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1. Fundamentals in Nursing (Jrkalbo)

1. Fundamentals in Nursing (Jrkalbo)

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Fundamentals in NURSING

I. DEFINITION OF NURSING NURSING - is a profession focused on assisting individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. Modern definitions of nursing describes it as a science and an art that focuses on promoting quality of life as determined by persons and families, throughout their life experiences from birth until the end of life. NURSING - Assisting the individual (sick or well) in the performance of those activities contributing to health, or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge- and in doing so, promote independence as much as possible. (Henderson) NURSING ± is providing the most favorable environment to an individual for nature to act in order to promote ³reparativeness´ and maintenance of health and well being. (Nightingale) NURSING ± is an art, (ability to perform nursing acts skillfully), and a science (body of knowledge which governs the profession) NURSING - is caring (Watson)

II. GOALS OF NURSING · Promotion of Health ± promoting a healthy lifestyle · Prevention of illness ± early detection and treatment · Restoration of health ± curing and healing, rehabilitation Care of the dying ± maintaining dignity and peaceful death III. SCOPE OF NURSING CARE · Individual · Families Communities IV. THEORETICAL FOUNDATIONS OF NURSING & HISTORICAL PERSPECTIVE y Metaparadigm of nursing ± identifies the core content of a discipline. y Persons ± recipient of nursing care. Represents an individual, a family, or a community. y Health ± represents a state of well-being mutually decided and agreed upon by the client and the nurse. y Environment ± may be internal or external to the person y Nursing ± is the science and art of the discipline.

Florence Nightingale Hildegard Peplau Virginia Henderson Lydia Hall

Focused on organizing and manipulating the physical, social and psychological environment in order to put the person in the best possible conditions for nature to act Presents nursing as an interpersonal process of therapeutic interactions between the nurse and the patient four phases of the nurse - patient relationship: orientation, identification, exploitation, and resolution Views nursing as doing for patients what they cannot do for themselves, and she identifies 14 components of nursing care that need to be considered. Focus around the three components of care, core, and cure. y Care -represents nurturance and is exclusive to nursing. y Core -involves the therapeutic use of self and emphasizes the use of reflection. y Cure -focuses on nursing related to the physician¶s orders. Nursing consists of the three theories of self care, self care deficit and nursing systems. y Self-care -includes the human¶s ability to care for him- or herself (self-care agency), basic conditioning factors, a totality of self-care actions needed (therapeutic self-care demand), and three categories of self-care requisites: universal, developmental, and health deviation. y Self-care deficit theory - identifies when nursing is needed because the person is incapable of or provide continuous effective self -care y Nursing systems theory- identifies three nursing systems as wholly compensatory, partly compensatory, and supportive-educative Behavioral system model for nursing has seven subsystems: y Attachment or affiliation y Dependence y Ingestive y Eliminative y Sexual y Aggressive y Achievement

Environmental Theory of Nursing Interpersonal Relationship Nurse ± Patient relationship 14 fundamental needs Definition of Nursing Care, core, cure Primary Nursing Holistic Nursing

Dorothea Orem

Theory of self - care

Dorothy E. Johnson

Behavioral System model

Faye G. Abdellah Ida Jean Orlando

focuses on problem-solving to move the patient toward health 21 common nursing problems relative to caring for patients Orlando believes that nurses provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. She emphasizes the importance of validating the need and evaluating care based on observable outcomes.

21 nursing problems Nursing Process Discipline

and cotranscending in many dimensions as possibilities unfold. and conservation of social integrity Presents a theory of goal attainment from an open system conceptual framework that integrates personal systems. Nursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to be nursed. Humans are unitary being in whom disease is a manifestation of the pattern of health. Levine identifies four principles of conservation: conservation of energy. space. conservation of structural integrity. which focus on the wholeness of human beings. Science of caring is built on a framework of seven assumptions and ten carative factors. and the nature and direction of human and environment change. Myra Levine Views nursing as human interaction: the dependency of individuals on one another. The essential characteristic of nursing is nurturance. interpersonal systems. She emphasizes the interpersonal nature of caring. role models (plans). Rogers developed the principles of homeodynamics. and intervenes in this interpersonal and interactive theory Modeling and Role-Modeling focuses on the importance of understanding the similarities (universalities) and differences (diversities) of peoples across cultures Health as expanding consciousness. the unitary nature of human beings and their environment. The nurse models (assesses). Philosophy Purpose Practice Art Perspective Theory Conservation theory Imogene King Martha Rogers Goal ± attainment theory Science of unitary man Josephine Paterson and Loretta Zderad Jean Watson Humanistic Nursing theory Science of caring Carative factors Human becoming theory Rosemarie Rizzo Parse Helen Erickson. Evelyn Tomlin. ministration of help. and validation that the actions were helpful. Transcultural nursing Expanding consciousness .Ernestine Wiedenbach Strongly believes that the nurse¶s individual philosophy or central purpose lends credence to nursing care. She believes that nurses help to meet the individual¶s need for help through the identification of the needs. describes the nurse as a co. Consciousness is the information capability of the system which is influenced by time. and movement and is ever-expanding. and Mary Ann Swain Madeleine Leininger Margaret Newman The focus of this theory is on the person. Emphasizes free choice of personal meaning in relating value priorities. Humanistic nursing cannot take place without the authentic commitment of the nurse to being with and doing with the client. and social systems. and includes the soul as an important consideration.participant with the client. concreting of rhythmical pattern in exchange with the environment. conservation of personal integrity.

trying to live in harmony with the earth by understanding the impact of interaction with nature and personal environment. MODELS OF HEALTH AND WELLNES CLINICAL MODEL ± health is viewed as absence of signs and symptoms ADAPTIVE MODEL ± a person is healthy if he/she can adapt to the different stressors of life. and "health is a positive concept emphasizing social and personal resources."( WHO "Ottawa Charter for Health Promotion´ 1986) WELLNESS Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall feeling of well-bein It is the physical state of good health as well as the mental ability to enjoy and appreciate being healthy and fit Wellness is first and foremost a choice to assume responsibility for the quality of your life.HEALTH. (WHO 1948) Is a "resource for everyday life. and feeling connected to the community Emotional -is demonstrated by the overall comfort with and acceptance of one¶s full range of feelings Intellectual .measures the satisfaction gained from a career and the degree to which you are enriched by that work.DEFINITION HEALTH Ability of the person to maintain a state of wellness. It begins with a conscious decision to shape a healthy lifestyle. COMPONENTS OF HEALTH AND WELLNESS Physical ± body¶s ability to function efficiently and effectively in work and leisure activities. to be healthy. Environmental . and taking action to protect the world around an individual. Social . as well as physical capacities. and using every power an individual possess to the fullest extent (Nightingale. participating in. to resist hypokinetic diseases.involves lifelong learning through formal education and informal life experiences Spiritual-refers to integrating beliefs and values with actions. not the objective of living". 1969) Is a state of being that people define in relation to their own value system Is a state of complete physical. Wellness is a mind set. ROLE PERFORMANCE MODEL ± an individual is healthy if he can satisfy societal roles. or ability to fulfill his/her duty or work EUDEMONISTIC MODEL ± refers to the actualization of ones potentials . mental and social well-being and not merely the absence of disease or infirmity. a predisposition to adopt a series of key principles in varied life areas that lead to high levels of well-being and life satisfaction.means being aware of. and to meet emergency situations. II. WELLNESS and ILLNESS I. III. Occupational .

and would develop the following: (S) ± signs and symptoms (S) ±syndromes. chemical. physical. Useful tools in developing programs for helping people change to healthier lifestyles and develop a more positive attitude toward preventive health measures.Helps determine whether an individual is likely to participate in disease prevention and health promotion activities.2 Health-Illness Continuum. sociophysiologic variables. psychosocial that by its presence or absence can lead to illness or disease Host -Persons who may or may not be at risk of acquiring the disease . cultural factors. Agent .HEALTH . there are three parameters on how to achieve high levels of wellness. as shown here. In this figure.drug side effects. lifestyle change necessary. duration of treatment and overall cost. represents the process of achieving high levels of wellness or the consequences of unhealthy lifestyle. and cues to action Likelihood to action ± depends on the perceived benefit versus the perceived barriers. HEALTH CARE ADHERENCE ± the extent to which behavior is congruent with medical or health advice.ILLNESS CONTINUUM ± a predictive grid that displays the likelihood of a person to participate in preventive health care Environment -All factors external to the host that may or may not predispose the person to the development of the disease HEALTH BELIEF MODEL . Otherwise. mechanical. severity of the disease. D S S A E G DISEASE / PREMATURE DEATH HIGH LEVEL OF WELLNESS Figure 1.ENVIRONMENT MODEL ± primarily used to predict an illness. an individual who continuously live an unhealthy lifestyle. These are: (A) ± Awareness. which is affected by various factors such as client¶s motivation.HOST .Any environmental factor or stressor. structural variables. AGENT . will be on the other side of the grid. Components Individual perceptions ± includes perceived susceptibility. and (D) ± Disorder or disability which may lead disease or premature death. (E) ± Education. and threat modifying factors ± includes demographic variables. seriousness. and (G) Growth.

administration of medications directed towards recovery or prevention of complications. ROM exercises.deals with promotion of healthy lifestyle and maintenance of current health.g. chest x ± ray. SECONDARY PREVENTION ± early detection and prompt treatment Examples: diagnosis and prompt interventions to reduce the effect of disease to achieve the possible level of health for the client (e. ILLNESS and DISEASE ILLNESS ± subjective state in which the person¶s functional faculties are thought to be diminished DISEASE ± alteration in body¶s physiology which reduces one¶s capacities and shortens the normal life span. and many more. y PRIMARY PREVENTION . Examples: immunization. pap smear. STAGES OF ILLNESS: STAGE 1 (Symptom experience) STAGE 2 (Assumption of the sick role) STAGE 3 (Medical Care contact) STAGE 4 ( Dependent Client Role) STAGE 5 ( Recovery or Rehabilitation) V.IV. avoidance of stress. CT scan) TERTIARY PREVENTION ± Directed towards rehabilitation and prevention of complications £ ¢ ¡   . PREVENTIVE HEALTH CARE LEVELS OF PREVENTION Examples: frequent turning of an immobilized client. eating a well balanced diet. Chronic illness ± longer duration with periods of remission and exacerbation. ETIOLOGY ± the cause of the disease CLASSIFICATIONS OF ILLNESS AND DISEASE: Acute illness ± severe symptoms but short duration which may or may not require medical interventions. complete blood count. adequate rest and sleep.

"Computers are incredibly fast. (Kozier et. seek. cost effectiveness. inaccurate and brilliant. Technological competence requires intentionality. and consult with others about health related information and concerns Nurses can be primary actors in the virtual arena of E-health. then we can assure of quality client care even in the most unlikely environment. Human beings are incredibly slow. Benefits of Tele-nursing · Nurses can actually view healing wounds.NURSING INFORMATICS Nursing Informatics ± is the integration of computer." . If this process is carried on through nursing. accurate and stupid. Together they are powerful beyond imagination. time value. but as an actual enhancement of care. The relationship between computer literacy. and nursing science. information. Nursing Informatics . education. The advent of technological breakthrough creates a sudden shift of paradigm in practice disciplines such as nursing. web information providers. accuracy and precision. serving as health advisors. and so on TERMS . and knowledge to support nursing practice.is the science of using computer information systems in the practice of nursing. The human ± machine tandem have proven a lot of change in terms of efficiency. and many more in various fields of science and commerce. deliver. can access physiological monitoring equipment to measure physical indicators such as vital signs and provide routine assessment and follow-up care without the client having to travel to the health care agency for an appointment. in acute and community settings. Confidence. and administration. commitment. information. E-HEALTH E-health is a client-centered World Wide Web-based network where clients and health care providers collaborate through ICT mediums to research. technological competence and a nurse's ability to care is congruent for quality care. along with compassion. The competent use of machine technology is becoming integral to nurses' work.al) Nursing Informatics is a growing specialty and will be of greater aid for nurses in the coming years. Computer literacy represents a proactive response to technology which enhances Caring in nursing TELE-NURSING Tele-nursing is the branch of telehealth that involves actual nursing and client interaction through the medium of information technology. Nurses need to develop technological know-how to keep pace with the rapid development of new health technologies.Albert Einstein CARING AND INFORMATICS Technological proficiency in nurses is a desirable attribute to function optimally in our changing health care system: not as a substitute for nurses' care. Nursing informatics .assists the management and processing of nursing data. Internet guides to help clients select reliable information resources. arrange. support group liaisons. research. New technologies have added a visual component to the interactions that augments the historic audio exchange. manage. refer. and conscience.

JPEG. in which the medium is a cartridge that can be removed.an electronic pathway through which data is transmitted between components in a computer. a commonly used data format for exchanging information between computers or programs. application menu . In computer language.American Standard Code for Information Interchange.a message that appears on screen.an acronym for Compact Disc Read-Only Memory.a copy of a file or disk you make for archiving purposes. Clipboard . card .A portion of memory where the Mac temporarily stores information. Called a Copy Buffer in many PC applications because it is used to hold information which is to be moved. like a hard drive. alert (alert box) .) control key . LZW. CPU . bug .a printed circuit board that adds some feature to a computer.The application or window at the front (foreground) on the monitor. background . compression .seldom used modifier key on the Mac. etc.a technique that reduces the size of a saved file by elimination or encoding redundancies (i.on the right side of the screen header.a program the converts programming code into a form that can be used by a computer.to start up a computer. application .a program in which you do your work. backup . control panel . . byte . The processing chip that is the "brains" of a computer. command . MPEG. cartridge drive .. CD-ROM .e.a programming error that causes a program to behave in an unexpected way. A program can run and perform tasks in the background while another program is being used in the foreground.a storage device. bit .the Central Processing Unit.the smallest piece of information used by the computer.the act of giving an instruction to your Mac either by menu choice or keystroke. either a one (1) or a zero (0). ASCII (pronounced ask-key ) . boot .a piece of computer information made up of eight bits.a program that allows you to change settings in a program or change the way a Mac looks and/or behaves.active program or window . as in word processing where text is "cut" and then "pasted". Derived from "binary digit". compiler . Lists running applications. bus . usually to tell you something went wrong.part of the multitasking capability.

finder .a connector inside the computer which allows one to plug in a printed circuit board that provides new or enhanced features.The cornerstone or home-base application in the Mac environment. extension . cursor . data . dialog box . drag .1.a system malfunction in which the computer stops working and has to be restarted.a file on a computer which tells it how to communicate with an add-on piece of equipment (like a printer). thereby launching the application and opening the document. The finder regulates the file management functions of the Mac (copying. font . database . . DOS .25 and 8 inch disks that were flexible).an invisible file in which the Finder stores a database of information about files and icons..a typeface that contains the characters of an alphabet or some other letterforms. which is controlled by the mouse.acronym for Disk Operating System used in IBM PCs.to transfer data from one computer to another.5 inch square rigid disk which holds data.a 3. (so named for the earlier 5. disk window .an electronic subdirectory which contains files. desktop . (If you are on the receiving end. file .(also . 2. document . the shaded or colored backdrop of the screen. control panel or other computer data. defragment .. usually arrow or cross shaped.a feature on the Mac which allows one to drag the icon for a document on top of the icon for an application.(the plural of datum) information processed by a computer. expansion slot .optimize) to concatenate fragments of data into contiguous blocks in memory or on a hard drive.a file you create. If you are on the sending end. as opposed to the application which created it. drag and drop . desktop file .to move the mouse while its button is being depressed. driver . you are downloading.an on-screen message box that appears when the Mac requires additional information before completing a command.The pointer. you are uploading). disk drive .a startup program that runs when you start the Mac and then enhances its function.the machinery that writes the data from a disk and/or writes data to a disk.the generic word for an application.) floppy . document.crash . renaming. download .an electronic list of information that can be sorted and/or searched. deleting. folder .the window that displays the contents or directory of a disk. the finder.

1024 bytes.fragmentation .a high-capacity storage medium that is read by a laser light.a gigabyte = 1024 megabytes. input and output devices. the short flashing marker which indicates where your next typing will begin. multi tasking .a small floating window that contains tools used in a given application. menu bar . kilobyte .a system error which causes the cursor to lock in place. . megabyte .to format a disk for use in the computer. hard drive . initialize . to print sideways on the page. freeze . highlight . launch . landscape . operating system . from the clipboard or copy buffer. gig . installer . PC .the system software that controls the computer. memory . hardware ± physical parts of the computer.a large capacity storage device made of multiple disks housed in a rigid case.. or other material. optical disk .a 1.a subdivision of a hard drives surface that is defined and used as a separate drive.38 MB/s MB .short for megabyte. file or folder.start an application.e.in printing from a computer. 155 Mb/s = 19. creates a new directory and arranges the tracks for the recording of data. palette .to insert text. icon .1024 kilobytes.to select by clicking once on an icon or by highlighting text in a document. paste .a graphic symbol for an application.a list of program commands listed by topic. insertion point . partition .The breaking up of a file into many separate locations in memory or on a disk. peripheral .the temporary holding menu . commonly used to refer to an IBM or IBM clone computer which uses DOS. high density disk .4 MB floppy disk.the horizontal bar across the top of the Mac¹s screen that lists the menus.acronym for personal computer.in word processing.software used to install a program on your hard drive. Measurements (summary) *a bit = one binary digit (1 or 0) *"bit" is derived from the contraction b'it (binary digit) -> 8 bits = one byte *1024 bytes = one kilobyte *K = kilobyte *Kb = kilobit *MB = megabyte *Mb = megabit *MB/s = megabytes per second *Mb/s = megabits per second *bps = bits per second i.running more than one application in memory at the same time.an add-on component to your computer. Includes central processing unit.

serial port .the command from the Special menu that shuts down the Mac safely.acronym for Write Once-Read Many.an all-important folder that contains at least the System file and the Finder. A UPS should have enough charge to power your computer for several minutes in the event of a total power failure.a port that allows data to be transmitted in a series (one after the other). System file .point .to write a file onto a disk.any menu that does not appear at the top of the screen in the menu bar. scroll box . such as the printer and modem ports on a Mac.files on disk that contain instructions for a computer.a central computer dedicated to sending and receiving data from other computers (on a network). software . when clicked. root directory . System folder .(1/72") 12 points = one pica in printing. shut down .acronym for Read Only Memory. save . spreadsheet . save as . server .acronym for Random-Access Memory. will expand the window to fill the whole screen. or jack on the Mac. zoom box .(a File menu item) to save a previously saved file in a new location and/or with a new name.a constantly charging battery pack which powers the computer.a connection socket.the main hard drive window.a program designed to look like an electronic ledger.a file in the System folder that allows your Mac to start and run.the horizontal bar at the top of a window which has the name of the file or folder it represents. start up disk .a small square in the upper right corner of a window which. Uninterruptible Power Source (UPS). giving you time to save your work and safely shut down. . WORM . memory that can only be read from and not written to. RAM . title bar . pop-up menu . (may pop up or down) port .the disk containing system software and is designated to be used to start the computer. an optical disk that can only be written to once (like a CD-ROM).the box in a scroll bar that is used to navigate through a window. ROM .

indicates nurses who demonstrate core nursing informatics competencies. education.6).indicates nurses who demonstrate advanced and specialized nursing informatics competencies Competencies: Technical . p. entry or user level . CAI. 6). GENERAL CONCEPTS IN NURSING INFORMATICS (Adopted from Fundamentals of Nursing by Kozier et. Intermediate or modifier level .al) Computer in Nursing Education Just as computers have become standard instructional tools in the primary and secondary school systems. . and Combine information to contribute to knowledge development in nursing" (Hebert. Teaching and Learning Computers enhance academics for both students and faculty in at least four ways. p.are related to the actual psychomotor use of computers and other technological equipment. interpret and organize data into information to affect nursing practice. 1999. 1999. Utility .LEVEL OF EXPERTISE AND COMPETENCIES IN NURSING INFORMATICS Levels of Expertise: Beginner. research and administration Leadership . and academic record keeping is facilitated by database programs. "The need to adopt a culture in nursing that promotes acceptance and use of information technology has been identified as an important parallel initiative to establishing Nursing Informatics competencies and educational strategies" (Hebert.are related to the ethical and management issues related to using computers and other technological equipment within nursing practice. classroom technologies. they are used extensively in all aspects of nursing education. education.indicates nurses who demonstrate intermediate nursing informatics competencies. research and administration Each of the three competency levels includes both knowledge and skills required to:" use information and communication technologies to enter. and strategies for learning at a distance.related to the process of using computers and other technological equipment within nursing practice. faculty members use technological teaching strategies in the classroom and for outside assignments. These include access to literature. Advanced or innovator level of competency . retrieve and manipulate data. Nursing programs require computerized libraries.

DEFINITIONS  is a systematic, rational and cyclical method of planning and providing nursing care PURPOSE  Solve nursing problems  Understand a nursing conditions Systematic Individualized Rationale Circular/Cycle ADPIE Unique Science sequence
ASSESSMENT Purpose: To establish database Activities: y Collection of Data y Organizing Data y Validating Data y Documenting Data

EVALUATION Purpose: to determine the effectiveness of the care plan and its corresponding actions whether to continue, terminate, or modify the care plan. Activities y Collects and compare data with the outcome

y Relate nursing actions to client¶s goals y Conclude problem status y Continue, modify or terminate the nursing care
IMPLEMENTATION Purpose: To assist client meet desired goals/outcomes and promote maximum level of functioning Activities: y Reassessment of Clients and their response to care y Determination of any need for assistance y Implementation of nursing interventions y Supervising delegated care y Documenting Nursing actions

DIAGNOSING Purpose: To identify and develop a list of nursing and collaborative problems Activities: y Analysis of Data y Identify strengths, risks, and health problems y Formulate diagnostic statements duly approved by NANDA

PLANNING Purpose: To develop an individualized, goal oriented and therapeutic care plan Activities: y Prioritizing needs y Formulation of Goals y Selection of Nursing Interventions y Writing Nursing Orders

STEPS OF THE NURSING PROCESS ASSESSMENT The vital first phase in the nursing process, assessment consists of the patient history, consultations, lab findings, pharmacological requisites, and the nurse¶s physical examination Nursing assessment is the systematic process of gathering, verifying and communicating data about a patient. It includes 2 steps (1) collection of data from a primary source (patient), and (2) collection of data from a secondary source (family, health professionals). The purpose of assessment is to establish a data base about the client¶s perceived needs, health problems and risks, related experiences, health practices, goals, values, and lifestyle. The information contained in the DATA BASE is the basis for an individualized plan of nursing care, developed and refined throughout the time the nurse cares for the client. Interview Purpose: To gather information, identify health concerns and provide health teaching. Goal: To develop rapport and trust with the client and to collect data. Stages: 1. Opening: The purpose is to establish rapport that is achieved through self-introduction, non-verbal gestures (e.g. handshake) etc. The purpose of the interview is explained at this stage. 2. Body: The nurse tries to ask the client using open and close-ended questions. 3. Closing: After the needed information has been gathered either parties may close the interview.

Types of data: Subjective Covert data or symptoms Client¶s perceptions about his health problems. Subjective data usually include feelings of anxiety, physical discomfort, or mental stress. Objective Overt data or signs Observations or measurements made by the data collector. The measurement of objective data is based on an accepted standard, such as the Fahrenheit or Celsius measure on a thermometer. In the physical examination of a patient ± involving inspection, palpation, percussion and auscultation ± objective data is collected about client¶s condition and underlying pathology. NURSING DIAGNOSIS Nursing diagnosis is a ³clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.´North American Nursing Diagnosis Association (NANDA) A nursing diagnosis is a statement that describes the patient¶s actual or potential response to a health problem that the nurse is licensed and competent to intervene. Components of a nursing diagnosis: Problem + Etiology + signs and symptoms / risk factors

The client¶s actual and potential responses are obtained from the assessment data base, a review of pertinent literature, the client¶s past medical records, and consultation with other professional, all of which are collected during assessment. The purpose is to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. Types of Nursing Diagnoses: Actual: the client shows manifestations of a health problem or condition. e.g. ineffective airway clearance High-Risk: A health problem or condition is likely to develop as a result of risk factors being assessed unless the nurse intervenes. e.g. Risk for injury Wellness: The client is healthy as assessed but he wishes to achieve a higher level of functioning. e.g. Readiness for enhanced social well being Possible ± a nursing diagnosis is which evidence is unclear unless further provided, but existing condition may predict a possible health problem e.g. Possible for alteration in nutrition r/t unknown etiology Syndrome ± a clustered nursing diagnosis. e.g. ±Disuse Syndrome PLANNING

outcomes. PLANNING STAGES Assign priorities to the nursing diagnosis Establish client goals / outcome Select appropriate nursing interventions Document the nursing diagnosis, expected outcomes and interventions. Evaluate the effectiveness of the plan of care BENEFITS OF A WRITTEN CARE PLAN A care plan that is well conceived & properly written helps decrease the risk of incomplete or incorrect patient care by: giving direction for individualized care providing continuity of care establishing professional communication serving as a key for patient assignments GOALS/EXPECTED OUTCOMES An expected outcome is the specific, step-bystep measurable criterion that leads to attainment of the goal & the resolution of the etiology for the nursing diagnosis. Outcomes are the desired responses of a client¶s condition in the physiological, social, emotional, developmental, or spiritual dimensions. This change in condition is documented through observable or measurable client responses. Patient goals may be either short term or long term.

The nursing plan of care refers to a WRITTEN PLAN of action designed to help nurses deliver quality patient care. It usually becomes part of the permanent part of the patient¶s health record and will be used by other members of the nursing team. The purpose is to develop individualized care plan that specifies client goals and expected


How the nurse will know the client¶s response has changed. What the client will do, when it will be done, and to what extent. Relate with the client in formulating expected outcomes. Includes client¶s health capabilities. Time estimate for outcome attainment.

3. Dependent: carried out by a nurse in collaboration with the physician. which involves assigning care for a client to another professional or individual while retaining accountability for certain care. The client may require intervention in the form of support. modify. Terminal: performed to indicate the client¶s condition at the time of discharge. Independent: nurses are licensed to act related to their knowledge and skills. Intermittent: performed at specified intervals. Evaluation may be: Ongoing: done while or immediately after implementing the nursing intervention. such as thrice a week. 2. Evaluative statements compare the data with the expected outcomes supported by evidences. client-family education. · The purpose is to assist the client meet desired goals or expected outcomes. or terminate the nursing interventions The nurse evaluates whether the client¶s behaviors or responses reflect a reversal or improvement in a nursing diagnosis or maintenance of a health state. treatment for the current condition. restore health and rehabilitation. . The purpose is to determine whether to continue. Interdependent/ Collaborative: carried out by a nurse with collaboration of other healthcare team.IMPLEMENTATION A nursing intervention is any action taken by the nurse to help the client move from a present health state to the health state described in the expected outcomes. prevent illness and disease. Goal met ± client¶s response is the same with goals Goal partially met ± only part of the desired outcome is met Goal unmet ± failure to achieve desired outcome in expected time. Types: 1. Consists of carrying out the interventions or delegating nursing interventions. promote wellness. or treatment to prevent future health problems. medication. EVALUATION Measures the client¶s response to nursing actions and the client¶s progress toward achieving goals.

Provide Privacy From Unnecessary Exposure. and sixth cranial nerves (oculomotor. To evaluate the effectiveness of prescribed medical treatment and therapy. too young. CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT Establish a Positive Nurse/Patient Rapport.PHYSICAL ASSESSMENT Physical assessment . fourth. systematic manner.Calibrated in cm to measure circumference Tongue depressor . Verbal Consent for the Assessment. Otoscope . Laryngeal mirror . or too confused to communicate clearly. Communicate Special Instructions to the Patient. choose a private place where others cannot overhear or see the patient. Provides data for planning intervention To confirm a diagnosis of disease or dysfunction. coffee) 2. Penlight / Flashlight to test pupillary reaction to light and third.Disposable sharp object to assess pain. instead of a random manner. EQUIPMENT AND SUPPLIES USED FOR PHYSICAL EXAMINATION: 1. If possible. It provides the foundation for the nursing care plan in which observations play an integral part in the assessment. sensory system 10. Obtain an Informed. Assure as much privacy as possible by using drapes appropriately and closing doors. Tape measure . trochlear. It is performed in an organized. PURPOSES FOR PERFORMING A PHYSICAL EXAMINATION To determine the patient's physiological function. The chief source of data is usually the patient unless the patient is too ill. Ophthalmoscope .Assess sensory system for light touch 3. Percussion hammer. This relationship will decrease the stress the patient may have in anticipation of what is about to be done to him. Ensure Confidentiality of All Data.Lighted instrument attached to a battery tube to visualize the eye¶s interior 6. To arrive at a tentative diagnosis when there is a health problem or disease. and evaluation phases.Wooden tongue blade to inspect oral cavity and stimulate gag reflex to assess ninth and tenth (glossopharyngeal and vagus) cranial nerves . Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health in order to plan for individualized care.is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. Safety pin . Aromatic substances . intervention. Explain what information is needed and how it will be used. Gloves reduce risk for transmission of microorganism 4.Metal instrument with mirror to inspect pharynx and oral cavity 5. vanilla.Instrument with rubber head to test reflexes 9.Test functioning of first cranial nerve (olfactory) (ex. Cotton balls .Special ear speculum that attaches to an ophthalmoscope to visualize external and middle ear (eardrum) 7. and abducens) 8.

