CHAPTER 1

NURSING AS PROFESSION

  This chapter entails the concepts of nursing as profession. It will provide

essential knowledge about qualifications of nursing as  profession, roles
and responsibilities of a nurse and different practice setting for nurses.

Duration: 1 hour

Intended Learning Outcomes:

            1. Define selected terms related to the profession of nursing.

          2. Discuss the modern definitions and philosophies of nursing.

          3. Describe practice setting and roles for nurses.

          4. Illustrate how nursing demonstrates characteristics of a profession.

NURSING AS PROFESSION

·         is a disciplined involved in the delivery of health care to the society and a 
service-oriented to maintain health and well-being of people.

·         is an art and a science.

·         not simply a collection of specific skills, and the nurse is not simply person
trained to perform specific task

·         The practice of professional nursing and nursing knowledge has been

developed over time through the development of nursing theories and research.

·         Theoretical models serve as frameworks for nursing curricula and clinical

practice
 

NURSE – originated from a Latin word NUTRIX, to nourish.

Characteristics of Nursing:

·         Nursing is caring.

·         Nursing involves close personal contact with the recipient of care.

·         Nursing is concerned with services that take humans into account as

physiological, psychological, and sociological organisms.

·         Nursing is committed to promoting individual, family, community, and

national health goals in its best manner possible.

·         Nursing is committed to personalized services for all persons without

regard to color, creed, social or economic status.

·         Nursing is committed to involvement in ethical, legal, and political issues in

the delivery of health care.

Personal Qualities of a Nurse:

1.    Must have a Bachelor of Science degree in nursing.

2.    Must be physically and mentally fit.

3.    Must have a license to practice nursing in the country.

** A professional nurse therefore, is a person who has completed a basic

nursing education program and is licensed in his country to practice
professional nursing.

Level of Proficiency according to Benner

1. Novice
- a beginner; one who is inexperienced, lacks confidence to demo safe practice,
requires verbal and physical cues

- beginner in nursing school, no experience, works only off of rules

- Focus is getting everything done that needs to be done

          - no previews level of experience

2. Advance Beginner

                   - a nurse who has some level of experience with the situation.

- as marginally competent skills; has had prior experience, requires occasional
support and cues, and knowledge is developing

- just passed the board examination, has the minimum competency for safe
practice, guided by rules
- Provides care around ordered care

3. Competent

-  1.5-2.5 years of work, organized and comfortable in most situations

-Recognize patterns and Gradual shift to focus more on patient

- demonstrate efficiency coordination and confidence in actions, conscious

deliberate planning is character of this skill level, efficient and organized

- having the ability to do what is needed

4. Proficient 

- a nurse who has 2-3 years experience and the same clinical position

- has a holistic view of a patient, learns from experience and able to see big
picture and many layers in situation

- perceive and understand situations as a whole, learns from experience what

typical events to expect in a situation and how plans need to be modified to
respond to these events, they can recognize when the expected normal pic does
not materialize, this understanding improves decision making and work becomes
less labored because nurse now has a perspective on which of the many existing
attributes and aspects in the present situation are important.

5. Expert

- as an intuitive grasp of each situation and zeros in on the acute region of the
problem, without wasteful consideration of a large range of unfruitful alternative
diagnosis and solutions

- operates from a deep understanding of total situation, their performance

becaus fluid, professional and highly proficient, highly skilled analytic ability is
necessary for those situations with which the nurse has had no previous
experience.

 Professional Responsibilities and Roles

            - Contemporary Nursing requires that the nurse possess knowledge and
skills for a variety professional roles and responsibilities. Changes in nursing have
expanded the role to include increased emphasis on health promotion and illness
prevention as well as concern for the client as a whole.

1. Caregiver/ Care provider

·         the traditional and most essential role

·         Helps the client regain health through the healing process. Healing is more
than just curing a specific disease, although treatment skills that promote
physical healing are important for care givers.

·         It helps the client and families set goals and meet those goals with a
minimal cost of time and energy.

·         Functions as nurturer, comforter, provider.

·         activities involves knowledge and sensitivity to what matters and what is

important to clients
·         show concern for client welfare and acceptance of the client as a person

2. Teacher/Educator

·         provides information and helps the client to learn or acquire new

knowledge and technical skills

·         encourages compliance with prescribed therapy.

·         promotes healthy lifestyles

·         interprets information to the client

3. Counselor

·         helps client to recognize and cope with stressful psychologic or social

problems; to develop an improve interpersonal relationships and to promote
personal growth

·         provides emotional, intellectual to and psychologic support

·         focuses on helping a client to develop new attitudes, feelings and

behaviors rather than promoting intellectual growth.

·         encourages the client to look at alternative behaviors recognize the choices

and develop a sense of control.

4. Change agent

·         initiate changes or assist clients to make modifications in themselves or in

the system of care.

5. Client advocate

·         involves concern for and actions in behalf of the client to bring about a
change.

·         promotes what is best for the client, ensuring that the client’s needs are
met and protecting the client’s right.
·         provides explanation in clients language and support clients decisions.

6. Nurse Administrator

·         Manages patient care and the delivery of specific nursing services within a
health care agency.

7. Researcher

·         investigates problems to improve nursing care and to further define and

expand the scope of nursing practice. He or she often works in an academic
setting, hospital, or independent professional or community service agency.

·         participates in scientific investigation and must be a consumer of research

findings.

8. Manager

·         Makes decisions, coordinates activities of others, allocate resource

·         Plans and  give direction, develop staff, monitors operations, give

the rewards fairly and represents both staff and administrations as needed.

·         Has personnel, policy, and budgetary responsibility for specific nursing unit

9. Clinical Nurse Specialist (CNS)

·         Expert Clinician in a specialized area of practice and may work in any

practice setting.

·         May specialize in a specific disease

·         Functions as an expert clinician, educator, case manager, consultant and

researcher to plan or improve the quality of care provided to the client and to the
family.

10. Certified Nurse-Midwife (CNM)

·         a nurse who has completed a program in midwifery;
independently provides prenatal and postnatal care and delivers babies to
woman with uncomplicated pregnancies.

11. Nurse anesthetist

·         a nurse who completed the course of study in an anesthesia school and
carries out pre-operative status of clients.

12. Nurse Educator 

·         A nurse usually with advanced degree, who beaches in clinical or

educational settings, teaches theoretical knowledge, clinical skills and conduct
research.

13. Nurse Entrepreneur

·         a nurse who has an advanced degree, and manages health-related

business.

Fields and Opportunities in Nursing

1. Hospital/Institutional Nursing – a nurse working in an institution with patients

Example: rehabilitation, lying-in, etc.

2. Public Health Nursing/Community Health Nursing – usually deals with families

and communities.

(no confinement, OPD only)

Example: brgy. Health Center

3. Private Duty/special Duty Nurse – privately hired

4. Industrial/Occupational Nursing – a nurse working in factories, office,

companies
5. Nursing Education – nurses working in school, review center and in hospital as
a Clinical Instructor.

6. Military Nurse – nurses working in a military base.

7. Clinic Nurse – nurses working in a private and public clinic.

8. Independent Nursing Practice – private practice, BP monitoring, home

service.  Independent Nurse Practitioner

TEACHER’S INSIGHT:

Nursing can be described as both an art and a science; a heart and a mind. At its
heart, lies a fundamental respect for human dignity and an intuition for a
patient’s needs. This is supported by the mind, in the form of rigorous core
learning. Due to the vast range of specialization and complex skills in the nursing
profession, each nurse will have specific strengths, passions, and expertise.

Nurses had conquered every aspect of lives, responsibilities can range from
making acute treatment decisions to providing health services in different field in
the society. The key unifying characteristic in every role is the skill and drive that
it takes to be a nurse. Through long-term monitoring of patients’ behavior and
knowledge-based expertise, nurses are best placed to take an all-encompassing
view of a patient’s wellbeing.

Before leaving this Chapter kindly proceed to Comprehension Assessment

page and complete the exercises provided.

CHAPTER 2

HISTORY OF NURSING

 This chapter cover the history and milestone nursing in the world and in the
Philippines. Significant persons with great influence in the practice of nursing
were provided. 
Duration: 1 hour

Intended Learning Outcomes:

          1. Discuss the different era in practicing Nursing.

          2.  Describe the various ways in delivering care in every period.

          3. Illustrate the progress of nursing practice.

4. Describe the contributions of individuals and different social group in each era
in the development of nursing.

HISTORY OF NURSING:

I. Period of Intuitive Nursing/Medieval Period

·         Nursing was “untaught” and instinctive. It was performed of compassion for

others, out of the wish to help others.

·         Nursing was a function that belonged to women. It was viewed as a natural

nurturing job for women. She is expected to take good care of the children, the
sick and the aged.

·         No caregiving training is evident. It was based on experience and

observation.

·         Primitive men believed that illness was caused by the invasion of the
victim’s body of evil spirits. They believed that the medicine man, Shaman or
witch doctor had the power to heal by using white magic, hypnosis, charms,
dances, incantation, purgatives, massage, fire, water and herbs as a mean of
driving illness from the victim.

Trephining – drilling a hole in the skull with a rock or stone without anesthesia
was a last resort to drive evil spirits from the body of the afflicted.

II. Period of Apprentice Nursing/Middle Ages

·         Care was done by crusaders, prisoners, religious orders

·         Nursing care was performed without any formal education and by people
who were directed by more experienced nurses (on the job training). This kind of
nursing was developed by religious orders of the Christian Church.

·         Nursing went down to the lowest level

-wrath/anger of Protestantism confiscated properties of hospitals and schools

connected with Roman Catholicism.

– Nurses fled their lives; soon there was shortage of people to care for the sick

– Hundreds of Hospitals closed, there was no provision for the sick, no one to
care for the sick

– Nursing became the work of the least desirable of women –

prostitutes, alcoholics, prisoners

·         Pastor Theodore Fliedner and his wife, frederika established the

Kaiserswerth Institute for the training of Deaconesses (the 1 st formal training
school for nurses) in Germany.

– This was where Florence Nightingale received her 3-month course of stude in
nursing.

III. Period of Educated Nursing/Nightingale Era 19 th-20th century

·         The development of nursing during this period was strongly influenced by:

a.) trends resulting from wars – Crimean, civil war

b.) arousal of social consciousness

c.) increased educational opportunities offered to women.

·         Florence Nightingale was asked by Sir Sidney Herbert of the British War
Department to recruit female nurses to provide care for the sick and injured in
the Crimean War.

·         In 1860, The Nightingale Training School of Nurses opened at St. Thomas
Hospital in London.

– The school served as a model for other training schools. Its graduates traveled
to other countries to manage hospitals and institute nurse-training programs.

– Nightingale focus vision of nursing Nightingale system was more on

developing the profession within hospitals. Nurses should be taught in hospitals
associated with medical schools and that the curriculum should include both
theory and practice.

– It was the 1st school of nursing that provided both theory-based knowledge and
clinical skill building.

·         Nursing evolved as an art and science

·         Formal nursing education and nursing service begun

FACTS ABOUT FLORENCE NIGHTINGALE

·         Mother of modern nursing. Lady with the Lamp because of her

achievements in improving the standards for the care of war casualties in the
Crimean war.

·         Born may 12, 1800 in Florence, Italy

·         Raised in England in an atmosphere of culture and affluence

·         Not contended with the social custom imposed upon her as a Victorian
Lady, she developed her self-appointed goal: To change the profile of Nursing

·         She compiled notes of her visits to hospitals and her observations of the
sanitary facilities, social problems of the places she visited.
·         Noted the need for preventive medicine and god nursing

·         Advocated for care of those afflicted with diseases caused by lack of

hygienic practices

·         At age 31, she entered the Deaconesses School at Kaiserswerth inspite of
her family’s resistance to her ambitions. She became a nurse over the objections
of society and her family.

·         Worked as a superintendent for Gentlewomen Hospital, a charity hospital

for ill governesses.

·         Disapproved the restrictions on admission of patients and considered this

unchristian and incompatible with health care

·         Upgraded the practice of nursing and made nursing an honorable

profession for women.

·         Led nurses that took care of the wounded during the Crimean war

·         Put down her ideas in 2 published books: Notes on Nursing, What It Is and
What It Is Not and Notes on Hospitals.

·         She revolutionized the public’s perception of nursing (not the image of a

doctor’s handmaiden) and the method for educating nurses.

IV. Period of Contemporary Nursing/20th Century

·         Licensure of nurses started

·         Specialization of Hospital and diagnosis

·         Training of Nurses in diploma program

·         Development of baccalaureate and advance degree programs

·         Scientific and technological development as well as social changes mark

this period.
o   Health is perceived as a fundamental human right

o   Nursing involvement in community health

o   Technological advances – disposable supplies and equipments

o   Expanded roles of nurses was developed

o   W.H.O. was established by the United Nations

o   Aerospace Nursing was developed

o   Use of atomic energies for medical diagnosis, treatment

o   Computers were utilized-data collection, teaching, diagnosis, inventory,

payrolls, record keeping, and billing.

o   Use of sophisticated equipment for diagnosis and therapy.

