Fundamentals of Nursing

Professor Darius J. Candelario RM,RN, MAN, MSN, US-RN #026-0031609 Vermont & Florida

³Nursing is an art & a science. It is the diagnosis and treatment of human responses to actual and potential health problems. Earlier emphasis was on care of the sick; now promotion of health is being stressed -ANA, Alfaro,R. ³The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, its recovery, or to a peaceful death. The client will perform these activities unaided if he had the necessary strength, will or knowledge. Nurses help the client gain independence as rapidly as possible -Virginia Henderson,ICN

A. NIGHTANGLE¶S THEORY (mid-1800) : Focuses on the patient and his environment. Developed and described the first theory of nursing. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. She believed that in the nurturing environment, the body could repair itself. Client¶s environment is manipulated to include appropriate noise, nutrition, hygiene, socialization and hope.

B. PEPLAU, HILDEGARD (1951) : Introduced the Interpersonal Model Defined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient relationship in which the nurse serves as a resource person, counselor and surrogate. Four Phases of the Nurse-Client Relationship: 1. Orientation: the nurse and the client initially do not know each other¶s goals and testing the role each will assume. The client attempts to identify difficulties and the amount of nursing help that is needed.

2. Identification: the client responds to help

professionals or the significant others who can meet the identified needs. Both the client and the nurse plan together an appropriate program to foster health. 3. Exploitation: the clients utilize all available resources to move toward a goal of maximum health functionality. 4. Resolution: refers to the termination phase of the nurse-client relationship. It occurs when the client¶s needs are met and he/she can move toward a new goal. Peplau further assumed that nurse-client relationship fosters growth in both the client and the nurse.

C. ABDELLAH, FAYE G. : Introduced Patient ± Centered Approaches to Nursing Model D. ORLANDO, IDA : Three elements±client behavior, nurse reaction & nurse actions ± compose the nursing situation E. LEVINE, MYRA : Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing includes: conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity. F. JOHNSON, DOROTHY : Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery.

G. ROGERS, MARTHA : Considers man as a unitary human being co-existing with in the universe, views nursing primarily as a science and is committed to nursing research. H. OREM, DOROTHEA : Developed the Self-Care Deficit Theory. She defined self-care as ³the practice of activities that individuals initiate to perform on their own behalf in maintaining life, health well-being.´ I. IMOGENE KING : Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Postulated the Goal Attainment Theory. Described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die with dignity.

J. BETTY NEUMAN: Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention. K. SIS CALLISTA ROY (Adaptation Theory): Views the client as an adaptive system. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. L. LYDIA HALL: Introduced the model of Nursing: What Is it? It focuses on the notion that centers around three components of CARE, CORE and CURE. Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related to the physician¶s orders. Core and cure are shared with the other health care providers.

M. Virginia Henderson : Introduced The Nature of Nursing Model. She identified fourteen basic needs. She postulated that the unique function of the nurse is to assist the clients, sick or well, in the performance of those activities contributing to health or its recovery, the clients would perform unaided if they had the necessary strength, will or knowledge. N. Madaleine Leininger (1978, 1984): Developed the Trans-cultural Nursing Model. O. Ida Jean Orlando (1961) : Conceptualized the Dynamic Nurse ± Patient Relationship Model. P. Ernestine Weidanbach (1964) : Developed the Clinical Nursing ± A Helping Art Model. Q. Jean Watson (1979-1992): Introduced the theory of Human Becoming

S. Josephine Peterson and Loretta Zderad (1976): Provided the Humanistic Nursing Practice Theory. T. Helen Erickson, Evelyn Tomlin, and Mary Ann Swain (1983) :Developed Modeling and Role Modeling Theory. U. Margaret Newman : Focused on health as expanding consciousness. She believed that human are unitary in whom disease is a manifestation of the pattern of health. She defined consciousness as the information capability of the system, which is influenced by time, space movement and is ever ± expanding.

Moral Theories
Freud (1961) Believed that the mechanism for right and wrong within the individual is the superego, or conscience. He hypnotized that a child internalizes and adopts the moral standards and character or character traits of the model parent through the process of identification. The strength of the superego depends on the intensity of the child¶s feeling of aggression or attachment toward the model parent rather than on the actual standards of the parent. Erikson (1964) Erikson¶s theory on the development of virtues or unifying strengths of the ³good man´ suggests that moral development continuous throughout life. He believed that if the conflicts of each psychosocial developmental stages favorably resolved, then an µegostrength´ or virtue emerges.

Kohlberg Suggested three levels of moral development. He focused on the reason for the making of a decision, not on the morality of the decision itself. At first level called the premolar or the pre-conventional level, children are responsive to cultural rules and labels of good and bad, right and wrong. However, children interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. At the second level, the conventional level, the individual is concerned about maintaining the expectations of the family, groups or nation and sees this as right. At the third level, people make post-conventional, autonomous, or principal level. At this level, people make an effort to define valid values and principles without regard to outside authority or to the expectations of others. These involve respect for other humans and belief that relationships are based on mutual trust.

Spiritual Theories
Fowler (1979) : Described the development of faith. He believed that faith, or the spiritual dimension is a force that gives meaning to a person¶s life. He used the term ³faith´ as a form of knowing a way of being in relation ³to an ultimate environment.´ To Fowler, faith is a relational phenomenon: it is ³an active madeof-being-in-relation to others in which we invest commitment, belief, love, risk and hope.´

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Caregiver Teacher Counselor Coordinator Leader Role Model Administrator Decision-maker Protector Client Advocate Manager Rehabilitator Comforter Communicator

HEALTH ³A state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.A dynamic state in which the individual adapts to changes in internal and external environment to maintain a state of well-being´ World Health Organization (WHO)

INTERNAL VARIABLES 1. Developmental Stage 2. Intellectual Background 3. Perception of functioning 4. Emotional and Spiritual Factors EXTERNAL VARIABLES 1. Family practices 2. Socioeconomic Factors 3. Cultural Background


(NEUMAN) - Degree of client wellness that exist at any point in time--ranging from an optimal wellness condition, with available energy at its maximum--to death, which represents total energy depletion. - Dynamic state that continuously alters as a person adapts to changes in the internal & external environment to maintain a state of physical, emotional, intellectual, social, developmental & spiritual wellbeing.

2. HIGH-LEVEL WELLNESS MODEL (HALBERT DUNN) - The high-level wellness model is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposely direction within the environment. It involves progress toward a higher level of functioning, an open-ended and everexpanding challenge to live at the fullest potential. Last, there is continued integration of health practices by the individual at increasingly, higher levels throughout life.

3. AGENT-HOST-ENVIRONMENT MODEL (LEAVELL) The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment.
a. AGENT ± is any internal or external factor that by its presence or absence can lead to disease or illness. b. HOST ± is the person or persons who may be susceptible to a particular illness or disease. Host factors are physical or psychosocial situations or conditions putting an individual or group at risk for becoming ill.

c. ENVIRONMENT ± consists of all factors outside of the host, physical environment includes economic level, climate, living conditions, and elements such as light and sound levels. Social environment consists of factors involving a person¶s or group¶s interaction with others, including stress conflicts with others, economic hardships and life crises such as the death of a spouse.

4. HEALTH-BELIEF MODEL (HBM) - Addresses the relationships between a person¶s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies. FOUR COMPONENTS: a. The individual¶s perception of susceptibility to an illness.For example, a client¶s needs to recognize the familial link for coronary artery disease. After this link is recognize, particularly when one parent and two siblings have died in their fourth decade from myocardial infarction, the client may perceive the personal risk of heart disease.

b. The individual¶s perception of the seriousness of the illness. - this perception is influenced and modified by demographic and sociophysiological variables, perceived threats of the illness and cues to action (for example, mass media campaigns and advice from family, friends, and medial professionals) c. The perceived threat of a disease. - this perception refers to beliefs a person holds about whether or not a disease poses a real threat to him. Perceived threat is influenced by certain cues to action in relation to health (e.g. mass-media campaigns, advice from others or a reminder a postcard from a dentist or physician).

d. The perceived benefits of taking preventive action. - This perception refers to beliefs a person holds about the effectiveness of preventive action he might take to prevent illness. Perceived barriers to taking preventive action may relate, for example, to whatever the person believes stands in his way. For example, a barrier to seeing a dentist regularly to prevent tooth decay may be a person¶s intense fear that the procedure is very painful. 5. EVOLUTIONARY-BASED MODEL - illness and death serves as an evolutionary function. - Evolutionary viability reflects the extent to which individual¶s function to promote survival and wellbeing.

6. HEALTH PROMOTION MODEL - A ³complimentary counterpart to models of health protection´ - Directed at increasing a client¶s level of well-being. - Explains the reasons for client¶s participation in health-promotion behaviors. The model focuses on three functions: ± It identifies factors (demographic and social) that enhance or decrease the participation in health promotion. ± It organizes cues into a pattern to explain the likelihood of a client¶s participation in healthpromotion behaviors. ± It explains the reasons that individuals engage in health activities.


PRIMARY PREVENTION -Generalized health promotion specific protection against disease. It precedes disease or dysfunction and is applied to generally healthy individuals or groups.

Health Promotion
‡ Health Education ‡ Good standard of nutrition adjusted to developmental phases of life ‡ Provision of adequate housing & recreation ‡ Marriage counseling and sex education ‡ Genetic screening ‡ Periodic selective exams

‡ Health education about accident and poisoning prevention, standards of nutrition and of growth and development for each stage or life, exercises requirements, stress management protection against occupational hazards, and so on ‡ Immunizations ‡ Risk assessment for specific disease ‡ Family planning services and marriage counseling ‡ Environmental sanitation and provision of adequate housing recreation, and work conditions

Specific Protection
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Use of specific immunizations Attention to personal hygiene Use of environmental sanitation Protection against occupational hazards Protection from accidents Use of specific nutrients Protection from carcinogens Avoidance of allergens

Emphasizes early detection disease, prompt intervention, and health maintenance for individuals experiencing health problems. Includes prevention of complications and disabilities.

Early Diagnosis and Prompt Treatment 
Case ² finding measures; individual and mass; selective examinations  Cure and prevention of disease process to prevent spread of communicable disease, prevent complications and shorten period of disability  Screening surveys and procedures any type (e.g., Denver Developmental Screening Test, hypertension screening)  Encouraging regular medical and dental checkup  Teaching self-examination for breast and testicular cancer  Assessing the growth and development of children  Nursing assessments and care provided in home, hospital, or other agency to prevent complications.

Disability Limitations 
Adequate treatment to arrest disease process and prevent further complications Provision of facilities to limit disability and prevent death

Restoration and Rehabilitation - Begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Its focus is to help rehabilitate individuals & restore them to an optimum level of functioning within the constraints of the disability 

Provision of hospital and community facilities for retraining and education to maximize use of remaining capacities  Education of the public and industries to use rehabilitated persons to the fullest possible extent  Selective placement  Work therapy in hospitals  Use of sheltered colony  Referring a client who has had a colostomy to a support group  Teaching a client who has diabetes to identify and prevent complications  Referring a client with a spinal cord injury to a rehabilitation center to receive training that will maximize use for remaining abilities

Difference between Health Promotion and Health Protection
Health Promotion  Not disease oriented  Motivated by personal, positive ³approach´ to wellness  Seeks to expand positive potential for health Health Protection  Illness or injury specific  Motivated by ³ avoidance´ of illness  Seeks to thwart the occurrence of insults to health and well-being

Factors Affecting the Nursing Shortage 
Aging Nurse Workforce ± Number of Nurses under 30 decreasing ± Number of nurses age 40-49 increasing with 40% older than 50 by 2010 ± New graduates entering workforce at an older age and will have fewer years to work  Aging of Nurses Faculty As nursing faculty retire, nursing programs may have fewer faculty to educate future nurses  Aging Population - Individuals 65 and older to double between 2000 and 2030 - Increasing health care needs of aging population 

Increased Demand for Nurses - Increased acuity of hospital clients requiring skilled and specialized nurses. - Shorter hospital stays resulting in transfer of clients to long term care and community settings, creating increased demand for nurses in the community  Workplace Issue - Inadequate staffing - Heavy workloads - Increased use of overtime - Lack of sufficient support staff - Inadequate recruiting and retaining nurses

- ³Stress refers to tension resulting from changes in the internal and external environment either: physiologic, psychologic or social factors.´ - ³Stress is the nonspecific response of the body to any demand made upon it´ Modern Stress Theory, Selye,H. *Stress is always a part of the fabric of life *Stress is not always something to be avoided *Stress does not always lead to distress *Stress may lead to another stress *A stress, whenever prolonged or intense may lead to exhaustion *Man, whenever he encounter stress, he tends to adapt to it

- The adjustments that a person makes in different situations; individuals¶ reaction to and attempt to deal with stress Types of Adaptation A. General Adaptation Syndrome (GAS) - Man, whenever he responds to stress, the entire body is involved - There are many similar manifestations that characterize different disease conditions; and there are very few specific manifestations that characterize a particular disease. Fever, weakness fatigue, headache, anorexia, pain are examples of manifestations that characterize various disease conditions.

Stages of GAS
1. Stage of Alarm (SA) ± The person becomes aware of the presence of threat or danger. ± Levels of resistance are decreased. ± Adaptive mechanisms are mobilized (fight-or-flight reaction). ± If the stress is intense enough, even at the stage of alarm, death may ensure. Example: profuse bleeding in amputated limb due to vehicular accident.