Facilitates insertion of instruments into body cavities Drape . Auscultation inspection use of sense of sight visual inspection/examination Example. lungs. spleen. abdomen. full bladder. Lubricant . Percussion. Palpation. contour and symmetry of the body. lesions. as well as scars. and consistency of various body parts. Tuning fork .Metal fork that vibrates when tapped and is used to perform Rinne test to assess eighth (acoustic) cranial nerve 13.Empty stomach or Large intestine high kidney. such as lymph nodes and breast tissue Types of palpation: Light palpation ± detects superficial mass ( 1 ³ depth ) Deep palpation ± palpates organ enlargement like liver. feces filled intestine Soft . heart. the skin is inspected for color. liver Dullness Flatness Thud ± like Very Dull auscultation use of sense of hearing with the use of the unaided ear or a stethoscope frequently assessed organs: heart. abrasions. and deformities. tone.Bones and muscles moderate ( very dense tissue ) . motor dexterity.Covers exposed body parts ASSESSMENT TECHNIQUES: ³IPPA´ ± Inspection.12. TONE Resonance Hyperresonance Tymphany QUALITY Hollow Booming Drum ± like PITCH EXAMPLE Low Healthy Lungs Very Loud Empysema High GI Bubbling. position. Throughout the examination the nurse should visually observe the client¶s general body appearances such as movement. and texture. and blood vessels HEALTH HISTORY: Biographic information Chief complaint Present health status Health history Family history Psychosocial factors Nutrition History of Present illness includes: Statement of general health before illness Date of onset Characteristics at onset Severity of symptoms Course since onset . mass and pulsations ( 3 ± 4´ in depth) percussion assess for vibration with the use of fingers The finger of one hand taps the finger of the other hand to generate vibration which can be used to determine a diagnostic sound. and rashes. palpation use of sense of touch The back of the hand can be used to assess skin temperature over an inflamed joint or a leg with impaired circulation because the skin at the back of the hand is thinner and sensitive to temperature changes The finger pads are also sensitive and are used to palpate the size.

any recent surgeries. or recurrent illnesses.Associated signs and symptoms Aggravating or relieving factors Effect on activities Treatments tried and results Additional assessment question: What do you think caused this problem? Is anyone else in the household sick? Past Health History ± any diseases and illness experienced in the past which includes childhood illnesses and immunization status. admission. . Family Health History ± any hereditary condition which makes the client susceptible of developing a disease.

20 15 ± 20 73 / 55 90 / 55 95 / 57 102 / 62 120/80 120/80 130 / 90 Decreases during sleep Lowest level: early morning Highest level: late afternoon or early evening FACTORS INFLUENCING VITAL SIGNS . 8 37 37 37 37 37 80 ± 180 80 ± 140 75 ± 120 50 ± 90 50 ± 90 60 .Vital SIGNS Also called Cardinal signs PURPOSE: To obtain baseline measurement of the patient¶s vital signs To assess patient¶s response to treatment or medication To monitor patient¶s condition after invasive procedures Refers to the measurement of ³ TPR ± BP ´ Temperature Pulse Rate Respiratory Rate Blood Pressure Variations in Vital Signs By Age Age Temp. 8 36 .100 30 ± 80 20 ± 40 15 ± 25 15 ± 25 15 ± 20 12 .100 60 . ( ° C) Pulse Respiratory Cycles/min BP ( mmHg) Diurnal variations / circadian rhythm Lowest level: 4:00 AM ± 6:00AM Highest level: 8:00 PM ± 12:00 AM Factor Exercise and metabolism Temperature Increases Pulse Short Term: increases Long ± term : lowers the resting rate and return time to the resting rate post exercise Increases Increases with sitting or standing . Decrease when lying down Respiration Rate and depth increases Blood Pressure Increases Anxiety and stress Postural changes Increases No change Increases Decreases with stooped or slumped positions due to decreased chest expansion None Increases Decrease with sitting or standing Newborn 1 Year 5±8 years old 10 years old Teen Adult Elderly 36 .

TEMPERATURE Reflects the balance between heat produced and heat lost from the body. Natural drying after excessive sweating Convection Dispersion of heat by air currents.the rate of energy use in the body needed to maintain essential activities age and exercise Thyroxine output . The air rises and is replaced by cooler air ex.Tepid Sponge Bath Insensible heat loss . Norepinephrine. .is the heat that is lost through the continuous. & symphatetic Nervous System Stimulation . Body continually produces heat as a by product of metabolism Factors that affect metabolism : Food metabolism Muscle Activity Increased thyroxine production Fever basal metabolic rate. The body usually has a small amount of warm air adjacent to it.Increases rate of cellular metabolism throughout the body(Chemical Thermogenesis) Epinephrine. HEAT PRODUCTION Heat is produced in the body¶s cells through food metabolism that results in the release of energy ENERGY ± measured in terms of heat 1 kilocalorie equals 1000 calories (the amount of heat required to raise the temperature of 1 kilogram of water 1°C). Facing a fan for cooling Conduction transfer of heat from one molecule to a molecule of lower temperature -( with contact) ex. unnoticed water loss that occurs with vaporization.Increase cellular metabolism HEAT LOSS Radiation transfer of heat from the surface of one object to another without contact between objects ex. or BMR . Warming through a drop light Evaporation Continuous insensible loss from the skin and lungs when water is converted from liquid to gas ex. Evaporation accounts for the greatest heat loss when body heat increases. accounting for 10% of basal heat production.

Core Temperature Measured thru tympanic and rectal routes 2. Unconscious or irrational patients 4. Presence of ear ache Conversion: 2. (hyperthermia). Diarrhea 3. Mouth breathers and pts. Surface Temperature Measured thru oral and axillary routes. Infants and very young children 2. less invasive Contraindications: 1.TYPES of TEMPERATURE 1. with oxygen Equipment : oral thermometer Slim tip Fever Intermittent . fingers.safest and non invasive .Least accurate Rectal ± most reliable measurement Contraindications: 1. Scarred tympanic membrane °C= (°F-32) x 5/9 Celsius to Fahrenheit °F= (°C x 9/5) + 32 . pear-shaped tip electronic thermometer : Battery-powered display unit with a sensitive probe(blue for oral and red for rectal) covered with a disposable plastic sheath for individual use Tympanic ± accessible. at regular intervals between periods of fever and periods of Normal or subnormal Temperature Remittent.Above 40°C ± hyperpyrexia ROUTES FOR ASSESSING BODY TEMPERATURE: Oral ± accessible and convenient Contraindications: 1. Constant ± a fever with minimal temperature fluctuations Hypothermia ± a body temperature of 35 degrees Celsius or lower resulting from cold weather exposure or artificial induction Frostbite ± freezing of the body¶s surface areas (earlobes.and toes) in extremely low temperatures Heat Stroke .a critical increase In body temperature ( 41 degree Celsius to 44 degree Celsius) resulting from exposure to high environmental temperatures Axilla . skin patch or temperature ± sensitive tape Alterations in Body Temperature: Pyrexia. Seizure-prone patients 5.fluctuation of body temp. Rectal abnormalities 2. Certain heart conditions 4.temperature above the usual range.fluctuations above Normal of more than 2 °C Relapsing ± a fever that subsides and after few days returns. Immunosuppressed Equipment: rectal thermomter Stubby. Patients with oral surgery 3. Significant ear drainage Fahrenheit to Celsius 3.

Sites y Temporal ± accessible. count number y y y y y y y y 1. Pulse volume describes the force with which the heart beats. it is described as intermittent or irregular Volume/amplitude ± amount of blood pumped with each heartbeat. The volume of the pulse varies with the volume of blood in the arteries. 3. When the pulse skips a beat occasionally. *A client in pain will have elevated pulse. 2.used routinely for infants and during shock or cardiac arrest when other peripheral pulses are too weak to palpate . an athletic may be lower. CHARACTERISTICS OF PULSE Rate ± number of beats per minute. the strength of the heart contractions.PULSE Wave of blood created by contraction of the left ventricle of the heart. weak or difficult to feel 0: absent pulse Cardiac Output ± 5-6 Liters of blood is forced out of the left ventricle per minute Pulse Deficit ± difference between the apical and radial counts taken simultaneously Equipment used to assess pulse rate: Alcohol swab Stethoscope Watch with second hand Measuring Radial Pulse: Inform client of the site at which you will measure the pulse rate Flex client¶s elbow and place lower part of arm across chest. and the elasticity of the blood vessels. the pulse is described as normal or regular. Pulse rhythm is the spacing of the heartbeats. Place your index and middle finger on inner aspect of client¶s wrist over the radial artery and apply light but firm pressure until pulse is palpated Count pulse rate by using second hand on a watch: a. used routinely for infants and when radial pulse is not accessible Carotid . For a regular rhythm.used to assess circulation to the feet Rhythm ± pattern or regularity of beats and interval between each beat.radial pulse =pulse deficit Femoral ± assess circulation to the legs and during cardiac arrest Brachial ± used in cardiac arrest of infants and used to asses for lower arm circulation and to auscultate for BP Radial ± used routinely to assess for character of peripheral pulses in adults Popliteal ± used to assess circulation to the legs and to auscultate leg blood pressure Posterior tibial ± used to assess circulation to the feet Dorsalis Pedis . assess this by compressing an artery with the pads of three fingers. Pulse Force/ Pulse Volume Grading: +3: bounding pulse +2: normal +1: thready pulse. . When the intervals between the beats are the same. used to assess for cranial circulation Apical ± used to auscultate heart sounds and assess apical . *Bradycardia: a pulse that is below normal *Tachycardia: a pulse that is above normal 4.

Raise client¶s gown to expose sternum and left side of chest. count rate for a full minute. count rate for 60 seconds. left of the midclavicular line to palpate the point of maximal impulse (PMI) 7. For an irregular rhythm. With client lying on left side. Locate Apex of heart: 3. effortless.of beats for 30 seconds and multiply by 2. When counting for the first time. count number of beats for a full minute. With dominant hand. locate suprasternal notch. Method of Assessment: Observing chest wall expansion and bilateral symmetrical movement of the thorax. Count lub-dub sound as one beat: 11. Start to count while looking at second hand of watch. Keep index finger of nondominant hand on the PMI. Should assess by counting the number of breaths per minute Equipment for Assessment: watch with second hand External Respiration.exchange of gasses between the Blood and the cells Inhalation/inspiration ±active process Exhalation/Expiration ± passive process due to elastic recoil Normal respiratory rate: 12-20 breaths per minute in adult (eupnea). quiet. b. Document RESPIRATORY RATE Respiratory assessment is the measurement of the breathing pattern. 12. and regular. Place index finger in intercostal space. 5.refers to the interchange of oxygen and CO2 in the alveolocapillary membrane Internal Respiration . count for a full minute Measuring Apical Pulse 1. 4. For a regular rhythm. 2. Palpate second intercostal space to left of sternum.counting downward until fifth intercostal space is located. 13. Respiratory Controls: Medulla Oblongata: Central Chemoreceptor Carotid and Aortic bodies: Peripheral Chemoreceptor . Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound 10. noting number of irregular beats. 5. put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 seconds to warm. 8. noting number of irregular beats. Place the back of the hand next to the client¶s nose and mouth to feel the expired air. automatic. Move index finger along fourth intercostal space left of the sternal border and to the fifth intercostal space. Assessment of respirations provides clinical data regarding the pH of arterial blood. 9. For an irregular rhythm. Normal breathing is slightly observable. 6.

causing whistling or sighing sounds Stridor .Ventricular relaxation AVERAGE: 120/80 mmHg DETERMINANTS. such as an intravenous infusion or arteriovenous fistula for renal dialysis Surgery involving the breast. uremia. arm. or hand Injury or disease to the shoulder. dry. wheezy or whistling sou BLOOD PRESSURE Pressure exerted by blood to the blood vessel wall SYSTOLIC . Wheezing . Pumping action of the heart Peripheral vascular resistance Blood volume Blood viscosity Techniques : The direct method requires an invasive procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. burns.sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation Gurgles/ Rhonchi. muscle spasm usually heard during exhalation .narrowing of airways.difficulty of breathing Orthopnea -DOB unless patient is sitting. shoulder. rapid breaths for about 30 seconds.Characteristics of Respiratory Wave Pattern ³RAR´ Rate Amplitude/depth Rhythm / Pattern Breathing Pattern and Sounds Kussmaul¶s . Cheyne-Stokes is the term for cycles of breathing characterized by deep. -CVP The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation are needed.high-pitched sounds heard on inspiration with laryngeal obstruction Crackles/ Rales . It usually precedes death in cerebral hemorrhage. or heart disease.Faster and deeper respiration without pauses in between panting Apneustic . course .sound caused by air passing thru airways narrowed by fluids. axilla. edema. followed by absence of respirations for 10 to 30 seconds.Prolonged grasping breathing followed by extremely short inefficient exhalation Dyspnea . or application of a cast or bandage . or hand. arm. Common site : brachial artery Contraindications for brachial artery: Venous access devices.ventricular contraction DIASTOLIC . can breathe only when in an upright position. such as trauma.

Points to remember when Assessing Blood Pressure: Equipment: Sphygmomanometer with proper size cuff Stethoscope Alcohol swabs 1. Document Conditions related to Blood Pressure: Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client¶s normal systolic pressure. Deflate cuff and wait for 2 mins if reasessement is needed 13. 11. Swishing sound (phase II).Factors affecting Blood Pressure: Age -Children normally have lower blood pressure at birth (80/60). such as: Decreased blood volume (e. A faint. Position arm at heart level. With dominant hand. Hypotension is caused by a disruption in hemodynamic regulation. or excitement can elevate the blood pressure. Palpate brachial artery. A regular exercise program can eventually decrease the resting blood pressure. with bladder centered over brachial artery 3. Older adults frequently have higher blood pressure due to a decrease in blood vessel elasticity.g. turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears. 10. Body Built-Blood pressure is usually elevated in an obese person. Slowly turn valve counterclockwise so that mercury falls at a rate of 2±3 mm Hg per second. 12. which gradually increases until the age of 18 when it becomes equal to the normal adult pressure. Sex . Abrupt. Listen for five phases of Korotkoff¶s sounds while noting manometer reading: 8.Men have higher blood pressure than women of the same age. Emotional Status. Select a cuff size that completely encircles upper arm without overlapping 2. Place bell piece over brachial artery below the level of the chest 6. worry. Pain. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified 7. noting reading when pulse is felt again. then slowly release valve (deflating cuff). Wrap the blood pressure cuff on the arm 1 inch above client¶s brachial pulsation. 5. 4. clear tapping sound appears and increases in intensity (phase I). Disease States and Medication -Some disease conditions and/or the medications influence the blood pressure. ± systolic pressure 9.Muscular exertion will temporarily elevate the blood pressure. turn valve clockwise to close. Intense sound (phase III).. Exercise. Sound disappears (phase V) ± Diastolic Pressure a. distinctive muffled sounds (phase IV).Fear. hemorrhage) . extend elbow with palm turned upward.Physical discomfort will usually elevate the blood pressure.

Diagnosis of hypertension is based on the average of two or more readings taken at each of two or more visits after an initial screening. myocardial infarction [heart attack]) Decreased peripheral vascular resistance (vascular dilation) (e. Orthostatic hypotension usually occurs with aging and is a common antiadrenergic side effect of several medications.g. Faulty techniques that constrict blood flow will produce a false high pressure reading: A cuff too narrow for the extremity A cuff that does not fit snugly around the extremity A cuff that is deflated too slowly .. shock) Orthostatic hypotension (postural hypotension) refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position.Decreased cardiac output (e. such as chlorpromazine hydrochloride.g.. Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

The highest possible score is 15. not applied to face None Oriented Confused conversation. words discernible Incomprehensible speech None Obeys commands for movement Purposeful movement to painful stimulus Withdraws from pain Abnormal (spastic) flexion. and sex Affect: Attentive. and best motor response. readily answers questions Memory: Responds appropriately to questions: Immediate: ³Why are you here?´ Recent: ³What did you eat for breakfast?´ Remote: ³Where were you born?´ Orientation : Person (self. cooperative. or shout Opens to pain. decorticate posture Extensor (rigid) response. clean. pleasant Speech : Articulate. decerebrate posture None Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 15 Motor Response Total Appearance: Neat.( Refer to table below) The score in each category is added in order to get the overall scale. Eye Opening Response Best Verbal Response GLASGOW COMA SCALE (GCS) TABLE: Spontaneous ( open with blinking at baseline) Opens to verbal command. Included in the GCS are: assessment of eye opening.NEUROLOGICAL ASSESSMENT NEUROLOGICAL ASSESSMENT Levels of Consciousness . others) Place Time .Can be measured by RLS (Reactive Level Score) and Glasgow Coma Scale REACTIVE LEVEL SCORE (RLS) Alert Drowsy Very Drowsy Unconscious Localizing Unconscious Withdrawing Decorticating Decerebrating Glasgow Coma scale is a tool used to measure the levels of consciousness and the degree of impairment. the patient is considered I comatose status. speech. If a score falls below 7. fluent. best verbal response. clothes appropriate to occasion. but able to answer questions Inappropriate responses. season.

I II III Olfactory Optic Oculomotor Trochlear Trigeminal Cribiform Plate Optic Canal Superior Orbital Fissure Superior Orbital Fissure V1: Sup Orb Fissure V2: Foramen Rotundum V3: Foramen Ovale Superior Orbital Fissure Internal Auditory Canal Special Sensory: Smell Smell Special Sensory: Sight Vision Somatic Motor: Superior, Medial, Inferior Rectus, Inferior Oblique ; Visceral Motor: Sphincter Pupillae Pupil Constriction, elevation of upper lid Somatic Motor: Superior Oblique Eye movement, Somatic Sensory: Face Somatic Motor: Mastication, Tensor Tympani, Tensor Palati Controls muscle of chewing Somatic Motor: Lateral Rectus Eye movement, Somatic sensory: Posterior External Ear Canal Special Sensory: Taste (Anterior 2/3 of Tongue) Somatic Motor: Muscles Of Facial Expression Visceral Motor: Salivary Glands, Lacrimal Glands Controls muscle for facial expression Special Sensory: Auditory/Balance Maintain equilibrium; hearing Somatic Sensory: Posterior 1/3 Tongue, Middle Ear Visceral Sensory: Carotid Body/Sinus Special Sensory: Taste Somatic Motor: Stylopharyngeus Visceral Motor: Parotid Controls muscle of throat Somatic Sensory: External Ear ; Visceral Sensory: Aortic Arch/Body ; Special sensory: Taste Over Epiglottis Somatic Motor: Soft Palate, Pharynx, Larynx (Vocalization and Swallowing) Visceral Motor: Bronchoconstriction, Peristalsis, Bradycardia, Vomitting Controls muscle of throat, thoracic and abdominal organs Somatic Motor: Trapezius, Sternocleidomastoid Controls neckmuscles Somatic Motor: Tongue Tongue movement



Abducens Facial


Acoustic Glossopharyngeal

Internal Auditory Canal Jugular Foramen



Jugular Foramen


Spinal Accessory Hypoglossal

Jugular Foramen Hypoglossal Canal

Neurologic Assessment
Motor Function assessment of the motor system involves testing for muscle size, tone, and strength under voluntary movements Reflexes

Assessment Tool
Muscle strength. Flexion and extension. Muscle tone

Normal Findings
· Equal ize on both ides of body · Usually firm · Equal strength on both sides of the body · Smooth , coordinated movements

Significant Findings
NOTE: Tics, tremors, fasciculations may suggest neurologic involvement.

Scale Response 0 Absent + Present but diminished ++ Normal +++ Mildly increased but not pathologic ++++ Markedly hyperactive; clonus may be present

Blink reflex Gag and swallow reflex Plantar response (Babinski reflex) Deep tendon reflex Biceps Triceps ± Brachioradialis Patellar ± NORMAL: extension of leg below the knee Achilles ± Normal: plantar flexion of feet Plantar (babinski) ± Normal: bending of toes downward

NOTE: Diminished or absent reflexes may suggest upper or lower motor neuron disease; however, this may also be found in normal people. (Reinforcement by isometric contraction such as asking patient to push his or her hands together while knee reflex is checked may increase reflex activity.) A positive Babinski¶s reflex may be seen in pyramidal tract disease or in the unconscious patient

Sensory Function

Asses for: (done after symmetric testing of the arms, legs, and trunk) Pain: ³Sharp or dull?´ Temperature: ³Hot or cold?´ Light touch: ³Feel touch?´ Vibration: ³Feel tuning fork vibrating against joint?´ Position sense (proprioception): ³Am I moving your toe up or down?´

NOTE: Inappropriate response indicates neurologic disorder.

Cerebellar Function

Perform Romberg¶s test: ask the client to stand erect, feet together and arms at side, first with eyes open, then closed. The nurse should stand close to the client to catch the client in the event of a fall

. Note the client¶s ability to maintain balance with eyes open and closed for 20 seconds with minimum swaying

NOTE: Loss of balance is termed ³positive Romberg test´ (indicates sensory ataxia). Uncoordinated gait may suggest cerebral palsy, parkinsonism, or drug side effect. Inappropriate movements suggest cerebellar disease

HEAD ASSESSMENT Assessment Assessment Tool
Head Inspection : Size or contour

Normal Findings

Significant Findings

Hydrocephalic Micrpcephalic Asymmetric



Smooth, nontender

NOTE: Scaling, masses, tenderness

Head circumference

Measuring Tape : (measured at largest point above eyebrow and behind occiput)

Between 5th and 95th percentile on standardized growth chart.

Exceeds chest circumference by 1±2 cm until 18 mo.

Soft. Posterior fontanel 0. Unusually small fontanel may indicate craniosynostosis(premature closure of sutures). Closes between 9 and 18 mo. bulges while crying. flat. . May be closed at birth or by 3 mo of age. NOTE: Unusually large fontanel may indicate hydrocephaly (faulty circulation or absorption of CSF).5±1 cm across. Delayed closure may indicate hydrocephaly.Anterior fontanel 3±4 cm in length and 2±3 cm in width until 9±12 mo of age.

tense or expressionless facies Tenderness Sinuses Frontal and maxillary sinuses nontender Cranial nerve: (CN)VII: facial. weak. puff cheeks.FACE ASSESSMENT Assessment Assessment Tool Face: Inspection Normal Findings Symmetric. frown. raise eyebrows. with symmetry noted Bilateral contractions of temporal and masseter muscles when teeth are clenched Able to distinguish touch on both sides of face Unable to purposely and symmetrically use facial muscles Weak or asymmetric contraction of muscles CN V: trigeminal: Motor CN V: trigeminal: sensory Unable to distinguish type and location of touch . motor Able to smile. with relaxed facial expressions Significant Findings Asymmetric. involuntary movements.

and dilation occurs to accommodate distant vision.Eye Assessment Visual acuity assessment of visual acuity is a simple. Presence of discharge.Pupils should be equal in size. Pupil should constrict quickly in direct response to light and the opposite pupil should also constrict. The upper eyelids cover only the uppermost part of the iris and are free from nystagmus (involuntary. noninvasive procedure that is performed with the use of a Snellen chart(a chart that contains various-sized letters with standardized numbers at the end of each line of letters) standardized numbers or denominators indicates the degree of visual acuity from a distance of 20 feet External lesions. Equality of eyelid movement Test extraocular muscle function: Record results. round. Pupil Size: Common Refractory Error: Myopia (nearsightedness) elongation of the eyeball or an error of refraction that causes the parallel rays to focus in front of the retina Hyperopia ( farsightedness) rays of light entering the eye are brought into focus behind the retina Presbyopia ( far sightedness) results from loss of elasticity of the lens of the eye Astigmatism ± unequal spherical curve of the cornea that prevents the light from being focused directly in a point on the retina . Differences between pupil size and reaction. with symmetrical convergence of eyes. rhythmical oscillation of the eyes). Eye movements should be symmetrical as both eyes follow the direction of the gaze. Internal lesions. Record results PERRLA (pupils equal. Pupillary accommodation causes constriction in response to objects that are near. reactive to light and accommodation).

prolonged loud noise. and softly whispers numbers on side of open ear. Occurs with conductive hearing loss resulting from diseases. Note Presence of external lesions. out of view to avoid client lipreading. Weber test: Hold the base of the vibrating fork with your thumb and index finger and place the base of the fork on center of top of client¶s head Sound perceived equally in both ears. Ammonia smell occurs during the end stage of renal failure from a buildup of urea. lipreading.Ear Assessment The nurse should observe the client for signs of hearing difficulty during the physical examination. and speaking in a loud voice. Halitosis (foul-smelling breath) occurs with tooth decay or disease of gums. Note Presence of discharge. Positive : conductive hearing loss ( impacted cerumen.. Mouth and Lip Assessment Mouth: Stand 12±18 inches in front of client and smell the breath. Bone conduction is equal to or greater than air conduction. cerum or pus in the middle ear. resulting from excessive exposure to loud noises). obstruction. Auditory acuity Whispered voice test: Nurse stands 1±2 feet away from client. Breath should smell fresh. such as turning the head. Increase voice volume until client identifies words correctly. Musty smell is caused by the breakdown of nitrogen and presence of liver disease. results indicate a ³negative´ Weber test. or sinuses or with poor oral hygiene Acetone breath (³fruity´ smell) is common in malnourished or diabetic clients with ketoacidosis. perforated tympanic membrane.g. fusion of the ossicles Sensorinueral hearing loss : auditory nerve damage . or damage to outer or middle ear. tonsils. Squamous cell carcinoma (most common form of oral cancer) usually involves the lower lip and may . Chancre (primary lesion of syphilis) is a reddish round. painless lesion with a depressed center and raised edges that appears on the lower lip. Lip Lip lesion: Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that rupture and crust over. Inability to hear words may indicate a highfrequency hearing loss (e. effect of ototoxic agent Rinne test: Vibrate prongs of tuning fork and place base of fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears sound Sound heard longer in front of the right auditory meatus than on the mastoid process because air conduction is twice as long as bone.