MILESTONE OF NURSING HISTORY

YEAR RELEVANT EVENTS
300 AD Entry of women to nursing
1100-1200 -formation of charitable institutions to care for the aged, sick, and
poor
-Hospital Brothers of St. Anthony's, Brothers of Misericordia, Alexian
Brothers
1633 Sisters of Charity founded by Louise de Marillac
-established the first educational program to be affiliated with a
religious nursing order
1809 -Mother Elizabeth Seton introduced the Sisters of Charity into
America, later known as the Daughters of Charity
1836 -Deaconess Institute of Kaiserwerth, Germany, founded
-institute where Florence Nightingale received her initial education in
nursing
1846 Florence Nightingale received the Yearbook of the Institution of
Deaconess at Kaiserwerth
1860 establishment of the Nightingale Training School for Nurses at St.
Thomas's Hospital in London, England
 -first organized program for training nurses
-also published Notes on Nursing: What It Is and What It Is Not, first
nursing philosophy based on health maintenance and restoration of
health
1860-1865 Dorothea Dix served as superintendent of the Union Army female
nurses
-Mother Bickendyke organized ambulance services, searched for
wounded, and supervised nurses
-Harriet Tubman tended to solders and led over 300 slaves to
freedom through the Underground Railroad movement
1874 -first nurses training school in Canada founded (St. Catherine's,
Ontario)
1882 United States rectified the -American Red Cross, founded by Clara
Barton
1897 - Initial discussion of nursing code of ethics
1901 -First University affiliated nursing program

- The Army Nurse Corps was established

1920 - Graduate nurse midwifery programs were established
1926 - American Nurses Association Code of Ethics was established
1948 - BROWN report: Dr. Esther Lucille Brown concluded that all nursing
education programs should be affiliated with universities and have
their own budgets.

- She recommended broad academic education within a university

and 2 years of nursing education focused on technical skills.
1949 Association of Operating Room Nurses formed.
1952 Dr. Mildred Montag established the first associate degree in Nursing
Program
1960  Yale University School defines Nursing as profession, interaction and
relationship between two human beings.

Early Beliefs, Practices and Care of the sick of Filipinos

·         Early Filipinos subscribed to superstitious belief and practices in relation to

health and sickness
·         Diseases, their causes and treatment were associated with mysticism and
superstitions

·         Cause of disease was caused by another person (an enemy of witch) or evil
spirits

·         Persons suffering from diseases without any identified cause were believed
bewitched by “mangkukulam”

·         Difficult childbirth were attributed to “nonos”

·         Evil spirits could be driven away by persons with powers to expel demons

·         Belief in special Gods of healing: priest-physician, word doctors,

herbolarios/herb doctors

Early Hospitals during the Spanish Regime – religious orders exerted efforts to

care for the sick by building hospitals in different parts of the Philippines:

o   Hospital Real de Manila San Juan de Dios Hospital

o   San Lazaro Hospital Hospital de Aguas Santas

o   Hospital de Indios

Prominent personages involved during the Philippine Revolution

·         Josephine Bracken – wife of Jose Rizal installed a field hospital in an estate

in Tejeros that provided nursing care to the wounded night and day.

·         Rose Sevilla de Alvaro – converted their house into quanters for Filipino
soldiers during the Phil-American War in 1899.

·         Hilaria de Aguinaldo –wife of Emlio Aginaldo organized the Filipino Red

Cross.
·         Melchora Aquino – (Tandang Sora) nursed the wounded Filipino soldiers,
gave them shelter and food.

·         Captain Salomen – a revolutionary leader in Nueva Ecija provided nursing

care to the wounded when not in combat.

·         Agueda Kahabagan – revolutionary leader in Laguna also provided nursing

services to her troops.

·         Trinidad Tecson (Ina ng Biak na Bato) – stayed in the hospital at Biac na

Bato to care for the wounded soldiers.

School Of Nursing

·         St. Paul’s Hospital School of Nursing, Intramuros Manila – 1900

·         Iloilo Mission Hospital Training School of Nursing – 1906

·         1909 – distinction of graduating the 1st trained nurses in the Phils. With no

standard requirements for admission of applicants except their “willingness to
work”

·         April 1946 – a board exam was held outside of Manila. It was held in the
Iloilo Mission Hospital thru the request of Ms. Loreto Tupas, principal of the
school.

o   St. Luke’s Hospital School of Nursing – 1907; opened after four years as
a dispensary clinic.

o   Mary Johnston Hospital School of Nursing – 1907

o   Philippines General Hospital school of Nursing – 1910

College of Nursing

o   UST College of Nursing – 1st College of Nursing in the Phils: 1877

o   MCU College of Nursing – June 1947 (1st College who offered BSN – 4 year
program)

o   UP College of Nursing – June 1948

o   FEU Institute of Nursing – June 1955

o   UE College of Nursing – Oct 195

MILESTONES OF NURSING IN PHILIPPINES

YEAR EVENTS
1909 3 female graduated as “qualified medical-surgical nurses”
1919 The 1st Nurses Law (Act#2808) was enacted regulating the practice of
the nursing profession in the Philippines Islands. It also provided the
holding of exam for the practice of nursing on the 2nd Monday of June
and December of each year.
1920 1st board examination for nurses was conducted by the Board of
Examiners, 93 candidates took the exam, 68 passed with the highest
rating of 93.5%-Anna Dahlgren theoretical exam was held at the UP
Amphitheater of the College of Medicine and Surgery. Practical exam at
the PGH Library.
1921 Filipino Nurses Association was established (now PNA) as the National
Organization Of Filipino Nurses

PNA: 1st President – Rosario Delgado

Founder – Anastacia Giron-Tupas
1953 Republic Act 877, known as the “Nursing Practice Law” was approved.

TEACHER’S INSIGHT:

 As a future Registered nurse you need to understand through history that
nursing profession has constantly demonstrated its capacity to adjust to shifting
and varied health care needs. It remains an exceedingly admired and highly
respected vocation in every era, it continuously attracts large numbers of new
human resources as it increases its demand in every nation. There is slight
reservation that nursing will continue to maintain its status as an extremely
significant profession, serving the health needs of every individual in various age
group.

Before leaving this Chapter kindly proceed to Comprehension Assessment

page and complete the exercises provided.

CHAPTER 3

COMMUNICATION 

This chapter focuses on the concepts of communication, its principles, types,

elements, techniques and process. It will enable the learners to use
communication skills in each phase of the health care process.

Duration: 3 hours

Intended Learning Outcomes:

          1. Define terms associated with communication in nursing practice.

          2. Describe differences between the levels of communication.

          3. Identify verbal and non verbal communication.

          4. Discuss the importance of communication skills in nurse client

relationship.

          5. Explain dimensions of helping relationship.

          6. Identify factors that influence communication in patients and co workers

in the health setting.

COMMUNICATION
-       is the process of exchanging information, thought, ideas, and feelings from
one individual to another.

-       is a two way process by which a message is passed from the sender to the
receiver with the objective that message sent is received and understood as
intended.

KINDS OF COMMUNICATION

1. Social Communication: it is the unplanned communication that gives

satisfaction to patients/families. It is often carried out while caring for the
patient/family .e.g., the Communication whiles a nurse performing a nursing
procedure.

2. Structured Communication: it is a planned communication.eg, teaching a

patient who has diabetes about self-insulin injection.

3. Therapeutic Communication: it is a planned or unplanned communication

that are used by nurses in many situations to relieve anxiety and fear of patients,
e.g., patient with end-stage renal failure, patient with

cancer.

THE BASIC ELEMENTS OF COMMUNICATION PROCESS

 1. The Sender.

-The communication process begins when a person, known as the

sender, generates a message. Messages stem from a person’s need to relate to
others, o create meanings, and to understand various situations.

2. The Message
-The message is a stimulus produced by a sender and responded to by a receiver.

-  Messages may be verbal, nonverbal, written materials, and artistic.

3. The Channel. The channel is the medium through which a message is

transmitted.

- There are three major communication channels: visual, auditory, and kinesthetic.

- The visual channel consists of sight and observation. The auditory channel
consists of spoken words and cues.

- The kinesthetic channel refers to experiencing sensations.

COMMUNICATION CHANNELS

Channels Mode of transmission

Visual

Congruent words

Sight

‘‘I see what you mean.’’

Observation

‘‘It looks perfectly clear that.’’

Auditory

Congruent words

Hearing

‘‘I hear you.’’

‘‘Tell me what you mean.’’

Listening ‘‘Sounds like you’re saying.’’

‘‘Tell me what you mean.’’

Kinesthetic

Congruent words

Procedural touch

‘‘How does that feel?’’

Caring touch

‘‘That is so touching.’’

4. The Receiver. The receiver is the person who intercepts the sender’s message.
Receiving is influenced by complex physiological, psychological, and
cognitive processes. The physiological component involves the process of
hearing.

5. Feedback. Feedback is the information the sender receives about the

receiver’s reaction to the message. The function of feedback is to provide the
sender with information about the receiver’s perception of a situation. Having
this information, the sender can then adjust the delivery of the message
to communicate more effectively.

MODES OR FORMS OF COMMUNICATION:

1. Verbal communication

-The spoken and or written words are the most frequent modes for conveying
information, one's ideas, thoughts and feelings to others.

Examples of spoken words are; face-to-face meeting, recording messages on

tapes, telephoning, radio, and television.
- Placement of words into phrases and sentences that are understandable to both
speaker and listener gives an order and a meaning to these symbols.

Content is verbal communication, the literal words that a person speaks.

Context is the environment in which communication occurs and can include the
time and the physical, social, emotional, and cultural environment (Weaver, 1996).
It also includes the circumstances or parts that clarify the meaning of the content
of the message.

2. Non- Verbal communication

-is the behavior that accompanies verbal content such as body language, eye
contact, facial expression, tone of voice, speed and hesitations in speech, grunts
and groans, and distance from the listener. Nonverbal communication can
indicate the speaker’s thoughts, feelings, needs, and values

that the speaker acts out mostly unconsciously.

Process denotes all nonverbal messages that the speaker uses to give meaning
and context to the message.

-The process component of communication requires the listener to observe the

behaviors and sounds that accent the words and to interpret the speaker’s
nonverbal behaviors to assess whether they agree or disagree with the verbal
content.

A  congruent message  is when content and process agree. For  example, a client
says, “I know I haven’t been myself.  I need help.” She has a sad facial expression
and a  genuine and sincere voice tone. The process validates  the content as being
true. But when the content and process disagree—when what the speaker says and
what he or she does do not agree—the speaker is giving an  incongruent
message.  For example, if the client says, “I’m here to get help” but has a rigid
posture, clenched fists, an agitated and frowning facial expression, and snarls the
words through clenched teeth, the message is incongruent. The process or observed
behavior invalidates what the speaker says (content).
  

LEVEL OF COMMUNICATION

1. Intrapersonal Level. Intrapersonal communication consists of the messages

one sends to oneself, including self-talk, or communication with oneself. A
person receiving internal or external messages organizes, interprets, and assigns
meaning to the messages.

2. Interpersonal Level. Interpersonal communication is the process that occurs

between two people either in face-to-face encounters, over the telephone, or
through other communication media.

3. Group Level. Group communication occurs when three or more people meet

in face-to face encounters or through another communication medium, such as
a conference call or webinar. This level of communication is complex because of
the number of people communicating intrapersonally and interpersonally and the
combinations of the people involved.

COMMUNICATION MODEL

Encoding: means translating the message into verbal (words) and non-verbal
symbols

(gestures, facial expression) that will communicate the intended message to the
receiver.

Decoding: the receiver perceives and interprets or decodes the sender's message
into information that has meaning.

Message Encoding Transmitting Decoding Action Feed back

Channel
-Facts -Words -Verbal -Sees, hears Ignores Exchange

-Idea -Gesture -Non verbal -Feels -Stores information

 -Concept -Facial -Face to face -Interprets -Delays between

-Feeling -Expressions -Group -Symbolizes -Performs sender and

-Color -Written Messages receiver

-Instructional for

media meaning

THERAPEUTIC COMMUNICATION

-is an interpersonal interaction between the nurse and client during which the
nurse focuses on the client’s specific needs to promote an effective exchange of
information.

-Skilled use of therapeutic communication techniques helps the nurse

understand and empathize with the client’s experience.

-All nurses need skills in therapeutic communication to effectively apply the

nursing process and to meet standards of care for their clients.

Therapeutic communication can help nurses to accomplish many goals:

• Establish a therapeutic nurse–client relationship.

• Identify the most important client concern at that moment (the client-centered
goal).

• Assess the client’s perception of the problem as it unfolded. This includes

detailed actions (behaviors and messages) of the people involved and the client’s
thoughts and feelings about the situation, others, and self.

