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Fundamentals of Nursing

Evolution of Nursing
1. PERIOD OF INTUITIVE NURSING since prehistoric times through early Christian era Nursing was untaught & instinctive, performed out of compassion for others Beliefs and Practices of Prehistoric Man Nursing was a function that belonged to women taking care of the children, the sick and the aged. Believed that illness causes the invasion of evil spirit through the use of black magic or voodoo. Believed that medicine man was called shaman or witch doctor having the power to heal using white magic. They also practiced trephining or drilling a hole in the skull with a rock or stone without anesthesia as a last resort to drive evil spirits from the body.

Contributions to Medicine and Nursing Babylonia a. Code of Hammurabi provided laws that covered every facet of Babylonian life including medical practice and recommended specific doctors for each disease and gave each patient the right to choose between the use of charms, medications or surgical procedures. Egypt a. Introduced the art of embalming b. Developed the ability to make keen observation and left a record of 250 recognized diseases c. Slaves and patients families nursed the sick Israel -Moses was recognized as the Father of Sanitation and wrote in Old Testament which: a. Emphasized the practice of hospitality to strangers and acts of charity b. Promulgated laws of control on the spread of communicable disease and the ritual of circumcision of the male child c. Referred to nurses as midwives, wet nurses or childs nurses whose acts were compassionate and tender China a. Believed that in using girls clothes for male babies keep evils away from them b. Prohibited the dissection of dead human body as a worship to ancestors c. They gave the world knowledge of material medica (pharmacology) India a. Men of medicine built hospitals, practiced an intuitive form of asepsis and were proficient in the practice of medicine and surgery b. Sushurutu made a list of function and qualifications of nurses. This was the first reference to nurses taking care of the patients. Ancient Greece a. Nursing was the task of untrained slave b. Introduced caduceus, the insignia of medical profession today c. Hippocrates was given the title of Father of Scientific Medicine. He made major advances in medicine by rejecting the belief that diseases had supernatural causes. He also developed assessment standards for clients, established overall medical standards, recognized a need for nurses.

Rome a. b. c.

The Romans attempted to maintain vigorous health, because illness was a sign of weakness Care of the ill was left to the slaves or Greek physicians. Both groups were looked upon as inferior by Roman society. Fabiola made her home the first hospital in the Christian world through the help of Marcella and Paula

2. PERIOD OF APPRENTICE NURSING extends from founding or religious nursing orders and ended in 1836 when KAISERWERTH INSTITUTE for the training of DEACONESSES in Germany was established Called Period of On-the-Job training

Crusades a. b. Military religious orders established hospitals staffed with men Knights of Lazarus was founded and primarily for the nursing care of lepers in Jerusalem after the Christians had conquered the city.

Rise of Secular Orders a. b. c. d. e. f. g. Religious taboos and social restrictions influenced nursing at the time of the Religious Nursing orders Hospitals were poorly ventilated and the beds were filthy There was overcrowding of patients: 3 or 4 patients regardless of diagnosis or whether dead or alive, may have shared one bed. Practice of environmental sanitation and asepsis were non-existent Older nuns prayed with and took good care of the sick, while younger nuns washed soiled linens, usually in the rivers. St. Catherine of Siena. The first Lady with a Lamp. She was a hospital nurse, prophetess, researcher and a reformer of society and the church. th In 16 century, hospitals were established for the care of the sick where hospitals were gloomy, cheerless, airless and unsanitary. People entered hospitals only under compulsion or as a last resort.

3. DARK PERIOD OF NURSING th th extends from period of reformation until US Civil War (17 to 19 century) Unity of Christian faith destroyed by Martin Luther No provisions for the sick Nursing became work of least desirable women 4. PERIOD OF EDUCATED NURSING begin when Florence Nightingale School of nursing opened Strongly influenced by the war, social consciousness, emancipation of women & increased educational opportunities offered to women 5. PERIOD OF CONTEMPORARY NURSING covers after WorldWarII to present Scientific & technological developments & social changes mark this period

Early Beliefs and Practices a. b. c. Beliefs about causation of disease (evil spirits, enemy or a with) People believed that evil spirits could be driven away by persons with powers to expel demons People believed in special gods of healing, with the priest-physician and Herbolarios

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Superstitious beliefs and practices in relation to health and sickness such as Herbmen or Herbicheros as one who practiced witchcraft Persons suffering from diseases without identified cause were believed to be bewitched by mangkukulam.

Spanish Period a. b. The religious orders exerted their efforts to care for the sick by building hospitals in the different parts of the Philippines Earliest hospitals established: Hospital real de Manila (1577) built to care for the Spanish kings soldiers San Lazaro Hospital (1578) built exclusively for patients with leprosy Hospital de Indio (1586) established by Franciscan Order; service was in general supported by alms and contributions from charitable individuals. Hospital de Aguas Santas (1590) founded by Brother J. Bautisita of the Franciscan Order. San Juan de Dios Hospital (1596) Founded by the Brotherhood of Misericordia and administered by the Hospitalliers of San Juan de Dios; support was derived from alms and rents; rendered general health service to the public.

Nursing during Philippine Revolution Prominent persons involved in nursing works Josephine Bracken installed a first hospital in an estate house in Tejeros; provided nursing care to the wounded night and day Rosa Sevilla de Alvero converted their house into quarters for the Filipino soldiers, during the Philippine-American War that broke out in 1899. Dona Hilaria de Aguinaldo wife of Emilio Aguinaldo; organized Filipino Red Cross under the inspiration of Apolinario Mabini Dona Maria Agoncillo de Aguinaldo econd wife of Emilio Aguinaldo; provided nursing care to Filipino soldiers during revolution. President of Filipino Red Cross branch in Batangas Melchora Aquino Nursed the wounded Filipino soldiers and gave them shelter and food Capitan Salome a revolutionary leader in Nueva Ecija; provided nursing care to the wounded when not in combat Agueda Kahabagan revolutionary leader in Laguna, also provided nursing services to her troops Trinidad Tecson Ina ng Biac na Bato, stayed in the hospital at Biac na Bato to care for the wounded soldiers. Filipino Red Cross Malolos, Bulacan was the location of the national headquarters Functions: a. Collection of war funds and materials through concerts, charity bazaars, and voluntary contributions b. Provision of nursing care to wounded Filipino soldiers Requirements for Membership a. At least 14 years old, age requirement for officer was 25 years old b. Of sound reputation

Hospitals and Schools of Nursing 1. Iloilo Mission Hospital School of Nursing (Iloilo City, 1906) a. It was run by the Baptist Foreign Mission Society of America. In March, 1944, 22 nurses graduated; in April 1944 graduate nurses took the first Nurses Board Examination at the Iloilo Mission Hospital.

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St Pauls Hospital School of Nursing (Manila, 1907) Established by the Archbishop of Manila, the Most Reverend Jeremiah Harty under the supervision of the Sisters of St. Paul de Chartes. It was located in Intramuros and it provided general hospital services with free dispensary and dental clinic a. Philippine General Hospital School of Nursing (1907) i. Anastacia Giron-Tupas, the first Filipino nurse to occupy the position of chief nurse and superintendent in the Philippines St. Lukes Hospital School of Nursing (Quezon City, 1907) Mary Johnston Hospital and School of Nursing (Manila, 1907) Philippine Christian Institute Schools of Nursing a. Sallie long Read memorial Hospital School of Nursing (Laoag, Ilocos Norte, 1903) b. Mary Chiles Hospital School of Nursing (Manila, 1911) c. Frank Dunn Memorial Hospital (Vigan, Ilocos Sur, 1912) San Juan de Dios School of Nursing (Manila, 1913) Emmanuel Hospital School of Nursing (Capiz, 1013) Southern Islands Hospital School of Nursing (Cebu, 1918)

First Colleges of Nursing in the Philippines 1. University of Santo Tomas College of Nursing (1946) 2. Manila Central University College of Nursing (1947) 3. University of the Philippines College of Nursing (1948) Nursing Leaders in the Philippines 1. Anastacia Giron-Tupas First Filipino nurse to hold the position of Chief Nurse Superintendent; founder of Philippine Nurses Association 2. Cesaria Tan First Filipino to receive a Masters degree in Nursing abroad 3. Socorro Sirilan pioneered in hospital social service 4. Rosa Militar a pioneer in school health education 5. Sor Ricarda Mendoza pioneer in nursing education 6. Conchita Ruiz first full-time editor of the newly named PNA magazine The Filipino Nurse 7. Loreto Tupaz Dean of the Philippine Nursing; Florence Nightingale of Iloilo

Concept of Health and Illness


WHO (World Health Organization) Health is a state of complete physical, mental & social well-being, and not merely the absence of disease/infirmity CLAUDE BERNARD Health is the ability to maintain the internal milieu. Illness is the result of failure to maintain the internal environment. WALTER CANNON Health is the ability to maintain homeostasis or dynamic equilibrium. NIGHTINGALE Health is being well & using ones power to the fullest extent. Health is maintained through prevention of disease via environmental health factors. HENDERSON Health is maintained through the individuals ability to perform 14 components of nursing care unaided.