The pharynx is pink. and moist without inflammation or lesions Pale or cyanotic lips may indicate systemic hypoxemia. consistency. mobility. ulcer. Ventral surface is slightly rough (taste buds). smooth. acromegaly. NOTE:Enlarged tongue may indicate glossitis or stomatitis or may occur with myxedema. and dorsum is highly vascular. size. vascular. Palates are concave and pink. cavities. Hard palate has ridges. lesionfree. and appearance of tonsils and uvula With phonation. or warty growth. soft palate is smooth pharynx using a tongue depressor and penlight . moist and smooth along lateral margins. firm. shape. Lips and mucosa should be pink. with free mobility. NOTE: Reddened. the soft palate and uvula rise symmetrically. cracked lips occur with dehydration or exposure to weather. Swollen lips (angioneurotic edema) result from allergic reactions Gums are pink. edematous uvula and tonsillar pillars with yellow exudate indicate pharyngitis. Note position and alignment Instruct client to say ³ah. or amyloidosis. Inspect teeth: note tarter. Small. Dry.´ Note the position. movable nodes are insignificant. NOTE: Prominent lateral deviation of sternocleidomastoid muscles (torticollis) is commonly associated with inflammation of viral myositis or trauma Lymph Nodes Palpate anterior and cervical lymph nodes (with gentle pressure) Note size. extraction and color. Inspect the hard and soft palate with penlight. Lymph nodes should not be palpable. and tenderness. NOTE: palpable lymph nodes indicates infectious process or malignancy THYROID Gland Position: Stand behind patient and gently push trachea to one Tongue: tongue lies midline. Neck Assessment Inspect Neck: Test sternocleidomastoid muscle Muscles are symmetrical with head in central position.appear as a thickened plaque.moist and firm Pale gums that bleed easily may indicate periodontal disease or vitamin C deficiency. Movement through full range of motion without complaint of discomfort or limitation.medium red or pink in color.

masses.inspect under natural sunlight for accuracy note color. Stage 2 pressure ulcer 2 y excoriation ± loss of epidermal layers exposing the dermis ex. varying in size from small to 1 ± 2inches. Abrasion y vascular and purpuric lesion y cherry angioma .ruptured chicken pox y scar ± fibrous tissue that replaces dermal tissue after injury ex. contour and consistency presence of lesion: primary lesion macule . Surgical incision y crust ± dried serum. Vitiligo. Right lobe may be slightly larger.) Auscultate over gland NOTE: Enlargement (goiter). Palpate extended side as patient swallows There should be no enlargement. chicken pox patch ± localized changes in skin pigmentation of <1cm in diameter . ex psoriasis bullae ± like vesicle but > 0.5 to 2 cm ex.5cm in diameter like elevated nevi vesicle ± elevated mass containing serous fluid accumulation between the upper layers of the skin example: 2nd degree burns.5cm in diameter. extends deeper than the papule into the dermis or subcutaneous tissues. or tenderness. size.5 cm in diameter. acne cyst ± subcutaneous or dermis mass ex: sebaceous cyst secondary lesion y scales ± flaking of the skin¶s surface ex. round lesion y spider angioma ± fiery red lesion up to 2 cm with central body surrounded by erythema and radiating legs ( in liver disease.localized changes in skin color < 1 cm in diameter like freckles papule ± solid elevated lesion < 0. Striae y ulcer ± depressed lesion of the epidermis and upper papillary layer of the dermis ex. ex.nails) Color. Dandruff . 0.side. tenderness nodule ± solid and elevated. psoriasis y erosion ± loss of epidermis ex.lipoma. erythema pustule ± pus filled vesicles or bullae. blood or pus on skin surface y fissure ± linear crack in the epidermis that can extend to the dermis ex. Chapped hands or lips y keloid ± enlarging of a scar past wound edges due to excess collagen formation ( more prevalent in dark skinned person y atrophy ± thinning of the skin surface and loss of markings ex.5cm in diameter . Impetigo. pressure ulcer stage 1 plaque ± solid elevated lesion > 0. may resemble a spider Assessment of the Skin Part of Integumentary system which includes: skin scalp.ruby red ± 1-3 mm. (Gland is normally slightly enlarged during pregnancy and puberty. Ex. <0. nodules. pregnancy) y venous star ± bluish . and anatomic location and distribution .mobility.

soles. noting the degree of indention. fading to green. Vellus ± fine.liver disease or drug interactions Common skin alterations: Melanin ± naturally occurring brown pigment ( ex decreased in albinism) Cyanosis . Indicates an increased pressure in superficial veins . Carotenemia (yellowish discoloration) is described as normal as a result of increased levels of carotenoid pigments in the palms. lips.y y or be linear. Ex varicose veins petechia ± reddish purple. unpigmented hair that covers most of he body parts Terminal Hair . eyebrows and eyelashes. infection.coarser. strong emotion Dryness usually occurs in dehydration Bromhidrosis ( body odor) caused by perspiration or bacterial decomposition Temperature: Sensation/ texture quality. Pitting edema scale: 1+ indentation of 1 cm or less 2+ indentation of 2cm 3+ indentation of 3cm 4+ indentation of 4cm 5+ indentation of 5cm Moistness and temperature. nipples. darker hair of scalp.ankles by applying pressure with fingers.bluish discoloration in the lips. and nails results from an increased amount of reduced hemoglobin in the blood caused by a cold environment or heart or lung disease. 1 ± 3mm in size ecchymosis ( bruise ) purplish blue. axillary and pubic hair becomes terminal with the onset of puberty . palpate dependent areas such as sacrum. and face from a diet high in carotene. and the glans penis. Jaundice (yellowish discoloration) results from increased bilirubin levels caused by red blood cell hemolysis in liver disease as observed first in the sclera and mucous membranes and then generalized. thickness. blood clotting disorders. flat round lesion . suppleness generalized roughness is seen in hypothyroidism Hair Hair is distributed over the body except for the palmar and plantar surfaces. mucous membranes. Moisture: wetness and oiliness Excessive moisture or perspiration (hyperhidrosis) caused by hyperthermia. yellow and brown usually results from blood vessel trauma may indicate vit C deficiency. hyperthyroidism.feet. Turgor and mobility Measures the elasticity of skin -determines degree of hydration For Mobility.

1:1 in adult presence of chronic pulmonary disease Ribs and interspaces .1:1 (equal) 1:2 in normal adult barrel chest . aneurysm. feels firm when palpated Clubbing : indicates hypoxia. costal angle Thoracic Expansion: Posteriorly. feels springy when palpated Koilonychia (spoon nail) concave curves associated with iron deficiency anemia Beau¶s line : transverse depression in the nails often associated with injury and severe systemic infections Paronychia: inflammation in the nail base associated with trauma and local infection y retraction of interspaces indicative of obstruction bulging during exhalation result of air outflow obstruction: tumor.Use palmar or ulnar surface Tactile Fremitus Increased. cardiac enlargement slope of ribs.Nails y The nail plate (translucent tissue that covers the distal portion of the digits and provides protection) changes with many disease processes Normal nail : angle of approximately 160 degrees between the fingernail and the nail base .conditions that increase density of thoracic tissue consolidation of pneumonia some lung tumor Tactile Fremitus Decreased obstruction of transmission of vibrationspleural effusion pleural thickening (fibrosis) pnemothorax bronchial obstruction COPD/emphysema y y y y Thorax Assessment Inspect for Thoracic contour : shape. symmetry . angle greater than 180 degrees .5 cm Feel during quiet I & E Palpate during deep inspiration Should be symmetrical Tactile Fremitus palpable vibrations of chest wall over lung fields from speech or sounds. and developmental: Pigeon chest Funnel chest Spinal Deformities Kyphosis AP to Lateral diameter till age 6 .level of 10th rib Thumbs should separate 3 .

and low-pitched sounds heard longer on inspiration than expiration that result from air moving through the smaller airways over the lung¶s periphery.thoracic Normal rate. grating sound Stridor: heard predominantly on inspiration as a continuous crowing sound y y y y y y y y y y . orthopnea shallow grunting Respiratory movement thoracic or abdominal Men & children . high-pitched crackling. gurgling sound of long duration) that sounds like water going down the drain after the plug has been pulled on a full tub of water Rhonchi: heard predominantly on expiration over the trachea and bronchi as a continuous. quality termed eupnea rhythmic effortless quiet symmetrical y Respiratory Auscultation: During auscultation. deep Hyperventilation :Hypoventilation Effort/Quality unlabored labored. Bronchovesicular breath sounds medium-pitched and blowing sounds heard equally on inspiration and expiration from air moving through the large airways. posteriorly between the scapula and anteriorly over bronchioles lateral to the sternum at the first and second intercostal spaces y Bronchial breath sounds loud and highpitched sounds with a hollow quality heard longer on expiration than inspiration from air moving through the trachea Adventiitous Breath Sounds Abnormal breath sounds are characterized by decreased or absent sounds.dyspnea. low-pitched crackling.abdominal breathers Women. Also called gurgle Wheezes: heard predominantly on expiration all over the lungs as a continuous sonorous wheeze (low-pitched snoring) or sibilant wheeze (high pitched musical sound) Pleural friction rub: heard on either inspiration or expiration over the anterior lateral lungs as a continuous creaking. low pitched musical sound. breezy. Crackles: heard predominantly on inspiration over the base of the lungs as an interrupted fine crackle (dry. popping sound of short duration) that sounds like a piece of hair being rolled between the fingers in front of the ear or a coarse crackle (moist.Lung Assessment Respiratory Pattern Rate adult NL: 12 . rhythm. the client should be instructed to breathe only through the mouth because mouth breathing decreases air turbulence that could interfere with an accurate assessment Note quality and location of lung sounds Vesicular breath sounds soft.20 resting tachypnea = > 20 bradypnea= <10 Rhythm Depth : shallow.

methyldopa. Nipples may be inverted from puberty. tender. color consistent with rest of body. Palpate Lymph Nodes: Position: place arms at side. . smooth deeply pigmented skin should be further evaluated.Breast and Axillae Assessment Position: sitting position on the edge of examining table or bed facing you For Female Breasts: Symmetric (Normal for dominant side to be slightly larger. making breastfeeding difficult. hard nodes may be due to hand or arm infection but may also be a sign of breast cancer. which may be indicative of obstructed lymphatic drainage Signs of breast cancer: peau d¶orange skin (edema/thickened skin with enlarged pores). convex contour Consistency: varies widely (Firm. areolar areas. noncircumscribed masses Areola Small elevations around the nipple (Montgomery¶s glands) are normal. nipples. Nipples Nipples should point upward and laterally or outward and downward. flattening. transverse inframammary ridge along lower breast edge should not be mistaken as abnormal mass NOTE: Reddened areas of breasts. infection. Usually elastic. no edema. reserpine. sometimes drug-related (spironolactone. Velvety. or tricyclic antidepressants) Axillae: Rash (may be caused by deodorant). no discharge Occasional hair around nipple NOTE: Asymmetrical nipple direction or recent nipple inversion. cimetidine. or inflammatory carcinoma Thickening or edema of breast tissue or nipple causes enlarged skin pores that give the appearance of an orange rind (peau d¶orange).) Significant differences in size or symmetry of breasts. retractions. manual stimulation. digitalis preparations. Place client¶s head in a flexed position (relaxes sternocleidomastoid muscle) NOTE: Enlarged. marijuana. everted ( in geriatric patients: Nipples become smaller and flatter) Intact skin. For Male breasts: Flat or muscular appearance without masses NOTE for Gynecomastia: a firm disk-shaped glandular enlargement on one or both sides resulting from imbalance in estrogen/androgen ratio. areolar areas. smooth. Hard. infection. oral contraceptives. axillae. or axillae may be an indication of inflammation. estrogens. or malignant or benign breast disease. or depression is indicative of nipple retraction. fixed. or nipples may be indicative of a tumor Skin: intact. irregular. Thickening of a previously inverted nipple may indicate a tumor Nipple discharge in nonpregnant or nonlactating woman may be caused by tranquilizers. phenothiazines. NOTE: Rashes or ulcerations may suggest cancer of mammary ducts (Paget¶s disease). dimpling.

.Heart Assessment Cardiac Landmarks 1. hands at sides or across chest. 3. Mitral area (left ventricular or apical area) is the fifth ICS at the left midcavicular line. with palpable thrill. palpable thrill Distinct abnormal findings on palpation and auscultation y thrills (vibrations that feel similar to what one feels when a hand is placed on a purring cat) y heaves (lifting of the cardiac area secondary to an increased workload and force of left ventricular contraction). heard without stethoscope. click (a high-pitched systolic sound created by the opening of the valve) or 2. may be associated with a thrill Grade V: Loud. 2. S1 heart sounds . bruits (blowing sounds that are heard when the blood flow becomes turbulent as it rushes past an obstruction ASSESSMENT OF THE ABDOMEN Place client in a supine position with knees flexed over a pillow. in adults it may be indicative of cardiac dysfunction S4 heart sounds (atrial gallop) sound resembles the pronunciation of the word ³Tennessee´ (le-lub-dub). or scoliosis Umbilicus is depressed and beneath the abdominal surface. Auscultation. Tricuspid area (right ventricular area or septal area) is the fifth ICS to the left of the sternum. Aortic area is the second intercostal space (ICS) to the right of the sternum. Inspect: Inspect abdomen from rib margin to pubic area Contour is flat or rounded and bilaterally symmetrical A convex symmetrical profile reveals either a protuberant abdomen (results of poor muscle tone from inadequate exercise or obesity) or distension (taut stretching of skin across abdominal wall Asymmetry may indicate a mass. Pulmonic area is the second ICS to the left of the sternum. a murmur (swishing or blowing sounds of long duration heard during the systolic and diastolic phases created by turbulent blood flow through a valve 3. Erb¶s point is located in the third ICS to the left of the sternum. 5. Percussion and Palpation ( ³ IAPP´ ) Assessment should always begin in the right lower quadrant (RLQ). bowel obstruction. enlargement of abdominal organs. audible with stethoscope in contact with chest wall Grade VI: Louder. Heart murmurs: Grades and Characteristics of Murmurs: Grade I: Barely audible Grade II: Audible immediately Grade III: Moderate intensity Grade IV: Loud.Atrioventricular heart sounds S2 heart sounds . 4.Semilunar heart sounds S3 heart sounds ± (Ventricular gallop) sound resembles the pronunciation of the word ³Kentucky´ (lub-dub-by ) S3 can be a normal physiological sound in children and young adults. y stenosis or regurgitation sounds: 1. Order of assessment: Inspection.

free from respiratory retractions. However. peritonitis. Pulsations of the abdominal aorta are visible in the epigastric area in thin clients Strong peristaltic movement may indicate intestinal obstruction. Marked pulsations in epigastric area may indicate an aortic aneurysm Auscultation: Order: RLQ. heard every 5 to 15 seconds as intermittent gurgling sounds in all four quadrants as a result of air and fluid movement in the gastrointestinal tract Hypoactive sounds may indicate decreased motility of the bowel. Ask the patient about urinary patterns such as retention. RUQ. Visible peristalsis slowly traverses the abdomen in a slanting downward movement as observed in thin clients. Order of palpation: RLQ..g. Ask the patient if he has noticed blood in his urine or if he has pain when urinating. When assessing the urinary system. LLQ. or enlarged organs. Palpate the bladder for distention and tenderness.Dullness is heard over organs (e. polyuria or oliguria. or an obstruction Hyperactive (loud. Examine the female genitalia with the patient in a dorsal recumbent position. Percussion: (deleted landmarks) Note when tympany changes to dullness. 2. 1. Uneven respiratory movement with retractions may indicate appendicitis. Genitourinary Assessment The male genitalia may be examined with the patient either standing or supine. the patient may feel the need to urinate. such as occurs with peritoneal irritation or paralytic ileus Absent bowels sounds (none heard for 3±5 minutes) may signal paralytic ileus. the liver). the patient should stand as you check for hernias or varicoceles. During deep palpation. Ask the patient to urinate into a y y y y . ascites (excessive fluid accumulation in the abdominal cavity) or full intestines Palpation: Never palpate over areas where bruits are auscultated.renal or femoral stenosis). nocturia. gurgling sounds similar to stomach growling. hematuria. Check for urine frequency and urgency. this is a normal response. urgency and frequency. LUQ Should feel smooth with consistent softness. LLQ. Large masses may be due to tumors. Dullness over the stomach or intestines may indicate a mass or tumor. incontinence. dysuria. 3. LUQ y High-pitched sounds.. Tenderness and increased skin temperature may indicate inflammation. feces. audible. Tympany is heard because of air in the stomach and intestines. RUQ.g. sounds also called borborygmi) may occur with diarrhea or hunger A bruit over an abdominal vessel reveals turbulent blood flow suggestive of an aortic aneurysm or partial obstruction (e. check for and evaluate edema.Umbilicus bulging may indicate a hernia Engorged or dilated veins around the umbilicus are associated with circulatory obstruction of superior or inferior vena cava Abdomen rises with inspirations and falls with expirations. Press deeply in the midline about 1 to 2 inches above the symphysis pubis.

and the ball of the foot. excessive muscle size (hypertrophy) without a history of muscle building exercises. and drape appropriately. it should appear pink and free of swelling or discharge. inflammation and discharge may signal urethral infection. or signs of inflammation. In any patient. and clarity. Compress the glans gently between your index finger and thumb to open the urethral meatus and inspect it for discharge. 3. 8. odor. The knees should be symmetrical and located at the same height in a forward-facing position. Spread her labia with a gloved hand and inspect the urethral meatus. nodules. .FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT 3=50% . MUSCLE TONE AND STRENGTH 0=COMPLETE PARALYSIS 1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE 2=25% . consistency. decreased muscle size (atrophy). and tenderness. 4. scars. pace and length of stride. 10. and 2 to 4 inches between the feet. 2. coordination. Have the patient stand with his feet together.NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE 5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE Musculoskeletal Assessment Gait Posture Muscular palpation Joint palpation Range of motion Muscle strength Procedure and Technique 1. Look for ulcers. Assess the sample for color. Assess the perineal area for character of skin and abnormal masses or discharge. striking the floor first. and walk back. Normal findings include smooth. spasticity (hypertonicity). or veins. 5.specimen cup. Have the male patient assume a supine position. Assess muscle strength and joint ROM. and balance. Assess muscle mass. Inspect the inguinal and femoral areas carefully for bulges. weakness (hypotonicity). Begin assessment of the male genital system by inspecting the penis. shape. Note their size. 6. 7. rather than the heel. Palpate each testis and epididymis. arms held out to the side or in front. Observe and evaluate his posture. coordinated movements. Inspect spinal curvature. Explain in advance what you are about to do. jerky or shuffling motions. A bulge that appears on straining suggests a hernia. Assess muscle tone. To assess fine motor coordination. Be sure to wear gloves. Note any swelling.NORMAL MOVEMENT AGAINST GRAVITY 4= 75%. erect posture. flaccidity (atony). toeing in or out. Ulceration usually indicates a sexually transmitted disease. 9. Ask the patient to walk away. If the patient is elderly or infirmed. lumps. Provide the patient with a gown. Abnormal findings include a wide support base. Ask. 4. Inspect the scrotum. To assess gross motor skills. 5. and involuntary twitching of muscle fibers (fasciculations). remain close and ready to help if he should stumble or start to fall. turn around. Look for nits or lice at the bases of the pubic hairs. have the patient perform range-of-motion (ROM) exercises (see Nursing Fundamentals I. Note the relation of one knee to the other. foot position. have the patient pick up a small object from a flat surface.

means accessing the body¶s tissue. if so. organ. assess client for allergy Intratest Focus: specimen collection and assisting or performing the test Use or practice standard precaution and sterile techniques Provide emotional and physical support to the client Post ± Test Focus: providing nursing care and follow ± up I. or cavity through some type of instrumentation procedure Non ± invasive . Ongoing client assessment and evaluation of the client¶s expected outcomes requires the incorporation of diagnostic findings Invasive . GIT.Indirect: Barium Swalllow ( upper GIT ) .DIAGNOSTIC EXAMINATIONS Diagnostic tests are either noninvasive or invasive.means the body is not entered with any type of instrument 3 phases of Diagnostic Testing: Pretest Focus: Client Preparation Consent is secured for every invasive procedure or diagnostic test For radiologic studies: special precautions for pregnant clients Know the supplies and equipment needed for a specific test Know if the client needs to be on NPO prior to the test and if a dye is needed. Diagnostic testing is a critical element of assessment. GIT.Direct visualizations ( invasive) Lower GI Endoscopy: Anoscopy Visualization of the anal canal Proctoscopy Visualization of the rectum Proctosigmoidoscopy Visualization of the rectum and sigmoid colon Position: knee chest or lateral Cleansing enema is needed Pre Test: laxative Post test: position in a supine manner for a few minutes Monitor for bleeding and perforation Colonoscopy Needs to be sedated Position: sims/ left side. knees flexed Post test: assess for bradycardia and hypotension Assess also for perforation Endoscopy ( UGI) Pre test: NPO Needs sedation Local spray anesthetic is administered Post Test: NPO until gag reflex returns Gastric Analysis Measures gastric pH and pepsin Pre Test: NPO for 12 hours Requires NGT insertion that is connected to a suction Specimen is taken every 15 min to one hour I.

Respiratory System Invasive Mantoux Test Purified protein Derivative Intradermal injection which will be read after 48 hours and 72 hours 10 mm induration is positive for Mycobacterium tuberculosis 5 mm induration for an HIV positive patient is already positive montoux test Bronchography Pre test: A radioopaque medium is injected into the trachea and bronchial tree Check for allergies to seafoods. Aneurysym clips. orthopedic screws Pre Test: NPO for 6 ± 8 hours Instruct client to remain still throughout the procedure II. indomethacin and colchicine these can alter results Taken in 3 consecutive days Stool for Ova and Parasites Specimen should be sent immediately ( warm and fresh ) Stool Culture Stool for Lipids To assess stool for steatorrhea Ultrasonography Needs to be on NPO for 8 to 12 hours Laxative prior to test Views cross sectional images of an organ using magnetic field CI: with pacemakers. iodine and lidocaine Requires to be on NPO for 6 ± 8 hours Meds prior to test: Atropine sulfate Valium Post: Remain on NPO until gag reflex returns Position on side lying Magnetic Resonance Imaging Bronchoscopy .To visulalize esophagus down to the jejunum Needs to be on NPO for 6 ± 8 hours Barium Sulfate is taken by mouth prior to the procedure Post test: Laxative is given to wash off barium White stool is observed for about 72 hours Barium Enema ( Lower GIT ) Visualize colon Pretest: low residue/clear liquid diet for 2 days laxative cleansing enema is administered in the morning before the test barium sulfate via rectal route post test: laxative increase OFI Fecalysis Guaic Stool Exam Used to assess Gastro intestinal Bleeding Pre Test: increase fiber diet 48 -72 hours prior No red meat. iron and steroids.

fever. crepitus. Instruct the client to wash hands carefully with soap and H2O for 24 hrs following the procedure Non ± invasive Chest X ± ray / fluoroscopy Metal objects and other jewelries should be removed prior to the test Sputum Examination obtained by expectoration or tracheal suctioning identify organisms or abnormal cells ideally taken early morning upon awakening sterile specimen is needed only 15 ml of sputum Rinse the mouth with water prior to collection Take several deep breaths and then cough forcefully Collect the specimen before antibiotics III. seafood & dyes NPO prior to procedure Post Test: No BP for 24 hrs in the affected extremity Monitor peripheral neurovascular status Assess for bleeding Monitor dye reaction Ventilation Perfusion Scan determines the patency of the pulmonary airways a radionuclide may be injected Pre Test: Assess for allergies to dye. Cardio Vascular System . or seafood Remove jewelry Review breathing methods Administer sedation Emergency resuscitation equipment For 24 hrs following the procedure. hypoxemia. handle body secretions carefully. and pneumothorax Notify the MD if complications occur Lung Scan Used to detect pulmonary embolism Pre test: radio isotope is injected Scans are taken with scintillation camera Thoracentesis Aspiration of fluid / air from pleural space Position : upright leaning on over bed table or Side lying Post Test: Position on the unaffected side to prevent leakage Lung Biopsy To detect malignancy Pre Test: NPO prior Local anesthetic Pressure during insertion and aspiration Administer analgesics & sedatives Post Test: Pressure dressing Monitor for bleeding Monitor for respiratory distress Monitor for complications: pneumothorax and air emboli Prepare for Chest ± X . bronchial perforation. hemorrhage. trachea & bronchi with a fiber-optic bronchoscope Pre test: NPO 6 ± 8 hours Needs to be sedated Post Test: Remain on NPO until gag reflex returns Monitor for complications: bronchospasm. iodine. dysrhythmia.visual examination of the larynx.ray for re evaluation Pulmonary Angiography insertion of a flouroscopy via the antecubital or femoral vein into the pulmonary artery it involves iodine or radiopaque or contrast material Pre Test: Assess for allergies to iodine.

and large square: 0. pumping function of the right side of the heart Normal range is SV : 0 -12 cm H20 RA : 4-10 cmH20.Invasive Hemodynamic Monitoring Central Venous Pressure Obtained by inserting a catheter into the external jugular. When it is wedged it is in the distal arterial branch of the pulmonary artery. measured from onset of Q wave to end of S wave ST segment a. elevation indicates hypervolemia.) a.) a.12 . measured after QRS complex to beginning of T wave T wave a.0. it allows visualization of the heart chambers.06-0. Purpose: Proximal port: measures RA pressure Distal port: measures Pulmonary Artery pressure and Pulmonary Capillary Wedge Pressure Normal Range: PAP : 4 ± 12mmHg PCWP : 4 ± 12 mmH Ensure that balloon is deflated with a syringe attached except when PCWP is read Irrigate line before each reading of PCWP Maintain client in same position for each reading Record PA systolic and diastolic readings at least every hour and PCWP as ordered. RV. represents ventricular repolarization b. follows ST segment ECG in MI: - . blood vessels and blood flow (angiography Pre Test: any allergies esp. indicates time interval between complete depolarization of ventricles and repolarization of ventricles b. measured from beginning of P wave to beginning of QRS complex QRS complex (NÛ= 0. and PA. to iodine keep client on NPO for 8-12 hrs Non Invasive: Electrocardiogram (ECG) Monitors the electrical activity of the heart strip: small square: 0. blood volume.04secs. Cardiac catheterization catheter is inserted into the right or left side of the heart to measure intracardiac pressures and oxygen levels in various parts of the heart with injection of a dye. or femoral vein and threading it into the vena cava. indicates AV conduction time or the time it takes an impulse to travel from the atria down and through the AV node b.2secs P wave: produced by atrial depolarization. antecubital.20 secs.10 secs. decreased level indicates hypovolemia Maintain zero point of manometer always at level of right atrium (midaxillary line) Stop ventilatory assistance during measurement of CVP Practice Strict Aseptic Technique Pulmonary Artery Pressure and Pulmonary Capillary Wedge Pressure Uses Swanz ± Ganz Catheter A multi lumen catheter with a balloon tip that is advanced through the superior vena cava into the RA. indicates SA node function P-R interval (NÛ= 0. The catheter is attached to an IV infusion and H2O manometer by a three way stopcock Assess pressure of the right atrium. indicates ventricular depolarization b.

Elevated ST segment Inverted T wave Q wave Echocardiography noninvasive recording of the cardiac structures using ultrasound Portable recorder (Holter monitor) provides continuous recording of ECG for up to 24 hrs assess activities of the heart which precipitate dysrythmias and time it occurred Exercise ECG (stress test) the ECG is recorded during prescribed exercise.2 to 5. NPO post MN.4 uU/ml Elevated in primary hypothyroidism & decreased in hyperthyroidism or secondary hypothyroidism Thyroid Scan Performed to identify nodules or growths in the thyroid glands Discontinue medications containing iodine 14 days prior to test and discontinue thyroid meds 4-6 weeks prior to test. before & after administration. No preparation needed Light pressure applied to aspiration site after the procedure Eight-hour intravenous ACTH Test Used to determine function of adrenal cortex Administration of 25 units of ACTH in 500 ml of saline over an 8-hr period 24-hr urine specimens are collected. may show heart disease when resting ECG does not Cardiac enzymes: in MI a. thyroiditis T3 and T4 resin Blood test for diagnosis of thyroid disorders Normal Value : T3: 80-230 ng/dL T4: 5-12 ng/dL increase in hyperthyroidism & decreased in hypothyroidism Thyroid Stimulating Hormone Test: Blood test used to differentiate the diagnosis of primary hypothyroidism from secondary hypothyroidism Normal value is 0. ACTH administration . Administration of I123 or I131 orally followed in 24 hrs. if iodine is used client will fast an additional 45 minutes after ingestion of radioactive isotope & scan is done after 24 hours. Aspartate aminotransferase (AST) (SGOT): 24 Hrs after chest pain e. Lactic dehydrogenase (LDH): 36 Hrs IV. Troponin T: detected 3-12 hours after chest pain b. normally steroid excretion increases threefold to fivefold ff. creatine phosphokinase (CPK ± MB): 6-12Hrs d. NEEDLE ASPIRATION OF THYROID TISSUE Aspiration of thyroid tissue for cytological exam. by a scan of the thyroid for the amount of radioactivity emitted. Normal value is 5-35% in 24 hours Increased: hyperthyroidism . Troponin I: detected 3-12 hrs c. for measurement of 17ketosteroids and 17-hydrocorticosteroids In Addison¶s disease. urinary output of steroids does not increase following administration of ACTH. Endocrine System Radioactive iodine reuptake A thyroid function test that measures the absorption of the iodine isotope to determine how the thyroid gland is functioning. thyrotoxicosis Decreased: hypothyroidism. A radio isotope of iodine or technetium is administered prior to the scanning of the thyroid gland.

the technologist will be able to see.6% to 8. Metal objects including jewelry. you will feel a slight pin prick when the needle is inserted into your vein. dentures and hairpins may affect the CT images and should be left at home or removed. You may have a warm.9% Diabetics with poor control: 9% or greater V. 4. Magnetic Resonance Imaging ( MRI ) noninvasive.5% or less Diabetics with fair control: 7. you may be given special instructions. And assess for seafood and iodine allergy. If you received a contrast material. You will be alone in the exam room during the CT scan. hear and speak with you at all times. Pregnant women may not be allowed to undergo this test. 6. usually painless medical test . then hourly for 3-5 hrs 3. however. flushed sensation during the injection of the contrast materials and a metallic taste in your mouth that lasts for a few minutes 5. you can return to your normal activities. NOTE: Disrupted or obstructed blood flow through the neck arteries may indicate the person is a risk of having a stroke Computed Tomography ( CT ± SCAN ) CT imaging uses special x-ray equipment to produce multiple images and a computer to join them together in cross-sectional views. client ingests 100g glucose. avoid strenuous exercise 8 hours before & after test 2. The ultrasound technician may apply a clear gel to the skin in order to help the transducer more freely over the body. If contrast medium will be used. 1. coffee & smoking 36 hours before testing fast midnight before test fasting blood glucose & urine glucose specimens obtained. eyeglasses. urine specimens may also be collected Glycosylated Hemoglobin : Is a reflection of how well blood glucose levels have been controlled for up to the prior 4 months Fasting is not needed Values: Diabetics with good control: 7. 2. if an intravenous contrast material is used. patient needs to be on NPO. There is no special preparation needed for this test. 3.In Cushing¶s syndrome. Pretest Reminders: 1. You may also be asked to remove hearing aids and removable dental work. After a CT scan. blood sugar drawn at 30 & 60 mins. Peripheral Vascular Disorders Non ± invasive Doppler Ultrasonography Non-invasive diagnostic procedure that changes sound waves into an image that can be viewed on a monitor. hyperactivity of the adrenal cortex increases the urine output of steroids in the second urine specimen tenfold Glucose Tolerance Test: Pre test: eat a high-carbohydrate (200 to 300 g) diet for 3 days before the test avoid alcohol. It is frequently used to detect problems with heart valves or to measure blood flow through the arteries.

