FUNDAMENTALS IN NURSING

IMMOBILITY
NATURE OF MOVEMENT
1. ALIGNMENT AND BALANCE
- Scoliosis and Osteoporosis
2. Gravity and Friction
- Body weight oppose movement
3. Skeletal System
- Joints, Tendons, Ligaments
4. Skeletal Muscle
- Provide breakage due to movement
5. Nervous System
- Primary control

PATHOLOGICAL INFLUENCES OF MOBILITY

1. Postural Abnormalities
- Posture
2. Muscular Abnormality
- Stroke patients w/ paralyzed side.
3. Damage to CNS
- Stroke
- Direct trauma to the musculoskeletal system.

FACTORS INFLUENCING MOBILITY

1. Systemic Factors
- SYSTEMS
A) METABOLIC CHANGES
- Endocrine metabolism
- Calcium reabsorption
- Functioning of the GI System (immobility leads to constipation)
B) RESPIRATORY CHANGES
- Lack of movement laces patients at risk for respiratory complications.
(any immobility can cause pneumonia)
C) Cardiovascular Changes
- Orthostatic hypotension
- Increased cardiac workload
- Thrombus formation (deep vein thrombosis)
 Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep
veins in your body, usually in your legs
D) Musculoskeletal Changes
- Muscle effect (Patient loose lean body mass)
- Skeletal Effect (impaired calcium metabolism)

URINARY ELIMINATION CHANGES

1. Immobility alters urine flow
2. Abnormal Gravitational Pull

INTEGUMENTARY CHANGES
1. High risk in sore pressure (Bed Sores)

PSYCHOLOGICAL EFFECTS
1. Patients with immobility have different emotional and behavioral response.
2. Depression
 NURSING INTERVENTION FOR IMMOBILITY
1. Range of Motion
- Active Range
- Passive Range
- Do to prevent contractures (Hardening of the joint)
2. Applying Compression
- Stockings or SCD (Sequential Compression Device)
- Provides circulatory support to avoid blood pooling.
- To also avoid DVT.
3. Incentive Spirometry/Deep Breathing Exercise
- Avoid Pneumonia
4. Use of heparin
- To avoid DVT

POSITIONING TECHNIQUE
1. Semi-Fowler
2. Supine Position
3. Prone position
4. Side-lying position

INFECTION
1. Infection
- Invasion of microorganisms resulting to a disease LIVE
2. Colonization
- Invasion of microorganisms in the DEAD

 Communicable Disease
- Can be transmitted
a) Symptomatic
- Presence of symptoms due to infection
b) Asymptotic
- Walang symptoms pero may sakit ka.

 Chain of infection
Infectious agent  Reservoir  Portal of Exit  Mode of transmission  Portal of Entry  Host.

INFECTION PREVENTION CONTROL

 INFECTION
- Invasion of microorganisms to a susceptible host resulting a disease
- Colonization – presence of growth of microorganisms with the host
- Communicable disease
- Symptomatic
- Asymptomatic
 CHAIN OF INFECTION

 Infectious agent
 Reservoir
 Portal of exit
 Mode of transmission
 Portal of entry
 Host

DEFENSE AGAINST INFECTION

 Body System Defense

HEALTH CARE ASSOCIATED INFECTIONS

 HAI – Health Care Associated Infections
 MDRO – Multi Drug Resistant Organisms

NURSING KNOWLEDGE BASE

FACTORS INFLUENCING INFECTION PREVENTION AND CONTROL
 S – STRESS
 A – AGE
 N – NUTRITIONAL STATUS
 D – DISEASE PROCESS

NURSING INTERVENTIONS: A PATIENT WITH HIGH RISK OF INFECTION

CONTROLLING TRANSMISSION
 Hand Washing/Hand Hygiene
 Isolation and Isolation Precautions
 Personal Protective Equipment
 Universal/Standard Precaution
 Transmission Based Precautions
- Contact Precaution
- Droplet Precaution
- Airborne Precaution
 Reverse Isolation

BODY DEFENSE SYSTEM

1. Barrier
- Skin
2. Phagocytosis
 - Wbc/Rbc
- Engulfing microorganisms

HAI – Healthcare Associated Infections

MDRO – Multi Drug Resistant Organism
FACTORS INFLUENCING INFECTION
S tress
A ge
N utritional Status
D isease Process

Controlling Transmission
1. Hand Hygiene
2. Isolation Precaution
3. PPE

TYPES OF PRECAUTION
1. Universal Precaution
- Hand Hygiene
2. Transmission Based Precaution
a) Contact Precaution
- Gowns, gloves, hand hygiene
b) Droplet Precaution
- Surgical Mask, Glasses
c) Airborne Precaution
- Viral
- MTC/MTV (Measles, TB, Varicella/C.pox)
3. Reverse Isolation
- Can easily contract disease

INFECTION
1. Infection – growth of microorganism in an are where they should not be growing.
2. Normal Flora – microorganism in a specific body part.
3. Asepsis
a) Medical/Clean technique
b) Surgical/Sterile Technique
4. Sepsis -acute organ dysfunction occurs (Infection in the blood)

2 Kinds of Infection:
a) Nosocomial
- Infection from hospital environment
b) Iatrogenic
- Infection from procedures done

How Infection Happens?

1. Number of organisms present in the area.
2. Severity of microorganism
3. Potency

HAND HYGIENE
Hand Hygiene – most effective infection prevention
 PURPOSE of HAND HYGIENE
1. Reduce number of microorganisms
2. Reduce Risk of transmission
3. Reduce risk of cross contamination among other patients.
4. Reduce transmission to oneself (nurse)
 ASSESSMENT
 1. Cut nails
2. Remove jewelry
3. Check skin for breakage
 PREPARATION
1. Assess factors that may contribute to possibility of infection.
2. If the client uses immune suppressive drugs.
3. Nutriotional Status
4. Signs and Symptoms
a) Localized
b) Systemic
5. Recent procedure that caused open wound

PATIENT SAFETY AND QUALITY

1. Patient Safety – reduces the risk for illness and injury (maintains patient functional status)

SCIENTIFIC KNOWLEDGE BASE

1. Environmental Safety – physical/psychosocial factor that may affect the patient.
2. Safe Environment – protect the health care worker as well.

BASIC NEEDS
1. Oxygen
2. Nutrition
3. Temperature
a) 18-25c – comfort zone
b) 42c – Heat Stroke

PHYSICAL HAZARDS
1. Safety Vehicle – the usage of seatbelt and airbags
2. Poison
3. Falls – major public health concern
4. Fire – Fire related deaths
5. Disaster – Natural , Manmade, Bioterorrism

TRANSMISSION OF PATHOGENS
1. Pathogen – microoganisms producing illness
2. Hands – most common men of transmission
3. Medical Asepsis and Hand Hygiene – most effective limiting transmission
4. Immunization – reduce/prevent transmission.

POLLUTION
1. Prolonged pollution can lead to disease conditions

NURSING KNOWLEDGE BASED

 RISK AT DEVELOPING CHANGES
1. INFANT, TODDLERS, PRESCHOOLERS.
a) Lead Poisoning
b) Accidental Burning
c) Falling from bike
d) Drowning
2. SCHOOL AGE
a) Head Injuries
b) Bike Accidents
3. ADOLOSCENTS
a) Risk taking behavior (smoking)
b) Drinking and Drugs

4. ADULT
a) Lifestyle Problem
b) Stress Related (GI Ulcer)
c)
Chain of Infection
3Ds
a. Delirium
b. Dementia
c. Depression

RISK IN HEALTH CARE AGENCY

 Patient Safety – one pressing health care challenges.
 Medical Errors - Non payment of the hospital.
1. Patient Inherit Accident
- Patient is the primary reason of the accident.
2. Procedure Related Accident
- Caused by healthcare provider
- Medication errors
- Dressing errors
3. Equipment Related Errors
- Malfunction or misuse of equipment
 5 Vital Signs
1. BP
2. Pulse
3. Respi
4. Temperature
5. Pain Assessment
 Pain Assessment
- Unpleasant sensory experience which is associated with tissue damage

CLASSIFICATIONS
a. Acute
- Sudden sensation of pain
b. Chronic
- Continuos
c. Cancer Pain
- Tumors
Physiologic Responses to Pain
- Anxiety, Fear (SNS)
- Cries
- Decreased gastric and intestinal motility
- Decreased in urinary retention
Pain = increase vital signs

8|Fundamentals in nursing
GENERAL OBESERVATION OF PAIN
1. Posture
2. Facial Expression
3. Joints and Muscles
4. Skin for scars

7 Behavioral Signs of Discomfort

1. Noisy Breathing
2. Negative Vocalization
3. Sad facial expression
4. Frightened F.
5. Frown
6. Tense body language
7. Fidgeting

APPROPRIATE NURSING DIAGNOSIS

1. Wellness Diagnosis
- Patient doesn’t feel pain anymore
2. Risk Diagnosis
- Future complications
- Assumptions
3. Actual Diagnosis

 Oxygen Saturation
Normal – 95-100%
 Oxygen Pressure
- 760 mmHg
- 754 (Inhale)
- 764 (exhale)
GASSES IN AIR
- 78% - Nitrogen
- 21% - Oxygen
- 1% - Other gases
 80-100 mmHg -normal oxygen in blood
 Oxygen Saturation
- Binding of oxygen and blood
 12-18 g/dl of hemoglobin
- Normal rbc count
 1.34% - 1 g of hemoglobin can carry oxygen
 Below 12g/dl - anemic

