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NURSING LICENSURE EXAM REVIEWER

ATIENZA, MARICHAR A., RN, MAN, Ph.D TOP THE BOARD EXAM
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TABLE OF CONTENTS I. III. FUNDAMENTALS OF NURSING II. NURSING RESEARCH LEADERSHIP AND MANAGEMENT V. IMCI VI. COMMUNICABLE DISEASES VII. MATERNAL AND CHILD NURSING VIII. PEDIATRIC NURSING IX. MEDICAL SURGICAL NURSING X. EMERGENCY NURSING XI. PSYCHIATRIC NURSING XII. PATHOGNOMONIC SIGN
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IV. COMMUNTIY HEALTH NURSING

ANTIDOTES
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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. 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 3. DARK PERIOD OF NURSING - extends from period of reformation until US Civil War (17th to 19th 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. Beliefs about causation of disease (evil spirits, enemy or a with) b. People believed that evil spirits could be driven away by persons with powers to expel demons c. People believed in special gods of healing, with the priest-physician and Herbolarios

d.Superstitious beliefs and practices in relation to health and sickness such as Herbmen or Herbicheros as one who practiced witchcraft e. Persons suffering from diseases without identified cause were believed to be bewitched by “mangkukulam”. Spanish Period a. The religious orders exerted their efforts to care for the sick by building hospitals in the different parts of the Philippines b. Earliest hospitals established: Hospital real de Manila (1577) – built to care for the Spanish king’s 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 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 one’s power to the fullest extent. Health is maintained through prevention of disease via environmental health factors. HENDERSON

aggressive. illness is an interference in the life cycle.Self Care & Self-Care Deficit Theory .Behavioral System Model . maintain & restore health MADELEINE LEININGER . ROY Health is a state & process of being & becoming an integrated & whole person. affiliative.Adaptation Model . dependence. interdependence & integration of the subsystems of the behavioral system.Health is maintained through the individual’s ability to perform 14 components of nursing care unaided.Wholly Compensatory.Man is an energy field in constant interaction with the environment .4 Phases on Nurse-Client Relationship: Orientation. . ROGERS Positive health symbolizes wellness.Nursing is service to individuals. comfort socialization and hope VIRGINIA HENDERSON . Partially Compensatory & Supportive-Educative HILDEGARD PEPLAU .Identified 21 nursing problems . light.Goal Attainment Theory . structural integrity.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 . self-concept.Conservation of energy.developed First Theory of Nursing . interaction. interdependence . Identification.Believed that adaptive human behavior is directed at an attempt to maintain homeostasis LYDIA HALL . Exploitation.Humans are more than & different from the sum of their parts SISTER CALLISTA ROY .Interpersonal Model . personal integrity and social integrity BETTY NEUMAN .Focused on changing & manipulating environment to put patient in best possible condition .Introduced model on Nursing:What Is It? NURSING THEORIES FLORENCE NIGHTINGALE .Each person is a unified biopsychosocial system in constant interaction wit a changing environment . 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.Nursing is humanistic & scientific mode of helping client thru specific cultural caring processes to improve or maintain health condition MYRA LEVIN .Each person has 7 subsystems: ingestive.Nature of Nursing Model . JOHNSON . role function.Health Care System Model . hygiene. 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. Resolution MARTHA ROGERS . families and therefore to society DOROTHY E.Four Conservation Principles .Transcultural Nursing Model .Man has needs with 4 Modes: physiological.Identified 14 basic needs .Environment includes noise.Nursing is a unique because it is concerned with all variables affecting response to stresses which are intra.Patient-Centered Approach to Nursing .Nursing assists individuals & groups to attain.Nurses assists sick and well clients FAYE ABDELLAH .Science of Unitary Human Beings .Conceptualized 3 Nursing Systems: . achievement. sexual & role identity behavior IMOGENE KING . inter and extrapersonal in nature DOROTHEA OREM . eliminative. nutrition.

Believes that each choice opens certain opportunities while closing others .. two minutes apart 6.Human Caring Model .binge eating followed by purging b. 5. self-care. At least two measurements should be done. orange peel skin d.Theory of Human Becoming . CORE(therapeutic use of self. Leavell & Clark’s Agent-Host-Environment Model (Ecologic Model) 5. self-healing ROSEMARIE RIZZO PARSE . Breast self-examinations 1.preferably seven days after onset of the menstrual cycle. do at the same time each month 3.exclusive to nursing. and smoking cessation 7. but when done regularly helps a woman understand how her breasts normally feel. unusual pain j. exercise. enabling-limiting & connecting-separating .Referred as: revealing-concealing. change in direction of nipple h. nurse reaction and nurse action ERNESTINE WEIDENBACH .Nursing is an art & science thru transpersonal transactions to help persons achieve mind-body-soul harmony which will generate self-knowledge.Each has own choice. Pre-hypertensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction. dimpling or puckering e. lump or thickening (breast or underarm) b. a sore on the breast that does not heal C. Done at the same time of the month . injury prevention Health Promotion Programs and Health Screening A.Focused on 3 Components: CARE(nurturance. Should be started by age twenty 2. bloody or spontaneous discharge i. Auscultatory method with a properly calibrated and fitting cuff should be used icide c. Most changes are benign.Emphasized need of validating need & evaluating care based on outcomes . SBP > 140 and / or DBP > 90 should be referred to a health care provider for antihypertensive drug therapy B. retracted nipple g.Emphasized free choice in value priorities . especially in nipple area f.Components of Clinical Practice are: Philosophy. Risky behaviors . purpose. Screening should be done annually beginning at age 21 for both males and females 2. Limited effectiveness. red or hot skin c. itch or rash. Smith’s Models of Health 4. Technique should be reviewed by a health care provider to ensure effectiveness 4.Dynamic Nurse-Patient Relationship Model .Clinical Nursing – A Helping Art Model . Health Promotion Model 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. uses reflection) & CURE (nursing related to physician’s orders) IDA JEAN ORLANDO . therefore nurse acts as guide NOT decision-maker MODELS OF HEALTH & ILLNESS 1. but unusual or spontaneous changes should be checked by a health a.Nurses meet individual needs thru identification of need.Nurse helps patients meet a perceived need that patients cannot meet for themselves . if no menstrual cycles. eating disorders .3 Elements of Nursing Situation: client behavior. Blood pressure screening 1. self-control. Health Belief Model (HBM) 3. substance abuse . practice and art . Screening for children and adolescents is also recommended but optimal interval has yet to be determined 3. administration of help and validation of action JEAN WATSON .restrictive eating . diet. Health – Illness Continuum 2. Adolescents (age 13-19) a.assist in assessment of behaviors that impact the health of individuals in the following developmental stages 1.