2. Stage of Resistance (SR) - Characterized by adaptation & parasympathetic nervous system activity. - Levels of resistance are increased & hormonal levels return to normal. - The person moves back to homeostasis & stabilization. 3. Stage of Exhaustion - Results from prolonged exposure to stress and adaptive mechanisms can no longer persist. - Unless other adaptive mechanism will be mobilized, death may ensue.

Local Adaptation Syndrome (LAS)
- Man may respond to stress through a particular body part or body organ (e.g. inflammation, backache, headache, diarrhea). Modes of Adaptation Physiologic/Biologic Adaptive Mode - e.g. enlargement of arm and chest muscles among men whose jobs include heavy lifting; people who live in countries with very hot/warm climate develop dark skin. This is due to overproduction of melanin to protect inner layers of the skin.

Psychologic Adaptive Mode - e.g. use of ego defense mechanism like denial, rationalization. Sociocultural Adaptive Mode - e.g. talking, acting, dressing like to people in a particular place Technologic Adaptive Mode -e.g. nurses learn how to use electronic devices and computers.

- ³A state of dynamic equilibrium; stability; balance; constancy; uniformity. It is now more commonly referred to as ³homeodynamics,´ because it is characterized by constant change.´ ‡ It is regulated by negative feedback mechanism.

Concepts of Homeostasis (³homeodynamics´) (Systemic Physiologic Response to Stress) A. Symatho-Adreno-Medullary Responses (Walter Cannon) (SAMR or Fight-or Flight Response)

Stressors: a. Physical injury b. Elevated body temp. c. Dehydration

SNS (norepinephrine)

Adrenal Medulla (Epinephrine & norepinephrine)


Brain: o alertness; restlessness Eyes: dilated pupils; o visual perception Mouth: q salivary secretion, thirst & dryness Heart: tachycardia; coronary vasodilation; o force of cardiac contractility; o cardiac output Lungs: hyperventilation, bronchodilation Blood vessels: peripheral vasoconstriction; oBP Skin: pallor; diaphoresis; cold, clammy skin Liver: o glycogenolysis, & gluconeogenesis; o blood glucose level Muscles: o glycogenolysis; o muscle tension G.I. Tract:qgastric motility;qHCl secretion; peristalsis; constipation; flatulence Spleen: contraction; q hemolysis Pancreas: q secretion. of insulin and pancreatic enzymes Urinary Bladder: relaxation of the detrusor muscles

B. Adreno ² Cortical Response
Stressor: Hypoglycemia (Blood glucose level = 60 mg/dl. And below) Hypothalamus Anterior Pituitary ACTH Adrenal Cortex
Glucocorticoid: Increases gluconeogenesis; Increases blood glucose levels Mineralocorticoid: Retention of sodium and water; Increase ECF volume Increase BP. Androgen/Estrogen: (sex hormones)

C. Neurohypophyseal Response
Stressors: Blood loss (hemorrhage, excess loss of body

Hypothalamus Posterior Pituitary ADH (antidiuretic) Kidneys (renal) tubules Retention of water in the renal Oliguria Conservation of Circulating Volume Prevention of Hypovolemic Shock

Local Physiologic Responses to Stress
Inflammation involves mobilization of specific and nonspecific defense mechanism in response to tissue injury or infection.


Prevention of Hypovolemic Shock Mechanical Chemical Microbial Electrical

1. Vascular Response -Transitory vasoconstriction followed immediately by vasodilation (due to the release of histamine, bradykinin, prostaglandin E) Increased Capillary Permeability Hyperemia: Redness (rubor) Heat (calor) Fluid / Cellular

Cont µd

Edema Pain (dolor) Compression of nerve endings by edema fluids Injury to nerve endings Release of bradykinin

Exudates Serous Serosanguinous Sanguinous Purulent Mucoid/catarrhal

Impaired function

Purposes of Inflammation
1. To localize tissue injury 2. To protect tissue from injury 3. To prepare tissue for repair Cellular Response ‡ Neutrophils. First to be launched at the site of tissue injury. ‡ Monocytes. Perform phagocytosis in chronic tissue injury. ‡ Lymphocytes. Responsible for immune response.

Processes Involved: ‡ Marginal/pavementation. Phagocytes line up at the peripheral walls of the blood vessels. ‡ Emigration/diapedesis. Phagocytes line up at the peripheral walls of the blood vessels. ‡ Chemotaxis. Injured tissues release substances, which exert magnet like force to the phagocytes to bring them to the area of injury. ‡ Phagocytosis. Phagocytes ingest or engulf the antigens. Healing Process (Reparative Phase) ± Regeneration. Involves replacement of damaged tissue cells by new cells which are identical in structure or function.

± Scar Formation. Involves replacement of damaged tissue cells by fibrous tissue formation. In the early stage, granulation tissue (pink or red, fragile gelatinous tissue) forms; later in the process, a cicatrix or scar forms because the tissue shrinks and the collagen fibers contract. Healing May also be classified as follows: First Intention: Occurs in clean-cut wound (e.g. surgical wound). The wound edges are approximated, there is minimal or no scar tissue formation (also primary intention healing or primary union)

Second Intention: Occurs when the wound is extensive and there is a great amount of tissue loss (e.g. decubitus ulcer). The repair time is longer; the scarring is greater (also, secondary intention healing). Third Intention: Occurs when there is delayed surgical closure of infected wound (also, tertiary intention healing)

A. Fever

The Systemic Manifestations of Inflammation:

endogenous pyrogens (prostaglandins, leukotrienes, bacterial endotoxins, interleukin 1) Hypothalamus Resetting of the body temperature set-point at a higher level Increasing heat production/decreasing heat loss (shivering; sweating is inhibited; vasoconstriction) Increased production of interferon (protects the cell from viral invasion) Increased phagocytic activity

b. Leukocytosis (elevated WBC) c. Elevated ESR (erythrocyte sedimentation rate) d. Lymphadenopathy e. Anorexia f. Headache g. Body Weakness/Fatigue h. Body Malaise

a. Eat a well balanced diet b. Get sufficient amount of rest c. Exercise regularly d. Use relaxation methods & techniques 1. Deep breathing 2. Guided imagery 3. Progressive relaxation: various muscles groups in the body are progressively & systematically tensed & relaxed, from head to toe

Suggested Steps: 1.Focus attention on a particular muscle group 2. Tense the muscle group upon which attention is focused 3. Maintain muscle tension for 5-7 secs. 4. Slowly relax the muscle group while continuing the focus 5. Repeat these steps for each muscle group in the body, from head to toe

4. Meditation: contemplative reflection & thought, & communication w/ self 5. Yoga: system of meditation & mental to attain a balance in the continuum of mend & body 6. Biofeedback: providing information to a subject about current status of some body function; goal-gain & maintain control in real-life circumstances E. Engage in social support system

Nursing Responsibilities in Stress Management
I. To assist client & his family to adapt to stress & manage it wisely II. Recommended four guideposts when the nurse helps the client to manage stress A. Eliminate as many stressors as possible B. Teach about both the beneficial and detrimental effects of stress C. Teach how to cope & adjust with stress

-³A deliberate, problem-solving approach to meeting the health care & nursing needs of patients´ -Sandra Nettina - The most efficient way to accomplish personalized care in a time of exploding knowledge and rapid social change. It assists in solving or alleviating both simple and complex nursing problems. Changing, expanding, more responsible role demands knowledgeably planned, purposeful, and accountable action by nurses

Reasons for documentation of nursing care:
1. Provide evidence of comprehensive and systematic nursing care 2. Satisfy requirements of regulatory agencies 3. Provide a legal document that reflects the care given to and the progress of the patient 4. Provide a data base for continuous quality improvement programs

Steps in the Nursing Process (ADPIE)
1. Assessment : Collection of personal, social, medical, and general data a. Sources: Primary (client and diagnostic test results) and secondary (family, colleagues, Kardex, literature) b. Methods b.1 Interviewing formally (nursing health history) and informally during various nurse-client interactions b.2 Observation b.3 Review of records b.4 Performing a physical assessment

Types of Assessment
1. Initial Assessment - Performed within specified time after admission to health care agency - To establish a complete database for problem identification, reference, and future comparison - example: Nursing admission assessment

2. Problem-focused assessment - Ongoing process integrated with care - To determine the status of a specific problem identified in an earlier assessment - To identify new or overlooked problems - example: Hourly assessment of client¶s fluid intake and urinary in an ICU. Assessment of client¶s ability to perform selfcare while assisting a client to bathe

3. Emergency assessment - During a physiologic or psychologic crises of the client - To identify life-threatening problems - example: Rapid assessment of a person airway, breathing status, and circulation during a cardiac arrest Assessment of suicidal for violence

4. Time-lapsed reassessment - Several month after initial assessment - To compare the client¶s current status to baselines data previously obtained - example: Reassessment of a client¶s functionally health patterns in a home care or outpatient setting or, in a hospital, at shift change

Example of subjective data:
³I feel weak all over when I exert myself.´ Client states he has a cramping pain in his abdomen. States ³I feel sick to my stomach.´ ³I¶m short or breath.´ Wife states: ³He doesn¶t seem so sad today´ ³I would like to see the chaplain before surgery.´

Examples of objective data: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Blood pressure 90/50 Apical pulse 104 Skin pale and diaphoretic Vomited 100 mL green-tinged fluid Abdomen firm and slightly distended Active bowel sounds auscultated in all four quadrants Lung sounds clear bilaterally; diminished in right lobe Client cried during interview Holding open Bible Has small silver cross on bedside table.

2. Nursing Diagnosis : Definition of client's problem: making a nursing diagnosis ³A nursing diagnosis is a definitive statement of the client's actual or potential difficulties, concerns, or deficits that are amenable to nursing interventions .This step is to organize, analyze and summarize the collected data. There are two components to the statement of a nursing diagnosis joined together by the phrase "related to"´ Part I: a determination of the problem (unhealthful response of client) Part II: identification of the etiology (contributing factors)

3. Planning: the nursing care plan, a blueprint for action remembering client is the center of the health team; client, family, and nurse collaborate with appropriate health team members to formulate the plan

Guidelines: a. Planned intervention may include independent, interdependent,and dependent functions of the nurse; prescriptions made by physician or allied health professionals may be included b. New diagnoses should be noted on the nursing care plan and progress notes as they are identified c. Client outcomes (goals of nursing intervention) are reflected in expected changes in the client c.1 Expected client outcome is written next to each nursing diagnosis on nursing care plan c.2 These outcomes must be objective, realistic, measurable alterations in the client's behavior, activity, or physical state; a time period should be set for achievement of the outcome

c.3 The outcome provides a standard of measure that can be used to determine if the goal toward which the client and nurse are working has been achieved d. Nursing interventions (nursing orders) are written for each nursing diagnosis and should be specific to the stated outcome or goal; each goal may have one or more applicable interventions 4. Implementation: the actual administration of the planned nursing care

5. Evaluation: Outcome and revision of nursing care plan a. Process is ongoing throughout client's treatment/hospitalization b. If outcome/goal is not reached in specified time, the client is reassessed to discover the reason c. Reordering of priorities and new goal setting may be necessary d. When diagnosis/problem is resolved, the date should be noted on care plan

Examples of Critical Thinking in the Nursing Process
Nursing Process Phase Assessing Critical Thinking Activities Making reliable observations Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating & Organizing data Categorizing data according to a framework Recognizing assumptions

Diagnosing Findings patterns and relationships among cues Identifying gaps in the data & Making Inferences Suspending judgment when lacking data Making interdisciplinary connections Stating the problems Examining assumptions Comparing patterns with norms Identifying factors contributing to the problem


Forming valid generalizations Transferring knowledge from one situation to another Developing evaluative criteria Hypothesizing & Making interdisciplinary connections Prioritizing client problems Generalizing principles from other sciences



Applying knowledge to perform interventions Testing hypothesis Deciding whether hypotheses are correct Making criterion-based evaluation

Advantages of nursing process
1. Encourages thorough individual client assessment by nurse 2. Determines priority of care 3. Provides comprehensive and systematic nursing care planning and delivery 4. Permits independent, creative, and flexible nursing intervention 5. Facilitates team cooperation by promoting: a. Contributions from all team members b. Communication among team members c. Coordination & Continuity of care

6. Provides for continuous involvement and input from client 7. Facilitates the "costing-out" of nursing services and care 8. Facilitates nursing research 9. Provides accurate legal document of client care

³Refers to reciprocal exchange of information, ideas, beliefs, feelings and attitudes between 2 persons or among a group. The need to communicate is universal. People communicate to satisfy needs. Clear and accurate communication among members of the health team, including the client, is vital to support the client's welfare´ -Dolores Saxton

Signs of Lack of Communication
a. Efforts to change the subject-the client may not understand what the nurse is saying b. Lack of questions c. Non-Verbal Clues : Blank expression, lack of eye contact, etc.