• Facilitate the client’s expression of emotions.

• Teach the client and family necessary selfcare skills.

• Recognize the client’s needs.

• Implement interventions designed to address the client’s needs.

• Guide the client toward identifying a plan of action to a satisfying and socially
acceptable resolution. 

Establishing a therapeutic relationship is one of the most important responsibilities

of the nurse when working with clients. Communication is the means by which a
therapeutic relationship is initiated, maintained, and terminated.

Characteristics of therapeutic communication:

1. Is purposeful and goal-directed

2. Has well-defined boundaries

3. Is client-focused

4. Is nonjudgmental

5. Uses well-planned, selected techniques

PRINCIPLES OF THERAPEUTIC INTERACTION

1. Plan to interview at an appropriate time: It is unwise to plan to talk with a

client during visiting hours, during change of shift, or when the client is distracted
by environmental stimuli.

2. Ensure privacy: It is both a legal mandate and an ethical obligation that nurses
respect the client’s confidence; this includes spoken words and medical records.
No one wants to discuss private matters when or where other people are
listening.
3. Establish guidelines for the therapeutic interaction: the nurse should share
certain information such as the nurse’s name and affiliation, purpose of the
interaction, the expected length of the contact with the client, and the assurance
of confidentiality.

4. Provide for comfort during the interaction: Discomfort can be distracting.

Pain interferes with a person’s ability to concentrate, thus, communication
becomes impaired.

5. Accept the client exactly as is: Being judgmental blocks communication.

6. Encourage spontaneity: The nurse gathers more data when the client is

talking freely. Also, the client experiences relief and freedom from worries by
talking without inhibition.

7. Focus on the leads and cues presented by the client: Asking questions just
for the sake of talking or for the satisfaction of one’s own curiosity does not
contribute to effective interviewing.

8. Encourage the expression of feelings: Simply allowing the client to talk is not
interviewing

9. Be aware of one’s own feelings during the interaction: The nurse's feelings
influence the interaction. For example, the nurse who becomes anxious may
change the subject or make comments that finalize the session.

PRIVACY AND RESPECTING BOUNDARIES

-Privacy is desirable but not always possible in therapeutic communication. An

interview or conference room is optimal if the nurse believes this setting is not
too isolative for the interaction. The nurse also can talk with the client at the end
of the hall or in a quiet corner of the day room or lobby, depending on the
physical layout of the setting.

Proxemics is the study of distance zones between people during communication.

People feel more comfortable with smaller distances when communicating with
someone they know rather than with strangers (Northouse & Northouse, 1998).
• Intimate zone (0 to 18 inches between people): This amount of space is
comfortable for parents with young children, y desire personal contact, or people
whispering. Invasion of this intimate zone by anyone else is threatening and
produces anxiety.

• Personal zone (18 to 36 inches): This distance is comfortable between family

and friends who are talking.

• Social zone (4 to 12 feet): This distance is acceptable for communication in

social, work, and business settings.

• Public zone (12 to 25 feet): This is an acceptable distance between a speaker

and an audience, small groups, and other informal functions (Hall, 1963).

Touch

- Touching a client can be comforting and supportive when it is welcome and

permitted. The nurse should observe the client for cues that show if touch is
desired or indicated.

- Example: Holding the hand of a sobbing mother whose child is ill is appropriate
and therapeutic. If the mother pulls her hand away, however, she signals to the
nurse that she feels uncomfortable being touched. The nurse also can ask the
client about touching (e.g., “Would it help you to squeeze my hand?”).

-Although touch can be comforting and therapeutic, it is an invasion of intimate

and personal space. As intimacy increases, the need for distance decreases.

Knapp (1980) identified five types of touch:

• Functional-professional  touch is used in examinations or procedures such as

when the nurse touches a client to assess skin turgor or a masseuse performs a
massage.
• Social-polite  touch is used in greeting, such as a handshake and the “air kisses”
some women use to greet acquaintances, or when a gentle hand guides
someone in the correct direction.

• Friendship-warmth  touch involves a hug in greeting, an arm thrown around the

shoulder of a good friend, or the back slapping some men use to greet friends
and relatives.

• Love-intimacy  touch involves tight hugs and kisses between lovers or close
relatives.

• Sexual-arousal  touch is used by lovers.

Four types of touch:

A—Functional–professional touch;

B—Social–polite touch

C—Friendship–warmth touch;

D—Love–intimacy touch.
ACTIVE LISTENING AND OBSERVATION

Active listening- means refraining from other internal mental activities and

concentrating exclusively on what the client says.

Active observation - means watching the speaker’s nonverbal actions as    he or

she communicates.

Active listening and observation help the nurse to:

• Recognize the issue that is most important to the client at this time.

• Know what further questions to ask the client.

• Use additional therapeutic communication techniques to guide the client to

describe his or her perceptions fully.

• Understand the client’s perceptions of the issue instead of jumping to

conclusions.

• Interpret and respond to the message objectively.

Peplau (1952) used observation as the first step in the therapeutic interaction. The
nurse observes the client’s behavior and guides him or her in giving detailed
descriptions of that behavior. The nurse also documents these details. To help the
client develop insight into his or her interpersonal skills, the nurse analyzes the
information obtained, determines the underlying needs that relate to the
behavior, and connects pieces of information (makes links between various
sections of the conversation).

A common misconception by students learning the art of therapeutic

communication is that they always must be ready with questions the instant the
client has finished speaking. Hence, they are constantly thinking ahead regarding
the next question rather than actively listening to what the client is saying. The
result can be that the nurse does not understand the client’s concerns, and the
conversation is vague, superficial, and frustrating to both participants. When a
superficial conversation occurs, the nurse may complain that the client is not
cooperating, is repeating things, or is not taking responsibility for getting better. 

EMPATHY is the ability to place oneself into the experience of another for a
moment in time. Nurses develop empathy by gathering as much information about
an issue as possible directly from the client to avoid interjecting their personal
experiences and interpretations of the situation.  The nurse asks as many questions
as needed to gain a clear understanding of the client’s perceptions of an event or
issue.

  

VERBAL COMMUNICATION SKILLS

 USING CONCRETE MESSAGES

-The nurse should use words that are as clear as possible when speaking to the
client so that the client can understand the message. Anxious people lose
cognitive processing skills—the higher the anxiety, the less ability to process
concepts—so concrete messages are important for accurate information
exchange.

- In a concrete message, the words are explicit and need no interpretation; the
speaker uses nouns instead of pronouns—for example, “What health symptoms
caused you to come to the hospital today?” or “When was the last time you took
your antidepressant medications?” Concrete questions are clear, direct, and easy
to understand. They elicit more accurate responses and avoid the need to go back
and rephrase unclear questions, which interrupts the flow of a therapeutic
interaction.

Abstract messages, in contrast, are unclear patterns of words that often contain
figures of speech that are difficult to interpret. They require the listener to
interpret what the speaker is asking.

-For example, a nurse who wants to know why a client was admitted to the unit
asks, “How did you get here?” This is an abstract message: the terms “how” and
“here” are vague. An anxious client might not be aware of where he or she is and
reply, “Where am I?” or might interpret this as a question about how he or she
was conveyed to the hospital and respond, “The ambulance brought me.” Clients
who are anxious, from different cultures, cognitively impaired, or suffering from
some mental disorders often function at a concrete level of comprehension and
have difficulty answering abstract questions. The nurse must be sure that
statements and questions are clear and concrete. 

USING THERAPEUTIC COMMUNICATION TECHNIQUES

-The nurse can use many therapeutic communication techniques to interact with
clients. The choice of technique depends on the intent of the interaction and the
client’s ability to communicate verbally. Overall the nurse selects techniques that
will facilitate the interaction and enhance communication between client and
nurse.

-Techniques such as exploring, focusing, restating, and reflecting encourage the

client to discuss his or her feelings or concerns in more depth.

-In contrast, there are many  non therapeutic techniques  that nurses should
avoid. These responses cut off communication and make it more difficult for the
interaction to continue. Many of these responses are common in social
interaction such as advising, agreeing, or reassuring. Therefore it takes practice
for the nurse to avoid making these typical comments.

THERAPEUTIC COMMUNICATION TECHNIQUES

Therapeutic Examples Rationale

Communication
Technique
Accepting— “Yes.” An accepting response indicates the
indicating nurse has heard and followed the
“I follow what you train of thought. It does not indicate
Reception said.” agreement but is nonjudgmental.

Nodding Facial expression, tone of voice, and

so forth also must convey
acceptance or the words will lose
 their meaning.
Broad openings— “Is there something Broad openings make explicit that
allowing the client to you’d like to talk the client has the lead in the
take the about?” interaction.

initiative in “Where would youFor the client who is hesitant about

introducing like to begin?”
talking, broad openings may
stimulate him or her to take the
the topic initiative.
Consensual “Tell me whether my For verbal communication to be
validation— understanding of it meaningful, it is essential that the
agrees with yours.” words being used have the same
searching for mutual meaning for both (all) participants.
“Are you using this
understanding, for word to convey that . . Sometimes words, phrases, or slang
accord . ?” terms

in the meaning of have different meanings and can be

the easily

words misunderstood.
Encouraging “Was it something Comparing ideas, experiences, or
comparison— like . . . ?” relationships brings out many
recurring themes.
asking that “Have you had similar
similarities The client benefits from making
experiences?” these comparisons because he or
and differences be she might recall past coping
noted strategies that were effective or
remember that he or she has
survived a similar situation.
Encouraging “Tell me when you To understand the client, the nurse
description of feel must see things from his or her
perspective. Encouraging the client
perceptions—asking anxious.” to describe ideas fully may relieve
the client to verbalize the tension the client is feeling, and
what he or she “What is happening?”
he or she might be less likely to take
perceives
 “What does the voice action on ideas that are harmful or
seem to be saying?” frightening.
Encouraging “What are your The nurse asks the client to consider
expression— feelings in regard people and events in light of his or
to . . . ?” her own values. Doing so
asking client to encourages the client to make his or
appraise “Does this contribute her own appraisal rather than
to accepting the opinion of others.
the quality of his or
her your distress?”

experiences
Exploring—delving “Tell me more about When clients deal with topics
further into a subject that.” superficially,
or idea
“Would you describe exploring can help them examine
it more fully?” the issue

“What kind of work?” more fully. Any problem or concern

can be

better understood if explored in

depth.

If the client expresses an

unwillingness to explore a subject,
however, the nurse must respect his
or her wishes.
Focusing— “This point seems The nurse encourages the client to
concentrating on a worth concentrate his or her energies on a
single point single point, which may prevent a
looking at more multitude of factors or problems
closely.” from overwhelming the client.

“Of all the concerns It is also a useful technique when a

you’ve mentioned, client jumps from one topic to
which is most another.
troublesome?”
Formulating a plan “What could you do It may be helpful for the client to
of to plan in advance what he or she
might do in future similar situations.
action—asking the let your anger out
client to consider Making definite plans increases the
kinds of behavior harmlessly?” likelihood that the client will cope
likely to be more effectively in a similar
“Next time this comes
situation.
appropriate in future up, what might you
do to handle it?”
situations
General leads— “Go on.” General leads indicate that the nurse
giving is listening and following what the
“And then?” client is saying without taking away
encouragement to the initiative for the interaction.
“Tell me about it.”
continue They also encourage the client to
continue if he or she is hesitant or
uncomfortable about the topic
Giving information “My name is . . .” Informing the client of facts
— increases his or her knowledge
“Visiting hours about a topic or lets the client know
making available the are . . .” what to expect.
facts
“My purpose in being The nurse is functioning as a
that the client needs resource person. Giving information
here is . . .”
also builds trust with the client.
Giving recognition “Good morning, Greeting the client by name,
— indicating awareness of change, or
Mr. S . . .” noting efforts the client has made
acknowledging, all show that the nurse recognizes
indicating “You’ve finished your
the client as a person, as an
list of things to do.”
individual. 
awareness
“I notice that you’ve
Such recognition does not carry the
notion of value, that is, of being
combed your hair.”
“good” or “bad.
Making “You appear tense.” Sometimes clients cannot verbalize
observations— or make themselves understood. Or
the client may not be ready to talk.
verbalizing what the “Are you
uncomfortable
nurse perceives
when . . . ?”