MEDICATION ADMINISTRATION
 PHARMACOKINETICS
Drugs Movement
-Movement of the drugs

 ABSORPTION- Absorb thorough the blood

 DISTRIBUTION- Distribute through the body
 METABOLISM
 EXCRETION- Feces

TYPES OF MEDICATION

9|Fundamentals in nursing
  THERAPEUTIC EFFECT- Intended effect
 SIDE EFFECT- Kasama sa effect ng drug
-Not detrimental
 ADVERSE EFFECT- Detrimental side effect
 TOXIC EFFECT- High dosage of drugs that can cause toxicity
 INDIOSYNCRATIC EFFECT- Unknown effect
 ALLERGIC REACTION- Stimulates immune system

MEDICATION ADMINISTRATION SCHEDULE

ABBREVIATION MEANING
ac Before meals
pc After meals
OD Once a day
BID Twice a day
TID Trice a day
QID 4 times a day
Q1H Every 1 hour
Q12H Every 12 hours
STAT Emergency (ASAP)
OD Am Once a day AM
OD Pm Once a day afternoon
PRN As needed

STANDARD OF SAFE NURSING PRACTICE

-To prevent medication error
 Right Patient
 Right Medication
 Right dosage
 Right route
 Right time
 Right Documentation

SYSTEM OF MEDICATION MEASUREMENT

 Metric system
 Apothecary
 Household measurement

METRIC APOTHECARY HOUSEHOLD

1 ml 15 minims 15 drops
5 ml 1 dram 1 teaspoon
15 ml 4 dram 1 tablespoon
30 ml 1 fluid ounce 2 tablespoon
240 ml 8 fluid ounce 1 cup
500 ml 1 pint 1 pint
1000 ml 1 quarts 1 quarts

 Medication - a substance used in the diagnosis, treatment, cure, relief, or prevention of health
problems. (Potter, et al., 2013, p. 565)

 The Nurse’s Responsibilities includes the following:

o 1) Evaluating the effects of the medications to the patient.
o 2) Educating the patient about the medications and its side effects.
o 3) Ensuring the adherence to the therapeutic regimen.

10 | F u n d a m e n t a l s i n n u r s i n g
 o And, 4) Evaluating the ability of the patient and the family to administer the medications.
(Potter, et al., 2013, p.565)

Route of Administration:
 The route of administration is influenced by the following:
o 1) the properties and the desired effects of the medication
o 2) and, the physical and mental condition of the patient. (Potter, et al., 2013, p.571)

Oral Route of Administration: (Potter, et al., 2013, p.593)

 Food delays stomach emptying which may decrease the therapeutic effects of oral medications. Most
oral medications reach their therapeutic action best if given 30 minutes to 1 hour before meals.
 Nurse need to take precautions for aspirations. Aspiration occurs when food, fluid or medications
intended for the Gastrointestinal inadvertently enters the respiratory tract. Position the client at 90
degrees when administering oral medications if not contraindicated by his or her condition. Slightly
flexing the neck in a chin-down position reduces risks for aspiration.
 When giving medications through gastric or enteric tubes, verify first the placement of the tubes. Use
liquid medications when possible. If liquid medications are not available crush simple tablets or open
gelatin capsules and dilute them in sterile water. Do not use tap water as tap water may contain
contaminants which may interact with the medications. Flush tubes with at least 15 mL of sterile water
before and after giving medications. Determine if the medication should be given on an empty
stomach or is not compatible with the feeding (e.g. phenytoin, carbamazepine [Tegretol], Warfarin
[Coumadin], Fluoroquinolones, proton pump inhibitors), the feeding can be withheld at least 30 minutes
before or 30 minutes after medication administration.

 Types of Oral Routes of Medication Administration:

o Oral, Buccal, Sublingual

 Oral
 Medications are taken in the mouth and swallowed.
 The oral route is the most commonly used route.
 Medications have slow onset action and prolonged effect.
 Easiest and preferred by most patients (Potter, et al., 2013, p.571)
 Buccal
 Medications that are taken in the mouth and are placed in the mucous
membranes of the cheeks to dissolve and be absorbed.
 Medications should not be chewed or swallowed.
 Alternate cheeks to with each subsequent dose to avoid mucosal irritation.
 Drinking liquids is avoided until medication is completely dissolved. (Potter, et al.,
2013, p. 572)
 Sublingual
 Medications that are taken in the mouth and are placed under the tongue to
dissolve and be absorbed.
 Medications should not be swallowed.
 Drinking is avoided until medication is completely dissolved. (Potter, et al., 2013, p.
571)

11 | F u n d a m e n t a l s i n n u r s i n g
Medication Forms Commonly Prepared for Administration by Oral Route (Potter, et al., 2013, p.567)
Solid Forms
 Capsule – Medication encased in a gelatin shell.
 Tablet – Powdered medication compressed into a hard disk or cylinder; in addition to primary
medication, contains binders (adhesive to allow powder to stick together), disintegrators (to promote
tablet dissolution), lubricants (for ease of manufacturing), and filters (for convenient tablet size).
 Caplet – Tablet shaped like a capsule coated for ease of swallowing.
 Enteric-coated – Coated tablet that does not dissolve in the stomach; coatings dissolve in the intestines,
where medication is absorbed.

Liquid Forms
 Elixir – Clear fluid containing water and/or alcohol; often sweetened
 Syrup – medication dissolved in a concentrated sugar solution.
 Extract – syrup dried from pharmacologically active medication, usually made by evaporating solution.
 Aqueous Solution – Substances dissolved in water and syrups.
 Aqueous Suspension – Finely divided drug particles dispersed in liquid medium; when suspension is left
standing, particles settle at the bottom of the container

Other Forms
 Troche (lozenge) – Flat round tablets that dissolve in the mouth; not meant for ingestion.
 Aerosol – Aqueous medication sprayed and absorbed in the mouth and upper airway; not meant for
ingestion.
 Sustained Release – Tablet or Capsule that contains small particles of a medication coated with
material that requires varying amount of time to dissolve.

Advantages and Disadvantages of the Oral Route. (Potter, et al., 2013, p.571)
 Advantages
o Convenient and Comfortable for Patients
o Economical
o Easy to Administer
o Often produce Local or Systemic Effects
o Rarely causes Anxiety for Patients

 Disadvantages
o Oral Route is Avoided when Patient has Alterations in the Gastrointestinal Functions (e.g.
Nausea, Vomiting), Reduced Motility (After General Anesthesia or Bowel Inflammation), and
Surgical Resection of Gastrointestinal Tract.
o Oral Administration is Contra-indicated in Patients Unable to Swallow. (e.g. Patients with
Neuromuscular Disorders, Esophageal Strictures, Mouth Lesions)
o Oral Administration is Contra-indicated in Unconscious or Confused Patient who is Unable or
Unwilling to Swallow or hold medication under tongue.
o Oral Medication cannot be administered when patients have gastric suction; are contra-
indicated before some test or surgery.

12 | F u n d a m e n t a l s i n n u r s i n g
 o Oral Medications sometimes Irritate lining of the Gastrointestinal Tract, Discolor Teeth, or have
Unpleasant Taste.
o Gastric secretions destroy some medications.

Drug Computation
Formula
Dose Ordered x Amount on Hand = Amount to be Administered
Dose on Hand

Dose Ordered – is the amount of medication prescribed

Dose on Hand – is the dose of medication supplied by the pharmacy
Amount on Hand – is the quantity of the medication that contains the Dose on Hand

Sample: The physician ordered 500mg of amoxicillin to be administered every 8 hours. The
bottle of amoxicillin shows 400mg/5ml

500 mg x 5 mL = 5 x 5mL = 25 mL = 6.25 mL

400 mg 4 4

FOUNDATIONS OF THE NURSING PRACTICE

 Patient Safety and Quality

 Safety
- Freedom from psychological and physical injury
- A basic human need

 Patient Safety
- A safe patient environment reduces the risk for illness and injury
- Helps contain the cost of health care
- Maintains patient’s functional status
- Increases patient’s sense of well being

SCIENTIFIC KNOWLEDGE BASE

 Environmental Safety
- Includes physical and psychosocial factors that influences or affect the life and survival of the patient
- A safe environment protects the health care worker as well

BASIC NEEDS - SAFETY

 Oxygen
- Not flammable but supports combustion

13 | F u n d a m e n t a l s i n n u r s i n g
- Smoking is banned in the hospital premises
- Carbon monoxide affects the oxygen of a person

 Nutrition
- Food and Drug Administration (FDA) regulations
- Food poisoning is the highest in children, pregnant women, and other adults
- Unsanitary preparation leads to risk for infection

 Temperature
- Comfort Zone in temperature (18.3 to 23.9 degrees)
- Extremes in temperature in summer and winter
- Affects comfort, productivity, and safety
- Prolonged exposures can lead to either hypothermia or heat stroke

PHYSICAL HAZARDS - SAFETY

 Motor Vehicle Accidents
- Safety in the vehicle - seat belt, air bags, laminated windshields
- Laws - driving license, safety belt use, child restraint use, use of helmet
- Risk is higher among 16 - 19 years old - lowest seat belt use, intoxication, drug use, not able to recognize
dangerous situation

