Narrative charting – paragraph format; in chronological order (after all the activities within the day, the body’s
 Focus charting –records changes or response of client to the temperature becomes high)
treatment; FDAR  Alterations in body temperature:
 SOAP, SOAPIE, SOAPIER & APIE o Pyrexia/fever – up to 40C
 Charting by Exception (CBE) –significant changes or abnormal  Onset/chill phase: Inc HR, RR, shivering, cold
manifestations or exception to what is normal; makes use of skin, cessation of sweating (vasoconstriction)
checklist  Course/Plateau phase: absence of chills, feels
warm, inc HR, RR, thirst
Legal guidelines for recording:  Abatement phase: flushed skin, sweating, dec
shivering (vasodilation)
 Do not erase, apply correction fluid or scratch out an error made
Common types of fever:
while recording
 Intermittent – within 24 hours, pt may
 Correct all errors promptly
experience fever or not
 Record only facts
 Remittent – within 24 hours, pt is febrile;
 Do not leave blank spaces on the nurse’s notes
wide fluctuation; e.g. influenza
 All record entries should be legible and written in ink (black)
 Constant – within 24 hours, febrile; minimal
 Chart only for yourself
fluctuation
 Avoid using generalized, empty phrases such as “status
unchanged” or “had a good day”  Relapsing – days of being febrile and days of
 Begin each entry with the time and end with your signature and being afebrile
title Nursing interventions:
 TSB during plateau phase
 Provide extra balnkets – feels chilled
Different types of reports:
 Incident report  Remove excess blankets – feels warm
 Telephone report – usually used during emergencies; lab  Adeq nutrition and fluids
reports  Reduce phy activity
 Telephone orders – RN are allowed to receive telephone orders;  Oral hygiene
ask MD of the complete name of the patient; if something is not o Hypothermia
clear/you’re not familiar, ask MD to spell it out, repeat the order,  Accidental
ask MD to sign it within 24 hours  Induced
 Transfer reports – from one hospital to another Heat exhaustion Heat stroke
Sweating, wet skin Hypothalamic set
 Change-of-shift reports – endorsement; safeguard the patient’s
dehydration dry
privacy/confidentiality; detailed endorsement should be done Dec blood volume Warm
in the nurse’s station not in bedside Dec BP irritable

Vital Signs Pulse


 Assessing the pulse
 Temperature o Palpation
 Pulse  Rate
 Respiration  Rhythm – pattern/interval
 Blood pressure  Pulse volume – strength or amplitude = +2 (normal
 Pain pulse volume)
*in some cases, Pulse oximetry is required  Elasticity of arterial wall
o Auscultation
Body Temperature
 Stethoscope
 Heat produced = heat lost
 Apical – PMI : 3-4th ICS MCL (< 7 y/o) , 4-5th ICS MCL
(>7 y/o)
*pulse deficit – difference of peripheral and apical  Deflating cuff too slowly : high
pulse; 2 nurse technique is better  Arm above level of heart : low
Respiration
 Assessing immediately after a meal or while client smokes or
 3 processes:
has pain : high
o Ventilation
 Failure to identify auscultatory gap : high
Factors:
 Intact CNS
Hemostasis, Stress and Adaptation
 Clear airway
 Adequate pulmonary compliance and recoil  Stress is a condition in which the person experiences changes
 Intact thoracic cavity in the normal balanced state
Assessment:  Stressor is any event or stimulus that causes an individual to
 Respiratory rate
experience stress
 Depth
 Rhythm 4 Models of Stress:
o Alteration of breathing pattern: 1. Stimulus- based
 Rate: tachypnea, bradypnea, apnea,  Disturbing or disruptive characteristics within the
eupnea environment
 Rhythm: Biot’s (shallow + apnea), 2. Response-based (Selye)
kussmaul’s (rapid + deep; met acidosis)  Non-specific response of the body to any demand made
 Volume upon it
 Ease and effort 3. Transaction-based
*Hypoventilation will lead to hypercapnea  Individual perceptual response rooted in psychological
*Hyperventilation will lead to hypocapnea and cognitive process
o Diffusion – movement of gases from higher to lower
4. Adaptation Model
concentration
 An anxiety provoking stimuli
o Perfusion – concentration of gases; affected by quantity
 People experience anxiety & increased stress when they
and quality of the blood
are unprepared to cope with stressful situations
*Inhalation/inspiration – 1 to 1.5 seconds
*Exhalation/expiration – 2 to 3 seconds
Sources of stress:
Blood Pressure o Intrinsic/internal stressor
o Extrinsic/external stressor
Arterial blood pressure o Developmental stressor
 Systolic pressure : <120 mmHg o Situational stressor
 Diastolic pressure : <80 mmHg
 Pulse pressure : 40 mmHg Characteristics of stress:
*Korotkoff sound o Fabric of life
o Organism reacts as a unified whole
Physiology of arterial BP o Not a nervous energy
 BP = CO x R o Not always results to feeling of distress
 Pumping action of the heart o Not always due to tissue injury
 Peripheral vascular resistance o Not always something to be avoided
1. Baroreceptors : dec BP = dec parasympathetic, inc o Whenever prolonged or intense may lead to exhaustion
sympathetic ( inc HR, VC, Inc BP)
2. Chemoreceptors : very sensitive to chemicals such as inc Factors influencing manifestations of stress:
CO2, dec O2, Ph dec = dec parasympathetic, inc sympathetic o Nature & intensity of stressor
(inc RR, inc HR, VC, inc BP) o Perception of the stressor
*found in aorta and carotid artery o Duration of exposure to stressor
3. RAAS o # of stressors experienced at a time
 Blood volume o Previous experience with a stressor
 Blood viscosity o Age
o Support people
Methods of BP taking:
 Auscultatory method  Homeostasis is the tendency of the body to maintain a state of
 Palpatory method balance or equilibrium while constantly changing
*post activity; take BP after 30 minutes of rest.
*for repeat BP, wait after 2-3 minutes Classification of homeostasis:
*normal BP for lower extremities: diastolic will always remain the o Physiologic – internal environment of body is stable and
same; more pressure in lower extremities (systolic) = will inc by 20 constant
to 30 mmHg o Psychologic – refers to emotional, psychological, mental
*Orthostatic hypotension: drop in BP of 30 mmHg, increase in PR of balance or state of well-being
40 mmHg; upright for 5 minutes
Characteristic of homeostatic mechanisms:
Sources of error in BP assessment:
o Self-regulatory(automatic)
 Bladder cuff too narrow : high
o Compensatory(counterbalancing)
 Bladder cuff too wide : low
o Regulated by feedback mechanism
 Arm unsupported : high
o Require several feedback mechanism to correct one
 Insufficient rest : high physiologic imbalance
 Deflating cuff too quickly : low Major Homeostatic Regulators
o Automatic nervous system o Diapedesis – squeezing out
o Sympathetic & para o Migration – inter to intra
o Endocrine system o Pavementing
o Pituitary thyroid parathyroid, pancreas& adrenal o Types of exudates
glands  Purelent
*Plus organ systems as respiratory, cardio, GI, renal  Sangenous
 Sero-sangenous
 Adaptation  Serous
o Adjustments
Reparative phase
 Modes of adaptation  Regeneration
o Physiologic  Fibrous tissue(scar) formation
Gas & LAS
Compensatory physical changes Types of wound healing
o Psychologic  Primary – minimal, well approximated, surgically created
o Involves a change in attitude or behaviour  Secondary – not approximated, massive tissue damage, higher
o Sociocultural risk for infection, longer healing time, more scar formation
o Changes in the person’s behaviour in  Tertiary – Delayed primary intention healing, wound was
accordance with norms, conventions & beliefs of incised but was left open for a period of days to promote
various groups drainage of secretion to reduce inflammation.
o Technological
o Involves the use of modern technology Systemic Manifestations
 Fever
 General Adaptation Syndrome  Malaise
o Involves sequence of events whenever a person  Increase plasma
encounters stress  Increase esr
o ACTH will stimulate adrenal cortex. AC once  Nausea & anorexia
stimulated, release cortisol. Sugar, Salt, Sex  Leukocytosis
o AM produces Epi(sympathetic) and Nor(Increase
 Wt loss
perfusion of blood in the kidneys, stimulates RAAS)
 Tachypnea and tachycardia
o Stages
Alarm – Awareness of stressor Mgt
Resistance – Repel, Adapt, Normalization, Increase 1. Elevate the area
resistance
2. Heat and cold application
Exhaustion – Decrease energy level, breakdown in
feedback, organ damage, decrease in physiological a. Cold - first 24-72hrs
function, exaggerated manifestations of the illness b. Heat – after 72hrs
o General physiological adaptive mechanisms 3. Diet = inc calorie, protein, vit c.
o SAMR – Symphatoadrenomedullary response fight or 4. Adeq h2o
flight) 5. Pharmacotherapy
 SNS 6. Surgery
 Adrenal Medulla 7. Monitor degree of inflammation, resolution of bleeding, adeq
 Epi and nor blood flow and nerve conduction distal to the area
Effects of SMR
 Increase alertness Heat vs Cold
 Pupillary dilation Vasodilation Vasoconstriction
 Dryness of the mouth Inc capillary permeability Dec capillary permeability
Inc cell metabolism Dec cell metabolism
 Increase HR
Inc inflammation Dec inflammation
 Bronchodilation Sedative effect Local anesthetic effect
 Increase RR
 Muscular contraction Heat and cold
 Increase Metabolism  Done for 30mins, average 15-20mins
 Constipation Dry heat
 Flatulence  Hot water bags –temp 110-120F
 Decrease output  Disposable
o Adrenocortical response  Floor lamp/gooseneck/heat cradle
o (Copy) o Bulb – 25watts
o Neurohypophyseal responses o Distance 18-24inches
o (copy) Dry cold application
o Local Adaptation Syndrome  Ice collar
o Aka process of inflammation  Ice cap
 Characterized by redness(rubor), Moist heat
 Warm moist compress
warmth(calor), swelling(tumor),
pain(dolor), functio laesa  Warm soaks
 Local manifestation  Sitz bath
o (copy) o Used to soak the client’s pelvic area
o Leukocytes enter the injured area o Immersion from the midthigh to the iliac crests or
umbilicus
o Water temp 40-43C o 5-10 slow breaths every 2 hours on waking hours
o Duration 15-20mins  Coughing exercise
o Light headed = stop, assess o Upright position
o Contraindicated: post brain, spinal or eye surgery
Oxygenation o To expel secretions
o Take two slow deep breaths; on the third breath, hold for
Signs of Hypoxia
a few seconds, cough twice without inhaling in between
 Inc reased restlessness or lihtheadedness
o May splint surgical incisions
 Rapid pulse
o Every 2 hours while awake
 Rapid, shallow respirations & dyspnea
 Incentive spirometry
 Inc BP
o A breathing device that provides visual feedback that
 Flaring of nares
encourages patient to sustain deep voluntary breathing
 Substernal or intercostals retractions and maximum inspiration
 Cyanosis (late sign of acute hypoxia) o To promote pulmonary expulsion
 Clubbing of fingers (late signs of chronic hypoxia) o 10 times every 1-2 hours (upon waking hours only)
o Hold the ball initially for 2-3 seconds until pt can hold it to
Normal breath sounds:
max of 6-10 seconds
1. Vesicular
 Chest physiotherapy
o Soft intensity, low pitched
o Postural drainage
o T5 onward
 Purposes:
o Peripheral luncg, base of the lung
 Aides in airway clearance of mucus in pts with
2. Bronchovesicular
retained tracheobronchial secretions
o Moderate intensity, moderate pitch
o T3-T5  Facilitates movement of secretions
o Bet scapulae lateral to the sternum  Contraindications: ICP more than 20 mmHg, head
3. Bronchial and neck injury, active hemorrhage, recent spinal
o High pitch, loud harsh sounds surgery, active hemoptysis, pulmonary edema,
o T1-T3 confused or anxious patients, rib fracture
o Anteriorly over trachea  When: morning (best time), at bedtime, 30 minutes to
1 hour before or 1-2 hours after meal
Adventitious breath sounds  Each position: assumed for 10-15 minutes
 Crackles (rales)– fine, short, interrupted crackling sounds  Entire treatment: should last only for 30 minutes
 Gurgles (rhonci)– continuous, low-pitched, coarse, gurgling,  Position: depends
harsh sound with moaning or snoring quality
 Friction rub – superficial grating or creaking sounds o Percussion
 Wheeze – continuos, high pitched, squeaky musical sounds  Rhythmical force provided by clapping the nurse’s
cupped hands against the client’s thorax
 Vocal (tactile) fremitus – faintly perceptible vibration felt
 Over affected segment for 1-2 minutes
through the chest wall when the client speaks
o Vibration – will mechanically dislodge secretions
Diagnostics  Performed by contracting al the muscles in the
 Sputum nurse’s upper extremities to cause vibration while
 Thoracentesis applying pressure to the client’s chest wall
o Specimen collection, removal of pleural fluid, instill meds  One hand over the other
o Pretest:  Should be done during the act of inhalation
 Consent, not to cough or talk during the procedure o Positioning percussion vibration removal of
(to prevent puncture of lungs), at the side of the bed secretions by coughing or suction
with upper torso supported on overbed table o If doctor ordered for steam inhalation/bronchodilator, do
o Posttest: it before the procedure; at least 20 minutes before the
 Auscultate breath sounds, observe for signs and procedure
symptoms of pneumothorax, shock, leakage at  Sucitoning
puncture, position: opposite of the o Purposes:
insertion/punctured site to be able to promote lung  Promote patent airway
expansion and recoil  Promote adequate exchange of O2 and CO2
 Bronchoscopy  Substitute for effective coughing
o Diagnosis, biopsy, specimen collection of  Specimen collection
structure/tissues, removal of foreign bodies o Size:
o Pretest: consent, remove dentures, oral hygiene, NPO 6-12  Adult: Fr 12 to 18
hours  Child : Fr 8-10
o Posttest: NPO until return of gag reflex, on side or semi  Infant : Fr 5-8
fowler’s, ice bags to throat, discourage talking or coughing *Fr 8: blue
*Fr 10: black
*Fr 14: green Suction
Respiratory Modalities
catheter
 Abdominal (Diaphragmatic) and pursed-lip breathing
*g. 18: brown
o Semi high fowler’s position *g. 21: light green
o Promote max lung expansion Hypodermi
*g. 23: light blue
o Slow deep breath, hold for a count of 3 then slowly exhale c needles
*g. 26-27: light orange
through mouth and pursed lip
*g. 18: green o Simple face mask
*g. 20: pink  Priority nursing interventions:
*g. 22: blue IV  Monitor frequently to check placement of
*g. 24: yellow cannula mask
o length: from tip of nose to earlobe (5 in)
 Support if with claustrophobia
 Nasopharyngeal: 5-6 inches
 Oropharyngeal: 3-4 inches  May be ordered by MD to replace mask with
 Nasotracheal: 8-9 inches nasal cannula while eating
 ET: length of ET + 1 cm  Remove mask adn dry skin every 2-3 hours if
 Tracheostomy: length of trachea + 1cm oxygen is running continuously. Do not use
o Duration of suction: 10-15 seconds powder around the mask
o Intermittent suctioning upon withdrawal using rotating
o Partial rebreathing mask
motion
 Priority nursing interventions:
o If to repeat, allow 30 seconds to 1 minute interval
 Set flow rate so that mask remains 2/3 full
o Hyperoxygenate the patient before, during and after
during inspiration
suctioning
o No > 3 suction passes per suctioning episodes  Keep reservoir bag free of twists or kinks
o Non rebreathing mask (will give patient most oxygen
*Unexpected situations & associated interventions:
 Patient vomits during suctioning concentration; has a one way flap valve)
o Remove the catheter  Priority nursing interventions:
o Change the catheter  Maintain flow rate so reservoir bag collapses
o Turn the patient to prevent aspiration only slightly during inspiration
 Secretions appear to be a stomach content  Check the valves and rubber flaps are
o Ask patient to extend neck slightly to prevent eh tube functioning properly (open during expiration
from passing into the esophagus and closed during inhalation)
 Epistaxis is noted with continued suctioning  Monitor SaO2 with pulse oximeter
o Notify the physician
o Anticipate the use of nasal trumpet o Venturi mask (gives the most precise oxygen
concentration)
Oxygen therapy  Priority nursing interventions:
 Special consideration:  Requires careful monitoring to verify FiO2 at
o Give with a doctor;s order flow rate ordered
o Careful and continuous assessment to evaluate need for  Check the air intake valves are not blocked
and its effect on the patient  Oxygen Hood (usually 10L/min)
o Special prec: o Make sure it’s primed with oxygen before placing it in the
 “NO SMOKING” and “O2 IN USE” signs patient’s head
 disconnect grounded electrical equipment  Oxygen tent (12 to 15 L/min)
 avoid use of oil, grease, alcohol and wool
 use a hand bell instead of electric one *Unexpected sit:
o Humidification is necessary  Child refuses to stay in tent
o Parent may play games with the child
 Nasal Cannula o Alternative methods of O2 delivery may be
Flow rate (L/min) % O2 delivered needed if child refuses
1 24%  It is difficult to maintain an O2 level above 40% in the
2 28% tent
3 32% o Ensure that the flap is closed and edges of tent
4 36% are tucked under the banket
5 40% o Check O2 delivery unit to ensure it is regulated
6 44%
Inhalation therapy
Priority nursing interventions:
 Moist inhalation