stress 1. alcoholism 3. with feet together and legs straight. cryptochidism c. Young adult (age 20-35) a. multiple medications D. and cardiopulmonary complications 4. To know whether the clients are likely to take action regarding their health A. lack of exercise . check for prominence of ribs on one side only and hip and leg asymmetry . illicit drug use d. substance abuse 1.d. change in size. lack of preventative health care e. Monthly self-examination should begin in adolescence. injury prevention c.lateral curvature and convexity of thoracic spine indicate scoliosis c. scapula. middle adult (age 35-65) a. substance abuse 1. substance abuse c. job 2. tobacco 2. hard lumps or nodules b. acceptance of aging 4. Recommendations vary but generally accepted to perform screening at onset of adolescence 2. older adult (age 65 and older) a. Scoliosis screening 1. since this is the highest risk group 2. illicit drug use d. impaired mobility.use of condoms e. starting a new job 2.onset of obesity b. family / divorce 3. Findings that should be reported to a health care provider include a. beginning a new family c. assess for misalignment of spinous processes . falls 2. or consistency of the testes Health locus of Control Model a. changing roles a. Testicular self-examinations 1. check adolescent for asymmetry of shoulders. have adolescent bend forward until back is parallel to floor. marriage b. alcoholism 3. or waist b. while standing. tobacco 2. injury prevention 1. seatbelts 3. hips. Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures E. shape. suicide 4. Technique: clothing should be removed from upper body a. lack of exercise c. obesity b. sexual behavior exposure to sexually transmitted diseases 2. Significantly more prevalent in girls than boys 3. Early intervention important because untreated scoliosis can lead to disfigurement. depression 3. eating disorders . Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as a. previous germ cell tumor in one testicle 4. stress 1. sexual behavior . family history of testicular cancer b.chest wall on side of convexity is prominent and scapula on side of convexity is elevated 5. obesity b. External – those who believe in charms and lucks d. Best time to perform exam is during or after a bath or shower when the scrotum is relaxed 3.

we ask them if they know the consequences .State where the person’s physical. emotional 2. Internal – recognizes that they are the reason for their illness STAGES OF HEALTH BeHAVIOR a.Transition stage . Iatrogenic – from treatment of a disease ACCORDING TO DURATION OR ONSET 1.5 ft 1.5 – 4 ft 4 – 12 ft 12 – 15 ft LEVELS OF PREVENTION 1.Becomes more passive and accepting . Allergic – abnormal response of body to chemical or protein subs or physical stimuli 7. Metabolic – disturbance in the process of metabolism 4. ASSUMPTION OF SICK ROLE . Termination – no relapse Illness and Disease ILLNESS .alteration in body functions resulting in reduction of capacities or shortening of normal life span Four ASPECTS OF SICK ROLE N – NOT HELD RESPONSIBLE FOR THE CONDITION O – OBLIGED TO GET WELL SOON S – SEEK COMPETENT HELP E – EXCUSE FROM SOCIETAL ROLE STAGES OF ILLNESS 1. are intense & subsides after a relatively short period of time 2. cognitive.Acute – symptoms are pronounced but more prolonged than in acute disease SPACE Intimate Personal Social Public Touching – 1. developmental or spiritual functioning is diminished or impaired .disease becomes active again with pronounced symptoms 3. Traumatic – due to injury 6. DEPENDENT PATIENT ROLE .encourage optimal health & increase person’s resistance to illness . defect in development.3 aspects: physical. RECOVERY / REHABILITATION . Action – execute the plan e. Pre – contemplation Stage . Hereditary – defect in genes of 1 or both parent transmitted to offspring 2. SYMPTOM EXPERIENCE . longer than 6 months and can affect functioning & may fluctuate between maximal functioning & serious relapses that may be life threatening & characterized by remission & exacerbation .period where the disease is controlled & symptoms are not obvious .Person becomes client dependent on health professional .has short duration & severe . Maintenance – provide positive reinforcement\ f.Seeks advice. prenatal infection 3. explanation.Gives up sick role & returns to former roles/functions CLASSIFICATION OF DISEASES ACCORDING TO ETIOLOGIC FACTORS 1. Deficiency – from inadequate intake or absorption of essential dietary factors 5.before illness . PRIMARY PREVENTION .not on the point to change in the next 6 months . intellectual. self-originated. spontaneous origin 9. Degenerative – from degenerative changes that occur in tissues or organs 10. Congenital – present at birth. social. Acute Illness . MEDICAL CARE CONTACT .assess the patient for their readiness to change b.S/S occurs abruptly . Idiopathic – unknown cause.Accepts / rejects HP’s suggestions . emotional.Acceptance of the illness .EXACERBATION.B.persists. Preparation – planning d.personal state in which the person feels unhealthy .Seeks advice of health professionals: validation. Chronic Illness . hereditary factors. Contemplation Stage . support.REMISSION.thinking of changing in the near future c.May regress to an earlier behavioral stage 5. Neoplastic – abnormal or uncontrolled growth of cells 8. Sub. reassurance 4. decision 3.Not synonymous with DISEASE DISEASE .