 Poison
- A substance that impairs health or destroys life when ingested, inhaled or absorbed by the body
- Drugs, medicines, other solid and liquid substances, gases and vapors
- Home accidental poisoning - greatest in toddlers, preschoolers, and young school age children
- Lead poisoning

 Falls
- A major public health concern
- Risk of falling is higher for age 65 and above , history of falling, reduced vision, and orthostatic hypotension,
lower extremity weakness, gait and balance problems, improper use walking aids, and effect of various
medications
- Physical Hazards - inadequate lighting, barriers along normal walking path and stairway, loose rug and
carpeting, and lack of safety devices at home

 Fire
- Fire Related Deaths - careless smoking (in bed at home)
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- Improper use of cooking equipment and appliances
- Safety - fire extinguisher , smoke detectors

 Disasters
- Natural Disasters - flood, tsunami, earthquake, hurricanes
- Man Made disasters
- Bio-terrorism - use of anthrax, small pox

 Immobility
 Infection Prevention and Infection Control
 Vital Signs
 Health Assessment and Physical Examination
 Medication Administration
 Complementary and Alternative Therapies

OXYGENATION
 Respiratory system
 Carina- Part of trachea
 Alveoli- functional unit of respiratory system.
 Anatomical dead space- do not have any dunction in exchanging gases.
 Type I cells- cell membrane
 Type II cells- surfactant decreases surface tension and. Decreases friction
 Type III cells- macrophages
 Respiratory System
 Nasal cavity- an anatomical dead space

Alteration in Respiratory Functioning

 Hypoventilation - "respiratory depression" occurs when ventilation is inadequate, gas exchange is
needed.
 Hyperventilation - occurs when rate on tidal volume of breathing eliminates more co2 then body
produce.
 Hypoxia - body or it's region is deprived of an adequate oxygen supply.
 Anoxia - absence of oxygen in region of body.

RESPIRATORY PHYSIOLOGY

15 | F u n d a m e n t a l s i n n u r s i n g
CARDIOVASCULAR SYSTEM
 Cerebral and Carotid Artery- Brain artery
 Cardiac output
 Heart= 1%
 Brain= 20%
 Kidneys= 20%
 Intestines= 10%
 SA NODE- pacemaker of the heart 60-100 bpm
 AV NODE- 40-60 bpm
 BUNDLE OF HIS- 20-40 bpm
 Ventilation- movement of gases in and out of the lungs

ARTERIES CARRIES BLOOD TO:

 Mesenteric artery- intestines
 Carotid artery- brain
 Coronary artery- heart
 Lymphatic artery- liver

EXCHANGE OF GASES
 oxygen transport- RBC
 Carbon dioxide problem- RBC in the form of carbonic acid.

CARDIOVASCULAR PHYSIOLOGY
 Starling Law of Heart - “The greater the stretch, the greater the contraction”
 All or None Law of heart - “The heart will function at is best heart to survive or could stop functioning.

16 | F u n d a m e n t a l s i n n u r s i n g
  Conduction system- a group of specialized cardiac muscle cells in the walls of the heart that send
signals to the heart muscle causing it to contract. The main components of the cardiac conduction
system are the SA node, AV node, bundle of His, bundle branches, and Purkinje fibers.
 Cardiac output is affected by the SV preload, intraload, and afterload
 Afterload- reflects the force that the left ventricle has to overcome to eject blood through the
aortic valve.
 C.O. formula = HR x SV (stroke volume) 80 x 70 = 5600mL / min blood
 Normal blood volume = 4-6 liters
 High blood- high afterload
 Low cardiac output- may lead to organ damage
Disturbance in Electrical Conduction
 Altered Cardiac Output
 Impaired Valvular Function
 Myocardial Ischemia - oxygen deprivation of tissue

ACUTE CARE OF PATIENTS WITH OXYGENATION PROBLEMS

 Hydration- intake of 1,500 to 2,000 ml/day.
 Humidification- process of adding water into the gas.
 Nebulization- adds moisture and medication into the inspired air.
 Coughing and deep breathing exercises- coughing permits patient to remove secretions in the upper
and lower respiratory tract. Dryness of deep breathing can increase volume and airway diameter.
 Incentive spirometry is used for deep breathing exercises
 Chest physiotherapy- mobilizing respiratory secretions. A group of therapies of respiratory secretions that
includes PD- pustular drainage CP- Chest percussion and CV- Chest Vibrations
 Suctioning- Indicated for patients who are unable to clear their secretions from coughing or other less
invasive procedure.
 Oxygen theraphy- The goal is to relieve and prevent tissue hypoxia by delivering oxygen concentration
in the ambient air.
 Nasal Candula- 1-6 liters/min
 Simple face mask- 6-12 liters/min
 Non breathable mask- 13-15 liters/min.

FLUIDS AND ELECTROLYTES

Fluid Distribution- 60% Fluids made in body

 Intracellular- 40% of body weight

 Extracellular- 20% of body weight
Two types
 Interstitial- between
 Intravascular- inside; only this can be measured
 Extracellular- outside the cell

AGE RELATED FLUID CHANGES

 Full term baby- 80% water
 Lean adult male- 60% Female- 50%
 Aged client- 40%

Passive Transport systems

 Diffusion
 Filtration
 Osmosis

Active transport system

 pumping ( sodium potassium pump)
 Requires energy expenditure
17 | F u n d a m e n t a l s i n n u r s i n g
  Diffusion- solutes. Molecules move across a biological membrane from an area of higher concentration
to an area of lower concentration

 Osmosis- solvent. Movement of solvent from an area of lower solute concentration to one higher
concentration and it occurs to a semi permeable membrane using big osmotic water pulling pressure.

 Filtration- Movement of solute and solvent across a membrane caused by hydrostatic (water pushing
pressure)
 Occurs at the capillary level
 If normal pressure gradient changes (as occurs with right-sided heart failure edema results from third
spacing.

ACTIVE TRANSPORT SYSTEM

 solutes can be moved against a concentration gradient
 Aka pumping
 Dependent on the presence of ATP
Fluid and Electrolyte Transport
Passive Transport Systems Active Transport System
Diffusion Pumping
Filtration Requires energy expenditure
Osmosis

Fluid types
 Isotonic- no changes
 Hypotonic- swelling cell
 Hypertonic- shrinking cell

 Isotonic solution- No fluid shift because solutions are equally concentrated. Has normal saline solution at
0.9% NaCl and it is the safest solution to give to patient.
 Hypotonic solution- Lower solute concentration and they are fluid shifts.

 Hypertonic solution- Higher solute concentration and fluid is drain into the hypertonic solution to create
a balance where cell shrinks. It has 5% dextrose in normal saline.

Electrolytes
 charged particles in a solution
 Ca+ions
 An(-)ions
 Integral part of metabollic and cellular peocesses

Cations
 Sodium
 Potassium
 Calcium
 Magnesium
Anions
 chloride
 Bicarbonate
 Phosphate
 Sulfate

Transmission of impulse
 more cations= more stimulation

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  More anion= more depressed

Electrolyte imbalances
 Hypo/Hypernatremia- sodium
 Hypo/hyperkalemia- potassium
 Hypo/hypermagnesimia- magnesium
 Hypo/hypercalcemia- calcium
 Hypo/hyperphospatemia- phosphate
 Hypo/hyperchloremia

NURSING INTERVENTIONS IN CORRECTION FLUIDS

 Oral replacement of fluids
 Parenteral replacement if fluids
 IV therapy
 SAFEST IV FLUID IS NORMAL SALINE

IV SOLUTION BASICS
D- DEXTROSE
NS- NORMAL SALINE
W- WATER

SIMPLIFYING SOLUTIONS OF IV Isotonic solution- normal saline 0.9%

 lactated ringer’s
 Solution
 DSW- because desociate it may be hypotonic

Hypotonic solution
 Half NS- 0.45% NaCl
 Sterile water

Hypotonic solution
 D5NS
 D5LR
 3% sodium chloride
 D5 1/2 NS
 D5 1/4 NS

SLEEP AND PAIN MANAGEMENT

 Sleep- provides healing and restoration and best possible quality of sleep-good health and recovery of
illness.
 Hospital environment and staff patients from getting adequate rest.
 Other patient’s have pre existing sleep problems (every four hours)

Physiology of sleep
 circadian rhythm- The 24 hour night cycle located in the hypothalamus
 Have influence in HR,temp, BP, hormones, secretions, sensory activity and mood.
 Sleep regulation- sleep regulator- Hypothalamus. Process S- Homeostatic process, Process C- circadian
(biological clock)
 Reticular Activating System- may lead to Coma

19 | F u n d a m e n t a l s i n n u r s i n g
STAGES OF SLEEP
 Stage 1- Light sleep, and it lasts for few minutes
 Stage 2- Light sleep, lasts for 10-20 mins, relaxation process
 Stage 3- Deep sleep, lasts for 15-30 mins
 STAGE 4- Deepest sleep, lasts for 15-30 mins, uninterrupted sleep, release of growth hormones (for
restoration of sleep)
 Rapid eye movement sleep (REM)- occurs after 90 minutes of sleep very difficult to arouse, patient is
usually dreaming. Sedatives to psychiatric patients 6-10 times to dream.

SLEEP DISORDERS
 Insomnia- difficulty falling asleep, frequently awaking from sleep, short periods of sleeps or sleeps that is
non restorative.
 Obstructive Sleep Apnea- Lack of airflow through the nose and mouth for a period of 10 seconds or
longer during sleep.
 Narcolepsy- Dysfunction of mechanisms that regulate sleep and wake states. Excessive daytime
sleepiness is the most complaint associated with disorder.
 Sleep deprivation- Insufficient sleep. Sleep of less than 6 hours per day.