o Steam inhalation: 12-18 inches, 15-20 minutes
*Unexpected Sit:
 Pt was fine on O2 delivered by nasa cannula but now  Dry inhalation
cyanotic, and the pulse oximeter reading less than o Metered dose inhaler: use of spacer, hold breaths for 10
93% seconds(for better absorption), 5 minutes interval
o Check to see that O2 tubing is still connected to
Chest tube and Drainage Systems
the flow meter and the flow meter is still on the
previous setting. Assess lung sound
 Used to drain fluid and air out of the mediastinum or pleural
 Areas over the ear or back of head are reddened space into a collection chamber to re-establish normal negative
o Ensure that the areas are adequately padded pressure for lung reexpansion
and that the tubing is connected
 Insertion: 2nd to 3rd ICS (air), 4th ICS (fluid)
 When dozing, pt begins to breathe through the mouth
o Temporarily place the nasal cannula near the  One bottle system: drainage and water seal in one bottle(water
mouth. If this does not raise the pulse oximetry seal: prevent external environmental air to go inside the patient’s
reading, you may need to obtain an order to pleural cavity); end of tube (2cm) should be immersed in sterile
switch the patient to mask while sleeping water
 Mask o Drainage +water seal with air vent open to air
o Water seal: immersed 2-3 cm sterile water o If suction is not set appropriately, adjust until the
o Bottle: keep 2-3 feet below chest level; never raise ordered amount is achieved. Keeping the tubing
above level of heart horizontal across the bed or chair before dropping
o Check for patency vertically into the drain device avoiding dependent
 Two bottle system: one for drainage and one for water seal loops optimize drainage
o Without suction o Notify physician if lack of drainage persists
 1st bottle: drainage; 2nd bottle: water seal  Drainage exceeds 100ml/hr or becomes bright red
 Intermittent bubbling in the 2nd bottle o Notify physician
o With suction  Chest tube drainage suddenly dec and water-seal chamber
 1st bottle: drainage and water seal; 2nd bottle: is not tidaling
suction control o Notify physician
 Normal: intermittent bubbling in water seal,
gentle bubbling in suction control bottle Artificial Airways
 2nd bottle: immerse tube 10-20 cm of sterile NSS  Oropharyngeal airway/ Oral airway
(stabilize pressure) o Prevents tongue from falling back against a posterior
 Protects pleura from trauma if the suction pharynx
pressure inadvertently increases o Measurement: from opening of mouth to ear (back angle of
 Three bottle system: drainage, water seal and suction control jaw)
(suction control: 20 cm of tube is immersed in sterile water) o Check for loose teeth, food and dentures
o 1st bottle: drainage; 2nd: water seal; 3rd: suction  Nasopharyngeal airway/Nasal trumpet
 2nd bottle: normal intermittent o Indications: Clenched teeth, enlarged tongue, need for
bubbling/fluctuations frequent nasal suctioning
 3rd bottle: normal gentle bubbling only o Measurement: from the tragus of the ear to the nostril plus
 Cont/vigorous bubbling: leak one inch
 No fluctuations: obstruction, lung re-expansion o Proper lubrication for easy insertion
 Endotracheal airway
*Fluctuations should synchronize with respiration (water seal) o Indications: route for mechanical ventilation, easy access
 Intermittent bubbling (normal); gentle intermittent bubbling for secretion removal, artificial airway to relieve
(water seal) mechanical airway obstruction
 Continuous bubbling (presence of leak); o Care of patients:
 No fluctuations  Repositioned at least every 24-48hrs
o Obstruction: check patient first before tubing  Depth and length during insertion should be
o Lung has re-expanded: validate maintained
*Xray validate lung re-expansion  Level of tube: gumline/biteline
 Maintain cuff pressure of 20-25mmHg
Nursing care:  Check lips for cracks and irritation.
 Occlusive dressing around the test tube insertion
 No dependent loops or kinks in the drainage tubing *Unexpected situations & associated interventions
 Drainage bottle below the client’s chest  Patient is accidentally extubated during suctioning
 Available at bedside: NSS bottle, gauze o Remain with patient. Instruct assistant to notify
 Gentle bubbling and tidaling is normal physician. Assess patient’s vital signs, ability to
 Intake and output per shift breathe without assistance and O@ sat. Be
 How do you measure the output? Prior, you should have the ready to administer assisted breathes with a
calibration on the bottle and place a mark for the output per bag-valve mask or administer O2. Anticipate
shift. DO NOT OPEN need for reintubation.
 Oxygen sat level decreases after suctioning
*Unexpected sit: o Hyperoxygenate pt
 Chest tube becomes separated from the drainage device o Auscultate breath sounds
o Put on gloves. Open NSS or water and insert the  Patient develops signs of intolerance to suctioning;
chest tube into the bottle while not contaminating O2 saturation level decreases and remains low after
the chest tube hyperoxygenationg ; patients
o Assess for signs of respi distress  Patient is accidentally extubated during tape change
o Notify physician o Stay with pt. Instruct assistant to nitofy MD.
o Do not leave pt Assess pts VS, administer O2, ambubag,
o Anticipate for chest x-ray reintubate
 Chest tube becomes dislodged  Patient is biting on ET
o Put on gloves. Immediately apply occlusive dressing o Bite block around ET or patients mouth
o Assess for signs of respi distress  Depth of ET changes with respi cycle
o Notify physician o Remove old tape. Repeat taping of ET. Ensure.
o Anticipate chest X-ray  Lung sounds are greater on one side
 While assessing the chest tube, you notice a lack of o Check depth. If advanced, lung sound is greater
drainage when there had been drainage previously on one side. Remove tape and move tube, place
o Check for kinks or clots in tubing properly. If not changed, assess. Notify MD
o Milking (squeezing and releasing small segments) of  Tracheostomy
the tube and stripping (squeezing length of tube o To maintain patent airway and prevent the risk for
without releasing it) of the tubing are NOT infection or respi tract
RECOMMENDED
o Care of pt with tracheostomy  Regular
 Sterile technique: acute phase o Has all essentials, no restrictions
 Clean technique: home care o No special diet needed
 1st 24hrs: trache care every 4 hrs  Clear liquid
 Prevent aspiration o “see-through” foods like broth, tea, strained juices,
*US & SI gelatine
 Patient coughs enough to dislodge trache o Recovery from surgery or very ill
o Keep spare trache, and obturator at bedside. Insert o Without residue
obturator into trache tube and insert trache into  Full liquid
stoma. Remove obturator. Secure the ties and o Clear liquids plus milk products, eggs
auscultate for lung sounds o Transition from clear to regular diet
 Soft diet
o Soft consistency and mild spice
o dysphagia
 Pulse Oximetry
 Mechanically soft
Nutrition o Regular diet but chopped or ground
o Difficulty chewing
 Sum of all the interactions between an organism and the food it  Bland
consumes o Chemically and mechanically non stimulating, no
 Combination of processes by which a living organism receives spicy food
and utilizes materials and substances o Ulcers or colitis
 Low residue
Nutrient classification o No bulky food, apples or nuts, fiber, foods having skin
 According to chemical nature and seeds
o Organic – CHON, CHO, Fat & vitamins o Rectal dse
o Inorganic – minerals & water  High calorie
 According to essentiality o High CHON, vitamin and fat
o Dietary essential – water soluble (body needs it daily) o Malnourished
o Non-essential  Low calorie
o Decreased fat, no whole milk, cream, eggs, complex
Assessing Nutritional Status
CHO
 Physical/Instrumental Method (Anthropometry)
o Obese
o Weight
 Diabetic
 Triceps skin fold
o Balance of CHON, CHO fat
 Body Mass Index = weight(kg)/ (height in mt)2
o Insulin-food imbalance
20-25% Normal
26-30%  High CHON
30-40% o Meat, fish, milk, cheese, poultry, eggs
Above 40% o Tissue repair and underweight
o Height  Low fat
o Mid upper arm circumference o Little butter, cream, whole milk, eggs
 Biochemical tests o Gallbladder, liver or heart dse
o Haemoglobin (12-18mg/dl)  Low cholesterol
 Dec: anemia o Little meat, cheese
o Hematocrit (40-50%) o Need to dec fat intake
 Dec: anemia; inc: dehydration  Low sodium
o Serum albumin (3.3-5g/dl) o No salt added during cooking
 Dec: malnutrition, malabsorption o Heart or renal dse
o Transferrin (240-480 mg/dl)  Tube feeding
o Total lymphocyte count (greater than 1800) o 1 cal = 1 ml of tube feeding (1:1)
 Dec: impaired nutritional intake, severe o E.g. (1:1) 1800 cal = 1800mL (6 equal feedings) = 300
debilitating dse mL
o BUN (17-18mg/dL) o E.g. (2:1) same example = 900ml
 Inc: starvation, high CHON intake, severe  Protein-modified diet
dehydration; dec: malnutrition, overhydration o Gluten free diet
o Creatinine (0.4-1.5 mg/dL)  Purpose: to eliminate gluten (CHON) from the
 Inc: dehydration; dec: reduction in total muscle diet
mass, severe malnutrition  Malabsorption syndromes and celiac dse
 Clinical examination  Avoid: barley, oats, wheat, cream sauces,
 Dietary survey breaded foods, cakes, breads, muffin
o 24 hour food recall o PKU diet
 Control intake of phenylalanine, an amino acid
Essential nutrients that cannot be metabolized
 Macronutrients
 Avoid: breads, meats, fish, poultry, cheese and
 Micronutrients
legumes, nuts, eggs.
o Low-purine diet
Types of diets:
 Indicated for gour, uric acid retention, kidney Indication: Bleeding, poison(unless corrosive), stomach
stones emptying(before procedure)
 Avoid: organ meats, fish and lobster, dried Position: Upright
Patency:
peas and beans, nuts oatmeal.
Placement:
*1000ml of NSS: adult 500ml of NSS: pedia, immerse with Ice if
Enteral and Parenteral Nutrition bleeding, inflow should equal the outflow. Stop if pinkish.
Enteral nutrition Parenteral nutrition Gastric decompression
Cancer Non-functional GIT  If using suction; can be intermittent or continuous and
Neurological & muscular d/o Extended bowel rest pressure can be low (20-40mmHg) or high (80-120mmHg)
GI d/o Preoperative
Respiratory failure with TPN
Removing NGT
prolonged intubation
Sitting
GI Tubes Take deep breath
 Levine tube
o Single lumen stomach tube Gastrostomy/jejunostomy feeding
 Salem-sump tube
o Double lumen stomach tube (the other lumen serves  Place in high fowlers position
as airway to prevent adherence of tube to the gastric  Check for patency: pour 15-30 H2O
mucosa)  Check for residual feeding
 Sengstaken-blakemore tube  Hold asepto syringe 3-6 inches above ostomy feeding
o Triple lumen stomach tube used to treat bleeding  Frequently assess for skin breakdown
esophageal varices *US & AI
 Minnesota-sump  Gastrostomy tube is leaking large amount of drainage
o 4 lumen stomach tube o Check tension of tube
 Cantor tube o Apply gentle pressure to tube while pressing external
o Single lumen intestinal tube bumper closer to the skin
 Harris tube o If the tube has an internal balloon holding it in place
o Single lumen intestinal tube o Check to make sure that the balloon is inflated
 Miller-Abbott tube properly
o Double lumen intestinal tube  Skin irritation is noted around insertion site.
*child: tip of nose to earlobe to sternum o Stop the leakage, as described above and apply a skin
*adult: tip of nose, earlobe, xiphoid process barrier
*intestinal tube: tip of nose, earlobe, xiphoid process + 8 to 12  Site appears erythematous and patient complains of pain at site
inches
Complications:
Insertion of NGT  Pulmonary aspiration
Position:
1. High fowler’s  Diarrhea/Constipation
2. Hyperextend neck  Tube occlusion/displacement
3. Slightly flex  Abdominal cramping, nausea and vomiting
Placement:  Delayed gastric emptying
1. CXR  Serum electrolyte imbalance
2. pH of gastric aspirate  Fluid overload
3. auscultation  Hyperosmolar dehydration