The cuff will be inflated and a machine called a plethysmograph measures the pulses from each cuff. 4. 2. Veins are not normally seen in an x-ray. internal (implanted) defibrillator 6. The test can be used to determine if there are any blocked or damaged arteries. all of which can be damaged. it may indicate a blockage. Assess for iodine allergies and for any history of allergic reactions Angiography Arteriography or angiography is test that uses xrays and a special dye to see inside the arteries. to seafoods and iodine) NPO for 2 to 6 hours Post Test: Monitor peripheral pulses on punctured extremity Pressure dressing and ice packs at the puncture site VI. Pre test preparation: Do not smoke for at least 30 minutes before the test.leg test used to see the veins in the leg. Venography Phlebogram . 5. which can distort MRI images. clothing from the arm and leg being tested should be removed. Hepato ± Biliary System Liver Function Test: . cochlear (ear) implant 7. Pens. the contrast material used for an MRI exam. Pre Test: Assess for allergies ( esp. watches. hairpins. Removable dental work. credit cards and hearing aids. Pins.leg. 3. Position: supine with the involved extremity elevated above the level of the heart Three blood pressure cuffs are wrapped snugly around your arm and leg. called gadolinium. pocketknives and eyeglasses. a dye. Limb plethysmography is a test that compares blood pressure in the legs and arms. These items include: ( because this will interfere with the magnetic field) 1. Jewelry. so a special dye (called contrast) is used to highlight them X-rays are taken as the dye flows through the leg. which produces loud thumping and humming noises during imaging.Useful in detecting Abdominal Aortic Anuersyms and deep vein thrombosis Some MRI examinations may require the patient to swallow contrast material or receive an injection of contrast into the bloodstream. metal zippers and similar metallic items. clips used on brain aneurysms You may request earplugs to reduce the noise of the MRI scanner. Venography . Invasive Plethysmography Plethysmography is a test used to measure changes in blood flow or air volume in different parts of the body. is injected into the blood stream. does not contain iodine and is less likely to cause an allergic reaction. It is usually done to check for blood flow blockages in the legs. The test records the maximum pressure produced when the heart contracts (systolic blood pressure) If there is a decrease in the pulse between the arm and leg. called contrast material. metal and electronic objects are not allowed in the exam room. X-rays will be taken to see how the dye flows through the arteries.

caffeine (These can affect all types of bilirubin. shock. CHF. and insulin. salicylates.5. alcohol. Serum glutamate pyruvate transaminase. Tissues with particularly high amounts of ALP include the liver. MI (between 6 hr and 3±4 days). a physiological product of RBC.4mg/dL Increased: Liver disorders. Rh or ABO incompatibility in newborn. DIC. Alanine transaminase Most accurate indicator of liver function 4±36 U/L (varies by method)0.Serum blood test: Albumin The normal range is 3. CVA. cirrhosis. salicylates AST/SGOT Male: 8±46 U/L Female : 7±34 U/L NB: 16±72 U/L Increased: Liver or biliary disorder.8mg/dL increased: Sickle cell anemia. mono. and bones increased: hepatocellular damage decreased: Hypothyroidism.: decreased serum albumin may result from liver disease(for example hepatitis. therefore an appearance of jaundice means that there is a breakdown of balance of bilirubin . pernicious anemia.4 . vit K deficiency. Decreased albumin may also be explained by malnutrition or a low protein diet. salicylates GGT ( Gamma-glutamyltranspeptidase) Male: 6±37 U/L Female: < 45 yr old 5±27 U/L . mono. Because albumin is made by the liver. pernicious anemia.07±0.6 _kat/L Increased: Liver disorders. It can also result from kidney disease. cancer. muscular trauma. They are asked to withheld prior to testing. obstructive jaundice Decreased: Barbiturates. alcohol. or hepatocellular necrosis). infectious mono. bile ducts. which allows albumin to escape into the urine. burns.0mg/dL Urine urobilinogen Bilirubin. MI. epilepsy. DKA. numerous meds Decreased: Exercise. is metabolized in the liver and excreted into bile ducts. muscular dystrophy. hemophilia. oral contraceptives Partial thromboplastin time activated (PTT) 28±40 sec or within 5 sec of control Increased: Heparin. numerous meds Direct: up to 0. placental insufficiency Normal range: Adult: 20±90 U/L . diabetes mellitus. biliary obstruction. growth hormone. androgens.) Total up up 1. leukemia Decreased: Extensive cancer Serum bilirubin : indirect: up to 0. shock. > 45 yrs old 6±37 U/L Child : 3±30 U/L Increased: Liver disease. numerous meds Decreased: Late pregnancy. CHF.4 g/dL. polycythemia. liver disease. CHF. Pre TesT: Drugs that can increase albumin measurements include anabolic steroids. malnutrition. MI. renal failure. A1AT (Alpha-1 antitrypsin ) Alpha-1 antitrypsin is ordered to help diagnose the cause of persistent jaundice and other signs of liver dysfunction ALP (Alkaline phosphatase ) a protein found in all body tissues. hemolytic anemia. Child: 60±270 U/L ALT SGPT. penicillin. infection or inflammation of muscle tissue Decreased: Pregnancy. septicemia.

and shifts of brain structures . ibuprofen. including the skull. brain. and sinuses. A special needle is used to remove the tissue from the liver pre test: the physician will take blood samples to make sure blood clots properly. spaceoccupying lesions. infarctions. Paracentesis also may be done to take the fluid out to relieve abdominal pressure or pain in people with cancer or cirrhosis.8 mg/dl / less than 17 umol/l (< 1mg/dl) Increased values: overburdening of the liver excessive RBC breakdown increased urobilinogen production re-absorption . orbits (eye sockets). thin needle put through the belly.2 ± 1. the patient will have to stop taking aspirin. cerebral edema. cerebral atrophy. hydrocephalus.2 Units or 0 . A type of brain scanning that may or may not require an injection of a dye Used to detect intracranial bleeding. One week before the procedure. Neurologic System CT SCAN A cranial CT scan is computed tomography of the head.a large hematoma restricted liver function hepatic infection poisoning liver cirrhosis Low values: failure of bile production obstruction of bile passage Ultrasound of the Liver Pre Test: Needs to be on NPO 8 ± 23 hours Increase fluid intake Laxative is administered a night prior the test Liver biopsy examines a small piece of tissue from the liver for signs of damage or disease. Pre Test: Empty bladder prior to test to prevent puncturing the bladder Check serum protein studies Intra Test: Position client: sitting or upright position Post Test: Monitor client¶s vital signs and rigidity of abdomen/ signs of peritonitis VII.metabolism and the patient may have a problem of liver or RBC production and destruction NV : 0. and anticoagulant NPO 2 ± 4 hours Vit K is injected Instruct to hold breath for 5 ± 10 seconds during the insertion of needle to prevent trauma to the diaphragm Intratest : position: left side or supine position with pillow under the right and Post test: Lie down on the right side for 4 hours with pressure dressing or apply pressure on the incision site to prevent bleeding Bed rest for 24 hours Paracentesis: a procedure to aspirate fluid that has collected in the peritoneum The fluid is taken out using a long. The fluid is sent to a lab and studied to find the cause of the fluid buildup.

Assess dye injection site for bleeding and monitor extremity for color.pens.cochlear (ear) implant . Do not eat or drink foods that have caffeine (such as coffee. Monitor allergic reaction from the dye 3. Inform the client of possible mechanical noises during the test 5. Provide replacement fluids because diuresis is expected if dye is used 2.Pre Test: 1. can be seen by the changes in the normal pattern of the brain's electrical activity. flushed sensation and metallic taste Post Test: 1.removable dental work. tumors. sleeping aids. cola. tea. Do not put any hair conditioner or oil on after shampooing. oils. Invasive Lumbar Puncture Insertion of a spinal needle through L3-L4 interspace into the lumbar subarachnoid space to obtain CSF. If he cannot fall asleep. creams. warmth. and lotions. an all-night recording of the brain's electrical activity may be done. pocketknives and eyeglasses. . The client may be asked not to sleep at all the night before the test or to sleep less (about 4 or 5 hours) by going to bed later and getting up earlier than usual If a child is going to be tested. Instruct the client to lie still and flat during test 3. or medicines used to treat seizures) should be WITH HELD before the test. If an EEG is being done to check a sleep problem. Shampoo the hair and rinse with clear water the evening before or the morning of the test. . Remove objects from the head 4. These items include: ( because this will interfere with the magnetic field) .jewelry. try to keep him or her from taking naps just before the test Intra test: The client may be asked to go to sleep.internal (implanted) defibrillator . he may be given a sedative to help fall asleep. and chocolate) for 8 hours before the test. metal zippers and similar metallic items. it is important that the hair be clean and free of sprays. Pretest: certain medicines (such as sedatives and tranquilizers. . Any conditions. .pins. When dye is injected ± there may be a hot. hairpins. Special sensors / electrodes are attached to the head and hooked by wires to a computer. such as seizures. and vascular abnormalities Provides more details than CT scan metal and electronic objects are not allowed in the exam room. muscle relaxants. credit cards and hearing aids.clips used on brain aneurysms Remove IV pumps during test If patient have pulse oximeter ± extra precaution is done Assess for claustrophobia EEG (electroencephalogram ) a test that measures and records the electrical activity of the brain. Assess allergies if dye is used 2. and the presence of distal pulses MRI ( magnetic resonance imaging ) Non-invasive procedure that identifies types of tissues. . watches. all of which can be damaged. which can distort MRI images.

Observe for changes in vital signs Myelogram Injection of dye or air into the subarachnoid space to detect abnormalities of the spinal cord and vertebrae Pre Test: 1. Pretest: 1. or a narrowing of the arteries Pre Test: 1. or instill air. Elevate head 15 ± 30 degrees for 6-8 hours if water ±based dye is used 3. into the vein of the arm. a clot . VIII. Place flat on bed for 6-8 hours if oil-based dye is used a contrast dye is injected into one or more arteries to make them visible. Heart patients are also told to not take any product with caffeine for at least 24 hours intratest: 1. The test involves injecting a very small dose of a radioactive chemical. 2. Musculoskeletal System Invasive: Cerebral Angiography Injection of contrast through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions . Assess for allergies 3. which helps doctors identify abnormal from normal functioning of organs and tissues. called a radiotracer. The client will be asked to lie down on a flat examination table that is moved into the center of a PET scanner²a doughnut-like shaped machine. Needs sedation Post Test: 1. tumor . oxygen use. dye or medications Contraindicated in clients with increased ICP Pre Test: Have the client empty the bladder Intra Test: 1.measure CSF pressure. The test is most frequently used to confirm cases of stroke . Hydration 2 days before 3. Position the client in lateral recumbent position and have the client draw knees up to abdomen and chin unto the chest 2. the contrast dye is injected into one or both of the carotid arteries in the neck. bulging of the artery walls. Flat on bed for 8 hours 2. and glucose metabolism. If taking Phenothiazine ± hold the medication 4. Generally. Remove metals PET SCAN (positron emission tomography ) A PET scan can measure such vital functions as blood flow. Observe for bleeding at puncture site¶ 3. The tracer travels through the body and is absorbed by the organs and tissues being studied. Provide hydration for at least 12 hours before the test 2. Maintain strict asepsis Post Test: 1. Assess for allergies 2. NPO 4-6 hrs prior the test 4. most patients are told not to eat anything for a minimum of 6 hours before the scan. Assess vital signs and neurologic condition 2.

scleroderma. The client should empty your bladder right before the scan. leukemia. limit fluids for up to 4 hours before the test because you will be asked to drink extra fluids after the radioactive tracer is injected. cirrhosis. dermatomyositis Antinuclear antibodies (ANA) Neg at 1 : 10 dilution . The client will lie on his back on a table and a large scanning camera will be positioned closely above him 2. He needs to lie very still during each scan to avoid blurring the pictures. cancer Decreased: Polycythemia vera. SLE. For a bone scan.Blood Test: ESR (Erythrocyte sedimentation rate) Male : Up to 15 mm/h Female: Up to 20 mm/h Child: Up to 10 mm/h Increased: Inflammation. rheumatoid arthritis.0 kU/L Positive: SLE or lupus nephritis C ± reactive Protein C-reactive protein measures general levels of inflammation in your body. hepatitis. Remove any jewelry that might interfere with the scan 5. 4. sickle cell anemia Rheumatoid Factor ( RF ) <1 : 20 or negative Increased: Rheumatoid arthritis. infectious mononucleosis Anti ± DNA Anti-DNA or Anti-DNP Normal: Negative . Take off all or most of the clothes. a radioactive tracer substance is injected into a vein in the arm. ulcerative colitis. He usually has to wait 1 to 3 hours after the radioactive tracer is injected before the bone scan is done. acute MI. Sjögren¶s syndrome. The tracer then travels through the bloodstream and into the bones Pretest: 1. scleroderma. 3. High levels of CRP are caused by infections and many long-term diseases Normal range: 0±1. Increase fluid intake to wash off radioactive tracer Arthroscopy Arthroscopy is a type of joint surgery in which a thin tube with a light source (called an arthroscope) is inserted into the joint through a small incision (cut) in the skin. SI units Negative Present / positive: SLE. infection. Post Test: 1. SI Units <2. allowing the doctor to see the inside of the joint . Intra test: 1. The client may be asked to move into different positions so the area of interest can be viewed from other angles. pregnancy.0 mg/dL or less than 10 mg/L (SI units) X ± rays ( Bones ) Used to asses fractures of the bones Bone Scan A bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown A bone scan can often detect a problem days to months earlier than a regular X-ray test. depending on which area is being examined (the client may be allowed to keep on his underwear if it does not interfere with the test). 2. CHF.

problems with the spine such as a herniated disc.Is or might be pregnant. Eyes and Ears Eyes Snellen¶s Chart Non invasive procedure to test visual acuity standardized numbers or denominators indicates the degree of visual acuity from a distance of 20 feet Tonometry A tonometry test measures the pressure inside your eye. Elevate head 15 ± 30 degrees for 6-8 hours if water ±based dye is used 2. NPO 8 hours prior to the test 2. take off jewelry that might be in the way of the X-ray picture. or iodine dye. especially if you take metformin (Glucophage). . Crutches may be needed if the foot or knee joint was examined. or warfarin (Coumadin). depending on the extent of the procedure and the doctor's preference.Surgery will not cure rheumatoid arthritis or stop the disease's progress. an eye disease that can cause blindness by damaging the nerve in the back of the eye (optic nerve) Tonometry measures IOP by recording the resistance of the cornea to pressure (indentation Pre test instruction: 1.Is allergic to any medicines. contrast material. A myelogram may be done to find a tumor.Has asthma. an infection. the joint should be used as infrequently as possible for several days. The client may need to take a laxative or have an enema before the test to empty the bowels. 2.Has bleeding problems or take bloodthinning medicines. Do not drink more than 2cups of fluid 4 hours before the test. Post test: 1. . Arthrocentesis a joint fluid aspiration Myelogram A myelogram uses a special dye (contrast material) and X-rays (fluoroscopy) to make pictures of the bones and the fluid-filled space (subarachnoid space) between the bones in the spine (spinal canal). or narrowing of the spinal canal caused by arthritis. 3. .Has ever had a severe allergic reaction (anaphylaxis). . Pretest: 1. which is called intraocular pressure (IOP) This test is used to check for glaucoma. such as aspirin. - Has diabetes. Assess if the client: . .Has epilepsy or a seizure problem. Place flat on bed for 6-8 hours if oil-based dye is used EMG ( electromyogram) An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction and electrical activity in response to stress Measuring the electrical activity in muscles and nerves can help find diseases that damage muscle tissue (such as muscular dystrophy) or nerves (such as amyotrophic lateral sclerosis or peripheral neuropathies) IX. heparin. . . Post Test: 1.Has had kidney problems. but it may improve function and provide some pain relief.

helps determine what kind of hearing loss the client has by measuring your ability to hear sounds that reach the inner ear through the ear canal (airconducted sounds) and sounds transmitted through bones (bone-conducted sounds). The eyedrops used to numb your eye may burn a little. Audiometry evaluates a person's ability to hear by measuring the ability of sound to reach the brain. effect of ototoxic agent Whisper Voice Test Nurse stands 1±2 feet away from client.2. X. resulting from excessive exposure to loud noises). This indicates conductive hearing loss resulting from diseases. Gonioscopy does not usually cause any discomfort. fusion of the ossicles Sensorinueral hearing loss : auditory nerve damage . Ears Tuning Fork Rinne test Vibrate prongs of tuning fork and place base of fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears sound Sound heard longer in front of the right auditory meatus than on the mastoid process because air conduction is twice as long as bone. and softly whispers numbers on side of open ear.g. prolonged loud noise.indicate a ³negative´ Weber test. Weber Test Hold the base of the vibrating fork with your thumb and index finger and place the base of the fork on center of top of client¶s head If sound is perceived equally in both ears. Inability to hear words may indicate a highfrequency hearing loss (e. If bone conduction. Gonioscopy Gonioscopy is an eye examination to look at the front part of the eye (anterior chamber) between the cornea and the iris. perforated tympanic membrane. time is equal to or greater than air conduction. Increase voice volume until client identifies words correctly. obstruction. Gonioscopy is a painless examination to see whether the area where fluid drains out of the eye (called the drainage angle) is open or closed. Genito ± Urinary System Non invasive U/A± see opposite page KUB X ± ray of the kidneys. bladder and bladder Pretest: 1. out of view to avoid client lipreading. Intratest: Numbing eyedrops are used. Positive : conductive hearing loss ( impacted cerumen. Do not drink alcohol for 12 hours before the test. Enema/ clean colon preparation prior to test . Pretest: 1. 3.. cerum or pus in the middle ear. Do not smoke marijuana for 24 hours before the test. remove contact lenses before this test and do not put them back in for one hour after the test or until the medicine used to numb the eye wears off. 2. or damage to outer or middle ear.

disease in the kidney Specific Gravity Glucose None Positive .010 ± 1.6 ± 8.0 (newborns) 1. excess solutes such as glucose / ketones Decreased: Excess fluid intake. DM Ketones Blood Protein Product of breakdown of fatty acids None 0 ± 2 RBCs Qualitative: none Quantitative: 10 ± 100 mg / 24 h 500 ± 800 OsM/Kg Positive in poorly controlled or uncontrolled DM Positive: bleeding Presnt if glomerular membrane has been damaged Osmolality Measures the solute concentration of urine Monitors Fluid and Electrolyte imbalances Increased: Fluid volume deficit Decreased: Fluid volume excess .025 Clinical Significance Increased: alkaline Decreased : acidosis Increased: fluid deficit .0 ± 7.0 (adults) 5.pH Description Evaluate the client¶s acid ± base status Urine ph is normally acidic with an average of 6 Indicator of urine concentration or the amount of solutes (wastes) present in the urine Method: Urinometer/hydrometer in a cylinder of urine Spectrometer / refractometer This is an inadequate measure of blood glucose Used to screen clients for DM and assess abnormal glucose tolerance during pregnancy Normal Value 4. dehydration.

7 mg/dL Newborn: 0.3±1. Observe for signs of infection 3.4 mmol/L Infant: 4±18 mg/dL / 1. hematuria will be observed 2. ascites. numerous meds Decreased: Fanconi¶s syndrome. the ureters. liver disorders. exercise.1 mmol/L) Child: 5±20 mg/dL /2. chronic renal failure. psoriasis. numerous meds Albumin 3.8±7.5 mg/dL / 0. needs to be on NPO for 6 ± 8 hours .0±8.5±6.5 mg/dL / 0.Invasive : Blood Studies: BUN 5±25 mg/dL ( SI UNIT: 1.8 g/dL Increased: Dehydration. chemotherapy. A series of X-ray pictures is then taken at timed intervals. Increase fluid intake 4. meds. SLE.7±7. scleroderma. MI Decreased: Inadequate protein intake.3±0.5±5. done with local anesthesia 3. tissue necrosis.33 mmol/L Increased: Gout. a dye called contrast material is injected into a vein in the arm. liver disease. also called a cystourethroscopy or. burns.5 mg/dL/ 53±133 µmol/L Child: 0. Needs to be on NPO for 6 ± 8 hours 2. the bladder. meds Cystoscopy Cystoscopy.4±6. eclampsia.0±5. renal disorders (cause usually not renal if serum creatinine normal). sedation is done 2. Increase fluid intake to excrete dye 2.0 g/dL or 52±68% of total protein Child: 4. sickle cell anemia. eclampsia Uric Acid Male: 4. shock. nephrotic syndrome Serum Creatinine 0.4 mmol/L Increased: Dehydration. massive muscle damage Decreased: Muscular dystrophy. dysuria.24±0. Asses for any delayed allergic reaction Renal Biopsy Renal tissue sample is taken and sent to a lab to detect any malignancy pre test: 1.51mmol/L Female: 2. chronic diseases. prolonged application of tourniquet prior to venipuncture Decreased: Malnutrition.0 mg/dL Increased: Impaired renal function. tissue destruction. Hodgkin¶s disease. alcohol. water overload.43 mmol/L Child: 2. Direct visualization of the urinary tract Position: lithotomy Post ± test: 1. Hot sitz bath to relieve pain IVP An intravenous pyelogram (IVP) is an X-ray test that provides pictures of the kidneys.16±0. more simply. Pretest: 1.5±5. a bladder scope. Pink tinged urine (24 ± 48 hours) . Bed rest 3.6±1. excessive purine intake.15±0. and the urethra During IVP. nephritic syndrome. Assess for allergy to seafoods and iodine or any history of allergic reaction Post test: 1. pregnancy. CHF. is a test to measure the health of the urethra and bladder.3 mg/dL / 0.

intra test: 1.2 x 12 10 / L M: 4.0 ± 5.5 ± 11. Laboratory tests are ordered to: Detect and quantify the risk of future disease Establish and exclude diagnoses Assess the severity of the disease process and determine the prognosis Guide the selection of interventions Monitor the progress of the disorder Monitor the effectiveness of the treatment Laboratory Values: Hematologic System: types of blood Cells Leukocytes Granulocytes Monocytes Bone Marrow Lymphocytes Plasma Cells Lymph Tissue Bone Marrow from megakaryocytes 4. increase fluids up to 3000ml per day 5. post test: bed rest for 24 hours 4. position client to PRONE 2.5 ± 5. (a substance dissolved in a solution. also called a solute) are present in a specimen. hold breath and remain still during needle insertion 3.9 x 1012 /L Major Function Transport hemoglobin Transporting carbon dioxide in the form of sodium bicarbonate Being an acid-base buffer for whole blood The protective system LABORATORY DATA Laboratory studies are usually simple measurements to determine how much or how many analytes. observe for bleeding tendencies and infections Cell Erythrocytes Origin Bone Marrow Range ( in SI Units) F: 4.0 x 9 10 /L Platelets 150 ± 300 x 10 / L 9 Vascular Repair .

5 ± 5.2 x 10 /L M: 4.53 26 ± 34 pg/RBC 310 ± 370 g/L 80 -100 fl Luekemia Hemorrhage Microcytic hypochromic anemia Chronic IDA IDA.41 ± 0.06% Segmented neutrophils Lymphocytes 0. Chron. parasites .5±11.46 M: 0. trauma Severe bacterial disease . .44% Lupus erythematosus. Anemia Acute chronic leukemias. agranulocytosis 4.0 WBC Differential % of total WBC Band Neutrophils 0±0.INC.0 ± 5. aplastic anemia.76% 0.INC.INC. Allergies.11% 0±0. Thalassemias. infections.31±0.36 ± 0.Analyte Red Blood Cell Count Hemoglobin SI Range F: 4. inflammatory diseases. Myelofibrosis .14±0.9 x 1012 / L F: 120 ± 150 g/L M: 139 ± 163 g/L 12 Increased Dehydration Induced hypoxia Polycythemia Obstructive lung disease Polycythemia High altitude burns Shock Dehydration Polycythemia Macrocytosis Spherocytosis Aplastic anemia Folic and Vit B12 109/L Acute leukemia.04% 0±0.INC. Chronic lymphocytic leukemia Decreased Anemias Hypothyroidism leukemias Anemia Severe hemorrhage Hematocrit Mean Red Cell Mean Red Cell Concentration Mean Red Cell Volume White Blood Cells F: 0. Hodgkin¶s disease Monocytes Eosinophils Basophils 0. surgery.02% Chronic inflammatory diseases ±INC. infarctions. Diabetic acidosis. malignancies .02±0.

4±9. hyperfibrinogenemias. polycythemia vera. which causes hemolytic anemia. macroglobulinemias. transfusion reactions. erythroblastosis fetalis. thalassemia major. spherocytosis resulting from autoimmune hemolytic anemia.4±9.3 IU/g hemoglobin AfricanAmericans M: 7. liver disease.Blood Type and Cross Matching a laboratory test that identifies the client¶s blood type and determines the compatibility of blood between a potential donor and recipient type O negative blood are often called universal donors type AB positive blood are called universal recipients Cell Type Antibodies Antigens A Anti ± B A antigen B Anti ± A B Antigen AB None A and B antigen O Anti ± A and Anti ± B None Hematologic Function Studies Test Erythrocyte sedimentation rate (ESR or sed rate) Normal Range Westergren: F: < 50 yr 0±25 mm/h > 50 yr 0±30 mm/h M: < 50 yr 0±15 mm/h > 50 yr 0±20 mm/h 0. Haptoglobin Glucose-6-phosphate dehydrogenase (G6PD) (red blood cell) F: 7.4 IU/g hemoglobin Whites 6. or splenectomy .8IU/g hemoglobin AfricanAmericans The test measures enzyme deficiencies that are hereditary. prosthetic heart valve transplantation. with multiple myeloma. obstructive jaundice. Decreased in sickle cell and iron deficiency anemia. Clinical disease traits are found in males Increased in hereditary spherocytosis. with inflammatory diseases high. hemoglobin C disease.5±9.10±0. sex-linked conditions carried on the female X chromosome. severe burns.4 IU/g hemoglobin Whites 6.6±10.30 g/L 12±35 ìmol/L Significance Alterations in the plasma proteins cause aggregation of the RBCs with an elevated ESR moderately. chemical poisoning.