“I notice that you’re

biting your lip.”
Offering self— “I’ll sit with you The nurse can offer his or her
making awhile.” presence, interest, and desire to
understand. It is important that this
oneself available “I’ll stay here with offer is unconditional, that is, the
you.” client does not have to respond
verbally to get the nurse’s attention.
“I’m interested in
what

you think.”
Placing event in “What seemed to lead Putting events in proper sequence
time or helps both the nurse and client to
up to . . . ?” see them in perspective.
sequence—clarifying
the “Was this before or The client may gain insight into
cause-and effect behavior and
relationship of after . . . ?”
consequences, or the client may be
events able to see that perhaps some
“When did this
things are not related.
in time happen
The nurse may gain information
about recurrent patterns or themes
in the client’s

behavior or relationships
Presenting reality— “I see no one else in When it is obvious that the client is
offering the misinterpreting reality, the nurse can
indicate what is real.
for consideration room.”
that “That sound was a car The nurse does this by calmly and
quietly expressing the nurse’s
which is real backfiring.” perceptions or the facts not by way
of arguing with the client or
“Your mother is not
belittling his or her experience.
here; I am a nurse.”
The intent is to indicate an
alternative line of thought for the
client to consider, not to “convince”
the client that he or she is wrong.
Reflecting— Client:  “Do you think Reflection encourages the client to
directing client recognize and accept his or her own
actions, thoughts, I should tell the feelings.
and feelings back to
doctor . . . ?” The nurse indicates that the client’s
client
point of view has value, and that the
Nurse:  “Do you think
client has the right to have opinions,
you should?”
make decisions, and think
independently.
Client:  “My brother
spends all my money
and then has nerve to
ask for more.”

Nurse:  “This causes

you to feel angry?”
Restating— Client:  “I can’t sleep. The nurse repeats what the client
repeating the has said in approximately or nearly
I stay awake all night.” the same words the client has used.
main idea expressed
Nurse:  “You have This restatement lets the client know
that he or she communicated the
difficulty sleeping.”
idea effectively.
Client:  “I’m really
This encourages the client to
mad,
continue.
I’m really upset.”
Or if the client has been
 Nurse:  “You’re really misunderstood,
mad and upset.”
he or she can clarify his or her
thoughts.
Seeking “I’m not sure that I The nurse should seek clarification
information— follow.” throughout interactions with clients.
Doing so can help the nurse to
seeking to make “Have I heard you avoid making assumptions that
clear that understanding has occurred when it
correctly?”
has not. It helps the client to
which is not
articulate thoughts, feelings, and
meaningful
ideas more clearly
or that which is
vague
Silence—absence of Nurse says nothing Silence often encourages the client
verbal but to verbalize, provided that it is
interested and expectant.
communication, continues to maintain
which eye contact and Silence gives the client time to
conveys organize
provides time for the
interest. thoughts, direct the topic of
client to put interaction, or
thoughts or
focus on issues that are most
feelings into words, important.

regain composure, or Much nonverbal behavior takes

place during silence, and the nurse
continue talking
needs to be aware of the client and
his or her own nonverbal behavior.
Suggesting “Perhaps you and I The nurse seeks to offer a
collaboration— can relationship in which the client can
identify problems in living with
offering to share, to discuss and discover others, grow emotionally, and
strive, to work with the improve the ability to form
the client for his or
her benefit triggers for your satisfactory relationships.
anxiety.”
The nurse offers to do things with,
“Let’s go to your rather than for, the client.
room, and I’ll help
you find what your
looking for.”
Summarizing— “Have I got this Summarization seeks to bring out
organizing straight?” the important points of the
discussion and to increase the
and summing up “You’ve said that . . .” awareness and understanding of
that both participants.
“During the past hour,
which has gone you and I have It omits the irrelevant and organizes
before discussed . . .” the pertinent aspects of the
interaction. It allows both client and
nurse to depart with the same ideas
and provides a sense of closure at
the completion of each discussion.
Translating into Client:  “I’m dead.” Often what the client says, when
feelings— taken literally, seems meaningless or
Nurse:  “Are you far removed from reality.
seeking to verbalize suggesting that you
feel lifeless?” To understand, the nurse must
client’s feelings that concentrate on what the client
he Client:  “I’m way out in might be feeling to express himself
the ocean.” or herself this way.
or she expresses only
Nurse:  “You seem to
indirectly feel

lonely or deserted.”
Verbalizing the Client:  “I can’t talk to Putting into words what the client
implied— you or anyone. It’s a has implied or said indirectly tends
waste of time.” to make the discussion less obscure.
voicing what the
client Nurse:  “Do you feel The nurse should be as direct as
that no one possible without being unfeelingly
has hinted at or understands?” blunt or obtuse. The client may have
difficulty communicating directly.
suggested
The nurse should take are to express
only what is fairly obvious;
Otherwise the nurse may be
jumping to conclusions or
interpreting the client’s
communication.
Voicing doubt— “Isn’t that unusual?” Another means of responding to
expressing distortions of reality is to express
“Really?” doubt. Such expression permits the
uncertainty about client to become aware that others
the “That’s hard to
do not necessarily perceive events in
believe.
the same way or draw the same
reality of the client’s
conclusions.
perceptions
This does not mean the client will
alter his or her point of view, but at
least the nurse will encourage the
client to reconsider or reevaluate
what has happened.

The nurse neither agreed nor

disagreed; however, he or she has
not let the misperceptions and
distortions pass without comment.

NON THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUES EXAMPLES RATIONALE
Advising—telling “I think you Giving advice implies that only the
the client what to should . . .” nurse knows what is best for the
do client.
“Why don’t you . . .”
Agreeing— “That’s right.” Approval indicates the client is “right”
indicating accord rather than “wrong.” This gives the
with the client “I agree.” client the impression that he or she is
 “right” because of agreement with the
nurse.

Opinions and conclusions should be

exclusively the client’s. When the
nurse agrees with the client, there is
no opportunity for the client to
change his or her mind without being
“wrong.”
Belittling feelings Client:  “I have nothing When the nurse tries to equate the
intense and overwhelming feelings
expressed— to live for . . . I wish the client has expressed to
Misjudging “everybody” or to the nurse’s own
I was dead.”
feelings, the nurse implies that the
the degree of the
discomfort is temporary, mild, self-
client’s discomfort Nurse:  “Everybody
limiting, or not very important.
gets
The client is focused on his or her
down in the dumps.”
own worries and feelings; hearing the
OR
problems or feelings of others is not
“I’ve felt that way helpful.
myself.”
Challenging— “But how can you be Often the nurse believes that if he or
demanding she can challenge the client to prove
President of the unrealistic ideas, the client will realize
proof from the United there is no “proof” and then will
client recognize reality. Actually challenging
States?”
causes the client to defend the
delusions or misperceptions more
“If you’re dead, why is
strongly than before.
your heart beating?”
Defending— “This hospital has a Defending what the client has
attempting to fine criticized implies that he or she has
protect someone or no right to express impressions,
something from reputation.” opinions, or feelings.
verbal attack
“I’m sure your doctor Telling the client that his or her
 has your best criticism is unjust or unfounded does
interests not change the client’s feelings but
only serves to block further
in mind.” communication.
Disagreeing— “That’s wrong.” Disagreeing implies the client is
opposing the “wrong.” Consequently the client feels
“I definitely disagree defensive about his or her point of
client’s ideas view or ideas.
with . . .”

“I don’t believe that.”

Disapproving— “That’s bad.” Disapproval implies that the nurse
denouncing the has the right to pass judgment on the
client’s behavior or “I’d rather you client’s thoughts or actions. It further
ideas wouldn’t . . .” implies that the client is expected to
please the nurse.
Giving approval— “That’s good.” “I’m Saying what the client thinks or feels
glad if “good” implies that the opposite is
sanctioning the “bad.” Approval, then, tends to limit
client’s that . . .” the client’s freedom to think, speak,
or act in a certain way. This can lead
behavior or ideas
to the client’s acting in a particular
way just to please the nurse.
Giving literal Client:  “They’re Often the client is at a loss to
responses— looking in my head describe his or her feelings, so such
with a television comments are the best he or she can
responding to a camera.” do. Usually it is helpful for the nurse
figurative comment to focus on the client’s feelings in
as though it were a Nurse:  “Try not to response to such statements.
statement of fact watch television.” OR
“What channel?”
Indicating the “What makes you say The nurse can ask, “What happened?”
existence of that?” or “What events led you to draw such
a conclusion?”
an external source “What made you do
— that?” But to question “What made you
think that?” implies that the client was
attributing the “Who told you that made or compelled to think in a
source of thoughts, you certain way. Usually the nurse does
feelings, and not intend to suggest that the source
behavior to others were a prophet?” is external but that is often what the
or to outside client thinks.
influences
Interpreting— “What you really The client’s thoughts and feelings are
asking to make his or her own, not to be interpreted
conscious that mean is . . .” by the nurse or for hidden meaning.
Only the client can identify or confirm
which is “Unconsciously you’re
the presence of feelings.
unconscious;
saying . . .”
telling the client
the

meaning of his or
her

experience
Introducing an Client:  “I’d like to die.” The nurse takes the initiative for the
unrelated topic— interaction away from the client. This
changing Nurse:  “Did you have usually happens because the nurse is
the subject uncomfortable, doesn’t know how to
visitors last evening?”
respond, or has a topic he or she
would rather discuss.
Making “It’s for your own Social conversation contains many
stereotyped good.” clichés and much meaningless chit-
chat. Such comments are of no value
comments— “Keep your chin up.” in the nurse–client relationship.
offering
“Just have a positive Any automatic responses will lack the
meaningless clichés attitude and you’ll be nurse’s consideration or
or better in no time.” thoughtfulness.

trite comments
Probing— “Now tell me about Probing tends to make the client feel
persistent used or invaded. Clients have the
questioning this right not to talk about issues or
concerns if they choose. Pushing and
of the client problem. You know I probing by the nurse will not
have to find out.” encourage the client to talk.

“Tell me your
psychiatric history.”
Reassuring— “I wouldn’t worry Attempts to dispel the client’s anxiety
indicating about by implying that there is not sufficient
reason for concern completely
there is no reason that.” devalue the client’s feelings.
for
“Everything will be all Vague reassurances without
anxiety or other right.” accompanying facts are meaningless
feelings to the client.
“You’re coming along
of discomfort just fine.”
Rejecting— “Let’s not discuss . . .” When the nurse rejects any topic, he
refusing to or she closes it off from exploration.
“I don’t want to hear In turn, the client may feel personally
consider or rejected along with his or her ideas.
showing about . . .”

contempt for the

client’s

ideas or behaviors
Requesting an “Why do you think There is a difference between asking
explanation— that?” the client to describe what is
occurring or has taken place and
asking the client to “Why do you feel that asking him to explain why. Usually a
provide reasons for “why” question is intimidating. In
thoughts, feelings, way?”
addition, the client is unlikely to know
behaviors, events “why” and may become defensive

trying to explain himself or herself.

Testing— “Do you know what These types of questions force the
appraising the kind of hospital this client to try to recognize his or her
client’s degree of is?” problems. The client’s
insight acknowledgement that he or she
“Do you still have the doesn’t know these things may meet
idea that . . . ?” the nurse’s needs but is not helpful
for the client.
Using denial— Client:  “I’m nothing.” The nurse denies the client’s feelings
refusing to admit or the seriousness of the situation by
that a problem Nurse:  “Of course dismissing his
you’re something—
exists everybody’s or her comments without attempting
to
something.”
discover the feelings or meaning
Client:  “I’m dead.” behind them.

Nurse:  “Don’t be silly.”

INTERPRETING SIGNALS OR CUES

 Cues   - are verbal or nonverbal messages that signal key words or issues for the
client.

-Finding cues is a function of active listening.

-Cues can be buried in what a client says or can be acted out in the process of
communication.

- cue words introduced by the client can help the nurse to know what to ask next
or how to respond to the client.

-  The following example illustrates questions the nurse might ask when responding
to a client’s cue:

Client: “I had a boyfriend when I was younger.”

Nurse: “You had a boyfriend?” (reflecting) “Tell me about you and your boyfriend.”
(encouraging  description) “How old were you when you had this boyfriend?”
(placing events in time or sequence)

Using the theme, the nurse can assess the nonverbal behaviors that accompany
the client’s words and build responses based on these cues. In the following
examples of identifying themes, the underlined words are THEMES and CUES to
help the nurse formulate further communication.

Theme of sadness:

Client: “Oh, hi, nurse.”  (face is sad; eyes look teary; voice is low, with little
inflection)

Nurse: “You seem sad today, Mrs. Venezia.”

Client: “Yes, it is the  anniversary  of my  husband’s

Nurse: “How long ago  did your husband die?”  (Or the nurse can use the other
cue.)

Nurse: “Tell me about your  husband’s death, Mrs. Venezia.”

Theme of loss of control:

Client: “I had a fender bender this morning. I’m OK. I lost my wallet, and I have to
go to the bank to cover a check I wrote last night. I can’t get in contact with my
husband at work.  I don’t know where to  start.”

Nurse: “I sense you feel out of control.” (translating into feelings)

TYPES OF CUES:

1. Overt cues are clear statements of intent such as, “I want to die.” The message
is clear that the client is thinking of suicide or self-harm.
2. Covert cues are vague or hidden messages that need interpretation and
exploration.

-for example, if a client says, “Nothing can help me.” The nurse is unsure, but it
sounds as if the client might be saying he feels so hopeless and helpless that he
plans to commit suicide.