Gavage Parenteral Nutrition


Postion
Placement  “Hyperalimentation”
Patency  gastric aspirate (<50cc of aspirate); medication  Site of insertion
(drugs are best absorbed in an empty stomach; give half of amount of o Infraclavicular: R or L subclavian vein, allows
feeding first if medication is gastric irritant, NOT at the end of feeding)
freedom of movement or ambulation
Maintain patency
Keep upright for 30 minutes o Supraclavicular: R or L jugular , hinders head and
12 -18 inches asepto neck movements
US & MI  Preparations/Procedures:
 Tube found not to be in the stomach or intestine o Explain procedure
o Replace the Tube o Valsalva maneuver as catheter being inserted with
 Pt. Complains with nausea after feeding head down in the opposite direction of insertion
o Make sure bed remains o Cover area with sterile dressing
o elevated and suction equip is at bedside o Regulate at ordered rate
o Check meds for antiemetics o Observe for air embolism, subcutaneous bleeding,
 When attempting to aspirate contents, the nurse notes that tube allergic reactions.
is clogged. o VS every 4 hrs
o Try using warm water to flush tube o CBG(hyperglycemia) and urine specific
o Never use stylet to unclog gravity(hyperosmolar diuresis)
o Tube may have to be replaced o Change tubing every 24hrs
o Monitor i/o
Lavage o Weigh once 1 day
o Do not “catch up” if delayed  R side lying with pillow against the abdomen
 Parenteral Nutrition Complications  Observe site for bleeding
o Air embolism Alteration on Stool Characteristics
o Catheter occlusion and sepsis  Acholic stool – gray, pale colored stool
o Electrolyte imbalance  Hematohezia – lower GI bleeding
o Hyper/hypoglycaemia  Melena – upper GI bleeding
o Thrombosis  Steatorrhea – stool with large amts of fat and foul smelling