NURSING KNOWLEDGE
 Environmental controls- closing the curtains between patients in semi private rooms. Dimming that lights
and reducing the noise.
 Promoting comfort- Keeping the bed clean and dry. Applying dry and moist heat and the use of pillow
in positioning
 Establishing rest periods and sleep- Avoid disrupting the sleep of patients by scheduling.
 Promoting safety and use of side rails- Patient with OSA. Frequent monitoring of and use of CPAP
device.
 Stress reduction- Providing information about procedures and surgeries. Check if sedatives is indicated.

PAIN MANAGEMENT
 Spinothalamic pathway- Substantia gelatinosa, Anterior Spirothalamic tract, Lateral spinothalamic tract,
Thalamus
 1st order neurons- Peripheral nerves transmit pain sensation
 2nd order neurons- Pain goes to parietal primary sensations
 Local Anesthesia- Blocks nerves
 Spinal Anesthesia- Blocks spinal
 Opiod Analgesics- IV/CNS decreases brain
 Non-opiod- Peripheral nerves

TYPES OF PAIN

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  Acute pain- Protective is usually with identifiable cause. Common in acute injury and it eventually
resolves with or without treatment.
 Chronic pain- Protective serves with no purpose. It usually lasts longer than 6 months. It does not have
identifiable cause. (e.g. Arthritis, Low back pain, peripheral neuropathy)
 Cancer pain- Caused by tumor progression and related pathological processes. Under treatment of
cancer pain is still frequent. Needs the use of opioids.
 Chronic episodic pain- Pain that occurs sporadically. over a period of time on and off pain. (e.g.
migraine headache for less than 14 days per month.)
 Idiopathic pain- Chronic pain in the absence of identifiable physical or psychological cause.

GATE CONTROL THEORY

 Non-painful input closes the nerve gates to painful input which prevents pain sensation from traveling to
the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.
 Composed of 2 gates- Nociceptive and Non-nociceptive.
 Flooding one gate will override the other.

MANAGEMENT OF PAIN
 Non Pharmalogical pain relief- Cognitive behavioral intervention (e.g. meditation, yoga and guided
imagery)
 Distractions- Person receives excessive sensory inputs, a person ignores the pain stimuli.
 Music therapy- Diverts person’s attention away from the pain.
 Relaxation- A form of cognitive behavioral therapy.
 Guided Imagery- A form of cognitive behavioral therapy.
 Therapeutic touch- Restores harmony is a person’s energy field.
 Cutaneous stimulation- Effective for producing physical and mental relaxation, reducing pain, and
enhancing pain medication.

PHARMALOGICAL INTERVENTIONS
 Analgesics- The moist common and effective method of pain relief.
 Non-opiod effects- It is not entirely clear, thought to decrease the production of prostaglandins.
 Opiod- For mild and moderate pain to control drugs and it is the action on the higher centers of the
brain that can cause numerous side effects. (e.g. morphine, demerol and feutancy.)
 Adjuvants- (Alternatives) Medications are not intended for pain but was discovered to work on treating
pain. (e.g. Tricyclic antidepressants, into convulsants, corticosteroids, sedatives - sleep medications.)
Overdosage- toxicity

OPIOD TOXICITY
 Confusion, hallucination, coma
 pupil constriction
 bradypnea, hypoventilation
 hypotension, bradycardia
 nausea vomiting, constipation
 pruritus (allergy to medications)
 tolerance
 withdrawal syndrome
 Correcting overdosage- morphine overdosage= Naloxone

NUTRITION
 DIGESTIVE TRACT
 Mouth
 Esophagus
 Stomach
 Small intestine
 Large intestine
 Anus
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  Cardiac sphincter

Physiology of digestive system

 digestion- Mechanical breakdown
 Metabolism and storage of nutrients
 Metabolism- All chemical reactions in the body
 Storage of nutrients- Glycogen and adipose
 Elimination- Removal of waste products

EATING DISORDERS
 Anorexia nervosa- Restriction of energy intake relative to requirements leading to significant low body
weight.
 Bulimia Nervosa- Recurrent episodes of binge eating with recurrent use compensatory mechanism.
 Dysphagia- Difficulty in swallowing. Signs or symptoms: coughing and choking when eating or drinking.
 Aspiration- entry of food or digestive contents into the lungs

THERAPEUTIC DIETS IN THE HOSPITAL

 ORAL FEEDINGS
 NPO- Nothing per orem (fasting)
 Clear liquid- coffee,tea, clear fruit juices, popsicles and ice chips
 Full liquid- ice cream, soups, custards, all fruit juices and frozen yogurt
 Mechanical soft/soft diet- flaked fish, rice,potatoes, bananas, pancakes (for dysphagia)
 Low sodium- for preventing hypertension
 Low fat/cholesterol- 300mg/day cholesterol
 Diabetic- balanced intake pf carbs proteins and fats.
 Regular diet and tolerated- no restrictions unless specified.

ENTRAL TUBE FEEDINGS

 provides nutrients into the G.I. Tract. Preferred method of meeting nutritional needs if a patient is unable
to swallow or take in nutrients orally.

TYPES
 Nasogastric tube (for stroke patients)
 PEG tube ( percutaneous endoscopic gastrostomy tube)
 Jejunostomy tube ( forgastric canncee patients)

PARENTERAL NUTRITION
 A form of nutrition provided intravenously.
 Indicated for nonfunctional GI tract extended bowel rest and preparation for GI operations.
 Central lines- connecting big veins that directs to the right atrium.

URINARY ELIMINATION
 basic human function

ROLE OF THE NURSE

 Assess patient’s urinary tract function
 Support bladder emptying
 Urinary catheter
 Monitoring of urine output
 Minimise risk of infection when bladder function is impaired.
 30 ML for moisturization -normal urine
 More than 30 ML- urinary stasis
 Less than 30 ML- urinary failure

URINARY ELIMINATION PROBLEM

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  Urinary retention- inability to partially or completely empty the bladder. Causes feeling of
pressure,discomfort or pain.
 UTI- The most common health care acquired infection. Most commonly caused by E.Coli. Signs and
symptoms may include pain and diaphoresis.
 Urinary incontinence- Complaint of any involuntary loss of urine. More common in women.

NURSING INTERVENTIONS.
 promoting normal micturition- routines of patients before voiding, provide privacy, respond to request
for toileting ASAP.
 Maintaining adequate fluid intake- teach the importance of adequate hydration, set schedule for
drinking extra fluids, identify fluid preference, encourage frequent sips of fluid, avoid drinking fluids 2
hours before bed time.
 Promoting complete bladder emptying- Help patient assure normal position while voiding, assess
mobility status of patients, perform perineal hygiene after voiding.
 Stimulate micturition sound of running water, dipping hand of patient in warm water.
 Bladder exercise, Kegel’s exercise
 Crede’s method on manual compression.
 Preventing infection- encourage women to wipe from front to back after voiding defecation, avoid
bubble baths, tight clothings, perfumed perineal washes, have patient void at regular intervals.
 Catheterization- Types of catheter, catheter sizes, catheter drainage system, routine catheter care,
preventing catheter associated infections, removal of in dwelling catheter.

HAZARDS OF CATHETER
 infection
 Trauma

TYPES OF URETHRAL CATHETERS

 Straight I
 Robinson
 Indwelling catheters (lasts up to 30 days)

GUIDELINES FOR PREVENTING CATHETER-ASSOCIATED URINARY INFECTIONS

 Have an established control program
 Catheterize clients only when necessary by using aseptic technique, sterile equipment and trained
personnel.
 Maintain a sterile closed- drainage system
 Do not disconnect the catheter and drainage tube
 Remove the catheter ASAP
 Follow and reinforce good hand washing technique
 Provide routine perineal hygiene, including cleansing with soap and water after defecation.
 Prevent contamination of the catheter with feces of the client.

BOWEL ELIMINATION
• Large intestine
• Cecum
• Appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Rectum
• Anus

Common bowel elimination patterns

 Constipation- A symptom, not a disease passage of hard, dry stools.
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  Impaction- Results when a patient has unrelieved constipation and is unable to express the hardened
feces reatained in the rectum.
 Diarrhea- Increase in the number of stools and the passage of liquid, unformed feces. (Must be less
than3 times a day) It is a 1st defense against toxins and it is not a disease.
 Incontinence- Inability to control the passage of feces and gas from the anus. Incontinence harms the
patient’s body image.
 Flatulence- Gas accumulation in the lumen of the intestines. A common cause of abdominal fullness,
pain and cramping.
 Hemorrhoids- Dilated, engorged veins in the lining of the rectum. They are either internal or external.

Nursing knowledge
 Cathartics and laxatives- medications which initiate and facilitate passage of stools. And Agents that
promote defication.
 Antidiarrheal agents- Decreases the intestinal muscle tone to slow the passage of feces. However, the
cause of diarrhea should be determined before effective treatment can be ordered.
 Enema- Instillation of a solution into the rectum and sigmoid colon, indicated to promote defecation by
stimulating peristalsis. (E.g. Innodium) Given 14 inches above the patient. Given 5-10 minutes. It is a
solution introduced into the rectum and large intestine. Distends large intestine and irritates the intestinal
mucosa thereby increasing peristalsis and the excretion of feces and flatus.