ROGERS Positive health symbolizes wellness. ROY Health is a state & process of being & becoming an integrated & whole person. OREM Health is a state characterized by soundness or wholeness of developed human structures & of bodily & mental functioning KING Health is a dynamic state in the life cycle, illness is an interference in the life cycle. NEUMAN Wellness is the condition in which all parts & subparts of an individual are in harmony with the whole system JOHNSON Health is reflected by the organization, interaction, interdependence & integration of the subsystems of the behavioral system.

NURSING THEORIES
FLORENCE NIGHTINGALE - developed First Theory of Nursing - Focused on changing & manipulating environment to put patient in best possible condition Environment includes noise, nutrition, light, hygiene, comfort socialization and hope VIRGINIA HENDERSON - Nature of Nursing Model - Identified 14 basic needs - Nurses assists sick and well clients FAYE ABDELLAH - Patient-Centered Approach to Nursing - Identified 21 nursing problems - Nursing is service to individuals, families and therefore to society DOROTHY E. JOHNSON - Behavioral System Model - Each person has 7 subsystems: ingestive, eliminative, affiliative, aggressive, dependence, achievement, sexual & role identity behavior IMOGENE KING - Goal Attainment Theory - Nursing assists individuals & groups to attain, maintain & restore health MADELEINE LEININGER - Transcultural Nursing Model - Nursing is humanistic & scientific mode of helping client thru specific cultural caring processes to improve or maintain health condition MYRA LEVIN - Four Conservation Principles - Conservation of energy, structural integrity, personal integrity and social integrity BETTY NEUMAN - Health Care System Model - Nursing is a unique because it is concerned with all variables affecting response to stresses which are intra, inter and extrapersonal in nature

DOROTHEA OREM - Self Care & Self-Care Deficit Theory - Conceptualized 3 Nursing Systems: - Wholly Compensatory, Partially Compensatory & Supportive-Educative HILDEGARD PEPLAU - Interpersonal Model - Nursing as interpersonal process of therapeutic interactions between an individual who is sick and a nurse who is especially educated to recognize & respond to the need - 4 Phases on Nurse-Client Relationship: Orientation, Identification, Exploitation, Resolution MARTHA ROGERS - Science of Unitary Human Beings - Man is an energy field in constant interaction with the environment - Humans are more than & different from the sum of their parts SISTER CALLISTA ROY - Adaptation Model - Each person is a unified biopsychosocial system in constant interaction wit a changing environment - Man has needs with 4 Modes: physiological, self-concept, role function, interdependence - Believed that adaptive human behavior is directed at an attempt to maintain homeostasis LYDIA HALL - Introduced model on Nursing:What Is It? - Focused on 3 Components: CARE(nurturance,exclusive to nursing, CORE(therapeutic use of self, uses reflection) & CURE (nursing related to physicians orders) IDA JEAN ORLANDO - Dynamic Nurse-Patient Relationship Model - Nurse helps patients meet a perceived need that patients cannot meet for themselves - Emphasized need of validating need & evaluating care based on outcomes - 3 Elements of Nursing Situation: client behavior, nurse reaction and nurse action ERNESTINE WEIDENBACH - Clinical Nursing A Helping Art Model - Components of Clinical Practice are: Philosophy, purpose, practice and art - Nurses meet individual needs thru identification of need, administration of help and validation of action JEAN WATSON - Human Caring Model - Nursing is an art & science thru transpersonal transactions to help persons achieve mind-body-soul harmony which will generate self-knowledge, self-control, self-care, self-healing ROSEMARIE RIZZO PARSE - Theory of Human Becoming - Emphasized free choice in value priorities - Believes that each choice opens certain opportunities while closing others - Referred as: revealing-concealing, enabling-limiting & connecting-separating - Each has own choice, therefore nurse acts as guide NOT decision-maker

MODELS OF HEALTH & ILLNESS 1. Health Illness Continuum 2. Health Belief Model (HBM) 3. Smiths Models of Health 4. Leavell & Clarks Agent-Host-Environment Model (Ecologic Model) 5. Health Promotion Model

Health Promotion Programs and Health Screening


A. Blood pressure screening 1. Screening should be done annually beginning at age 21 for both males and females 2. Screening for children and adolescents is also recommended but optimal interval has yet to be determined 3. Auscultatory method with a properly calibrated and fitting cuff should be used 4. Person should be seated quietly in a chair for at least five minutes with feet on the floor and arms supported at heart level 5. At least two measurements should be done, two minutes apart 6. Pre-hyerptensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction, exercise, diet, and smoking cessation 7. SBP > 140 and / or DBP > 90 should be referred to a health care provider for antihypertensive drug therapy B. Breast self-examinations 1. Should be started by age twenty 2. Done at the same time of the month - preferably seven days after onset of the menstrual cycle; if no menstrual cycles, do at the same time each month 3. Technique should be reviewed by a health care provider to ensure effectiveness 4. Limited effectiveness, but when done regularly helps a woman understand how her breasts normally feel. 5. Most changes are benign, but unusual or spontaneous changes should be checked by a health a. lump or thickening (breast or underarm) b. red or hot skin c. orange peel skin d. dimpling or puckering e. itch or rash, especially in nipple area f. retracted nipple g. change in direction of nipple h. bloody or spontaneous discharge i. unusual pain j. a sore on the breast that does not heal C. Risky behaviors - assist in assessment of behaviors that impact the health of individuals in the following developmental stages 1. Adolescents (age 13-19) a. eating disorders anorexia nervosa - restrictive eating bulimia nervosa - binge eating followed by purging b. injury prevention wearing of seat belts wearing of helmets sports injuries homicide and suicide c. substance abuse tobacco underage drinking illicit drug use d. sexual behavior number of sex partners use of contraception unintended pregnancy

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exposure to sexually transmitted diseases

Young adult (age 20-35) a. eating disorders - onset of obesity b. injury prevention motor vehicle accidents occupational hazards homicide and suicide c. substance abuse tobacco alcohol use illicit drug use d. sexual behavior sexually transmitted disease - use of condoms unintended pregnancy e. stress 1. changing roles a. marriage b. beginning a new family c. starting a new job 2. depression

middle adult (age 35-65) a. obesity b. lack of exercise c. substance abuse 1. tobacco 2. alcoholism 3. illicit drug use d. lack of preventative health care e. stress 1. job 2. family / divorce 3. acceptance of aging 4. older adult (age 65 and older) a. obesity b. lack of exercise c. substance abuse 1. tobacco 2. alcoholism 3. illicit drug use d. injury prevention 1. falls 2. seatbelts 3. suicide 4. multiple medications D. Scoliosis screening 1. Recommendations vary but generally accepted to perform screening at onset of adolescence 2. Significantly more prevalent in girls than boys 3. Early intervention important because untreated scoliosis can lead to disfigurement, impaired mobility, and cardiopulmonary complications

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Technique: clothing should be removed from upper body a. while standing, check adolescent for asymmetry of shoulders, scapula, hips, or waist b. assess for misalignment of spinous processes - lateral curvature and convexity of thoracic spine indicate scoliosis c. with feet together and legs straight, have adolescent bend forward until back is parallel to floor; check for prominence of ribs on one side only and hip and leg asymmetry - chest wall on side of convexity is prominent and scapula on side of convexity is elevated 5. Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures Testicular self-examinations 1. Monthly self-examination should begin in adolescence, since this is the highest risk group 2. Best time to perform exam is during or after a bath or shower when the scrotum is relaxed 3. Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as a. family history of testicular cancer b. cryptochidism c. previous germ cell tumor in one testicle 4. Findings that should be reported to a health care provider include a. hard lumps or nodules b. change in size, shape, or consistency of the testes

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Illness and Disease


ILLNESS personal state in which the person feels unhealthy - State where the persons physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired - Not synonymous with DISEASE DISEASE alteration in body functions resulting in reduction of capacities or shortening of normal life span STAGES OF ILLNESS 1. SYMPTOM EXPERIENCE - Transition stage - 3 aspects: physical, cognitive, emotional

2. ASSUMPTION OF SICK ROLE - Acceptance of the illness - Seeks advice, support, decision 3. MEDICAL CARE CONTACT - Seeks advice of health professionals: validation, explanation, reassurance 4. DEPENDENT PATIENT ROLE - Person becomes client dependent on health professional - Accepts / rejects HPs suggestions