increase fiber. maintain ideal body weight.seeks to identify specific illness/condition at an early stage with prompt intervention to prevent or limit disability . cardiac rehab. SITTING OR SEATED. avoid alcohol. palpate each separately along margin of sternocleidomastoid b. PRONE-face lying position with head turned to sides/abdomen-lying position CLASSIFYING HEART MURMURS BY INTENSITY Grade I: Difficult to hear.support client’s achievement of successful adaptation to known risks. FOWLER’Sa. even with stethoscope Grade II: Quiet. reduce fat. PERCUSSION – tapping body parts to produce sounds 4. heard with stethoscope Grade III: Moderately loud. adult: <130 mm Hg Systolic / <85 mm Hg diastolic BLOOD PRESSURE (BP) Common Mistakes during Upper Extremity BP Checks a false low systolic reading Peripheral BP Measurement in the legs exed -40 mmHg higher than in the brachial artery rtery Internal carotid arteries in neck a. LATERAL – side-lying position 8. INSPECTION – uses sense of sight 2. Semi-Fowler’s – head of bed elevated at 15-45 degrees angle b.back-lying with or without pillow 3. has a thrill Range of normal blood pressure 1. TERTIARY PREVENTION – after illness . AUSCULTATION – listening to body sounds with a stethoscope POSITIONS 1. monthly BSE..back unsupported & legs hanging freely 4. Specific Protection . SECONDARY PREVENTION = during illness . 30-60mg Hg child over age two: 8595/50-65 mm Hg 2. Prompt Treatment .Early Diagnosis. DORSAL/SUPINE. DORSAL RECUMBENT – back-lying position with knees flexed. heard with a stethoscope partially off chest. speech therapy after laryngectomy PHYSICAL EXAMINATION . school age: 100-110/50-65 mm Hg 3.occurs after a disease or disability has occurred & recovery process has begun .Health Promotion.Protect client’s privacy during entire procedure . PT after CVA.CEPHALOCAUDAL approach .Prepare needed materials before starting procedure MODES OF EXAMINATION: 1. High Fowler’s – head of bed raised at 80-90 degrees angle 6. complete immunization program 2. no thrill Grade IV: Loud.ACTIVITIES: annual physical exam. regular PAP smear.seeks to halt the disease or injury process & obtain optimal health status . optimal reconstitution or establishment of high-level wellness . LITHOTOMY. GENUPECTORAL/KNEE-CHEST. well-balanced diet.ACTIVITIES: quit smoking. hips externally rotated 2.Determine mental status and LOC . auscultate both sides d. has thrill Grade VI: Can be heard with a stethoscope off chest. normal findings: strong thrusting pulse c.seeks to prevent disease or condition at a prepathologic state . Detection. SIM’S – semi prone 9. adolescent: 110-120/65-85 mm Hg 4.ACTIVITIES: self monitoring of CBG among diabetics. sptum exam for TB 3.known as health maintenance . child under age 2 weighing at least 2700g: use flush technique. may have a thrill Grade V: Very loud. normal findings: no sound heard . attending selfmanagement education.back-lying with feet supported in stirrups 5. regular exercise. Screening. adequate fluids. PALPATION – uses sense of touch 3.kneeling with torso at 90 degrees angle to hips 7.

Normal range of peripheral pulses . Plantar flexion .The act of lying prone or face downward. Olfactory (CN I) PULSE GRADING SCALE No pulse-0 Weak pulse-1+ Difficult to palpate-2+ Normal-3+ Bounding-4+ 2. k.adolescent/adult: 60 to 100 beats/minute Pitting Edema Grading Scale 1+ Barely detectable-0 to ¼ inch pitting(mild) 2+ Indentation of <5mm-¼ to ½ inch pitting(moderate) 3+ Indentation of 5-10mm. constriction causes bruit 3.e. Popliteal: behind the knee 9. Abduction . Brachial: in the antecubital area of arm 5. h. Temporal: over temporal bone lateral to eye 2.Extension of the foot so that the forepart is depressed with respect to the position of the ankle j.Neck 1. Radial: on thumb side of wrist 6. Peripheral arteries and veins a. client in supine position with head elevated at 45 degrees b. Extension . Eversion . Femoral: below the inguinal ligament 8.Turning outward e. Dorsalis pedis: along top of foot b. in the case of digits.½ to 1 inch pitting(severe) 4+ Indentation of >10mm. the uterus).The condition of being on the back or having the palm of the hand facing upward or the foot turned inward and upward CRANIAL NERVE FUNCTION 1. d.. Posterior tibial: on inner side of each ankle 10.A turning inside out of an organ (e.The act of bending or condition of being bent in contrast to extension. Ulnar: medial wrist Leg 7. Pulse .Lateral movement of the limbs away from the median plane of the body. Supination . normal findings: pulsations not evident c. Carotid: over the carotid artery in neck Chest 3. Apical: between 4th and 5th intercostal space usually mid-clavicular line Arm 4. toward the axial line of a limb. Flexion . Adduction .Movement of a limb or eye toward the median plane of the body or. Pronation . Inversion .locations LOCATIONS OF PULSES Head .Extreme or abnormal extension. Hyperextension . c. g.greater than 1 inch(severe) Normal rates of Respiration newborn: 35 to 40 breaths/minute Range of motion . or lateral bending of the head or trunk b. jugular venous pressure (JVP): not to exceed 3 cm above level of sternal angle 4.toddlers: 90 to 140 beats/minutes . Optic (CN II) . or posterior aspect of the body.A movement that brings the members of a limb into or toward a straight position f. Dorsiflexion .g. Jugular veins a.Movement of a part at a joint to bend the part toward the dorsum. i.infants: 120 to 160 beats/minutes .preschool/school-age: 75 to 110 beats/ minute .normal findings: able to move joints through required range of motion a.