A. Be aware that effective communication requires skill in both sending and receiving messages 1. Verbal: for example, words and tone of voice 2. Written 3. Nonverbal: for example, facial expression, eye contact, and body language

B. Recognize the high stress-anxiety potential of most health settings created in part by: 1. Health problem itself, treatments and procedures 2. Exclusive behavior of personnel 3. Foreign environment 4. Change in lifestyle, body image, and self concept 5. Inability to use normal coping skills such as exercise or talking with friends

C. Recognize the intrinsic worth of each person 1. Listen, consider wishes when possible, and explain when necessary 2. Avoid stereotyping, snap judgments, and unjustified comparisons 3. Be nonjudgmental and non-punitive in response and behavior D. Be aware that each individual must be treated as a whole person E. Recognize that all behavior has meaning and usually results from the attempt to cope with stress 1. Be aware of importance of value systems & significance of cultural differences 2. Be sensitive to personal meaning of experiences to clients

3. Recognize that giving information may not alter the client's behavior 4. Recognize the defense mechanisms that the individual is using 5. Recognize own anxiety and cope with it F. Maintain an accepting, open environment 1. Accept the client but set limits on inappropriate behavior 2. Identify and face problems honestly 3. Value the expression of feelings & be nonjudgmental

G. Recognize the client as a unique person 1. Use names rather than labels such as room numbers or diagnoses & maintain the client's dignity 2. Be courteous toward the client, family, and visitors 3. Permit personal possessions where practical (e.g., own nightclothes, pictures, and toys) 4. Explain at the client's level of understanding and tolerance & encourage expression of feelings

H. Support a social environment that focuses on client needs 1. Use problem-solving techniques that focus on the client 2. Be flexible in carrying out routines and policies

Special Considerations in Communication
Clients with Hearing Loss Signs of hearing Loss a. speech deterioration b. indifference c. social withdrawal d. suspicion e. tendency to dominate conversation

Nursing Interventions:
a. Face client directly, make sure your face is clearly visible b. Before discussion, tell the client the topic you are going to discuss c. Ensure that the client has access to hearing aid and that it is functional d. Speak slowly and distinctly; do not shout ; keep sentences short and simple e. Use written information to enhance spoken word ; resort to writing if unable to understand f. Pay attention when the person speaks;facial & physical gestures helps understand what the person is saying

Clients with Aphasia Aphasia Syndromes a. Wernicke¶s Aphasia : patient speaks readily but speech lacks clear content, information and direction b. Anomic or Amnesic Aphasia : speech is almost normal but marred by word-finding difficulty c. Conduction Aphasia : comprehension of language is good but has difficulty repeating spoken material d. Non-fluent Aphasia : speech is sparse and produced slowly and with effort and poor articulation e. Global Aphasia: severe disruption of all aspects of communication (verbal, written, reading, understanding)

Nursing Interventions:
a. Face client & establish eye contact b. Use gestures, pictures and communication boards c. Limit conversations to practical matters d. Keep background noise to a minimum; keep environment simple and relaxed e. Do not shout or speak loudly; speak at normal rate and volume (patient not hearing impaired!) f. Give client time to understand and respond; allow plenty of time to answer g. If clients has problems speaking, ask ³yes´ or ³no´ questions

Client with Stroke ³Refers to onset and persistence of neurologic dysfunction lasting for longer than 24 hours and resulting from disruption of blood supply to the brain´ Nursing Interventions a. Approach the client from the side of intact vision b. Remind the client to turn head in the direction of visual loss to compensate for loss of visual field c. Explain location of object when placing it near the client d. Always put client care items in same places

e. Put objects within client¶s reach and on unaffected side f. Encourage client to repeat sounds of the alphabet g. Speak slowly and clearly h. Use simple sentences with questions or pictures i. Reorient client to time, place and situation j. Provide familiar objects & minimize distractions k. Repeat & reinforce instructions

Clients with Dementia ³Dementia is a disturbance involving multiple cognitive deficits including memory impairment.Primary dementias are degenerative disorders that are progressive, irreversible and not due to any other conditions.´ Nursing Interventions a. Be calm & unhurried; identify yourself & address the person by name each meeting b. Keep conversations short & focused ; use simple words and phrases c. Do not ask the client to make decisions d. Be consistent e. Avoid distractions f. Use reality oriented techniques

A. Promotion of normal elimination 1. Urination a. Adequate fluid intake b. Normal adult urinary output=80ml/hr 2. Bowel elimination a. Adequate fluid intake b. Regular exercise c. Regular fruit juices, raw fruits & vegetables as needed d. Normal bowel evacuation: varies in healthy individuals; no more than 3 mov¶ts. /day-3X/wk.


B. Urinary Incontinence: Involuntary release of urine Diagnosis of urinary incontinence a. History & physical examination b. Urinalysis-tells whether blood or infection present c. Cystoscopy- tells whether abnormalities are present d. Post-void residual-measures amount of urine remaining in bladder after voiding e. Stress test-determines if urine leaks after bladder is stressed due to coughing, lifting, etc.

Treatment a. Drug therapy
± Antispasmodic & anticholinergic-relax &increase capacity of bladder ± Alpha-adrenergic agonists-increase urethral resistance

b. Kegel exercises-strengthen weak muscles around the bladder, *also very effective in preventing Perineal lacerations. c. Behavioral training-client learns different way to control urge to urinate d. Bladder retraining e. Surgery-repair of weakened or damaged pelvic muscles or urethra

Nursing Interventions a. Provide skin care, protective undergarments b. Establish toileting schedule-provide easy access to bathroom & privacy c. Teach client Kegel exercises: 

Stop & start urinary stream while voiding Hold contraction for 10 secs. & relax fro 10 secs. Work up to 25 repetitions 3X a day Cleanse urethral meatus after each void Acidify urine Increase daily intake of fluids

d. Prevent infection
± ± ±

C. Catheterization
Purposes  Relieve acute urinary retention  Relieve chronic urinary retention  Drain urine preoperatively & postoperatively  Determine amount of post-void residual  Accurately measure output in the critically ill  Obtain sterile urine specimen  Continuous or intermittent bladder irrigation

Types of Catheter & General Guidelines a. Indwelling Catheter  Use a closed drainage system  Advance catheter almost to bifurcation of catheter, esp. in male patients  Inflate balloon w/in guidelines of manufacturer only after urine is draining properly, then slightly w/draw catheter  Secure catheter to patient¶s thigh, allowing for some slack to accommodate movement & to lessen drag on patient  Ensure tubing is over patient¶s leg Care of indwelling catheter  Cleanse around area where catheter enters urethral meatus  Do this w/ soap & water during the daily bathing routine & after defecation 


Don¶t pull on catheter while cleansing Don¶t use powder or spray around perineal area Don¶t open the drainage system Avoid raising the drainage bag above the level of the bladder  Avoid clamping the drainage tubing  Catheter is only irrigated when an obstruction, usu. Following prostate or bladder surgery (e.g., potential blood clots) is anticipated b. Suprapubic Catheter ± Placed to drain the bladder ± Achieved via a percutaneous catheter or by way of an incision through the abdominal wall

c. Intermittent Self-catheterization  Purpose: to drain the bladder  Employed by the client w/ Spina Bifida & other neuromuscular diseases; can be taught to children 7-8 yrs. Procedure: ± Gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container ± Wash hands ± Cleanse urethral meatus & surrounding area ± Lubricate tip of catheter ± Insert catheter until urine flows ± W/draw catheter when urine flow stops ± Clean off residual lubricant from meatus ± Dispose of urine ± Wash hands

D. Ostomies
Types of ostomies a. Ileostomy ‡ Liquid to semi-formed stool, dependent upon amount of bowel removed ‡ May skew fluid & electrolyte balance, especially potassium & sodium ‡ Digestive enzymes in stool irritate skinDo NOT give laxatives ‡ Ileostomy lavage may be done if needed to clear food blockage ‡ May not require appliance set; if continent ileal reservoir or Koch pouch

b.Colostomy  Ascending-must wear appliance--semi-liquid stool  Transverse-wear appliance--semi-formed stool  Loop stoma o Proximal end-functioning stoma o Distal end-drains mucous o Plastic rod used to keep loop out o Usually temporary  Double barrel ‡ Two stomas ‡ Similar to loop but bowel is surgically severed 

Sigmoid ‡ Formed stool ‡ Bowel can be regulated so appliance not needed ‡ May be irrigated Stoma assessment a. Color-should be same color as mucous membranes (normal stoma color- Red not dusky or pale: sign of infection) b. Edema-common after surgery. Bleeding-slight bleeding common after surgery

Prevent complications of mobility 1. Skin change-decubitus ulcer a. Turn client q 2 hrs. b. Use heel/elbow protectors c. Use alternate pressure mattress or sheepskin 2. Musculoskeletal changes a. Start ROM exercises to affected joints b. Provide foot board &/or foot cradle (best for gout) c. Position & turn q 2 hrs. 3. Respiratory changes-pneumonia, atelectasis a. Instruct client to cough & deep breathe q 2 hrs. b. Turn q 2 hrs. c. Suction if needed (tracheostomy suctioning ADULTmaximum 15 seconds; therapeutic 10 seconds, INFANTS ± 5 to 10 secs.) d. Chest physiotherapy as needed

4. Cardiovascular system changes a. Orthostatic / Postural hypotension(sign & symptomsdizziness, headache & pallor): Instruct client to change position slowly; especially prone to supine or standing. This is commonly seen as a SIDE EFFECT of Vasodilators , Anti-hypertensives & Anti-cholinergics. b. Increased cardiac workload: discourage Valsalva maneuver c. Thrombus/embolus formation  Apply anti-embolic stockings  Turn q 2 hrs.  Start anti-coagulation therapy if indicated  Initiate exercise 5. Urinary changes: renal calculi, UTI a. Increase fluid intake (2000-3000 cc/day) 6. Psychosocial changes: Provide stimuli to maintain orientation

B. Types of exercise 1. Passive-carried out by the nurse w/out assistance from client; purpose is to retain joint mobility &circulation 2. Resistive-carried by the client working against resistance; purpose is to increase muscular strength 3. Isometric-carried out by the client w/ no assistance; purpose is to increase muscular strength 4. Range of Motion (ROM)-joint is moved through entire range; purpose is to maintain joint mobility 5. Active-performed by the patient; purpose is to maintain mobility, muscle strength & muscle size

C. Use of mechanical aids to promote mobility 1. Crutches a. Support feet and legs during walking b. Adjust hand bars to allow 15-20 degrees of elbow flexion c. Use well-fitting shoes with non-slip soles d. Use rubber suction tips on crutches e. May be used temporarily or permanently f. Teach client crutch walking

2. Cane a. Provides stability when walking and relieves pressure on weight-bearing joints b. Adjust cane w/ handle @ level of greater trochanter: elbow flexed at 30-degree angle c. Teach client to hold cane close to body, & hold in hand on stronger side d. Move cane @ same time as the weaker leg 3. Walker a. to assist in weight-bearing mobility b. Teach client how to sit & turn D. Prosthetic devices-used to replace a missing body part E. Brace-support for weakened muscles

³A feeling of distress, suffering or agony caused by stimulation of specialized nerve endings´ -Patricia Novac Theories of Pain a. Specificity theory proposes that pain can be initiated only by painful stimuli. b. Pattern theory-stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and muscles to respond c. Gate Control Theory-pain impulses can be altered or regulated by gating mechanisms along nerve pathways. This theory explains how past and present experiences can influence the perception of pain.

Pain Assessment
Influencing factors
± Past experience with pain ± Age (tolerance generally increases with age) ± Culture and religious beliefs ± Level of anxiety ± Physical state (fatigue or chronic illness may decrease tolerance)

Characteristics of pain
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Location Quality Intensity Timing and duration Precipitating factors Aggravating factors Alleviating factors Interference with Activities of Daily Living Patterns of response

Types of Pain 1. Acute: Self-Limited, has a beginning and an end lasting up to 6 mos. 2. Chronic: Persistent or episodic pain lasting >6 mos. Medical Treatment ± Pharmacologic ± Nonpharmacologic Intervention a. Acupuncture ‡ Oriental method: insert fine needles at specified body sites ‡ How acupuncture works physiologically: Unknown

b. Relaxation Techniques-biofeedback, visualization, meditation, hypnosis-to help client control anxiety c. Electronic Stimulation such as Transcutaneous Electric Nerve Stimulation (TENS)-electrodes applied over the painful area or along nerve pathway d. Distraction-focusing client¶s attention on something other than pain e. Massage-generalized cutaneous stimulation of the body; makes the client more comfortable due to muscle relaxation f. Ice and Heat Therapies-effective in some circumstances; ice may decrease the prostaglandins which intensify the sensitivity of pain receptors g. Guided Imagery-using one¶s imagination in a guided manner to achieve a specific positive effect

PatientPatient-Controlled Analgesia (PCA)
Type of intravenous pump that allows the client to administer his own narcotic analgesic (e.g., morphine) on demand within preset dose and frequency limits. Goal: To achieve more constant level of analgesia as compared to PRN IM injection. In general, causes less sedation and lower risk of pulmonary depression. Used most often for postoperative pain management; also used for intractable pain in terminal illness. PCA pump may be used solely on PCA mode or may be combined with a continuous basal mode where client is receiving continuous infusion of narcotic in addition to self-administered bolus injections.

Nursing Interventions
1. Instruct client in use of PCA pump a. Demonstrate how to push control button. b. Explain concept of patientcontrolled analgesia. 2. Frequently assess client¶s level of consciousness (LOC), RR, and degree of pain relief.

Electrical Stimulation Technique for Pain Control Transcutaneous Electrical Nerve Stimulator (TENS)
Noninvasive alternative to traditional methods of pain relief Used in treating acute pain (e.g., post-op pain) and chronic pain (e.g., chronic low back pain chronic) 1. Consists of impulse generator connected by wires to electrodes on skin ; produces tingling, buzzing sensation in the area

2. Mechanism based on gate-control theory: electrical impulse stimulates large diameter nerve fibers to ³close the gate´ a. Don¶t place electrodes over incision site, broken skin, carotid sinus, eyes, laryngeal or pharyngeal muscles. b. Don¶t use in client with cardiac pacemaker. c. Provide skin care.  remove electrodes once a day; wash area with soap & water, & air dry  wipe area with skin prep pad before reapplying electrode  assess area for signs of redness; reposition electrodes if redness persists for more than 30 mins.

