Basic Human Needs

Activity, Mobility and Exercise

Introduction
Movement is an activity most people take for granted. The ability
to move and be active result to positive benefits to ones health status.
Mobility is often considered an indicator of overall health because it
influences the correct functioning of many body systems. Maintaining
functional mobility and desired activity levels are important for both
psychological and physiological reasons.
A knowledge of the principle of the body movements and skills in
their application are important to both the patient and the nurse.
Exercise and the body movements are often prescribed as supportive
measures to meet the clients particular health needs. When these are
not prescribed specifically, it becomes a nursing responsibility to plan a
daily program of activity to meet the clients needs for movements and
exercise.
It is equally important that the nurse uses her body in a way
which not only avoids muscle strain but uses energy efficiently. But the
practice of good body mechanics is not restricted to nursing care, it is
integral to healthy living for all people.
Body Mechanics.
Is the efficient, coordinated, and safe use of your body to produce
motion and maintain balance during the activity. Effective use of
body mechanics prevents injury to self and clients.
Principle s of Body Mechanics
1. Balance is maintained and muscle strain is avoided as long as the line of the gravity
passes through the base of support.
2. The wider the base of support and the lower the center of the gravity, the greater the
stability.
3. Balanced is maintained with minimal effort when the base of support is enlarged in
the direction in which the movement will occur.
4. Objects that are close to the center of the gravity are move with least effort.
5. The greater the preparatory isometric tensing, or construction of muscles before
moving an object, the less the energy required to move it and the less the likelihood of
musculoskeletal strain injury.
6. The synchronized use of as many large muscle groups as possible during an activity
increases overall strength and prevents muscle fatigue and injury.
7. The closer the line of gravity to the center of the base of support the greater its
stability.
8. The greater the friction against the surface beneath an object, the greater the force
required to move an object.
9. Pulling creates less friction than pushing.
10. The heavier the object, the greater the force needed to move an object.
11. Moving an object along a level surface requires less energy than moving an object up
an inclined surface or lifting it against the force of the gravity.
12. Continuous muscle exertion can result in muscle strain and injury.
Physiologic Response to Immobility
Musculoskeletal System
Decrease in muscle strength.
Muscle atrophy.
Disuse osteoporosis.
Demineralization.
Fibrosis and ankylosis.
Contracture.

Cardiovascular System
Use of valsalva maneuver.
Orthostatic (postural) hypotension.
Thromboplebitis.

Respiratory System
Atelectasis.
Hypostatic pneumonia.
Respiratory acidosis.
Metabolic and Nutritional Systems
Anorexia
Hypoproteinemia.
Hypercalcemia.

Urinary System
Urinary stasis.
Urinary tract infection.
Renal calculi.
Incontinence.
Retention with overflow.
Urinary reflux.

Fecal Elimination
Constipation.
Flatulence.
Integumentary System
Loss of skin turgor.
Decubitus ulcer.

Psychosocial Response
Decreased motivation to performed activities of daily living.
Decreased perception of time and space which may lead to confusion.
Increased sense of powerlessness which lowers self-esteem.
Diminished ability to make decisions, concentrate or cope.
Inability to sleep that may lead to weakness and personality changes.
Etiology and Phatogenesis of Pressure Sores
Pressure Sores/Decubitus Ulcers/Pressure Ulcers/Bedsores or Distortion Sores.
Reddened areas, sore or ulcers of the skin occurring over body proiminences.
They are due to interruption of the blood circulation to the tissue, resulting in a
localized ischemia.

Causes of Pressure Sores

Pressure.
Friction.
Shearing force.
Risk Factors in the Formation of Pressure Sores.
Immobility and inactivity.
Inadequate nutrition.
Hypoproteinemia.
Excessive body heat.
Fecal and urinary incontinence.
Decreased mental status.
Diminished sensation.
Stages of Pressure Sore Formation
Stage I Non blanchable erythema of intact skin.
Stage II Partial-thickness skin loss involving epidermis
and or dermis. The ulcer is superficial and
presents clinically as an abrasion, blister or
shallow crater
Stage III Full-thickness skin loss involving damage or
necrosis of subcutaneous tissue that may
extend down to, but not through underlying
fascia. The ulcers presents clinically as deep
crater.
Stage IV Full-thickness skin loss with extensive
destruction, tissue necrosis or damage to
muscle, bone or supporting structures as
tendon or joint capsule.
A. Preventing and Treating Pressure Sores
Provide smooth firm, wrinkle-free foundation on which the client can lie.
Use foam, rubber pads, artificial sheepskins, egg crate or flotation mattress
under pressure areas.
Apply thin layer of cornstarch to the bed sheet or wheelchair seat cover.
Reduce shearing force by elevating head of bed of bedfast clients no more than
30 degrees.
Ongoing assessment of early signs and symptoms of pressure sores.
Change position of bedfast clients every 15 minutes to 2 hours.
Meticulous hygiene.
Keep skin clean and dry.
Apply powder to tissues with limited blod flow.
Avoid massaging bony prominences with soap when bathing the client.
Use superfatted soaps and water.
Massage pressure areas gently.
Apply cream or lotion on dry skin.
Client teaching on prevention of pressures sores.
B. Treatment of Decubitus Ulcer
Clean pressure sore daily, preferably in a whirlpool bath.
Clean and dress the sore using surgical asepsis.
If the pressure sore is not infected, cover it with an occlusive dressing and leave
the wound undisturbed for few days.
If the pressure sore is infected, obtain a sample of drainage for C & S (culture
and sensitivity test).
Reposition client every two hours.
Apply a small amount of cornstarch to bedsheet.
Keep head of bed flat or elevated at a maximum of 30 degrees.
Use a special mattress or pad.
Teach the client to move.
Encourage ambulation or sitting in wheelchair.
Provide ROM (range of motion) exercise.
Nursing Interventions to Promote Activity and Exercise
1. ADL (Activities of Daily Living)
2. Protective positions.

Protective Devices
1. Hand rolls and rubber balls.
2. Trochanter roll.
3. Foorboard and boot splints.
Exercises
1. Purpose
2. To maintain good body alignment.
3. To improve muscle strength.
4. To improve muscle tone.
5. To improve circulation
6. To relieve muscle spasm.
7. To relieve pain.
8. To prevent or correct contracture deformities.
9. To promote sense of well-being.
Types of Exercises
1. Active ROM.
2. Passive ROM.
3. Active-Resistive ROM.
4. Active-Assistive ROM.
5. Isotonic.
6. Isometric.
Transport of Client

Bed to Wheel Chair

Position wheelchair parallel to the bed.
Lock the wheel of the wheelchair.

Bed to Stretcher
Place the stretcher parallel to the bed.
Lock the wheels of the bed and stretcher.
Push the stretcher from the end where the clients head positioned.
When entering the elevator, maneuver the stretcher so that the clients head goes in first.

Always lock the wheels on bed, stretcher, or wheelchair. Unexpected movements may results
to injury.
Assisting Clients in Ambulation
Purposes
1. To increase muscle strength and joint mobility.
2. To prevent some potential problems of immobility.
3. To increase the clients sense of independence and self-
esteem.
Ambulance the client gradually to prevent orthostatic hypotension.
If orthostatic hypotension or extreme weakness occurs, assist the
client quickly in a sitting position and lower the head between the
knees. Lowering the head facilities blood flow to the brain.
Ensure safety of the client during ambulation.