Becomes more passive and accepting May regress to an earlier behavioral stage

5. RECOVERY / REHABILITATION - Gives up sick role & returns to former roles/functions

CLASSIFICATION OF DISEASES
ACCORDING TO ETIOLOGIC FACTORS 1. Hereditary defect in genes of 1 or both parent transmitted to offspring 2. Congenital present at birth; defect in development, hereditary factors, prenatal infection 3. Metabolic disturbance in the process of metabolism 4. Deficiency from inadequate intake or absorption of essential dietary factors 5. Traumatic due to injury 6. Allergic abnormal response of body to chemical or protein subs or physical stimuli 7. Neoplastic abnormal or uncontrolled growth of cells 8. Idiopathic unknown cause, self-originated, spontaneous origin 9. Degenerative from degenerative changes that occur in tissues or organs 10. Iatrogenic from treatment of a disease ACCORDING TO DURATION OR ONSET 1. Acute Illness - has short duration & severe - S/S occurs abruptly , are intense & subsides after a relatively short period of time 2. Chronic Illness - persists, longer than 6 months and can affect functioning & may fluctuate between maximal functioning & serious relapses that may be life threatening & characterized by remission & exacerbation - REMISSION- period where the disease is controlled & symptoms are not obvious - EXACERBATION- disease becomes active again with pronounced symptoms 3. Sub- Acute symptoms are pronounced but more prolonged than in acute disease

LEVELS OF PREVENTION
1. PRIMARY PREVENTION - encourage optimal health & increase persons resistance to illness - seeks to prevent disease or condition at a prepathologic state - Health Promotion, Specific Protection - ACTIVITIES: quit smoking, avoid alcohol, regular exercise, well-balanced diet, reduce fat, increase fiber, adequate fluids, maintain ideal body weight, complete immunization program SECONDARY PREVENTION - known as health maintenance - seeks to identify specific illness/condition at an early stage with prompt intervention to prevent or limit disability - Early Diagnosis, Detection, Screening, Prompt Treatment - ACTIVITIES: annual physical exam, regular PAP smear, monthly BSE, sptum exam for TB TERTIARY PREVENTION - support clients achievement of successful adaptation to known risks, optimal reconstitution or establishment of high-level wellness

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occurs after a disease or disability has occurred & recovery process has begun seeks to halt the disease or injury process & obtain optimal health status ACTIVITIES: self monitoring of CBG among diabetics, PT after CVA, cardiac rehab, attending selfmanagement education, speech therapy after laryngectomy

PHYSICAL EXAMINATION CEPHALOCAUDAL approach Determine mental status and LOC Protect clients privacy during entire procedure Prepare needed materials before starting procedure

MODES OF EXAMINATION: 1. 2. 3. 4. INSPECTION uses sense of sight PALPATION uses sense of touch PERCUSSION tapping body parts to produce sounds AUSCULTATION listening to body sounds with a stethoscope

POSITIONS 1. 2. 3. 4. 5. DORSAL RECUMBENT back-lying position with knees flexed, hips externally rotated DORSAL/SUPINE- back-lying with or without pillow SITTING OR SEATED- back unsupported & legs hanging freely LITHOTOMY- back-lying with feet supported in stirrups FOWLERSa. Semi-Fowlers head of bed elevated at 15-45 degrees angle b. High Fowlers head of bed raised at 80-90 degrees angle GENUPECTORAL/KNEE-CHEST- kneeling with torso at 90 degrees angle to hips LATERAL side-lying position SIMS semi prone PRONE-face lying position with head turned to sides/abdomen-lying position

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Health Assessment 1. Purposes of health assessment a. data collection b. supplement, confirm or refute historical data c. identify changes in client's status d. evaluate the outcomes of care Components of health assessment: history and physical a. History I. chief complaint a. location b. quality c. quantity d. precipitating or aggravating factors e. duration f. associated findings II. general health status III. medical history IV. family history V. social history

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occupation activity level sleep nutrition medications; including substance use/abuse psychosocial factors

Physical exam: skills 1. Inspection a. process of observing the differences between normal physical signs and deviations b. requires knowledge of normal physical signs throughout the lifespan c. principles of Inspection - in good lighting and with whole body part visible - observe each area for size, shape, color, and position - compare body parts bilaterally for symmetry 2. Palpation a. use touch to assess resistance, resilience, roughness, texture and mobility b. palpation may be either light or deep in pressure - use light palpation to determine tenderness - deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs c. use palmar surface of fingers to determine position, texture, size, consistency, and pulsation; also presence and shape of mass d. use back of hand to test temperature e. use palm of hand to sense vibration

Percussion a. tap the body with fingertips: to detect fluid, or to assess location, size, density and borders of organs. b. tapping the body produces vibration and sound waves which you hear as percussion tones c. methods direct: striking the body surface with two fingers indirect: striking the middle finger of the nondominant hand on the back surface with the fingers of the dominant hand rather than the body surface, while keeping the palm and remaining fingers off the body d. character of percussion sounds depends on the density of the tissue being percussed. Characteristics of Percussion Sounds a. Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such as the stomach b. Resonance: Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungs

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Hyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in the presence of trapped air (such as emphysematous lung) d. Flatness: Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle Dullness: Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver) Auscultation a. listening (with unassisted ear or stethoscope) to sounds made by the body b. assess presence of sounds and their character - frequency (high or low pitch) - loudness (loud or soft) - quality (blowing, gurgling, booming, thudlike, hollow, flat) - duration (short, moderate, long) reporting general appearance and behaviors o gender and race o age o obvious signs of distress o body type o posture o gait o body movements o hygiene o dress o affect and mood o speech

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Health Assessment by Body Part Eye


1. History a. current findings b. past problems c. family history - glaucoma, cataracts d. harmful exposure - chemical sunlight Physical exam a. vision test b. extraocular muscle functions (EOM's) c. external eye structures d. internal eye structures and red reflex e. optic disc f. retinal vessels Geriatric alterations of eye a. arcus senilis - Opaque white ring about the periphery of the cornea, seen in aged persons; caused by the deposit of fat granules in the cornea or by hyaline degeneration. b. pupils often miotic (smaller) with slower dilation c. iris may appear paler d. retina may appear paler e. disc may be slightly smaller and more opaque

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presbyopia color perception may be dimmed

Ear
1. History a. presenting problem or injury b. presence of hearing loss c. use of hearing assist d. associated findings e. onset f. precipitating factors g. aggravating and alleviating factors h. lifestyle factors: swimming, musician i. medical history j. family history of allergy or hearing disease k. medications Inspection - external ear a. observe size, shape and symmetry of both ears b. auricles are normally level with each other, and upper point of attachment is in a straight line with the lateral canthus of the eye c. inspect ear skin for color, lesions, rash and scaling d. inspect area behind auricle for tophus (A deposit of sodium biurate in tissues near a joint, in the ear, or in bone in gout) Palpation a. palpate auricle, tragus and mastoid area for tenderness and elevated local temperature b. normal findings: auricle is normally smooth without lesions c. estimate size of external auditory meatus Otoscopic examination a. adult: grasp auricle and pull up and back to straighten external ear canal before inserting otoscope b. child: grasp auricle and pull down and back c. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies d. expect a small amount of moist, usually orange cerumen (ear wax). Cerumen is usually dry in Asians, Native Americans, and the elderly e. tympanic membrane - normal finding: translucent, shiny, light gray, taut disk; free from tears or breaks - test its mobility: ask client to say "ah" or swallow. Intact membrane will vibrate slightly Hearing acuity: Four tests a. gross hearing is tested by client's response to normal conversation b. whispered word or ticking watch test c. Weber test: tuning fork of 512 cps is set to vibrate and placed perpendicularly on the midline vertex of the skull. Client asked to report in which ear sound is heard. If heard in one ear, suspect sensorineural loss in the other d. Rinne test - compares sound conduction: air versus bone - set tuning fork to vibrate - place on mastoid process - ask client whether the sound is heard and when it can no longer be heard. Note how long the sound can be heard. - when client states that sound is gone, immediately move the tuning fork to about 2 cm from auditory canal

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ask the client again whether there is sound and when it stops normal finding: latter sound should be heard twice as long as that of mastoid sound Geriatric alterations a. ear lobes may appear pendulous b. presbycusis -

Mouth and Pharynx


1. Inspection: normal findings a. temporomandibular joint: smooth jaw excursion; easy mobility b. lips and buccal mucosa: symmetrical, pink; smooth and moist c. teeth and gums: 32 adult teeth; pink gums d. tongue: symmetry; pink; moist; papilla present e. hard and soft palate: hard palate is pale, immovable with transverse rugae; soft palate is pink and movable f. Oropharynx: symmetrical; midline uvula, tonsils may be present on either side Geriatric alterations a. mucosa may be drier b. sense of taste may be diminished c. decreased saliva d. lips thinner, shiny e. teeth may appear yellowish f. tongue may appear smoother