Nursing Assessment & Interventions for Pain
1. Evaluate objectively the nature of the patient¶s pain: location, duration, quality, & impact on daily activities. 2. Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain). Take careful history of prior & present medications, response, & side effects. 3. Assess relief from medications & duration of relief. (Use the same measuring scale every time). 4. Base the initial analgesic choice on the patient¶s report of pain. 5. Administer drugs orally whenever possible; avoid intramuscular injection. 6. Administer analgesia ³around the clock´ rather than PRN.

7. Convey the impression that the patient¶s pain is understood & that the pain can be controlled. 8. Take a careful pain history. Explore pain interventions that have been used & their effectiveness. Determine if the intensity of the pain correlates w/ the prescribed analgesic. 9. Reevaluate the pain frequently. The requirement for analgesia should decrease if other treatment is given, including radiation/chemotherapy. 10. Use alternative measures to relieve pain such as imaging, relaxation, & biofeedback. 11. Provide ongoing support & open communication. 12. Consider referral to a pain specialist for intractable pain.

13. Provide education. A. Method of administration of medications & importance of maintaining prescribed schedule B.Need to call health professionals if pain has increased or occurred in another area of the body C. Side effects of medication ± Constipation-best treated prophylactically ± Nausea-antiemetic therapy helpful ± Tolerance-increasing doses often required achieving the same effect. This is a normal physiologic response to opioids. Patient reports shorter duration of effect. There is no maximum opioid dose as long as side effects are tolerable. ± Addiction usually isn¶t a problem to needed narcotics.

- A state of consciousness in w/c the individual¶s perception & reaction to the environment are decreased A. Physiology 1. Reticular Activating System (RAS)-maintains a state of wakefulness & mediates some stages of sleep. Sleep is an active process involving the RAS & a dynamic interaction of neurotransmitters. 2. Serotonin is a major neurotransmitter associated w/ sleep. It is derived from its precursor Tryptophan, a naturally occurring amino acid. It decreases activity of RAS, thereby inducing & sustaining sleep. Other neurotransmitters-acetylcholine & norepinephrine appear to be required for the REM sleep cycle.

B. Theories

1. Active Theory of Sleep: proposes that there are centers that cause sleep by inhibiting other brain centers. 2. Passive Theory of Sleep: states that the RAS simply fatigues & therefore becomes inactive thus, sleep occurs. C. Stages 1. NREM (Non-Rapid Eye Mov¶t.) Stage A. Very light sleep; drowsy, relaxed; readily awakened-Stage (St.) 1 B. Light sleep; eyes are still; HR & RR decrease slightly; body temperature falls-St. 2 C.Domination of PNS; body process slows further; difficult to arouse-St. 3 D. Deep sleep; difficult to arouse; q V/S; q metabolism, brain waves, muscles relaxed-St. 4

2. REM (Rapid Eye Mov¶t.) Stages a. Eyes appear to roll b. ³Paradoxical Sleep´ c. Close to wakefulness but difficult to arouse d. Dream state of sleep e. Sympathetic Nervous System dominates f. Flow of gastric acid increases g. Restores a person mentally-learning, psychological adaptation & memory h. The sleeper reviews the day¶s events & processes & restores information D. Functions 1. NREM-body restoration 2. REM-increases synthetic processes in the brain

E. Sleep-promoting Nursing Interventions 1. Warm bath- relaxes muscles, which induces sleep. 2. Drink Milk ± rich in tryptophan, which induces sleep. 3. Attend to individual¶s bedtime rituals that promote sleep 4. Emphasize adequate exercise. *Exercise at least 2 hrs. Before sleep to enhance NREM, not immediately before sleep. 5. Give or advise high protein food; they contain tryptophan, w/c is a CNS depressant. 6. Assess habits of sleep rhythm & wake-up time. 7. Avoid caffeine & alcohol in the evening. 8. Make sure client goes to bed when sleepy. 9. Use the bed mainly for sleep. 10. Be judicious in using minor tranquilizers.

F. Common Sleep Disorders 1. Insomnia: *difficulty in falling asleep *intermittent sleep *premature awakening 2. Hypersomnia: *excessive sleep (daytime or night time) *r/t psychologic problems, CNS damage, metabolic disorders 3. Narcolepsy/Sleep Attack: *overwhelming sleepiness *REM uncontrolled 4. Sleep Apnea: periodic cessation of breathing during asleep; characterized by snoring 5. Parasomnias a. Somnambolism/Sleep Walking b. Night Terrors: After having slept for few hrs., the child bolts upright in bed, shakes & screams, appears pale & terrified. c. Nocturnal Enuresis/Bedwetting d. Soliloquy/Sleep-talking

e. Bruxism: clenching & grinding of teeth during sleep; may erode & diminish the height of dental crowns & may cause the teeth to become loose Physical Assessment Use the following techniques of examination as appropriate for eliciting findings: Inspection a. Begins with first encounter with the patient and is the most important of all the techniques b. Is an organized scrutiny of the patient¶s behavior and body c. With knowledge and experience, the examiner can become highly sensitive to visual clues. d. The examiner begins each phase of the examination by inspecting the particular part with the eyes.

Palpation ‡ Involves touching the region or body part just observed and noting what the various structures feel like. ‡ With experience comes the ability to distinguish variations of normal from abnormal. ‡ Is performed in an organized manner from region to region. Percussion ‡ By setting underlying tissues in motion, percussion helps in determining whether the underlying tissue is air filled, fluid filled, or solid. ‡ Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner.

There are five basic notes produced by percussion, which can be distinguished by differences in the qualities of sound, pitch, duration, and intensity. These are: Relative Relative Relative Example Intensity Pitch Duration Location 1. Flatness Soft High Short Thigh 2. Dullness Medium Medium Medium Liver 3. Resonance Loud Low Long Normal lung 4. Hyper Very loud Lower Longer Emphysemat resonance ous lung 5. Tympany 5. Gastric air Tympany bubble or puffed out cheek

c. The technique for percussion may be described as follows: 1 .Hyperextend the middle finger of your left hand, pressing the distal portion and joint firmly against the surface to be percussed. ± Other fingers touching the surface will damp the sound. ± Be consistent in the degree of firmness exerted by the hyper extended finger as you move it from area to area or the sound will vary. 2. Cock the right hand at the wrist, flex the middle finger upward, and place the forearm close to the surface to be percussed. The right hand and forearm should be as relaxed as possible.



With a quick, sharp, relaxed wrist motion, strike the extended left middle finger with the flexed right middle finger, using the tip of the finger, not the pad. (A very short fingernail is a must!) Aim at the end of the extended left middle finger (just behind the nail bed) where the greatest pressure is exerted on the surface to be percussed. Lift the right middle finger rapidly to avoid damping the vibrations. The movement is at the wrist, not at the finger, elbow, or shoulder; the examiner should use the lightest touch capable of producing a clear sound.

a. This method uses the stethoscope to augment the sense of hearing. b. The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 25 to 38 cm (10-15 inches), and the head should have a diaphragm and a bell. ± The bell is used for low-pitched sounds such as certain heart murmurs. c. The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breath sounds. d. Extraneous sounds can be produced by clothing, hair and movement of the head of the stethoscope.

Thermometer Sphygmomanometer Oto-ophthalmoscope Flashlight Tongue Depressor Cotton applicator stick Stethoscope Reflex Hammer Tuning Fork Safety Pin

Additional items include disposable gloves and lubricant for rectal examination and a speculum for examination of female pelvis

Importance²Many major therapeutic decisions are based on the vital signs; therefore, accuracy is essential. Vital Signs or Cardinal Signs are: ‡ Body temperature ‡ Pulse ‡ Respiration ‡ Blood pressure ‡ Pain

Body Temperature
Types of Body Temperature a. Core temperature ±temperature of the deep tissues of the body. b. Surface body temperature Normal Adult Temperature Ranges 1. Oral 36.5 ±37.5 ºC 2. Axillary 35.8 ± 37.0 ºC 3. Rectal 37.0 ± 38.1 ºC 4. Tympanic 36.8 ± 37.9ºC

Methods of Temperature-Taking Temperature1.    Oral ± most accessible and convenient method. Wash thermometer before use. Take oral temp 2-3 minutes. Allow 15 min to elapse between client¶s food intake of hot or cold food, smoke Contraindications ‡ Young children an infants ‡ Patients who are unconscious or disoriented ‡ Who must breath through the mouth ‡ Seizure prone ‡ Patient with oral lesions ,post oral surgery, and with nasal contraptions

2. Rectal- most accurate measurement of temperature Rectal‡ Position- lateral position with his top legs flexed and drape him to provide privacy. ‡ Insert thermometer by 0.5 ± 1.5 inches ‡ Hold in place in 2 minutes ‡ Do not force to insert the thermometer Contraindications ‡ Patient with diarrhea ‡ Recent rectal or prostatic surgery or injury because it may injure inflamed tissue ‡ Recent myocardial infarction

3. Axillary ± safest and non-invasive non‡ Pat the axilla dry ‡ Hold it in place for 9 minutes because the thermometer isn¶t close in a body cavity Note: 1. Use the same thermometer for repeat temperature taking to ensure more consistent result 2. Store chemical-dot thermometer in a cool area because exposure to heat activates the dye dots.

Temperature Routinely, where accuracy is not crucial, an oral temperature will suffice. A rectal temperature is the most accurate. Unless contraindicated (as in a patient with a severe cardiac arrhythmia), a rectal temperature is often preferred. 

May vary with the time of day. oOral: 370C (98.60F) is considered normal. May vary from 35.80C to 37.30C (96.40-99.10F) oRectal: Higher than oral by 0.40C to 0.50C (0.70-0.90F).

Nursing Interventions in Clients with Fever
‡ Monitor V.S ‡ Assess skin color and temperature ‡ Monitor WBC, Hct and other pertinent lab records ‡ Provide adequate foods and fluids. ‡ Promote rest ‡ Monitor I & O ‡ Provide TSB ‡ Provide dry clothing and linens ‡ Give antipyretic as ordered by MD

Pulse ± It¶s the wave of blood created by contractions of the left ventricles of the heart. Normal Pulse rate 1 year 80-140 beats/min 2 years 80- 130 beats/min 6 years 75- 120 beats/min 10 years 60-90 beats/min Adult 60-100 beats/min Tachycardia ± pulse rate of above 100 beats/min Bradycardia- pulse rate below 60 beats/min Irregular ± uneven time interval between beats.

Radial Pulse ‡ Gently press your index, middle, and ring fingers on the radial artery, inside the patient¶s wrist. ‡ Excessive pressure may obstruct blood flow distal to the pulse site ‡ Counting for a full minute provides a more accurate picture of irregularities.

Pulse Palpate the radial pulse and count for at least 30 seconds. I f the pulse is irregular, count for a full minute and note the number of irregular beats/min. Note: Whether the beat of the pulse against your finger is strong or weak, bounding or thread. 

Normal adult pulse is 60 to 80 beats/min; regular in rhythm. Elasticity of the arterial walls, blood volume, and mechanical action of the heart muscle are some of the factors that affect strength of the pulse wave, which normally is full and strong.

Doppler device ‡ Apply small amount of transmission gel to the ultrasound probe ‡ Position the probe on the skin directly over a selected artery ‡ Set the volume to the lowest setting ‡ To obtain best signals, put gel between the skin and the probe and tilt the probe 45 degrees from the artery. ‡ After you have measure the pulse rate, clean the probe with soft cloth soaked in antiseptic. Do not immerse the probe

Respiration - is the exchange of oxygen and carbon dioxide between the atmosphere and the body

Assessing Respiration ‡ Rate ± Normal 14-20/ min in adult ‡ The best time to assess respiration is immediately after taking client¶s pulse ‡ Count respiration for 60 second ‡ As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.

Respiration Count the number of Normally 16 to 20 respirations taken in 15 respirations/min. seconds and multiply by 4. Note: Rhythm and depth of breathing.

Blood Pressure
Adult ± 90- 132 systolic 60- 85 diastolic Elderly 140-160 systolic 70-90 diastolic ‡ Ensure that the client is rested ‡ Use appropriate size of BP cuff. ‡ If too tight and narrow- false high BP ‡ If too lose and wide-false low BP

‡ Position the patient on sitting or supine position ‡ Position the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading ‡ Use the bell of the stethoscope since the blood pressure is a low frequency sound. ‡ If the client is crying or anxious, delay measuring his blood pressure to avoid falsehigh BP

Blood Pressure Measure the blood pressure in both arms. Palpate the systolic pressure before using the stethoscope in order to detect an auscultatory gap.* Apply cuff firmly; if too loose, it will give a falsely high reading. Use cuff in appropriate size: a pediatric cuff for children; a leg cuff for obese people. The cuff should be approximately 2.5 cm (1 inch) above the antecubital fossa.

Normal range: Systolic²95-140 mm Hg Diastolic²60-90 mm Hg A difference of 5 to 10 mm Hg between arms in common. Systolic pressure in lower extremities is usually 10 mm Hg higher than reading in upper extremities. Going from a recumbent to a standing position can cause the systolic pressure to fall 10 to 15 mm Hg and the diastolic pressure to rise slightly (by 5 mm Hg).

Electronic Vital Sign Monitor
‡ An electronic vital signs monitor allows you to continually tract a patient¶s vital sign without having to reapply a blood pressure cuff each time. ‡ Example: Dinamap VS monitor 8100 ‡ Lightweight, battery operated and can be attached to an IV pole ‡ Before using the device, check the client7s pulse and BP manually using the same arm you¶ll using for the monitor cuff. ‡ Compare the result with the initial reading from the monitor. If the results differ call the supply department or the manufacturer¶s representative.