5±6. children 133±144 mEq/L. chronic infection. newborns Clinical Significance : Increased: excessive intake of sodium without water.5±3. iron deficiency and untreated pernicious anemias. adult 138±144 mEq/L. diarrhea. primary aldosteronism. Blood and urine specimens are obtained at 30 minutes.135±148 mEq/L. Normal Range 0. chloride. Requires fasting The test is conducted as follows: Initial blood and urine specimens are obtained. 1 hour. 2 hours. and phosphate.0% Infants 0.This test is used to screen for diabetes mellitus.5±2. hereditary spherocytosis. An electrolyte is an element or compound that. diabetes insipidus. An oral loading dose of glucose is administered. radiation Therapy Adults 0.30% saline > 0. IV. and folic acid deficiencies. magnesium. hyperalimentation) without fluid correction.0% Children 0.45% saline < 0. Reticulocyte count Used to differentiate between hypoproliferative and hyperproliferative anemias.30%±0. potassium. calcium. vitamin B12 . when dissolved in water or another solvent. to assess blood loss and bone marrow response to therapy.5±2. 3 hours.0% Blood Chemistry Blood Glucose Glucose measurement is performed by either : Skin puncture or venipuncture fasting blood sugar (FBS) normal fasting value is 70 to 115 mg/dl nonfasting (usually 2-hours postprandial) less than 120 mg/dl 2-hour postprandial . and sometimes 4 hours after loading dose.50% saline Significance Increased in hemolytic and sickle cell anemia. treatment of anemias from iron. renal failure .5% Newborns 2. Glycosylated Hemoglobin Reflects serum glucose for the past 2 ± 4 months Most accurate Serum Electrolytes These tests measure the serum concentration of sodium. if the results are abnormal. separates into ions and provides for cellular reactions Sodium . high solute concentration (tube feeding. salt water drowning. the practitioner may order a glucose tolerance test A glucose tolerance test is the most accurate test for diagnosing hypoglycemia and hyperglycemia (diabetes mellitus).Test Osmotic fragility Test measures the fragility of RBCs to aid in the diagnosis of hereditary spherocytosis. Decreased in aplastic.

metabolic and respiratory acidosis. starvation. children 4.hyperventilation. leukemia. steatorrhea. potassium-conserving diuretics. corticosteriods. respiratory acidosis.4± 4.7±5. adult 1. adult 1.5 mg/dl. heart failure. Crohn¶s disease. glycogen. burns and other massive tissue trauma. hypoparathyroidism Phosphate .5 mg/dl Ionized 1. bowel resection.9 mEq/L. intake.3±2. metabolic acidosis. IV solutions and enemas. Magnesium . metabolic alkalosis.5±5.4±2. bone catabolism (multiple myeloma. rapid infusion of aged blood). newborn Clinical Significance: Increased : hyperparathyroidism. drugs (ammonium chloride. children 1. hereditary alabsorption. potassium penicillin.0 mEq/L. 3. muscle necrosis. Decreased: prolonged vomiting and gastric suction.7±4. ion exchange resin. diuretics (mannitol. diarrhea.Decreased: excessive intake of water without sodium (oral.5±6. phosphate-binding antacids Blood Enzymes Isoenzyme CPK1 (BB) Normal Range 0 IU/I Clinical Significance Primarily in brain/indicative of cerebrovascular accident Exclusively in myocardium/indicative of myocardial infarction Found in skeleton and myocardium/skeletal muscle disorders CPK2 (MB) 0±7 IU/I CPK3 5±70 IU/I CPK Isoenzymes Enzymes are globular proteins produced in the body that catalyze chemical reactions within the cells by promoting the oxidative reactions and synthesis of various chemicals. drugs (aminoglycosides.2. newborns Clinical Significance : Increased: high potassium intake (oral. diuretics(ethacrynic acid and furosemide). blood transfusion. enemas containing magnesium.9 mEq/L.0 mEq/L. diabetic ketoacidosis. 3. newborn Clinical Significance : Increased: chronic renal failure. antacids containing aluminum. dehydration. cisplatin.0 mEq/L.3. children. Cushing¶s disease. Decreased: alcohol withdrawal.7 mEq/L. bone tumors). Decreased: chronic diarrhea and alcoholism. hypoparathyroidism. chemotherapeutic agents). sedatives). loop diuretics Chloride . pancreatitis. tap water enemas).32 mmol/L Clinical Significance : Increased: hyperparathyroidism. Decreased: renal failure. immobility.5 mg/dl. children 1. such as lipids. glucose). IV therapy. cirrhosis.13±1. nephrosis and massive diuretic therapy Potassium (serum) .3±2.9 mEq/L. drugs (magnesium sulfate.4±10. IV therapy. adult 4.5±5.6±2. drugs (adrenal steroids. Addison¶s disease. newborn Clinical Significance : increased: renal insufficiency.vomiting and gastric suction Calcium . renal disease.Total 8. sprue.6 mEq/L. digitalis). . adult. Decreased: drugs (diuretics. phenylbutazone). caffeine. hyperphosphatemia.urea.6±2.4±2. and adenosine triphosphate (ATP). primary aldosteronism.6 mEq/L.7 mg/dl.1. nontropical sprue. acute adrenalcortical insufficiency. antacids.1.

metastatic carcinoma. Chylomicrons²mainly ingested triglycerides 2. High-density lipoproteins (HDLs)²50% protein 5.35 ± 7. hepatic carcinoma 0±8 IU/L Amylase Aspartate aminotran sferase Lipase 5'Nucleotida se Total: 40±220 IU/L 0±35 IU/L Blood Lipids Cholesterol and other fats cannot dissolve in the blood. Very low-density lipoproteins (VLDLs)² mainly endogenous triglycerides 3. RBCs Primarily in heart. kidneys. Low-density lipoproteins (LDLs)²moderate amounts of phospholipids with 50% cholesterol 4. lymph nodes Liver and skeletal Tissue Liver and skeletal tissue LDH4 LDH5 3±8 0±5 Digestive Enzymes Enzyme Alanine aminotran sferase Aldolase Normal Range 0±30 IU/L Clinical Significance Hepatocellular Damage Anemia (hemolytic and megaloblastic). infectious mononucleosis. to a lesser extent in pancreas. cirrhosis Acute pancreatitis Biliary cirrhosis.LDH Isoenzymes Isoenzyme LDH1 LDH2 LDH3 Normal Range 17±33 27±37 18±25 Clinical significance Primarily in heart. The types of lipoproteins: 1. skeletal muscle tissue damage Pancreatitis Hepatitis. then will thrombus which will then cause CVA or MI Lipid Normal Risk for CHD Range/Border Line Cholesterol < 200 mg / dl > 250 mg/dl 200 ± 239 LDL < 130 mg/dl > 160 mg /dl Cholesterol 130 ± 159 mg/dl HDL > 40 mg /dl < 35 mg/dl Cholesterol 35 -40 mg/dl Triglyceride < 250 mg/dl > 500 mg /dl 250 ± 500 mg/dl Arterial Blood Gas Measures the acidity and the levels of oxygen and carbon dioxide in the blood. they have to be transported to and from the cells by special carries called lipoproteins (blood lipids bound to protein). When too much LDL circulates in the blood. RBCs Primarily in lungs. LDL is the major cholesterol carrier in the blood. granulocytic leukemia. it can slowly build up in the walls of the arteries feeding the heart and brain which will form atherosclerotic plaque. Normal Blood Gas Values Ph 7. thyroid. kidneys. adrenal glands. extrahepatic obstruction.45 Pco2 35 ± 45 mmHg PO2 80 ± 100 mmHg HCO3 22 ± 26 mmHg 0±1 CherryCrandell U/L 0±17 U/L .

8 seconds F: 9. used to evaluate warfarin sodium therapy.5 ± 11.5 ± 2.0 mcg/mL 0.2 ± 5.7. then it is partial compensation Coagulation Studies: aPTT ( activated partial Thromboplstin) normal value: 20 to 36 seconds measures the time it takes for a citrated plasma to clot. 3 seconds INR : 2 ± 3 seconds for warfarin therapy INR : 3 ± 4. if not assess the respiratory and metabolic function indicator If respiratory imbalance: assess HCO3 concentration: If normal it is uncompensated If abnormal.Interpretation Key Points: In acidosis. assess PCO2 ± if opposite to the response of Ph then it is respiratory imbalance if not look at HCO3 concentration. 3. Ph is low: in alkalosis.. high alkalosis 2. then it is partial compensation If metabolic imbalance: assess PCO2 If normal it is uncompensated If abnormal.0 ng/mL 150 ± 300 ng/mL 1.0 ± 12. INR evaluates the effects of oral anticoagulants Antidote: Vit K Thyroid Lab data: Used to evaluate thyroid disorders Normal Range 0.5 -1.35 .4 microunits/mL 5.6 to 11.20 mcg/mL . A COMPENSATION has occurred if the Ph is in normal range (7.after a partial thromboplastin to clot antidote: warfarin sodium/coumadin Prothrombin time and International Normalized Ration (INR) M: 9.mcg/dl 80 ± 230 ng/dl TSH (thyroid stimulating Hormone) / thyrotropin Thyroxine Triiodothyronine Hepatitis Test: Serological tests ( detects specific virus ) HIV/AIDS The following tests detects presence of antibodies Enzyme Linked immunosorbent assay ( ELISA) Western Blot .3 mEq/L 50 ± 150 ng/mL 10.assess Ph ± low acidic.5 ± 5. Ph is high The respiratory function indicator is PCO2 and the metabolic function indicator is HCO3 Steps: 1.CONFIRMATORY TEST Immunofluorescence assay ( IFA) CD4+ T cell counts: Monitors / evaluates the progress of the virus Normal : 500 ± 1600 cellµ/ Acetaminophen ( Tylenol) Amikacin ( Amikin) Amitriptyline ( Elavil ) Carbamazepine (tegretol) Chloramphenicol Digoxin ( Lanoxin ) Imipramine(Tofranil) Lidocaine Lithium Phenobarbital Phenytoin (dilantin) 10 ± 20 mcg/mL 25 ± 30 mcg/mL 120 ± 150 ng/mL 5 ± 12 mcg/ mL 10 ± 20 mcg/mL 0. assess HCO3 ± if HCO3 concentration is proportionate with the Ph then it is a metabolic imbalance 4.45).5 seconds for high dose of warfarin therapy Measures the amount of time it takes for a clot formation .

The syringe is then rotated to mix the blood with the heparin to prevent clotting Direct pressure must be applied to the puncture site until all bleeding has stopped. critical care nurses can perform a blood analysis and within seconds to minutes have a measurement upon which to change or implement an intervention Venipuncture To assses Venous Blood Test tubes ( vacuum Tubes ) are used to collect blood specimens. Allen¶s test is performed prior to drawing of arterial blood. With advances in POCT technology over the past two decades. Vacuum Tube Color Coding: Red²no additive Lavender²EDTA (ethylenediaminotetraacetic acid) Light blue²sodium citrate Green²sodium heparin Gray²potassium oxalate Black²sodium oxalate Arterial Puncture To assess Arterial Blood Gas ( ABG ) Blood gases are ordered to evaluate: y Oxygenation y Ventilation and the effectiveness of respiratory therapy y Acid-base level of the blood Arterial blood samples are drawn from a peripheral artery (e. To test for specific microorganism Cytology ( identify origin. a minimum of 5 minutes.. do pharngeal suctioning\ 3. If client cannot cough. radial or femoral) or from an arterial line. structure. Best collected in the morning upon awakening 2.g.SPECIMEN COLLECTION Sputum Specimen: Purpose: For Culture and sensitivity test. function and pathology of cells) For AFB to detect TB Done in 3 consecutive days Evaluate effectiveness of therapy NOTE: 1. . however. Mouth care should be done prior to obtaining specimen ( water only) 4. 1 ± 2 tablespoon or 15 ± 30 ml (4 ± 8 fluid dram) of sputum is needed Throat Culture: Collected from the mucosa of the oropharynx and tonsillar region with the use of culture swab Purpose: detect specific microorganism This is an invasive procedure Position of patient: sitting position ( if tolerated ) Extension of tongue ( to expose the pharynx) Let the patient say ³ah´ to relax the throat muscles Blood collection Laboratories employ a phlebotomist (an individual who performs venipuncture) to collect blood specimens. it is the responsibility of a nurse to know how to perform a venipuncture Point of care testing (POCT) is a common practice in critical care settings and is proving to be a costeffective. ( performed to measure the collateral circulation to the radial artery) The arterial blood sample is collected in a 5-ml heparinized syringe.

otherwise. 1000 hours. should be a complete. Clotting disorders 6. or midstream) specimen collection is done to secure a specimen uncontaminated by skin flora. Symptomatic peripheral vascular disease 7. or 72 hours If a specimen is needed over a prolonged period of time.. and to withdraw blood for analysis It is standard practice to mark each lumen of a multilumen catheter with the name of the infusion (e. a clean container is enough. The urine is collected in a plastic gallon container that contains preservatives. . This retards bacterial growth and stabilizes the analytes The last urine collection. The analytes in the urine drainage bag change. Drawing blood for Hgt monitoring The common sites for capillary punctures are the: Heel²most common site for neonates and infants Fingertip²the inner aspect of palmar fingertip used most commonly in children and adults Earlobe²when the client is in shock or the extremities are edematous Central Lines A central line refers to a venous catheter inserted into the superior vena cava through the subclavian. Blood can be withdrawn for sampling by accessing the port using strict sterile technique Urine Collection The different methods of urine collection are: Random collection (routine analysis) It can be collected at any time using a clean cup The urine does not have to be collected in a sterile container. If there have been changes on ventilator settings 4.g. Collection from a closed urinary drainage system Urine collection from a client with an indwelling Foley catheter with a closed drainage system The urine specimen should not be obtained from the drainage bag. for treatment. Collect urine from the aspiration port that is used for sterile urine collection Clean-voided specimen / Clean Catch Urine Clean-voided (clean-catch. all stools must be placed into a container and refrigerated. Anticoagulant therapy 5. forced voiding at the exact timed period. internal. Immediately after breathing and suctioning treatments 3. Obtained on first voiding in the morning Stool Collection Stools can be collected for either a one-time defecation or over 24. fluid or medication) Implanted Port port-a-cath (a port that has been implanted under the skin) over the third or fourth rib The port has a catheter that is inserted into the superior vena cava or right atrium through the subclavian or internal jugular vein.Arterial punctures should not be performed: 1. this will cause inaccurate results. Timed collection done over a 24-hour period. If the client is hyperthermic 2. Negative Allen test Capillary Puncture Skin punctures are performed when small quantities of capillary blood are needed for analysis or when the client has poor veins. discard the specimen at the beginning of the collection and save all other voided specimens until 1000 hours the following day The collection container should be refrigerated or kept on ice throughout the 24 hours. Ex. 48. or external jugular vein A central line is inserted when a peripheral route cannot be obtained.

4 mg 1. peanuts. whole-wheat products. beta-carotene found in dark-orange and darkgreen fruits and vegetables (carrots. spinach) Fortified milk. fish. dairy products WATER SOLUBLE VITAMINS C 60 µg 60 µg Thiamine (B1) Riboflavin (B2) Niacin (B3) B6 1. green leafy vegetables Meat. poultry. walnuts . pumpkins. bone formation 80 µg 65 µg Green leafy vegetables. meat. eggs. nuts Dairy products.6 mg Chicken. destruction of free radicals.5 mg 1. fish. poultry.7 mg 19 mg 1. milk. liver.fish. and amino acids to energy Assistance in at least 50 enzyme reactions²the most important regulate nervous system activity Fruits and vegetables (especially citrus fruits) Fortified and whole grains. pork. seeds. lean cuts of pork. healing Converting carbohydrates and fats to energy Converting bodily fuels to Energy Converting carbohydrates. green leafy vegetables. eggs. whole-wheat and fortified grain products. cell Function Immune system functioning. broccoli. enriched breads and cereals 2 mg 1.Nutrition NUTRITION Vitamins and Minerals Vitamin / Mineral Recommended Daily Allowance Uses Food Source Men Women FAT SOLUBLE VITAMINS A 1000 RE 800 RE Proper vision. liver.3 mg 15 mg Collagen synthesis. destruction of free radicals (by-products of metabolism that can cause vascular damage) Blood clotting. fats. milk. legumes (beans and peas). growth Liver. whole grains D E K 5 µg 10 mg 5 µg 8 mg Proper bone formation. nfection fighting. fish Vegetable oils. assistance n iron absorption. eggs.

tangerines. and aiding muscle contractions Building bone. DNA synthesis. fish. maintaining immune function. dried beans and peas. formation of major enzymes Promotion of healing and growth. fish. dairy products MINERALS Calcium 800 mg Phosphor us Magnesiu m Iron 800 mg 800 mg 800 mg 350 mg 280 mg 10 mg 15 mg Zinc 15 mg 12 mg Iodine Selenium 150 µg 70 µg 150 µg 55µ g Building bone. egg yolks Seafood. DNA synthesis. poultry. pumpkins) In nearly all foods Nuts.Folate 200 µg 180 µg Manufacturing of DNA and new body cells Manufacturing of new body cells and mature new red blood cells. maintenance of nerve growth. protection of nerve cells Liver. oysters. seafood Meat. meat. fortified orange juice. breads. and a normal sense of taste Helping the thyroid regulate Metabolism Destruction of free radicals. fortified grain products Meats. legumes. green vegetables. poultry. assistance in relaxing muscles after contractions Transporting oxygen in red blood cells and muscle cells. transmitting nerve impulses. formation of enzymes Dairy foods. helping the body utilize energy and reproduce cells Holding calcium in tooth enamel. canned sardines and salmon with the bones. cereal grains. milk. cereals . fruits B12 2 µg 2 µg Meat. iodized table salt Fish. legumes. smaller amounts in some fruits and vegetables (broccoli. leafy vegetables.

g. fish or poultry looks like. 10 carrot slices or three Brussels sprouts. diarrhea. Your bagel would only have to be the size of a hockey puck to equal one serving (one ounce) of bread. mechanical irritants. and a small (6-ounce) glass of juice counts as a serving too. Rice. prunes). A 1 1/2 cup portion of cooked beans make a great stand-in for three ounces of meat. Half a baseball will do it for veggies like green beans.Tips Fats. biliary indigestion. oils and Sweet Treats. One serving (one and onehalf ounces) of cheese is about the size of six dice or three dominoes. A deck of cards or a small fist describes what one serving (three ounces) of meat. Vegetables 3 to 5 servings a day. milk. it should be easy to get a few servings at a time. vegetables Bland diet Low fiber. plums. Go easy. A small (6-ounce) glass of tomato or other vegetable juice works too. Since that equals about eight green beans. Fish. That's all it takes to get one halfcup serving. Two tablespoons of peanut butter² about the size of a golf ball²are a third of a serving. Picture filling half a baseball with fruit. fruits (except cranberries. meat. Poultry. Indicated to patients with renal stones (Acidic stones) E. prunes.g. and hiatal hernia BRAT Diet Banana. Milk. put a baseball-sized portion (one cup) on your plate. Toast Indicated for patients with diarrhea Butterball diet Spare protein but high in carbohydrates Indicated for patients with liver disorders Clear liquid Diet To relieve thirst and help maintain fluid balance Indicated for post-operative patients and following vomiting and gastroenteritis Diabetic Diet/ Well balance diet The purpose is to maintain near to normal blood glucose level Indicated to patients with diabetes mellitus . Eggs and Nuts 2 to 3 servings a day. whole grains Alkaline ash diet Retards the formation of acid renal stones. Yogurt and Cheese 2 to 3 servings a day. If you're talking leafy-green veggies like spinach. carrots and Brussels sprouts. plums. THERAPEUTIC DIETS Acid-ash diet Retards the formation of alkalinic renal stones Indicated to patients with renal calculi (Alkaline stones) E. Bread. chemical stimulants Indicated for patients with gastritis. cranberries. Meat. It's easier to eat your share than it sounds. cheese. Whole fruits only need to be about the size of a tennis ball. eggs. Rice and Pasta 6 to 11 servings a day. Fruit 2 to 4 servings a day. A serving of milk or yogurt is one cup (or one small container of yogurt). Cereals. Apple. kale or collard greens.

postsurgical patients. and also. with diverticolosis. Rye. with hyperlipedemia High Protein Diet Lean-meat. transition from full-liquid to general diet. renal calculi. renal diseases. It is a Chinese belief. no to fermented foods Vegan Diet Diet of the Seventh Day Adventists . Banana. eggs. hypertension cholecystitis and cholelithiasis Low Residue diet Reduces the bulk of stools Indicated to patients with ulcerative colitis.Full liquid diet It serves to provide nutrition to patients who cannot chew or tolerate solid foods Indicated to patients with stomach upsets. Wheat This is the diet of a patient who suffers from celiac¶s Disease Halal Diet No pork diet Diet of the Muslims High Fiber Diet Fruits and vegetable It speeds up the passage of food to the digestive tract. PIH. Oat. it softens the stool. No to ABC¶s. diverticulitis.Avocado.Indicated to patients who are constipated. Canned and Processed Foods. and steroid therapy Soft diet Used to provide nutrition for those patients who have problems in chewing For patients with ill-fitting dentures. Low fat/cholesterol Diet It serve the purpose of reducing hyperlipedemia. and to patients with intolerance to fats Indicated to patients with cardiovascular diseases. hypertension. patients with gastrointestinal disturbances such as gastric ulcers and cholelithiasis Tyramine-free Diet Use to prevent hypertensive crisis for patients who are taking-in MAOI antidepressant. patients who will undergo surgery of the GI tract Low Sodium Diet Indicated to patients with cardiovascular and renal disorders Purine restricted diet To reduce uric acid Indicated to patients with gouty arthritis. and hyperuricemia Sodium-restricted diet Indicated to patients with heart failure. cheese. Indicated to patients with nephrotic syndrome Kosher Diet Meat ad milk cannot be served simultaneously Diet of the Orthodox Jews Low carbohydrate diet Indicated to patients with dumping syndrome Yin Diet Cold deserts after a surgery. after progression from clear liquid diet Giordano Diet Spare protein Indicated to patients who suffers from Chronic renal Failure Gluten free Diet No to B R O W ± Barley. patients who underwent resection of the small intestines.

Properly handle the patient's body to prevent pain or injury. Follow specific physician's orders. .THERAPEUTIC NURSING PROCEDURES POSITIONING CLIENTS BASIC PRINCIPLES IN POSITIONING OF PATIENTS 1. 7. Maintain the patient's safety. Obtain assistance. 5. Maintain good patient body alignment. Position Description Therapeutic Use FOWLER¶S Head of bed up 30 to 90 degrees 1. High Fowler¶s: sitting upright at 90 degrees Semi-Fowler¶s: head and torso elevated 45 to 60 degrees 2. to move heavy or helpless patients. 2. Think of the patient in bed as though he were standing. Reassure the patient to promote comfort and cooperation. 4. 6. Low Fowler¶s: head and torso elevated to 30 degrees Knees slightly flexed Promote maximum lung expansion Relieve DOB/ SOB KNEECHEST DORSAL RECUMBE NT Flat on back with legs flexed at hips and knees Feet flat on mattress For perineal and rectal examination prone with weight of upper body supported on flat surface by chest ‡ Hips and knees flexed to elevate buttocks Flat on back with legs flexed 90 degrees at hips and knees ‡ Feet up in stirrups To prevent further cord prolapse. if needed. Promotes Maximum exposure of Rectum LITHOTOM Y For vaginal/ perieneal procedures and assesment . Keep in mind proper body mechanics for the practical nurse. 3.

PRONE SIMS TRENDELE N-BURG¶s ‡ Flat on abdomen with knees slightly flexed ‡ Head turned to side ‡ Arms flexed at side ‡ Halfway between side lying and prone with bottom knee slightly flexed ‡ Lower arm behind back ‡ Upper arm flexed. hand near head ‡ Head is low with body and legs elevated on an inclined plane ‡ Side lying with upper leg flexed at hip and knee ‡ Lower arm flexed with shoulder positioned to avoid weight of body on shoulder Flat on back with body in anatomic alignment Common Positions after surgery / after a procedure: Autograft: site is immobilized for 3 to 7 days Burns of face and Head: elevate head of bed Circumferentiated burns of Extremities: elevate extremities above the level of the heart Skin graft: elevate and immobilize Mastectomy: Semi fowler¶s with affected arm elevated on a pillow Perineal and Vaginal Procedures: Lithothomy Positions Hypiphysectomy: Elevate head of bead ( prevent ICP ) Thyroidectomy: Semi ± fowlers position May use sand bags or pillows for the head and neck Hemorrhoidectomy: Lateral Side Lying Position GERD: Reverse Trendelenburg¶s Liver Biopsy: During: Supine with right side of upper abdomen exposed Right arm is raised and extended over the left shoulder behind the head After: Right Lateral side lying position Small pillow or folded towel under the puncture site for 3 hours NGT Insertion: High fowler¶s position with head tilted forward Irrigations and tube feedings Semi fowlers ( 30 ° ) LATERAL RECUMBE NT SUPINE .

knees flexed upto the abdomen and head is bent so that chin is resting on the chest Fetal position After: Supine ( 4 to 12 hours ) . affected extremity is kept straight Cardiac Catheterization: Affected extremity is kept straight and head is elevated to no greater than 30 ° Congestive Heart Failure and Pulmonary Edema: Upright Preferably legs dangling to the side of the bed to decrease venous return Varicose Vein: Leg elevation above heart level Cataract Surgery: After: Semi to fowler¶s position and position patient on the back or non operative side Retinal Detachment: If gas bubble is injected: Face down or toward the unoperative side Autonomic Dysreflexia: High Fowler¶s Position Cerebral Anuerysm: Semi ± fowler¶s to fowler¶s position CVA: Hemorrhagic Strokes: HOB is elevated to 30° Ischemic Strokes: Flat Craniotomy: Should NOT be positioned on the operative site Semi to fowler¶s position Laminectomy: Back is kept straight Logroll client ICP: Semi ± Fowler¶s to Fowler¶s Position LP: During: Lateral (side lying ) position. leaning forward Laryngectomy: Semi fowler¶s or fowler¶s position Bronchoscopy: Semi ± fowler¶s Postural Drainage: Lung segment to be drained should be in the uppermost position Thoracentesis: During: Sitting on the edge of the bed and leaning over the bedside table or Lying in bed on the affected side with head of bed elevated ( 45°) After: Position on the unaffected side Abdominal Anuerysm Resection: After: Fowler¶s Position Amputation of the Lower Extremities: 1st 24 hours: Elevate foot of the bed. stump supported with pillows but not elevated Prone Position for 10 ± 30 mins twice a day Arterial Vascular Grafting of an Extremity Bed rest for 24 hours.Rectal Enemas/ Irrigations: Sim¶s Position Sengstaken ± Blakemore and Minnesota tubes: Maintain elevation of head of the bed COPD: Sitting position.

Lock all wheelchair or litter wheels before transferring the patient from the bed. increase time up in the chair and ambulation gradually. Top covers which may be pulled too tightly over the feet and legs. or other equipment. Support the affected side or extremities of the patient when ambulating or moving. Place pillows in front of and behind the patient's trunk to support his alignment in the lateral position. The bed should be in the flat position at a comfortable working height. Position yourself with your feet apart and your knees flexed close to the side of the bed Place your arms under the patient so that a major portion of the patient's weight is centered between your arms. urine. The patient lying on tubes. 5. when it is utilized. Check on the patient frequently. and feces causing the bed to be wet. On the count of three. Allow some of patient's own possessions (such as a pillow or afghan) when possible. 3. move the patient to the side of the bed. 7. Reassure the patient of his personal safety against injury and over-exertion. PRINCIPLES OF ASSISTING PATIENTS OUT OF BED 1. Reduce the noise and light in the patient's room. drains. to include alarms sounding without cause Log rolling Logrolling is a technique used to turn a patient whose body must at all times be kept in a straight alignment (like a log). syringe caps. 4. The arm of one nurse should support the patient's head and neck. rocking backward on your heels and keeping the patient's body in correct alignment. Change the bed position (head and knee).SCI: Immobilze on a spinal backboard Myelogram: After: Water Soluble dye: HOB elevated 30 to 60 degrees If Oil based : supine Total Hip Replacement: Avoid internal and external Rotation Avoid adduction and side lying on the operative side Maintain abduction if on supine position ( pillows between legs) Do not cross legs To promote relaxation : Obtain comfortable bedding. Check for mechanical reasons for discomfort: Bed linens which are gathered and wrinkled under the patient. This technique is used for the patient who has a spinal injury. If necessary. Place a signal cord or call-light button within easy reach of the patient while he is up. . Lower the side rail on the side of the body at which you are working. Soiled dressings. 6. Plastic mattress covers that wrinkle and cause pressure. get additional help to assist you in ambulating the patient. Stabilize the footstool. 8. Do not overtire the patient. Nonfunctioning equipment. 2.

The arm is adducted when it is moved from an outstretched position toward the body. y To prevent contracture. TYPES OF EXERCISES Passive These exercises are carried out by the nurse. . BODY MOVEMENT Flexion -The state of being bent.Lateral movement of a body part toward the midline of the body. Active Assistive. Full patient cooperation is required. Isometric exercises are done to maintain muscle strength when a joint is immobilized. Circumduction is a combination of abduction.The palm or sole is rotated in an upward . preventing thrombus and embolus formation. adduction. or tension on bones. without assistance from the patient.The state of exaggerated extension. y To maintain and build muscle strength. Rotation -Turning of a body part around an axis. and atrophy of muscles. Adduction . Supination.ACTIVE AND PASSIVE RANGE OF MOTION EXERCISE PURPOSES OF EXERCISE FOR THE IMMOBILE PATIENT y To maintain joint mobility is done by putting each of the patient's joints through all possible movements to increase and/or maintain movement in each joint. These are active exercises performed by the patient by pulling or pushing against an opposing force. without assistance. y To increase tolerance for more activity. y To stimulate circulation. and flexion. y To improve coordination. Active exercises are performed by the patient. lengthening of muscle. extension. atony (insufficient muscular tone). These exercises are performed by the patient with assistance from the nurse. Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction. Active. The cervical spine is flexed when the chin is moved toward the chest. Isometric These exercises are performed by the patient by contracting and relaxing muscles while keeping the part in a fixed position. Extension -The state of being in a straight line. The head is rotated when moved from side to side to indicate "no. Active assistive exercises encourage normal muscle function while the nurse supports the distal joint. The arm is abducted when it is held away from the body. The cervical spine is extended when the head is held straight. Resistive. The cervical spine is hyperextended when the person looks overhead. toward the ceiling. Abduction -Lateral movement of a body part away from the midline of the body." Circumduction -Rotating an extremity in a complete circle. to increase muscle strength. Hyperextension .

10. 7. Ask the patient to tilt his or her head backward. 4. active-assistive. 7.) 8. Avoid overexerting the patient. starting with the neck and moving down. Don gloves and lubricate tube in water or a water soluble lubricant. (Never use mineral oil or petroleum jelly. 12. Plan when range of motion exercises should be done 3. and preferably five times. direct tube . 2. or active. Plan whether exercises will be passive. The joints of helpless or immobile patients should be exercised once every eight hours to prevent contracture from occurring. Joints are exercised sequentially. Gastric tube Insertion Purpose: y Administer tube feedings and medications to clients who cannot take in food per orem ( Gavage ) y Prevent gastric distention. areas are exposed so that the joints can be both moved and observed. but never force a joint to the point of pain. 6. 13. 5. 8. do not continue the exercises to the point that the patient develops fatigue. Support the extremity when giving passive exercise to the joints of the arm or leg. Range-of-motion exercises should be done at least twice a day. Use passive exercises as required. Put each joint needing exercise through the range of motion procedure a minimum of three times. during the bath. however. Start gradually and move slowly using smooth and rhythmic movements appropriate for the patient's condition. Involve the patient in planning the program of exercises and other activities because he/she will be more apt to do the exercises voluntarily. During the bath is one appropriate time. 9. encourage active exercises when the patient is able to do so. Some exercises may need to be delayed until the patient's condition improves. 3. Use a small strip of adhesive tape to mark the measured distance on the tube. and gently advance the NG tube into an unobstructed nostril. Expect the patient's heart rate and respiratory rate to increase during exercise.GUIDELINES FOR RANGE OF MOTION EXERCISES 2. Return the joint to its neutral position. 5. The warm bath water relaxes the muscles and decreases spasticity of the joints. Gather the necessary equipment. 11. nausea and vomotting y To remove stomach contents for laboratory analysis y To lavage / wash stomach in case of poisoning or over dose of medication Procedure: 1. Position the patient in a sitting position Check nostrils for patency by asking the patient to breathe through one naris while occluding the other. Stretch the muscles and keep the joint flexible. Another appropriate time might be before bedtime. Keep friction at a minimum to avoid injuring the skin. 6. 4. Measure length of NG tubing to be inserted by measuring the distance from tip of nose to ear-lobe and from ear-lobe to about 1 inch beyond base of xiphoid process. Explain procedure to the patient Wash hands. Move each joint until there is resistance. Also.