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Skin
1. General Appearance - Inspection a. Color a. varies with body part, and from person to person b. color ranges - "white" skin: Ivory or light pink to ruddy pink - dark skin: light to dark brown or olive b. Alterations in skin color - hyperpigmentation - hypopigmentation - cyanosis - jaundice - erythema c. Moisture d. Temperature e. Texture: varies from part to part - smooth or rough - supple or tight - indurated f. Turgor - normally decreases with age - decreased in dehydration g. Vascularity - in older people, capillaries are more fragile - petechiae h. Edema i. Lesions normal finding: free of lesions

age-related changes include keratosis senilis, cherry angiomas, and atrophic warts. Primary lesions 1. Macule - Discolored spot or patch on the skin, neither elevated nor depressed, of various colors, sizes, and shapes 2. Papule - A small, red, elevated area on the skin, solid and circumscribed; a pimple 3. Patch - A small circumscribed area distinct from the surrounding surface in character and appearance. 4. Plaque - A patch on the skin or on a mucous surface 5. Vesicle = A small sac or bladder containing fluid. *A blisterlike small elevation on the skin containing serous fluid. 6. Bulla = A large blister or skin vesicle filled with fluid; a bleb 7. Pustule - A small elevation of the skin filled with lymph or pus 8. Nodule - A small node Secondary lesions (arise from primary) 1. scale 2. crust 3. lichenification 4. scar 5. excoriation 6. ulcer 7. fissure 8. keloid 9. erosion For every lesion, note eight aspects: 1. color 2. location 3. texture 4. size 5. shape 6. type 7. grouping

Heart
1. 2. Assess the heart through the anterior thorax (front chest) Inspection and palpation a. Client in supine position or with head elevated at 45 degrees b. Anatomical landmarks of the heart 1. second right intercostal space - aortic area 2. second left intercostal space - pulmonic area 3. third left intercostal space - Erb's point 4. fourth left intercostal space - tricuspid area 5. fifth left intercostal space - mitral (apical) area 6. epigastric area at tip of sternum c. Apical impulse 1. fourth or fifth left intercostal space, midclavicular line 2. may or may not be seen 3. normally a short, gentle tap

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Auscultation a. client takes three positions: sitting, supine, left lateral recumbent b. use stethoscope to auscultate heart sounds c. S1 - closing of the mitral valve - after long diastolic pause and - before short systolic pause - heard best at apex d. S2 e. f. closing of aortic valve after short systolic pause and before long diastolic pause heard best over aorta - second right interspace high pitched, dull in quality

Pulse deficit Murmurs

CLASSIFYING HEART MURMURS BY INTENSITY


Grade I: Difficult to hear, even with stethoscope Grade II: Quiet, heard with stethoscope Grade III: Moderately loud, no thrill Grade IV: Loud, may have a thrill Grade V: Very loud, heard with a stethoscope partially off chest; has thrill Grade VI: Can be heard with a stethoscope off chest; has a thrill

Vasculature
1. Blood Pressure a. Reflects relationship between cardiac output, peripheral vascular resistance, blood volume and viscosity, and arterial elasticity b. Factors influencing blood pressure 1. age 2. stress 3. race 4. drugs 5. diurnal (day-night) variations 6. gender c. Alterations in blood pressure 1. hypertension 2. hypotension d. Range of normal blood pressure 1. child under age 2 weighing at least 2700g: use flush technique, 3060mg Hg child over age two: 85-95/50-65 mm Hg 2. school age: 100-110/50-65 mm Hg 3. adolescent: 110-120/65-85 mm Hg 4. adult: <130 mm Hg Systolic / <85 mm Hg diastolic

BLOOD PRESSURE (BP) Common Mistakes during Upper Extremity BP Checks Too wide a bladder or cuff produces false low reading Too narrow a bladder or cuff produces false high reading Cuff wrapped too loosely produces a false high reading Deflating cuff too slowly produces false high diastolic reading Deflating cuff too quickly produces a false low systolic and false high diastolic reading Inaccurate inflation level produces a false low systolic reading Taking the blood pressure in lower extremities

Peripheral BP Measurement in the legs Use the popliteal artery behind knee as a stethoscope auscultatory site Position the client prone or sitting with knees slightly flexed Use wide, long cuff; wrap it so that the bladder is over the posterior aspect of midthigh Systolic blood pressures in legs are 20-40 mmHg higher than in the brachial artery Diastolic pressure in the legs is about the same as in the brachial artery 2. Internal carotid arteries in neck a. palpate each separately along margin of sternocleidomastoid b. normal findings: strong thrusting pulse c. auscultate both sides d. normal findings: no sound heard e. constriction causes bruit Jugular veins a. client in supine position with head elevated at 45 degrees b. normal findings: pulsations not evident c. jugular venous pressure (JVP): not to exceed 3 cm above level of sternal angle Peripheral arteries and veins a. Pulse - locations

3.

4.

LOCATIONS OF PULSES Head - Neck 1. Temporal: over temporal bone lateral to eye 2. Carotid: over the carotid artery in neck Chest 3. Apical: between 4th and 5th intercostal space usually mid-clavicular line Arm 4. Brachial: in the antecubital area of arm 5. Radial: on thumb side of wrist 6. Ulnar: medial wrist Leg 7. Femoral: below the inguinal ligament 8. Popliteal: behind the knee 9. Posterior tibial: on inner side of each ankle 10. Dorsalis pedis: along top of foot

b.

Normal range of peripheral pulses - infants: 120 to 160 beats/minutes - toddlers: 90 to 140 beats/minutes - preschool/school-age: 75 to 110 beats/ minute - adolescent/adult: 60 to 100 beats/minute Rhythm - regular (normal) or irregular Strength - reflects volume of blood ejected with each beat - grading system

c. d.

PULSE GRADING SCALE


No pulse-0 Weak pulse-1+ Difficult to palpate-2+ Normal-3+ Bounding-4+ e. f. g. h. equality alterations dysrhythmias tissue perfusion - Temperature - Color: cyanosis - Clubbing - Edema

Pitting Edema Grading Scale 1+ Barely detectable-0 to inch pitting(mild) 2+ Indentation of <5mm- to inch pitting(moderate) 3+ Indentation of 5-10mm- to 1 inch pitting(severe) 4+ Indentation of >10mm- greater than 1 inch(severe)

Lungs 1. 2. History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever Inspection a. General appearance: respirations - breathing should be quiet and easy - respiration involves ventilation, diffusion, and perfusion of gases - factors influencing respirations exercise pain anxiety stress anemia posture drugs: narcotics, amphetamines - Normal rates of Respiration

newborn: 35 to 40 breaths/minute infant: 30 to 50 breaths/minute toddler: 25 to 35 breaths/minute school age: 20 to 30 breaths/minute adolescent/adult: 14 to 20 breaths/minute adult: 12 to 20 breaths/minute

Depth: deep, normal, shallow Rhythm: regular, irregular; Normal finding: regular Skin color Chest wall configuration normal findings: symmetrical with bilateral muscle development a-p to transverse ratio range: 1 to 5: 2 to 7

3.

Palpation a. feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry b. crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneumothorax) c. vocal fremitus - vibration felt when patient speaks - increased over areas of consolidation Percussion - normal findings: resonance heard throughout lung fields Auscultation a. normal findings: quiet breathing throughout all lung fields b. whispered pectoriloquy - client whispers "one, two, three" - over normal areas of the lung, only faint sounds are heard - over consolidated areas, the words are more distinct c. Egophony - client says "E" - over consolidated areas, the sound is a nasal "A" Alterations in lung function 1. cough 2. expectoration 3. dyspnea 4. bradypnea 5. tachypnea 6. hyperpnea 7. apnea 8. Cheyne-Stokes respiration 9. Kussmaul's breathing 10. Biot's breathing 11. grunting 12. retractions 13. hemoptysis 14. pain 15. accessory muscle use 16. cyanosis 17. adventitious sounds

4. 5.

6.

a.

Pursed-lip breathing prolonged exhalation breathing out through puckered lips

b.

Pleural friction rub -

7.

grating sound produced by inflamed pleura rubbing together usually heard loudest over lower lateral anterior chest at end of inspiration Pediatric differences a. smaller, shorter, more pliable airways, b. underdeveloped supporting cartilage c. above two factors increase the risk of obstruction due to mucus, edema, or foreign body d. flexible larynx more susceptible to spasm e. immature immune system f. incomplete myelinization g. increased basal metabolic rate h. decreased ability to mobilize secretions i. less forceful cough

Breasts
1. Inspection (performed with client in lying, sitting, or standing position) a. b. c. d. size: vary from convex to pendulous symmetry (the left breast is commonly larger than the other) skin: color, venous pattern, possibly a few hairs around areola Alterations - retraction - dimpling - lesions - edema - inflammation - alterations with pregnancy and lactation enlargement of breasts soreness of nipples during lactation possible striae Nipple and Areola - size - color: ranges from pink to brown - shape areola: round or oval nipples: everted - symmetry: normally symmetrical - direction: normally nipples point in same direction Alterations

e.

f.

discharge inverted nipples bleeding

2.Palpation - Breast - Lymph nodes - normal findings: not palpable - Breast tissue 1. client in supine position with hand placed behind neck 2. methods of examining breast tissue a. clockwise or counterclockwise circling breast from nipple outward b. back and forth with fingers moving up and down each breast 3. consistency: a. varies widely from person to person b. normal findings: dense, firm and elastic 4. alteration - fibrocystic disease of the breast 5. Geriatric alterations relaxed breasts may appear elongated or pendulous decrease in glandular tissue Abdomen 1. History a. pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping b. changes in micturition including: change in amount and color of urine, irritation of the lower urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain Inspection a. Landmarks - Xiphoid process: marks upper boundary of abdomen - Symphysis pubis: marks lower boundary - abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ - Normal findings - skin texture and color should be consistent with rest of body - stria may be present - umbilicus is normally flat or concave midway between xiphoid and symphysis pubis - abdomen may be flat, concave or convex; all three are normal if there is symmetry - you may note peristalsis movement or aortic pulse - voiding: steady, straight stream with no pain or post void dribble Percussion a. normal findings: tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150cc) bladder b. Liver border - usually noted in the 5th, 6th or 7th intercostal space - distance between upper and lower borders should range between 6 to 12 cm at right midclavicular line c. Spleen

2.