Glossopharyngeal (CN IX) and Vagus (CN X) . tactile and painful stimuli 3. Returns to sleep quickly. place. Responds only to pain 2. Difficult to arouse 2. Acoustic (CN VIII) -2 feet -2 feet ity to hear spoken word 9. auditory. Alterations in LOC ALTERATIONS IN LEVEL OF CONSCIOUSNESS 1. Speaks and responds slowly and appropriately 1.. Facial (CN VII) Level of consciousness (LOC) normal findings 1. Glasgow Coma Scale 5. 6. Trigeminal (CN V) bilateral pressure 12. Sleeps but easily aroused 2. 10. 4. "ah" Deviation: inability to taste or identify taste on the posterior tongue 11. and abducens (CN VI) ation: Unequal or absent rise of uvula and soft palate as the client says. alert 2. Oculomotor (CN III). Hypoglossal (CN XII) Absent or one-sided blinking of eyelids 7. Aroused only through pain 2. Gag and blink reflexes intact 1. trochlear (CN IV). and situation 2. time. Awake and aware of person.total or partial blindness of one or both eyes 3. may respond inappropriately 1. No verbal response 1. able to carry out simple commands 4. Responds appropriately and to verbal stimuli 1. responds appropriately to visual. No response to pain anterior two-thirds of the tongue smile symmetrically 8. Spinal accessory (CN XI) 5.

nurse’s actions Yura & Walsh – suggested 4 components of the process:assessing.Problem-solving tool in utilizing clinical application of knowledge & theory in nursing practice . IMPLEMENTATION 1. Diagnosis. STRUCTURED – emergency situation / limited time . do. Objective Data (signs) METHODS OF DATA COLLECTION 1.DIET M .decision making/ critical thinking 3. (2) diagnosis of actual & potential health problems as integral part of nursing practice. decision.ACTIVITY D .2. nursing action Ida Jean Orlando – 3-Step Process:client’s behavior. EVALUATION purpose: 1. selecting nursing interventions – based on the etiology DEPENDENT: A .therapeutic communication 2.nursing process as: discover. evaluation a. outcome identification. structure evaluation c. Wellness diagnosis b. Syndrome Format: P – problem / diagnostic label E – etiology / risk factors S – s/s or defining characteristics *collaborative problems – focused on complications and bothe nurses and doctors work C. PLANNING Steps: a. (4) 6 steps. Subjective Data (symptoms) 2. Goals and objectives are met 2. decide. planning.TREATMENT d. nurse’s reaction.assessment. diagnosis. effectiveness of interventions done 3 aspect: a. 3-Step Process: note observation. Cognitive Skills . ABC. UNSTRUCTURED – establish rapport C.OPD or clinic B. writing the NCP e.cornerstone of nursing profession . SEMI – STRUCTURED – put follow – up questions on the list . nursing process b. Planning. Secondary b. discriminate American Nurses Association – innovations introduced: (1) diagnosis as separate step. Primary 2. Risk Diagnosis D. identify outcomes and goals . ASSESSMENT TYPES OF DATA 1. validation Dorothy Johnson. establishing priorities framework used are: Maslow’s Hierachgy. planning.MEDICATION I .based on the problem c.6-Step Process – Assessment. No reflexes or muscle tone Note: dying clients will proceed through these levels in this above-listed sequence. Observation SOURCES OF DATA 1. outcome evaluation b. implementation. Technical Skills . process evaluation . delve. NURSING DIAGNOSIS 5 TYPES a. Outcome. ministration of care. Affective skills – communication skills d. Interview A.IVT T .hands on skill 2. Actual Diagnosis c. Implementation & Evaluation The Nursing Process History Lydia Hall – originated term Nursing Process. Identification. Possible Diagnosis e.introduced 3-Step Process:assessment. implementing and evaluating Knowles. (3) outcome identification as distinct step. THE NURSING PROCESS .