If the tube is curled in the mouth or throat. Clean or dispose of equipment appropriately. Assist the patient to a normal position for eating. Note the nostril used and the patient¶s tolerance of the procedure. INTERMITTENT (BOLUS) TUBE FEEDING 1. NOTE: If the patient coughs or gags. if feeding held due to excess gastric residual. 3. or quickly instill 20 ml air into the tube while auscultating for gurgling sound over the gastric area. check physician¶s orders or follow unit policy regarding residual as the determinant of whether to administer or avoid feeding (commonly held if residual greater than 100 mL ). As the tube approaches the nasopharynx. Connect the NG tube to suction if ordered. 7. raise head of bed at least 30 degrees. 10. ask the patient to flex head toward chest (to close the trachea) and allow him or her to swallow sips of water or ice chips as the tube is advanced into the esophagus (about 3 to 5 inches each time the patient swallows). and organize supplies. 5. 6. to prevent entrance of air into the stomach. 17. 9. Clamp the tube and maintain elevation of the head of the bed at least 30 degrees for 30 to 60 minutes following feeding to prevent aspiration. leaving 1 inch intact at the opposite end 14. Prepare dietary formula. Secure the tube after checking for proper placement by cutting a 3-inch strip of 1-inch tape and then splitting the tape lengthwise at one 13. Allow formula to flow slowly by gravity. withdraw the tube to the pharynx and repeat attempt to insert the tube. Ask the patient to continue swallowing until the tube reaches the premeasured mark. 12. turn patient on right side and recheck residual in 30 to 60 minutes. Verify gastric tube placement by aspirating gastric contents and checking its pH level (this may be difficult with small-bore duodenal tubes). 15. Wash hands. Continue to add formula to the syringe barrel until feeding is complete. 8. check the mouth and oropharynx. Place syringe barrel (with plunger removed) into the end of the tube and slowly pour formula into the barrel until it is almost full. 16. Repeat with the other split tape end. Place the intact end of the tape on top of the patient¶s nose. if patient cannot tolerate this position or it is contraindicated. Aspirate and measure gastric residual and reinstill contents through tube.toward back of throat and down. 11. regulate formula administration rate by adjusting the height of the syringe (typically held 6 to 8 inches above tube insertion site). 10. formula should be at room temperature to prevent gastrointestinal muscle cramping. end. . Explain procedure to the patient. and wrap one side of the split tape end around the tube and secure on a nostril. don gloves. 9. 11. Follow the feeding with water as ordered or 30 to 50 ml to flush the tube. Check for proper tube placement in the stomach by aspirating with a syringe for gastric drainage or by instilling about 20 mL of air into the NG tube while listening with a stethoscope for a gurgling sound over the stomach. 2. Wrap adhesive tape around the distal end of the tubing and attach a safety pin through the tape tab to the patient¶s gown. Document how placement was validated and whether tubing was left clamped or attached to other equipment. 4. Document the size and type of tube inserted. or clamp. Wash hands. do not allow the syringe to completely empty.

bag emptied half full Healthy stoma is red: a color change ( dark black to blue is notifeable) Stool is liquid Post op drainage is dark green then yellow as the client begins to eat . wet fecal material . ‡ Check gastric residuals every four hours during continuous tube feedings.12. 4. 5. Monitor bowel sounds. prevent skin breakdown. After checking residual between bolus feedings. 2. follow steps 1 to 6 above. ‡ Replace bag and tubing every 24 hours or according to agency policy to decrease chance of organism growth and contamination of feeding. simply hang the bag above the pump. ‡ Check tube placement at least once per shift. Colostomy Care OSTOMIES ± divert and drain fecal material/ bowel resection temporary ( trauma / inflammatory condition) permanent ( Cancer / congenital or Birth defects ) Stoma ± red. bowel regularity. constant flow not regulated. 1. Pour no more than 1 can (240 mL) or approximately 4 hours¶ volume into the bag (bacterial growth is promoted when formula hangs for prolonged periods at room temperature). can be bowel trained . gastric residual check. 14. If using a pump designed for tube feedings. no redness or irritation 2 to 5 inches surrounding the area. For bolus feeding. Maintain elevation of head of bed at least 30 degrees while dietary formula infuses and for 30 to 60 minutes thereafter.Document tube placement. Ileostomy ± no irrigation . and hydration on any patient receiving tube feedings. bowel regularity. if feedings are stopped.normal. and hydration on any patient receiving tube feedings. Insert the bag¶s tubing into the pump mechanism and set pump to deliver appropriate volume. type and amount of feeding. calculate the drip rate and regulate manually with the tubing clamp. and patient tolerance CONTINUOUS TUBE FEEDING The feeding bag is hung on an IV pole about 12 inches above the patient¶s head if dietary formula is delivered by gravity. the drop factor is regulated to deliver the ordered rate of flow. initial slight bleeding . flush tube with water after checking residuals. If using gravity delivery method. unclamp the tubing and start the pump. follow by using water to clear the tubing unless contraindicated 13. 6. Prime the tubing by allowing the formula to run through and expel air. appliance all the time . Related care: ‡ Monitor bowel sounds. pouch may not be worn and emptied after every defecation Ascending colon colostomy: liquid stool Transverse Colon Colostomy: loose to semi formed Descending Colon Colostomy: close to normal Stool Monitor color changes in the stoma: Normal color : pink or red Pale pink : low hgb / hct Purple black: compromised circulation If pouch is not in place: Place petroleum jelly gauze over the stoma to keep it moist followed by a dry sterile dressing . clamp the tube and attach it to the patient¶s feeding tube. 3. no burning sensation Colostomy ± can irrigate . meticulous skin care.

stimulates peristalsis and excretion of feces Non ± retention Enema: Fluids: tap water soap suds NSS Hypertonic Fluids Height of solution: 18 inches above the rectum Retention Enema: Fluids: Carminative enema Oil (mineral . cottonsee) Types: Cleansing Enema It irritates the colon producing peristalsis by distending the colon with volume fluid High enema Target: colon 1L of solution is introduced Low enema Target: rectum and sigmoid process ½ L is administered Carminative Enema Aims to expel flatus About 60mL to 180 mL of solution is administered Retention enema Uses oil based solution( which acts as stool softeners and facilitates passage of feces) Administer oil into the rectum and sigmoid colon. 24-48 hours if eroded or ulcerated with deodorant ( Charcoal filter Disk. Bismuth ) y refer to enterostomal therapy nurse for complications Enema Administration: Enema is a solution introduced into the rectum and large intestines. press buttocks together to prevent feces from expelling For abdominal cramps: stop temporarily . then the oil is retained for 1 ± 3 hours Return flow / colonic Irrigation Aims to expel flatus Uses an inflow ± outflow process that is repeated 5 ± 6 times Solution container is lowered so that the fluid backs out through the rectal tube into the container Intravenous Therapy Height of solution: 12 inches above the rectum IV therapy is administering fluids / medications through a vein Purpose: sustain clients who are unable to take foods/fluids via oral route used to replace fluids and electrolytes Position: Left Lateral ( adult) dorsal recumbent ( child) After administering the solutions. olive. Its aim is to distend the intestine and irritate the intestinal mucosa. but can have any food at tolerated after 6 weeks« yogurt recommended y dry skin before applying appliance y karaya ± barrier to prevent contamination with excreta y appliance can be up to 2 weeks .Precautions y avoid gas forming foods and nuts .

compatibility of drug with the solution. dose and frequency of medication to be incorporated/push & others affecting the procedure (xray. plastic container (bag) or presence of sediments or insect.provides vascular access for immediate or rapid delivery of substances or medications especially in emergency situation Scope of Practice Role Definition. check labels against the physician¶ order label for any medication(s) that are added: date. the Nurse¶s Code of Ethics and the established Nursing Standards of Safe Nursing Practice Basis of Practice Legal therapeutic prescription of a licensed physician. Board of Nursing Resolution No.the I.(Patient controlled analgesia ) For Blood products.V Therapy Ethico-legal Implications Key points prior to initiation of I.V nurse in compliance with PRC. anesthetics : G 14.Tx of the extremities. any presence of holes on plaster cover (packaging).18 or 19 For Standard IV fluid and clear liquid IV : G 22 or 24 For clients with small veins: G 24 .V nurses are registered nurse committed to ensure the safety of all patients receiving I.V set and equipment preparation check for expiration date check for clarity.25 Filters Used to prevent particles from entering the client¶s vein Needleless System Drip Chambers Microdrip chambers Used if solution contains potent medication that needs to be titrated Used if fluid will be infused at slow rate ( about 50 mL per hour) Macrodrip Chambers Drop factors varies from 10 ± 20 drops/mL . time. Thorough knowledge of the vascular system. The initiation of intravenous therapy is upon the written prescription of a licensed physician which is checked for the following: type and amount of solution flow rate type.V therapy Physician¶s prescribed treatment.16. Patient assessment Factors to consider for IV Therapy duration of therapy cannula size condition of the vein / skin type of solution patient¶s level of consciousness patient¶s activity patient age dominant arm clinical status of patient I. function ability of Infusion Pump. interrelatedness of the body system with proficiency in the skill of the IV nurse. medication and amount. The I. 08 series of 1994 shall uphold the Philippine Nursing Act of 1991.

that is. Higher osmolality than the body Movement is from cell to extracellular compartment Crytalloids Used for fluid volume replacement Contains mostly of electrolytes Colloids Or plasma expander Used in cases such as severe hemorrhage and hypovolemia Flow rate: amount of fluid _ drop factor on tubing box ÷ running time stated in total number of minutes Colloid Type of Solution Isotonic Solutions Fluid Uses ( D5W) y 5% dextrose in 0.9% saline ( NS ) y 5% dextrose in water y Supplies calories as carbohydrates. Hypotonic Hypotonic fluids have an electrolyte content below 250 mEq/L.45% saline ( 5% D/1/2 Solution y Dextran y Albumin y Maintains pressure colloid osmotic . Lower osmalality than the body thus causing movement of solutes into the cells by osmosis Used to prevent cellular edema Hypertonic Hypertonic fluids have an electrolyte content above 375 mEq/L. prevents dehydration. maintains water balance.Administration of Medications and IV solutions Types of IV solutions Isotonic Isotonic fluids have an osmolality the same as that of blood.33 % Saline (1/3 NS) y 3% Saline ( 3% NS) y Replaces fluid and electrolyte loss y 5% Saline ( 5% NS) y 10% Dextrose in water ( D10 W) y 5% dextrose in 0.45 Saline ( ½ NS) y Replaces fluid and electrolyte loss y 0.9% saline ( 5% D/NS) y 5% Dextrose in 0. promotes sodium diuresis Hypertonic y 0.25% Saline ( ¼ NS) y 0.255% saline (5% D ¼ NS) y Lactated Ringers solution ( LR) Hypotonic y 0. about 310 mEq/L of total electrolytes.

pus is rarely detectable.warm. Infiltration ± Edema. and coolness at the site ( may not have back flow) Catheter Embolism ± decrease in BP. high Blood Pressure. cyanosis. (Volutrol. hypotension. BOLUS: . . SECONDARY INFUSION: . decreased LOC . erythematous skin over an indurated or tender vein with purrulent drainage from the cannula wound. pooling of medication ) Veins in the scalps ( for infants) Complications of IV Therapy Local /Phlebitis. Purulent thrombophlebitis. Soluset. Warm erythematous skin over an indurated or tender vein an often precedes or is associated with more severe infections. ¥ ¤ Bacteremic catheter related infection is defined as a positive blood culture with clinical or microbiologic evidence that strongly implicates the catheter as source of infection. (Piggyback) Hang higher than Primary. pain along the vein. Buretrol. moist cough and crackles Hematoma ± ecchymosis.Administration of a drug over a period of several hours. Cellulitis.Pus may drain spontaneously or express by pressure. pain. cyanosis Circulatory Overload ± distented jugular vein.involves only the insertion site and manifest as pericatheter inflammation . dyspnea. weak and rapid pulse. immediate swelling and leakage of blood at the site of insertion and painful lumps Air embolism ± tachycardia. VOLUME CONTROL SET: .Warm erythematous and often tender skin surrounding the site of cannula insertion. forearm. usually over 30-60minutes. dyspnea.Infusion Sets / infusion pumps INFUSION TECHNIQUES CONTINUOUS.Administration of medication in a relatively short span.Medication given all at one time Through an existing port or lock.Chamber in IV tubing that holds a portion of the solution from a larger container.Administration of a drug that has been diluted in a small volume of IV solution. INTERMITTENT: . Avoids overloading Circulatory System.) Selection of IV Site Veins in the hands . antecubital ( most suitable access) Veins in the lower extremities ( not suitable because of high risk for embolism.

Types of Blood Products: Fresh Whole Blood²complete components Red Blood Cells Used to replace erythrocytes 1 unit increases hgb by 1g/dl and hct by 2 ± 3 % after transfusion White Blood Cells / Granulocyte Concentrate Rarely used Platelets Used to treat thrombocytopenia Administered rapidly over 15 to 30 minutes Fresh Frozen Plasma Used to provide clotting factors or for volume expanders Albumin To maintain colloid osmotic pressure 4. Remain with the patient for at least 5 minutes after transfusion has begun. Check patient¶s ID band for proper identification. (Blood must be stored at a temperature between 1° and 6°C. and reaction in the patient¶s record. maintain IV access with 0.9% normal saline. 7. (Flush again with saline after completion of product. Stop infusion of blood product. 13. 6.Chills . product ID check.Do not store blood products in nursing unit refrigerators.Do not discontinue IV access if an undesirable reaction occurs. and at least every 30 minutes until the infusion is completed.) 11.Flushing or rash . procedure (including time infusion begun and completed). Check baseline vital signs (VS) and report any abnormal findings to the physician before beginning infusion of component. Validate teaching.. 5. Check VS 15 minutes after product infusion has begun.Burning at injection site . 14. 12. Check expiration date on product. . Warm blood in approved blood warmer for use in rapid transfusions or for neonatal exchange transfusions. 2.Fever . 3. Verify accuracy of component with another licensed nurse or physician. Verify physician¶s order.) . send blood and blood set to the lab and reasseintensive monitoring if any of the following occurs: .Administration Products of Blood and Blood Guidelines in Administering Blood and Blood Products: 1. then 15 minutes later.Pain in any area . 8. Flush any solution from present IV line with 0. and notify the physician .) . Check manufacturer¶s information before using any pump to administer product.Do not use a blood filter for more than 6 hours nor administer more units than recommended by the manufacturer. assessment (including VS). Administer a maximum of 50 mL of product over the first 15 minutes of transfusion.) Contraindications : . 16. Explain procedure to patient and tell him or her to report any unusual symptoms or sensations that may occur during infusion.Itching . . Ascertain that the IV line is present and not infiltrated before beginning infusion. (Some pumps may cause hemolysis of red cells.9% normal saline. 15. 9.Do not heat blood products in a microwave oven. Initiate infusion within 30 minutes from the time the product is released from the blood bank.Do not save blood administration tubing for future use. Complete the infusion within a 4 hours. 10. (Doing so could result in cellular damage.

) TPN solutions are nutritionally complete.TPN. Central Venous Tunneled Catheters ( CVT) are catheters with single. Huber needle port Guidelines: 1. chills. based on the patient¶s weight and caloric/nutrient needs. with 0.2-3 L /24H ± FINE BACTERIAL FILTER USED TNA-TOTAL NUTRIENT ADMIXTURE AMINO ACID. according to agency policy. Content . (Both nurse and patient should wear a mask during the procedure. Maintain patency by flushing catheter according to agency policy. Nausea and Vomiting. diminished / absent lung sound ) . solutions refrigerated and warmed just prior to administration ) Pneumothorax ( dyspnea . ecchymosis. Five hundred milliliters of 10 or 20 percent fat emulsion (lipids) is also administered to meet the patient¶s remaining nutritional needs. Clamps should not be used on the Groshong as they may damage the catheter.infuse and draw blood. wound healing. 4.Medications Atrial. 2.9% normal saline after medication administration and after withdrawal of blood samples. This catheter is flushed. Monitor the patient for infection. CVTCs can be used for months or years if infection does not occur 6. and trace elements. Dressing changes are made on all catheters using sterile technique.TPN Total parenteral nutrition (TPN) is delivered via a central venous catheter to reverse starvation and promote tissue synthesis. and total parenteral nutrition as well as for obtaining blood samples for lab tests. malaise) Infection ( IV tubing and filter Q24 changed. y Insulin is often added to the content as needed to control blood glucose. DEXTROSE AND LIPIDS-1 LITER /24 HOURS ± NO FILTER DIRECT COMPLICATIONS: hyperglycemia. fever. and normal metabolic function. and all medication dosages and blood sample withdrawals are followed by saline and heparin flushes. blood products.Hickman/Biovac and Groshong. ACCESS: peripheral< 2 weeks ± phlebitis PIC ± Basilic / cephalic PCC ± subclavian Triple Lumen.mixture of: y dextrose (20 to 70 percent) y amino acids y multivitamins y electrolytes. Usually he catheter is flushed with twice the catheter volume of heparinized saline at specified intervals. 5. TPN-AMINO ACIDDEXTROSE. double. or triple lumens and can be used for administering drugs.hyperosmolar(HA. The Groshong catheter is not flushed with heparin because it has a valve that restricts blood backflow. 3.

Weigh patient daily. greases. VC = (VT) + ( IRV ) + (ERV) The volume left in the lungs after normal quiet exhalation IC = (VT) +( IRV ) The volume left in the lungs after a normal exhalation FRC = ( ERV ) + ( RV) Normal Value 500 Inspiratory Reserve Volume ( IRV ) Expiratory Reserve Volume (ERV) Total Lung Capacity ( TLC ) Residual Volume (RV ) Vital Capacity 3100 1200 6000 1200 4800 Inspiratory Capacity ( IC ) Functional RESIDUAL Capacity ( FRC ) 3600 2400 O2 Therapy safety precautions: 1. 7. Check vital signs (including blood pressure) at least every 6 hours after initiating infusion. Change IV line setup every 24 hours.) 2. Avoid use of volatile and flammable materials such as alcohol.) 9. Order TPN solutions from the pharmacy in a timely manner. administer sliding scale insulin as ordered. Monitor blood glucose every 6 hours. 5. 8. Only lipids may be ³piggybacked´ carefully through the TPN line beyond the in-line filter. Verify central line placement after initial insertion via chest (radiograph) prior to beginning ( pneumothorax or hemothorax is a risk with central line placement. those clients who have reduced lung diffusion of oxygen through the respiratory membrane. (High glucose content of TPN can cause an osmotic diuresis and lead to dehydration. Check central line insertion site frequently for signs of infection ( which may lead to sepsis) 4. remove the next container from the refrigerator an hour before needed to prevent central infusion of cold solutions. Pulmonary Volumes and Capacities: Description Tidal Volume (VT) Volume inhaled and exhaled during normal quiet breathing Maximum amount of air that can be inhaled over and above a normal breath Maximum amount of air that can be exhaled following a normal breathing Total volume of the lungs at maximum inflation TLC = (VT) + ( IRV ) + (ERV) + ( RV ) The amount of air remaining in the lungs after maximal inhalation Total amount of air that can be inhaled after a maximal inspiration. Do not administer IV piggyback or direct IV push medications through or draw blood samples from the TPN line. NO Smoking 2. ether and acetone . 3. heart failure leading to inadequate transport of oxygen.) 6. Follow agency policy regarding frequency of dressing changes and procedure. Oxygen Therapy Indicated to clients who need additional oxygen. oils.INDIRECT COMPLICATION Hypoglycemia Guidelines: 1. (TPN fluidsare an excellent medium for bacterial growth.

6. If a hospital bed is available. rotate airway 180 degress downward. Place on a tilt table. and slip it to the uvula into the oral pharynx Suction and mouth care as needed Never tape the airway in place Nasopharyngeal Airway From the nose to the oropharynx Frequents oral and nasal care Endotracheal Tube y Suction as needed to prevent pooling of secretions and keep the airway patent y Monitor cuff pressure ( should be 20 ± 25 mm Hg or as recommended) to prevent tracheal tissue necrosis y Mouth care as needed y Provide humidified oxygen y Communicate frequently using pad and pen. Use suction or assisted cough before changing position to insure removal of any secretions drained while in that position. 4. Place 3-5 wood blocks. that are 2 inches by 4 inches. Incentive Spirometry: Sustained maximal inspiration device Measures the flow of air inhaled through the mouthpiece Used to expand collapsed alveoli loosen secretions and improved pulmonary ventilation Artificial Airway Orophharyngeal and Nasopharyngeal Airway y y y y y Devices that keeps the airway open / patent Oropharynheal airways stimulates gag reflex and SHOULD only be used with altered LOC When inserting. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip 3. To drain the upper portions of your lungs.Postural Drainage Drainage by gravity Pre therapy: Administer bronchodilator or nebulization therapy Frequency: 2 ± 3 times a day Best time:  Before breakfast  Before lunch  Before bedtime CI: spinal cord injury Sequence: Positioning. in a stack that is 5 inches high. you should be in a sitting position at about a 45 degree angle. under the foot of a regular bed. put in Trendelenburg position (head lower than feet) 2. cough / suctioning To drain the middle and lower portions of your lungs: Positions: 1. y If with mechanical vent ensure alarms are functioning y y . hold it by the outer flange. Remain in each position approximately five to ten minutes. 7. Lower head and chest over the side of the bed. Vibration. Stack 18-20 inches of pillow under hips. Percussion. with head lower than feet. 5. with distal end pointing up Should be inserted along the top of the tongue with the distal end pointing up When the distal end reached the back of the mouth.

soak inner cannula in antiseptic soak with hydrogen peroxide. rinse well suction as needed and do oral care frequently Suctioning Aspiration of secretions through a catheter that is connected to a suction machine or wall suction outlet Catheters: 1. tie new tie before removing the old tie to prevent accidental dislodgement use precut gauze and perform care once a day at least. Prepare trash receptacle. 4. Wash hands. 6. Open tipped . 5.Most effective in aspirating secretions 2. 2. a mist collar or a 4 ix 4 guaze may be held in place with a cotton tie over the stoma to filter the air as it enters. diamond fashion. male patient supine with legs slightly spread. 3. Place waterproof pad under buttocks. Arrange for adequate lighting.Less irritating Oral suctioning: Yankauer device / oral suction tube Catheter have a thumb port which serves as a controller when suctioning Notes: NEVER suction more 10 ± 15 seconds Use aseptic technique when suctioning HYPEROXYGENATE prior to suctioning Do oral care after suctioning DO NOT suction while inserting the catheter When u close the thumb port with your finger the suctioning is done Open thumb port ( no suction is done) Suction in a circular manner/ by rotating catheter ( ensures all surfaces are reached and prevents trauma) Apply intermittent suction on withdrawal of the catheter Urinary Catheterization Procedure 1. 8. Whistle tipped . Drape patient.Tracheostomy Surgical incision of the trachea which is used as a long term airway support Tracheostomy tube components: Outer cannula with flange Inner cannula Obturator Inflatable cuff( secures the placement of the tube) Tracheostomy tubes have an outer cannula with a flange ( which rests on the neck) this allows the tube to be secured in place with a tie / tape The obturator is used to insert the outer cannula and then removed. Provide privacy. with sheet. Position the female patient supine with knees flexed. Explain procedure to the patient. This should remain at the bedside incase the tube will be dislodged and needs reinsertion NOTE: children donot require cuffed tubes because their tracheas are resilient enough to seal the air space around the tube Tracheostomy care: Air is not filtered and humidified therefore. . 7.

25. 5. If patient has sudden pain. Allow irrigation solution to return by gravity. away from the sterile field. Chest Tube: Types of Chest Tube Drainage System: Simple drainage system a simple drainage system that can be connected to suction or to a Heimlich valve. Collect specimen if needed. NOTE: Each swab is used only once and discarded into the trash receptacle. 23. Place waterproof pad beneath the patient¶s hips. the system has a fluid-collection bottle and a watersealed bottle.9. and patient¶s tolerance of procedure. cleanse perineum (female) from clitoris toward anus with top-to-bottom motion or retract foreskin (male) and use circular motion from meatus outward. IF INDWELLING 19. 17. disconnect drainage tubing. Using aseptic technique. Gather equipment. along with a pressure-regulating bottle. 20. Don sterile gloves. 14. Attach catheter to collection tubing if not already connected by manufacturer. 22. Using provided antiseptic solution and cotton balls or swabs. Test balloon if catheter will be indwelling. . Lubricate catheter. spread labia (female) or retract foreskin (male). Instill 30 mL of solution into bladder. 10. 11. 15. Three-bottle drainage system. 18. Explain procedure to the patient. Catheter Irrigation: 1. Wash hands. 21.) 7. Open kit using sterile technique. Tape catheter to patient¶s inner thigh. amount and appearance of urine. 24. This hand is no longer sterile. This bottle helps the system maintain a measured.Repeat this step at least three times. Pour sterile normal saline into a sterile basin and draw into sterile irrigation syringe. Slowly insert catheter until urine is noted (2 to 3 inches for female or 7to 8 inches for male)For male patient. then advance catheter slightly and reinflate. 2. 3. This helps to stop the problem of air moving back into the chest. Set up sterile field (off bed if the patient may contaminate). Inflate balloon. 13. deflate balloon. Discard gloves and equipment. Water Seal Drainage System addition of a water-sealed bottle to the simple drainage system. hold penis perpendicular to body and pull up gently during insertion. Document size and type of catheter inserted. 16. Wash perineum with soap and water if soiled. 8. With nondominant hand. constant negative pressure and negative flow. (Avoid contaminating end of catheter tube or drainage system. and it also provides greater capacity for the collection of blood or body fluids without any clogging of the suction outlet/connection. 12. The fluid-collection bottle would have measurement markings on it to help clinicians track the amount of fluid collected. Remove catheter if it is not indwelling. 4. Pull catheter gently to check adequacy of balloon. Allow slack for patient movement. Wash hands and don gloves. 6.

attach drainage unit to the tube. Do NOT strip the tube. assess the patient¶s condition. (Stripping greatly increases the negative pressure applied to the pleural space and can cause tissue damage. 4. fill chamber to the ordered level. 6. If drainage slows or stops. ‡ Keep drainage unit below chest level. continue toward the Collection chamber. Gather equipment and unwrap Pleur-Evac or other closed-chest drainage apparatus. and appearance of the tube insertion site. Maintain extra lengths of tubing by coiling it on the bed in order to prevent dependent loops that may slow/stop drainage. patient respiratory status. and advance suction until gentle bubbling occurs in suction-control chamber. 4. Attach long (drainage unit) tube to suction source. type and amount of drainage. Note accumulated drainage in the collection chamber at the start of each shift or more frequently if warranted by patient condition. and attach it to the patient¶s chest tube. especially with vigorous bubbling. the column of fluid rises with inhalation and falls with exhalation. Observe the water-seal chamber for bubbling. if ordered. 5. and encourage coughing and deep breathing. unless the patient is on a ventilator. 3. Check the water-seal and suction-control fluid levels at the start of each shift and replace water as necessary.water will evaporate from the suctioncontrol chamber. Bubbling is normal on exhalation when the patient has a pneumothorax. including time initiated/ discontinued. obtain a new drainage system. 3. squeezing the tube with only one hand at a time. typically 20 cm H2O.To check fluid levels. grasp and squeeze it between the fingers and palm of one hand. ‡ If the drainage system is broken and no new drainage system is immediately available. details related to chest dressing. obtain a new system. gently ³milk´ the chest tube from proximity to the patient toward the collection chamber: to milk the tube. 6. Fill the water-seal chamber to the 2-cm level according to manufacturer¶s instructions regardless of whether suction is to be used. Amount of suction applied to the pleural space is determined by the height of fluid in the suction-control chamber and not the wall suction source. encourage the patient to cough and deep breathe.) 7. MAINTENANCE 1. stripping involves both hands with one holding the tube while the other squeezes and pulls toward the drainage chamber. 2. Document system function. Observe the water-seal chamber for fluctuations (tidaling) that occur with the patient¶s ventilations. ‡ If drainage system is turned over or water seal disrupted: re-establish water seal. bleeding. place the end of the chest tube in a bottle of saline or water and place the bottle below chest level. continuous bubbling indicates an (abnormal) air leak in the system. If suction is ordered. . Hang drainage unit from the bed frame 5. and pain. After chest tube insertion (by the physician) and before tube clamp removal. 8. and mark the date and time of observation on the collection chamber.Chest Tube care 1. Notes for safety: ‡ Maintain all connections in the system to prevent inadvertent entrance of air into the patient¶s pleural space. If secretions were present in the disrupted system. 2. release and repeat with the other hand on the next lower portion of the tube.temporarily turn off the wall suction.