-The nurse can explore this covert cue to clarify the client’s intent and to protect
the client.

Other word patterns that need further clarification for meaning

include metaphors, proverbs, and clichés. When a client uses these figures of
speech, the nurse must follow up with questions to clarify what the client is trying
to say.

Metaphor is a phrase that describes an object or situation by comparing it to

something else familiar.

Client: “My son’s bedroom looks like a bomb went off.”

Nurse: “You’re saying your son is not very neat.”  (verbalizing the implied)

Proverbs are old, accepted sayings with generally accepted meanings.

Client: “People who live in glass houses shouldn’t throw stones.”

Nurse: “Who do you believe is criticizing you but actually has similar problems?”

(encouraging  description of perception)

Cliché is an expression that has become trite and generally conveys a stereotype.

-For example, if a client says “she has more guts than brains,” the implication is
that the speaker thinks the woman to whom he or she refers is not smart, acts
before thinking, or has no common sense. The nurse can clarify what the client
means by saying, “Give me one example of how you see Mary as having more
guts than

brains” (focusing).

NONVERBAL COMMUNICATION SKILLS

-Nonverbal communication is behavior that a person exhibits while delivering

verbal content.

- It includes facial expression, eye contact, space, time, boundaries, and body
movements. Nonverbal communication is as important, if not more so, than
verbal communication.

- It is estimated that one-third of meaning is transmitted by words and two-thirds

is communicated nonverbally.

Knapp and Hall (2002) list the ways in which nonverbal messages
accompany verbal messages:

• Accent: using flashing eyes or hand movements

• Complement: giving quizzical looks, nodding

• Contradict: rolling eyes to demonstrate that the meaning is the opposite of

what one is saying

• Regulate: taking a deep breath to demonstrate readiness to speak, using “and

uh” to signal the wish to continue speaking

• Repeat: using nonverbal behaviors to augment the verbal message such as

shrugging after saying, “Who knows?”
• Substitute: using culturally determined body movements that stand in for words
such as pumping the arm up and down with a closed fist to indicate success.

THE MEANS OF NON –VERBAL COMMUNICATION

1. Physical appearance including adornment

Personal appearance, body shapes, size, hair styles. Clothing and

adornment are sometimes rich sources of information about a person.

Clothing may convey social and financial status, culture, religion and selfconcept.

2. Posture and gait

The way people walk and carry themselves are often reliable indicators of

self-concept: mood and health.,e.g., erect posture and a n active, purposeful

walk suggest a feeling of well-being, while tens posture suggests anxiety or

anger.

3. Facial expressions

The face is the most expressive part of the body. Feeling of joy, sadness,

fear, surprise, anger and disgust can be conveyed by facial expressions.

Many facial expressions convey a universal meaning, e.g, the smile conveys
happiness.

4. Eye Contact

The eyes may provide the most revealing and accurate of all communication

signals, because they are a focal point on the body. Mutual eye contact
acknowledges recognition of the other person and a willingness to maintain
communication, e.g., patient who feels weak or defenseless often avoids eye
contact.

5. Body movements and gestures

Body movements may sometimes take the place of speech, eg, a shrug of the

shoulders to say," I don't know". Some of the basic communication gestures are
the same throughout the world and convey the same message, e.g, nodding the
head is almost universally used to indicate yes, and the hand shake is a victory
sign.

6. Touch.

Touch is the most personal form of communication because it brings people into
a close relationship, e.g, hand patting, put your hand on patient's shoulder.

7. Tone of voice

It can cause people to listen to speech or to be inattentive and unresponsive.

An individual's personal warmth, honesty and competence is often displayed by

the tone he uses with others, the pause, volume, and rate of speech.

8. Symbols

A symbol is a sign that represents an idea. e.g, means male, and means female.

9. Signals

A signal is assign to give instructions or warning. e.g, the patient puts on the
signal light when he wishes to call a nurse, traffic signals, etc.

Facial Expression - The human face produces the most visible, complex, and
sometimes confusing nonverbal messages (Weaver, 1996).

-Facial expressions can be categorized into expressive, impassive, and confusing:

• An expressive  face portrays the person’s moment-by-moment thoughts,
feelings, and needs. These expressions may be evident even when the person
does not want to reveal his or her emotions.

• An impassive  face is frozen into an emotionless, deadpan expression similar to a

mask.

• A confusing  facial expression is one that is the opposite of what the person
wants to convey.

A person who is verbally expressing sad or angry feelings while smiling is an

example of a confusing facial expression. (Cormier et al., 1997; Northouse &
Northouse, 1998).

- To ensure the accuracy of information, the nurse identifies the nonverbal

communication and checks its congruency with the content (van Servellen, 1997).
An example is “Mr. Jones, you said everything is fine today, yet you frowned as
you spoke. I sense that everything is not really fine” (verbalizing the implied).

Body Language - (gestures, postures, movements, and body positions) is a

nonverbal form of communication.

Closed body positions, such as crossed legs or arms folded across the chest,
indicate that the interaction

-might threaten the listener, who is defensive or not accepting.

-A better, more accepting body position is to sit facing the client with both feet
on the floor, knees –parallel, hands at the side of the body, and legs uncrossed or
crossed only at the ankle.

-Hand gestures add meaning to the content. A slight lift of the hand from the
arm of a chair can punctuate or strengthen the meaning of words.

- Holding both hands with palms up while shrugging the shoulders often means
“I don’t know.” Some people use many hand gestures to demonstrate or act out
what they are saying, while others use very few gestures.
     
        Closed body position                                               Accepting body
position

Vocal Cues - are nonverbal sound signals transmitted along with the content.
The voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment
the sender’s message.

·         Volume, the loudness of the voice, can indicate anger, fear, happiness, or
deafness.

·         Tone can indicate if someone is relaxed, agitated, or bored.

·         Pitch varies from shrill and high to low and threatening.

·         Intensity is the power, severity, and strength behind the words, indicating
the importance of the message.

·         Emphasis refers to accents on words or phrases that highlight the subject

or give insight on the topic.
·         Speed is number of words spoken per minute. Pauses also contribute to
the message, often adding emphasis or feeling.

The use of extraneous words with long, tedious descriptions is

called CIRCUMSTANTIALITY, it can indicate the client is confused about what is
important or is spinning an untrue story (Morley et al., 1967).

It is important for the nurse to validate these nonverbal indicators rather than to
assume that he or she knows what the client is thinking or feeling (e.g., “Mr.
Smith, you sound anxious. Is that how you’re feeling?”).

Eye Contact

-The eyes have been called the mirror of the soul because they often reflect our
emotions.

-Messages that the eyes give include humor, interest, puzzlement, hatred,
happiness, sadness, horror, warning, and pleading.

- looking into the other person’s eyes during communication, is used to assess
the other person and the environment and to indicate whose turn it is to speak

- it increases during listening but decreases while speaking (Northouse &
Northouse, 1998).

-While maintaining good eye contact is usually desirable, it is important that the
nurse doesn’t “stare” at the client.

Silence - Silence or long pauses in communication may indicate many different

things.
- It is important to allow the client sufficient time to respond, even if it seems like
a long time. It may confuse the client if the nurse “jumps in” with another
question or tries to restate the question differently.

UNDERSTANDING THE MEANING OF THE COMMUNICATION

- Few messages in social and therapeutic communication have only one level of
meaning; messages often contain more meaning than just the spoken words
(deVito, 2002). The nurse must try to discover all the meaning in the client’s
communication.

- For example, people who outwardly appear dominating and strong and often
manipulate and criticize others in reality may have low self-esteem and feel
insecure. They do not verbalize their true feelings but act them out in behavior
toward others. Insecurity and low self-esteem often translate into jealousy and
mistrust of others and attempts to feel more important and strong by
dominating or criticizing them.

UNDERSTANDING CONTEXT

- Understanding the context of communication is extremely important in

accurately identifying the meaning of a message.

-Think of the difference in the meaning of “I’m going to kill you!” when stated in
two different contexts: anger during an argument, and when one friend discovers
another is planning a surprise party for him or her. -Understanding the context of
a situation gives the nurse more information and reduces the risk of assumptions.

- To clarify context, the nurse must gather information from verbal and nonverbal
sources and validate findings with the client.

BARRIERS OF THERAPEUTIC COMMUNICATION 

1. Language Differences.

When English is the clients’ second language, they may have problems navigating
through the health care system. An inability to communicate effectively with
health care providers adversely affects clients’ responses to interventions.

2. Culture Differences

Some of the communication variables that are culture specific include eye
contact, proximity to others, direct versus indirect questioning, and the role of
social small talk.

3. Gender

Sending, receiving, and interpreting messages can vary between men and
women. The effect and use of nonverbal cues are often gender dependent.

For example, women tend to be better decoders of nonverbal cues, and men
prefer more personal distance between themselves and others than do women.

4. Health status

The client who is oriented will communicate more reliably than a client who is
delirious, confused, or disoriented.

5. Developmental level.

Communicating with children requires the use of different words and approaches
than those used with adults because a child cannot think in abstract concepts.
Relating at the client’s developmental level is necessary for understanding.

6. Emotion

When the nurse or the client is anxious, communication may change, stop, or
take a nonproductive course. Nurses should be aware of their own feelings and
try to control them in order to ensure progress in the interview.

7. Use of health care jargon.

Nurses and other health care providers have a language unique to their
subculture. Nurses who use health care jargon with clients are likely contributing
to blocked communication. Terms or phrases such as ‘‘CBC,’’ ‘‘BP,’’ and ‘‘take your
vitals’’ are often misinterpreted by clients and families. It is important that nurses
use language that is easily understood and explain medical terminology so that it
is clear to clients and families.

NURSE-CLIENT COMMUNICATION

1. One of the most important aspects of nursing care is communication. Good

communication skills are essential whether the nurse is gathering admission
information, taking a health history, teaching, or implementing care.

2. Interpersonal communication is an exchange of information between the nurse

and the client. This basic level of communication occurs between 2 or more
people in small group and is the most common form of communication in
nursing.

3. Nurses have both an ethical and a moral responsibility to use any information
gathered from the client in the client's best interest.

PHASES OF NURSE-CLIENT COMMUNICATION

1. Introduction: Fairly short; expectations clarified; mutual goals set

2. Working: Major portion of the interaction; used to accomplish goals outlined

in introduction; feedback from client essential.

3. Termination: Nurse asks if client has questions; summarizing the topic is

another way to indicate closure.

FACTORS AFFECTING NURSE-CLIENT COMMUNICATION

1. Nurse: many factors pertaining to the nurse influence nurse-client
communication. Include:

a. The nurse's state of health

b. Home situation

c. Workload

d. Staff relations

e. Past experiences as a nurse can all impact the attitude, thinking, concentration,
and emotions of the nurse.

2. Client: factors related to the client that must be considered include

a. social factors

b. religion

c. family situation

d. visual ability

e. hearing ability

f. speech ability

g. level of consciousness

h. language proficiency

i. state of illness.

COMMUNICATION WITH THE HEALTH CARE TEAM

1. Oral communication

Oral communication takes place among all health care team members.
To provide continuity of care to the client, all persons who provide that care
communicate orally concerning that care

2. Shift report

Vital to continuity of client care is the shift report (report about each client
between shifts). An oral report is the most common. The charge nurse of the
outgoing shift may report to all members of the incoming shift or only to the
incoming charge nurse who, in turn, shares the information with the appropriate
caregivers on the incoming shift.

3. Written communication

Most written communication relates to the client's chart. All aspects of a client's
care are recorded on that client's chart. Requisitions to x-ray or to physical or
respiratory therapy and requests for laboratory

services for a client are all forms of written communication.

4. Electronic communication

Computers are being used extensively in the business offices of health care
agencies and have been so for years. The introduction of computers into the
departments of direct client care has been slower.

In many places, computers are used by client care departments to send

requisitions to other departments and to receive test results.

a. Nurse-student nurse

b. Nurse-nursing assistant

c. Nurse- nurse

d. Nurse-physician

e. Nurse-other health professionals

f. Group communication
g. Telephone

TEACHER’S INSIGHT:

Establishing a therapeutic relationship is one of the most important

responsibilities of the nurse when working with clients especially to ill people.

Communication is the means by which a therapeutic relationship is initiated,

maintained, and terminated. To have effective therapeutic communication, the
nurse also must consider privacy and respect of boundaries, use of touch, and
active listening and observation.

Moreover communication in the health setting is vital in practicing our role as

care provider, it help us to deliver continues care and sustain good collaborative
work with other health allies.

Before leaving this Chapter kindly proceed to Comprehension Assessment

page and complete the exercises provided.

CHAPTER 4

NURSING PROCESS 

         This chapter covers concepts in applying nursing process and its components in the
delivery of nursing care.