3.

4.

left posterior midaxillary line: dullness at 6th to 10th rib left intercostal space in anterior axillary line: tympany

5.

6.

7.

Palpation a. normal findings: soft with no palpable masses, no tenderness or rigidity b. bladder noted as a bulge in abdomen when filled with more than 500cc of urine c. deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable Auscultation a. bowel motility - normal findings: audible in all quadrants b. vascular sounds - normal findings i. no vascular sounds over aorta or femoral arteries ii. renal artery bruits can be heard Alterations a. distention b. ascites c. paralytic ileus d. borborygmus e. guarding (muscles contract) f. tenderness g. pain Geriatric alterations a. increased fat deposits over abdominal area b. muscle tone more lax

Musculoskeletal 1. 2. History: participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living Inspection - gait - normal findings: client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through - posture and balance - normal findings upright stance with parallel alignment of hips and shoulders feet aligned; toes pointing straight ahead convex curve to thoracic spine concave curve to lumbar spine can stand still without swaying or tilting extremities normal findings: bilateral symmetry in length, circumference, alignment, position and number of skin folds

3.

4.

Palpation - all muscles, bones, joints - normal findings: muscles firm, non-tender Range of motion - normal findings: able to move joints through required range of motion a. b. Abduction - Lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk Adduction - Movement of a limb or eye toward the median plane of the body or, in the case of digits, toward the axial line of a limb.

c. d. e. f. g. h. i. j. k.

Dorsiflexion - Movement of a part at a joint to bend the part toward the dorsum, or posterior aspect of the body. Eversion - Turning outward Extension - A movement that brings the members of a limb into or toward a straight position Flexion - The act of bending or condition of being bent in contrast to extension. Hyperextension - Extreme or abnormal extension. Inversion - A turning inside out of an organ (e.g., the uterus). Plantar flexion - Extension of the foot so that the forepart is depressed with respect to the position of the ankle Pronation - The act of lying prone or face downward. Supination - The condition of being on the back or having the palm of the hand facing upward or the foot turned inward and upward

5. 6.

7.

Muscle strength and symmetry - normal findings: arm on dominant side generally stronger Alterations - Kyphosis - An exaggeration or angulation of the normal posterior curve of the spine, giving rise to the condition commonly known as humpback, hunchback, or Pott's curvature. - Lordosis - Abnormal anterior convexity of the lumbar spine. - Scoliosis - A lateral curvature of the spine - pain Geriatric alterations - stance less upright with head and neck forward - lumbar curvature less pronounced - height decreased - gait slower to initiate and stop - less knee and ankle lifts - steps may be shorter and more rapid - may need to hold onto furniture as age increases - muscles atrophy with disuse - weaker grip - active range of motion may be slower and limited in one or more joints - joints appear larger than surrounding tissue; may be stiff

Neurological system 1. History 2. Mental status a. Mini-Mental Status Exam (MMSE) - A commonly used assessment tool to quantify a person's cognitive ability. It assesses orientation, registration, attention and calculation, and language. Scoring is from 0 to 30, with 30 indicating intact cognition 3. Emotional status - normal findings: affect matches speech 4. Cranial nerve function CRANIAL NERVE FUNCTION 1. Olfactory (CN I) Can identify variety of smells Deviation: Inability to identify aroma

2. Optic (CN II) Has visual acuity and full visual fields Fundoscopic exam reveals no pathology Deviation: Inability to identify full visual fields - total or partial blindness of one or both eyes

3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) Follows up to six cardinal positions of gaze Pupils are unremarkable Exhibits no nystagmus and no ptosis Deviation: one or both eyes will deviate from its normal position

5. Trigeminal (CN V) Clenches teeth with firm bilateral pressure Has no lateral jaw deviation with mouth open Feels a cotton wisp touched to forehead, cheek and chin Differentiates sharp and dull sensations on face Corneal reflex; blinks when cotton is touched to each cornea Deviation: Absent or one-sided blinking of eyelids

7. Facial (CN VII) Has facial symmetry with and without a smile Can raise the eyebrows symmetrically and grimace Can shut eyes tightly Can identify sweet, sour, salt or bitter on the anterior tongue Deviation: Irregular and unequal facial movements Deviation: Inability to taste or identify taste Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances on the anterior two-thirds of the tongue Deviation: Inability to smile symmetrically

8. Acoustic (CN VIII) Can hear a whisper at 1-2 feet Can hear a watch tick at 1-2 feet Does not lateralize the Weber test Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test Deviation: Inability to hear spoken word

9, 10. Glossopharyngeal (CN IX) and Vagus (CN X) Swallows and speaks without hoarseness Palate and uvula rise symmetrically when patient says "ah" Bilateral gag reflex Can identify taste on the posterior tongue Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah" Deviation: Absent gag reflex

Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI) Resists head turning Can shrug against resistance Deviation: Weak or absent shoulder and neck movement

12. Hypoglossal (CN XII) Can stick tongue out and move it from side to side Can push tongue strongly against resistance Deviation: Tongue deviates to side 5. Level of consciousness (LOC) - normal findings 1. alert 2. responds appropriately to visual, auditory, tactile and painful stimuli 3. able to carry out simple commands 4. Glasgow Coma Scale 5. Alterations in LOC ALTERATIONS IN LEVEL OF CONSCIOUSNESS Alert 1. 2.

Awake and aware of person, place, time, and situation Responds appropriately and to verbal stimuli

Lethargic 1. Sleeps but easily aroused 2. Speaks and responds slowly and appropriately Obtunded 1. Difficult to arouse 2. Returns to sleep quickly; may respond inappropriately Stuporous 1. Aroused only through pain 2. No verbal response Semicomatose 1. Responds only to pain 2. Gag and blink reflexes intact Comatose 1. No response to pain 2. No reflexes or muscle tone

Note: dying clients will proceed through these levels in this above-listed sequence.

ROLES & FUNCTIONS OF A NURSE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Care provider Communicator / Helper Teacher Counselor Client Advocate Change Agent 7. Leader 8. Manager 9. Researcher 10. Case Manager 11. Collaborator

THE NURSING PROCESS cornerstone of nursing profession Problem-solving tool in utilizing clinical application of knowledge & theory in nursing practice 6-Step Process Assessment, Diagnosis, Outcome, Identification, Planning, Implementation & Evaluation

The Nursing Process History Lydia Hall originated term Nursing Process. 3-Step Process: note observation, ministration of care, validation Dorothy Johnson- introduced 3-Step Process:assessment, decision, nursing action Ida Jean Orlando 3-Step Process:clients behavior, nurses reaction, nurses actions Yura & Walsh suggested 4 components of the process:assessing, planning, implementing and evaluating Knowles- nursing process as: discover, delve, decide, do, discriminate American Nurses Association innovations introduced: (1) diagnosis as separate step, (2) diagnosis of actual & potential health problems as integral part of nursing practice, (3) outcome identification as distinct step, (4) 6 steps- assessment, diagnosis, outcome identification, planning, implementation, evaluation TYPES OF DATA 1. 2. Subjective Data (symptoms) Objective Data (signs)

METHODS OF DATA COLLECTION 1. 2. Interview Observation

SOURCES OF DATA 1. 2. Primary Secondary

Vital Signs
BODY TEMPERATURE The balance between heat production and heat loss * Body heat is primarily produced by metabolism & regulated by hypothalamus TYPES OF BODY TEMPERATURE 1. 2. Core Temperature-temperature of deep tissues of the body (oral/rectal) Surface Temperature- temperature of the skin, subcutaneous tissue and fat (Axilla)

FACTORS AFFECTING BODY HEAT PRODUCTION 1. 2. 3. 4. 5. Basal Metabolic Rate (BMR) Muscle Activity Thyroxine Output Epinephrine, norepinephrine & sympathetic stimulation Increased temperature of body cells

PROCESSES INVOLVED IN HEAT LOSS 1. 2. 3. 4. Radiation transfer of heat from one surface to another without contact Conduction transfer of heat from one surface to another with difference of temperature Convection dissipation of heat by air currents Evaporation continuous vaporization of moisture from the skin, oral mucous, respiratory tract