PYREXIA – body temperature above normal range 2. Radiation – transfer of heat from one surface to another without contact 2. PROBLEM ORIENTED MEDICAL RECORD 4 papers only a.5 inches . FDAR NURSING INFORMATICS OCTOBER 1995 – first ANA certification exam in nursing informatics 1977 – first nursing information system conference was held in USA 1.Take temperature 2-3 minutes RECTAL ROUTE – BEST CORE TEMP. STANDARDS OF NURSING CARE. MANAGEMENT INFORMATION SYSTEM – the mngt. RELAPSING FEVER – on and off fever w/in days 4. oral mucous. Basal Metabolic Rate (BMR) 2.. Conduction – transfer of heat from one surface to another with difference of temperature 3. respiratory tract ALTERATIONS IN BODY TEMPERATURE 1.Insert 0. METHODS OF TEMPERATURE TAKING ORAL ROUTE – MOST ACCESSIBLE . & treatment of data pertaining to organizational process 2. Problem List – 1st page c.Let stay for 2 mins AXILLARY ROUTE – safe and non invasive . & treatment of data pertaining to patient care process TELEMEDICiNE – ABLE TO GIVE MEDICAL ORDERS AT A DISTANCE FACTORS AFFECTING BODY HEAT PRODUCTION 1. HYPERPYREXIA – very high fever. reliable .Instruct to take deep breath during insertion . SOURCE OREINTED MEDICAL RECORD Narrative charting Each page each department 2. INTERMITTENT FEVER – on and off fever fluctuates w/in 24 hrs 2. Epinephrine. CONSTANT FEVER – abrupt increase in temp. BEDSIDE ACCESS TO CHART FORMS 4. REMITTENT FEVER – wide fluctuating temp that happens w/in 24 hrs but all above normal 3. Surface Temperature. Databse b. subcutaneous tissue and fat (Axilla) .Lubricate before insertion.DOCUMENTATION 1.5-1. HYPOTHERMIA – subnormal core body temperature TYPES OF FEVER 1. Muscle Activity 3. Core Temperature-temperature of deep tissues of the body (oral/rectal) 2. Thyroxine Output 4. norepinephrine & sympathetic stimulation 5.Wash thermometer before & after use utilizing proper technique . Evaporation – continuous vaporization of moisture from the skin. Progress Notes 3.the mngt. Convection –dissipation of heat by air currents 4.Safest & non-invasive Vital Signs BODY TEMPERATURE The balance between heat production and heat loss * Body heat is primarily produced by metabolism & regulated by hypothalamus Lowest temp : 4-6am and Highest temp: 4-6 pm TYPES OF BODY TEMPERATURE 1. drank hot/cold beverage or smoked .allow 15 mins when pt took food. HOSPITAL INFORMATION SYSTEM . Plan of Care d.Most accessible & convenient method .temperature of the skin. . Increased temperature of body cells PROCESSES INVOLVED IN HEAT LOSS 1. do not force. CHARTING BY EXCEPTION Chart only abnormal or significant findings Consists of : FLOW SHEET.Most accurate measurement .Assist in assuming lateral position . 41degrees & above 3.

Act of breathing Pulse Rate . Old and older adults.responsible for deep. Pons – contains: .Reflects core temp – easily obliterated ARTERIAL WALL ELASTICITY.above 100 bpm (adult) Bradycardia – below 60 bpm (adult) RHYTHM – pattern & intervals of beat VOLUME – strength of pulse – felt with moderate pressure – obliterated with great pressure .5 secs . checking for pulse deficit.Pat dry the axilla before placing thermometer.Exhalation – 3 secs 2. used in checking pulse deficit.represent stroke volume PROCESSES: 1. assessment pulse for adults.Pneumotaxic Center-responsible for rhythmic quality . cardiac arrest in infants. soft & pliable PRESENCE/ABSENCE OF BILATERAL EQUALITY. smooth. pneumonia 2. SUPRASTERNAL RETRACTION – above clavicle. Ventilation . circulation in the brain o Carotid massage – stimulates vagal nerve – decrease HR Brachial pulse – assess BP. Diffusion 3. cardio medicine drugs Femoral pulse – perfusion in the lower extremities. ABG specimen Popliteal pulse – perfusion of the lower leg.. ASTHMA RESPIRATORY CENTERS 1. ABG specimen Apical pulse – children </= 3 yrs.absence indicates CV disorder         Temporal pulse – perfusion f face Carotid pulse – pulse during cardiac arrest. INTERCOSTAL RETRACTION – outline of the ribs.Inhalation/ inspiration – 1. alternative site for BP taking Posterior Tibial and Dorsalis Pedis – perfusion of the foot RESPIRATORY RATE .Apneustic Center. prolonged inspiration 3. .Place arm tightly for 9 minutes TYMPANIC . SUBSTERNAL RETRACTION – under breast bone 3. ABG specimen Radial pulse – normal routine. Do not rub. Medulla Oblongata – primary 2. Perfusion Costal – thoraxic muscle – 7 years old Diaphragmatic – abdominal muscle CHEST MOVEMENTS 1.artery feels straight. Carotid & Aortic bodies-contains peripheral chemoreceptors Tachycardia.

Read lower meniscus of mercury level of sphygmomanometer at eye level to prevent Error of Parallax 10.name given to a drug by the manufacturer.pressure of blood due to contraction of ventricles Diastolic Pressure – pressure when ventricles are at rest Pulse Pressure – difference bet. treatment. Date and Time 3. The sound during BP taking is called KOROTKOFF sound 9. 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 Doctor’s Orders Standing Order – carried out until the specified period of time or until discontinued by an order . Dose of Drug 5.caffeine intake before taking BP 3.name that describes precisely the constituents of drugs Brand name. Drug Interaction – effects of one drug are modified by the prior or concurrent administration of another drug.4. smoking. Arm must be at the level of the heart 6. relief or prevention of disease. Route of Administration 6. Position in supine or sitting 5. Tissues come to require the substance to function normally. it may cause false low reading Medication Administration Medications – substance administered for diagnosis. Systolic & diastolic pressures Hypertension – abnormally high BP over 140 systolic or over 90 diastolic for at least 2 consecutive readings Hypotension – abnormally low BP. AKA secondary effect. of the nervous system. Time or Frequency 7. AKA trademark. AKA physical dependence. ERROR OF PARALLAX – if eye level is higher than level of lower meniscus of mercury. Side Effect – Unintended effect of the drug. Name of Drug 4. cure. below 100/60 ASSESSMENT OF BLOOD PRESSURE 1. Allow 30 mins after exercise. AKA desired effect. 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 BLOOD PRESSURE . Use appropriate size of BP cuff 4. Ensure client is rested 2. Apply cuff 1 inch above antecubital space snugly and smoothly 7. 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.unexpected peculiar response to the drug Drug Abuse – inappropriate intake of a substance. either continually or periodically Drug Dependence – person’s reliance to take a drug/substance which will produce an intense reaction upon withdrawal Addiction – due to biochemical changes in body tissues esp. Habituation – emotional reliance on a drug to maintain sense of well being. Use bell of the stethoscope 8. 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. AKA psychological dependence. Signature of Physician Effects of Drug Therapeutic Effect – intended primary effect. deep or shallow RHYTHM – observe for regularity of exhalations and inhalations QUALITY / CHARACTER – respiratory effort & sound of breathing 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 Doctor’s Order 1.Measure of pressure exerted by blood as it pulsates through arteries Systolic Pressure. Name of Patient 2. Muscle & joints – contains proprioreceptors ASSESSMENT OF THE RESPIRATORY RATE RATE – Normal is 12-20 in adult DEPTH – may be normal.