Bed position for client care
Position Placement Use Cardiac, respiratory, neurosurgical condition Necessary degree elevation for ease breathing, promotes skin integrity; client¶s comfort For client comfort; contraindicated for vascular disorder Semi-Fowler¶s Head of bed 30° angle Low-Fowler¶s Head of bed 15° angle


Lower section of bed (under knees) slightly bent





Head of bed lowered and foot raised

Percussion, vibration, and drainage; promotes venous return

Reverse trendelenburg¶s

Bed frame is titles Gastric up with foot of the conditions, prevent bed esophageal reflux

Amputation: lower extremity
- No pillows under stump after first 24 hours - Turn patient prone several times a day Rationale: - Prevents flexion deformity of the limb

Appendicitis: ruptured
- Keep in fowler¶s position - not flat in bed Rationale: - Keeps infection from spreading upward in the peritoneal cavity

Burns (extensive)
- Usually flat for first 24 hours Rationale: - Potential problem is hypovolemia, which will be more symptomatic in a sitting position

Cast, extremity
- Keep extremity elevated Rationale: - Prevent edema

- Head elevated with supratentorial incision - flat with cerebellar or brainstem incision Rationale: - Reduces cerebral edema, which contributes to increase intracranial pressure

Flail chest
- Position on affected side Rationale: - Reduces the instability of the chest wall that is causing the paradoxical respiratory movements

Gastric resection
- Lie down after meals Rationale: - May be useful in preventing dumping syndrome

Hiatal hernia (before repaired)
- Head of the bed is elevated with shock blocks Rationale: - Prevents esophageal irritation from gastric regurgitation

Hip prosthesis
- Keep affected leg in abduction (splint or pillow between legs) - Avoid adduction and flexion of the hip - Use trochanter roll along outside of femur anterior joints capsule incision to keep affected leg turned slightly inward - No trochanter roll with posterior joint capsule incision as leg is turned slightly outward

Rationale: - If affected hip is flexed and allowed to adduct and
internally rotate, the head of the femur may be displaced from the socket

Laminectomy; fusion
- Avoid twisting motion when getting out of bed, ambulating Rationale: - Prevent shearing force on the spine

Liver biopsy
Place on right side, and position pillow for pressure Rationale: - Prevents bleeding

Lobectomy - Do not put in Trendelenberg position - position of comfort - sides, back Rationale: - Pushes abdominal contents against diaphragm - May cause respiratory embarrassment

Mastectomy - Do not abduct arm first few days
Rationale: - Puts tension on suture line - Elevate hand and arm higher than shoulder if lymph glands removed Rationale: - Prevents lymphedema

- Turn only toward operative side for short periods - No extreme lateral positioning Rationale: - Gives unaffected lung room for full expansion - Prevents mediastinal shift - In case of bleeding there will be no drainage into the unaffected bronchi

Radium implantation in cervix
- Bed rest - usually may elevate to 30 degrees Rationale: - Must keep radium insert positioned correctly

Respiratory distress
- Orthopnea position usually desirable Rationale: - Allows for maximum expansion of lungs

Retinal detachment
- Affected area toward bed - complete bed rest
- No sudden movements of head - Face down if gas bubble in place Rationale: - Gravity may help retina fall in place; prevents further tearing - Any sudden increase in intraocular pressure may further dislodge retina

Straight traction
- Check specific orders about how much head may be elevated Rationale: - Body is used as the countertraction this must not be less than the pull of the traction

Balanced suspension traction
- May give patient more freedom to move a bout than in straight traction Rationale: - In balanced suspension additional weights supply contertraction

Unconscious patient
- Turn on side with head slightly lowered - ³coma´ position Rationale: - Important to let secretion drain out by gravity - Must prevent aspiration

Ileofemoral bypass; arterial insufficiency
- Do not elevate legs Rationale: - Arterial flow is helped by gravity - Flexion of the hip compresses the vessels of the extremity Rationale: - Avoid hip flexion

Vein strippings; vein ligations
- Keep legs elevated Rationale: - Prevents venous stasis - Do not stand or sit for long periods Rationale: - Prevents venous pooling

Selected Nursing Procedures
Principles and Practices of Surgical Asepsis All objects used in a sterile field must be sterile. ‡ All articles are sterilized appropriately by dry or moist heat, chemicals, or radiation before use. ‡ Always check a package containing a sterile object for intactness, dryness, and expiration date. Any package that appears already open, torn, punctured, or wet is considered unsterile.

‡ Storage areas should be clean, dry, off the floor, and away from sinks ‡ Always check chemical indicators of sterilization before using a package. The indicator is often a tape used to fasten the package or contained inside the package. The indicator changes color during sterilization, indicating that the contents have undergone a sterilization procedure. If the color change is not evident, the package is considered unsterile. Commercially prepared sterile packages may not have indicators but are marked with the word sterile.

Sterile objects become unsterile when touched by unsterile objects. ‡ Handle sterile objects that will touch open wounds or enter body cavities only with sterile forceps or sterile gloved hands. ‡ Discard or resterilize objects that are considered questionable, assume the article is unsterile.

Sterile items that are out of vision or below the waist level of the nurse are considered unsterile. ‡ One left unattended, a sterile field is considered unsterile. ‡ Sterile objects are always kept in view. Nurses do not turn their backs on a sterile field. ‡ Only the front part of a sterile gown (from the waists to the shoulder) and 2 inches above the elbows to the cuff of the sleeves are considered sterile. ‡ Always keep sterile gloved hands in sight and above waist level; touch only objects that are sterile. Sterile draped tables in the operating room or elsewhere are considered sterile only at surface level. ‡ Once a sterile field becomes unsterile, it must be set up again before proceeding.

Sterile objects can become unsterile by prolonged exposure to airbone micro-organisms. ‡ Keep doors closed and traffic to a minimum in areas where a sterile procedure is being performed because moving air can carry dust and microorganisms. ‡ Keep areas in which sterile procedures are carried out as clean as possible by frequent damp cleaning with detergent germicides to minimize contaminants in the area. ‡ Keep hair clean and short or enclose it in a net to prevent hair from failing on sterile objects. Microorganisms on the hair can make a sterile field unsterile. ‡ Wear surgical caps in operating rooms, delivery rooms, and burn units.

‡ Refrain from sneezing or coughing over a sterile field. This can make it unsterile because droplets containing covering the mouth and the nose should be worn by anyone working over a sterile field or an open wound. ‡ Nurses with mild upper respiratory tract infections refrain from carrying out sterile procedures or wear masks. ‡ When working over a sterile field, keep talking to a minimum. Avert the head from the field if talking is necessary. ‡ To prevent microorganisms from failing over a sterile field, refrain from reaching over a sterile field unless sterile gloves are worn and refrain from moving unsterile objects over a sterile field.

‡ Unless gloves are worn, always hold wet forceps with the tips below the handles. When the tips are held higher than the handles, fluid can flow onto the handle and become contaminated by the hands, When the forceps are again pointed downward, the fluid flows back down and contaminates the tips. ‡ During a surgical hand wash, hold the hands higher than the elbows to prevent contaminants from the forearms from reaching the hands.


‡ ‡ ‡

Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action. Sterile moisture-proof barriers are sued beneath sterile objects. Liquids (sterile saline or antiseptics) are frequently poured into containers on a sterile field. If they are spilled onto the sterile field, the barrier keeps The liquid from seeping beneath it. Keep the sterile covers on sterile equipment dry. Damp surfaces can attract microorganisms in the air. Replace sterile drapes that do not have a sterile barrier underneath when they become moist.

The edges of a sterile field are considered unsterile ‡ A 2.5-cm (1-in) margin at each edge of an opened drape is considered unsterile because the edges are in contact with unsterile surfaces. ‡ Place all sterile objects more than 2.5 cm (1 in.) inside the edges of a sterile field. ‡ Any article that falls outside the edges of a sterile field is considered unsterile.

The skin cannot be sterilized and is unsterile.Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis. ‡ Use sterile gloves or sterile forceps to handle sterile items. Prior to a surgical aseptic procedure, wash hands to reduce the number of microorganisms on them ‡ When a sterile object becomes unsterile, it does not necessarily change in appearance. The person who sees a sterile object become contaminated must correct or report eh situation. Don¶t a set up a sterile field ahead of time for future use.

Nosocomial Infections
Most Common Microorganisms Urinary Tract Escherichia coli (80%) Enterococcus species Pseudomonas aeruginosa Causes Improper catheterization technique Contamination of closed drainage system Inadequate hand washing Inadequate hand washing Improper dressing change technique

Surgical Sites Staphylococcus aureus Enterococcus species Pseudomonas aeruginosa

Bloodstream Coagulase-negative staphylococci Staphylococcus aureus Enterococcus species

Inadequate hand washing Improper intravenous fluid, tubing, and site care technique

Pneumonia Staphylococcus aureau Pseudomonas aeruginosa Enterobacter species

Inadequate hand washing Improper suctioning technique

Steps to follow other Exposure to Blood borne Pathogens
‡ Report the incident immediately to appropriate personnel within the agency. ‡ Complete an injury report. ‡ Seek appropriate evaluation and follow-up. This includes: ± Identification and documentation of the source individual when feasible and legal ± Testing of the source for hepatitis B, hepatitis C, and HIV when feasible and consent is given ± Making results of the test available to the source individual¶s health care provider ± Testing of blood of exposed nurse (with consent) for hepatitis B, hepatitis C, and HIV antibodies ± Postexposure prophylaxis if medically indicated

‡ For a puncture / laceration:
± Encourage bleeding ± Wash / clean the area with soap and water ± Initiate first-aid and seek treatment if indicated.

‡ For a mucous membrane exposure (eyes, nose, mouth), saline of water flush for 5 to 10 minutes.

Postexposure Protocol (PEP)
HIV: ‡ For ³high-risk´ exposure (high blood volume and source with a high HIV titer): three-drug treatment is recommended. Must be started within 1 hour. ‡ For ³increased risk´ exposure (high blood volume or source with a high HIV titer): three-drug treatment is recommended. Must be started within 1 hour. ‡ For ³low-risk´ exposure (neither high blood volume nor source with a high HIV titer): two-drug treatment is considered. Must be started within 1 hour. ‡ Drug regimens vary. Drugs commonly used are zidovudine, lamivudine, didanosine, and indinavir. ‡ HIV antibody test done shortly after expsosure (baseline), and 6 week, 3 months, and 6 months after ward.

Hepatitis B ± Anti-HBs testing 1 to 2 months after last vaccine close. ± Anti-BHs testing 1 to 2 months after last vaccine close. Hepatitis C ± Anti-HVC and ALT at baseline and 34 to 6 months after exposure Selected Safety Hazards throughout the Life Span ± Developing fetus: Exposure to maternal smoking, alcohol consumption, addictive drugs, x-rays (first trimester), certain pesticides ± Newborns and infants: Falling, suffocation in crib, choking from aspirated milk or ingested objects, burns from hot water or other spilled hot liquids, automobile accidents, crib or playpen injuries, electric shook, poisoning

± Toddlers: Physical trauma from falling, banging into objects, or getting cut by sharp objects; automobile accidents; burns; poisoning; drowning; and electric shock ± Preschoolers: injury from traffic, playground equipment, and other objects; choking, suffocation, and obstruction of airway or ear card by foreign objects; poisoning; drowning fire and burns; harm from other people or animals ± Adolescents: Vehicular (automobile, bicycle) accidents, recreational accidents, firearms, substance abuse ± Older adults: Falling, burns, and pedestrian and automobile accidents

Applying Restraints
‡ Obtain consent from the client or guardian. ‡ Ensure that a physician¶s order has been provided or, in an emergency, obtain one within 24 hours after applying the restraint. ‡ Assure the client and the client¶s support people that the restraint is temporary and protective. A restraint must never be applied as punishment for any behavior or merely for the nurse¶s convenience. ‡ Apply the restraint in such a way that the client can move as freely as possible without defeating the purpose of the restraint. ‡ Ensure that limb restraints are applied securely but not so tightly that they impede blood circulation to any body area or extremity.

‡ Pad bony prominences (e.g., wrists and ankles) before applying a restraint over them. The movement of a restraint without padding over such prominences can quickly abrade the skin. ‡ Always tie a limb restraint with a knot (e.g., a clove hitch) that will not tighten when pulled. ‡ Tie the ends of a body restraint to the part of the bed that moves to elevate the head. Never tie the ends to a side rail or to the fixed frame of the bed if the bed position is to be changed. ‡ Assess the restraint every 30 minutes. Some facilities have specific forms to be used to record ongoing assessment. ‡ Release all restraints at least every 2 to 4 hours, and provide range-of-motion (ROM) exercises and skin care.

‡ Reassess the continued need for the restraint at least every 8 hours. Include an assessment of the underlying cause of the behavior necessitating use of the restraints. ‡ When a restraint is temporarily removed, do not leave the client unattended. ‡ Immediately report to the nurse in charge and record on the client¶s chart any persistent reddened or broken skin areas under the restraint. ‡ At the first indication of cyanosis or pallor, coldness of a skin area, or a client¶s complaint of a tingling sensation, pain, or numbness, loosen the restraint and exercise the limb. ‡ Apply a restraint to that it can be released quickly in case of an emergency and with the body part in a normal anatomic position. ‡ Provide emotional support verbally and through touch.