Bowel Elimination Fecal Elimination Problems


 Constipation
Assessment o Interventions:
 IAPP approach  Regular exercise regimen
 Bowel sounds (4 quadrants)  High fiber foods
o Active: every 5-20 secs  Fluid intake of 2-3 L/day
o Hypoactive: 1 per min  Do not ignore the urge to defecate
o Hyperactive: every 3 seconds  Allow time to defecate
o Absent: none heard in 3-5 minutes  Avoid over the counter meds
 Fecalysis – an inch of formed stol, 15-30 mL of liquid stool  Laxatives as ordered
 Fecal occult blood testing/guiac test
o False-positive: 3 days prior, avoid dark colored foods Types of laxatives:
o False-negative: avoid intake of Vit C more than 500mg
 Diagnostic examination Type Action examples
o Upper Gi series (Barium Swallow) Bulk-forming Inc fluid, gaseous Metamucil,
 Fluoroscopic ecam of the upper GI or solid bulk Citrucel
Emollient/ stool Softens, delays Colace
 Pre-test:
softener drying of feces
 NPO from midnight or 6-8 hours pretest Stimulat/irritant Irritates, Dulcolax,
 Barium will taste chalky stimulates Senokot,
 Post-test: castor oil
 Laxatives to enhance elimination of barium and Lubricant Lubricate Mineral oil
prevent impaction Saline/osmotic Draws water into Epsom salts,
intestine mg citrate,
 Increase OFI
milk of
o Lower GI series (Barium Enema) magnesia
 Pre-test
 NPO 8 hours pretest Enema
 Enema in the morning of test  Types:
 Laxative or suppository o Cleansing enema
 Cramping may be experienced during  Prior to diagnostic test
 Post-test  In cases of constipationand impaction
 Laxative and fluids to assist in expelling the  Either be:
barium  High enema: 12-18 in
o Endoscopy  Low enema: 12 in (reach only the descending
 Pre-test colon)
 NPO 6-8 hrs o Carminative enema
 Consent  60-80 mL fluid
 Local anesthetic  To expel flatus
 Hoarseness and sore throat for several days o Retention enema
 Post-test  Solution retained for 1-3 hours
 NPO until with gag reflex  Oil enema, antibiotic, antihelmintic, nutritive
 Warm normal saline gargles o Return-flow enema
o Colonoscopy  To expel flatus
 Pre-test  Alternating flow of 100 to 200 of fluid in and out of the
rectum
 NPO 6 hours
 Administration:
 Laxatives and enemas
o Appropriate size
 Consent
 Adult: Fr22-30
 Instrument will be inserted in the rectum
 Child: Fr 12-18
 Patient must have a good plt count
o Correct volume
 Post-test
 Adult: 750-1000 mL
 Observe for rectal bleeding and signs of
 Adolescent: 500-750 mL
perforation
o Length of insertion
o Liver biopsy
 Adult: 3 to 4 in
 Pre-test
 Child: 2 to 3 in
 NPO 6-8 hours
 Infant: 1 to 1 ½ in
 Consent
* ENEMAS UNTIL CLEAR: when no solid fecal material exists,
 Hold breath during biopsy but solution maybe colored
 Post-test  Types of Solutions:
 VS q hour x 8-12 hours
Solution Constituents Action the drainage port then aspirate with syringe puncturing in a
Hypertonic E.g. sodium Draws water into slanting motion (to allow the self sealing effect of the catheter);
phosphate colon 10 cc
solution
Hypotonic Tap water Distends the colon, Types of Urinary Alterations
stimulates, softens  Urgency
Isotonic Normal saline Distends colon, o 150-200 mL will give the urge to void; 600 cc “kelangan ko
stimulates, softens na umihi”; bladder can hold urine up to 1000 to 1.,500 mL
Soadsuds 3-5ml soap to 1L Irritates mucosa,  Dysuria
water distends colon o Painful urination
Oil Mineral oil, olive Lubricates feces
 Frequency
oil, cotton seed oil
o Voiding at an interval of less than 2 hours
 Hesitancy
US & AI o Difficulty initiating urination
 Solution does not flow into rectum  Nocturia
o Reposition rectal tube. If solution will still not flow, o Frequent urination at night
remove tube and check for any fecal contents  Retention
 Patient cannot retain enema solution for adequate amount of o Incapability of bladder to empty itself
time  Residual urine
 Patient cannot tolerate large amount of enema sol o Normal amt: 50-100cc
o Amount and length of administration may have to be  Polyuria
modified if pt begins to complain of pain  Oliguria
 Patient complains of severe cramping o Voiding less than 30cc
 Anuria
 Fecal Impaction
o Output of 0 to 10 cc per hour
o Interventions
 Incontinence
 Increased fluid intake
o Functional
 Sufficient bulk in the diet
 Intact structure; cannot hold the urine
 Adequate activity and exercise
o Overflow
 Oil retention enema  cleansing enema 2-4 hrs after
 Over distended bladder
 Stool softeners or suppositories
o Reflex
 Digital removal of stool if ordered – scissor like. <10-15
 Bladder is filled with a pre-determined amount
mins, interval of 30 mins to avoid vasovagal stimulation
o Stress
 Diarrhea
 Increase in abdominal pressure
o Interventions
o Urge
 At least 8 glasses of water/day
 Once the patient feels the urge to void, he/she will
 Diet
void
1. Inc sodium and potassium
2. BRA diet Urine tests
3. Dec intake of insoluble fiber  Routine analysis
4. Dec fatty foods  Urine culture and sensitivity
5. Avoid caffeine drink  Timed urine specimens (a period or duration of time wherein
 Flatulence the urine is collected)
o Interventions  Renal function test
 Limit carbonated beverages, use of drinking straws o BUN
and chewing gums o Creatinine clearance
 Avoid gas formin  Intravenous Pyelogram
 Fecal incontinence  Fluoroscopic visualization of the tract
o Involuntary passage of feces o Pre-test
o Often associated with neurologic, mental, or emotional  Assess for iodine sensitivity
impairments  Enema the night before
 Hemorrhoids  Consent
o Dilated, engorged veins in the lining of the rectum  NPO for 8 hours
o Intervention o Post-test
 Hemorrhoidectomy  Force fluids
 Cystoscopy
Bladder Elimination
 Pre-test
Assessment o General or local anesthesia
 Urine characteristics o Consent
o pH: 4.6-8.0 o NPO
o Specific gravity: 1.010 – 1.025 o Enema as ordered
o Colour: amber/straw  Post-test
o Odor: aromatic upon voiding o Force fluids
o Transparency: clear o Pink tinged urine 24-48 hours
*how to collect urine for urinalysis (without cath): at least 10cc, o Warm sitz bath and analgesics
clean catch, midstream; (with cath): kink connecting tube for at
least 30 minutes (for urine to pull in the catheter) then disinfect Implementation
 Prevent UTI o Stop inflation of balloon, withdraw the solution/NSS,
o Frequent voiding (q2-4 hours) catheter may still be in the urethra. Insert catheter
o Avoid use of harsh soaps, bubble bath, powder or sprays and additional 0.5-1 in slowly and attempt to inflate
on perineal area balloon again
o Proper perineal hygiene
o Increase acidity of urine (Cranberry) Bladder irrigation
 Managing urinary incontinence  Open system (Intermittent)
o Bladder training o For instillation of meds or irrigation of catheter
 Inhibiting urge-to-void sensation  Closed system (Intermittent or continuous)
o Pelvic muscle exercise – Kegel’s exercise o For those who had genitourinary surgery
 Contracting for 3-5 secs; 10 contractions/session; 5 o For instillation of meds, promoting homeostasis,
times daily flushing of clots or debris
o Positive reinforcement
o Meticulous skin care
o Avoid stimulants at night Care of Clients with Pain
o External drainage device (males) Pain
 Condom catheter – leaving 2.5cm/1in between the  Sensation of physical and mental suffering or hurt that usually
end of penis and rubber (to prevent penile irritation causes distress or agony to the one experiencing it
and promote adeq drainage of urine)  Highly subjective
o Provide privacy  Unpleasant but protective mechanism of the body
o Provide fluids to drink Common Theories of Pain Transmission
o Assist in proper positioning for voiding  Specificity theory
o Serve clean and warm bedpan o When a specific nerve fiber was stimulated it will
o Allow to listen to sound of running water cause pain sensation
o Alternate warm and cold water over perineum  Pattern theory
o Promote relaxation o If the nerve fiber was stimulated intensely, it will
o Provide adeq time for voiding produce pain
o Cholinergic drugs as ordered (urecholine)  Affect theory
o Manual pressure on the bladder (Crede’s maneuver) o That a person will feel pain,
o Urinary catheterization as ordered  Gate control theory
 Intermittent/single catheterization o If the small diameter fiber is active it will open the
 Indwelling/retention catheterization gate, pain impulses will be carried through the spinal
 Continuous bladder irrigation cord
Indications for catheterization:  Physiology of pain
 Decompression
o Transduction
 Instillation
 Pain receptors can be excited by
 Irrigation
mechanical, thermal or chemical stimuli
 Specimen collection
o Transmission
 Urine measurement
 Pain impulse travels from periphjeral
 Residual urine
nerve fiber to the spinal cord
 Hourly urine output
o Modulation
 Promotion of healing GUT
*Neuroregulators
Catheterization  Substances that affect transmission of
 Size nerve stimuli
o Children: Fr 8-10
o Increases pain impulses:
o Female adult: Fr 14-16 (Fr12 young girls)
o Substance P, prostaglandins
o Male adult: Fr 16-18
o Bradykinins(universal stimulus for pain)
 Position  Decreases pain impulse
o Male: supine with thighs slightly abducted
o Female: dorsal recumbent  Perception
 Length of insertion o When a client becomes conscious of the pain
o Female: 2-3 inches  Actual feeling of pain
o Male: 7-9 inches  Pain assessment
 Anchor o Fifth VS
o Female: inner thigh o Mnemonic for pain assessment
o Male: top of thigh or lower abdomen  COLDER
 PQRST
US & AI  Precipitated
 No urine flow is obtained and you note that catheter is in the
 Quality
vaginal orifice
 Region
o Leave the catheter in place, get a new set then insert
a new catheter then remove the first catheter  Severity/intensity
 Urine flow is initially well established and urine is clear but after  Time
several hours flow dwindles  11 point pain intensity scale
o Check tubing for kinks  Wong –Baker FACES Rating scale
 Pt complains of extreme pain when you are inflating the balloon
 Non-pharmacologic intevertions for pain control  A syndrome brought about by prolonged
o Target domain of pain control disturbance in sleep
 Body(massage) o Slow processing of thoughts
 Mind(Yoga,meditation)
 Spirit(worships, pilgrimage) Mobility and Immobility
 Social interactions(support group)  Four Basic Elements of Body Movements
o Alignment and posture
Promotion of Comfort, Rest and Sleep o Joint mobility
 Rest o Balance
o State of calmness, relaxation w/o emotional strss or o Coordinated movement
freedom from anxiety  Effects of Immobility
 Sleep o Musculo-Skeletal system
o State of consciousness in which the individual  Disuse atrophy
perception and reaction to environment is decreased  Decrease in size of muscles
o Physiology of sleep  Contracture
 Reticular activating system(RAS)  Shortening of muscle fibers
Passive theory – state of alertness  Ankylosis
 Bulbar synchronizing region(BSR)  Stiffening of joints that impaires mobility
Active theory – releases serotonin, leads to  Disuse osteoporosis
sleep  Withdrawing of calcium from the bones
o Types of Sleep that may result to renal calculi
o NREM o CV system
 (deep restful sleep/slow-wave sleep)  Orthostatic Hypotension
 St 1 – very light, drowsy, relaxed, eyes  Thrombophlebitis
roll from side to side, lasting few mins  Inspect for LE for redness, sweilling
 St. II – light sleep, body processes slow  Palpate for tenderness
further(decrease PR/RR), eyes are  Wear stockings
still; lasts abt. 10-20mins o Respiratory
 St. III – domination of the PNS; difficult  Atelectasis
to arouse; not disturbed by sensory  Deep breathing
stimuli; snoring; muscles totally  Exercise
relaxed; 15-30mins  Rom
 St. IV – delta sleep; deep slow wave  Turning
sleep; PR/RR drop by 20-30%; rarely  Hypostatic Pneumonia
moves; very difficult to arouse; 15-  Pooling of secretions
30mins. Activation of growth  Do deep breathing
hormones  Turning
o REM(rapid eye movement)  Percussion
 Where most dreams take place  Steam inhalation
 Brain is highly active, hence, paradoxical sleep  Adeq hydration
 Increase oxygen consumption in brain  Respiratory Acidosis
 Brain trying to save the information o Metabolic
 Decreased metabolic rate
o Common sleep d/o
 Anorexia
 Insomnia
 Demineralization
 Initial
 Hypercalcemia
 Intermittent
o Urinary
 Terminal
 Urinary retention
- Early to wake up, elderlies
 Urinary stasis
 Hypersomnia
 Renal calculi formation
 Excessive sleepiness
 UTI
 Narcolepsy
o Integumentary
 Sudden attack of overwhelming
 Ischemia
sleepiness
 breakdown
 Sleep apnea
 Bedsore
 Temporary cessation of breathing
 Pressure - perpeniducar force
while sleeping
 Friction – parallel
 Parasomnia
 Shearing - combined
o Somnambulism
 RF: Immobility, moisture, excessive body
 Sleep walking
heat, advanced age, nutrition, hygiene
o Night terrors
 Stages
 Nocturnal eneuresis
- Non blanchable
 Soliloquy
- Partial thickness
 Nocturnal erections
- Full thickness
 Bruxism
-
*Sleep deprivation
- Full with extensive destruction
o Types of Exercises
 Isotonic
 Dynamic
 Tension is constant and muscle shortens to
produce contraction
 Isometric
 Static
 Change in muscle tension but no change in
length hence no movement