Types of Enema

Cleansing
 High Enema
 Low Enema

Retention
 Return Flow Harris
 Flush
 Colonic irrigation

Chief dangers of Enema

 Irritation of the rectal mucosa by too much soap or irritating soap
 Negative effectiveness of Hypertonic or hypotonic solution on the body fluid sand electrolytes.
 Tap water enemas can cause water intoxication.

Commonly used enema solutions for adults

 100 ml
 Commercially prepared- 90-120 ml of a hypertonic solution such as sodium phosphate.
 Saline- 500-1000 ml of normal saline
 Tap water- 500-1000 ml of tap water
 Soap- 3-5 ml of white bland soap to 1000 ml of water
 Oil- 90-120 ml of oil, commercially prepared mineral, olive or cotton seed.

Guidelines for administering enema

 Temperature- Adult (40.5- 43 Celsius) Children (37.7 Celsius)
 Some oil retention enemas are given at 33 Celsius
 Distance of ingestion of an adult- 7-10 cm or 3-4 inches
 Distance of ingestion of children- 5-7.5 cm or 2-3 in
 Distance of ingestion of infants- 2.5-3.5 cm or 1-1.5 in

Guidelines for administering enema

 Length of the solution should be retained
 Oil retention enema- 1-3 hrs
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  Other enemas- 15 minutes

Height of the container

 Adult- High cleansing enema- 30-45 cm or 12-18 in
 Children- Other enemas- 30 cm or 12 in
 Infants- 7.5 cm or 3 in

Assuming a lateral position for enema

 Left side lying position because of the rectum

Colostomies
 Patients with temporary or permanent bowel diversions have a unique elimination needs.
 An individual with a colostomy wears a pouch to collect efficient or output from the stoma.
 A healthy stoma should be pink or red.
 Skin protection is important because the effluent land digestive enzyemes.

SKIN INTEGRITY AND WOUND CARE

Chapter 48 Skin Integrity and Wound Care

The skin is the body’s largest organ, comprising 15% of the total body weight. The skin provides:
A protective barrier against disease-causing organisms
A sensory organ for pain, temperature, and touch
Vitamin D synthesis
Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing
pattern will help students recognize alterations that require intervention.

2 Scientific Knowledge Base: Skin

Dermal-epidermal junction
Separates dermis and epidermis
Epidermis
Top layer of skin
Dermis
Inner layer of the skin
The epidermis has several layers. The stratum corneum is the thin, outermost layer that is flattened with dead
keratinized cells. The basal layer divides, proliferates, and migrates towards the epidermal surface.
The dermis provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and
organs. The dermis is made of collagen, blood vessels, and nerves.

3 Pressure Ulcers Pressure ulcer Pathogenesis

Pressure sore, decubitus ulcer, or bed sore
 Pressure is the major element in the cause of pressure ulcers.
Pathogenesis
 Pressure intensity- –Tissue ischemia can occur due to capillary occlusion for a prolonged period of time
–Patient’s with decreased sensation cannot respond to discomfort associated with ischemia hence tissue
death results
Blanching- occurs when normal red tones of the light skinned client is absent (doesn’t occur in darkly
pigmented skin)
 Pressure duration- –Low pressure over a prolonged time period and High-intensity pressure over shot
period
 Tissue tolerance- –Depends on integrity of the tissue and the supporting structures
–Shear, friction and moisture make skin more susceptible to damage from pressure
–Ability of underlying skin structures to assist with redistribution of pressure
 A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It
results from pressure in combination with shear and/or friction.
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  Pressure is the major contributor to pressure ulcers.
 If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for
a prolonged period of time, tissue ischemia occurs. If left untreated, tissue death results.
 Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-
skinned clients.
 Pressure duration assesses low and extended pressures. Low pressures over a prolonged period of time
can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell
death.
The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures.

4 Risk Factors for Pressure Ulcer Development

 Impaired sensory perception-Patients are more risk for impaired skin integrity than those with normal
sensation. Patients are unable to feel when a part of their body undergoes increased, prolonged,
pressure or pain.
 Alterations in Level of consciousness- patients who are confused or disoriented, those who have
expressive aphasia or the inability to verbalize. they feel pressure but are not always able to understand
how to relieve it.
 Impaired mobility- Patients unable to independently change positions are at risk for pressure ulcer
development.
 Shear- Shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle
and bone are stationary.
 Friction- The force of two surfaces moving across one another such in the mechanical force exerted
when skin is dragged across a coarse surface.
 Moisture- The presence and duration of moisture on the skin increases the risk of having ulcer formation.
It reduces The resistance of the skin to other physical factors.
 These six factors contribute to pressure ulcer formation.
 Clients with altered sensory perception for pain and pressure are at risk because they cannot feel their
body sensations.
 Clients who are unable to independently change positions are at risk because they cannot change or
shift off of bony prominences.
 Clients who are confused or disoriented or who have alterations in LOC are unable to protect
themselves.
 Sheer is the force exerted parallel to skin resulting from both gravity pushing down on the body and
resistance (friction) between the client and a surface.
 Friction is the force of two surfaces moving across one another, such as the mechanical force exerted
when the body is dragged across another surface.
 The presence and duration of moisture on the skin reduces the skin’s resistance to other physical factors.

5 Classification of Pressure Ulcers

Pressure ulcer staging describes the pressure ulcer depth at the point of assessment.
 Stage I
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Discoloration of
the skin may be present.
 Stage II
Partial-thickness skin loss involving epidermis, dermis, or both present as a shallow, open ulcer with a red-pink
wound bed without slough.
 Stage III
Full-thickness tissue loss with visible fat but bone, tendon, and muscles are not present.
 Stage IV
Full-thickness tissue loss with exposed bone, muscle, or tendon or subcutaneous fat.
The National Pressure Ulcer Advisory Panel (NPUP) has defined pressure ulcers.
 Unstageable/Unclassified: Full-thickness skin or tissue loss-depth unknown- Full-thickness tissue loss in
which actual depth of an ulcer is completely obscured by slough (yellow, tan or grey) or eschar (tan,
brown or black in the wound bed is unstageable.

26 | F u n d a m e n t a l s i n n u r s i n g
  Suspected, deep-tissue injury- depth unknown- It its a purple or maroon localized area discolored intact
skin or a blood-filled blister caused by the damage of underlying soft tissue from pressure or shear.

6 Wounds Classification Wound healing Repair Complications

Two methods are currently used to classify skin wounds:
 Describe the status of skin integrity, cause of the wound, severity or extent of the injury or damage and
cleanliness of the wound
 Describe qualities of the wound tissue such as color
 wound healing occurs by primary or secondary intention.
 Primary intention occurs when the edges are closed approximated.nPrimary intention = edges are well
approximated or closed; risk of infection low; heals quickly; minimal scar formation
–Example: surgical wound
 Secondary intention occurs when the wound heals with scar tissue.Secondary intention = wound is left
open until becomes filled with scar tissue; chance of infection is great; longer healing time
–Example: burn, pressure ulcer, severe laceration

 The form wound repair- takes depends on the wound’s thickness. Partial thickness will heal via the
inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers.
Full-thickness wounds heal via inflammatory response, proliferation, and remodeling.

 Complications of wound healing
 - Hemorrhage/hematoma- Bleeding from a wound site Occurs within several minutes unless large blood
vessels are involved or poor clotting function of a patient.
 Infection–Second most common health care associated infection. Microorganisms invade the wound
tissues.
 Dehiscence = partial or total separation of wound layers
 Evisceration = protrusion of visceral organs through wound opening
 Fistulas = abnormal passage between two organs or between organs and the outside of the body
 includes hemorrhage, infections, dehiscence, evisceration, and fistulas.
 Process of wound healing- The tissue layers involved and their capacity for regeneration determine the
mechanism for repair for any wound.

7 Nursing Knowledge Base

Prediction and prevention of pressure ulcers
 Norton Scale- to assess the risk for pressure ulcer in adult patients. The five subscale scores of the Norton
Scale are added together for a total score that ranges from 5-20.
Physical and mental condition, activity, mobility, and continence
 Braden Scale- The purpose of the scale is to help health professionals, especially nurses, assess a
patient's risk of developing a pressure ulcer.
 Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
When a client develops a pressure ulcer, the length of stay is extended and the overall cost of care increases.
 Even though preventive measure are expensive they should be used. Prevention includes special beds
and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.

8 Factors Influencing Pressure Ulcer Formation and Wound Healing

Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
For maintenance of skin and wound healing, clients need 1500 kcal/day. At times enteral or parenteral nutrition
may need to be provided. See Chapters 44: Nutrition, Chapter 50: Care of Surgical Clients. Clients need
vitamins A and C, calories, and proteins to heal. See Table 48-5.
Tissue perfusion occurs when tissue oxygenation fuels cellular function. Clients who are in shock or who are
diagnosed with diabetes mellitus are at risk for poor tissue perfusion.
27 | F u n d a m e n t a l s i n n u r s i n g
Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization
and tissue destruction. Signs of wound infection include: pus; change in odor, volume, or redness of tissue;
fever; or pain.
Body image changes due to a wound may cause problems with self-concept.

9 Assessment Skin Presence of ulcers Mobility Nutrition and fluid status

Pain
Existing wounds, appearance, character
Wound culture
Baseline assessments as well as continual assessments all provide valuable data that will indicate skin integrity
as well as any risks for pressure ulcer development.
\
10 Nursing Diagnosis and Planning
The assessment will reveal important information regarding the client’s status.
Use NANDA-I–approved diagnoses.
Write client goals and outcomes specific to the client’s needs.