Duration: 3 hours

Intended Learning Outcomes:

          1. Define selected terms related to Nursing Process.

          2. State the purpose of Nursing Process

            3. State and describe each component of the process.

 
 NURSING PROCESS

-Specific to the nursing profession

-A framework for critical thinking

- It’s purpose is to: “Diagnose and treat human responses to actual or potential health
problems”

- Organized framework to guide practice

- Problem solving method - client focused

- Systematic- sequential steps

- Goal oriented- outcome criteria

- Dynamic-always changing, flexible

- Involves looking at the whole patient at all times

- It provides a "road map" that ensures good nursing care & improves patient outcomes

Critical Thinking- nurses need to use Nursing process

- Always thinking about your thinking, and your actions, and your decisions

Basis in using Critical Thinking:

·         Deal w/ complex problems on a daily basis

·         Work w/ patient that are unique

·         Provide holistic care

Advantages of Nursing Process:

- Provides individualized care

-Client is an active participant

-Promotes continuity of care

-Provides more effective communication among nurses and healthcare professionals

-Develops a clear and efficient plan of care

-Provides personal satisfaction as you see client achieve goals

- Professional growth as you evaluate effectiveness of your interventions

1. ASSESSMENT

-First step of the Nursing Process

-systematic, deliberate process by which the nurse collects and analyzes data about the patient

-Gather Information/Collect Data through Nursing Interview (history), Health Assessment -

Review of Systems, Physical Exam

-Entire plan is based on the data you collect, data needs to be complete and accurate

- Make sure information is complete & accurate

5 Activities Needed to Perform a Systematic Assessment

-Collect data
-Verify data

-Organize data

-Identify Patterns

-Report & Record data

Sources of data:

a. Primary Source - Client / Family

b. Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic
tests…..

Types of data:

a. Subjective -from the client (symptom)  “I have a headache”

b. Objective - observable data (sign) Blood Pressure 130/80

Example:

·         Obtain info from nursing assessment, history and physical (H&P) etc…...

·         Client diagnosed with hypertension

·         BP 160/90mmhg

·         2 Gm Na diet  and antihypertensive medications were prescribed

·         Client statement “ I really don’t watch my salt”  “ It’s hard to do and I just don’t get it

Comprehensive data collection:

- Begins before you actually see the patient (Nurse report from ER, Chart reviews)

- Continues with admission interview and physical assessment once you meet patient.

- Other information resources include:  family, significant others, nursing records, old medical
records, diagnostic studies, relevant nursing literature.

- Consider age, growth & development

 

The 4 effective communication skills during patient assessment:

·         Open-ended questions - prompts patients to describe a situation in more than one or two
words

·         Back channeling - use of active listening prompts such as "all right", "go on", or "uh huh"

·         Probing - encouraging a full description without trying to control the direction the story
takes

·         Close ended questions- limit answers to one or two words such as "yes" "no" or a number
or frequency of a symptom

VITAL SIGNS- indicators of health status, these measures indicate the effectiveness of
circulatory, respiratory, neural and endocrine body functions.

-it provides data to determine a client’s usual state of heath (baseline data).

-it is a quick and efficient way of monitoring a client’s condition or identifying problems
evaluating the client’s response to intervention.

Guidelines for Measuring Vital Signs:

I. Body Temperature 

- Reflects the balance between the heat produced and the heat lost from the body

-Measured in heat units called degrees

Two kinds:

·         Core temperature - The temperature of the deep tissues of the body and remains relatively
constant.

·         Surface temperature - Is the temperature of the skin, in the subcutaneous tissue, and fat.

                                           - Rises and falls in response to environment.

 
Factors Affecting the Body’s Heat Production:

·   Basal Metabolic Rate (BMR)

-The rate of energy utilization in the body required to maintain essential activities such as
breathing.

-Metabolic rates increase with age.

-In general, the younger the person, the higher the BMR.

·   Thyroxine Output

-Increased thyroxine output increases the rate of cellular metabolism throughout the body.

-Epinephrine, norepinephrine and sympathetic stimulation

-These hormones immediately increase the rate of cellular metabolism in many body tissues.

-Epinephrine and norepinephrine directly affect the liver and muscle cells, thereby increasing
cellular metabolism.

Factors affecting Heat Loss:

·   Radiation

-Is the transfer of heat from the surface of one object to the surface without contact between the
two objects.

-Example: nude person standing in a room of a normal room temperature.

·   Conduction

-Is the transfer from one molecule to a molecule of lower temperature.

-Conductive transfer cannot take place without contact between the molecules.

·  Convection

- Dispersion of heat by air currents.

·   Vaporization

- Is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the
mouth and from the skin.
 

 Factors Affecting Body Temperature:

·  Age

-Infants are greatly influenced by the temperature of the environment.

-Children’s temperature continue to be more variable than those adults until puberty.

-Many older people are at risk of hypothermia.

·  Diurnal Variations (circadian rhythms)

-Body temperature normally change throughout the day, varying as much as 1.0C

-Highest body temperature:  1600-1800 hours

-Lowest: 0400 and 0600 hours

·  Exercise

- Hardwork and strenuous exercise can increase body temperature to as high as 38.3 C to 40 C

·  Hormones

- In women, progesterone secretion at the time of ovulation raises body temperature by about .3
C to 0.6 C above basal temperature.

·  Stress

-Stimulation of the SNS can increase the production of epinephrine and norepinephrine, thereby
increasing metabolic activity and heat production.

·  Environment

-Extremes in environmental temperature affect a person’s temperature regulatory systems.

Common Types of Fever:

·   Intermittent

- Body temperature alternates at a regular intervals between periods of fever and periods of
normal or subnormal temperatures.
·   Remittent

- Wide range of temperature fluctuations (more than 2 C) over a period of 24 hours, all of which
are above normal

·   Relapsing

- Short febrile periods of a few days are interspersed with periods of 1-2 days of normal
temperature.

·   Constant

- Fluctuates minimally but always remains above normal.

·   Fever spike

- A temperature that rises to fever level rapidly following a normal temperature and then returns
to normal within a few hours.

Clinical Manifestations:

·   ONSET (COLD OR CHILL PHASE)

-Increased heart rate, increased RR and depth, Shivering, Pallid, cold skin, Complaints of feeling
cold, Cyanotic nail beds ,“Gooseflesh” appearance of the skin, Cessation of sweating.

·   COURSE (PLATEAU)

-Absence of chills, Skin that feels warm, Photosensitivity, Glass-eyed appearance, Increased PR
and RR, Increased thirst, Mild to severe dehydration, Drowsiness, restlessness, delirium,
convulsions, Herpetic lesions of the mouth, Loss of appetite, Malaise, weakness and aching
muscles

·   DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)

-Skin that appears flushed and feels warm, Sweating, Decreased shivering, possible dehydration

Assessing Body Temperature:

SITE ADVANTAGES DISADVANTAGES

ORAL Accessible and -Thermometers can break if bitten.
convenient
 -Inaccurate if client has just ingested hot or cold food or
fluid or smoked.

-Could injure mouth following oral surgery.

RECTAL Reliable -Inconvenient and more unpleasant for clients.

-Difficult for clients who cannot turn to the side.

-Could injure the rectum following rectal temperature.

- Presence of stool may interfere with the thermometer

placement.
AXILLARY Safe and non- -The thermometer must be left in place a long time to obtain
invasive an accurate measurement.
TYMPANIC Readily -Can be uncomfortable and involves risk of injuring the
MEMBRANE accessible; membrane if the probe is inserted too far.
reflects the core
temperature, very -Repeated measurements may vary.
fast
- Presence of cerumen may affect the reading.
TEMPORAL Safe and -Requires electronic thermometers that may be inexpensive
ARTERY noninvasive; very or unavailable.
fast

II. Pulse

-Wave of blood created by contraction of the left ventricle of the heart.

-Peripheral pulse-a pulse located away from the heart.

-Apical pulse-central pulse, located at the apex of the heart, also called PMI

 Factors Affecting the Pulse:

·  Age - As age increases, the pulse rate gradually decreases.

·  Gender - After puberty, the average male’s pulse rate is lower than females.

·  Exercise - the PR normally increases with activity.

·  Fever - PR increases

·  Medications- Digitalis-decreases PR
         - Epinephrine-increases PR

·  Hypovolemia - Loss of blood from the vascular system normally increases PR.

·  Stress - Increases rate as well as the force of the heartbeat.

·  Position Changes - When a person is sitting or standing, blood usually pools in dependent
vessels of  the venous system.

            -Pooling results in transient decrease in the venous blood return to the heart and  
subsequent reduction in BP and increase in HR.

·   Pathology- Certain diseases such as some heart conditions or those that impair oxygenation
can alter PR.

AGE PULSE AVERAGE AND RANGES

Newborn 130 (80-180)
1 year 120 (80-140)
5-8 years old 100 (75-120)
10 years 70 (50-90)
Teen 75 (50-90)
Adult 80 (60-100)
Older adult 70 (60-100)

PULSE SITES:
PULSE SITE REASONS FOR USING SPECIFIC PULSE SITE
Radial -Readily accessible
 
Temporal -Used when radial pulse is not accessible
Carotid -Used during cardiac arrest/shock in adults

-Used to determine circulation to the brain

Apical -Routinely used for infants and children up to 3 years of
age.

-Used to determine discrepancies with radial pulse.

-Used in conjunction with some medications.

Brachial -Used to measure blood pressure

-Used during cardiac arrest for infants

Femoral -Used in cases of cardiac arrest/shock

-Used to determine circulation to the leg

Popliteal -Used to determine circulation to the lower leg
Posterior -Used to determine circulation to the foot
tibial
Dorsal Pedal -Used to determine circulation to the foot
Assessing the Pulse:

·  Commonly assessed by palpation or auscultation.

·  Use the middle three fingertips for all pulse sites except for the apex of the heart.

·  Use moderate pressure.

·  A Doppler ultrasound stethoscope is used for pulses that are difficult to assess.

·  The pads on the most distal aspects of the finger are most sensitive areas for detecting pulse.

·  The nurse should be aware of the following:

               o   Any medication that could affect the heart rate.

               o   Whether the client has been physically active. If so, wait 10-15 minutes until the
client has rested and the pulse has slowed to its usual rate.

               o   Any baseline data about the normal heart rate for the client.

               o   Whether the client should assume a particular position.

III. Respirations

·  Act of breathing

·  Inhalation or inspiration: intake of air into the lungs.

·  Exhalation or expiration: refers to the breathing out or the movement of gases from the lungs
to the atmosphere.

·  Ventilation: is also used to refer to the movement of air in and out of the lungs.

Two types of breathing:

·  Costal (thoracic) breathing- involves the external intercostal muscles and other accessory
muscles, such as sternocleidomastoid muscles.
           - Can be observed by the movement of the chest upward and outward.

·  Diaphragmatic breathing - Involves the contraction and relaxation of the abdomen.

           - Observed by the movement of the abdomen, which occurs as a result of the diphragm’s
contraction and downward movement

Assessing Respirations:

·  Resting respirations should be assessed when the client is relaxed because exercise affects
respirations.

·  Before assessing, a nurse should be aware of;

                o   patient’s normal breathing pattern

                o   influence of the client’s health problems on respirations

·  Any medications or therapies that might affect respirations

·  The relationship of the client’s respirations to cardiovascular function

What should be assessed?

·   Rate

·   Depth

·   Rhythm

·   Quality

·   Special characteristics of respirations

RATE
Eupnea Normal rate & depth
Bradypnea Abnormally slow
Polypnea/ Abnormally fast
Tachypnea respirations
Apnea Cessation of breathing

Depth:
·  Deep – are those in which a large volume of air is inhaled & exhaled, inflating most of the
lungs

·  Shallow – involve the exchange of a small volume of air and often the minimal use of lung
tissue

Rhythm:

·   Cheyne-stokes breathing- Rhythmic waxing and waning of respirations from very deep to
very shallow breathing and temporary apnea.

Ease of Effort:

·   Dyspnea- difficult and labored breathing

·   Orthopnea- ability to breathe only in upright sitting or standing positions.

BREATH SOUNDS:

·  Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction

·  Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper
airway

·  Wheeze – continuous, high-pitched musical squeak or whistling sound occurring on expiration

and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

·  Bubbling- gurgling sounds heard as air passes through moist secretions in the respiratory tract

·  Crackles – dry or wet crackling sounds simulated by rolling a lock of hair near the ear

·  Gurgles – coarse, dry, wheezy or whistling sound more audible during expiration as the air
moves through tenacious mucus or narrowed bronchi

CHEST MOVEMENTS:

·   Intercostal retractions- indrawing between the ribs

·   Substernal retractions- indrawing beneath the breast bone

·   Suprasternal retraction- indrawing above the clavicles

IV. Blood Pressure

·  A measure of the pressure exerted by the blood moves in waves

·  SYSTOLIC PRESSURE – the pressure of the blood as a result of contraction of the ventricles

·  DIASTOLIC PRESSURE – the pressure when the ventricles are at rest

·  PULSE PRESSURE-difference between SBP and DBP- Normal=40 mmHg

Factors Affecting Blood Pressure:

·  Age- BP rises with age

·  Exercise- Physical activity increases the cardiac output and hence the blood pressure.