 Active
 Done by patient himself w/o assistance
from the nurse
 Active-assistive
 Performed independently by the client
which is then continued or assisted by the
nurse for the patient to complete the ROM
 passive
 Exercise done the pt with the complete
assistance from the nurse
 Resistive
 Pt moves or tenses his muscles against a
resistance
Sulcular technique – 45 degree angulation

Types of massage:
Effleurage – relaxes the muscles
Petrissage
Martha Rogers
FUNDAMENTALS OF NURSING  Man as a unitary being
Elizabeth Cortez, RN, MAN
Nutrix – latin words; to nourish Imogene King
NURSING  Interacting systems framework
 Is an art and science
 total patient care Betty Neuman
 focuses on environment  Total person model theory
 individual, family, community  3 types of stressors: intra-personal, extra personal,
interpersonal
THEORETICAL FOUNDATIONS OF NURSING  Primary, secondary, tertiary levels of prevention
Theory – set of concepts to explain a phenomenon
Paradigm - pattern Parse
4 Metaparadigms of Nursing  Theory of Human Becoming
 Person
 emphasizes how individual chose and bear responsibility for
 Health patterns of personal health
 Environment
 Nursing Patricia Benner
 Novice of expert theory
NURSING THEORISTS  Stage 1: Novice
Florence Nightingale  Stage 2: Advance beginner
 May 12, 1830 – August 13, 1910
 Stage 3: Competent (2-3 years)
 Environmental sanitation  Stage 4: Proficient (3-5 years)
 Stage 5: Expert
Hildegard Peplau
 Skills acquisition
 Interpersonal process
 Psychodynamic theory of Nursing
Joyce Travelbee
 Phases of Nurse-patient relationship: Orientation (client seeks
 Human to human relationship
), Identification (independence, dependence), Exploitation
(accept service of nurse), and Resolution
Ernestein Weidenbach
 Clinical Nursing: A Helping Art
Virginia Henderson
 1897-1996
Pender
 14 fundamental needs
 Health promotion model
Faye Abdellah FILIPINO NURSING THEORISTS
 March 13, 1919 Carmencita Abaquin
 Typology of 21 Nursing problems  Chairman of Board of Nursing
 Patient-centered approach  PREPARE ME intervention
 P – presence which in
Lydia Hall  RE – reminisce therapy
 Core (therapeutic use of self), Care (nursing function), Cure  P - prayer
(medical)
 Re - relaxation
 Jean Watson
 ME - medication
 10 Carative factors
 Nursing process Sr. Caroline Agravante
 The CASAGRA Transformative Leadership model
Ida Jean Orlando-Pelletier
 5 C’s for Transformational leadership: creative, caring, critical,
 Dynamic nurse-patient relationship contemplative, collegial
Madeleine Leininger Carmelita Divinagracia
 Transcultural theory of nursing  COMPOSURE Behavior for wellness
 COMpetence
Myra Levine  Presence of Prayer
 4 Principles of Conservation
 Open mindedness
 Entergy, structural integrity, social integrity, and personal
 Stimulation
integrity
 Understanding
 Respect
Sister Callixta Roy
 Relaxation
 Adaptation model of Nursing
 Empathy
 4 mode of adeptatiton
 Role function, interdependence, physiological, self concept
Mila Delia Llanes
Dorothea Orem
 Conceptual model on Core Competency Development
 Self-Care model
 Universal self care requirement (nutrition, oxygenation),
Ma. Irma Bustamante
developmental self care requirement (developmental tasks),
 The effects of the Nursing Self-Esteem Enhancement (NurSe)
health care deviation self care requirement
Program to the Self-Esteem of Filipino Abused Women
 3 Nursing systems: wholly compensatory ,partially
compensatory, supportive-educative compensatory
Sr. Letty Kuan
 Retirement and Role Discontinuity
Dorothy Johnson
 Behavioral theory of Nursing
T. Fliedner – founder of the first organized school of nursing
Rose Nicolet – helped establish the first school of nursing in the Normal Hall in PNU is used as training ground – same instruction (central
Philippines school idea) for 6 months then go back to hospital
Lilian Wald- founder of Public Health Nursing Act 2493 (1915) – Medical act which included Sec.7 & 8 about nursing
practice which mandated registration and examination
HISTORICAL DEVELOPMENT OF NURSING Act 2808 (1919)
Intuitive - First true nursing law
- Out of love, sickness caused by black spirits, based on instinct - Board of Examiner for Nurses (BEN)
- Shamans, spells, rituals - 1 Doctor and 2 Nurses
- 1920 – First board examination
Trephining – boring a hole into a skull without anesthesia to release evil - Anna Dulgent – first board exam topnotcher
spirits
Egyptians – art of embalming, anatomy and physiology GN Program (Graduate Nurse) – 1 year
Moses – Father of Sanitation, asepsis, art of circumcision After World War II, BSN degree for four years was given by UST (1946).
China – material medica – book of pharmacology Managerial, teaching and supervision position. Equal to Master’s degree
Babylonians – Bill of Rights, Code of Hammurabi (made by King 
Hammurabi which include freedom to refuse treatment), medical fee RA 877 – BEN is composed of BSN
India – Shushurutu – list of function of the nurse – combination of 1966 – Master’s degree needed
masseur, caregiver RA 6136 – can administer intravenous meds as long as physician, violaion
Romans – Fabiola – a rich matron who contributed her home to serve as of professional autonomy; did not materialize but instead nurse prepared
first hospital medication and doctor administered until 1992 but it had conflict with
Apprentice the drug administration principle of “administer what you prepare”
- Experienced (through trial and error) nurse teaches new 1960s – 5-year curriculum
volunteer nurses who usually came from religious orders 1976 – 4-year curriculum; GN program was phased out, practicing GNs
- Nursing the sick and wounded from the wars must go back to 4th year to earn a BSN degree but they won’t take board
- Charles Dickens – novel “Martin Chuzzlewit” about Sairy Gump exam anymore since they are already licensed
and Betsy Prag (exemplification of nurses in the Dark Period of 1980 – overlapping of 4 and 5 year curriculum graduates
Nursing) RA 7164 (1992) – IV training for nurses by ANSAP, signed by Cory
- Pastor Theodore Fliedner (Protestant) – first training school Aquino, valid only after 2 months
for Nursing, “Deaconess School of Nursing”, 6 months program RA 9173 (2002) – New Nurse Practice Act
at Kaiserswerth,Germany
Labor laws least likely affect supply and demand for nurses abroad
Educated RECEIPIENT OF CARE
Florence Nightingale Concept of Man
- First theory author, first nurse-researcher - Biological
- Lady with a Lamp/ Mother of Modern Nursing o Anatomy
- 3 months of study from Kaiserswerth - Emotional/Psychological
- Developed her own training “Nightingales System of Nursing o Id, Ego, Superego
Education” which is implemented in St. Thomas Hospital in - Socio-Cultural
London o Norms and practices
- Correlate theory and practice, updates, continuing education, - Spiritual
research, self supporting nursing school (separate from
hospital) Holism – consider the multi-factorial nature of man
- Changed image of nursing, revolutionized practice Maslow’s Hierarchy of Needs
- Professionalized as a nursing - Physiological, safety and security, love and belongingness, self-
- Notes of Nursing: What it is, What it is not, Notes on Hospitals esteem, self-actualization
- Ranked according to how critical need is to survival
Nursing as a profession is not as old as mankind but nursing as an act
itself is. Richard Kelish
Contemporary - Emphasized stimulation needs after physiological needs before
- Modern nursing practice safety and security
- Sex, exploration, manipulation