11 Implementation Health promotion Topical skin care Positioning

Protect bony prominences, skin barriers for incontinence.
Positioning
Turn every 1 to 2 hours as indicated.
Support surfaces
Decrease the amount of pressure exerted over bony prominences.
Support surfaces include mattresses, integrated bed systems, mattress replacement, overlay or set cushion.
Table 48-8 presents support surfaces.

12 Acute Care Wound management Debridement Nutrition Client education

Mechanical, autolytical, chemical, or surgical/sharp
Nutrition
Client education
You will want to take a holistic approach to wound management. You will want to work with the dietician,
wound care nurse, and pharmacist to ensure all client needs are met.
An individualized plan of care must be developed for each client, taking into account age, nutrition, present
medical conditions, and other contributing factors.
Client education is a must. You need to impress on the client and client’s family the importance of nutrition,
fluids, and body positioning.

13 Dressings Dry or moist Hydrocolloid Hydrogel Wound V.A.C. Gauze

Protects the wound from surface contamination
Hydrogel
Maintains a moist surface to support healing
Wound V.A.C.
Uses negative pressure to support healing
The use of dressings requires an understanding of wound healing and factors that influence healing. A variety
of dressing materials are available. You will learn various dressing techniques in the nursing skills lab.
The choice of dressings and the method of dressing a wound influence healing.
A proper dressing does not allow a full thickness wound to become dry with scab formation.

14 Dressings Changing Securing Comfort measures

Know type of dressing, placement of drains, and equipment needed.
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently cleanse the wound.
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Administer analgesics before dressing change.
Follow health care facility for policies and procedures.
Document findings and report to other staff members.
For very complex dressing care, consult with the wound care/enterostomal nurse or carefully develop a step-
by-step procedure to provide consistent wound care.
Make sure to offer pain medications before beginning wound care/dressing changes.

15 Wound Cleansing Cleansing Irrigation Suture Care Drainage Evacuation

Apply noncytotoxic solution.
Irrigation
Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle
Suture Care
Consult health care facility policy.
Drainage Evacuation
Portable units that exert a safe, constant, low-pressure vacuum to remove and collect drainage
Wound cleansing removes surface debris, preventing the invasion of healthy tissue.
Normal saline works best. Betadine, hydrogen peroxide, and acetic acid are toxic to fibroblasts, the key
component in wound healing.
Always refer to health care facility policy and procedures for wound care and wound irrigation.
If available, consult the enterostomal/wound care nurse.

16 Bandages and Binders Bandages Binder application

Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin
Binder application
Breast, abdominal, sling
At times, simple gauze dressings do not supply adequate immobilization or support to a wound. Bandages and
binders are applied over or around dressings to provide extra protection and/or therapeutic benefits by
creating pressure over a body part, immobilizing a body part supporting a wound, reducing or preventing
edema, or securing a splint or dressing.
When binder or bandages are applied, an assessment must be made.
Ask students what they should assess?
Answers may include: inspect skin for abrasions, edema, discoloration, open wounds, circulatory impairment
(coolness, pallor, cyanosis, pulses, swelling, numbness or tingling).

17 Heat and Cold Therapy Assessment for temperature tolerance

Bodily responses to heat and cold
Factors influencing heat and cold tolerance
Education
Before beginning heat or cold therapy, you will need to identify and understand the normal body responses to
localized temperature variations.
Heat and cold applied to an injured body part provides therapeutic benefit.
Ask students to identify when heat and cold are used.
Answers may include:
Heat: arthritis, degenerative joint disease, localized muscle strain, menstrual cramping, hemorrhoid, perianal
inflammation or local abscess.
Cold: direct trauma such as sprain, strain, fracture, muscle spasms, superficial laceration, minor burn, arthritis,
after an injection or joint trauma.
Education will be an important component. Those who suffer from decreased sensations should be very careful
when using these therapies.

18 Evaluation
Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client
has met the identified outcomes or goals.

PLANNING/ SELECTING NURSING INTERVENTIONS

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Nursing Interventions
 Activities the nurse plans and implements to help a patient achieve an identified goal.
 Any treatment based on clinical judgement and knowledge that the nurse performes to enhance
patient outcomes.

When planning nursing interventions

 The nurse must know What is to be done
 When the activities is to be done
 Duration for each intervention
 Any follow-up activity
 Date interventions were selected
 Sequences in which nursing activities are to be performed
 Signature of the nurse writing the plan of care.

Types of Nursing Interventions

 Independent/Nurse-initiated interventions- Actions the nurse as licensed to initiate on the basis of the
knowledge and skills.
 Dependent/Physician-initiated interventions- Actions the nurse is involves carrying out physician
prescribed orders.
 Interdependent/Collaborative interventions- Actions that involve the nurse that carries out in
collaboration with other health terms.

Components of nursing interventions

 PDx (Diagnostics)- Weighing, Vas, High monitoring
 PTx (Therapeutic)- Administering of paracetamol 500 mg = 1 tablet
 PEx ( Education for health teaching)- Teaching the patient to have proper care such as drinking
medicines on the right time
 HGT- Hemo Gluco Test (Blood sugar test)

Criteria for selecting Nursing Interventions

 Safe and appropriate for the patient
 Congruent with other therapies
 Develop the behavior in the goal statement
 Realistic
 Necessary to asses and monitor effect of medical treatment

Writing individualized Nursing Interventions on Care Plan

 Nursing interventions in NCP should be Dated when they are written
 Relieved regularly as intervals

IMPLEMENTATION

 Doing a task
 Delegating
 Documenting

 Putting the nursing carte plan into action of the expected outcome.

 Done to resolve/reduce identified nursing problems on the patient, with the patient and for the patient.

Purposes
 Promote health
 Prevent illness
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  Restore Health
 Assist patient in achieving desired health
 Facilitating with altered health promotion

Stages of care
 Health promotion
 Preventing Screening Illness
 Curative
 Rehabilitation

Involves:
 Giving nursing care/carrying out the planned nursing activities

Aspects of nurse’s role

 Care aspects
 Curative
 Protective
 Teaching
 Patient advocate

EVALUATION

 Based on plan
 Terminal behavior demonstrated by patient
 Consistency

Evaluation statement
 Conclusion+Supporting data
 Goal Met
 Goal partially met
 Goal Not met
Fundamentals of Nursing RLE
Nursing Diagnosis
Diagnosing
 interpret assessment data.
 Identify client strength & problems
 NANDA diagnostic label + etiology = N. Diagnosis

Nursing Diagnosis

 clinical judgement concerning a human response to health conditions/ life processes or a vulnerability
for that response by an individual, family, group, community.
 Provides basis for nursing intervention selection to achieve outcomes
 Domain includes health states that nurses are educated and licensed to treat
 Judgement made only after thorough, systematic data collection
 Describes continuum of health states: deviations from health, presence of risk factors and areas of
enhanced personal growth.

Kinds of Nursing Diagnoses based STATUS

 Actual Diagnosis
 Health Promotion Diagnosis
 Risk Nursing Diagnosis
 Syndrome Diagnosis
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Actual Nursing Diagnosis
 client problem that is present at the time of nursing assessment
 based on the presence of associated s/sx
o (ex) Ineffective airways clearance r/t excessive secretions.
 Disturbed sleep pattern r/t inability to assume usual sleep position.

Health Promotion Diagnosis

 client's preparedness to implement behaviors to improve health condition
o Readiness for enhanced communication
o Readiness for enhanced self care

Risk Nursing Diagnosis

 Clinical judgement that a problem does not exist but the presence of risk factors indicate that a problem is
likely to develop unless nurses intervene
o Risk for deficient fluid volume
o Risk for impaired religiosity related to confinement to bed.

Syndrome Nursing Diagnosis

 Comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a
certain situation or event.

Nursing diagnoses that have similar interventions.

 Disuse Syndrome
 Environmental Interpretation syndrome
 Post trauma Syndrome
 Risk for post trauma syndrome
 Rape trauma syndrome
 Relocation stress
 Risk for relocation stress
 Self- care deficit syndrome

Components of NANDA Nursing Diagnosis

1. Problem (diagnostic label) and definition - problem statement/diagnostic label, describes the client's
health problem/ status or response for which nursing theraphy is given.

Ex. Deficient, impaired, decreased, ineffective, compromised.

2. Etiology (related factors & risk factors) - identifies one or more probable causes of a health problem,
gives direction to the required nursing therapy & enables the nurse to individualize the client's care. (
combine diagnostic label and etiology)

3. Defining Characteristics - clusters of signs & symptoms that indicate the presence of a particular
diagnostic label. ( combine diagnostic label, etiology and defining characteristics.)

Collaborative Problems
- type of potential problem that nurses manage using both independent and physician- prescribed
interventions,
- present when a particular disease or treatment is present

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Steps of Diagnostic Process
1. Analyzing Data
2. Identifying health problems, risk & strengths
3. Formulating diagnostic statement

Analyzing Data
a. Comparing data w/ standards
Identify significant cues:

 (+) or (-) change in health status or pattern

 Varies from norm of client's population
 (+) developmental delay

b. Clustering cues
- process of determining the relatedness of facts and determining whether any patterns are present, whenever
the data represents isolated incidents and the data are significant.