               -Thus, 20-30 minutes of rest following exercise is indicated before the BP can be
assessed.

·  Stress- Stimulation of the SNS increase CO and vasoconstriction of the arterioles, thus
increasing BP.

However, severe pain can decrease BP greatly by inhibiting the vasomotor center and producing
vasodilation.

·  Race - African American males over 35 years have higher BP than European American males
of the same age.

·  Gender - After puberty, females usually have a higher blood pressure than males of the same
age; d/t hormonal variations. After menopause, women generally have higher BP than before.

·  Medications- Many medications including caffeine, may increase or decrease BP.

·  Disease process - Any condition affecting the cardiac output, blood volume, blood viscosity,
and/or compliance of the arteries has a direct effect of the BP.

  

Classification of Blood Pressure:

CATEGORY SBP DBP

Normal <120 <80
Prehypertension 120-139 80-89
Hypertension, Stage 1 140-159 90-99
 Hypertension, Stage 2 >160 >100

V. Pain

- The International Association for the Study of Pain (IASP) defines pain as “an unpleasant
sensory and emotional  experience, which we primarily associate with tissue damage or describe
in terms of such damage, or both.

Pathophysiology of Pain:

-Pain is explained as a combination of physiologic phenomena in addition to a psychosocial

aspect that influences the perception of pain.

-The pathophysiologic phenomenon of pain is summarized by the processes of transduction,

transmission, modulation, and perception.

·  Transduction

-Noxious stimuli (tissue injury) trigger the release of biochemical mediators (e.g.,
prostaglandins, bradykinin, serotonin, histamine, substance P)that sensitize nociceptors.

-Noxious or painful stimulation also causes movement of ion across cel membranes, which
excites nociceptors.

-Pain medications can work during this phase by blocking the production of prostaglandin (e.g.
ibuprofen)or by decreasing the movement of ions across the cell membrane (e.g. local anesthetic)

·  Transmission

-The second process of nociception, transmission of pain, includes three segments.

-Pain control can take place during this second process of transmission. For
example,opioids(narcotics)block the release of neurotransmitters, particularly substance P, which
stops the pain at the spinal level.

First Segment- Pain impulse travels from the peripheral nerve fibers to the spinal cord. Substance
P serves as the neurotransmitter, enhancing the movement of impulses across the nerve synapse
from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord.
Two types of nociceptor fibers cause transmission to the dorsal horn of spinal cord: C fibers
which transmit dull, aching pain and a delta which transmits sharp, localized pain.

Second Segment- Transmission from the spinal cord and ascension, via spinothalamic tracts, to
the brainstem and thalamus.
Third Segment- Involves transmission of signals between the thalamus to the somatic sensory
context where pain perception occurs.

·  Perception

-The third process is when the client become conscious pain.

-It is believed that pain perception occurs in the cortical structures, which allows for different
cognitive-behavioral strategies to be applied to reduce the sensory and affective components of
pain.

-For example, nonpharmacologic interventions such as distraction, guided imagery, and music
can help direct the client’s attention away from the pain.

·  Modulation

-Often described as the “descending system”, this fourth process occurs when neurons in the
brainstem send signals back down to the dorsal horn of the spinal cord. These descending fibers
release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit
the ascending noxious (painful impulses in the dorsal horn.

Melzack and Wall in 1965 proposed the gate control model emphasizing the importance of the
central nervous system mechanisms of pain; this model has influenced pain research and
treatment.

Classifications of Pain:

·  Acute pain-usually associated with an injury with recent onset and duration of less than six
months and usually less than a month.

·  Chronic Pain-  usually associated with a specific cause or injury and is described as a constant

·  Cancer Pain- often due to the compression of peripheral nerves or meninges or from the
damage to the structures following surgery, chemotherapy, radiation, or tumor growth and
infiltration

·  Phantom Limb Pain – it is a pain perceived by a residual body part.

Physiologic Responses to Pain:

-Pain elicits stress response in the human body triggering the sympathetic nervous system,
resulting in physiologic responses such as the following:
  Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide
 Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
 Decrease in cognitive function, mental confusion, altered temperament, high
somatization, and dilated pupils
 Increased heart rate, peripheral, systemic, and coronary vascular resistance, blood
pressure
 Increased respiratory rate and sputum retention resulting in infection and atelectasis
 Decreased gastric and intestinal motility
 Decreased urinary output resulting in urinary retention, fluid overload, depression of all
immune responses
 Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons,
decreased insulin, testosterone
 Hyperglycemia. Glucose intolerance, insulin resistance, protein catabolism
 Muscle spasm resulting in impaired muscle function and immobility, perspiration

Factors Affecting the Pain Experience:

1.    Ethnic and Cultural Values

2.    Developmental Stage

3.    Environment and Support People

4.    Past Pain Experiences

5.    Meaning of Pain

6.    Anxiety and Stress

Health Assessment for Pain

Collecting Subjective Data

 Pain is a subjective phenomenon and thus the main assessment lies in the client’s
reporting. The client’s description of pain is quoted. The exact words used to describe the
experience of pain are used to help in the diagnosis and management.

A. History of Present Illness

  Use the COLDSPA mnemonic as a guideline to collect information. In addition the
following questions help elicit important information.

Character: Describe the pain in your own words. How does it feel, look sound, smell and so
forth?

Clients are quoted so that terms used to describe their pain may indicate the type and source.
The most common terms used are: throbbing, shooting, stabbing sharp, cramping, gnawing, hot-
burning, aching, heavy, tender, splitting, tiring-exhausting, sickening, fearful, punishing.

Onset: When did the pain begin?

The onset of pain is an essential indicator for the severity of the situation and suggests a source.

Location: Where is the pain located? Does it radiate or spread? The location of the pain helps to
identify the underlying cause.

Duration: How long does the pain lasts? Does it recur? Is the pain continuous or intermittent?

Understanding the course of the pain provides a pattern that may help to determine the source.

Severity: How bad is it?

To determine the degree of perceived pain.

Pattern: What factors relieve your pain? What factors increase your pain?

Identifying factors that relieve or increase pain helps to determine the source and the plan of
care.

Associated factors: Are there any concurrent symptoms accompanying the pain?

Accompanying symptoms also help to identify the possible source. For example, right lower
quadrant pain associated with nausea, vomiting and the inability to stand up straight is possibly
associated with appendicitis.

B.  Past Health History

 Have you had any previous experience with pain?

Past experiences of pain may shed light on the previous history of the client in addition to
possible positive or negative expectations of pain therapies.
C.  Family History

 Does any in your family experience pain?

To assess possible family-related perception or any past experiences with person in pain.

 How does pain affect your family?

To assess how much the pain is interfering with the client’s family relations.

D.  Lifestyle and Health Practices

 What are your concerns about pain?

Identifying the client’s fears and worries helps in prioritizing the plan of care and providing
adequate psychological support.

 How does your pain interfere with the following?

-General Activity

-Mood/Emotions

-Concentration

-Physical Ability

-Work

-Relations with other people

-Sleep

-Appetite

-Enjoyment of life

 These are the main lifestyle factors that pain interferes with. The more the pain interferes with
the client’s ability to function in his/her daily activities, the more it will reflect on the client’s
psychological status and thus the quality of life.
Collecting Objective Data: Physical Examination

 Objective data are collected by using one of the pain assessment tools.
 The main tool used are the Verbal Descriptor Scale(VDS), Wong-Baker Faces Scale,
Numeric Rating Scale(NRS) and Visual Analog Scale(VAS).

Verbal Descriptor Scale(VDS) -Ranges pain on a scale between mild, moderate, and severe.

Wong-Baker Faces Scale(FACES)  -Shows different facial expression where the client is asked
to choose the face that best describes the intensity or level of pain being experienced; this works
well with pediatric clients.

Numeric Rating Scale(NRS) -Rates pain on a scale from 0 to 10 where o reflects no pain and 10
reflects pain at its worst.

Visual Analog Scale(VAS) -Rates pain on a 10cm continuum numbered from 0 to 10 where 0

reflects no pain and 10 reflects pain at its worst.

 Physical Assessment(Patients with Pain)

Inspection:

1. Observe posture.

-Client appears to be slumped with the shoulders not straight indicate being disturbed or
uncomfortable.

-Client is inattentive and agitated.

-Client might be guarding affected area and have breathing patterns reflecting distress.

2. Observe facial expression.

-Client’s facial expressions indicate distress and discomfort, including frowning, moans, cries
and grimacing.

-Eye contact is not maintained, indicating discomfort

3. Inspect joints and muscles.

- may result in muscle tension.

4. Observe skin for scars, lesions, rashes, changes or discoloration.

-Bruising, wounds, or edema maybe the result of injuries or infections, which may cause pain.

Pediatric and Geriatric Adaptations to Pain

INFANT

-perceives pain

-responds to pain with increased sensitivity

-older infant tries avoid pain, for example. Turns away and physically resists

Selected Nursing Interventions:

·  Give a glucose pacifier.

·  Use tactile stimulation

·   Play music or tapes of a heartbeat.

TODDLER AND PRESCHOOLER

-develops the ability to describe pain and its intensity and location

-often responds with crying and anger because child perceives pain as a threat to security

-may consider pain as a punishment

-feels sad

-may learn there are gender differences in pain expression

-tends to hold someone accountable for the pain

Selected Nursing Interventions:

 Distract the child with toys, books, pictures. Involve the child in blowing bubbles as a
way of “blowing away the pain.
 Appeal to the child’s belief in magic by using a “magic” blanket or glove to take away
the pain.
  Hold the child to provide comfort.
 Explore misconceptions about pain.

SCHOOL-AGE CHILD

 tries to be brave when facing pain.

 rationalizes in attempt to explain the pain.
 responsive to explanations
 can usually identify the location and describe the pain
 with persistent pain, may regress to an earlier stage of development

Selected Nursing Interventions:

 Use imagery to turn off “pain switches”.

 Provide a behavioral rehearsal of what to expect and how it will look and feel.
 Provide support and nurturing.

ADOLESCENT

·         may be slow to acknowledge pain

·         recognizing pain or “giving in” may be considered weakness

·         wants to appear brave in front of peers and not report pain

Selected Nursing Interventions:

·         Provide opportunities to discuss pain.

·         Provide privacy.

·         Present choices for dealing with pain. Encourage music or TV for distraction.

·         ADULT

·         behaviors exhibited when experiencing pain may be gender-based behaviors learned as a

child

·         may ignore pain because to admit it is perceived as a sign of weakness or failure

·         fear of what pain means may prevent some adults from taking action
Selected Nursing Interventions:

·         Deal with any misconceptions about pain.

·         Focus on the client’s control in dealing with the pain.

·         Allay fears and anxiety when possible.

ELDERLY

·         may have multiple conditions presenting with vague symptoms

·         may perceive pain as part of the aging process

·         may have decreased sensations or perceptions of the pain

·         lethargy, anorexia, and fatigue may be indicators of pain

·         may withhold complaints of pain because of fear of the treatment, of any lifestyle changes
that may be involved, or of becoming dependent

·         may describe pain differently, that is, as “ache”, “hurt”, or “discomfort”

·         may consider it unacceptable to admit or show pain

Selected Nursing Interventions:

·         Thorough history and assessment is essential.

·         Spend time with the client and listen carefully.

·         Clarify misconceptions.

·         Encourage independence whenever possible.

PHYSICAL EXAMINATION

·         Conducted from head to toe (cephalo-caudal technique).

·         Determine the mental status and level of consciousness (LOC) at the beginning of
examination.
PURPOSES

—  Gather baseline data about the client’s health

—  Supplement, confirm or refute data obtained in the midwifery history

—  Confirm & identify midwifery diagnosis

—  Make clinical judgments about a client's changing health status and management

—  Evaluate the physiological outcomes of care

PREPARATION

1. Explain the procedure

2. Inform the client the need to assume a special position
3. Tell the client that appropriate draping will be provided.
4. Control room temperature, and provide warm blanket.
5. Ask the client to empty the bladder.
6. Encourage the client to defecate.
7. Use a relaxed voice tone and facial expressions to put the client at ease.
8. Encourage the client to ask questions and report discomfort felt during the examination.
9. Have a family member or a third person of the client’s gender in the room during
assessment of genitalia
10. At the conclusion of the assessment, ask the client if he or she has any concerns or
questions

POSITIONS:

Sitting

 Use this position for the assessment of head, neck, back, posterior thorax, and lungs,
breasts, axillae, heart, vital signs, and upper extremities
 It provides full expansion of lungs, and provides better visualization of symmetry of
upper body part.
Supine

 back lying position with legs extended, without small pillow under the head
 for the assessment of head, and neck, anterior thorax, and lungs, breasts, axillae, heart,
abdomen, extremities, pulses, vital signs, vagina
 Most normally relaxed position. It provides easy access to pulse sites.