Anastacia Giron-Tupas Calling the name of the patient – self esteem need
- grand lady of Philipine Nursing Suctioning of baby’s mouth – physiologic
- Founded PNA Fulfillment – self-actualization
Needs are interrelated and must all be met
Hilaria Aguinaldo – development of Red Cross Satisfy one need and satisfy others
Loreto Tupas – Florence Nightingale of Iloilo All needs have a stimulus; universal; and can be deferred/delayed to a
Melchora Aquino – Tandang Sora certain extent
Sex is important to the survival of the race, not the person.
History of Nursing in the Philippines
Pre-Spanish SAMPLE QUESTIONS
- Spaniards colonized the Philippines 1. Mans energy is limitless – FALSE
2. As a psychosocial organism, man is like all other men – FALSE
First hospital – Hospital de Real de Manila (1577) 3. The intellect allows man to choose what he likes or longs to do
1578 – San Lazaro Hospital, Intramuros – leprosy and mental illness – FALSE, Will allows you to choose
Hospital de San Gabriel – Chinese General Hospital
Aliping sagigilid and aliping namamahay – first volunteer nurses who HEALTH, DISEASE, AND ILLNESS
served as apprentice in the first hospitals
1878 – Escuela de Practicantes (UST) – first school for Nursing (short- Health – complete and optimum wellbeing and not only the absence of
lived) disease or infirmity; a process
1906 – Iloilo Mission Hospital School for Nursing – 6 months training, no
board exam (NON-EXISTENT) Models of Health
Mission Hospital (1901) – still existent Judith Smith
1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital Clinical Model
- Absence of signs and symptoms of disease
- Narrowest Body adapts to the changes in the environment which leads to
Homeostasis (Walter B. Cannon)
Role Performance Model Cloud Bernard - called homeostasis as “therapeutic milieu”
- Able to perform job Adaptation - change to maintain integrity of the environment
Modes of Adaptation
Adaptive Model - Biogical/Physiological – homeostatic mechanism
- Capable of adjusting - Emotional/Psychological
- Although there is infirmity, he is able to find ways to cope - Socio-cultural
- Technological
Eudaemonistic Model
- Maximization of potential and mission in life Principles of Homeostatic Mechanisms
- Fulfillment of his purpose in life - Automatic, self-regulatory
- Compensatory
Levell and Clark - Negative feedback except for uterine contraction during labor
Ecologic Model of Health - Has limits
- Epidemiological triad –agent, host, environment
- Any of these triad must be manipulated or enhanced to One physiologic error is corrected by several homeostatic mechanisms
maintain health STRESS RESPONSE
Lazarus’ Stress Response Theory
Multiple Causation Theory of Disease General Adaptation Syndrome (GAS) - a physiological response is a
- health is affected by different factors in the environment systemic response
Local Adaptation Syndrome (LAS) - Only a part of the body
Rosenstock Bekker’ s Health Belief Model GAS Stages
- Individual perception affect modifying factors which may  Alarm
influence likelihood of action - Awareness of stressor
- Increase in vital signs
Travis’Illness-Wellness Continuum - Mobilization of defense
Health is in a spectrum which moves into polarity of directions - Decreased body resistance
Dunn’s High Level Wellness Grid - Increased hormone level
- health axis “Favorable/Unfavorable environment”  Resistance
- Repel of stressor; overcome
Quadrants: - Adaptation
- High level wellness in a favorable environment - Normalization of hormone levels and vital signs
- Emergent high levels in Level Wellness in an unfavorable - Increase in body resistance
environment - Going back to pre-stress state
- Poor Health in an Unfavorable Environment  Exhaustion
- Poor health in a favorable environment - Unable to overcome stressor
- - Decreased energy level
- Breakdown in feedback mechanism
Disease – defect/abnormality/dysfunction in structure and function - Organ/tissue damage; decreased physiological
(physically) function
Illness – broad; may involve issues other than physical - Exaggeration of
“I have the disease but not ill” – TRUE
“I am ill but I have no disease” (schizophrenia, etc) – TRUE General Adaptation Response
Socio-cultural illnesses – manana culture, Sympathoadreno-medullary Response (SAMR)
Spiritually ill – not following the church, not going to mass - activation of sympathetic system which stimulated adrenal
medulla
Schumann’s Stages of Illness Behaviors - Release of epinephrine and norepinephrine ---- > inc.
1. Symptom experience physiological activities
2. Assumption of sick role - Sympathetic stimulation (inc. HR, RR, BP, visual perception,
3. Medical care contact metabolism – glycogenolysis in liver, dec. GI, GU)
4. Dependent client role - Propanolol (Inderal) – bronchoconstriction
5. Convalescence/ Rehabilitation
Adrenocortical Response
Opposite of health is illness, not disease Anterior pituitary gland Adreno corticotropic hormone  adrenal
STRESS cortex
- Response Based Model - Physiological involved (1) release of aldosterone  kidneys  increase Na reabsorption
- Transaction-based Model - Cognitive, psychological (2) release of cortisol  fats & CHON catabolism  glucose
- Stimulus Based Model – live events/ change
- Adaptation Model – anxiety provoking stimulus Neurohypophyseal Response
Posterior pituitary gland release
CRISIS (1) Antidiuretic hormone  kidneys  inc. Na, H2O reabsorption
- disequilibrium, not merely psychological but physiologic as  dec. urine output, inc. blood volume, inc. BP
well (shock) (2) Inc. oxytocin (aids in ejaculation/sperm motility)  uterine
- spontaneous resolution is 6 weeks contraction
- grieving process: 4 years
Methods to decrease stress:
Stressor - Progressive relaxation – muscle tension
- Internal/ intrinsic - Benzon relaxation method – dimming the light, music
- External - Yoga, meditation
- Developmental/ Maturational - Ventilation of feelings
- Situational
Local Adaptation Syndrome
Eustress – helpful stress Inflammatory Response
Distress – harmful to health All infections cause an inflammatory response
Not all tissue damage results to inflammation
Inflammation can heal spontaneously as long as the body can manage  Risk for/ Potential for
 Wellness - readiness and enhancement/ achieve higher level of
I. Vascular Stage functioning
(1) vasoconstriction which limits injury and contain damage  Syndrome – “syndrome”
(transient)  Possible – vague/ unclear – possible/probable
(2) Release of chemical mediators – kinins
a. Bradykinin – most potent vasodilator/ universal Prioritization of Nursing Diagnosis
pain stimulus, inc. chemical activity  warmth  Airway,breathing, circulation
(calor), redness (rubor)
b. Prostaglandin PLANNING
(3) Capillary permeability  swelling (tumor), pain (dulor),  Short Range
temporary loss of function (function laesa)
 Long Range
II. Cellular Stage
*Must be SMART (Specific, Measurable, Attainable, Realistic, Time
(1) Neutrophils – bands and segmenters in differential count; first
bound)
one to arrive. If elevated, it suggests acute infection
Classify as dependent, interdependent, collaborative
(2) Lymphocytes, Monocytes, or Macrophages – suggests chronic
IMPLEMENTATION
infection.
 Reassess if the patient still needs intervention
(3) Eosinophils – allergy
 Determine if you need assistance
(4) Basophils - healing
 Carry out intervention, ensure that we have background
III. Exudating  Document
Types of Exudate
 Serous – plasma - waterry EVALUATION
 Sanguinous/hemorrages – blood  Process - nurse
 Serosaguinous - pink  Structure - system
 Pus – purulent/ suppurative  Outcome – patient
 Catarrhal - mucin
 Fibrin fibers - fibrinous DOCUMENTATION OR CHARTING
STAT – now
Ad lib – as desired
IV. Reparative
PRN –as required
Phagocytosis – ingestion of foreign substances
OD – right eye/ once a day
Macrophages  Monocytes
OS – left eye
Chemotaxis – movement of substances to a chemical signal
OU – both
Healing methods:
AD – right ear
 Cold compress for first hours then warm compress after
AS – left ear
 Nutrition and fluid intake AU – both ears
Ss – half
NURSING PROCESS ERROR: draw a straight line, signature, initials
A – Assessment
D - Diagnosis Types of Documentation
P – Planning 1. Source Oriented Recording – narrative account by nurse
I - Implementation 2. Problem Oriented Recording (POR) – problems ranked
E – Evaluation according to priority by the health care team, date dissolved,
An overlapping of process can be noted since it is cyclic progress notes, problem list
ASSESSMENT a. FDAR – Focus, Data, Action, Response (patient)
Data Collection – first step in assessment b. SOAPIER – subjective, objective, assessment,
 Primary/ Secondary planning, implementation, evaluation, revision
 Object (over)/ Subjective (covert) 3. Computer Assisted Recording – problem with privacy
4. Flow Chart
Methods of Gathering Data 5. Charting by Exception (CBE) – only significant change is
Interview documented
 therapeutic and non communication
 Health history Case Management done with a Critical Pathway
o Medical history – disease focused (physiological) Variance
o Nursing history – needs, psychosocial dimension, - Comprehensive and make sure that it won’t legally be implicated
spiritual aspects
PHYSICAL EXAM (Plan Order)
Observation - Cephalocaudal
 Use of senses to gather data o Inspect, palpation percussion, auscultation
 Clinical eye – comes with practice and experience o Inspection, auscultation, percussion, and palpation
sequence on abdomen to prevent stimulation of
Examination peristalsis and for the patient to follow a more
 Inspection, Palpation, Percussion, Auscultation comfortable to least comfortable examination

After data collection, synthesis, analysis and validation are performed Focused Assessment – on specific part/symptom
DIAGNOSIS*
Problem + etiology +defining symptoms Bruit – normal if with AV fistula, abnormal in other since it may signify
*Guided by the NANDA arterial occlusion
Knowledge deficit – kulang sa kaisipan
Knowledge deficiency – ku SMARlang sa kaalaman (preferred) Auscultate the scrotum in inguinal hernia since it may have bowel sounds
Self care deficit - acceptable
Types of Nursing Diagnosis Compare each body part to the other
 Actual
POSITIONING - Flat – bones, muscles
- Sitting - Tympany - abdoment
- High Fowlers (90%) - Resonant - lungs
- Orthopneic position (leaning on a table, hands extended) - Hyperresonance – abnormal (emphysema)
- Supine, Back Lying, Dorsal, Horizontal Recumbent
- Flat on Bed – no pillow Typanism – kabag
- Dorsal Recumbent – legs flexed to relax abdominal muscles,
abdominal palpation/ exam – followed by diagonal draping DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant
- Standing/Errect – curvature of the spine
- Prone/ Face-lying position Parts of the Stethoscope
- Sim’s Position, Left lateral, Side-lying – rectal exam, suppository Diaphragm – high pitched; lung sounds
insertion, enema administration Bell – low pitched; heart sounds
- Knee Chest position/ Geno-pectoral position/ Jack Knife position
– rectal exam, dysmenorrhea Adventitious breath sounds – no abnormal sounds
- Kraaske – inverted V
- Lithototomy – stirrups Respiratory Sounds
- Trendelenburg – foot up; head down Wheezing – narrowed airway; asthma, bronchitis
- Reverse trendelenburg – head up, foot down Crackles – rubbing hair in small airways; retained secretions;
- Modified trendelenburg – only leg up for shock: L Girgles (Rhonchi)- rubbing hair in wide airway
Stridor – noisy breathing
MCNAP – training to perform internal examination Stertor – laryngeal spasm

Chest Cardiac Sounds


- Pectus excavatum – funnel chest (congenital); compression of - 5th ICL MCL at the PMI
heart and breathing - Llllleft – Pulmonic valve
- Pectus carinatum – pigeon chest – deformity for rickets (Vit D - Rrrrrr- Aortic valve
deficiency); AP diameter decreased
Posture NPH – Ntrmediate
- Kyphosis Humulin R- rapid
- Lordosis Glargular – rapid
- Scoliosis – lateral
Skin Bowel Sounds
- Capillary refill test = 1-2 seconds - Normoactive: 5-30 bowel sounds per minute
- Icteric sclera - Wait 3-5 mins before concluding that bowel sounds are absent
- Cyanosis – late sign of oxygen deprivation - Hyperactive – Borborygmus
- Vitiligo - Paralytic ileus – paralysis after surgery
- Erythema
- Pallor Voice Transmitted Sounds
- Egophony – say “E” but hears “A”
Nail Beds - Whispered Pertoriloquy – whisper but we hear it loudly,
- Clubbing - Beyond 180 degree due to dec. oxygen secondary to consolidation
- Koilonychia -Spoon shaped nail due to iron deficiency anemia - Vocal fremitus
- Onycholysis/Oncolysis – separation of nail
- Paronychia – severe inflammation of nail Shifting dullness to check for ascites
- Unguis incartatus - ingrown toenail
LABORATORY EXAMS
PALPATION - Properly collect the specimen
- Light (indentation half an inch) - Give instructions correctly
o Fontanels, buldges, pulses, lymph nodes, thyroids,
symmetry, neck veins, edema Urinalysis
- Deep - Color: Amber, tea-colored (biliary d/o), urobilinogen
- Odor: Aromatic/ Ammoniacal (decomposed urine)
IE is a form of palpation - pH: Acidic – does not favor bacterial growth
Chest expansion must be symmetrical - Specific gravity: 1.050-1.025, if elevated urine is concentrated,
Tactile fremitus - sound that is palpable suspect dehydration
- Increase in consolidation, pneumonia - Phosphates/Urates: Normal
- Decrease in pneumothorax - Glycosuria – Diabetes (BS is more than 200mg)
Thrill – palpable murmur - Hematuria – Stones, BPH, renal diseases, UTI
Edema – on dependent area and may occur in legs - Albuminemia – protein in urine, eccampsia
- Pitting/Non-Pitting - Pyuria – UTI
- Cyllinduria – cast in urine (stones)
Anasarca – generalized edema - First voided urine, mid stream to clean the urethra first
Peri-orbital edema – about the eye - Sterile specimen
- Indwelling catheter – wait in the end of the catheter for 30
PERCUSSION mins
- Touch and healing - Indwelling catheter – aspirate from 10ml syringe
- Wee bag (*)
Tuning Fork - Ketonuria - ketone
- Weber’s test/ Lateralization test – conduction hearing
- Rhinne’s Test – bone-air conduction Urine Culture & Sensistivity Test
- Exact microbe
Indirect Palpation - Result is final only after 5-7 days
- Flexor – Hiitting - Same collection process but less amount
- Pleximeter – Receiving - Ideal is catheterized cath
Sounds
- Dull - organ Chemical Tests for Urine
- Clinitest – way to determine sugar in urine (glycosuria) Thoracentesis
- Benedict’s test – used Benedict’s solution then heat to check for - aspiration of pleural fluid through a needle
potency: must remain blue; if not blue, discard - orthopneic position
- NO BOILING - informed consent
o Then add 3-10 drops of urine then heat - Fluid - 7-8 or 8-9 in intercostal posterior axillary line
o Negative results - Air - 2-3, 3-4 in intercostals
o Negative: Blue - Needs chest x-ray
o +1 - Green - Positioned lying on unaffected side
o +2 - Yellow
o +3 – Orange Thoracostomy
o +4 - Red - to return to negative pressure
o Collected before meals
- Heat and Acetic Acid Test – test of albuminuria; divide into 3 Abdominal Paracentesis
parts then add 2/3 urine, then 1/3 acetic acid - Aspiration of peritoneal fluid in ascites
o Turbid/Cloudy – positive - Semi-sitting/sitting position
o Not reliable since no microscopic instruments were - Void before procedure
used - May be therapeutic or diagnostic
o Done mostly in the community, NO BOILING - Watch out for hypovolemia