If the client becomes dizzy or starts to fall, during ambulation, slowly and gently lower
him to the floor and call for help. If the client is at high-risk for falls, two nurses may be
required to assist with ambulation.
Safety
Safe Environment
One where the likelihood of becoming ill or injured because of factors in the
environment is reduced to the lower degree of possibility.
One in which people can function safely and one in which they obtain a sense
of security.
Characteristic of Safe Environment
1. Adequate lighting.
2. Neat and clean.
3. Safe equipment.
4. Noise level is comfortable.
5. Cleanliness.
6. Medication.
7. Temperature of environment.
8. Relative humidity.
9. Free of pollution.
Factors that Affect Peoples Ability to Protect
Themselves
1. Age.
Infant, toddler, preschooler.
School-age.
Adolescent.
Adult.
Older adult.
2. Orientation and level of consciousness.
Unconscious/semiconscious.
Neurologic impairment.
Inability to communicate.
Paralyzed.
Confused.
Alcohol withdrawal.

Unable to perceive stimuli that may cause trauma or injury

3. Emotions

Acute anxiety
Depression
Preoccupation with pain/illness

Alter ability to perceive environmental hazards

4. Injury or illness
Ill, weak people are prone to accidents
5. Sensory or communication impairment
Unable to perceive potential danger or express needs
for assitance
6. Information/Safety awareness
Knowledge deficit on safety increases risk for various
types of accidents
Risks in Health Care Agency

1. Falls.
2. Client-inherent accidents.
3. Procedure-related accidents.
4. Equipment-related accidents.
Safety Precaution in Health
Infants
Some of the special precautions to be observe in the care of the infants are
as follows:
Provide only toys that are soft and large and that do not have parts
that can be removed and swallowed.
Always have the sides of the crib up when the baby is not being
handled.
At feeding time, hold the baby.
Put pins, needles, buttons and nails out of reach of the baby
because infants like to put things in their mouth.
Use guard rails at the top and bottom of the stairs when the baby
starts to crawl.
Cover electric outlets and install safety outlets if possible.
Do not leave a baby alone in the bath or in a bed or a table because
the baby may roll off.
Toddlers
Some special precautions in toddlers are as follows:
Knives and other sharp toolsand matches need to be
kept away from the toddlers reach.
Pots on the stove need to be kept on the back burners,
away from the toddlers reach.
Cleaning solutions and insecticides need to be kept in
lock cupboard.
All medicines need to be stored in a lock cupboard.
The play area outside should be free of deep ditches,
wells and pools.
Teach the toddledrs what no and dont mean and
what these words are meant when they are spoken at
times of risk for the toddler or for others.
Preschoolers
Accident prevention includes teaching them to observe and to act safely.

School-age Children
School-age children have the following needs to protect themselves:
School-age children need to learn to use equipment such as the stove and the garden
equipment safely.
They will need to understand traffic rules before bicycling.
They will still need help and supervision with much equipment, and if they live in
the country, they will need to handle farm animals.

Adolescents
Some safety measures that adolescents require in order to prevent accidents are as
follows:
Developing in inner discipline.
Wearing safety helmets when riding motorcycles and similar vehicles.
Learning to swim and understanding water safety.
Understanding the danger involved in the use of drugs and alcohol.
Adults
Alcohol is a significant factor in accidents. Need to learn not to
drink if they are driving motor vehicles or boating.

Elderly
Toys need to be out of the way, rugs need to be fastened so that
they will not slip. Handrailings in the bathroom and the
placement of dishes and frequently used supplies within easy
reach.
Safety Precautions in Illness
1. Falls and other Mechanical Trauma
Bedsides tables and over bed tables are placed near the bed or chair so that patients
do not need to overreach and consequently lose their balance.
Patients who have had surgery or have been in bed for some time are advised to have
assistance when first getting out of bed.
Footstools are supplied with rubber feet, which do not slip, and wheelchairs with
locks on the wheels.
Floors have nonslip surface; rugs and carpeting are fixed securely in place so that
they will not slip.
The environment is kept tidy so that people do not trip over light cords, toys or
misplaced furniture.
Some hospitals provide ambulating patients with railings along the corridors and in
the bath rooms.
Use of protective devices such us side rails and restraints may be indicated in the
certain situations.
a) Siderails help a patient from falling out of bed.
b) Restraints prevent falls or injury.
Guidelines in applications of Restraints
1. Allow the patient as much freedom to move as possible and at
the same time serve the purpose of the restraint.
2. The patients circulation must not be occluded by the restraint.
3. Pad bony prominences under a restraint in order to avoid skin
abrasions.
4. The restraint needs to permit the body to assume its normal
position.
5. Use at least conspicuous type or restraint possible.
6. At the first indication of occlude of peripheral circulation, the
restraint needs to be loosened and limb exercised.
7. Remove restraints at least every 2 hours for 30 minutes.
8. Restraints application requires doctors order.
9. Secure doctors order for each episode of restraints application.
10. Ideally, application of restraints require consent from relatives
or significant others.
2. Burns
Burns can be prevented in healthcare by:
Testing bath water for temperature when the client has sensory
impairment.
Checking heating pads, heat lamps, steam inhalator, and other
electrical equipment to be sure they are functioning properly.
Assisting clients when handling hot beverages as needed.

3. Chemical Trauma
Assistance necessary to prevent accidents:
Label the medication in large enough print so that the patient can
read it.
Parents with young children may need cautioning to place the
medicine out of reach of the children.
Patients who take their own medication out of the hospital will
need to have these recorded charts and have the physicians
permission.
4. Radiation Injury
Can injure skin and other parts of the body.
Factors that directly affect the degree of exposure
to radiation are as follows:
The longer the time that a person is in the presence of the
radiation the greater the exposure.
The closer a person is to the source of the radiation the greater
the exposure.
Substances such as lead can be used to shield a person from
radiation.

Safety of the client should always be given priority when providing care.
Safe nursing care environment is of utmost consideration in every
health care setting.
Comfort, Rest and Sleep

Pain.
A sensation of physical or mental hurt or suffering that causes distress or
agony to the experiencing it.
Theories of Pain
1. Pattern Theory states that pain perceived if the stimuli is intense enough.
2. Specific Theory states that there are specific nerve receptors for particular
stimuli.
3. Gate Control Theory conceptualizes that there is a gate in the spinal cord
called substantia gelatinosa.
4. Affect Theory avers that the pain is emotional.
5. Parallel Processing Model believes that the physiological or neurological
deciphering of the pain sensation and the cognitive emotional properties
occur along the different nerve fibers.
Factors Influencing the Pain Experience
1. Age
2. Sex
3. Childhood
4. Cultural Background
5. Psychological Factors
6. Previous Experience
7. Religious Beliefs
8. Expected Response
9. Setting
10. Diagnosis
11. Physical/Mental Health
12. Knowledge/Understanding
 Pain threshold. Amount of pain stimulation a person
requires before feeling pain.
Pain tolerance. Maximum amount and duration or
pain that an individual is willing to endure.
Pain Perception. Actual feeling of pain.
Bradykinin. Universal stimulus for pain.
Hyperalgesia. Excessive sensitivity to pain.
 Physiology of Pain
Stimuli Nerve Fibers (nociceptors)

A-Delta fibers C-fibers

(large,myelinated) (small, unmyelinated)
Conduct impulses rapidly conduct impulses slowly
Sharp, pricking pain dull, aching burning sensation
Superficial somatic pain deep somatic and visceral pain

Spinal Cord
(Substantia Gelatinosa)

Thalamus
(Center for awareness of pain)

Cerebral Cortex
(Center for interpretation of pain)

Responses
Types of Responses to Pain
1. Involuntary Responses
Physiologic responses e.g. sympathetic response,
parasympathetic response
2. Voluntary Responses
Behavioral responses e.g. crying, moaning, grimacing etc.
Emotional responses e.g. depression, withdrawal, social
isolation

Three Stages of Pain Response

Activation begins with the perception of brain.
Rebound experienced is intense but grief.
Adaptation pain last for many hours.
Classification of Pain
A. Types of Pain
Cutaneous or Superficial Pain occurs over the body surface
or skin segment.
Somatic Pain occurs in the skin, muscles or joints.
Visceral Pain - arises from stimulation of pain receptors in the
abdominal cavity and thorax.
Referred Pain perceived at an area other than the site of
injury.
Intractable Pain resistant to cure or relief.
Phantom Pain felt in a body part no longer present.
Radiating Pain felt at the source and extends to surrounding
tissues.
Psychogenic Pain due to emotional factors, with no
physiologic basis.
Intermittent Pain pain that stops and starts again.
B. Location
Provides information on the organ affected.