Bathing an Adult or Pediatric Client
Process ‡ To remove transient microorganisms, body secretions and excretions, and dead skin cells ‡ To stimulate circulation to the skin ‡ To produce a sense of well-being ‡ To promote relaxation and comfort ‡ To prevent or eliminate unpleasant body odors

Assessment ‡ Condition of the skin (color, texture and turgor, presence of pigmented spots, temperature, lesions, excoriations, and abrasions) ‡ Fatigue ‡ Presence of pain and need for adjunctive measure (e.g., an analgesic) before the bath ‡ Range of motion of the joints ‡ Any other aspect of health that affect the client¶s bathing process (e.g., mobility, strength, cognition) ‡ Need for use of clean gloves during the bath

Equipment ‡ Basin or skink with warm water (between 43 and 46C or 3110 and 115F) ‡ Soap and soap dish ‡ Linens: bath blanket, two bath towels, washcloth, clean grown or pajamas or clothes as needed, additional bed linen and towels, if required ‡ Gloves, if appropriate (e.g., presence of body fluids or open lesions) ‡ Personal hygiene article (e.g., deodorant, powder, lotions) ‡ Shaving equipment for male clients ‡ Table for bathing equipment

‡ Prepare the bed and position the client appropriately. ‡ Position the bed at a comfortable working height. Lower the side rail on the side close to you. Keep the other side rail up. Assist the client to move near you. This avoids undue reaching and straining and promotes good body mechanics. ‡ Place bath blanket over top sheet. Remove the top sheet from under the bath blanket by starting at client¶s shoulders and moving linen down toward client¶s feet. Ask the client to grasp and hold the top of the bath blanket while pulling linen to the foot of the bed. The bath blanket provides comfort, warmth, and privacy. Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be changed, place it in the linen hamper. ‡ Remove client¶s gown while keeping the client covered with the bath blanket. Place gown in linen hamper.

Make bath mitt with the washcloth. A bath mitt retains water and heat better than a cloth loosely held and prevents ends of washcloth from dragging across the skin. Wash the face. Circular Motion. Begin the bath at the cleanest area and work downward to-ward the feet. ‡ Place towel under client¶s head. ‡ Wash the client¶s eyes with water only and dry them well. Use a separate corner of the washcloth for each eye. Using separate comers prevents transmitting microorganisms from one eye to the other. Wipe from the inner to the outer canthus. This prevents secretions from entering the nasolacrimal ducts. ‡ Ask whether the client wants soap used on the face. Soap has a drying effect, and the face, which is exposed to the air more than other body parts, tends to be drier. ‡ Wash, rinse, and dry the client¶s face ears, and neck. ‡ Remove the towel from under the client¶s head.

‡ Wash the client¶s eyes with water only and dry them well. Use a separate corner of the washcloth for each eye. Using separate comers prevents transmitting microorganisms from one eye to the other. Wipe from the inner to the outer canthus. This prevents secretions from entering the nasolacrimal ducts. ‡ Ask whether the client wants soap used on the face. Soap has a drying effect, and the face, which is exposed to the air more than other body parts, tends to be drier. ‡ Wash, rinse, and dry the client¶s face ears, and neck. ‡ Remove the towel from under the client¶s head. Wash the arms and hands. (Omit the arms for a partial bath.)

‡ Place a towel lengthwise under the arm away from you. It protects the bed from becoming wet. ‡ Wash, rinse, and dry the arm by elevating the client¶s arm and supporting the client¶s wrist the elbow .Use long, firm strokes from wrist to shoulder, including the axillary area. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. ‡ Apply deodorant or powder if desired. ‡ (Optional) Place a towel on the bed and put a washbasin on it. Place the client¶s hands in the basin. Many clients enjoy immersing their hands in the basin and washing themselves. Soaking loosens dirt under the nails. Assist the client as needed to wash, rinse, and dry the hands, paying particular attention to the spaces between the fingers. ‡ Repeat for hand and arm nearest you. Exercise caution if an intravenous infusion is present, and check its flow after moving the arm.

Wash the chest and abdomen. (Omit the chest and abdomen for a partial bath. However, the areas under a woman¶s breast may require bathing if this area is irritated or if the client has significant perspiration under the breast.) ‡ Place bath towel lengthwise over chest. Fold bath blanket down to the client¶s public area. Keeps the client warm while preventing unnecessary exposure of the chest. ‡ Lift the bath towel off the chest, and bathe the chest and abdomen with your mitted hand using long, firm strokes . Give special attention to the skin under the breasts and any other skin folds particularly if the client is overweight. Rinse and dry well. ‡ Replace the bath blanket when the areas have been dried.

Wash the legs and feet. (Omit legs and feet for a partial bath.) ‡ Expose the leg farthest from you by folding the bath blanket toward the other leg being careful to keep the perineum covered. Covering the perineum promotes privacy and maintains the client¶s dignity. ‡ Lift leg and place the bath towel lengthwise under the leg. Wash, rinse, and dry the leg using long, smooth, firm strokes from the ankle to the knee to the thigh. Washing from the distal to proximal areas promotes circulation by stimulating venous blood flow. ‡ Reverse the coverings and repeat for the other leg.

‡ Wash the feet by placing them in the basin of water ‡ Dry each foot. Pay particular attention to the spaces between the toes. If you prefer, wash one foot after that leg before washing the other leg. ‡ Obtain fresh, warm bathwater now or when necessary. Water may become dirty or cold. Because surface skin cells are removed with washing, the bathwater from dark-skinned clients may be dark, however, this does not mean the client is dirty. Raise side rails when refilling basin. This ensures the safety of the client.

Wash the back and then the perineum. ‡ Assist the client into a prone or side-lying position facing away from you. Place the bath towel lengthwise alongside the back buttocks while keeping the client covered with the bath blanket as much as possible. This provides warmth and undue exposure. ‡ Wash and dry the client¶s back, moving from the shoulders to the buttocks, and upper thighs, paying attention to the gluteal folds ‡ Perform back massage now of after completion of bath. ‡ Assist the client to the supine position and determine whether the client can wash the perineal area independently. If the client cannot do so, drape the client and wash the area.

Assist the client with grooming aids such as powder, lotion, or deodorant. ‡ Use powder sparingly. Release as little as possible into the atmosphere. This will avoid irritation of the respiratory tract by powder inhalation. Excessive powder can cause caking, which leads to skin irritation. Systematic Way for Bed Bath ± Eyes (inner to outer) ± Face (circular) ± Ears & Neck (circular) ± Arms & Hands (distal to proximal) ± Chest & Abdomen (long firm strokes-longitudinal) ± Legs & Feet (distal to proximal) ± Back & Perineum (shoulders to buttocks then upper thighs - distal to proximal)

‡ ‡

‡ ‡ ‡ ‡

Using a Metered ± Dose Inhaler Make sure the canister is firmly and fully inserted into the inhaler. Remove the mouthpiece cap and, holding the inhaler upright; shake the inhaler vigorously for 3 to 5 seconds to mix the medication evenly. Exhale comfortably (as in a normal full breath. Hold the canister upside down. Hold the MDI 2 TO 4 cm (1 to 2 in) from the open mouth Put the mouthpiece far enough into the mouth with its opening toward the throat. Close the lips tightly around the mouthpiece. An MDI with a spacer or extender is always placed in the mouth.

Administering the Medication ‡ Press down once on the MDI canister (which release the dose) and inhale slowly and deeply through the mouth. ‡ Hold your breath for 10 seconds. This allows the aerosol to reach deeper airways. ‡ Remove the inhaler from or away from the mouth. ‡ Exhale slowly through-pursed lips. Controlled exhalation keeps the small airways open during exhalation. ‡ Repeat the inhalation if ordered. Wait 20 to 30 second between inhalations of bronchodilator medications so the first inhalation has a chance to work and the subsequent dose reaches deeper into the lungs.

‡ After the inhalation is completed, rinse mouth with tap water to remove any remaining medication and reduce irritation and risk of infection. ‡ Clean the MDI mouthpiece after each use. Use mild soap and water, rinse it, and let it air dry before replacing it on the device. ‡ Store the canister at room temperature. Avoid extremes of temperature. ‡ Report adverse reactions such as restlessness, palpitation, nervousness, or rash to the physician. ‡ Many MDIs contains steroids for an anti-inflammatory effect. Prolonged use increases the risk of fungal infections in the mouth.

Height and weight
‡ It is essential in calculating drug dosage, contrast agents, assessing nutritional status and determining the height-weight ratio. ‡ Weight is the best overall indicator of fluid status, daily monitoring is important for clients receiving a diuretics or a medication that causes sodium retention. ‡ Weight can be measured with a standing scale, chair scale and bed scale. ‡ Height can be measured with the measuring bar, standing scale or tape measure if the client is confine nin a supine position.

Pointers: ‡ Reassure and steady patient who are at risk for losing their balance on a scale. ‡ Weight the patient at the same time each day. (usually before breakfast), in similar clothing and using the same scale. ‡ If the patient uses crutches, weigh the client with the crutches or heavy clothing and subtract their weight from the total determined patient¶ weight.

Laboratory and Diagnostic examination
Urine Specimen 1. Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test ‡ Best time to collect is in the morning,first voided urine ‡ Provide sterile container ‡ Do perineal care before collection of the urine ‡ Discard the first flow of urine ‡ Label the specimen properly ‡ Send the specimen immediately to the laboratory ‡ Document the time of specimen collection and transport to the lab. ‡ Document the appearance, odor, and usual characteristics of the specimen.

24-hour urine specimen 24‡ Discard the first voided urine. ‡ Collect all specimen thereafter,until the following day ‡ Soak the specimen in a container with ice ‡ Add preservative as ordered according to hospital policy Second-Voided urine ± required to assess glucose level and for the presence of albumen in the urine. ‡ Discard the first urine ‡ Give the patient a glass of water to drink ‡ After few minutes, ask the patient to void

Catheterized urine specimen
‡ Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected. ‡ Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary surgery.

‡ Stool Specimen
1. Fecalysis ± to assess gross appearance of stool and presence of ova or parasite ± Secure a sterile specimen container ± Ask the pt. to defecate into a clean , dry bed pan or a portable commode. ± Instruct client not to contaminate the specimen with urine or toilet paper( urine inhibits bacterial growth and paper towel contain bismuth which interfere with the test result.

2. Stool culture and sensitivity test
‡ To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.

3. Fecal Occult blood test
± are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer, detecting melena stool ‡ Test sample from several portion of the stool.

a Instructions: ‡ Advise client to avoid ingestion of red meat for 3 days ‡ Patient is advise on a high residue diet ‡ avoid dark food and bismuth compound ‡ If client is on iron therapy, inform the MD ‡ Make sure the stool in not contaminated with urine, soap solution or toilet paper

Blood specimen
‡ No fasting for the following tests: - CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes ‡ Fasting is required: - FBS, BUN, Creatinine, serum lipid ( cholesterol, triglyceride)

Sputum Specimen
1. ‡ ‡ ‡ Gross appearance of the sputum Collect early in the morning Use sterile container Rinse the mount with plain water before collection of the specimen ‡ Instruct the patient to hack-up sputum 2. Sputum culture and sensitivity test ‡ Use sterile container ‡ Collect specimen before the first dose of antibiotic

3. Acid-Fast Bacilli Acid‡ To assess presence of active pulmonary tuberculosis ‡ Collect sputum in three consecutive morning 4. Cytologic sputum examto assess for presence of abnormal or cancer cells.

Diagnostic tests

PPD test ± read result 48 ± 72 hours after injection.  For HIV positive clients, induration of 5 mm is considered positive  Bronchography  Secure consent  Check for allergies to seafood or iodine or anesthesia  NPO 6-8 hours before the test  NPO until gag reflex return to prevent aspiration

Thoracentesis ± aspiration of fluid in the pleural space.  Secure consent, take V/S  Position upright leaning on overbed table  Avoid cough during insertion  Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity  Check for expectoration of blood. This indicate trauma and should be reported to MD immediately.

Holter Monitor ± it is continuous ECG monitoring, over 24 hours period  The portable monitoring is called telemetry unit Echocardiogram ± ultrasound to assess cardiac structure and mobility  Client should remain still, in supine position slightly turned to the left side, with HOB elevated 15-20 degrees Electrocardiography If the area is excessively hairy, clip it ‡ Remove client`s jewelry, coins, belt or any metal ‡ Tell client to remain still during the procedure

Cardiac Catheterization  Secure consent  Assess allergy to iodine, V/S for baseline information ‡ Have client void before the procedure ‡ Monitor PT, PTT, ECG prior to test ‡ NPO for 4-6 hours before the test ‡ Shave the groin or brachial area ‡ After the procedure: bed rest to prevent bleeding on the site, do not flex extremity ‡ Elevate the affected extremities on extended position to promote blood supply back to the heart and prevent thrombplebities ‡ Monitor V/S especially peripheral pulses ‡ Apply pressure dressing over the puncture site ‡ Monitor extremity for color, temperature, tingling to assess for impaired circulation.