Quantitative Urine Exam Lumbar Puncture/ Tap


- 24-hour Urine Collection – HCG, urinary amylase, urinary - L3, L4, L5, subarachnoid space
catecholamines, urinary creatinine, urine albumin, - Paralysis risk low
corticosteroids - Fetal position – widens the angle of the lumbar spine
o 6pm order, discard urine on 6pm, start on 6:01pm - 50-200mm – normal CSF pressure
o Whole amount of urine, need not be midstream - Prepare 4 test tubes since every test requires a different test
o Preserve in ice – cold storage tube
o Leeway of 15-30mins; get urine after deadline as - Label test tubes and seal with appropriate cover; not with
long as not too far cotton
- Fractional Urine Collection – shorter span; time determined by - Xanthochromic – hemolyzed blood; yellowish discoloration
doctor - Flat on bed after procedure (6-8 hours) to prevent spinal
headache
Fecalysis
- Color of stool is influenced by stercobilin Diagnostic Exams
- Clay colored = acholic stool = biliary track obstruction - Visualization procedures
- Hematochezia = red = lower GI bleeding - Endoscopy
- Melena = blood = upper GI bleeding o direct visualization; lighted instrument
- Steatorrhea = fat = gall bladder rpoblem - X-Ray – graphy
- Foul smelling – indole and skatole o Contraindicated in pregnant women due to
- Soft/formed terratogenic effect
- Dead bacteria, fibers, amorphous phosphates – normal - Transformed
- Live bacteria – abnormal o Ultrasound/ Sonogram
- After 1 hour, the stool cannot be used for fecalysis
- Collect abnormal looking feces, not the one which is well Electroencephalography (EEG)
formed - Shampoo hair before and after procedure
- Sedative must be withheld
Stool Culture and Sensitivity - Determining seizure disorders
- Determining exact microorganism
- Result also final after 5-7 days Electrocardiography (ECG)
- Sterile container
Electromyogram (EMG)
Guiac Test - Invasive
- Occult blood test - Phase 2 – insertion of needle into muscle
- No meat, highly colored food, iron preparation, Vit. C in diet
- 3 days occult blood sample CBC needs a heparinized syringe
-
Sputum Exam Magnetic Resonance Imaging
- Done in early morning since secretions already pooled - CI: steel implant and pace maker
- Sputum C &S – may give oral hygiene to remove mouth - Some ortho implants/prosthesis are allowed
bacteria - Assess for claustrophobia
- Acid Fast Bacilli – 3 consecutive days - Needs consent since it’s expensive
- Sputum Cytology – cancer cells - With contrast in special procedures
- Eosinophil determination – to determine allergic reaction - NPO – to avoid aspiration in case of untoward reaction
- If unconscious, suction may be done: mucus trap
Computed Tomography Scan
Blood Examinations - Lesion must be bigger
- FASTING - Dye and NPO
o Triglyceride (1-12 hours), BUN (6-8 hours), HDL,
LDL, FBS, Total Protein, Albumin Globulin ration, Positron Emission Tomography
uric acid - Radioactive glucose (Fluorine)
- NON FASTING - Cancer cells have strong affinity for glucose; detect cancer sites
o Crea, Na, K, Ca, CBG (but pre meals) of metastasis

CBG Nuclear Medicine Thyroid Scan


- before meals - Nodule/tumor on thyroid
- prick at the side since low blood vessels
For abdominal scans laxative, (castor oil/ Dulcolax) and NPO may be o Given through IV port and the xray series is made
necessary o Assesses kidney’s ability to filter
o Assesses presence of stones
Opthalmoscopy o If reverse, retrograde pyelography
- Opthalmoscope
- Used in determining cataract - Oral Cholecystography
- Dim the light and focus light of opthalmoscope in the eye o Iapanoic acid (Telepaque) – taken every 5-10 minute
- Fundoscopy may be determined interval; 6 tablets
o Low fat meal the day before the exam
Otoscopy o Laxative + NPO
- Otoscope
- A cannula is inserted in the external auditory canal Ultrasound/ Sonogram
- No need for written consent - US Brain
- US Heart (2D ECHO, Echocardiography)
Rhinoscopy o Regurgitation
- Rhinoscope o Stenosis
- Hyperextend the neck - US Lungs
- US Breast/ Sonomamogram
3 y/o above – up & back o Needs tranducer
3 y/o below – down & back - US Abdomen
o Colon – laxative, NPO
In all scopes, there is always a light at the end o Kidney – KUB
o Pelvic ultrasound – drink 6-8 glasses to have a full
Endoscope bladder; do not allow to void
- Can be used for surgery, biopsy o Gallbladder ultrasound
- Pharyngoscopy - Transvaginal Ultrasound
- Bronchoscopy o Will outline fallopian tube, uterus and ovaries
- Langyngoscopy o consent
- Esophagogastroduedenoscopy - Transrectal Ultrasound
- Anoscopy o Consent
- Proctoscopy – rectum o Empty the bladder for comfort and good
- Sigmoidoscopy visualization
- Coloscopy – anus to ileum o Visualization of uterus/ prostate
o Cleansing enema until clear
- Remove dentures ADMITTING A CLIENT
- Remove gag reflex by local anesthetic agent and check gag
reflex Types of Bed
- Resume food only when gag reflex is present - Closed – in anticipation for an admission
- Consent and NPO - Open
- Urethroscopy - Post-Op/ Surgical/ Anesthetic/ Heater bed
- Cystoscopy – bladder, written consent, cystoclysis set up - Occupied
(continuous flow of sterile water which also exits)
- Colposcopy – vaginal examination, needs vaginal speculum Principle of Bedmaking
o Shirodkar – tying the cervix so that miscarriage is - Body Mechanics: Bed from knees, wide base of support
avoided; incompetent cervix - Obtain help
- Asepsis, do not let linen touch uniform
Roentgenography - Do not let the linen fall into ground
- Electromagnetic radation photography - Finish one side of bed first
- Xray but without contrast medium - Remove wrinkles to have aesthetic value
- Chest X-Ray o Top sheet – excess linen in foot part
o Not definitve of TB o Bottom sheet – excess linen in head part
- Mammography
o Examination of breast CHANGING GOWN
- Scout Film of Abdomen - Remove with free arm first in changing gown
- KUB - If both with contraption, any arms

ORIENTING THE CLIENT


Upper GI Series ASSESSMENT
- Esophagus, stomach, duodenum HISTORY TAKING
- Barium swallow (dye) – outline the GI system, flavored, has PHYSICAL EXAM
constipating effect – inc. fluid VITAL SIGNS
- Uses laxative, NPO DOCUMENT
- Enema to evacuate barium to prevent fecal impaction - chief complaint only found on admission sheet

Lower GI Series DISCHARGE OF PATIENT


- Barium enema - may be against medical advise (DAMA) but it needs doctor’s
- Outline of colon order
- Laxative and cleansing enema until it is clean - health instruction
- Pink phosposoda (oral cleansing enema) - Illegal detention (false imprisonment)
- Evacuate barium through enema to prevent fecal impaction

Excretory Urography VITAL SIGNS


- Intravenous Pyelography Children – RR, PR,T
o Hypaque- - made from iodine substance; check for * BP can also be obtained in children
allergy for seafoods
o Laxative + NPO Types of Temperature
Core temp. – more important; cant be affected by environment Pulse Strength = pulse volume
Surface temp. – more important in children since hypothalamus not yet +1 – collapsible. thready
developed +2 – normal
+3 - full
Poikilothermia – temp is same with environment; newborn +4 – full, bounding
Homeothermia – different with the environment

Factors that affect Body Temperature Corrigan pulse/ Waterhammer pulse –thready and with full expansion
1. Age followed by sudden collapse
2. Ovulation – temp is higher; progesterone
3. Activity – inc. BMR
4. Environment Respiration
Kinds:
Temperature conversion Internal
C-F multiply 1.8 + 32 External
F-C subtract 32/ 1.8
Normal: 16-20
Methods of taking body temperature
- Oral – CI in brain damage, mental illness, retarded, problem Eupnea – normal breathing
with nose and mouth, tooth extraction, contraption in nose and Bradypnea
mouth, altered LOC, dyspnea, seizures, 7 y/o below Tachypnea/Polypnea
o 2 mins Dyspnea
- Rectal – CI in imperforate anus, rectal polyps, hirschprung’s
disease, diarrhea, increase ICP, cardiac disease (may cause Katupnea - Difficulty of breathing while in sitting position
vagal stimulation) Trepopnea - ease when in side-lying position
o Not safe since it can cause rectal trauma Hyperpnea – inc. rate and depth of respiration
o 1 min Cheyne-stokes
- Axillary – 3mins Biot’s respiration –
- Tympanic – external ear. CI in otitis, ear surgery Kausmaul’s Breathing – hyperventilation, blow off excess CO2 which may
- Temporal Scanner - done in temporal lead to alkalosis

Most convenient way is temporal! BLOOD PRESSURE


Tympanic is most accurate!
Factor’s Affecting Blood pressure
Temperature can be checked every 30 mins since hypothalamus can only - Age, Gender
fluctuate the temp. every 30 mins - Activity, exercise, stress
- Time of the day
Spot Vital Signs – HR, RR, BP Kinds
Thermopacifier – for crying babies - Direct – venous pressue, CVP, invasive, cutdown (5-12mmHg)
Plastic strip Thermometer – Amitemp - Indirect
o Palpatory
Pyrexia – 37.5-38 degrees and above o Ausultatory
Hyperpyrexia – 41 degrees
Korotkoff’s sounds
Types of Fever Pulse pressure
Intermittent Pulse deficit (systolic - diastolic)
Remittent – goes down but does not go normal Mean Arterial Pressure ([2D+S]/D)
Relapsing -
Constant/Continuous

Heat Stroke – depletion of fluid, hypothalamus does not regulate Classification SBP DBP Lifestyle
Hypothermia – induced (surgery), extreme temperature mmHg mmHg Modification

Pulse Optimal <120 And <80 Encouraged


- Temporal
Pre- 120-139 Or 80-89 YES
- Carotid – cardiac arrest
hypertension
- Apical
- Brachial Stage 1 HPN 140-159 Or 90-99 YES
- Radial – thumb site Stage 2 HPN >160 Or > 100 YES
- Femoral Stage 3 HPN > 180 Or > 110 YES
- Popliteal
Choose the higher BP
Affected by the following:
1. Age – the younger, the faster False Low Reading
2. Activity - BP cuff to wide
3. Stres - Arm is above the level of heart
4. Drugs - Deflating too quickly – low systolic
a. Inc. - anticholinergic, sympathomimetic
b. Dec – cardiac glycoside Inverse of above, high