- grouping of data/cues that point to the existence of a health problem.

c. Identifying gaps and inconsistence of data

- include final check to ensure that data are complete and correct.

- skillful assessment minimizes gaps and inconsistencies of data.

- possible sources of inconsistencies: measurement error, expectations and inconsistent or unreliable reports.

Identifying Health Problems, Risks & Strengths

 Identifying problems that support tentative actual and risk diagnoses

 Establish the client's strengths, resources and abilities to cope
 Determine whether the client's problem is a nursing diagnosis or a collaborative problem.

Formulating Diagnostic Statement

a. Basic two- part statement
b. Basic three- part statement
c. One- part statement

Basic two-part nursing diagnosis

Problem (P)
 Statement of the client's health state or response
 Diagnostic label
Etiology (E)
 Factors contributing to or probable causes of the responses

(ex) Constipation r/t prolonged laxative use

Severe anxiety r/t threat to physiologic integrity: possible CA diagnosis.

Basic three-parts nursing diagnosis

Problem (P)
 Statement of the client's health state or response
 Diagnostic label
Etiology ( E)

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  Factors contributing to or probable causes of the responses.
Signs & Symptoms (S)
 Defining characteristics manifested by the client.

(ex)
Situational low self- esteem r/t feelings of rejection by husband as manifested by hypersensitivity to criticism.

Altered dentition related to chronic use of tobacco as manifested by tooth enamel discoloration.

One part Statement

 Consist of a NANDA label only
 Health promotion diagnoses & syndrome diagnoses
(ex) rape- trauma syndrome and readiness for enhanced parenting

Variations Basic Formats

1. Writing unknown etiology when defining characteristics are present but the nurse does not know the
cause or contributing factors.
(ex) Noncompliance (medication regimen) r/t unknown etiology.

2. Using complex factors when there are too many etiologic factors,

(ex) Chronic low self-esteem r/t complex factors

3. Using the word possible, to describe either the problem or the etiology require more data about the
client's problem or etiology.
(ex) Possible low self esteem r/t loss of job and rejection by family.

4. Using secondary to divide the etiology into two parts.

(ex) Risk for impaired skin integrity r/t decreased peripheral circulation secondary to diabetes.

5. Adding a second part to the general response or NANDA label to make it more precise.
(ex) Impaired Skin Integrity (left lateral ankle) r/t decreased peripheral circulation.

Nursing Diagnosis Medical Diagnosis

Statement of nursing Made by physicians
judgement
Refers to a condition refers to a condition
that nurses by virtue of that only physician can
their education, treat
experience and
experience are
licensed to treat.
Describe human Refers to disease
response, client's processes.
psychological &
spiritual responses to an
illness or health
problem
Nursing actions - Nursing actions
independent primarily dependent

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Guidelines for writing a Nursing diagnosis

1. State in terms of a problem, not a need

 Deficient fluid volume r/t fever
o Fluid replacement r/t fever

2. Word the statement so that it is legally advisable.

 Impaired skin integrity r/t immobility
o Impaired skin integrity r/t improper positioning

3. Use nonjudgemental statements

 Spiritual distress r/t inability to attend church services secondary to immobility.
o Spiritual distress r/t strict rules necessitating church attendance.

4. Make sure that both elements of the statements do not say the same thing.
 Impaired skin integrity r/t immobility
o Impaired skin integrity r/t ulceration of sacral area.

5. Be sure that cause & effect are correctly stated.

 Pain: severe headache r/t fear of demands of student life
o Pain r/t severe headache

6. Word the diagnosis specifically and precisely to provide direction for planning nursing intervention.
 Impaired oral mucous membrane r/t decreased salivaton secondary to radiation of neck.
o Impaired oral mucous membrane r/t noxious agent.

7. Use nursing terminology rather than medical terminology to describe the client's response.
 Risk for ineffective airway clearance r/t accumulation of secretions in lungs
o Risk for pneumonia

8. Use nursing terminology rather than medical terminology to describe the probable cause of the
client's response.
 Risk for ineffective airway clearance r/t accumulation of secretions in lungs.
o Risk for ineffective airway clearance r/t emphysema

Planning
 Developing a plan of care to assist the patient to an optimum or improved level of functioning in the
problem areas identified in the nursing diagnosis

 Nurse works with the client to set goals/ outcomes to prevent, correct or relieve health problems and
determine appropriate nursing interventions

Planning Process
1. Setting Priorities
2. Establishing client goals/ desired outcomes
3. Selecting nursing Interventions
4. Writing individualized nursing interventions on care plan.

Setting Priorities

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- Determine which problems identified during the assessment phase are in need of IMMEDIATE attention and
which problems may be dealt with at a later time.

Guide in Setting Priorities

 Maslow's Hierarchy of needs
 ABC's of Life
 Life preservation

Consider:
1. The most important problems to the patient
2. Effect of potential problems
3. Costs, resources available, personnel, time needed

Establishing Goals
• describes a change in the patient’s health status or functioning
• desired outcome of nursing care that which you hope to achieve with your patient
• expected outcome, predicted outcome, outcome criterion, objective

Long term & Short term goals

Situation: Frail elderly man with a

pressure ulcer on his sacral area

Long term goal Short term goal

The patient’s At the end of

sacral area will the first week,
exhibit no the patient’s
evidence of a pressure ulcer
pressure ulcer. has decreased
in size by a
quarter inch.

Guidelines for Writing Goals

 S – Specific
 M – Measurable
 A – Attainable
 R – realistic
 T – Time bounded

SPECIFIC GOAL
Nursing Dx: bathing self-care deficit r/t presence of a heavy cast in the left leg

Goal: The patient will be able to bathe with assistance within the next 24 hours.

MEASURABLE GOALS
• The patient will be able to ambulate by tomorrow.
• The patient will be able to ambulate with assistance from bed to bathroom by tomorrow.

ATTAINABLE AND REALISTIC GOALS

• The patient will be able to drink fluid amounting to 1200 mL within an 8-hour period.
• The patient will be able to drink fluid amounting to 1200 mL within an hour.

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TIME BOUNDED
• The patient will be able to bathe with assistance within period of hospitalization.
• The patient will be able to ambulate with assistance from bed to bathroom by tomorrow.
• The patient will be able to drink fluid amounting to 1200 mL within an 8-hour period.

Guideline for writing goals

Write goals in terms of patient outcomes, not nurse activities.

• Whenever possible, the goal is important and valued by the patient, the nurses, and the physician.
• Derive each goal from only one nursing diagnosis.
• Keep the goal short.

Goal Statement= patient’s behavior + criteria of performance + time + conditions (if needed)

Examples of Goal Statements

Nursing Diagnosis
Imbalanced Nutrition: more than body requirements r/t poor eating habits

Goals

Will lose 20 lbs. within 12 wks.

Will reach target wt. of 122 lbs. by June. 20, 2012
Will identify 10 low-calorie snacks he is willing to try within 3 days

Nursing Diagnosis
Impaired physical mobility r/t general muscle weakness

Hyperthermia r/t infectious process

Goal
Before discharge, patient will ambulate the length of hallway independently.

Body temperature will decrease from 38.50C to 37.50C within 2 hours

Nursing Diagnosis
acute pain r/t post-surgical incision

risk for infection r/t presence of open wound on the right forearm

Goal
verbalization of decreased pain from a scale of 2 to 1(where 3=severe, 2=moderate, 1=mild, 0=no pain) within
the shift

will not manifest any sign of infection during hospitalization

Variables that Influence Goal Outcome Achievement

a. patient variables
• patient’s changing ability
• willingness to participate in the plan of care
• previous responses to nursing interventions
• progress towards goal

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 b. nurse variables
• nurse’s level of expertise and creativity
• willingness to provide care
• available time

c. resources
• adequacy of staff, equipment and supplies
• financial resources of the patient
• adequacy of community-based resources

d. ethical and legal guides to practice

• laws and regulations
• ethical dimensions of clinical practice

Massage

- the manipulation of tissues (by stroking, kneading, or tapping) with the hand or an instrument for
remedial or hygiene purposes

Types of Massage Strokes

Effreuge,Petrissage, Tapotement

Purposes of Massage
 To relieve muscle tension
 To promote physical & mental relaxation
 To relieve insomnia
 To improve muscle & skin functioning
 To provide relief from pain

Duration: 5- 20 min in accordance w/ the client’s tolerance.

Equipment: lotion or oil

Procedure:
 Explain the procedure to the client.
 Perform handwashing.
 Provide privacy.
 Prepare the client (position: prone).
 Pour a small amount of lotion onto the palms of your hands and hold it for a minute .
 Effleurage entire back.
 Optional: Petrissage the back & shoulders of the client.
 Apply moderate pressure movements up to the back.
 Optional: Effleurage & petrissage the upper back & shoulders, using long soothing strokes.
 Apply pressure strokes along the spinal column.
 Using gentle pressure, apply large circular movements to the back.
 Complete the massage by using light effeurage to the entire back. With each massage stroke, lessen
the pressure.
 Pat dry any excess lotion with a towel.
 Assist the client to a position of comfort.
 Document the massage & the client’s response.

Hot and Cold Application

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- A therapy applied to body part for local or systemic change in the body’s temperature for various therapeutic
purposes.