B. Duration
a) Acute Pain. Lasts for less than 6 months.
b) Chronic Pain. Lasts for more than 6 months.

D. Character/Quality
Whatever description the client gives, accept it as it is.

E. Intensity/Severity
Use scale 0 to 10. 0 no pain; 1-3 mild pain; 4-6 moderate pain; 7-10 severe pain

F. Factors Relieve/Aggrevate Pain

e.g. chest pain in the angina pectoris can be relieved by rest or nitroglycerin.

G. Effects of ADL
e.g. the back pain in a client with herniated nucleus pulposus which can no longer be
relieved by medications may require surgery.
Neurosurgery for Relief of Pain
Neurectomy interrupts cranial or peripheral nerves by an
incision.
Rhizotomy interruption of the anterior or posterior nerve
root area close to the spinal cord.
Cordotomy or Spinothalmic Tractotomy - interruption of
pain-conducting pathways within the spinal cord.
Tractotomy resection of the anterolateral pathway in the
brainstem.
Gyrectomy removal of the postcentral gyrus (part of the
sensory cortex of the brain)
Hypophysectomy destroying of the pituitary gland by
injection with absolute alcohol.
Pain Modulation
Endogenous Oploids
Chemical regulators that may modify pain.
Enkephalins inhibit the release of substance P, a
neurotransmitter which enhances transmission of pain
impulses.
Endorphins more potent than enkyphalins.
Dynorphins have analgesic effect, 50 times more
potent than endorphins.
Nursing Care of the Patient with Pain
1. Techniques that stimulates the skin.
Therapeutic touch.
Contralateral stimulation.
Vibration.
Heat and cold application.
Counterirritants.
Acupuncture.
TENS(Transcutaneous Electrical Nerve Stimulation)

2. Techniques that distract attention.

Staring .
Slow, rhythmic breathing.
Recite, sing.
Describe something in detail.
Listen to music.
Conversation.
Read, play games.
Busy oneself (chores, hobbies)
Favorite toy
Techniques that Promote Relaxation
a) Conventional Methods
Relax muscles.
Listen to music.
Guided imagery.
Meditation, Yoga, Biofeedback.
Autogenic Training.
b) Analgesic.
c) Placebo.
Rest and Sleep
Rest
Diminished state of activity, calmness, relaxation without
emotional stress; freedom from anxiety

Sleep
A state consciousness in which the individuals perception and
reaction to the environment are decreased.
Physiology of Sleep
Reticular Activating System (RAS) maintains a stae of wakefulness and
mediates some stages of sleep.

Serotonin major neurotransmitter associated with sleep.

Theories of Sleep

Active Theory of Sleep proposes that there are centers

that cause sleep by inhibiting other brain centers.

Passive Theory of Sleep states that the RAS of the

brain simply fatigues and therefore becomes inactive
thus, sleep occurs.
Stages of Sleep
NREM (Non-Rapid Eye Movement) Stage
a) Very light sleep. Stage 1
Drowsy, relaxed.
Readily awakend.
b) Light sleep. Stage 2
Eyes are still.
Heart and respiratory rate decreases slightly.
Body temperature falls.
c) Domination of PNS. Stage 3
Body process slows further.
Difficult to arouse.
d) Deep sleep. Stage 4
Difficult to arouse.
Decrease BP, RR, PR, Temp;
Metabolism, Brain waves, Muscles relaxed.
REM (Rapid Eye Movement) stage
Eyes appear to roll.
Paradoxical Sleep
Close to wakefulness but difficult to arouse.
Dreamstate of sleep.
Sympathetic Nervous System dominates.
Flow of gastric acids increases.
Restores a person mentally-learning, psychologic
adaptation and memory.
The sleeper reviews the days events and process
and stores information.
Functions of Sleep

NREM body restoration

REM increase in synthetic process in the brain

Nursing Interventions to Promote Sleep
1. Helping nurse-patient relationship.
2. Promote comfort and relaxation.
3. Create restful environment.
4. Attend to bedtime rituals.
5. Adequate exercise.
6. High protein food.
7. Observe habits of sleep periodicity and wake-up time.
8. Avoid caffeine and alcohol in the evening.
9. Go to bed when sleepy.
10. Use the bed mainly for sleep.
11. Use the sedative-hypnotics judiciously.
Common Sleep Disorders
1. Insomnia
Difficulty in falling asleep
Intermittent sleep
Premature awakening
2. Hypersomnia
Excessive sleep
Related to psychologic problems, CNS damage, metabolic disorders
3. Narcolepsy Sleep Attack
Overwhelming sleepiness
REM uncontrolled
4. Sleep Apnea
Periodic cessation of breathing during asleep. Characterized by snoring.
5. Parasomnias
Somnambulism. Sleep walking
Night terrors. After having slept for hours, the child bolts upright, shakes, screams, appears pale
and terrified.
Nocturnal enuresis. Bedwetting.
Soliloquy. Sleep talking.
Nocturnal erections. Wet dreams usually experienced by adolescents males.
Bruxism. Clenching and grinding of teeth
Ethico-Moral-Legal Responsibility in Nursing

Ethical Principles of Professional Patient Relationships

Veracity
Means telling the truth.

Fidelity
Means being faithful to ones commitments and promises.

Privacy
Ensuring that the patients body is appropriately covered, not
discussing medically irrelevant physical features and not engaging
in discussion of intimate details about patient unless necessary in
provision of care.
Confidentiality
Information of client be kept in private.
Privileged Communication
Information given to a person who is forbidden by law from disclosing the
information in a court without consent of the person who provided it.
Legal Roles of Nurses
1. Provider of service.
2. Liability.
3. Standards of Care.
4. Employee or Contractor for Service.
5. Contractual Relationships.
a) Independent Nurse Practitioner
b) Nurse Employed by a Hospital.

Inappropriate Behaviors
Hitting client in any part of the body.
Assisting in criminal abortion.
Taking drugs from the clients supply for personal use.

6. Citizen.
Rights are privileges or fundamental powers to which an
individual is entitled unless they are revoked by law or given up
voluntarily.
Responsibilities are the obligation associated with rights.

Areas of Potential Liability of Nursing

1. Crime. Act omitted in the violation of public law
and punishable by fine and/or imprisonment.
Classification of Crime
Felony crime of serious nature.
Manslaughter second degree murder
Misdemeanor offense of a less serious nature and is usually
punishable by fine or short-term jail sentence.
2. Tort. A civil wrongdoing committed against a person
or a persons property.
a) Intentional Torts
Fraud false presentation of some fact with intention.
Invasion of Privacy withhold himself from public scrutiny.
Defamation careless disregard for truth, results in injury to
the reputation of the person.
Libel defamation by means of print, writing or pictures.