let us take a closer look on the standards of perioperative nursing from admission until discharge. and checked regularly 10. limiting the number. and transmission Clean and dirty technique Surgical Asepsis Sterile technique All practices intended to keep an area or objects free of all microorganism. If in doubt. Gravity may contaminate the sterile field therefore AVOID overreaching 7.´ ASEPSIS -Is the freedom from disease ± causing microorganism Types : Medical Asepsis All practices intended to confine a specific microorganism to a specific area. growth. Overexposed pack is already unsterile 6. Do not pour fluids on the sterile field 9. and out of vision are considered unsterile 3. One of the highlights of the licensure examination is perioperative nursing. consider it unsterile 5. above the head. . Sterile instruments should be stored well. There is a 1 by 1 inch border that is considered unsterile in every sterile pack 4. and destroy all microorganism PRINCIPLES OF ASEPTIC TECHNIQUE 1. the outer flap should be opened away from you first 11. The outer pack of a double ± wrapped instrument is considered unsterile 12.ASEPSIS AND PERIOPERATIVE NURSING ³Universal Precautions takes us back to the area where presence of mind matters most. Things below the waist. the Operating Room. Moisture is a good medium for contamination 8. In this chapter. Honesty and presence of mind should be of greater value when maintaining sterility. Only sterile objects should be on the sterile field 2. When opening a pack.

eye protection.Negative Airflow Pressure .Use of mask .Door must be kept closed . while heat application is done after 72 hours.Standard Precaution Promote hand washing . Check the area of applications are done every 15 minutes. mucous membrane Standard plus + + + Airborne Precaution Disease Measles Chicken Pox Varicella Zoster Virus Tuberculosis Ways of Protection . 2.Room: negative Pressure . Wound Dressings Purpose:  Protect from injury and bacterial contamination  Maintain humidity  For thermal insulation  Absorb drainage and at the same time debride the wound  Prevent hemorrhage  To splint and immobilize wound  Provide comfort Wound Healing Inflammation Phase HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----(34DAYS) Proliferative Phase FIBROBLAST²COLLAGEN---CAPILLARIES---GRANULATION TISSUE---ESCHAR---(3 ± 21 DAYS) Maturation Phase (21 DAYS ± 2 YEARS) Droplet Precaution Contact Precaution Adenovirus Diphtheria Epiglottitis Influenza Meningitis Mumps Pertusis Pnuemonia Sepsis Rubella MDR (multi drug resistant ) Enteric Infections (e.Mask client when in contact with others and when leaving the room Use of mask ( also by the patient especially when leaving the room ) Room: private room or can be cohorted or grouped HEAT AND COLD THERAPY An intervention that reduces inflammation Principles: 1. clostridium difficile) Respiratory Syncytial virus Wound Infections Skin infestations: Impetigo Pediculosis Scabies Eye infections conjunctivitis room: private room or can be cohorted or grouped together use of GLOVES and GOWNS . masks. secretions. Cold application is generally safer than heat application.g. Cold application is done within 72 hours after an injury.Must be in a single room . use of gloves. non intact skin . The application of heat and cold is done at a maximum of 30 minutes (an average of 1520 minutes) 5. Heat application usually requires a doctor¶s order 3. and gowns when in contact with clients APPLIES TO: blood. all body fluids.Use of high ± efficiency particulate air filter In the room . 4.

removal and examination of tissue (e. and postoperative PERIOPERATIVE NURSE . Curative/Ablative-removal of a diseased organ or structure (e.Use sterile gloves or clean gloves . (e. cleft palate repair).repair or restoration of an organ or structure (e. disease.g.Cleanse the wound from the center outward. PERIOPERATIVE NURSING Perioperative . . harelip.Acts as a patient advocate for patients undergoing surgical and invasive procedures . colostomy. Reconstructive. Palliative. teaches.g. . or disorder and has three phases: preoperative. ..NOTE: ³Wet-to-dry dressing change´ describes the technique of applying several layers (the number of layers depends on the size of the wound area and the patient) of saline-soaked dressings next to the wound and covering these with dry dressings.refers to the total span of surgical intervention. and evaluate treatment of the patient . Surgical intervention is a common treatment for injury. implement. during.g..repair a congenitally malformed organ or tissue.Provides specialized nursing care to patients before.Types of dressing: Dry to Dry Trap necrotic debris and exudate Wet to Dry Uses saline and anti microbial solution this softens debris as it dries and dilute exudate Wet to damp Wound debrided if gauze is removed Variation at drying WOUND DEBRIDED IF GAUZE REMOVED ( VARIATION at DRYING) Wet to Wet Keeps wound moist ( wound is bathed ) Moisture dilutes viscous exudate Notes: . .relief of pain (for example. Restorative . rhizotomy-interruption of the nerve root between the ganglion and the spinal cord). manages.Use gauze pads (which may be lifted with sterile forceps) to cleanse the wound with prescribed antiseptic solution.NOTE: Iodine solutions may cause skin irritation if they are left on the skin between dressing changes .is a nurse who provides patient care. and after their surgical and invasive procedures .Works closely with all members of the surgical team CLASSIFICATIONS OF SURGERY Reason/Purpose Diagnostic. and studies the care of patients undergoing operative or other invasive procedures.. intraoperative. biopsy).Helps plan. cosmetic improvement). rhinoplasty.g. appendectomy). using a new gauze pad for each outward motion.

and has the potential of postoperative complications. and results in few complications COMMON PSYCHOLOGICAL DISTRESS PRIOR TO SURGERY y Anxiety y Loss of a body part. involves major body organs or life-threatening situations. carries a higher degree of risk. y Fear of the unknown (Most common fear) y prior surgical experiences (positive/negative) y type of surgery y location site Nursing History y past & present y meds y diet y allergies (latex) y personal habits y occupation y finances y family support y knowledge of surgery y attitude Physical Exam Diagnostic tests y CBC y Electrolytes y Creatinine y Urinalysis y x-ray exams y EKG y Blood Type y PTT and PT y Platelet y Blood donations PREOPERATIVE CHECKLIST y History and physical examination y Name of procedure on surgical consent y Signed surgical consent y Laboratory results y Client is wearing an identification bracelet y Allergies have been identified y NPO y Skin preparation completed y Vital signs assessed PREOPERATIVE PHASE Begins when a decision for surgery is made until the client is admitted at the operating room.surgery that can be delayed Optional ± Patient may opt to have or not to have surgery Degree of Risk Major. y Unconsciousness and not knowing or being able to control what is happening.requires hospitalization. carries a low risk. y The effects of surgery on his lifestyle at home and at work.brief. y Pain. PREOPERATIVE ASSESSMENT: Risk Factors y Age y Nutritional and health status y fluid & electrolytes imbalances y radiation y cardiopulmonary y chemotherapy y meds y family history . y Separation from family and friends.Degree of Urgency Urgent ± needs immediate interventions Elective. y Exposure of his body to strangers. y Fear of death. is usually prolonged. Minor.

Hepatic.ANESTHESIA Types 1. Versed y Anticholinergic y Atropine. type of intravenous solution.y y y y y y Jewelry removed Dentures removed Client is wearing a hospital gown and hair cover Client has urinated Location of IV site. Novocain. Local General Anesthetics y Inhaled General Anesthetics y Nitrous oxide. rate of infusion is identified The prescribed preoperative medication has been given Anesthetic agents y Xylocaine. renal. Regional 3. however. It ends when the patient is transferred to the post-anesthesia recovery room. scopolamine y Sedative-hypnotic Atarax. Seconal. THE SURGICAL TEAM A. General 2. PREOPERATIVE HEALTH TEACHINGS y leg and deep breathing exercises. Geriatric concerns 2. ROM exercises y Moving patient . coughing and splinting y Preoperative medications : when they are given & their effects y Postoperative pain control y Explanation & description of post anesthesia care recovery room y Discussion of the frequency I assessing V/S & use of monitoring equipments PREOPERATIVE . Nembutal NURSING RESPONSIBILITIES 1. enflurane. The surgeon is ultimately responsible for performing the surgery effectively and safely. Assess for preexisting problems such as cardiac.sensory decline 3. Address safety issues . he is dependent upon other members of the team for the patient's emotional well being and physiologic monitoring. or respiratory. carbocaine Topical y Dermoplast (benzocaine) ADJUNCTIVE ANESTHESIA y Opioid analgesic Alfenta Demerol and Morphine y Benzodiazepine Valium. cardiac respiratory and renal decline 4. cyclopropane y Inhaled liquid y halothane. hepatic. . The Surgeon The surgeon is the leader of the surgical team. isoflurane y Intravenous Anesthetic y Pentothal (thiopental) Local/Regional y Epidural y Infiltration y Nerve Block y Spinal y Topical INTRAOPERATIVE PHASE The intraoperative phase is the period during which the patient is undergoing surgery in the operating room. Vistaril.

(5) Advising the surgeon of impending complications and independently intervening as necessary. The scrub nurse or assistant wears sterile gown. . helping monitor the patient¶s condition. Induction. maintains surgical asepsis while draping and handling instruments. upper abdominal surgery. (1) There are three phases of general anesthesia: induction. and carry out the nursing care plan. medications. The circulating nurse is a professional registered nurse who is liaison between scrubbed personnel and those outside of the operating room. Anesthesiologist/Anesthetist. opening packages so that the scrub nurse can remove the sterile supplies. MAJOR CLASSIFICATIONS OF ANESTHETIC AGENTS A. maintenance. (4) Continuous monitoring of the physiologic status of the patient to include oxygen exchange. and surgery of the upper and lower extremities. There are three major classifications of anesthetic agents: general anesthetic. (A) General anesthesia is used for major head and neck surgery. The scrub nurse must have extensive knowledge of all instruments and how they are used. and vital signs. and supplies. intracranial surgery. and gloves. and blood components. and arranging for transfer of specimens to the laboratory for analysis.B. The circulating nurse is free to respond to request from the surgeon. Maintenance (surgical anesthesia) begins with the initial incision and continues until near completion of the procedure. When the patient is given drugs to produce central nervous system depression. regional anesthetic. D. systemic circulation. preparing labels. and needles used during the operation to prevent the accidental loss of an item in the wound. cap. (3) Anticipating the need for equipment. (2) Assisting the surgeon and scrub nurse to don sterile gowns and gloves. mask. anesthesiologist or anesthetist. A general anesthetic produces loss of consciousness and thus affects the total person. (3) Continuous monitoring of the physiologic status of the patient for the duration of the surgical procedure. The circulating nurse does not scrub or wear sterile gloves or a sterile gown. (rendering the patient unconscious) begins with administration of the anesthetic agent and continues until the patient is ready for the incision. Circulating Nurse. Scrub Nurse/Assistant. deliver supplies to the sterile field. sutures. counting the number of sponges. instruments. and assists the surgeon by passing instruments. The responsibilities of the anesthesiologist or anesthetist include: (1) Providing a smooth induction of the patient's anesthesia in order to prevent pain. The scrub nurse or scrub assistant is a nurse or surgical technician who prepares the surgical set-up. and emergence. instruments. and local anesthetic. (2) Maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. An anesthetist is a registered professional nurse trained to administer anesthetics. Other responsibilities include: (1) Initial assessment of the patient on admission to the operating room. and at the end of the operation. (4) Saving all used and discarded gauze sponges. C. it is termed general anesthesia. An anesthesiologist is a physician trained in the administration of anesthetics. thoracic surgery. obtain supplies. neurologic status.

and is used for surgery of the lower abdomen. (b) It produces complete loss of consciousness. outside the spinal canal. It may be applied topically to skin surfaces and the mucous membranes in the nasopharynx. (e) It is safe and has minimal side effects. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects. (d) It dulls reflexes. and urinary retention. wounds. or rectum or injected intradermally. (2) Routes of administration of a general anesthetic agent are: rectal (which is not used much in today's medical practices). intravenous infusion. The patient remains awake but loses sensation in the specific region anesthetized. In some instances. administration of a general anesthetic requires the use of one or more agents. and burns. The injection of an anesthetic. that is. it is termed regional anesthesia. . C)Local anesthesia is administration of an anesthetic agent directly into the tissues. (1) Regional anesthesia may be accomplished by nerve blocks. perineum. No single anesthetic meets the criteria for an ideal general anesthetic. open skin surfaces. To obtain optimal effects and decrease likelihood of toxicity. (B) A regional or block anesthetic agent causes loss of sensation in a large region of the body. and lower extremities. and inhalation. and extremities. Topical anesthesia is used on mucous membranes. Side effects of spinal anesthesia include headache. (c) It provides a degree of muscle relaxation. (c) Epidural block. face. mouth.Emergence begins when the patient starts to come out from under the effects of the anesthesia and usually ends when the patient leaves the operating room. hypotension. reflexes are lost also. When an anesthetic agent is injected near a nerve or nerve pathway. into the cerebrospinal fluid in the subarachnoid space causes sensory. The disadvantage is that it carries major risks of circulatory and respiratory depression. (b) Subdural blocks are used to provide spinal anesthesia. and leave the patient unaware of the physical trauma. the agent is injected through the lumbar interspace into the epidural space. vagina. Local infiltration is used in suturing small wounds and in minor surgical procedures such as skin biopsy. The advantage of general anesthesia is that it can be used for patients of any age and for any surgical procedure. The advantage of local anesthesia is that it acts quickly and has few sideeffects. through a lumbar puncture. (3) Characteristics of the ideal general anesthetic are: (a) It produces analgesia. or subdural or epidural blocks (a) Nerve blocks are done by injecting a local anesthetic around a nerve trunk supplying the area of surgery such as the jaw. Often an intravenous drug such as thiopental sodium (Pentothal) is used for induction and then supplemented with other agents to produce surgical anesthesia.. motor and autonomic blockage.

The available equipment. to produce the prothrombin necessary for blood clotting. Regulation of fluids and electrolytes. The patient's age. General anesthesia produces all of these responses. Renal insufficiency may alter the excretion of drugs and influence the patient's response to the anesthesia. Well-controlled cardiac conditions pose minimal surgical risks. Patients may be taking medication for conditions unrelated to the surgery. oral. The choice of route and the type of anesthesia is primarily made by the anesthetist or anesthesiologist after discussion with the patient. and cardiovascular function. (c) Anticoagulants--may precipitate hemorrhage. These conditions also predispose the patient to postoperative lung infections. (b) Antibiotics--may be incompatible with anesthetic agent. Of particular concern are pulmonary function. Factors considered by the anesthetist or anesthesiologist when selecting an agent are the smoking and drinking habits of the patient. preoperative assessment should include a thorough medication history. Preferences of the anesthesiologist or anesthetist and the patient. The patient's condition. inhalation. can affect the patient's reaction to the anesthetic agent. and are unaware of the potential for adverse reactions of these medications with anesthetic agents. Pulmonary function is adversely affected by upper respiratory tract infections and chronic obstructive lung diseases such as emphysema. many factors effect the selection of an anesthetic agent: The type of surgery. For example. resulting in untoward reactions. The patient's previous experiences with anesthesia. Local anesthesia results in loss of sensation in a small area of tissue. and to metabolize nutrients essential for healing following surgery. Whether by intravenous. Those in the mycin group may cause respiratory paralysis when combined with certain muscle relaxants used during surgery. especially when intensified by the effects of general anesthesia. The skill of the anesthesiologist or anesthetist. Regional anesthesia does not cause narcosis. (a) Adrenal steroids--abrupt withdrawal may cause cardiovascular collapse in long-term users. or recent myocardial infarction drastically increase the risks.SELECTION OF AN ANESTHETIC AGENT Depending on its classification. (1) Because some medications interact adversely with other medications and with anesthetic agents. Liver diseases such as cirrhosis impair the ability of the liver to detoxify medications used during surgery. analgesia (insensibility to pain). The anticipated length of the procedure. Severe hypertension. . may be impaired by renal disease. but does result in analgesia and reflex loss. anesthesia produces states such as narcosis (loss of consciousness). increase the effects of the anesthesia. hepatic function. whether prescribed or over-thecounter. loss of reflexes. (2) Drugs in the following categories increase surgical risk. as well as acid-base balance. Medications. and the presence of disease. patients with cardiovascular problems or diabetes mellitus may continue to receive their prescribed medications. and relaxation. congestive heart failure. any medications the patient is taking. Medication is usually withheld when the patient goes to surgery. but some specific medications are given even then. The location and type of anesthetic agent required. or rectal route. and increase the risk from the stress of surgery. renal function.

To repair or remove traumatized tissue and structures. Pain is usually greatest for 12 to 36 hours after surgery. REASONS FOR SURGICAL INTERVENTION Descriptors used to classify surgical procedures include ablative. To prevent disease or injury. Most people recover from surgery without incident. decreasing on the second and third post-op day. decreasing its energy and resistance. (3) Early detection of complications. To relieve symptoms or pain. (2) To relieve the patient's discomfort. Call the patient by name in a normal tone of voice and tell him repeatedly that the surgery is over and that he is in the recovery room. Following the operation. The difference between the recovery room and surgical intensive care are: (1) The recovery room staff supports patients for a few hours until they have recovered from anesthesia. Analgesics may be administered in patient controlled infusions. preventing it from blocking the throat and allows mucus or vomitus to drain out of the mouth rather than down the respiratory tree. THE RECOVERY ROOM a. When the reflexes return. To visualize internal structures during diagnosis. The recovery room is defined as a specific nursing unit. which accommodates patients who have undergone major or minor surgery. resulting in respiratory depression from the anesthesia. but the recovery room nurse must be aware of the possibility and clinical signs of complications. and transplant. (4) Prevention of complications. To improve appearance. Position the unconscious patient with his head to the side and slightly down. Surgery traumatizes the body. constructive. (2) The surgical intensive care staff supports patients for a prolonged stay. This position keeps the tongue forward. These descriptors are directly related to the reasons for surgical intervention: To cure an illness or disease by removing the diseased tissue or organs. thus contributing to shock. the patient usually spits out the airway. Complications or problems are relatively rare. (e) Tranquilizers--may increase the hypotensive effect of the anesthetic agent.(d) Diuretics--may cause electrolyte (especially potassium) imbalances. the patient is carefully moved from the operating table to a wheeled stretcher or bed and transferred to the recovery room. General nursing goals of care for a patient in the recovery room are: (1) To support the patient through his state of dependence to independence. palliative. thus analgesics are most effective if given before the patient's pain becomes severe. The patient usually remains in the recovery room until he begins to respond to stimuli. To obtain tissue for examination. diagnostic. Patients who have had spinal anesthetics usually lie flat for 8 to 12 hours. Do not place a pillow under the head during the immediate postanesthetic stage. An artificial airway is usually maintained in place until reflexes for gagging and swallowing return. . Tension increases pain perception and responses. Complications that should be prevented in the recovery room are respiratory distress and hypovolemic shock. Recovery Room Care The postoperative phase lasts from the patient's admission to the recovery room through the complete recovery from surgery. Analgesics are usually administered every 4 hours the first day. Anesthesia impairs the patient's ability to respond to environmental stimuli and to help himself. The return of reflexes indicates that anesthesia is ending. which may last 24 hours or longer. reconstructive.

an oropharyngeal airway is inserted to prevent the tongue from obstructing the passage of air during recovery from anesthesia. (e) Repeat these steps three times every hour while awake. Reinforce the deep breathing exercises the patient was taught preoperatively. violent contraction of the vocal cords. (1) A laryngospasm is a sudden. Deep breathing exercises hyperventilate the alveoli and prevent their collapse. place the patient in a semi-Fowler's position. in conjunction with deep breathing. If permitted. Ambulate the patient as ordered. Oropharyngeal airway. respiration is less effective because of the anesthesia and pain medication. an unconscious or semiconscious patient should be placed in a position that allows fluids to drain from the mouth. During the surgical procedure with general anesthesia. Ask the patient to: (a) Exhale gently and completely. vomitus or secretions should be removed promptly by suction. the alveoli do not inflate and may collapse. After removal of the endotracheal tube by the anesthesiologist or anesthetist. b. a complication which may happen after the patient¶s endotracheal tube is removed. the endotracheal tube is removed by the anesthesiologist or anesthetist and replaced by an oropharyngeal airway (figure 8-4). and facilitate oxygenation of tissues.RESPIRATORY DISTRESS Respiratory distress is the most common recovery room emergency. Turn the patient as ordered. While in a semi-Fowler's position. Upon completion of the operation. . improve lung expansion and volume. (c) Hold his breath and mentally count to three. with support for the neck and shoulders. (3) Ineffective airway clearance may be related to the effects of anesthesia and drugs that were administered before and during surgery. It may be caused by laryngospasm. aspiration of vomitus. Coughing is painful for the postoperative patient. helps to remove retained mucus from the respiratory tract. help to expel anesthetic gases and mucus. To prevent aspiration. (d) Exhale as completely as possible through pursed lips as if to whistle. The endotracheal tube may be connected to a mechanical ventilator. As a result. POSTOPERATIVE PATIENT CARE ACCORDING TO BODY SYSTEM Respiratory System The cough reflex is suppressed during surgery and mucous accumulates in the trachea and bronchi. If possible. and because deep respirations cause pain at the incision site. Coughing. After surgery. an endotracheal tube is inserted to maintain patent air passages. The airway is left in place until the patient is conscious. or depressed respirations resulting from medications. to aid lung expansion. (b) Inhale through the nose gently and completely. (2) Swallowing and cough reflexes are diminished by the effects of anesthesia and when secretions are retained. and retained secretions increase the potential for respiratory infection and atelectasis. the patient should support the incision with a pillow or folded bath blanket and follow these guidelines for effective coughing: (a) Inhale and exhale deeply and slowly through the nose three times.

An incentive spirometer may be ordered to help increase lung volume. often have difficulty urinating after surgery.(b) Take a deep breath and hold it for 3 seconds. then insert the spirometer's mouthpiece into his mouth. Most patients learn to use this device and can carry out the procedure without a nurse in attendance. Do not use the spirometer immediately before or after meals. particularly in the lower abdominal and pelvic regions. (a) While in an upright position. the patient should take two or three normal breaths. inflation of alveoli. thrombophlebitis and emboli are potential complications of surgery. . 3. (d) Repeat this sequence 10 times during each waking hour for the first 5 post-op days. 2. (a) Provide physical support for the first attempts. report this event to the supervisor. Ambulate the patient as ordered. (b) Have the patient dangle the legs at the bedside before ambulation. Monitor the patient from time to time to motivate them to use the spirometer and to be sure that they use it correctly. (c) Monitor the patient's blood pressure while he dangles. Cardiovascular System Venous return from the legs slows during surgery and may actually decrease in some surgical positions. do not ambulate. (c) Exhale slowly and fully. (f) Take another deep breath. and facilitate venous return. 1. pressing the backs of the knees down toward the mattress on extension. The fear of pain may cause the patient to feel tense and have difficulty urinating. The patient may tell you that he feels a sense of fullness and urgency. If the patient does not have a catheter. then. (g) Repeat these steps every 2 hours while awake. Report this event to the supervisor. (d) Repeat leg exercises every 1 to 2 hours. point the toes toward the chin (dorsiflex) and toward the foot of the bed (plantar flex). Assist the patient to void. The area over the bladder may feel rounder and slightly cooler than the rest of the abdomen. (b) Inhale through the mouth and hold the breath for 3 to 5 seconds. Urinary System Patients who have had abdominal surgery. make a circle with the toes. instruct the patient to exercise the legs while on bedrest. Leg exercises are easier if the patient is in a supine position with the head of the bed slightly raised to relax abdominal muscles. Venous return is increased by flexion and contraction of the leg muscles. (b) Alternately. keeping the leg straight. To prevent thrombophlebitis. Leg exercises (figure 8-8) should be individualized using the following guidelines. and has not voided within eight hours after return to the nursing unit. (c) Raise and lower each leg. (d) Take a deep breath with the mouth open. With circulatory stasis of the legs. (c) Give two or three "hacking" coughs while exhaling with the mouth open and the tongue out. (e) Cough deeply once or twice. (a) Flex and extend the knees. Palpate the patient's bladder for distention and assess the patient's response. (d) If the patient is hypotensive or experiences dizziness while dangling. The sensation of needing to urinate may temporarily decrease from operative trauma in the region near the bladder.

protect the wound from injury and contamination. 8. 1. and . 5. Ask the patient if he has passed gas since returning from surgery. further assessment should be made and your findings reported and documented. in which no dressing is used to cover the wound. If the first urine voided following surgery is less than 30 cc. Measure and record urine output. If there is blood or other abnormal content in the urine. Document nursing measures and the results in the nursing notes. 6. indicating an absence of peristalsis. in which a dressing is applied. complains of increased or constant pain from the wound.Important laboratory data include an elevated white blood cell count and the causative organism if a wound culture is done. the doctor may apply SteriStrip® to the wound to give support as it continues to heal. A last measure may require the insertion of a nasogastric or rectal tube. the doctor may order medication or an enema to facilitate peristalsis and relieve distention. 10. 6. Provide privacy so that the patient will feel comfortable expelling gas. Report to the supervisor if the patient complains of abdominal distention. Ambulate the patient to assist peristalsis and help relieve gas pain. (a) Advantages. 7. Assess abdominal distention. notify the supervisor. report this to the supervisor. Auscultate for bowel sounds. The basic objective of wound care is to promote tissue repair and regeneration. increased pain. After the staples or sutures are removed. 9. and document in nursing notes. There are two methods of caring for wounds: the open method. 3. 4. 5. 2. which is a common postoperative discomfort. Follow nursing unit standing operating procedures (SOP) for infection control.(a) Assist the patient to the bathroom or provide privacy. Instruct the patient to tell you of his first bowel movement following surgery. Report your assessment to the supervisor. Encourage food and fluid intake when the patient in no longer NPO. If nursing measures are not effective. you should evaluate the patient's general condition and laboratory test results. so that skin integrity is restores. In addition to assessment of the surgical wound. anorexia. Integumentary System wound irrigations and cultures. Staples or sutures are usually removed by the doctor using sterile technique. Nausea and vomiting may result from an accumulation of stomach contents before peristalsis returns or from manipulation of organs during the surgical procedure if the patient had abdominal surgery. Record the bowel movement on the intake and output (I&O) sheet. Dressings absorb drainage. . Generalized malaise. (b) Position the patient comfortably on the bedpan or offer the urinal. and the closed method. especially if bowel sounds are not audible or are high-pitched. Gastrointestinal System Inactivity and altered fluid and food intake during the perioperative period alter gastrointestinal activities. when caring for the patient with a Foley catheter. and an elevated body temperature and pulse rate are indicators of infection. or the patient complains of pain when voiding. 4. wound edges are swollen or purulent drainage.

y Administer the medications. y Document the medications given as soon as possible. 3. Follow SOP for infection control. psychological. causing superficial injury. 3. 8. 5. Coordinate with team leader for "take-home" wound care supplies and prescriptions for selfadministration. and food tolerance). Apply all nursing implications related to the patient diets (serving. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection). 6. Offer each drug separately if administering more than one drug at the same time. Items may be packaged individually or all necessary items may be in a sterile dressing tray. 4. use appropriate aseptic techniques when changing the dressing and follow precautions for contact with blood and body fluids. 4. Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock). gather needed supplies. Wear gloves when touching blood. 7. return to duty. 2. (b) Disadvantages. . damp. Precautions for Contact with Blood and Body Fluids 1. Do not give direct client care if you have open or weeping lesions or dermatitis. Maintain and monitor all IV sites. an open wound. and protective eyewear. a surgical mask. 2. Finally. wear gloves. Prepare the patient and the family for disposition (transfer. observe proper asepsis techniques with needles and syringes). 9. accurately calculate dosages. Dressings create a warm. Next. Administer analgesics as ordered. Supply the patient or family member with written instructions for: 10. or non-intact skin of all clients and when handling items or surfaces soiled with blood or body fluids. GENERAL POSTOPERATIVE NURSING IMPLICATIONS 1. . If procedures commonly cause droplets or splashing of blood or body fluids to which universal precautions apply. Never leave medications at the bedside for the patient to take later. sharp instruments. and assisting the patient to a position that is comfortable for him and for you.provide physical. providing privacy for the procedure. prepare the patient for the dressing change by explaining what will be done. and aesthetic comfort for the patient. discharge). First. Participate with the health team in the patient's nutrition therapy. recording intake. Take precautions to prevent injuries by needles. and dark environment conducive to the growth of organisms and resultant infection. It is especially important to wash hands thoroughly before and after changing dressings and to follow the Center for Disease Control (CDC) guidelines. Wash hands thoroughly after removing gloves and if contaminated with blood or with body fluids that contain visible blood. to include the following. Administer IV fluids as ordered. y Check the patient's identification wristband to ensure positive identification before administering medications. or sharp devices. Monitor vital signs as ordered. y Prepare the medications (check labels. body fluids containing visible blood. y Check each medication order against the doctor's order. Apply all nursing implications related to the patient receiving analgesics whether narcotic or nonnarcotic. as appropriate. Document the patient's disposition in the nurse's notes in accordance with unit SOP. y Remain with the patient and see that the medication is taken. Dressings can rub or stick to the wound.

anxiolytics ) Legal Implication: 2 standards for applying restraints: 1. wheelchairs and stretchers 5. do ambubagging Observe proper transfer techniques for non ambulatory patients Electrical Safety: avoid overloading any circuit Read warning labels on all equipment Radiation Safety: Label potentially radioactive material . sedatives. Then report fire) ( close doors to confine fire ) ( use extinguisher if available ) Extinguisher: PASS P ± Pull the pin while holding the extinguisher upright A ± Aim nozzle at the Base of the fire S ± Squeeze the handle firmly S ± sweep the fire y y y y Do not use elevator Turn of oxygen and appliances For patients with mechanical Ventilation . Behavior management standard: if client is a danger to self or others 2. Medical Surgical Care Standard: if it is related to any procedure The nurse will apply the restraints BUT the physician must see the client WITHIN 1 HOUR for evaluation. after the evaluation is VALID for 4 HOURS ( remove clients from the utility ) ( Activate Fire alarm. Lock all beds . Provide adequate lightning 2. Keep bed in low position with side rails up. Nueroleptics. Restraints y A protective device used to limit physical activity of a client or a body part y Used to immobilize an extremity or extremities Types: Physical ± involves manual or physical or mechanical device. material or equipment Chemical ± use of medications ( e. and emergency management of client¶s in biologic crisis will be comprehensively reviewed. Or a written order must be obtained within 24 hours The written order. Eliminate clutter and obstruction in the room 3. Personal items should be within reached 4. A system not only applicable in the examination. total of 30 minute per shift) Shield : use LEAD apron Never touch radiation implants with bare hands ( use forceps and put in a lead container) Falls To prevent falls: 1. Provisions of safety. In this Chapter. but also in the actual clinical experience´ FIRE Fire: RACE: R ± Rescue A ± Alarm C ± Confine E ± Extinguish Principle: Distance: keep distance of at least 3 feet Time: limit time when doing nursing procedures and communicating with patient ( 5 minutes per contact. g.PROVISION OF SAFETY Safety in emergency ³Nurses are known to work best under pressure.