MRI secure consent,  the procedure will last 45-60 minute  Assess client for claustrophobia  Remove all metal items ‡ Client should remain still ‡ Tell client that he will feel nothing but may hear noises ‡ Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI. ‡ Client with cardiac and respiratory complication may be excluded

UGIS ² Barium Swallow
‡ NPO after midnight ‡ force fluid after the test to prevent constipation/barium impaction ‡ Tell client that the stool will turn white 24 to 48 hours after the test

LGIS ² Barium Enema
a. instruct client on low-residue diet 1-3 days before the procedure b. administer laxative evening before the procedure c. NPO after midnight d. administer suppository in AM e. Enema until clear f. force fluid after the test to prevent constipation/barium impaction g. Tell client that the stool will turn white 24 to 48 hours after the test

Liver Biopsy
‡ ‡ ‡ ‡ ‡ Secure consent, NPO 2-4 hrs before the test Monitor PT, Vit K at bedside Place the client in supine at the right side of the bed Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD insert the needle Right lateral post procedure for 4 hours to apply pressure and prevent bleeding Bed rest for 24 hours Observe for S/S of peritonitis

‡ ‡ ‡


Secure consent, check V/S  Let the patient void before the procedure to prevent puncture of the bladder  Check for serum protein. excessive loss of plasma protein may lead to hypovolemic shock.

Lumbar Puncture
‡ obtain consent ‡ instruct client to empty the bladder and bowel ‡ position the client in lateral recumbent with back at the edge of the examining table ‡ instruct client to remain still ‡ obtain specimen per MDs order

Steam Inhalation 

It is dependent nursing function. Heat application requires physician¶s order.  Place the spout 12-18 inches away from the client¶s nose or adjust the distance as necessary. Suctioning  Assess the lungs before the procedure for baseline information.  Position: conscious ± semi-Fowler¶s  Unconscious ± lateral position 


Size of suction catheter- adult- fr 12-18 Hyper oxygenate before and after procedure Observe sterile technique Apply suction during withdrawal of the catheter Maximum time per suctioning ±15 sec

Nasogastric Feeding (gastric gavage)
Insertion: Fowler¶s position Tip of the nose to tip of the earlobe to the xyphoid Hyperextend the neck to gently advance the tube to nasopharynx ‡ Tilt the head forward once the tube reaches the throat and ask the client to swallow as the tube is advance.

Tube Feeding 


Semi-Fowler¶s position Assess tube placement Assess residual feeding Height of feeding is 12 inches above the tube¶s point of insertion  Ask client to remain upright position for at least 30 min.  Most common problem of tube feeding is Diarrhea due to lactose intolerance


Check MD¶s order Provide privacy Position left lateral Size of tube Fr. 22-32 Insert 3-4 inches of rectal tube If abdominal cramps occur, temporarily stop the flow until cramps are gone.  Height of enema can ± 18 inches

‡ Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are done to promote evacuation of feces at a regular and convenient time ‡ Recommended with sigmoid colostomy ‡ Initiated 5 to 7 days postop ‡ Done in semi ± Fowler¶s position; then sitting on a toilet bowl once ambulatory. ‡ Use warm normal saline solution 

Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently  Dilate stoma with lubricated gloved finger before insertion of catheter  Lubricate catheter before insertion.  Insert 3 to 4 inches of the catheter into the stoma  Height of solution 12 inches above the stoma  If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution until peristalsis relaxes.

‡ Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then remove catheter to drain for 15 to 20 minutes. ‡ Clean the stoma, apply new pouch

Urinary Catheterization
Verify MD¶s order Practice strict asepsis Perineal care before the procedure Catheter size: male-14-16 , female ± 12 ± 14 Length of catheter insertion male ± 6-9 inches ,female ± 3-4 inches For retention catheter: Male ±anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure Female- inner aspect of the thigh     

Foot Care  Soaking the feet of diabetic client is no longer recommended  Cut nail straight across Mouth Care  Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables  Dental check every 6 mounts Oral care for unconscious client  Place in side lying position  Have the suction apparatus readily available

Hair Shampoo  Place client diagonally in bed  Cover the eyes with wash cloth  Plug the ears with cotton balls  Massage the scalp with the fatpads of the fingers to promote circulation in the scalp.

Fundamentals of nursing Normal Values Bleeding time Prothrombin time Hematocrit Male Female Hemoglobin male female Platelet RBC male female 1-9 min 10-13 sec 42-52% 36-48% 13.5-16 g/dl 12-16 g/dl 150,00- 400,000 4.5-6.2 million/L 4.2-5.4 million/L

Normal Values Amylase 80-180 IU/L 0-0.4 mg/dl Bilirubin(serum)direct 0.2-0.8 mg/dl indirect total 0.3-1.0 mg/dl PaCo2 35-45 pH 7.35-7.45 HCO3 22-26 mEq/L Pa O2 80-100 mmHg SaO2 94-100%

‡ Normal values Sodium 135- 145 mEq/L Potassium 3.5- 5.0 mEq/L Calcium 4.2- 5.5 mg/dL Chloride 98-108 mEq/L Magnesium 1.5-2.5 mg/dl BUN 10-20 mg/dl Creatinine 0.4- 1.2 CPK-MB male 50 ±325 mu/ml female 50-250 mu/ml

Fibrinogen FBS Glycosylated Hgb (HbA1c) Uric Acid ESR male female Cholesterol Triglyceride

200-400 mg/dl 80-120 mg/dl 4.0-7.0% 2.5 ±8 mg/dl 15-20 mm/hr 20-30 mm/hr 150- 200 mg/dl 140-200 mg/dl

Lactic Dehydrogenase 100-225 mu/ml Alkaline phospokinase 32-92 U/L Albumin 3.2- 5.5 mg/dl

± Do not add salt or seasoning containing sodium when preparing foods. ± Do not use salt in the table ± Avoid high sodium foods ± Limit milk products to 2 cups daily ± Substituting lemon juice and various spices to enhance food flavor and to be more palatable

‡ Processed foods smoked and cured products, canned meat and sardines. ‡ Commercial soups, bouillon cubes, powdered dehydrated soups ‡ MSG, Worcestershire, soy sauce, mustard, horseradish, , bbq sauce, steak sauce, catsup ‡ Saltines, baking powder, muffins, bisquick, pretzels, corn bread ‡ Olives, pickles, salted popcorn, TV dinners

LOW FAT DIET Need to avoid: ‡ Fats, avocados, meat, olives, nuts LOWCHOLESTEROL DIET ‡ The fat content of the diet is modified to increase the ratio of polysaturated fatty acids to saturated fatty acids. ‡ Organ meats are restricted because they are high in cholesterol although low in total fat. ‡ Only 2 whole eggs per week are used because egg yolk is high in cholesterol. Egg white may use as desire.

Coronary artery disease Low fat diet: ‡ Visible fat (e.g. butter, cream, salad dressing, cooking oil) is restricted to 1 tsp per meal ‡ Only lean milk, skim milk, and no more than 7 eggs per week are used. ‡ Foods are not prepared with added fat for cooking ‡ Vegetables oil is used in cooking and food preparation. Coconuts and palm oils are not allowed because of their high content of saturated fats.

± High calorie, high CHON, high CHO ± Small frequent feeding ± Provide mouth care prior to feeding

Pulmonary Tuberculosis ‡ High calorie, high CHON, high CHO ‡ Small frequent feeding ‡ Oral care before feeding

Bronchial asthma ‡ High calorie food ‡ Avoid over eating ‡ Increase fluid to 2 ± 3 liters per day ‡ Liver cirrhosis ‡ High in calorie ‡ 3000 calories per day ‡ High CHO content ‡ Moderate to high CHON ‡ Moderate to low fat If with hepatic encephalopathy low to no CHON

‡ Food allowed: ‡ Toast, cereals, rice, tea, fruit juice, and hard candies ‡ Limit CHON to 20g per day at the onset of severe hepatic failure ‡ Na is also restricted as well as fluid when edema and ascites are present. ‡ Crisp foods should be avoided because of the possibility of esophageal varices

Acute pancreatitis ‡ Initially NPO to reduce pancreatic secretions ‡ When food is allowed: small frequent feeding ‡ High CHO because it least stimulate the pancreas ‡ High CHON, low fat ‡ Usually bland diet ‡ No stimulants (e.g. caffeine) ‡ No alcohol ‡ Supplemental fat soluble vitamins may be given

Renal Calculi Oxalate stones Foods not allowed: ‡ Spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans , chocolate, cocoa, instant coffee, ovaltine, tea ‡ Calcium stone ‡ Foods not allowed ‡ Milk, cheese, ice cream, yogurt, food containing flour, all beans except green beans, lentils, fish with fine bones, dried fruits, chocolate, cocoa

Uric Acid Stone Foods need to avoid ‡ Sardines, herring, mussels, sweet breads, liver, kidney, goose, venison, meat soup, chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham, legumes, salted anchovies. Chronic Renal Failure ‡ Protein, sodium, potassium, phosphorus and fluids are controlled to meet each client¶s need ‡ Protein source should be of high biologic value. ‡ High Na and high K foods should be avoided ‡ Sufficient calories and nutrients are provided to meet daily requirements

‡ Foods to avoid:
± Foods high in Na ± cured meats, pickled foods, canned soup and stew, cold cuts, soy sauce, salad dressing ± Avoid salt substitute because they contain KCl ± Foods high in K ± dried foods, legumes, orange, banana, melons, deep green and deep yellow vegetables, beans and peas. ± Foods high in CHON ± 0.5 g/kg ideal body weight

Diabetes Mellitus ‡ Distribution of daily calories averages: ‡ 50%-60% from CHO ± (of 90% - 95% should be complex carbohydrates) ‡ 20 % from CHON ‡ 30 % from fats (of which 20 % should be polysaturated) ‡ Diet should also include 10 to 15 g of fiber

Hyperthyroidism ‡ High calorie diet ± 4000 to 5000 kcal/day ‡ This is accomplished with six full meals a day and snacks high in CHON, CHO, minerals and vitamins and ascorbic acids ‡ Offering fluids frequently prevent volume deficit to diaphoresis and insensible water loss ‡ Highly seasoned and high fiber food should be avoided. (Hypermotile GI tract) ‡ Avoid coffee, cola and tea ‡ Milk is an excellent food source that provide both Ca and CHON

1. How should the a. Draw up the NPH nurse prepare for an insulin, then the injection for a regular insulin in patient who takes the same syringe both regular and b. Draw the regular NPH insulin? insulin, then the NPH insulin in the same syringe c. Use two separate syringe d. Check with the physician

2. Which of the a. Maintain the drainage tubing and collection following is the bag level with the primary nursing patient¶s bladder intervention necessary for all b. Irrigate the patient with 1% Neosporin solution patients with a three times daily foley catheter in c. Clamp the catheter for place? 1 hour to maintain the bladder elasticity d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.

3. How does a 24-hour a. The first voided specimen is urine collection differ discarded from a simple urinalysis? b. The last voided specimen id discarded c. Urine does not need to refrigerate d. The specimen must be labeled

4. While coughing, a post-op abdominal surgery patient complains of a sudden sharp abdominal pain. The nurse observes that the patient¶s wound edges have separated and the viscera are exposed. The nurse should?

a. Notify the physician immediately b. apply a sterile strip to the wound edges c. Encourage the client to cough harder d. Apply a sterile wet saline compress

5. A hemovac is use to do all of the following except?

a. Promote wound healing b. Remove the drainage from the surgical wound c. Lessen postoperative discomfort d. Prevent wound infection

6. All of the following nursing interventions are correct when using Z tract method of drug injection except?

a. Prepare the injection site with alcohol b. Use a needle that is at least 1 inch long c. Aspirate for blood before injection d. Rub the site vigorously after the injection to promote absorption

7. The best way to instill eye drops is to:

a. Instruct the patient to look upward, and drop the medication into the center of the lower lid. b. Instruct the patient to look ahead, and drop the medication into the center of the lower lid c. Drop the medication into the lower cantus regardless of position d. Drop the medication into the center of the cantus regardless of the position

8. If transfusion reaction occurs, the nurse should:

a. Call the MD and wait the order based on the specific type f reaction b. Stop the transfusion immediately and keep the vein open with saline c. Slow the transfusion rate and observe for an increase in severity of the reaction d. Slow the transfusion and request a venipuncture for retyping to start the second transfusion

9. Gilda, a 19yr-old student, has been sexually assaulted. When assisting the physical examination, the nurse should do all of the following except:

a. Have the patient shower and wash the perineal area before the examination b. Assess and document any bruises and laceration c. Record a history of the event, using the patient¶s own words d. Label all blood clothes and place each item in a separate brown bag so that any evidence can be given to the police

10. What stages of illness is considered when a person comes to believe something is wrong?

a. Medical care contract b. Assumption of sick roll c. Symptoms experience d. Dependent patient roll

11. A client will receive an IM injection. The nurse decided to give it in the dorsogluteal area. The position is:

a. Sim¶s b. Prone c. Prone with toes pointing inward d. standing

12. In giving enema, it is recommended that the enema cannot be held higher than:

a. 12 inches above the patient¶s buttocks b. 12 inches above the floor c. 18 inches above the patient¶s buttocks d. 18 inches above the floor

13. The most common position for taking the blood pressure is:

a. Lying down with arms at heart with palm down b. Sitting with arms at heart level with palm down c. Sitting with arm at the level of heart with palm up d. Lying down with arms at heart level with palm up

14. An unconscious client tend to keep her eyes open. The nurse should give special eye care and be kept closed to prevent:

a. Conjunctivitis b. Corneal scarring c. Development of retinitis d. All of these

15. A 19-yr-old female a. Allow her as much as she need for each is admitted with a meal diagnosis of anorexia b. Explain the nervosa. Which of importance of an the following should adequate diet the nurse include in c. Observe her during the care plan? and one hour after each meal d. Use a random pattern for surprise weight

16. The nurse is giving a. Ask the mother what the child¶s name is medication to an b. Look at sign above the infant. What is the bed that states the best way to assess the child¶s name identity of the infant? c. Compare the bed number with the bed number of the care plan d. Compare the ankle band with the name of the care plan

17. The nurse is caring for a client who has been placed in cloth restraints. To ensure the client¶s safety, the nurse should:

a. Wrap each wrist with gauze dressing beneath the restraints b. Remove the restraints every two hours and inspect the wrists c. Keep the head of the bed flat at all times d. tie the restraints using a square knot

18. An elderly woman receives Digoxin 0.25 mg for treatment of her CHF. Which of the following physiologic responses indicates that the Digoxin is having the desired effect?