Slander defamation by spoken word, stating unprivileged

or false words by which reputation is damged.
Assault
Attempt or threat to touch another person unjustifiably.

Battery
The willful touching of a person (including persons clothes or something the person is
carrying) that may or may not cause harm.

False imprisonment
Is the unlawful restraint or detention of another person against his/her
wishes.

a) Unintentional Torts.
Negligence failure to behave in a reasonably and prudent manner.
Malpractice negligent act of a person engaged in professions or
occupations.
Elements of Proof of Nursing Negligence and Practice
Potential Malpractice Situations in Nursing.
Selected Facts of Nursing Practice
1. Informed Consent.
2. Death and Related Issues.
Postmortem care.
Autopsy.
Organ Donation.
Inquest.
Euthanasia
3. DO NOT Resuscitate Orders (DNR)
4. Abortions.
A Patients Bill of Rights
You have the right to receive considerate, respectful and compassionate care in a safe
setting regardless of your age, gender, race, national origin, religion, sexual orientation,
gender identity or disabilities.
You have the right to receive care in a safe environment free from all forms of abuse,
neglect, or mistreatment.

You have the right to be called by your proper name and to be in an environment that
maintains dignity and adds to a positive self-image.

You have the right to be told the names of your doctors, nurses, and all health care team
members directing and/or providing your care.

You have the right to have a family member or person of your choice and your own doctor
notified promptly of your admission to the hospital.

You have the right to have someone remain with you for emotional support during your
hospital stay, unless your visitors presence compromises your or others rights, safety or
health. You have the right to deny visitation at any time.
You have the right to be told by your doctor about your diagnosis and possible prognosis,
the benefits and risks of treatment, and the expected outcome of treatment, including
unexpected outcomes. You have the right to give written informed consent before any
non-emergency procedure begins.
 You have the right to have your pain assessed and to be involved in decisions about
treating your pain.
You have the right to be free from restraints and seclusion in any form that is not
medically required.
You can expect full consideration of your privacy and confidentiality in care
discussions, exams, and treatments. You may ask for an escort during any type of
exam.
You have the right to receive detailed information about your hospital and
physician charges.
You can expect that all communication and records about your care are confidential,
unless disclosure is permitted by law. You have the right to see or get a copy of your
medical records. You may add information to your medical record by contacting the
Medical Records Department. You have the right to request a list of people to whom
your personal health information was disclosed.
You have the right to give or refuse consent for recordings, photographs, films, or
other images to be produced or used for internal or external purposes other than
identification, diagnosis, or treatment. You have the right to withdraw consent up
until a reasonable time before the item is used.
You have the right to access protective and advocacy services in cases of abuse or
neglect. The hospital will provide a list of these resources.
You, your family, and friends with your permission, have the right to participate in
decisions about your care, your treatment, and services provided, including the right
to refuse treatment to the extent permitted by law. If you leave the hospital against
the advice of your doctor, the hospital and doctors will not be responsible for any
medical consequences that may occur.
 You have the right to agree or refuse to take part in medical research
studies. You may withdraw from a study at any time without
impacting your access to standard care.
You have the right to communication that you can understand. The
hospital will provide sign language and foreign language
interpreters as needed at no cost. Information given will be
appropriate to your age, understanding, and language. If you have
vision, speech, hearing, and/or other impairments, you will receive
additional aids to ensure your care needs are met.
You have the right to make an advance directive and appoint
someone to make health care decisions for you if you are unable. If
you do not have an advance directive, we can provide you with
information and help you complete one.
You have the right to be involved in your discharge plan. You can
expect to be told in a timely manner of your discharge, transfer to
another facility, or transfer to another level of care. Before your
discharge, you can expect to receive information about follow-up
care that you may need.
The Dying Persons Bill of Right
1. I have the right to be treated as a living human being until I die.
2. I have the right to maintain a sense of hopefulness however changing its focus may
be.
3. I have the right to be cared for by those who can maintain a sense of hopefulness,
however changing this might be.
4. I have the right to express my feelings and emotions about my approaching death in
my own way.
5. I have the right to participate in decisions concerning my care.
6. I have the right to expect continuing medical and nursing attention even though cure
goals must be changed to comfort goals.
7. I have the right not to die alone.
8. I have the right to be free from pain.
9. I have the right to have my question answered honestly.
10. I have the right not to be deceived.
11. I have the right to have help from and for my family in accepting my death.
12. I have the right to die in peace and dignity.
13. I have the right to retain my individuality and not be judged for my decisions which
may be contrary to beliefs of others.
14. I have the right to discuss and engage my religious and/or spiritual experiences,
whatever these may mean to others.
15. I have the right to expect that the sanctity of the human body will be respected after
death.
16. I have the right to be cared for by caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some satisfaction in helping me
face my death.
Implementing Special Nursing Measures
Medication Administration
Definition of Terms
Medication. Substance administered for diagnosis, cure,
treatment, relief or prevention of diseases. Also called
drug.
Prescription name. Name given to a drug before it
becomes official.
Official name. Name after which the drug is listed in one
of the official publication.
Chemical Name. Name which describe the constituents of
drugs precisely.
Brand Name. Name given to a drug by the manufacturer.
Pharmacology. Study of the effects of drugs on living
organisms.
Posology. Study of the dosage or amount drugs given in
the treatment of diseases.
Types of Doctors Order
1. Standing Order. Carried out until the specified
period of time or until it is discontinued by another
order.
2. Single Order. Carried out for one time only.
3. STAT Order. Carried out once or immediately.
4. PRN Order. Carried out as the patient requires.
Parts of Legal Doctors Order
Name of Patient
Date and Time
Name of Drug
Dose of Drug
Route of Administration
Time of Frequency
Signature of the Physician
Effects of the Drug
Therapeutic Effect. Primary effects intended, also called
the desired effect.
Side Effect. Effect that is untended, also called secondary
effect.
Drug Allergy. Immunologic reaction to the drug.
Anaphylactic Reaction. Occurs usually immediately
following administration of the drug.
Drug Tolerance. Decreased physiologic response to the
repeated administration of a drug.
Cumulative Effect. Increasing response to the repeated
doses of a drug that occurs when the rate of administration
exceeds the rate of metabolism.
Idiosyncratic Effect. Unexpected peculiar response to the
drug.
Drug Abuse. Inappropriate intake of substance.
 Drug Dependence. Persons reliance to take a drug or
substance.
Addiction. Due to biochemical changes of the body
tissues, especially the nervous system.
Habituation. Emotional reliance on a drug.
Drug Interaction. Effects on one drug are modified by the
prior or concurrent administration of another drug.
Drug Antagonism. Conjoint effect of two drugs.
Summation. Combined effect of two drugs produces a
result that equals the sum of the individual effects of each
agent.
Synergism. Combined effects of drugs are greater than the
sum of each individual agent acting independently.
Potentiation. Concurrent administration of two drugs in
which one drug increases the effect of the other drug.
Therapeutic Action of Drugs
Palliative. Relieves the symptoms of disease but not
affect the disease itself.
Curative. Treats the disease condition.
Supportive. Sustain body functions until other
treatment of the bodys response can take over.
Substitutive. Replaces body fluids or substances.
Chemotherapeutic. Destroys malignant cells.
Restorative. Returns the body to health.
General Properties of Drugs
1. Drugs do not confer any new function on a tissue or
organ in the body.
2. Drugs in general exert multiple actions rather than
single effect.
3. Drugs interaction results from physiochemical
interaction between the drug and a functionally
important molecule in the body.
Pharmacokinetic Factors in Drug Therapy
1. Absorption. Process by which a drug passes from its site of
administration into the bloodstream
Factors That Affect Drug Absorptions
a) Blood Flow. Rich blood supply enhances absorption.
b) Pain. Slows gastric emptying rate, so the drug remains longer in the
stomach.
c) Stress. Causes vasoconstriction, drugs will be absorbed slowly.
d) Foods. Interfere with drug absorption.
e) Exercise. Decreases blood circulation to the GI tract.
f) Nature of the absorbing surface. Transport of drug molecules is
faster through a single layer of cells.
g) Solubility of the drug. Drug must be in solution, liquid drugs are
absorbed faster than solid drugs.
h) pH. Acidic drugs are best absorbed in the acidic environment,
alkaline are best absorbed in alkaline environment.
i) Drug concentration. High concentration tends to be more rapidly
absorbed than low concentrations.
j) Dosage form. Maybe combined with another substance from which
it is slowly released.
2. Distribution. Is the transport of a drug from its
site of absorption to its site of action.
Factors That Affect Drug Distribution
a) Plasma-Protein Binding
b) Volume Distribution
c) Barriers to Drug Distribution
Blood Brain Barrier
Placental Barrier
d) Obesity
e) Receptor Combination
3. Metabolism or Biotransmission.
Factors that Affect Drug Metabolism
1. Age
2. Nutrition
3. Insufficient amounts of major body hormones.
4. Excretion. Process by which drugs are
eliminated from the body.
Factors that Affect Drug Excretion.
Renal Excretion.
Drugs can affect elimination of other drugs.
Blood concentration levels.
Half life.
Physiologic Changes Associated with Aging that Influence
Medication Administration and Effectiveness
1. Altered Memory.
2. Less Acute Vision. Increase risk of error in taking
medications.
3. Decrease in renal function resulting in slower
elimination of drugs.
4. Less complete and slower absorption from
gastrointestinal tract.
5. Increased proportion of fat to lean body mass which
facilitates retention of fat soluble drugs and increases
potential for toxicity.
6. Decreased liver function, which hinders
biotransformation of drug.
7. Decreased organ sensitivity. These may lead to
underresponse to drugs.
8. Altered quality of organ responsiveness, resulting in
adverse effects becoming pronounced before therapeutic
effects are achieved.
PRINCIPLES OF MEDICATION ADMINISTRATION
1. Observe the 7 Rights of drug administration
The Right Medication
when administering medications, the nurse compares the label of themedication container with
medication form. The nurse does this 3 times:

Before removing the container from the drawer or shelf

As the amount of medication ordered is removed from the container

Before returning the container to the storage

Right Dose
when performing medication calculation or conversions, the nurse should haveanother qualified
nurse check the calculated dose

Right Patient
an important step in administering medication safely is being sure the medicationis given to the
right client.

To identify the client correctly:

The nurse check the medication administration form against

the clients identification bracelet and asks the client to state his or her name
to ensure the clients identification bracelet has the correct information.
RIGHT ROUTE
if a prescribers order does nor designate a route of administration, the
nurseconsult the prescriber. Likewise, if the specified route is not
recommended, the nurse should alert the prescriber immediately.
RIGHT TIME
a. the nurse must know why a medication is ordered for certain times of the
day and whether the timeschedule can be altered b. each institution has are
commended time schedule for medications ordered at frequent intervalc.
Medication that must act at certain times are given priority (e.g insulin should
be given at a preciseinterval before a meal )

RIGHT DOCUMENTATION
Documentation is an important part of safe medicationadministration

The documentation for the medication should clearly reflect the clients name,
the name of theordered medication,the time, dose, route and frequency

Sign medication sheet immediately after administration of the drug

Right Approach
2. Practice Asepsis wash hand before and after
preparing the medication to reduce transfer
of microorganisms.

3. Nurse who administer the medications are responsible

for their own action. Question any order thatyou
considered incorrect (may be unclear or appropriate)

4. Be knowledgeable about the medication that you

administer

A fundamental rule of safe drug administration is: Never

administer an unfamiliar medication.
5. Keep narcotics in lock place.
6. Use only medications that are in clearly labled
containers.
7. Return liquid that are cloudy in color to the pharmacy.
8. Administering the medication, identify the client
correctly.
9. Do not leave the medication at the bedside.
10. The nurse who prepares tdrug administers it.
11. If the client vomits after taking the medication, report
this to the nurse in charge or physician.
12. Preoperative medications are usually discontinued
during the postoperative period unless orderd to be
continued.
13. When a medication is omitted for any reason, record the
fact together with the reason.
14. When a mediciation error is made, report it immediately
to the nurse in charge or physician.
Routes of Drug Administration
1. Oral administration
Advantages
a. The easiest and most desirable way to administer medication
b. Most convenient
c. Safe, does nor break skin barrier
d. Usually less expensive
Disadvantages
a. Inappropriate if client cannot swallow and if GIT has
reduced motility
b. Inappropriate for client with nausea and vomitingc.
c. Drug may have unpleasant tasted.
d. Drug may discolor the teeth.
e. Drug may irritate the gastric mucosa.
f. Drug may be aspirated by seriously ill patient.
 Drug Forms for Oral Administration
Solid: tablet, capsule, pill, powder
Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline
sunbstances.
Syrup: sugar based liquid medication
Suspension: water based liquid medication
Emulsion: oil based liquid medication.
Elixir: alcohol based liquid medication.

Never crush enteric coated or sustained release tablets.

Crushing enteric-coated tablets allows the irritating medication to
come in contact with oral or gastric mucosa, resulting in
mucositis or gastric irritation.
Crushing sustained release medication allows all the medication
to be absorbed at the same time , resulting in a higher than
expected initial level of the medication and a shorter than
expected duration of action.
2. Sublingual
A drug that is placed under the tongue, where it dissolves.
When the medication is in capsule and ordered sublingually, the fluid
must be aspirated from the capsule and placed under the tongue.
A medication given by the sublingual route should not be swallowed, or
desire effects will not be achieved

Advantages
Same as oral, plus-
Drug can be administered for local effect.
Drug is rapidly absorbed in the bloodstream.
Disadvantages
If swallowed, drug may be inactivated by gastric juices.
Drug must remain under the tongue until dissolved and absorbed.
3. Buccal
A medication is held in the mouth against the mucous membranes of the
cheek until the drug dissolves.
The medication should not be chewed, swallowed, or placed under the
tongue (e.g sustained release nitroglycerine, opiates,antiemetics,
tranquilizer, sedatives)
Client should be taught to alternate the cheeks with each subsequent
dose to avoid mucosal irritation
Advantages
Same as oral plus-
Drug can be administered for local effect.
Ensures greater potency because drug directly enters the blood and bypass
the liver.

Disadvantages
If swallowed, drug may be inactivated by gastric juice.
4. TOPICAL
Application of medication to a circumscribed area of the body.

a. Dermatologic
includes lotions, liniment and ointments, powder

Before application, clean the skin thoroughly by washing the area

gently with soap and water,soaking an involved site, or locally
debriding tissue.