Medical surgical Standard allows until 12 hours for the physician to write the written order Key Points: y Orders must be renewed daily y Ensure that the restraints allow some movement of the body part y Nuerovascular and Circulatory assessment should be checked every 30 minutes and restraints must be removed every 2 hours to 4 hours ( or according to hospital policy) y Permission of the client or the family Is required y A restraint must never be applied as a punishment for any behavior or merely for the nurse¶s convenience y Pad bony prominence before applying restraints y Never tie the ends to the side rails or to the fixed frame of the bed y Never leave the patient unattended when restraints are removed temporarily Kinds of Restraints Adults: y Jacket Restraints y Belt Restraints y Mitt or hand Restraints y Limb Restraints Infants and Children y Mummy restraints and Crib Nets Restraints y Elbow Restraints .

and assess for head and neck injuries. each must be dealt with immediately. sore throat. 4. Treatment may be delayed for several hours if necessary. Airway maintenance with cervical spine Method Depth Compression (rate / minute) 120 100 100 100 Ventilation: Compression Ratio Cycles / minute Neonate Infant <1 yr Child 1± 8 yr Adult 2 fingers 2 fingers 1 hand (heel) 2 hands 1/2±1 1/2±1 1±1 ½ 1 1/2±2 1:5 1:5 2 : 30 20 20 5 immobilization: Use jaw thrust.CLIENTS IN BIOLOGIC CRISIS AND FIRST AID Emergency Triage The purpose of triage is to classify severity of illness or injury and determine priority needs for efficient use of health care providers and resources. and chronic illnesses such as cancer or sickle cell disease. Vital signs are stable. and insert artificial airway as needed. simple lacerations. As life-threatening problems are identified. 5. significant pain. clear secretions. 2. 3. Treatment must be immediate. establish two large-bore IVs. Administer high-flow oxygen. and multisystem trauma. Injuries: Expose patient to completely assess for injuries. sternum 1. These patients frequently arrive by ambulance. CPR Guidelines Trauma in Emergency Setting PRIMARY SURVEY . and draw blood for cross-match. Circulation with hemorrhage control: Use pressure as needed. Nonurgent: Minor illnesses or injuries such as rashes. uncomplicated extremity fractures. Breathing: Intubate if needed. Examples: fever. chest pain of cardiac origin. 3. Category: 1. or chronic low back pain. Examples: Cardiopulmonary arrest. Emergent: Conditions that are life threatening and require immediate attention. 2. Neurologic status: Assess and document LOC. assess pupil reaction to light. pulmonary edema. Treatment can be delayed indefinitely Age Cardiac Compression Location Center sternum Center sternum Center sternum Lower half. Urgent: Conditions that are significant medical problems and require treatment as soon as possible.

and fibula on side of impact Pelvic fractures Pedestrian hit by large vehicle or dragged under vehicle Front seat occupant (lap and shoulder restraint worn) Front seat occupant (lap restraint only) Head. 1. and lower abdomen Head. abd. 4. Take history and complete head-to-toe assessment. Continue to monitor components under primary survey as well as adequacy of urine output. ribs.SECONDARY SURVEY The secondary survey consists of a history and a complete head-to-toe assessment. at any time during the secondary survey. Insert urinary catheter unless there is gross blood at meatus. chest. Obtain Chest X . face. tibia. ribs. and lower abdomen Cervical or lumbar spine. Insert NG tube (OG if facial fractures are involved). 3. abdominal injuries fractures of femur. and document findings. pelvis. laryngeal fracture. chest. If. pelvis.ray 7. aorta. the patient¶s condition worsens. face. 2. 8. Assess urinary output and check urine for blood. 6. pelvis Unrestrained driver Front seat passenger (unrestrained. Administer tetanus prophylaxis (see Tetanus Prophylaxis) and antibiotics (question regarding allergies first) if indicated. head. return to the steps in the primary survey. The purpose of the survey is to identify problems that may not have been identified as life threatening. Splint fractures. chest. posterior dislocation of acetabulum Hyperextension of neck with associated high cervical fractures Compression fractures of lumbosacral spine and fractures of calcaneus (heel bone) . aorta. chest. head-on collision) Back seat passenger (without head restraints. Predictable Injury in a Trauma Patient: Trauma Pedestrian hit by car Injuries Head. rear-end collision) Fall injuries with landing on feet Fractures of femurs and/or patellas.

3. Opisthotonos Opisthotonos: Rigid hyperextension of the spine. The head and heels are forced backward and the trunk is pushed forward. brain tumor.) 4. and hyperpronated. 2. It can result from head injury. and vigorous plantar flexion of lower extremities indicate lesion in cerebral hemisphere. or intracerebral hemorrhage. and anticonvulsants. sedatives. Seen in meningitis. Do not flex or rotate neck. 9. ICP monitoring via a fiberoptic catheter may be used to continuously assess changes in ICP. Meds that may be used include osmotic diuretics. corticosteroids. MANIFESTATIONS OF INCREASED ICP ‡ Headache ‡ Change in level of consciousness ‡ Irritability ‡ Increased systolic BP ‡ Decreased HR (early) ‡ Increased HR (late) ‡ Decreased RR ‡ Hemiparesis ‡ Loss of oculomotor control ‡ Photophobia (light sensitivity) ‡ Vomiting (with subsequent decreased headache) ‡ Diplopia (double vision ‡ Papilledema (optic disk swelling) ‡ Behavior changes ‡ Seizures · Bulging fontanel in infants MANAGEMENT OF INCREASED ICP Increased ICP should be treated as a medical emergency 1. 10. basal ganglia. 12. Teeth may be clenched (may be seen with opisthotonos). neuromuscular blocking agents. 5. 7. meningitis. Indicates brain stem pathology and poor prognosis. 11. tetanus. adducted. Ventricular tap may be performed if unresponsive to other measures. Extension. internal rotation. Monitor fluids and electrolytes (diuretic administration can predispose the patient to hypovolemic shock). and strychnine poisoning. Keep head in neutral alignment. encephalitis. wrist. and/or diencephalon or metabolic depression of brain function. Elevate head of bed 15 to 30 degrees. 6. with adduction of upper extremities. . Insert Foley catheter. Decerebrate rigidity Decerebrate rigidity: Arms are stiffly extended. Restrict fluids. Discourage patient activities that result in use of Valsalva¶s maneuver. Closely monitor vital signs and perform neuro checks. and fingers. Keep environment as quiet as possible. Legs and feet are stiffly extended with feet plantar flexed. hydrocephaly. seizures. 8. (Output may be profound if diuretic is given. Schedule all procedures (including bathing and especially suctioning) to coincide with periods of sedation. Ventilator may be used to maintain PaCO2 between 25±35.Medical Emergencies Increased intracranial Pressure Increased intracranial pressure (ICP) is defined as intracranial pressure above 15 mm Hg. Establish IV access. Rigid Postures (with Neurological Conditions): Medical Emergency: Decorticate rigidity Decorticate rigidity: Flexion of the arm.

clammy skin Cyanosis Altered mental ability treatment O2 Epinephrine Corticosteroids Antihistamine IV fluids Aminophylline Cardiogenic shock Failure to maintain blood supply to circulatory system and tissues because of inadequate cardiac output. After the seizure. 4. depressors) into the patient¶s mouth. turn the patient to the side and ascertain patency of airway. and spasms of respiratory tract.. tongue blades. fluid shifts. Acute left or right ventricular failure Acute mitral regurgitation Acute ventricular septal defect Acute pericardial tamponade Acute pulmonary embolism Acute myocardial Infarction IV fluids O2 Dopamine Norepinephrine Nitroprusside if BP adequate Dobutamine . 5. cool skin Convulsions possible Increased pulse rate Weak pulses Cardiac dysrhythmias Prolonged capillary fill time Cool. 3. ease him or her to the floor to prevent fall. If the patient is standing or sitting when seizure begins.SEIZURES: EMERGENCY CARE OF PATIENT DURING SEIZURE ACTIVITY 1. 2. Move furniture and other objects on which the patient may injure himself or herself during uncontrolled movements. Causes Allergic reaction Signs and Symptoms Respiratory distress Hypotension Edema Rash Pale. Do not put objects (e.g. edema. Allow the patient to rest or sleep without disturbance  What to document after seizure: y Presence of aura y Circumstances in which the seizure activity occurred y Time of the onset of seizure activity y Muscle groups involved (and whether unilateral or bilateral) y Total duration of seizure activity y VS y Behavior after seizure y Injury SHOCK Type Anaphylactic shock Description Dilation of blood vessels.

Divided into ³early warm´ (increased cardiac output) and ³later cold´ (decreased cardiac output). contour. and dry skin Elevated temperature Flushed. Elevate injured extremity and apply ice (do not apply ice directly to skin).. or length) y Local and/or point tenderness that increases in severity until splinting y Localized ecchymosis y Edema y Crepitus (grating sound) on palpation y False movement (unnatural movement at fracture site) y Loss of function related to pain First Aid Management Assess and document: Alignment Warmth Tenderness Sensation Motion Circulatory status distal to injury Intactness of skin Cover open fractures with a sterile dressing. warm. Splint injured extremity. . Never attempt to force bone or tissue back into wound. Antibiotics Possibly vasopressors Neurogenic shock Increase in vascular capacity and subsequent decrease in blood volume: space ratio resulting from profound vasodilation. cool skin Anxiety Hypotension Bradycardia Bounding pulse Pale. Circulatory failure and impaired cell metabolism associated with septicemia. wounds. blood.Type Hypovolemic shock Description Decrease in intravascular volume relative to vascular capacity.) O2 Elevate legs Volume expanders Supine position O2 IV fluids Possibly Vasopressors O2 IV fluids Culture.g. (Progressive swelling may make it impossible to remove rings without cutting). Anesthesia Spinal cord injury Septic shock Endotoxins released most commonly by gram-negative organism FRACTURES Signs and Symptoms y Obvious deformity (in alignment. Remove rings from fingers immediately if upper extremity is involved. warm skin Vasodilation (early) Vasoconstriction (late) Decreased WBC at first Normal urinary output (early) Decreased urinary output(late) treatment Control bleeding IV fluids (Replace type F&E lost if known. urine. sputum. Causes Hemorrhage Vomiting Diarrhea Any excess loss of body fluids Signs and Symptoms Hypotension Decreased pulse pressure Tachycardia Rapid respiratory rate Pale. Results from blood volume deficit of at least 25% and larger interstitial fluid deficit. e.

or heart disease) Major . dermis. feet. will not blanch with pressure ‡ Painless in the center of the burn 3 Degree ( Full Thickness ) rd American Burn Asso. ears. numbness. or white ‡ If red. face. or perineum Second-degree burns >25% BSA for adult or > 20% BSA for child ‡ Third-degree burns • 10% BSA ‡ All burns of hands. burning.Assess for and document frequently the five Ps: Pain Pulselessnes Pallor Paralysis Paresthesia (e.. mottled. Classification of Burns: Minor Moderate Second-degree burns over _15% BSA (body surface area) for adult or < 10% BSA for child ‡ Third-degree burns of 2% Second-degree burns over 15 to 25% BSA for adult or 10 to 20% BSA for child ‡ Third-degree burns of 2% to 5% BSA ‡ Burns not involving eyes. leathery appearance ‡ May be charred. and into subcutaneous tissues ‡ Dry. tingling) TYPES OF FRACTURES BURNS Classification st 1 Degree Burn 2nd Degree Burn Description involves epidermis only Erythematous and painful skin Looks like sunburn Superficial partial thickness Extends beyond epidermis superficially into dermis Red and weepy appearance Very painful Formation of blisters Deep partial thickness Extends deep into dermis May appear mottled Dry and pale appearance Extends through epidermis. face. or perineum ‡ All inhalation injuries ‡ Electric burns ‡ All burns with associated complications of fractures or other trauma ‡ All high-risk patients (with such conditions as diabetes. ears. feet. eyes. hands.g. COPD.

First Aid Management of Burns
1. First, evaluate respiratory system for distress or smoke inhalation (any abnormal respiratory findings in rate, effort, noise, or observations of smoky odor of breath or soot in nose or mouth). 2. Assess cardiovascular status. (Look for symptoms of shock.) 3. Assess percentage and depth of burns, as well as presence of other injuries. 4. Flush chemical contact areas with sterile water; 20 to 30 minutes of flushing may be needed to remove chemical. Fifteen to 20 minutes of normal saline irrigation is preferable for chemical burns to eyes. Contact lens must be removed prior to eye irrigation. 5. Insert IV line(s) for major and some moderate burns. (Establish more than one large-bore IV site if possible.) Attempt to insert IV(s) in unburned area(s). 6. Weigh patient to establish baseline and assist in determination of fluid needs. 7. Fluid resuscitation with Ringer¶s lactate or Hartmann¶s solution for the first 24 hours as follows: 4 mL fluid x kilograms of body weight x percent of burned BSA. Administer 1/2 of fluid in first 8 hours. Administer 1/4 of fluid in second 8 hours. Administer 1/4 of fluid in third 8 hours. NOTE: Time is calculated from time of injury, not time of admission. 8. Administer analgesics as indicated. 9. Remove easily separated clothing. Soak any adherent clothing to facilitate removal. NOTE: Keep patient warm. Removal of clothing may result in rapid and dangerous drop in temperature.

10. Cover burn area with sterile dressing. 11. Put on Hold NPO until function of GI system is evaluated. 12. Insert NG tube for gastric decompression if indicated. 13. Insert Foley catheter (to monitor urine output) for severe and some moderate burns. 14. Assess need for and administer tetanus prophylaxis 15. Frequently monitor vital signs (be aware that patients who have inhaled smoke are subject to progressive swelling of the airway for several hours following injury), ABGs, and serum electrolytes. 16. Monitor urine output and titrate fluids to maintain: 30 to 50 mL urine/h in the adult;0.5 to 2 mL urine/kg of body weight/h in the child Tetanus Prophylaxis Td: Tetanus and diphtheria toxoids adsorbed (for adult use). TIG: Tetanus immune globulin (human). For children younger than 7 years old, diphtheria and tetanus toxoids and pertussis vaccine adsorbed (or diphtheria and tetanus toxoids adsorbed, if pertussis vaccine is contraindicated) is preferable to tetanus toxoid alone. For persons 7 years old and older, Td is preferable to tetanus toxoid alone.

POISONING Management: 1. Focus initially on the ABCs of life support: A - Establish and maintain airway. B - Assess RR, and provide oxygen and respiratory support PRN. C - Assess HR and BP, establish IV access, and keep warm (shock may occur). 2. Attempt to identify poison. 3. Contact poison control center for directions 4. Vomiting is to be induced only if the patient is conscious and nonconvulsive and only if the ingested substance is noncorrosive (corrosives will further damage esophagus if vomited and may also be aspirated into the lungs). Vomiting may be induced by tickling the back of the throat or administering ipecac syrup in the following dosages: Ipecac syrup (PO) Child under 1 year: 5±10 mL followed by 100 to 200 mL water Child 1 year or older: 15 mL followed by 100 to 200 mL water Adult: 15 mL followed by 100 to 200 mL water Dose may be repeated after 20 minutes if patient does not vomit. 5. Gastric lavage with NG tube can be used to remove poison but must not be attempted if corrosive has been ingested (corrosives severely damage tissue and NG tube may cause perforation). Corrosives include strong acids and alkalies such as drain cleaners, detergents, and many household cleaners as well as strong antiseptics such as bichloride of mercury, phenol, Lysol, cresol compounds, tincture of iodine, and arsenic compounds. 6. Corrosives should be diluted with water and the poison control center contacted immediately. Activated charcoal may be given via NG tube. Destructionand/or swelling of esophageal and airway tissue is likely with corrosive ingestion. 7. Monitor respiratory status closely.

8. If several hours have passed since poison ingestion, large quantities of IV fluids are given to promote diuresis. Peritoneal dialysis or hemodialysis may be required. 9. Continue ABCs of life support and monitor fluids, electrolytes, and urine output. Chemical Eye Contamination: Flush eye with sterile water for 15 to 20 minutes, allowing water to drain away from uncontaminated eye. Respiratory acidosis Treat underlying cause IV fluids Bronchodilators Mechanical ventilation O2 Metabolic acidosis Correct underlying cause IV sodium bicarb Seizure precautions Monitor and correct electrolyte imbalances Respiratory alkalosis Treat underlying cause Breathe into paper bag to > PaCO2 Sedatives and calm environment Metabolic alkalosis Correct cause IV normal saline IV potassium, as indicated Seizure precautions Monitor and correct electrolyte imbalances

Due date? Contractions? Frequency? Duration? Ruptured BOW? Bleeding? Number of previous pregnancies (gravida)? Number of births (pararity)? Problems with past deliveries? Problems with pregnancy? Has the baby moved today? OBSERVE Size of abdomen Fundal height Presentation (cephalic or breech) Fetal heart tones (not assessed if birth is imminent) Signs of Imminent Birth y Mother is experiencing tension, anxiety, diaphoresis, and intense contractions. y With a contraction, the mother catches her breath and grunts with involuntary pushing (with inability to respond to questions). y A blood ³show´ is caused by a rapid dilatation of the cervix. y The anus is bulging, evidencing descent. y Bulging or fullness occurs at the perineum. ³Crowning´ of the head at the introitus of a multiparous mother means that the birth is very imminent. In nulliparous birth, it means that the birth may be up to 30 minutes later. (Birth is near when the head stays visible between contractions.) What to do What NOT to do


Inspect the placenta for completeness Do not put your fingers into the birth canal. Do not cut the cord unless you have sterile equipment. Dry the baby off. Do not ³strip´ or ³milk´ the umbilical cord. Do not allow the mother¶s bladder to become distended. 7. Question and examine the patient in privacy. Allow the baby to emerge slowly. 4. Wait for the placenta to separate. Encourage patient to seek shelter if abuse is suspected. 6. Do not allow the baby to become cold. Synchronous contershock Indications: ‡ Ventricular fibrillation ‡ Pulseless ventricular tachycardia NOTE: CPR efforts should be enacted during preparation for defibrillation. ‡ multiple injuries ‡ bilateral distribution of injuries ‡ injuries at different stages of healing ‡ fingernail marks ‡ bruises shaped like a handprint or instrument ‡ rope burns ‡ cigarette burns ‡ bites ‡ spiral fractures ‡ burns Appropriate nursing actions: 1. Defibrillation: To terminate ventricular fibrillation by electric countershock. Do not push on the uterus to try to deliver the placenta. Do not try to pull out the baby¶s arm. 3. Examine entire body. Ask specific questions related to suspected abuse 5. Hold the baby at or slightly above the level of introitus. METHOD Domestic Violence Clues of abuse in patient history: ‡ frequent injuries reported as ³accidental´ ‡ history of repeated miscarriages ‡ vague or changing description of pain or injury ‡ lack of patient cooperation during collection of subjective and/or objective data Common sites of injuries caused by physical abuse: ‡ head and neck (most common) ‡ breasts ‡ chest · abdomen Signs of possible abuse: . Do not hold the baby below the mother¶s perineum. 2. Do not force rotation of the baby¶s head after the head emerges. Put the baby next to the mother¶s skin and allow nursing. Call law enforcement immediately if violence is threatened (do not warn the perpetrator of this action). Assure confidentiality. Be aware that the perpetrator may retaliate if exposed by the patient. 8.Keep calm. Give patient contact information for community resources. Do not put traction on the cord or pull on the cord Do not hold the baby up by the ankles. Clear the airway. Do not overstimulate the baby by slapping.

and then shocks repeated. 3.1. allowing the heart to pump more effectively. remove gel from your hands and the sides of the paddles. and remove any gel that may have fallen on the patient¶s chest. 100 J. 8. (To prevent burns and improper conduction. Energy levels for biphasic models are 50 J. Give ³Stand Clear´ command.) 2. Apply one electrode below right clavicle just to the side of the upper sternum. epinephrine given. Asynchronous or Fixed Rate . 150 J. then 360 J. Synchronized countershock The defibrillator is synchronized to the client¶s R wave Oxygen should be stopped during the procedure Pacemakers Temporary or permanent device that provides electrical stimulation and maintains heart rate when the intrinsic pacemaker fails Types: 1. Set defibrillator at 200 joules (J) 6. Place two gel pads on the patient¶s bare chest or apply gel to entire surface of paddles. using pressure to ensure firm contact with the patient¶s skin. Apply second electrode just below and lateral to left nipple. Temporarily discontinue oxygen (if applicable). 5. Automatic External Defibrillator Used in prehospital setting Cardioversion Treatment for arrhythmias The procedure restores the normal heart rate and rhythm. Push discharge buttons in both paddles simultaneously. 9. Remove paddles and assess patient and ECG pattern. 7.Paces at preset rate regardless of client¶s intrinsic rhythm . Synchronous / demand Pacemaker . CPR should be continued. Successive attempts at defibrillation may deliver 200 to 300 J. Grasp paddles by insulated handles only. if three rapidly administered shocks fail to defibrillate. IV access accomplished.Paces only if the client¶s intrinsic rate falls below the set pacemaker rate 2. AHA recommends that. 4. and ascertain that no one is touching patient or bed. 10.

Only the ³ self ´ can experience . Abbreviated Grief .Pathologic grieving 5.Cannot be verified by others 3. Actual .GRIEF.Loss can be situational or developmental Sources of Loss Aspect of Self ( physiologic function / psychologic .´ Depression silence Acceptance ³I¶m ready´ Response or reaction to loss Bereavement Subjective Response Mourning Behavioral Response Types of Grief Responses: 1. Anticipatory .Suppressed grieving Stages of Grieving Engel Shock and Disbelief (accepts situation but denies emotionally) Awareness Restitution ( do rituals of mourning) Resolving Loss Idealization Outcome Sander Shock Awareness of Loss Conservation/Withdrawal (social withdrawal/ needs time to be alone) Healing: The turning point (acceptance) Renewal (new self ± awareness.Extended / lengthy and severe grieving . Perceived .Genuinely felt grief but brief 2.Can be recognized by others 2. Dysfunctional Grief . Anticipatory Grief . learning to live independently without loved ones) Bargaining ³if only I could live a little longer. Inhibited Grief . DEATH and DYING Loss Actual or potential situation where in something valued is changed / lost / gone That something can be: significant others. LOSS. security etc Types of Loss 1. abortion 4.Grieving in advance Death and Dying Concept of Death .Examples are unacceptable loss that cannot be spoken about like suicide.May deny loss or grieve beyond expected time 6. sense of well being. Unresolved Grief .Experienced before the actual loss . job.Unable to acknowledge the loss to other people . body part) External to oneself Separation from accustomed environment Loss of loved or Valued person Grief KÜbler Ross Denial ³ No! not me´ Anger ³why me?´ 3. Disenfranchised Grief .

Assisting the client to a peaceful death. consistent with the client¶s values.Provides specific instructions about what medical treatments the client choose to refuse in the event that the client is incapable of making decisions Health Car Proxy . flat brain waves and ECG (asystole) . Meeting Physiologic Needs of the dying client y Airway clearance y Hygiene / bathing y Nutrition y Urinary and fecal elimination 6.Notarized / witnessed statement appointing SOMEONE ELSE (relative or friend) to manage health care treatment and decisions when the client is incapable of doing so.When cerebral cortex( this is the brain center) is irreversibly damaged Legal Aspects Related to Death Advance Health Care Directives Variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become incapable of verbalizing their care preference 2 types: Living Will .Infancy to 5 years . Arranging an appointment with a clergy or a spiritual adviser if the client wishes to. Suggesting/introducing options available like location of care (at home or hospital) 4. 5. Maintaining humanity . Use of therapeutic communication for the family to be able to express feelings Hospice Care Current trend in nursing care Common setting : home or in a nursing home Goal: facilitates peaceful and dignified death . Done by helping clients die with dignity 2. Nursing Responsibility in Dying Patients 1. Support client¶s will and hope because dying clients often strive for self fulfillment more than for self preservation. 9. Providing spiritual support 7. death is final 9-12 years old ± death as inevitable and end of life Heart ± lung death Indications of death: . Facilitating expressions of feelings and emotions about death 8. Supporting Family 10. Euthanasia Mercy killing Act of painlessly putting to death persons suffering from incurable / terminal/ distressing disease Autopsy Postmortem examination Done in certain cases where death is sudden to know the cause of death and in some legal cases Do ± Not ± Resuscitate Orders DNR / no Code y Ordered by physician when the client / health care proxy has verbalized the wish for no resuscitation when the client will have respiratory or cardiac arrest y DNR indicates that the goal of treatment is a comfortable dignified death and further life sustaining interventions will not be done to patients any longer.Total lack of response to external stimuli. no muscular movement and reflexes.no concept of death 5 -9 years old ± begins to understand death. beliefs and culture 3.Cerebral death or higher brain death .Durable Power of Attorney for Health Care .

Acknowledge the client¶s feelings and struggles y Be honest with the client especially on questions about death y Have an available time for the client to be able to listen. Identify religious belief of clients 3. follow agency policy to maintain the ordered fluid delivery rate with D10W until the TPN is available. Document intake and output measurements.) y . supplies must be removed 4.) Do not attempt to ³catch up´ on fluids if rate inadvertently slows. A shroud is used to wrap the body 8. and pH changes are possible. Monitor lab values. Post Mortem Care Stages of PMC 1. support and interact with him / her. tubes. 13. and amount of urinary drainage. color. 10. (Liver complications. appearance. Do post mortem care according to hospital policy 2. A complete bath is not necessary ( the mortician will do the bathing 6. All equipment. Identification band should be attached before the body is taken to the morgue 7. (High glucose content of fluid stimulates release of insulin. and patient¶s response to procedure. When a new container of TPN is needed. which may cause hypoglycemia if fluids are discontinued abruptly. A pillow is placed under the head and shoulders to prevent discoloration in the face 5. 12.Eligible for hospice care are those diagnosed / predicted to die within 6 months Rigor Mortis (stiffening of the body. electrolyte imbalances. Must Know for Nurses in caring for dying Clients: y Identify personal feelings about death and how they can affect when caring for dying patients y Focus on client¶s needs y Ask client and family support about the client¶s usual coping with stress y Provide caring and genuine concern 11. starts in the involuntary muscles like the heart etc. but is not available.) ( 2 ± 4 hours after death) Algor Mortis (gradual decrease of temperature) Livor Mortis ( discoloration of the body) Intervention Position the body naturally (in natural / neutral manner) Place dentures (if there is) Close eyes and mouth 9. Discontinue TPN solution gradually at the end of therapy to prevent hypoglycemia.

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