Pattern of Beat (Rhythm) Oxygenation


- Regular - Nasal cannula
- Irregular - Nasal catheter
o Bigeminal pulse - Hood
o Trigeminal pulse - Mask
o Simple face mask
o Partial rebreather No hypervitaminosis in water soluble since it is easily eliminated in
- Steam/Aerosol inhalation urine
o No steam in babies, may burn patient
o Use saline solutionizer Overweight – increase in macronutrients; may progress to obese
o Nebu Marasmus
- calorie malnutrition
Safety since oxygen is flammable - Old man facie, intercostals and subcostal retractions
Humidification since air is dry, use sterile distilled water Kwashiorkor
COPD – low flow oxygen (1-3LPM) - moon face, Globular abdomen, edema
- protein malnutrition
Auscultate for respiratory secretion build up.
VITAMIN DEFICIENCIES
Chest Physiotherapy (CPT) Vit A (Retinol)
Pursed lip breathing – inhale and exhale with pursed lip - Healthy eyes, skin, and gums
Deep, breathing and coughing - Deficiency: Xeropthalmia (night blindedness) – Bitot’s spot
- Severe: Keratomalacia (irreversible)
Most efficient way to remove secretions is to cough! Vit D (Calciferol)
- Not coming form the sun; but sunlight activates it
Suction – removal of secretions through negative pressure, if adult above - Enhances calcium and phosphorus absorption
150mmHg. If kids, below 100. The smaller the diameter the higher the - Deficiency: Ricketts
pressure - Severe: Osteomalacia
o Bow legged – genu varum
Lubricate suction tip with water and insert up to 10 seconds only then o Knock knee – genu valgum
hyperoxygenate the patient o Pectus carinatum (Harrison’s groove)
o Spinal deformity
Sterile method\ o Stunted growth
You can store calcium up to 31 years
Incentive spirometer – not how the ball goes up, but how it stays afloat
Vit E (Tocopherol)
WATER - Antioxidant: remove free radicals
- Amount should not go 400 units because if it exceeds. It
Child – has 70- 90 percent water becomes prooxidant
Adult – has 50-70 percent water - En hances RBC maturation
- Deficiency: anemia
Males have more water than females since they have more adipose tissue Vit K (Menadione)
- Anti-hemorragic
NUTRITION - Deficiency: hemorrhagic, bleeding
- Subtotal of how foods are utilized
Kaesselbach’s plexus - prone to epistaxis
Macronutrients
- Give off calories for energy B Vitamins
Micronutrients - Metabolism since these have enzymatic activity
- No calories, vitamins and nutrients
Vit B1 (Thiamin)
Sources: - Deficiency: Beri-beri; Wernicke-Korsakoff Syndrome
CHO – 4 calories/gm; first to be burned - Edema in wet Beri-beri
FATS – 9 colories/gm; stored as adipose tissue
CHON – 4 calories/gm; meat Vit B2 (Riboflavin)
Alcohol – 7calories/gm - Deficiencies: Ariboflavinosis, cheilosis
o Angular stomatitis - mouth fissures
Egg yolk – vitamin A
Vit B3 (Niacin)
Vitamins - Deficiency: Pellagra – butterfly sign, cassel’s collar
- Fat soluble - ADEK
- Water soluble – B complex , C Vit B5 (Pantothenic Acid)
- Keeps integrity of hair
Better to exercise before a meal to burn fat - Deficiency: alopecia

Macrominerals Vit B6 (Pyridoxin)


- 100 mg or more - Deficiency: Neuritis

Microminerals Vit B12 (Cyanocobalamin)


- Less than 100 mg - Definition: pernicious anemia, neuritis
- Zinc, iron, iodine
Vit C (Ascorbic)
Potato – highest in potassium - Inc. absorbtion of iron
- Deficiency : scurvy – easy bruising, gums, perifollicular lesion,
The tip of the banana has the highest amount of potassium hemorrhage

Iodine – prevent cretinism Nutritional Problems


Zinc – to improve appetite 1. Antropometric Measurement
Iron - correct anemia a. BMI – kg/m2
i. Underweight – below 18
Hypervitaminosis – increase in vitamins intake; occurs commonly in fat ii. Normal – 18-24
soluble iii. Overweight – 24 above
2. Biochemical Assay – laboratory exams
3. Clinical signs – sx/s
4. Dietary History Catheter can be placed in one month as long as no signs of infection
a. Food habits
Condom Catheter – must be secured through a belt
Anorexia – no eating
Bulimia – binge-purge syndrome Fides’ Maneuver – application of pressure in the bladder to stimulate
urine
Mgt:
- Hygiene Bowel Elimination
- Small frequent feeding
- Serve attractively Diarrhea – watery stools; ORESOL; banana rice apple

EXTRA-ORAL FEEDING Constipation – hard stools; laxative; Psilium (bulk-formers), Castor oil (GI
- NGT/ Levine’s Tube irritant)
o French 12-18 (bigger)
o Endoscopic intubation Tenesmus – urge to but unproductive of stool
o Measure length
o Gavage/lavage Fecal impaction
o Drain by gravity; decompression - constipation and seepage of watery stools
 Monitor for F&E imbalance - No enema
o Diagnostic procedure - Digital/Manual extraction with doctor’s order
- Monitor for vagal stimulation; stop if signs are noted
Check patency and position of NGT
- Aspirate gastric content Eructation/ Belching
- Place in water - Expulsion of gases through mouth
- Auscultate for gurgling sounds
- X-ray (1st) Flatulence/Typanism
- pH method (2nd) – pH of 6 and below, give feeding - Avoid gas forming foods: cauliflower, cola
- - Carminative enema – expel flatus
Withhold feeding if more than 100ml residue - Rectal tube insertion – inserted in anus then placed in water
for 20 mins; if need to be repeated wait for 2-3 mins. to
French is directly proportional to size prevent anal sphincter damage
Gauge is inversely proportional to size

Percutaneous Endocopic Gastrostomy (PEG) Enema


- No need to check if tube is on the stomach since tube is - Must be lukewarm
inserted surgically - Retention – allow solution to remain; barium enema
o Do not go beyond 150 ml
Dumping syndrome - Non-Retention – do not remain, cleansing enema
- Rapid emptying of gastric contents into the intestines o No limit of water

Duodenostomy Siphoning Enema /Return-flow enema


Jejunostomy – most prone to dumping syndrome; semi-sitting - Retained enema
- Right side lying to evacuate remaining enema solution
Intravenous Hyperalimentation/ TPN
- Kabiven Height of enema can is 18 high pressure ; 12 inches low pressure
- Watch out for gylcosuria and blood sugar
- May necessitate insulin MEDICATIONS
- Large needle since it is central route Suspension - refrigerate
- Monitor for complications
Parenteral
Intradermal
ELIMINATION - Gauge 25 -25
- Insert only the bevel; zero to 15 degree angle
Urine Elimination - Epidermal
1200 – 1500cc/day - Sensitivity test
Normal output:30ml/hour Subcutaneous
Urge to urinate: 300-500ml - Stretch if fat, pinch if thin
- Adipose layer of the buttocks, arms
Poliacuria – frequent, scanty urine - Best site is abdomen, below the umbilicus!
Urgency- urge but unproductive of urinate - Gauge 23-25, 5/8 inch inserted
Retention – stimulate urination, running water, warm water over - If long needle, insert 5/8; if short 90 degree
perineum, warm compress, straight catheterization Intramuscular
- Must be strictly 90 percent
Catheterization: - 1-1.5 inch
- Straight - Gauge 22-23
- Indwelling
o 2 way – inserted by nurse Z-track technique
o 3 way – do not attempt to insert; MD only - Deep IM
o Female: dorsal recumbent; Fr 12-14; inner thigh - Prevent leakage of solution to tissue
o Male: supine with legs apart; Fr 16-18; lower part of -
abdomen or upper thigh; position the penis NO INSERTION IN GLUTEUS MAXIMUS, BUT ON MINIMUS AND MEDIUS
perpendicular to the body
Intravenous
NEVER INFLATE THE BALLOON UNLESS URINE FLOWS IV Push – check backflow, if none do not insert
If inserted in vagina, keep in place but insert another one
IV infusion pump – for more accurate drip - Atrophy
Soluset – chamber up to 100cc; microset calibration - Disuse syndrome
- Trochanter roll to prevent external rotation of femur
Opthalmic solution – lower conjunctival site; 1-2 drops at maximum
CHANGE SKIN EVER TWO HOURS!
Rectal Suppository – go beyond the anal sphincter
Inhaler – may use spacer Pressure Ulcer
- Decubitus ulcer/ bed sore
DO NOT USE INHALER IN STEROIDS TO PREVENT MOUTH SORES! - Prone in bony surfaces
- 1 – non blanchable erythema
HEAT AND COLD APPLICATION - 2 – open lesion
Do not prolong more than 20 mins because of rebound - 3- with fat exposed
- 4 – exposed mucles and bones
Inflammation – first 24 hours cold, after heat
Pain – cold to block nerve Dressing
- Transparent barrier
Cold - Gauze not used
- Ice cap - To absorb exudates
- Compress - Hydrocolloid
- After 15 mins
TSB SLEEP
- Do anterior first - Stages of Sleep
- Use 1 washcloths - NREM 1
- NREM 2 – easily arousable
Hot Water Bath – prevent burns - NREM 3 – not easily arousable
- REM – paradoxical sleep/ looks awake but really asleep
Sitz Bath - 6-8 hours – 4-5 cycles of sleep
- immersion of 110-115 degrees Fahrenheit - RAAS system is responsible
- do not remove rectal pack, remove rectal dressing
- may have cerebral hypoxia – put ice cap on forehead Insomnia – warm bath, massage, milk (tryptophan), medication
Parasomnia – periods of waking up while asleep
WOUND MANAGEMENT Somabulism – sleep walking; lock the door
No gauze cause it can stick to skin Soliloquy – sleep talk
Center to outer when cleaning Notcurnal enuresis (night)/Diurnal enuresis (morning) - Bed wet, place
diaper
Jackson Pratt Bruxism – anxiety; grinding of teeth
- keep in negative pressure; remove drainage Hypersomnia – excessive sleep; may have hypothyroid, DKA
- in head injury, can have JP but not on negative pressure since it Narcolepsy – uncontrolled desire to sleep; ampethamine - taken after
can interfere with ICP breakfast, anorexiant
Hemovac
- also on negative pressure
PAIN
Perineal care - Subjective
- one stroke one direction - May have psychogenic pain as well
- Acute – less than 6 months
Oral Care - Chronic – more than 6 months
- manage in sulcus - Intractable – not relieved
- gumline out
- can have circular Wong and Baker Scale – 1-10 rating
Phantom pain – pain from amputated limb
Oral hygiene for unconscious Gate Theory of Pain - Substantia gelatinosa
- supine, head turned to one side
- antiseptic solution Pain threshold
- May be psychological/ physiological
Shampoo o Heat and cold
- Prevent dandruff o Imagery and distraction
- Anti-sebborheic
DEATH
Pediculosis Thanantology – study of death
- Head lice
- Pediculocide Stages of Grieving by Kubler Rosss

EXERCISE AND ACTIVITY Post-mortem care


Active-assitive – one side help the affected side - Must be pronounced dead by physic
Isotonic – jogging; change in length Rigor Mortis - stiffening
Isometric – mucle tension no change in length Algor Mortis – change in temperature
Isokinetic – weights Livor Mortis – color change

Aerobic –exceed oxygen needs


Anerobic - does not exceed oxygen needs

Immobility
- Thrombus formation
- Edema
- Constipation
- Urinary stasis – stones- calculi

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