Use surgical asepsis when open wound is present

Remove previous application before the next application

Use gloves when applying the medication over a large surface. (e.g
large area of burns)

Apply only thin layer of medication to prevent systemic

absorption. b.
b. Opthalmic
- includes instillation and irrigation
1. Instillation to provide an eye medication that the client requires.
2. Irrigation To clear the eye of noxious or other foreign materials.
Position the client either sitting or lying.
Use sterile technique
Clean the eyelid and eyelashes with sterile cotton balls moistened with
sterile normal saline fromthe inner to the outer canthus
Instill eye drops into lower conjunctival sac.
Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional
drops need to beadministered. This is for proper absorption of the
medication.
Avoid dropping a solution onto the cornea directly, because it causes
discomfort.
Instruct the client to close the eyes gently. Shutting the eyes tightly causes
spillage of themedication.
For liquid eye medication, press firmly on the nasolacrimal duct (inner
cantus) for at least 30seconds to prevent systemic absorption of the
medication.
c. Otic.
Instillations
To soften earwax.
To reduce inflammation and treat infection.
To relieve pain.
Irrigation
To remove cerumen or pus.
To apply heat.
To remove foreign body.
d. Nasal
e. Inhalation.
f. Vaginal.
Vaginal Irrigation-is the washing of the vagina by a liquid at
low pressure. It is also called douche.
5. Rectal can be use when the drug
has objectionable taste or odor.

6. PARENTERAL
administration of medication by needle.
a. Intradermal. Under the epidermis. (ID)
b. Subcutaneous. Into the subcutaneous tissue. (SC)
c. Intramascular. Into the muscle (IM)
d. Intravenous. Into the vein. (IV)
e. Intraarterial. Into the artery.
f. Intraosseous. Into the bone.
Intradermal
under the epidermis.
The site are the inner lower arm, upper chest and back,
and beneath the scapula.
Indicated for allergy and tuberculin testing and for
vaccinations.
Use the needle gauge 25, 26, 27: needle length 3/8, 5/8
or
Needle at 1015 degree angle; bevel up.
Inject a small amount of drug slowly over 3 to 5 seconds
to form a wheal or bleb.
Do not massage the site of injection. To prevent
irritation of the site, and to prevent absorption of the
drug into the subcutaneous
b. Subcutaneous
vaccines, heparin, preoperative medication, insulin, narcotics.
The site: outer aspect of the upper arms, anterior aspect of the thighs, Abdomen,
Scapular areas of the upper back, Ventrogluteal, Dorsogluteal
Only small doses of medication should be injected via SC route.
Rotate site of injection to minimize tissue damage.
Needle length and gauge are the same as for ID injections
Use 5/8 needle for adults when the injection is to administer at 45 degree angle; is
use at a 90degree angle.
For thin patients: 45 degree angle of needle
For obese patient: 90 degree angle of needle
For heparin injection :do not aspirate. Do not massage the injection site to prevent
hematoma formation
For insulin injection: Do not massage to prevent rapid absorption which may result
to hypoglycemic reaction.
Always inject insulin at 90 degrees angle to administer the medication in the pocket
between the subcutaneous and muscle layer. Adjust the length of the needle
depending on the size of the client.
For other medications, aspirate before injection of medication to check if the blood
vessel had been hit. If blood appears on pulling back of the plunger of the syringe,
remove the needle and discard the medication and equipment.
c. Intramuscular
Needle length is 1, 1 , 2 to reach the muscle layer
Clean the injection site with alcoholized cotton ball to reduce microorganisms
in the area.
Inject the medication slowly to allow the tissue to accommodate volume.
Sites:
1. Ventrogluteal site
The area contains no large nerves, or blood vessels and less fat. It is farther from
the rectal area, so it less contaminated.

Position the client in prone or side-lying.

When in prone position, curl the toes inward.
When side-lying position, flex the knee and hip. These ensure relaxation of
gluteus muscles and minimize discomfort during injection.
To locate the site, place the heel of the hand over the greater trochanter, point
the index finger toward the anterior superior iliac spine, then abduct the middle
(third) finger. The triangle formed by the index finger, the third finger and the
crest of the ilium is the site.
2. Dorsogluteal site
Position the client similar to the ventrogluteal site
The site should not be use in infant under 3 years ,
because the gluteal muscles are not well developed yet.
To locate the site, the nurse draw an imaginary line from
the greater trochanter to the posterior superior iliac
spine. The injection site id lateral and superior to this
line.
Another method of locating this site is to imaginary
divide the buttock into four quadrants. The upper most
quadrant is the site of injection. Palpate the crest of the
ilium to ensure that the site is high enough.
Avoid hitting the sciatic nerve, major blood vessel or
bone by locating the site properly.
3. Vastus Lateralis
Recommended site of injection for infant
Located at the middle third of the anterior lateral aspect of the thigh.
Assume back-lying or sitting position.

4. Rectus femoris site located at the middle third, anterior aspect of

thigh.

5. Deltoid site
Not used often for IM injection because it is relatively small muscle and
is very close to the radial nerve and radial artery.

To locate the site, palpate the lower edge of the acromion process and
the midpoint on the lateral aspect of the arm that is in line with the
axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below
the acromion process.
IM injection Z tract injection
Used for parenteral iron preparation. To seal the drug
deep into the muscles and prevent permanent staining
of the skin.

Retract the skin laterally, inject the medication slowly.

Hold retraction of skin until the needle is withdrawn
Do not massage the site of injection to prevent leakage
into the subcutaneous.
GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF MEDICATIONS
1. Check doctors order.
2. Check the expiration for medication drug potency may increase or decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful. Client
may have anxiety, which can increase the pain.
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size. To minimize tissue injury.
6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones.
7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow
easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
10. Introduce the needle in quick thrust to lessen discomfort.
11. Either spread or pinch muscle when introducing the medication. Depending on the size of the
client.
12. Minimized discomfort by applying cold compress over the injection site before introduction of
medicati0n to numb nerve endings.
13. Aspirate before the introduction of medication. To check if blood vessel had been hit.
14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling
tissues as needle is withdrawn.
15. Massage the site of injection to haste absorption.
16. Apply pressure at the site for few minutes. To prevent bleeding.
17. Evaluate effectiveness of the procedure and make relevant documentation.
d. Intravenous

The nurse administer medication intravenously by the following method:

As mixture within large volumes of IV fluids.
By injection of a bolus, or small volume, or medication through an existing
intravenous infusion line or intermittent venous access (heparin or saline lock)
By piggyback infusion of solution containing the prescribed medication and a
small volume of IV fluid through an existing IV line.
Most rapid route of absorption of medications.
Predictable, therapeutic blood levels of medication can be obtained.
The route can be used for clients with compromised gastrointestinal function or
peripheral circulation.
Large dose of medications can be administered by this route.
The nurse must closely observe the client for symptoms of adverse reactions.
The nurse should double-check the six rights of safe medication.
If the medication has an antidote, it must be available during administration.
When administering potent medications, the nurse assesses vital signs before,
during and after infusion.
Types of IV Fluids
1. Isotonic solution has the same concentration as the body
fluid
D5 W
Na Cl 0.9%
plainRingers lactate
Plain Normosol M