Therapeutic
Comfort
Rehabilitation

TRANSFER OF HEAT OR LOSS OF HEAT OCCURS IN ANY WAYS OF THE FOLLOWING:

Conduction – Contact
Convection – movement
Evaporation- through liquid –gas transfer
radiation – electromagnetic waves
Conversion – transfer from one energy to another

Heat Application
Indications of Heat Application
1. Relieves aches and pain
2. Comfort and relief
3. Client with musculoskeletal problem

Cold Application
Cold application is most often used for sport injury
1. Relieves pain
2. Limit inflammation and suppuration
3. Control bleeding

Indications for HEAT Application

1. Promotes wound healing
2. Relieves pain
3. Relieves muscle tension and joint stiffness
4. Warms part of the body
5. Reduces edema / swelling
6. Eliminate toxic products

COLD – SUPPURATION – PUS FORMING PROCESS OF DISCHARGING PUS

Guidelines in Local Applications of heats and cold

1. Determine the client ability to tolerate therapy
2. Identify conditions that might be contraindicate treatment
3. Explain the application to the client
4. Assess the skin area to which the heat and cold to be applied
5. Ask the client to report any discomfort
6. Return to the client 15 mins after stating the heat and cold
7. Remove the equipment
8. Examine the area which heat and cold was applied, record client response.

Factors to Consider in Safe Application of Heat and Co

1. Patient’s Condition
 Age
 Circulatory or neurologic deficiencies

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  Level of consciousness
 Amount of body fats
 Condition of the skin in the area being treated
 Patient’s diagnosis

2. Adaptation of thermal receptors

3. Thermal application must be stopped before “rebound phenomenon” begins

SIGNS OF TISSUE DAMAGE

a. bluish & mottled skin appearance
b. numbness
c. stiffness
d. pallor
e. sometimes blister & pain

2. Moisture conducts heat better than air

3. Length of exposure and the area to be exposed
4. Condition of the equipment

Local Effects of Heat

Vasodilatation and increases blood flow to the affected area

 Increase supply of oxygen
 Promote soft tissue healing
 Used for client with (joint stiffness, low back pain)
 Sedative effect
 Improve circulation

Increase supply of oxygen, nutrients, antibodies, and leukocytes

Decreased blood viscosities

Disadvantages of Heat Application

 Increase Capillary Permeability
 Extra cellular fluid & substance as plasma to pass through the capillary walls
 Edema

Systematic effect of heat

 Heat applied on large body area
 Excessive peripheral vasodilation
 Drop in BP
 Fainting attack

Contraindications to the use of Heat Applications

 The first 24 hours after traumatic injury (heat increase bleeding and swelling).
 Active hemorrhage (heat causes vasodilatation and increase bleeding)
 Non inflammatory edema (heat increases capillary permeability and edema).
 Skin disorder (heat can burn or cause further damage to the skin).
 Localized malignant tumor (heat increase cell growth and accelerate metastases).

Local effect of cold

 Lowers the temperature of the skin and underlying tissue
 Vasoconstriction
40 | F u n d a m e n t a l s i n n u r s i n g
  Decrease capillary permeability
 Slow bacterial growth
 Decrease inflammation
 Local anesthetic effect

Decrease Blood circulation

Delayed re –absorption of fluid
Increased coagulation of blood

Systematic Effect of Cold

 Excessive cold application
 Vasoconstrictions
 Increased BP
Prolonged cold = shivering

Contraindications to the use of Cold Application

 Open wound (cold can increase tissue damage by decreasing blood flow to an open wound ).
 Impaired circulation (cold can further impair nourishment of the tissue).
 Allergy and hypersensitive to cold application.
 Some people react by decrease Bp.
 Inflammatory response (swelling, joint pain).

Description Temperature Application

Very Cold Below 15 C Ice bag
Cold 15-18 c Cold packs
Cool 18-27 c Cold
compresses
Tepid 27-37 c Alcohol
sponge bath
Warm 37-40 c Warm bath
Hot 40-46 c Hot soak, hot
compresses
Very Hot Above 46 c How water
bag for adult

Classification of Hot Applications

Local

Dry Heat Moist Heat

 Hot water bottles  Hot water bottles
 Chemical heating  Chemical heating
bottles bottles
 Infrared rays  Infrared rays
 Ultraviolet rays  Ultraviolet rays
 Electric cradles  Electric cradles
 Electric heating  Electric heating
pads pads

General

Dry Heat Moist Heat

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  Sun Bath  Steam Baths
 Electric cradles  Hot packs
 Blanket Bed  Whirlpool Bath (Full
immersion bath)

Classification of Cold Applications

Local

Dry Cold Moist Cold

 Ice bags  Ice to suck
 Ice collar  Cold compress
 Ice packs  Evaporating lotion
 Chemical cold
packs

General

Dry Cold Moist Heat

 Hypothermia  Cold sponging
 Cold bath
 Cold packs

Methods of Applying heat and cold

 Hot water bag (bottle)
 More common source of dry heat
 Inexpensive
 Improper use leads to burning
 Hot & Cold Packs
 Commercially prepared hot and cold packs provide heat or cold for designated time
 Electrical Pads
 Provide constant heat
 Are light weight
 Some place have water proof covers to placed over a moist dressing
 Ice bags
 Filled either with ice chips

 Compresses
 Can be either warm or cold
 Are moist gauze dressing applied to a wound
 Soak
 Refers to immersing a body part in a solution
 Sterile technique is generally indicated for open wound
 Sitz Bath or hip bath
 Used to soak a client's pelvic area
 The client's sit on the chair nd immersed in the solution
 Cooling Sponge Bath

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  Promoting heat loss through conduction
 Companied by antipyretic medication

TRANSFER OF HEAT OR LOSS OF HEAT OCCURS IN ANY WAIST OF THE FOLLOWING:

Conduction – Contact
Convection – movement
Evaporation- through liquid –gas transfer
Tadiation – electromagnetic waves
Conversion – transfer from one energy to another
DIATHERMY
a medical and surgical technique involving the production of heat in a part of the body by high-frequency
electric currents, to stimulate the circulation, relieve pain, destroy unhealthy tissue, or cause bleeding vessels to
clot.

Hot Water Bag Application

1. Check the order & specify
2. Identify the patient
3. Assess the general condition of the patient
4. Explain the procedure
5. Prepare equipment & supplies.
6. Wash hands.
7. Provide privacy & comfort
8. Check temperature of water. Fill the hot water bag half to 2/3 full.
9. Expel remaining air from bag. Fasten up securely. Check for leaks.
10. Cover the bag with towel or other protector & apply to prescribed area.
11. Remove hot water bag after 15- 20 minutes (or as ordered by the physician).
12. Evaluate
13. Document
14. Perform hand hygiene.

Ice Bag Application

1. Check the order & specify
2. Identify the patient
3. Assess the general condition of the patient
4. Explain the procedure
5. Prepare equipment & supplies.
6. Wash hands.
7. Provide privacy & comfort
8. Place towel or absorbent pad under area to be treated.
9. Prepare ice bag or collar:
a) Fill bag with water, secure cap & invert.
b) Empty water & then fill bag 2/3 full with small ice chips.
c) Release excess air from bag by squeezing its sides before securing cap.
d) Wipe bag dry.
e) Apply snugly over area.
10. Check condition of the skin every 5 minutes
11. After 15- 20 minutes (or as ordered by the physician), remove cold application & gently dry off any
moisture.
12. Assist client to comfortable position.
13. Evaluate
14. Document
15. Perform hand hygiene.
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Exceeding normal temperature ranges can damage tissues.

Rebound Phenomenon: Heat

 Occurs at the time that maximum therapeutic effect of hot and cold application achieved
 Heat produces maximum vasodilation in 20-30 mins
 Continuation beyond 30-45 minutes causes TISSUE CONGESTION, the blood vessels CONSTRICTS

Now the opposite effect is occurring because of vascular constriction

Recovery time of 1 hr is advised before reapplication

Rebound Phenomenon: Cold

 Maximum VASOCONSTRICTIONS occurs when the skin temperature reaches 15˚ or in about 30 mins to 1
hour
 VASODILATION begins as a protective device to prevent the body tissue from freezing
 Recovery time of 1 hr is advised before reapplication

Backrubs
Purpose
Stimulate circulation
Prevent skin breakdown
Soothing
Refreshing
 May be performed after drying off
the back during the bath.
 Position of Patient: Prone or side-lying
 Expose only the back, shoulders, upper arms. Cover remainder of body
 Lay towel alongside back
 Warm lotion in your hands—still explain that it may be cool and wet.
 Start in the sacral area, moving up the back.
 Massage in a circular motion over the scapula.
 Move upward to shoulders, massage over the scapula
 Continue in one smooth stroke to upper arms and laterally along side of back down to iliac crests.
 Do NOT allow your hands to leave the patient’s skin
 End by telling your patient that you are finished

NOTE

 Some Patients Are Not Allowed To Have Back Rubs!

 Check With The Nurse And The Care Plan
 If When Applying Lotion You Notice Reddened Areas Of Skin--- Massage Around The Area But Not Over
The Reddened Area

THERAPEUTIC COMMUNICATION

Verbal Communications
 Largely conscious
 Consider the ff:
 Pace and intonation
 Simplicity

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  Clarity & brevity
 Timing & Relevance
 Adaptibility
 Credibility
 Humor

Non Verbal Communications

 Body language (gestures, body movements, use of touch, physical appearance including adornment
 Physical appearance (clothing & adornment)
 Posture & Gait
 Facial Expression
 Gestures

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