1. Increase heart rate 2. Decrease cardiac output 3. Increase urine output 4. Decrease myocardial contraction force

19. The nurse is planning care for a client with cervical radiation implants. Which nursing intervention will be included in the plan of care?

a. Implement strict isolation protocol b. Provide a lead apron fro the client c. Use only disposable supplies and equipment in the client¶s room d. Limit visitors to 30 minutes per day

20.The nurse is planning care for a client who is having a gastroscopy performed. Included in the plan of care for the immediate post gastroscopy period will be*

a. Maintain nasogastric tube b. Assess gag reflex prior to administration of fluid c. Assess frequently for pain and medicate as per MDs order d. Measure abdominal girth every four hours

21. The nurse is caring for a client who is to have a lumbar puncture (LP). How should the client be position during the procedure?

a. Prone with the head turned to the left b. Side-lying in a fetal position c. Sitting at the edge of the bed d. Trendelenburg position

22. A adult client has central line placed for IV fluids. When the nurse enters the room, the IV bottle is empty, the IV line is full of air, and the client is dyspneic. What is the best nursing action?

a. Notify the MD and administer oxygen via nasal cannula immediately b. Hang another IV bag as soon as possible, and remove the air from the IV catheter c. Clamp the tubing and place the client on the left side with the head down d. Begin CPR and call the code team

23. The nurse is caring for the client who has just returned to the nursing unit following a leftabove-the-knee amputation. How should the client be positioned?

a. Place the stump flat on bed to prevent contractures b. Place the stump on a pillow to prevent edema c. Place the client on prone position to prevent contractures d. Place the client in reverse Trendelenburg position to promote arterial flow

24. The nurse is caring for a person during seizure. What is the priority assessment at this time?

a. Present of an aura b. Length of seizure c. What precipitated the seizure d. Type and progression of seizure activity

25. The physician has ordered a sputum specimen for culture and sensitivity. In order to obtain a good specimen, the nurse should:

a. Teach the client to deep breathing and coughing techniques b. Use nasotracheal suctioning c. Obtain the specimen after starting antibiotics d. Withhold food and fluid 30 minutes prior to specimen collection

26. A nurse is called to a client¶s room by another nurse. When the nurse arrives at the room, the nurse discovers that a fire had occurred in the client¶s waste basket. The first nurse has removed the client from the room. What is the second nurse¶s next action?

a. Evacuate the unit b. Extinguished the fire c. Confine the fire d. Activate the alarm

27. A nurse is planning care for a client who is experiencing anxiety following a myocardial infarction. Which nursing intervention should be included in the plan of care?

a. Provide detailed

explanation of all procedures b. Administer cyclobenzaprine (Flexeril) to promote relaxation c. Limit family involvement during the acute phase d. Answer questions with factual information

28. A nurse is caring for a client with type I diabetes mellitus. Which of the following laboratory results would indicate a potential complication associated with this disorder?

a. Blood glucose of 112 mg/dL b. Ketonuria c. Blood urea nitrogen (BUN) 18 mg/dL d. Potassium 4.2 mEq

29. A client has had arterial blood gases drawn. The results are as follows: pH of 7.34, PaCo2 of 37 mm Hg, PaO2 of 79, HCO3 of 19 mEq/L. A nurse interprets that the client is experiencing:

a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

30. A woman comes into an emergency room in a severe state of anxiety following a car accident. The most important nursing intervention at this time would be to:

a. Remain with the client b. Put the client in a quiet room c. Teach the client deep breathing d. Encourage the client to talk about her feelings and concerns

31. A nurse has an order to institute aneurism precautions for a client with a cerebral aneurysm. Which of the following items would the nurse document in the plan of care for this client?

a. Instruct the client not to strain with bowel movements b. Allow the client to read and watch television c. Limit out-of-bed activities to twice a day d. Encourage the client to take his or her own bath

32. A home health care nurse is assessing a client¶s functional abilities and ability to perform activities of daily living (ADL¶s) The nurse focuses the assessment on:

a. Self-care such as toileting, feeding and ambulating b. The normal everyday routine in the home c. Ability to do light housework, heavy house work and pay the bills d. Ability to drive a car

33. A nurse is given instructions on site care to a hemodialysis client who has had a arteriovenous (AV) fistula implanted to the right arm. The nurse determines that the client needs further instructions if the client states an intention to:

a. Avoid carrying heavy objects on the right arm b. Sleep on the right side c. Report increased temperature, redness, or drainage at the site d. Perform range of motion exercises routinely on the right side

34. The nurse is caring for a newly admitted adult client with a diagnosis of Hepatitis A. The MOST significant routine infection control strategy, in addition to handwashing, is

A. Implementing a ventilation flow B. Wearing a mask during care C. Using a gown to change linens D. Gloving while handling bedpans

35. Which of the following nursing diagnosis would place an 86 year-old client at GREATEST risk for falls?

A. Sensory perceptual alterations related to decrease vision B. Alteration in mobility related to fatigue C. Impaired gas exchange related to retained secretions D. Altered patterns of urinary elimination related to Nocturia

36. When suctioning a client with a tracheostomy, which of the following is inappropriate action by the nurse?

a. The nurse initiates suction as the catheter is withdrawn. b. The nurse inserts 3-5 inches of the catheter into the tracheostomy. c. The nurse applies suction for 5-10 seconds d. The nurse uses a new sterile catheter with each insertion

37. After a subtotal gastrectomy, a client was returned to the surgical unit. The nurse can best prevent pulmonary complications by:

a. Helping an oral airway in place b. Maintaining a constant oxygen flow rate c. Promoting frequent turning and deep breathing to mobilize secretions d. Suctioning secretions are necessary

38. The client with Parkinson's disease would most likely manifest which of the following?

a. Intellectual impairment b. Toni-clonic seizures c. Flattened affect d. Changes in sensation

39. A client with cervical injury complains of throbbing headache, blurring vision, and nasal congestion. The nurse should assess for:

a. Bladder distension b. Drop in blood pressure c. Increased pulse rate d. Adventitious breath sound

40. The client had an a. Place a pillow amputation of the between the thigh right lower limb. To b. Lie on the abdomen prevent hip flexion 30 minutes qid contracture, the c. Turn from side to nurse teach the client side every two to: hours d. Perform hamstring muscle setting exercises tid

a. Palpate the femoral 41. To assess the artery of the affected neurovascular leg status of an extremity casted b. Assess the affected leg for positive Homan¶s from the ankle to sign the thigh, the nurse should: c. Compress and release the toenails of the affected foot d. Instruct the client to flex and extend the knee of the affected leg

42. On the first postoperative day after the left modified radical mastectomy, the NCP of the client should include which of the following?

a. Encouraging the client to wear a breast prosthesis b. Keeping the left arm and shoulder immobilize c. Placing the client in semi-Fowler¶s position with left arm and head elevated d. Changing the pressure dressing as necessary

43. The type I diabetic client is on insulin therapy. To avoid lipodystrophy, the nurse should teach the client to do which of the following:

a. Exercise regularly b. Massage the injection site c. Inject insulin at room temperature d. Rotate injection site 1. A, b only 2. a, c, d 3. C, d only 4. b, c, d

44. The nurse is caring for an 82-year-old male client. The client experienced hearing loss caused by aging. The nurse expect which of the following in the client?

a. Copius, moist cerumen b. Difficulty hearing woman¶s voice c. Red/ swollen tympanic membrane d. Hearing better in noisy environment

45. The client had been diagnosed to have angina pectoris. His physician prescribed nitroglycerine SL tablets for chest pain. The nurse should teach a client to suspect that the tablets have lost their potency when:

a. Stinging sensation is experience under the tongue b. The tablets are stored in clear plastic c. Pain is unrelieved but facial flushing is increased d. Onset of relief of chest pain is delayed

46. When taking the blood pressure of a client who has had thyroidectomy, the nurse notices the client has spasm of the hand and notifies the MD. While awaiting the MD;s order, the nurse should prepare for replacement of:

a. b. c. d.

Calcium Magnesium Bicarbonate Potassium chloride

47. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be

a. Elevate the arm no higher than heart level b. Remove the cast c. Assess capillary refill of the exposed hand and fingers d. Apply a warm soak to the hand

48. A client has a serum A) repeat glucose of 385 mg/dl. glycohemoglobin in Which of these 24 hours orders would the B) B) document nurse question first? accuchecks, intake and output every 4 hours C) C) humulin N 20 units IV push D) D) IV fluids of 0.9% normal saline at 125 ml per hour

49. During a fluid exchange for the client who is 48 hours post insertion of the abdominal Tenckhoff catheter for peritoneal dialysis, the nurse knows that the appearance of which of the following needs to be reported to the health care provider immediately?

A) Slight pink tinged drainage B) Abdominal discomfort C) Muscle weakness D) Cloudy drainage

50. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is

a. Reconnect the tube b. Raise the collection chamber above the client's chest c. Call the health care provider d. Clamp the chest tube

51. To prevent a pulmonary embolus in a client on bed rest, the nurse should:

a. Limit the client¶s fluid intake b. Encourage deep breathing and coughing c. Use the knee gatch when the client is in bed rest d. Teach the client to move the legs when in bed

52. In the post anesthesia unit, while caring for the client who has received a general anesthetic, the nurse should notify the physician if the:

a. Client pushes the airway out b. client has snoring respiration c. Respirations are regular but shallow d. Systolic BP drops from 130 to 90 mmHg

53. When teaching a client about orthostatic hypotension, the nurse should explain that it can be modified by:

a. Wearing support stocking continuously b. Lying down for 30 minutes after taking medications c. Avoiding tasks that require high energy expenditure d. Sitting on the edge of the bed a short time before rising

54. A client has edema in the lower extremities during the day and disappears at night. The nurse should suspect:

a. Lung disease b. Pulmonary edema c. Myocardial infarction d. Right ventricular infarction

55. A client is

a. Restrict fluids admitted to the b. Elevate the legs hospital and has c. Apply elastic edematous ankles. bandage To best limit d. Do range of motion edema of the feet, exercise

the nurse should prepare to:

56. Two hours after a cardiac catheterization that was assess via the right femoral route. An adult client is complaining of numbness and pain in the right foot. The nurse should:

a. Call the physician b. Check the client¶s pedal pulses c. Take the client¶s blood pressure d. Recognize that this is an expected response

57. A client has an IV infusion. If the IV infusion infiltrates, the nurse should;

a. Elevate the IV site b. Discontinue the infusion c. Attempt to flash the tube d. Apply warm moist soaks

58. A client receiving an anticoagulant for a pulmonary embolism. The drug that is contraindicated for client receiving anticoagulant is:

a. Ferrous sulfate b. Acetylsalycylic acid c. Isoxsuprine (vasodiland] d. Thorazine

59. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

60. A patient has just A. Check the surgical returned from the dressing to ensure operating room with that it is intact. a retention (Foley) B. Confirm the catheter, an IV, and placement of the oral an oral airway, and airway. is still unresponsive. C. Examine the IV site Which assessment for infiltration. should be made first? D. Observe the Foley for drainage.

61. A nurse is providing A) Increase oral fluid care to a 63 year-old intake client with B) Encourage visits pneumonia. Which from family and intervention friends promotes the client¶s C) Keep conversations comfort? short pneumonia. D) Monitor vital signs frequently

62. The physician orders an arterial blood gas (ABG) for a 50-year-old man receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mmHg, pCO2 42 mmHg, pO2 90 mmHg. The nurse should:

A. increase the rate of oxygen flow the patient is receiving. B. elevate the head of the bed. C. document the results in the chart. D. instruct the patient to cough and deep breathe.

63. When caring for a client who has just had a arteriovenous shunt inserted for hemodialysis, the nurse should:

a. Cover the entire cannula with an elastic bandage b. Use strict aseptic technique when giving shunt care c. Notify the physician if bruits is heard in the cannula d. Take the blood pressure every 4 hours from the arm that contain the shunt

64. Preoperative teaching for a client is to have a cataract surgery should include the importance of:

a. Remaining flat for 3 hours b. Eating a soft diet for 2 days c. Breathing and coughing deeply d. Avoiding bending from the waist

65. When caring for a client after a cardiac catheterization, it is most important that the nurse:

a. Help client to ambulate b. Administer oxygen c. Check the ECG every 30 minutes d. Check the pulse distal to the insertion site

66.The physician a. Withholding all fluid performs a for 72 hours colostomy. During b. Limiting fluid intake the immediate for several days postoperative period, c. Having the client nursing care should change the stoma bag include: d. Keeping the skin around the stoma clean and dry

67. Formation of urinary calculi is a complication that may be encountered by the client with paraplegia. A factor that contributes to this condition is:

a. High fluid intake b. Inadequate kidney function c. Increase intake of calcium d. Accelerated bone demineralization

68. Which client is at highest risk for development of decubitus ulcers?

A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

69. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?

A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

70. It may be redundant that health care provider, including professional nurse, agree to ³do no harm´ to their client. The principle that describes this agreement is called: a. Beneficence b. Accountability c. Nonmaleficence d. Respect for autonomy

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