2. Hypotonic has lower concentration than the body fluids.

NaCl 0.3%
3. Hypertonic has higher concentration than the body fluids.
D10W
D50W
D5LR
D5NM
Nursing Interventions in IV Infusion
1. Verify the doctors order
2. Know the type, amount, and indication of IV therapy.
3. Practice strict asepsis.
4. Inform the client and explain the purpose of IV therapy to
alleviate clients anxiety.
5. Prime IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the
periphery with alcoholized cotton ball to prevent infection.
7. Shave the area of needle insertion if hairy.
8. Change the IV tubing every 72 hours. To prevent
contamination.
9. Change IV needle insertion site every 72 hours to prevent
thrombophlebitis.
10. Regulate IV every 15-20 minutes. To ensure administration of
proper volume of IV fluid as ordered.
11. Observe for potential complications.
Complication of IV Infusion
1. Infiltration the needle is out of nein, and fluids
accumulate in the subcutaneous tissues.
Assessment:
Pain, swelling, skin is cold at needle site, pallor of the site,
flow rate has decreases or stops.
Nursing Intervention:
Change the site of needle
Apply warm compress. This will absorb edema fluids and
reduce swelling
2. Circulatory Overload
Results from administration of excessive volume of IV fluids.
Assessment:
Headache
Flushed skin
Rapid pulse
Increase BP
Weight gain
Syncope and faintness
Pulmonary edema
Increase volume pressure
SOB
Coughing
Tachypnea
shock

Nursing Interventions:
Slow infusion to KVO
Place patient in high fowlers position. To enhance breathing
Administer diuretic, bronchodilator as ordered
3. Drug Overload the patient receives an excessive
amount of fluid containing drugs.
Assessment:
Dizziness
Shock
Fainting
Nursing Intervention
Slow infusion to KVO.
Take vital signs
Notify physician
4. Superficial Thrombophlebitis
it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large
bore catheters.
Assessment:
Pain along the course of vein
Vein may feel hard and cordlike
Edema and redness at needle insertion site.
Arm feels warmer than the other arm

Nursing Intervention:
Change IV site every 72 hours
Use large veins for irritating fluids.
Stabilize venipuncture at area of flexion.
Apply cold compress immediately to relieve pain and inflammation; later with
warm compress to stimulate circulation and promotion absorption.

Do not irrigate the IV because this could push clot into the systemic circulation
5. Air Embolism Air manages to get into the circulatory system; 5 ml
of air or more causes air embolism.
Assessment:
Chest, shoulder, or backpain
Hypotension
Dyspnea
Cyanosis
Tachycardia
Increase venous pressure
Loss of consciousness

Nursing Intervention
Do not allow IV bottle to run dry
Prime IV tubing before starting infusion.
Turn patient to left side in the trendelenburg position. To allow air to
rise in the right side of the heart. This prevent pulmonary embolism.
Nerve Damage may result from tying the arm too tightly to
the splint.
Assessment
Numbness of fingers and hands

Nursing Interventions
Massage the are and move shoulder through its ROM
Instruct the patient to open and close hand several times each
hour.
Physical therapy may be required

Note: apply splint with the fingers free to move.

BLOOD TRANSFUSION THERAPY

Objectives:
1. To increase circulating blood volume after surgery,
trauma, or hemorrhage
2. To increase the number of RBCs and to maintain
hemoglobin levels in clients with severe anemia
3. To provide selected cellular components as replacements
therapy (e.g clotting factors, platelets, albumin)
Nursing Interventions:
1. Verify doctors order. Inform the client and explain
the purpose of the procedure.
2. Check for cross matching and typing. To ensure
compatibility
3. Obtain and record baseline vital signs
4. Practice strict Asepsis
5. At least 2 licensed nurse check the label of the blood
transfusion
 Check the following:
Serial number
Blood component
Blood type
Rh factor
Expiration date
Screening test (VDRL, HBsAg, malarial smear)

this is to ensure that the blood is free from blood-carried diseases and therefore,
safe from transfusion
6. Warm blood at room temperature before transfusion to prevent
chills.
7. Identify client properly. Two Nurses check the clients identification.
8. Use needle gauge 18 to 19. This allows easy flow of blood.
9. Use BT set with special micron mesh filter. To prevent administration
of blood clots and particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30
minutes. Adverse reaction usually occurs during the first 15 to 20
minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction.
12. Do not mixed medications with blood transfusion. To prevent
adverse effects
Do not incorporate medication into the blood transfusion
Do not use blood transfusion line for IV push of medication.
13.
14. Administer 0.9% NaCl before, during or after BT. Never administer
IV fluids with dextrose. Dextrose causes hemolysis.
15. Administer BT for 4 hours (whole blood, packed rbc). For plasma,
platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting
factor can easily be destroyed.
Complications of Blood Transfusion
1. Allergic Reaction it is caused by sensitivity to
plasma protein of donor antibody, which reacts with
recipient antigen.
Assessments
Flushing
Rush, hives
Pruritus
Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic it is caused by
hypersensitivity to donor white cells, platelets or
plasma proteins. This is the most symptomatic
complication of blood transfusion
Assessments:
Sudden chills and fever
Flushing
Headache
Anxiety
3. Septic Reaction it is caused by the transfusion of
blood or components contaminated with bacteria.
Assessment:
Rapid onset of chills
Vomiting
Marked Hypotension
High fever
4. Circulatory Overload
it is caused by administration of blood volume at a rate
greater than the circulatory system can accommodate.
Assessment
Rise in venous pressure
Dyspnea
Crackles or rales
Distended neck vein
Cough
Elevated BP
5. Hemolytic reaction. It is caused by infusion of
incompatible blood products.
Assessment
Low back pain (first sign). This is due to inflammatory response of
the kidneys to incompatible blood.
Chills
Feeling of fullness
Tachycardia
Flushing
Tachypnea
Hypotension
Bleeding
Vascular collapse
Acute renal failure
Nursing Interventions when complications occurs in Blood transfusion

1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.

2. Start IV line (0.9% Na Cl )
3. Place the client in fowlers position if with SOB and administer O2
therapy.
4. The nurse remains with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as
antihistamines, vasopressor, fluids, and steroids as per physicians
order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine
presence of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are
saved and returned to the laboratory for analysis.
Computation of Dosage of Medication
Formula For Computation of Dosage
1. Oral Medications: Solids

Desired dose = Quantity of Drug

Stock dose
(D/S = Q)

2. Oral/Parenteral Medications: Liquids

Desired dose x dilution = Quantity of drug

Stock dose
(D/S x Dilution = Q)
3. IV Fluid Rate

gtts/min = Volume in cc x gtt factor

no. of hours x 60 min
cc/hr = Volume in cc or gtts/min x 4
no. of hours
duration in hours = Volume in cc
cc / hr

4. Converstion of temperature
1. C to F = (C x 1.8) + 32 (Note: 1.8 is 9/5)
2. F to C = (F 32) (.55) (Note: .55 is 5/9)
5. Pediatric Doses
a. Clarks Rule

Wt. in lbs x Usual adult dose = Safe Childs Dose

150

b. Frieds Rule

Age in mos x Usual adult dose = Safe Childs Dose

150

c. Youngs Rule

Age in years x Usual adult dose = Safe Childs Dose

Age in years + 12
Equivalents
Common Household Measurements
1 quart 4 cups
1 pint 2 cups
1 cup 8 ounces
1 teacup 6 ounces
1 tablespoon(tbsp) 3 tsp; 15-16 mls
1 teaspoon (tsp) 60 gtts; 4-5 mls
(Note: 1 ounce = 30 mls)
Apothecary Measurements
60 minims 1 fluidram
8 fluidrams or 480 minims 1 fluidounce
16 fluidounces 1 pint (pt. or O)
2 pints 1 quart (qt)
4 quarts 1 gallon (C)
Metric Measurements
Units of volume (Liter L)
1 ml. (millimiter) 0.001 L (1/1,000)
1 cl. (centiliter) 0.01 L (1/100)
1 dl. (deciliter) 0.1 L (1/10)
1 decaliter 10 L