BUCCAL -held in the mouth against mucous membranes of the cheek. use gloves over large areas 2. Nasal – for astringent effect. milk. INTRADERMAL – thru the dermis beneath epidermis . swallowed or placed under the tongue ADVANTAGES: local effect.patient. 13. capsule. elixir. 3.dose. irrigations • Instillations-softens earwax. pill. ointment • Pat dry area. safe & does not break the skin barrier DISADVANTAGES: inappropriate for those with nausea & vomiting.Curative – treats the disease condition Supportive – sustains body functions until other treatment of the body’s response can take over Substitutive – replaces body fluids / substances Chemotherapeutic – destroys malignant cells Restorative – returns/repairs body to health Principles of Drug Administration 1. When meds is omitted for any reason. suspension. less expensive. Do not leave medications at the bedside. remove foreign body 4. may be inactivated by gastric juices IV. RECTAL ADVANTAGE: Used when odor/taste is not favorable DISADVANTAGE: absorption is unpredictable REMINDERS: needs refrigeration. jelly. Otic – instillations. use gloves for insertion. facilitate drainage.oil-based ELIXIR. The nurse who prepares the drug must be the one to administer it. may be inactivated by gastric juices. powder 2. Identify patient correctly before administering medications. irritate gastric mucosa Oral Drug Forms 1. approach 2. must remain under the tongue until dissolved/absorbed III. ORAL ADVANTAGES: most convenient. Practice asepsis. report to nurse in charge or physician. If patient vomits. 14.nebulizers. Return liquid that are cloudy in color.lie on left & breathe thru mouth. other alkaline substance SYRUP-sugar-based SUSPENSION-water-based EMULSION. thin layer needed.Proetz position-ethmoid/sphenoid 5. 8. Irrigations-flush eye of noxious/foreign material 3. 6.Administration by needle 1. Ophthalmic – instillations.Instillations-provides meds. dysphagia.Never crush enteric-coated or sustained-release medication II. apply heat. -RIGHT drug. position. liquid. irrigations . • Empty bladder first. recording.alcohol-based . SOLID – tablet.route. foam & suppository • Vaginal Irrigation – washing of vagina by liquid at low pressure. discolor teeth. reduced GIT motility. MDI 6. treat infections . Keep narcotics locked. greater potency because drug directly enters blood & bypass the liver DISADVANTAGES: if swallowed. TOPICAL -application of medications to a circumscribed area of the body 1. LIQUID – syrup. Be knowledgeable about the meds you administer. emulsion.time. 5.Parkinson’s position-frontal/maxillary . reduce inflammation & treat infection. rapid absorption in the bloodstream DISADVANTAGES: if swallowed. Nurses administering medications are responsible for their own actions. Routes of Drug Administration I. PARENTERAL . position • Irrigating can shld be 12 in higher • Remain in bed for 5-10 mins after V. Observe the “7 Rights” of drug administration. Preoperative meds are usually discontinued during postop unless ordered to be continued. AKA douche. seriously ill May give unpleasant odor/taste.Drugs placed under the tongue ADVANTAGES: for local effect. When med error is made. 11. loosen secretions. use surgical asepsis. cream. report ASAP. 7. Inhalation. SUBLINGUAL . liniments. relieve pain • Irrigations. must remain on the side for 20 minutes for absorption VI. record the fact & the reason. 9. Use only medications that are clearly labeled. 12.remove cerumen. Should not be chewed. Dermatologic-lotions. Vaginal – local therapeutic effect but has limited use FORMS: tablet. 10. 4.