ALTERATIONS IN BODY TEMPERATURE 1. 2. 3. PYREXIA body temperature above normal range HYPERPYREXIA very high fever, 41degrees & above HYPOTHERMIA subnormal core body temperature

TYPES OF FEVER 1. 2. 3. 4. INTERMITTENT FEVER REMITTENT FEVER RELAPSING FEVER CONSTANT FEVER

METHODS OF TEMPERATURE TAKING ORAL ROUTE Most accessible & convenient method allow 15 mins when pt took food, drank hot/cold beverage or smoked Wash thermometer before & after use utilizing proper technique Take temperature 2-3 minutes

RECTAL ROUTE Most accurate measurement Assist in assuming lateral position Lubricate before insertion, do not force. Insert 0.5-1.5 inches Instruct to take deep breath during insertion Let stay for 2 mins

AXILLARY ROUTE Safest & non-invasive Pat dry the axilla before placing thermometer. Do not rub. Place arm tightly for 9 minutes

Normal Adult Temperature Ranges

Methods Oral

Ranges 36.5-37.5 C (97.6-99.6 F)

Axillary

35.8-37 C (96.6 98.6 F)

Rectal

37.0 38.1 C (98.6 100.6 F)

Tympanic

36.8 37.9 C (98.2 100.2 F)

PULSE RATE Wave of blood created by contraction of the LV of the heart, regulated by ANS

FACTORS AFFECTING PULSE RATE 1. 2. Age Sex/gender

3. 4. 5. 6. 7. 8.

Exercise Fever Medications Hemorrhage Stress Position changes

PULSE SITES 1. 2. 3. 4. 5. 6. 7. 8. 9. Temporal Carotid Apical Brachial Radial Femoral Posterior tibial Popliteal Pedal

ASSESSMENT OF THE PULSE Normal Pulse Rate

Newborn - 1 month 1 year 2 years 6 years 10 years adult

80 180 bpm 80- 140 bpm 80 130 bpm 75 120 bpm 60 90 bpm 60 100 bpm

Tachycardia- above 100 bpm (adult) Bradycardia below 60 bpm (adult) RHYTHM pattern & intervals of beat VOLUME strength of pulse Normal felt with moderate pressure Full / Bounding obliterated with great pressure Thready easily obliterated ARTERIAL WALL ELASTICITY- artery feels straight, smooth, soft & pliable PRESENCE/ABSENCE OF BILATERAL EQUALITY- absence indicates CV disorder

RESPIRATORY RATE
- Act of breathing PROCESSES: 1. Ventilation - Inhalation - Exhalation 2. Diffusion 3. Perfusion

RESPIRATORY CENTERS 1. Medulla Oblongata primary 2. Pons contains: - Pneumotaxic Center-responsible for rhythmic quality - Apneustic Center- responsible for deep, prolonged inspiration 3. Carotid & Aortic bodies-contains peripheral chemoreceptors 4. Muscle & joints contains proprioreceptors ASSESSMENT OF THE RESPIRATORY RATE RATE Normal is 12-20 in adult DEPTH may be normal, deep or shallow RHYTHM observe for regularity of exhalations and inhalations QUALITY / CHARACTER respiratory effort & sound of breathing

BLOOD PRESSURE
Measure of pressure exerted by blood as it pulsates through arteries

Systolic Pressure- pressure of blood due to contraction of ventricles Diastolic Pressure pressure when ventricles are at rest Pulse Pressure difference bet. Systolic & diastolic pressures Hypertension abnormally high BP over 140 systolic or over 90 diastolic for at least 2 consecutive readings Hypotension abnormally low BP, below 100/60

ASSESSMENT OF BLOOD PRESSURE


1. 2. 3. 4. 5. 6. Ensure client is rested Allow 30 mins after exercise, smoking,caffeine intake before taking BP Use appropriate size of BP cuff Position in supine or sitting Arm must be at the level of the heart Apply cuff 1 inch above antecubital space snugly and smoothly

7. 8. 9. 10.

Use bell of the stethoscope The sound during BP taking is called KOROTKOFF sound Read lower meniscus of mercury level of sphygmomanometer at eye level to prevent Error of Parallax ERROR OF PARALLAX if eye level is higher than level of lower meniscus of mercury, it may cause false low reading

Medication Administration
Medications substance administered for diagnosis, cure, treatment, relief or prevention of disease. AKA as drug Prescription Name name given to a drug before it becomes official Official Name name after which the drug is listed in one of the official publications Chemical Name- name that describes precisely the constituents of drugs Brand name- name given to a drug by the manufacturer. AKA trademark. Pharmacology study of effects of drugs on living organisms Posology study of dosage or amount of drugs given in the treatment of diseases Types of Doctors Orders Standing Order carried out until the specified period of time or until discontinued by an order Single Order carried out for only once STAT Order carried out at once PRN Order only as patient requires or needed Parts of A Legal Doctors Order 1. Name of Patient 2. Date and Time 3. Name of Drug 4. Dose of Drug 5. Route of Administration 6. Time or Frequency 7. Signature of Physician Effects of Drug Therapeutic Effect intended primary effect. AKA desired effect. Side Effect Unintended effect of the drug. AKA secondary effect. Drug Allergy immunologic reaction to the drug Anaphylactic Reaction severe allergic reaction Drug Tolerance decreased physiologic response to repeated administration of a drug Cumulative Effect increased response to repeated doses of drug that occurs when the rate of administration exceeds the rate of metabolism or excretion Idiosyncratic Effect- unexpected peculiar response to the drug Drug Abuse inappropriate intake of a substance, either continually or periodically Drug Dependence persons reliance to take a drug/substance which will produce an intense reaction upon withdrawal Addiction due to biochemical changes in body tissues esp. of the nervous system. Tissues come to require the substance to function normally. AKA physical dependence. Habituation emotional reliance on a drug to maintain sense of well being. AKA psychological dependence. Drug Interaction effects of one drug are modified by the prior or concurrent administration of another drug, thereby increasing or decreasing the pharmacological action Drug Antagonism conjoint effect of two drugs is less that the drugs acting separately

Summation combined effect of two drugs produces result that equals the sum of the individual effects of each agent Synergism combined effects of drugs is greater than the sum of each individual agent acting independently Potentiation concurrent administration of two drugs in which one drug increases the effect of the other drug Therapeutic Actions of Drugs Palliative relieves symptoms of disease but does not affect the disease itself Curative treats the disease condition Supportive sustains body functions until other treatment of the bodys response can take over Substitutive replaces body fluids / substances Chemotherapeutic destroys malignant cells Restorative returns/repairs body to health Principles of Drug Administration 1. Observe the 7 Rights of drug administration. -RIGHT drug,dose,time,route,patient, recording, approach 2. Practice asepsis. 3. Nurses administering medications are responsible for their own actions. 4. Be knowledgeable about the meds you administer. 5. Keep narcotics locked. 6. Use only medications that are clearly labeled. 7. Return liquid that are cloudy in color. 8. Identify patient correctly before administering medications. 9. Do not leave medications at the bedside. 10. The nurse who prepares the drug must be the one to administer it. 11. If patient vomits, report to nurse in charge or physician. 12. Preoperative meds are usually discontinued during postop unless ordered to be continued. 13. When meds is omitted for any reason, record the fact & the reason. 14. When med error is made, report ASAP.

Routes of Drug Administration I. ORAL ADVANTAGES: most convenient, less expensive, safe & does not break the skin barrier DISADVANTAGES: inappropriate for those with nausea & vomiting, dysphagia, reduced GIT motility, seriously ill May give unpleasant odor/taste, discolor teeth, irritate gastric mucosa Oral Drug Forms 1. SOLID tablet, capsule, pill, powder 2. LIQUID syrup, suspension, emulsion, elixir, milk, other alkaline substance SYRUP-sugar-based SUSPENSION-water-based EMULSION- oil-based ELIXIR- alcohol-based - Never crush enteric-coated or sustained-release medication II. SUBLINGUAL - Drugs placed under the tongue ADVANTAGES: for local effect, rapid absorption in the bloodstream DISADVANTAGES: if swallowed, may be inactivated by gastric juices, must remain under the tongue until dissolved/absorbed