Units of Weight (Gram G or gm

1 mcg. (microgram) 0.000001 G (1/1,000,000)
1mg. (milligram) 0.001 G (1/1,000)
1 cg. (centigram) 0.01 G (1/100)
1 dg. (decigram) 0.1 G (1/10)
1 kg. (kilogram) 1,000 G

Units of Length (Meter m)

1mm. (millimeter) 0.001 m (1/1,000)
1 cm. (centimeter) 0.01 m (1/100)
1 dm. (decimeter) 0.1 m. (1/10)
1 hectometer
Other Important Unit Equivalents
1 G (gram) 15 gr.
1 gr. (grain) 60 mg.
1 mg. (milligram) 1,000 mcg.
1 ml. (milliliter) 1cc.; 15 gtts.; 60 mcgtts.; 1 G
1 L (liter) 1 qt,; 1,000 mls
1 gal. (gallon) 4 L; 4 qt.; 4,000 mls
1 oz. (ounce) 30 G ; 30 mls ; 30 cc
1 kg. (kilogram) 2.2 lbs.
1 lb. (pund) 16 oz.
Coping With Loss, Grieving and Death
Definitions of Terms
Loss. An actual or potential situation in which a
valued object, person or the like is inaccessible or
changed so that it is no longer perceived as valuable.
Bereavement. Is the subjective response to a loss
through the death of a person with whom there has
been a significant relationship.
Grief. The total response to the emotional experience
of theloss and is manifested in thoughts, feelings, and
behaviors.
Mourning. The behavioral process through which
grief is eventually resolved or altered; it is often
influenced by culture and custom.
Development of Concept of Death
1. Infancy to 5 years
Does not understand concept of death.
Believes death is revirsible, a temporary departuer or sleep.
2. 5-9 years
Understands that death is final.
Believes own death can be avoided.
Associates dath with agression or viloence.
3. 9-12 years
Understands death as the inevitable end of life.
Begins to understand own mortality.
4. 12-18 years
Fears of lingering death.
May fantasize that death can be defied, acting out defiance through recless behavior.
Views death in religious and philosophic terms.
5. 18-45 years
Has attitude towards death that is influenced by religious and cultural beliefs.
6.
7. 45-65 years
Accepts own mortality.
Encounters death or parents and some peers.
Experiences peak of death anxiety.
8. 65 years
Fears prolonged illness.
Encounters death of familymemebers and peers.
Sees death as ahaving multiple meanings.
Kubler - Ross Stages of Grieving
1.Denial.
Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the
situation concerned. It's a defense mechanism and perfectly natural. Some people can become locked
in this stage when dealing with a traumatic change that can be ignored. Death of course is not
particularly easy to avoid or evade indefinitely.
2. Anger
Anger can manifest in different ways. People dealing with emotional upset can be angry with
themselves, and/or with others, especially those close to them. Knowing this helps keep detached and
non-judgmental when experiencing the anger of someone who is very upset.
3 .Bargaining
Traditionally the bargaining stage for people facing death can involve attempting to bargain with
whatever God the person believes in. People facing less serious trauma can bargain or seek to
negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining
rarely provides a sustainable solution, especially if it's a matter of life or death.
4 .Depression
Also referred to as preparatory grieving. In a way it's the dress rehearsal or the practice run for the
'aftermath' although this stage means different things depending on whom it involves. It's a sort of
acceptance with emotional attachment. It's natural to feel sadness and regret, fear, uncertainty, etc. It
shows that the person has at least begun to accept the reality.
5 . Acceptance
Again this stage definitely varies according to the person's situation, although broadly it is an
indication that there is some emotional detachment and objectivity. People dying can enter this stage
a long time before the people they leave behind, who must necessarily pass through their own
individual stages of dealing with the grief.
Martocchios Five Cluster of Grief
1. Shock and disbelief
May feel numb, anger, sadness, guilt, may deny loss
2. Yearning and protest
Anger and withdrawal
3. Anguish, disorganization, and despair
Decreased interest in future, decision making difficult, may feel lack of purpose in
living, crying common
4. Identification in bereavement
May imitate deceased's habits, traits, and goals
5. Reorganization and restitution
Grieving does not stop at once, typical patterns of life return, no timetable can be
set
Engels Stages of Grieving
1. Shock & disbelief refusal to accept loss
2. Developing awareness anger may be directed at
hospitals, nurses
3. Restitution mourning
4. Resolving the loss attempts to deal w/ painful
void5. Idealization produces image of dead persons
that almost devoid of undesirable features
5. Outcome importance of the lost object
as source of support
Symptoms Of Grief
1. Repeated somatic distress
2. Tightness in chest
3. Choking or shortness of breath
4. Sighing
5. Empty feeling in the abdomen
6. Loss of muscular power
7. Intense subjective distress
Assisting Clients w/ their Grief
1. Provide opportunity for the persons to tell their story.
2. Recognize & accept the varied emotions that people
express in relation to a significant loss.
3. Provide support for the expression of difficult
feelings, such as anger & sadness
4. Include children in their grieving process.
5. Encourage the bereaved to maintain established
relationships.
6. Acknowledge the usefulness of mutual help groups
7. Encourage self-care by family members particularly, the
primarily caregivers.
8. Acknowledge the usefulness of counseling for especially
difficult problems.
Nursing Diagnosis: Clients w/ Grief & Loss
1. Anticipatory grieving related to: perceived
potential loss of loved one
2. Dysfunctional grieving related to: multiple past
or current losses
3. Impaired adjustment related to: disability
requiring change in life style
4. Social isolation related to:
inability to engage in satisfying
personal relationships
Care of the Dying Client
Signs of Impending Clinical Death
1. Loss of muscle tone
relaxation of the facial muscles(jaw may sag)
difficulty speaking
difficulty swallowing & gradual loss of the gag reflex
decreased activity of the GIT
possible urinary & rectal incontinence
diminished body movement

2. Slowing circulation
diminished sensation
mottling & cyanosis of the extremities
cold skin, first in the feet & later in the hands, ears, & nose

3. Provide spiritual support

need for love
Indications of Death
No response to external stimuli
No muscular movement, esp during breathing
No reflexes
Flat encephalogram
In instances of artificial support, absence of brain
wavesfor at least 24 hours
Nursing Interventions For Dying Client
Assist the client achieve a dignified and peaceful death

Spiritual Care of the Dying Patient

It is important that the dying person receives
appropriate spiritual care. This can be a comfort to the
patient and to their family during this difficult time.
Some patients may not wish to access such support and
these wishes should be respected. It is good practice to
check with the patient what they would like. If they are
not able to do so themselves, check with a family
member. When patients require spiritual care every
effort should be made to contact clergy or pastoral
carers from the appropriate faith group.
Nursing Diagnosis for Dying Patients
1. Fear related to:
Knowledge deficit
Lack of social support in threatening situation
Negative impact on survivors
2. Hopelessness related to:
Prolonged restriction of activity resulting in isolation
Deteriorating physiologic condition
Terminal illness
Long term stress
Perceived significant loss of loved one, youth influence
3. Powerlessness related to:
Chronic debilitating disease
Terminal illness
Institutional environment
Interpersonal behavior of other
Changes of The Body After Death
Rigor Mortis: body becomes stiff within 4 hours after
death as a result of decreased ATP production. ATP
keeps muscles soft and supple.
Algor Mortis: Temperature decreases by a few degrees
each hour. The skin loses its elasticity and will tear
easily.
Livor Mortis: Dependant parts of body become
discolored. The patient will likely be lying on their back,
their backside being the 'dependant' body part. The
discoloration is a result of blood pooling, as the
hemoglobin breaks down.