affected arm warmer than the other NSG. pulmonary edema. Regulate every 15-20 minutes. SUBCUTANEOUS – SITES: outer aspects of UA. Change IV tubing every 72 hours.Most rapid route.2. INT: slow IV infusion (KVO). 5. D5NM) Nursing Interventions: 1. Circulatory Overload – from administration of excessive volume of IV fluids S/S: headache. INTRAMUSCULAR – use 1” – 2” needle to reach the muscle layer • SITES: ventrogluteal. LOC NSG.do not massage & give at 90° 3. no backflow NSG. tachycardia. vein feels hard & cordlike. bevel up • Inject over 3-5 sec to form a wheal/bleb • Do not massage the site 2. anterior aspect of thighs. amount. preoperative meds. IV rate decreases/stops.3%) C. large bore catheter S/S: pain along the vein. 6. syncope. Hypertonic – has higher concentration than body fluids (D10W. administer diuretic.INT: massage area & move shoulders thru ROM. cyanosis. Hypotonic –has lower concentration than body fluids (NaCl 0. irritating soln/drugs. INT: change IV site every 72H. narcotics.9%. scapular area of the back.3 or 5 mL p to 10 mL Deltoid Non deltoid 23 -25 21-22 1 in 1. fluids accumulate in the subcutaneous tissues S/S: pain.5-1 ml & rotate sites • Use 5/8 needle for adults when given at 45 degrees (thin pts. Know the type. Infiltration – needle out of vein. SOB. rectus femoris.5/ 8 “ 3/8 – 5/8 “ . NaCl 0.same concentration as body fluids (D5W. abdomen. pallor at site.INT: do not allow bottle to “run dry”. predictable INDICATIONS: pts with compromised GI function. open/close hands several times each hour. Prime IV tubing to expel air. 4. ½ for 90 degrees (obese pts) • Insulin Injection. cough. cold skin. ventrogluteal & dorsogluteal areas INDICATIONS: vaccines. shock NSG. turn to left side in Trendelenburg position 6. 2. dyspnea. insulin. Observe for complications. Superficial Thrombophlebitis – due to overuse of vein. heparin • Small doses only – 0. clot formation. Nerve Damage – due to overly tight tying of the splint S/S: numbness of fingers/hands NSG. fainting. PT if required 7. beneath the scapulae INDICATIONS: for allergy & tuberculin testing & vaccinations • Needle at 10-15 degrees angle.: slow IV infusion (KVO). Z-track 4. INTRAVENOUS – direct IV. use large veins for irritating fluids. edema & redness over site.INT: change IV site. weight. plain NM) B. Isotonic Solution. prime tubings before starting IV. apply warm compress 2. D5LR.).SITES: inner lower arm. bronch odilator as ordered 3. swelling.5 inch degree Almost parallel to the skin 15 degress Average = 45 degrees Fat = 90 degress Average = 90 degrees Thin= 45 degrees Complications of IV Infusion: 1. increased PR. stabilize area. 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 length ¼ . shock NSG. D50W. increases venous pressure. 3. Inform client & explain purpose of IV therapy. Air Embolism . IV push or infusion . apply cold compress immediately then warm compress after 5. flushed skin. Drug Overload – excessive amount of drugs in the fluids S/S: dizziness. high fowler’s position. dorsogluteal (<3 y/o). inform physician 4. increased venous pressure. Speed Shock – D/T rapid administration of IV fluids NSG. plain LR.INT: to avoid speed shock & cardiac arrest. indications of IV. hypotension. Change /alter IV needle insertion site every 72 hours. vastus lateralis. upper chest & back. Intradermal mL Gauge 1 mL 25 -27 Subcutaneous 1 or 2 mL 25 Intramuscular 1. 7. INT.BP.RR. rapid introduction of medications TYPES OF IV FLUIDS: A. deltoid.air enters the system (at least 5 ml or more) S/S: chest/shoulder/back pain.

yperkalemia BT REACTION H.universal recipient . refrigerate 3-5 days . BT should be done less than 4hrs for WB & PRBC and 20 minutes for plasma.NURSING MANAGEMENT 1.AB. Use RED ballpen when charting 10.Start at slow rate (10 gtts/min)& remain at bedside for 15-30 mins 14. Check for serial number 9.250 cc packed of RBC. Never administer IV with dextrose 17. Check for expiration date 8. platelets. cryoprecipitate 15.It may destroy vital product of the blood . Observe for Complication C. Administer 0. 16.Type O universal donor .ir embolism T.emolytic A. and dark color 11. during or after BT.Proper Refrigeration .irculatory overload A. Regulate @ KVO or 100 cc/hr to prevent circulatory overload for first 30 minutes .itrate intoxication H. Avoid mixing the drugs at BT line 13.llergic P.hrombo cytophenia .Let the room temperature warm the blood @ 30minutes 12.85% of people is RH RH (+) 3.1 platelet bag refrigerate 5-6 days 2.9% NaCl before. Check blood unit for presence of bubbles. For 1st hour . With filter (BT set) 5. During & after BT 10 especially q15minns. Gauge 18 of needle 6. cloudiness. Monitor VS before.Majority of BT reaction occurs within 1hr. Aseptical assemble all materials needed for BT 4. Never warm the BLOOD .yrogenic C. Check for name of the client 7. Proper blood typing & cross matching .

Asepsis and Infection Control INFECTION – invasion of body tissue by microorganismsASEPSIS – 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 person’s 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 – organism’s 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 .

Biologic – animals (rats. urethral catheter .VEHICLE TRANSMISSION – transfer by way of vehicles or contaminated items (food. laughing within 3 feet . Private rooms f. stethoscope. mosquitoes) .antibodies are produced by the body in response to infection NATURAL – antibodies formed in presence of active infection in the body. HANDWASHING an the elbows . animals.Prevent transmission of bloodborne & moist body substance pathogens ASEPTIC PRACTICES 1. suction gauges. at least 15 minutes 3. Masks b. BOILING WATER – least expensive.CONTACT TRANSMISSION – direct/indirect . drainage tubes . sporicidal & penetrates fabric .DROPLET TRANSMISSION – when MM are exposed to secretions of an infected personwho is coughing. ISOLATION SYSTEMS MODES OF TRANSMISSION . Caps & shoe covers d.vectors can be biologic or mechanical .GIT-vomitus.Urinary Tract – urine.Convalescent Period – S/S start to abate until client returns to normal state of health ETIOLOGIC AGENT – may be bacteria. mattress) . plants.Expensive & requires 2-5 hours . milk. vaginal discharge . It is lifelong.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 . CLEANING.sputum .Color indicator strips change color to indicate sterilization GAS STERILIZATION – ethylene oxide is colorless gas that can penetrate plastic. virus. water. pillows.Reproductive Tract. food & other heat-sensitive items CHEMICALS – are effective disinfectants . Used for oxygen.permits organism to enter host . DISINFECTION & STERILIZATION – physical removal of dirt & debris by washing. snails. inexpensive & stable in light & heat.non-toxic . vagina. feces. dusting or mopping fection – chemical or physical process to reduce number of potential pathogens on a surface but not necessarily the spores – complete destruction of all microorganisms including spores METHODS OF STERILIZATION STEAM STERILIZATION – autoclaving uses supersaturated steam under pressure . Chlorine is used. nose. open wound -30 seconds each hand 2.Mechanical – infected inanimate objects (contaminated needles/syringes) PORTAL OF ENTRY . environment PORTAL OF EXIT – (from reservoir) . Equipment & refuse handling 4. catheter .Through body orifice such as mouth.Ethylene oxide is toxic to humans RADIATION . saliva.Respiratory Tract. 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 CLASSIFICATIONS: A. rectum OR breaks in the skin or MM SUSCEPTIBLE HOST – host is a person who is at risk for infection. sneezing. Gowns c. utensils. inexpensive. whose body defense mechanism are unable to withstand the invasion of the pathogen TYPES OF IMMUNIZATION ACTIVE IMMUNIZATION. rubber.Attacks all types of microorganisms rapidly. Standard Precautions . Gloves e. cotton or other subs.semen.Universal Precaution & Body-Substance Isolation . USE OF BARRIERS a. BP apparatus.Blood – needle puncture.Used for drugs.ionizing radiation penetrates deeply to objects . fungi or parasites RESERVOIR – humans.droplet.