III. BUCCAL -held in the mouth against mucous membranes of the cheek. Should not be chewed, swallowed or placed under the tongue ADVANTAGES: local effect, greater potency because drug directly enters blood & bypass the liver DISADVANTAGES: if swallowed, may be inactivated by gastric juices IV. TOPICAL -application of medications to a circumscribed area of the body 1. Dermatologic-lotions, liniments, ointment Pat dry area, use surgical asepsis, thin layer needed, use gloves over large areas 2. Ophthalmic instillations, irrigations - Instillations-provides meds, Irrigations-flush eye of noxious/foreign material 3. Otic instillations, irrigations Instillations-softens earwax, reduce inflammation & treat infection, relieve pain Irrigations- remove cerumen, apply heat, remove foreign body 4. Nasal for astringent effect, loosen secretions, facilitate drainage, treat infections - Parkinsons position-frontal/maxillary - Proetz position-ethmoid/sphenoid 5. Inhalation- nebulizers, MDI 6. Vaginal local therapeutic effect but has limited use FORMS: tablet, liquid, cream, jelly, foam & suppository Vaginal Irrigation washing of vagina by liquid at low pressure. AKA douche. Empty bladder first, position Irrigating can shld be 12 in higher Remain in bed for 5-10 mins after V. RECTAL ADVANTAGE: Used when odor/taste is not favorable DISADVANTAGE: absorption is unpredictable REMINDERS: needs refrigeration, use gloves for insertion, position- lie on left & breathe thru mouth, must remain on the side for 20 minutes for absorption VI. PARENTERAL - Administration by needle 1. INTRADERMAL thru the dermis beneath epidermis SITES: inner lower arm, upper chest & back, beneath the scapulae INDICATIONS: for allergy & tuberculin testing & vaccinations Needle at 10-15 degrees angle, bevel up Inject over 3-5 sec to form a wheal/bleb Do not massage the site 2. SUBCUTANEOUS SITES: outer aspects of UA, anterior aspect of thighs, abdomen, scapular area of the back, ventrogluteal & dorsogluteal areas INDICATIONS: vaccines, preoperative meds, narcotics, insulin, heparin Small doses only 0.5-1 ml & rotate sites Use 5/8 needle for adults when given at 45 degrees (thin pts.), for 90 degrees (obese pts) Insulin Injection- do not massage & give at 90

3. INTRAMUSCULAR use 1 2 needle to reach the muscle layer SITES: ventrogluteal, dorsogluteal (<3 y/o), vastus lateralis, rectus femoris, deltoid, Z-track 4. INTRAVENOUS direct IV, IV push or infusion - Most rapid route, predictable INDICATIONS: pts with compromised GI function, rapid introduction of medications TYPES OF IV FLUIDS: A. Isotonic Solution- same concentration as body fluids (D5W, NaCl 0.9%, plain LR, plain NM) B. Hypotonic has lower concentration than body fluids (NaCl 0.3%) C. Hypertonic has higher concentration than body fluids (D10W, D50W, D5LR, D5NM) Nursing Interventions: 1. Know the type, amount, indications of IV. 2. Inform client & explain purpose of IV therapy. 3. Prime IV tubing to expel air. 4. Change IV tubing every 72 hours. 5. Change /alter IV needle insertion site every 72 hours. 6. Regulate every 15-20 minutes. 7. Observe for complications. Complications of IV Infusion: 1. Infiltration needle out of vein, fluids accumulate in the subcutaneous tissues S/S: pain, swelling, cold skin, pallor at site, IV rate decreases/stops, no backflow NSG.INT: change IV site, apply warm compress 2. Circulatory Overload from administration of excessive volume of IV fluids S/S: headache, flushed skin, increased PR,BP,RR, weight, SOB, syncope, cough, increased venous pressure, pulmonary edema, shock NSG. INT: slow IV infusion (KVO), high fowlers position, administer diuretic, bronchodilator as ordered 3. Drug Overload excessive amount of drugs in the fluids S/S: dizziness, fainting, shock NSG. INT.: slow IV infusion (KVO), inform physician 4. Superficial Thrombophlebitis due to overuse of vein, irritating soln/drugs, clot formation, large bore catheter S/S: pain along the vein, vein feels hard & cordlike, edema & redness over site, affected arm warmer than the other NSG. INT: change IV site every 72H, use large veins for irritating fluids, stabilize area, apply cold compress immediately then warm compress after 5. Air Embolism - air enters the system (at least 5 ml or more) S/S: chest/shoulder/back pain, hypotension, dyspnea, tachycardia, cyanosis, increases venous pressure, LOC NSG.INT: do not allow bottle to run dry, prime tubings before starting IV, turn to left side in Trendelenburg position 6. Nerve Damage due to overly tight tying of the splint S/S: numbness of fingers/hands NSG.INT: massage area & move shoulders thru ROM, open/close hands several times each hour, PT if required 7. Speed Shock D/T rapid administration of IV fluids NSG.INT: to avoid speed shock & cardiac arrest, give most IV push meds over 3-5 minutes

Blood Transfusion
4 objectives / Purpose 1) To replace circulating blood volume 2) To increase oxygen carrying capacity of the blood 3) Combat infection if decrease WBC 4) Prevent bleeding if decrease platelet NURSING MANAGEMENT 1.Proper Refrigeration - 250 cc packed of RBC, refrigerate 3-5 days - 1 platelet bag refrigerate 5-6 days 2. Proper blood typing & cross matching - Type O universal donor - AB- universal recipient - 85% of people is RH RH (+) 3. Aseptical assemble all materials needed for BT 4. With filter (BT set) 5. Gauge 18 of needle 6. Check for name of the client 7. Check for expiration date 8. Check for serial number 9. Use RED ballpen when charting 10. Check blood unit for presence of bubbles, cloudiness, and dark color 11. Never warm the BLOOD - It may destroy vital product of the blood - Let the room temperature warm the blood @ 30minutes 12. Avoid mixing the drugs at BT line 13. Regulate @ KVO or 100 cc/hr to prevent circulatory overload for first 30 minutes Start at slow rate (10 gtts/min)& remain at bedside for 15-30 mins 14. BT should be done less than 4hrs for WB & PRBC and 20 minutes for plasma, platelets, cryoprecipitate st 15. Monitor VS before. During & after BT 10 especially q15minns. For 1 hour - Majority of BT reaction occurs within 1hr. 16. Administer 0.9% NaCl before, during or after BT. Never administer IV with dextrose 17. Observe for Complication

BT REACTION
H- emolytic A- llergic P- yrogenic C- irculatory overload A- ir embolism T- hrombo cytophenia C- itrate intoxication H- yperkalemia

BLOOD TRANSFUSION REACTION SIGNS AND SYMPTOMS NURSING MANAGEMENT Hemolytic Reaction
Dizziness Headache Dyspnea Hypotension Flushed skin Palpitation lumbar/ sterna / flank pain Red port wine urine Stop BT Notify doctor Flush with PNSS to prevent hemolysis Administer isotonic solution to counter act shock and prevent tubular necrosis Never dispose the blood unit and send and send it to the blood bank for reexamination Obtain urine and and blood sample of the client and send it to the laboratory for reexamination Monitor VS and allergic reaction

Allergic Reaction

Fever Chills Dyspnea Larygospasm Bronchial wheezing Urticaria

Stop Notify Flush Antihistamine and paracetamol as ordered If positive to hypotension and shock adminester corticosteroid and epinephrine

Pyrogenic Reaction
-Fever producing agent

Fever

Stop Notify Flush Antipyretic as ordered

Circulatory Overload

Dyspnea Orthopnea Rales and Crackles sound on chest upon auscultation

Stop Notify Administer diuretis as ordered

Citrate Intoxication

Hypocalcemia Tetani

Stop Notify Flush

Hypercalcemia indicates if the blood is expired

Asepsis and Infection Control


INFECTION invasion of body tissue by microorganisms

ASEPSIS absence of disease-producing microorganisms; being free from infection MEDICAL ASEPSIS practices designed to reduce number & transfer of microorganisms SURGICAL ASEPSIS practices that render & keep objects/areas free from microorganisms; sterile technique SEPSIS presence of infection SEPTICEMIA transport of infection throughout the body or blood CARRIER person / animal, with or without signs of illness but who harbors pathogens within his body that can be transferred to another CONTACT person / animal known or believed to have been exposed to a disease RESERVOIR natural habitat for growth & multiplication of microorganisms TRANSIENT FLORA microorganisms picked up as a result of normal activities & can be removed easily. RESIDENT FLORA microorganisms that normally live on a persons skin STERILIZATION process by which all microorganisms including spores are destroyed DISINFECTANT substance that destroys pathogens but generally not including spores ANTISEPTIC substance that inhibits growth of pathogens but does not necessarily destroy them BACTERICIDAL chemical that kills microorganisms BACTERIOSTATIC agent that prevents bacterial multiplication but does not kill all forms of organisms CONTAMINATION process by which something is rendered unclean / unsterile DISINFECTION process by which pathogens but not their spores are destroyed COMMUNICABLE DISEASE results if infectious agent can be transmitted to another by direct/indirect contact thru vector/vehicle INFECTIOUS DISEASE results from invasion & multiplication of microorganisms in a host PATHOGEN disease-producing microorganism PATHOGENICITY ability to produce a disease VIRULENCE vigor with which the organism can grow & multiply SPECIFICITY organisms attraction to a specific host OPPORTUNISTIC PATHOGEN causes disease only in susceptible individuals

NOSOCOMIAL INFECTION hospital-acquired infection ISOLATION separation of persons with communicable disease from another so that transmission is prevented ISOLATION TECHNIQUES practices designed to prevent transfer of specific microorganisms ETIOLOGY study of causes