Wear masks. 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. Laceration 6.Private room. only cooked/canned foods allowed 5. goggles. wear masks 2. e. Puncture 5. Wear gown if soiling & splashes are expected 5. raw foods. Protective Isolation . 3-6 days 2. GIT & urinary tract are not entered 2.for small-particle droplet that may remain suspended in the air & dispersed by air current (varicella. Transmission-Based Precautions 1. structures. accidental wounds. negative airflow. Inflammatory Phase – immediate. Prevent unnecessary traffic & air currents around sterile area g. use gloves. Discard all single-used items 8.prevent infection for people with compromised resistance (leukopenia.open. joints KINDS OF WOUND DRAINAGE EXUDATE – material that escapes from blood vessels during the inflammatory process 1. Vibration 3. SURGICAL ASEPSIS PRINCIPLES: a. fresh. Dirty/Infected Wounds – with dead tissue & evidence of infection TYPES OF WOUND: According to cause 1.for those transferred by hand-or skin-to-skin contact (clostridium difficile. no infection . tendon. Clean & reprocess all equipment 7. Perform handwashing 3.Private room. DROPLET PRECAUTION . TB.for large-particle droplet & dispersed by air current (H. A person who is considered sterile who becomes contaminated must reestablish sterility i. with evidence of inflammation 4. CONTACT PRECAUTION . Percussion (clapping) 2.respiratory. Sterile articles may touch only sterile surface/articles to maintain sterility. undergoing chemoRx. Penetrating wound TYPES OF WOUND HEALING 1. 3. Deep crater. measles -Private room. GIT & urinary tract entered 3. SEROUS EXUDATE – blister from burns 2. 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. face shield if sprays/splashes are expected 4. Contusion 3. shigella. gowns & other protective barriers when exposure to infected material is likely C.Private room. Never assume that an object is sterile. Surgical technique is team effort. diphtheria. Primary Intention healing 2. Moisture causes contamination. d. f. minimal inflammation. closed . Sterile equipment/areas must be kept above the waist & on top of the sterile field. impetigo) . Remove soiled protective items immediately 6. Proliferative Phase – 3rd to 21 days 3. Always face the sterile field. mycoplasma pneumoniae) . Abrasion 4. Use private room or consult with Infection Control Department B. c. Wound Care TYPES OF WOUNDS: According to contamination 1. AIRBORNE PRECAUTION . PURULENT EXUDATE 3.respiratory. open. no fresh fruits/flowers. Wear clean gloves 2. influenza. potted plants allowed. Stage 4 – full-thickness skin loss with necrosis or damage to muscle. bone. Contaminated Wounds. Prevent injuries 9. restrict visitors.1. Secondary Intention healing PHASES OF WOUND HEALING 1. extensive burns) . rubella. Clean Wounds – uninfected. Incision 2. SANGUINEOUS (Hemorrhagic) EXUDATE Oxygenation Kinds of Chest Physiotherapy 1. b. unused sterile articles are no longer sterile after the procedure h. Postural drainage . wear masks within 3 ft. Clean-contaminated Wounds – also surgical wounds.

Medimist Inhalation . High flow administration devices ADMINISTRATION OF OXYGEN Indications: hypoxemia Signs of Hypoxemia: . Low flow administration devices 2. 2. Steam Inhalation – semifowler’s position & position spout 12-18 inches away from nose 2. unconscious: lateral position 3. Apply suction during withdrawal of catheter 9. Assess effectiveness / document INCENTIVE SPIROMETRY -Enhance deep inspiration INTERMITTENT POSITIVE PRESSURE BREATHING Administer oxygen at pressures higher than the atmospheric pressure OXYGEN SYSTEMS 1. Apply suction for 5-10 seconds (max 15) 10. conscious: semi-fowlers b.Increased pulse rate . Provide oral & nasal hygiene 13. Aerosol Inhalation 3. Hyperventilate 100% before & after 11. Lubricate catheter 8. Assess indications for suctioning. Don sterile gloves 6. Apply proper pressure 4. Insert proper length of catheter 7. Allow 20-30 sec interval between each suction 12.Substernal / intercostals retractions . nasal flaring .Light headedness . Position properly: a. Use appropriate size of catheter Adult: Fr 12-18 Child: Fr 8-10 Infant: Fr 5-8 5. DOB.Cyanosis ALTERATIONS IN RESPIRATORY FUNCTION HYPOXIA Insufficient oxygenation of tissues CLINICAL SIGNS: SUCTIONING 1. Dispose contaminated equipment/matls safely 14.Restlessness RHYTHM CHEYNE-STOKES – marked rhythmic waxing & waning of respirations from very deep to very shallow and temporary apnea KUSSMAUL’S (Hyperventilation) – increased rate & depth of respiration APNEUSTIC – prolonged gasping inspiration followed by very short inefficient expiration BIOT’S – shallow breaths interrupted by apnea .Rapid. shallow breathing.Bronchial Hygiene Measures 1.