STAGES OF INFECTIOUS PROCESS


Incubation Period from entry of microorganism to the body to onset of S/S Prodromal Period from onset of non-specific S/S to appearance of specific S/S Illness Period specific S/S develop & become evident Convalescent Period S/S start to abate until client returns to normal state of health ETIOLOGIC AGENT may be bacteria, virus, fungi or parasites RESERVOIR humans, animals, plants, environment PORTAL OF EXIT (from reservoir) Respiratory Tract- droplet,sputum GIT-vomitus, feces, saliva, drainage tubes Urinary Tract urine, urethral catheter Reproductive Tract- semen, vaginal discharge Blood needle puncture, open wound

MODES OF TRANSMISSION
CONTACT TRANSMISSION direct/indirect DROPLET TRANSMISSION when MM are exposed to secretions of an infected personwho is coughing, sneezing, laughing within 3 feet - VEHICLE TRANSMISSION transfer by way of vehicles or contaminated items (food, water, milk, utensils, pillows, mattress) - AIRBORNE TRANSMISSION when fine particles are suspended in the air for a long time & dispersed by air current then inhaled/deposited to a host VECTOBORNE TRANSMISSION - vectors can be biologic or mechanical - Biologic animals (rats, snails, mosquitoes) - Mechanical infected inanimate objects (contaminated needles/syringes) PORTAL OF ENTRY - permits organism to enter host - Through body orifice such as mouth, nose, vagina, rectum OR breaks in the skin or MM SUSCEPTIBLE HOST -

host is a person who is at risk for infection, whose body defense mechanism are unable to withstand the invasion of the pathogen

TYPES OF IMMUNIZATION
ACTIVE IMMUNIZATION- antibodies are produced by the body in response to infection NATURAL antibodies formed in presence of active infection in the body. It is lifelong. ARTIFICIAL antigens (vaccines/toxoid) are administered to stimulate Ab production PASSIVE IMMUNIZATION antibodies are produced by another source (animal/human) NATURAL Ab from mother to baby ARTIFICIAL Immune serum (antibody) from an animal or another human is injected

ASEPTIC PRACTICES
1. HANDWASHING Handwashing is the single most important infection control practice. Handwashing for medical asepsis is done by holding hands lower than the elbows Use running water, soap & friction for 15-30 seconds each hand Wash hands before and after client contact CLEANING, DISINFECTION & STERILIZATION Cleaning physical removal of dirt & debris by washing, dusting or mopping Disinfection chemical or physical process to reduce number of potential pathogens on a surface but not necessarily the spores Sterilization complete destruction of all microorganisms including spores

2.

METHODS OF STERILIZATION
STEAM STERILIZATION autoclaving uses supersaturated steam under pressure - non-toxic , inexpensive, sporicidal & penetrates fabric - Color indicator strips change color to indicate sterilization GAS STERILIZATION ethylene oxide is colorless gas that can penetrate plastic, rubber, cotton or other subs. Used for oxygen, suction gauges, BP apparatus, stethoscope, catheter - Expensive & requires 2-5 hours - Ethylene oxide is toxic to humans RADIATION - ionizing radiation penetrates deeply to objects - Used for drugs, food & other heat-sensitive items CHEMICALS are effective disinfectants - Attacks all types of microorganisms rapidly, inexpensive & stable in light & heat. Chlorine is used. BOILING WATER least expensive, at least 15 minutes 3. USE OF BARRIERS a. Masks b. Gowns c. Caps & shoe covers d. Gloves e. Private rooms f. Equipment & refuse handling ISOLATION SYSTEMS

4.

CLASSIFICATIONS:
A. Standard Precautions - Universal Precaution & Body-Substance Isolation - Prevent transmission of bloodborne & moist body substance pathogens 1. Wear clean gloves 2. Perform handwashing 3. Wear masks, goggles, face shield if sprays/splashes are expected 4. Wear gown if soiling & splashes are expected 5. Remove soiled protective items immediately 6. Clean & reprocess all equipment 7. Discard all single-used items 8. Prevent injuries 9. Use private room or consult with Infection Control Department B. Transmission-Based Precautions 1. AIRBORNE PRECAUTION - for small-particle droplet that may remain suspended in the air & dispersed by air current (varicella, TB, measles -Private room, negative airflow, wear masks

2. DROPLET PRECAUTION - for large-particle droplet & dispersed by air current (H. influenza, diphtheria, rubella, mycoplasma pneumoniae) - Private room, wear masks within 3 ft. 3. CONTACT PRECAUTION - for those transferred by hand-or skin-to-skin contact (clostridium difficile, shigella, impetigo) - Private room, use gloves, gowns & other protective barriers when exposure to infected material is likely C. Protective Isolation - prevent infection for people with compromised resistance (leukopenia, undergoing chemoRx, extensive burns) - Private room, restrict visitors, no fresh fruits/flowers, raw foods, potted plants allowed, only cooked/canned foods allowed 5. SURGICAL ASEPSIS

PRINCIPLES: a. Moisture causes contamination. b. Never assume that an object is sterile. c. Always face the sterile field. d. Sterile articles may touch only sterile surface/articles to maintain sterility. e. Sterile equipment/areas must be kept above the waist & on top of the sterile field. f. Prevent unnecessary traffic & air currents around sterile area g. open, unused sterile articles are no longer sterile after the procedure h. A person who is considered sterile who becomes contaminated must reestablish sterility i. Surgical technique is team effort.

Wound Care
TYPES OF WOUNDS: According to contamination 1. Clean Wounds uninfected, minimal inflammation, closed - respiratory, GIT & urinary tract are not entered 2. Clean-contaminated Wounds also surgical wounds, no infection - respiratory, GIT & urinary tract entered 3. Contaminated Wounds- open, fresh, accidental wounds, with evidence of inflammation 4. Dirty/Infected Wounds with dead tissue & evidence of infection TYPES OF WOUND: According to cause 1. Incision 2. Contusion 3. Abrasion 4. Puncture 5. Laceration 6. Penetrating wound TYPES OF WOUND HEALING 1. 2. Primary Intention healing Secondary Intention healing

PHASES OF WOUND HEALING 1. 2. 3. Inflammatory Phase immediate, 3-6 days rd Proliferative Phase 3 to 21 days Maturation Phase 21 days to 2 years

STAGES OF PRESSURE ULCER FORMATION Stage 1 non-blanchable erythema signaling potential ulceration Stage 2 partial-thickness skin loss (abrasion, blister or shallow crater) involving epidermis & dermis Stage 3 full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down but not thru fascia. Deep crater. Stage 4 full-thickness skin loss with necrosis or damage to muscle, bone, structures, tendon, joints KINDS OF WOUND DRAINAGE EXUDATE material that escapes from blood vessels during the inflammatory process 1. 2. 3. SEROUS EXUDATE blister from burns PURULENT EXUDATE SANGUINEOUS (Hemorrhagic) EXUDATE

Oxygenation
Kinds of Chest Physiotherapy 1. 2. 3. Percussion (clapping) Vibration Postural drainage

Bronchial Hygiene Measures 1. 2. 3. Steam Inhalation semifowlers position & position spout 12-18 inches away from nose Aerosol Inhalation Medimist Inhalation

SUCTIONING
1. 2. Assess indications for suctioning. Position properly: a. conscious: semi-fowlers b. unconscious: lateral position Apply proper pressure Use appropriate size of catheter Adult: Fr 12-18 Child: Fr 8-10 Infant: Fr 5-8 Don sterile gloves Insert proper length of catheter Lubricate catheter Apply suction during withdrawal of catheter Apply suction for 5-10 seconds (max 15) Hyperventilate 100% before & after Allow 20-30 sec interval between each suction Provide oral & nasal hygiene Dispose contaminated equipment/matls safely Assess effectiveness / document

3. 4.

5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

INCENTIVE SPIROMETRY -Enhance deep inspiration INTERMITTENT POSITIVE PRESSURE BREATHING Administer oxygen at pressures higher than the atmospheric pressure OXYGEN SYSTEMS 1. Low flow administration devices 2. High flow administration devices ADMINISTRATION OF OXYGEN Indications: hypoxemia Signs of Hypoxemia: - Restlessness - Increased pulse rate - Rapid, shallow breathing, DOB, nasal flaring - Light headedness

Substernal / intercostals retractions Cyanosis

ALTERATIONS IN RESPIRATORY FUNCTION HYPOXIA Insufficient oxygenation of tissues CLINICAL SIGNS:

Early Signs
Tachycardia Increased rate & depth of respirations Slight increase in systolic BP Bradycardia Dyspnea

Late Signs

Decreased systolic BP Cough hemoptysis

RHYTHM
CHEYNE-STOKES marked rhythmic waxing & waning of respirations from very deep to very shallow and temporary apnea KUSSMAULS (Hyperventilation) increased rate & depth of respiration APNEUSTIC prolonged gasping inspiration followed by very short inefficient expiration BIOTS shallow breaths interrupted by apnea