Dorsal recumbent

 back lying position with knees flexed and hips externally rotated, with small pillow under
the head.
 Head, neck, anterior thorax and lungs, breasts, axillae, heart and abdomen, extremities,
peripheral pulses, vital signs and vagina.
 Position is used for abdominal assessment because it promotes relaxation of abdominal
muscles

Lithotomy

 back lying position with feet supported in stirrups; hips should be in line with the edge of
the table
 for the assessment of female genitalia, rectum and female reproductive tract
 Provides maximal exposure of genitalia and facilitates insertion of vaginal speculum

Sim’s

 side-lying position with lowermost arm behind the body and uppermost leg flexed.
 For the assessment of rectum and vagina
 Flexion of knee and hip improves exposure of rectal area
Prone

 face-lying position with or without a small pillow

 assessment of posterior thorax, hip movement

Knee-chest (Genu-pectoral)

 kneeling position with torso at a chest.

 Assessment of rectum
 Provides maximal exposure to rectal area.

Fowler’s

 Semi-fowler’s – head of bed elevated at 15-45 degree angle.

 High Fowler’s – head of bed raised at 80-90 degree angle.

CHAPTER 4.2: NURSING PROCESS

PHYSICAL EXAMINATION TECHNIQUES

Inspection

 visual examination

-Should be deliberate, purposeful, and systematic

-is concentrated watching
-it is close, careful scrutiny, first of the individual and as a whole and on each
body system

 begins the moment you first meet your client

 inspection always comes first
  the health care worker inspects with the naked eye  and with a lighted
instrument
 in addition to visual observations, olfactory and auditory cues are noted
 inspection is used to assess moisture, color, and texture if body surfaces as
well as shape , position ,size, symmetry of the body
 requires good lighting, adequate exposure, and occasional use of certain
instruments to enlarge your view.

Guidelines:

 Make sure the room has a comfortable temperature.

 Use good lighting, preferably sunlight.
 Look & observe before touching.
 Compare appearance of symmetric body parts or both sides of any
individual body part.

Auscultation

 requires the use of stethoscope

 Guidelines:

1. Eliminate distracting noises

2. Expose the body part you are going to auscultate
3. Press the diaphragm firmly
Palpation

 Factors/ characteristics to assess are:

1. Texture
2. Temperature of skin area
3. Location/position, size, consistency, mobility of organs or masses
4. Distention
5. Pulsation
6. Presence of pain upon pressure
7. Presence of lumps

 Different parts of the hands are best suited for assessing different factors:

1.    finger pads

2.    grasping action of the fingers and thumb

3.    dorsal

4.    ulnar or palmar

TYPES OF PALPATION:
1.      Light Palpation

 place dominant hand lightly on the surface of the structure

 there should be very little or no depression
 feel the surface using circular motion
 use this technique to feel for pulse, tenderness, surface, texture,
temperature & moisture

2.  Moderate Palpation

 depress the skin surface 1-2 cm (.5-.75 in) with your dominant hand
 use circular motion to feel for easily palpable body organs and masses
 note for size, consistency and mobility of structures you palpate

3. Deep Palpation

 place your dominant hand on the skin surface and your non dominant
hand on top of your dominant hand to apply pressure
 surface depression should be 2.5 cm and 5 cm (1-2 in)
 allows you to feel very deep organs or structures that are covered by thick
muscle

a. Bimanual Palpation

-use two hands, placing one on each side of the body part being palpated
-use one hand to apply pressure and the other hand to feel the structure
-note the size, shape, consistency and mobility of the structures you palpate
             MODERATE PALPATION

            DEEP PALPATION-BIMANUAL

       LIGHT PALPATION-BIMANUAL

Percussion

·  involves tapping body parts to produce sound waves that enable the examiner
to assess underlying structures

·  Uses:
-Eliciting pain: percussion helps detect inflamed underlying structures.
-Determining location, size and shape

-Determining density
-Detecting abnormal masses
-Eliciting reflexes

·  Types:
1. Direct Percussion

2. Indirect or mediate Percussion

·  Procedure:
a. place middle finger of non-dominant hand on body part you are going to
percuss
b. use pad of middle finger of the other hand to strike the middle finger of non-
dominant hand that is placed on the body part

c. withdraw finger immediately

d. deliver 2 quick taps and listen carefully
e. use quick, sharp taps by flexing wrist

Sounds elicited by percussion:

1.      Resonance
-intensity: LOUD
-pitch: LOW
-length: LONG
-quality: HOLLOW
-origin: NORMAL LUNG

2.      Hyper-resonance

-intensity:VERY,LOUD
-pitch:LOW
-length:LONG
-quality:BOOMING
-LUNG W/ EMPHYSEMA

3. Tympany
-intensity: LOUD
-pitch: HIGH
-length: MODERATE
-quality: DRUMLIKE
-PUFFED-OUT CHEEKS

4. Dullness

-intensity: MEDIUM
-pitch:  MEDIUM
-length: MODERATE
-quality: THUDLIKE
-DIAPHRAGM, PLEURAL EFFUSION, LIVER

5. Flatness

-intensity: SOFT
-pitch: HIGH
-length: SHORT
-quality: FLAT
-MUSCLE, BONE

Special considerations:

1.    The sequence of methods for physical examination of the abdomen is as

follows: Inspection, Auscultation, Percussion and Palpation (IAPePa). No
abdominal palpation among clients with tumor of the liver or the kidneys.

2.    During physical examination of the abdomen, it is important to flex the knees

to relax the abdominal muscles, thereby facilitating the examination of abdominal
organs.

3.    The sequence of examining the abdomen is as follows: right lower quadrant,

right upper quadrant, left upper quadrant and left lower quadrant (RLQ, RUQ,
LUQ, LLQ).

4.    The best position when examining the chest is sitting/upright position. This
permits the examination of both the anterior and posterior chest.

5.    The best position when examining the back is standing position. This enables
the examiner to assess the posture, and the gait of the client.

6.    If instrumental vaginal examination is done, pour warm water over the
vaginal speculum before use. To ensure comfort.
7.    Is a female client is examined by a male doctor, a female staff must be in
attendance. This ensures that the procedure is done in ethical manner.

LABORATORY AND DIAGNOSTIC EXAMINATIONS

Specimen used: Urine, Stool, Sputum, Blood, Body secretions

A. URINE SPECIMEN

Specimen Collection:

1. Clean-catch, midstream urine specimen for routine urinalysis, culture and

sensitivity test (C & S)

·         the best time to collect: early morning, first voided specimen

·         Provide sterile container

 Do perineal care before collection of urine specimen to reduce

microorganisms at the external genitals
 Discard the first flow of urine to ensure that the urine specimen is
uncontaminated
 Collect the midstream: 30-50 ml, for routine urinalysis; 5-10 ml for urine C
&S
 Discard the last flow of urine especially among males
 Label the specimen properly
 Send the specimen immediately to the laboratory

2. 24-hours urine specimen

 Discard first voided specimen

 Collect all specimen thereafter until same time the following day
 Soak specimen in a container with ice
  Add preservative as ordered/ according to the policy of the institution.

3. Second-voided urine specimen

 Ask the patient to void, discard the first urine specimen

 Give the patient one glass of water to drink
 After few minutes, ask the patient to void again, and collect this urine
specimen
 This type of specimen is required for tests for glucose in urine

4. Catheterized Urine specimen

 Clamp the catheter for 30 minutes to I hour

 Cleanse the drainage port of the 2-way Foley catheter with alcohol
swab/cotton ball
 Use sterile needle and syringe to aspirate urine specimen from the
drainage port

Test for glucose in urine

Benedict’s test:

 Collect urine specimen before meals

 Put 5 ml of Benedict’s solution into the test tube
 Heat the benedict’s solution; there should be no color change. (if the color
of the solution is altered upon heating, it is considered contaminated
 Add 8-10 drops of urine
 Heat the Benedict’s solution with urine (do not boil)

Interpretation of results:

blue – (-) negative

Green - +

Yellow - ++

Orange - +++

Red - ++++

Test for Albumin in the Urine:

Heat and Acetic Acid Test:

 Collect urine specimen before meals

 Imaginary divide the test tube into three parts
 Put 2/3 parts of urine into the test tube
 Add 1/3 part acetic acid. DO NOT HEAT. Acetic acid explodes when heated
 CLOUDINESS indicates albuminuria

B. STOOL SPECIMEN

1.    Routine Fecalysis – to assess gross appearance of ova/parasites

·         Secure sterile specimen container

·         Instruct patient to defecate in a bedpan. If desired, allow the patient to void

first

·         Use tongue depressor to collect the stool specimen

·         Collect 1 teaspoonful or 1 inch of well-formed stool

·         Label the specimen and bring immediately to the laboratory

2. Stool culture and sensitivity test

·         To assess the specific etiologic agent causing gastroenteritis and bacterial

sensitivity to various antibiotic
·         Use sterile test tube and sterile cotton-tipped applicator

·         Label the specimen properly

·         Send specimen immediately to the laboratory

3. Guaiac Stool Examination (Occult blood determination) – microscopic study of

stool for presence of bleeding in the gastrointestinal tract

·         Provide hemoglobin-free diet for 3 days

·         Avoid red or dark-colored foods

·         Temporarily discontinue iron therapy

·         Positive guaiac stool exam indicates peptic ulcer disease and gastric cancer

C. SPUTUM SPECIMEN

1.        Gross appearance of the sputum

·                  Collect early morning specimen

·         Use sterile container

·         Rinse mouth with plain water before collection of specimen. Do not use
mouthwash

·         Instruct patient to hack-up sputum to ensure that it comes from the lungs
and lower airways

2.  Sputum Culture and Sensitivity test  – to assess the specific etiologic agent
causing respiratory tract infection and bacterial sensitivity to various
antibiotics.

·                Use sterile container

·         Collect sputum specimen before the first dose of antimicrobials

3.  Acid-Fast Bacilli (AFB) staining  – to assess presence of active pulmonary
tuberculosis

- Collect sputum for 3 consecutive mornings.

2. NURSING DIAGNOSIS

- Second step of the Nursing Process

- provide a basis for selection of nursing interventions so that goals and

outcomes can be achieved

-Interpret & analyze clustered data

-Identify client’s problems and strengths

-Formulate Nursing Diagnosis (NANDA: North American Nursing Diagnosis

Association)-Statement of how the client is RESPONDING to an actual or
potential problem that requires nursing intervention

- responsible for recognizing health problems, anticipating complications,

initiating actions to ensure appropriate and timely treatment.

- Apply critical thinking to problem identification

-Requires knowledge, skill, and experience

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

Within the scope of nursing practice Within the scope of  medical practice
Identify responses to health and illness Focuses on curing pathology
Can change from day to day Stays the same as long as the disease is
present
Formulating a Nursing Diagnosis

·         Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)

·         Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)

·         Don’t state 2 separate problems in one diagnosis

·         Refer to NANDA list in a nursing text book (  North American Nursing

Diagnosis Association it formally identifies, develops, and classifies nursing
diagnoses)

Composed of 3 parts:

 Problem statement ( Diagnostic Label)-based on your assessment of client

(gathered information),

- pick a problem from the NANDA list

-  the client’s response to a problem

 Etiology- what’s causing/contributing to the client’s problem

- determine what the problem is caused by or related to (R/T)

 Defining Characteristics- what’s the evidence of the problem

-then state as evidenced by (AEB) the specific facts the problem is based on…

EXAMPLE:

Ineffective therapeutic regimen management   related to difficulty

maintaining lifestyle changes and lack of knowledge as evidenced by B/P=
160/90, dietary sodium restrictions not being observed, and client statements of
“I don’t watch my salt”  “It’s hard to do and I just don’t get it”.

 
TYPES OF NURSING DIAGNOSIS

Actual- Patient problem & Causes if known

- Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea,
and pain AEB height 5’5” weight 105 lbs.

Risk - Problem & Risk Factors

- patient is at risk for developing this problem

      Example: Risk for falls RT altered gait and generalized weakness

Wellness- (NANDA) describes human responses to levels of wellness in an

individual, family, or community that have a readiness for enhancement
                Example: Family coping: potential for growth RT unexpected birth of
twins.

COLLABORATIVE PROBLEMS:

-Require both nursing interventions and medical interventions

     EXAMPLE: Client admitted with medical diagnosis of pneumonia

Collaborative problem = respiratory insufficiency

Nursing interventions: Raise Head of the Bed, Encourage rest and deep breathing

Medical interventions: Antibiotics IV, O2 therapy

SOURCES OF DIAGNOSTIC ERROR:

1. Patient response not medical diagnosis

2. NANDA diagnostic statement not symptom
3. Treatable cause or risk factor not a clinical sign or chronic problem that is not
treatable
4. Problem caused by the treatment or diagnostic study not the treatment or
study itself
5. Patient response to equipment not equipment itself
6. Patient's problems not your problems with nursing care
7. Patient problem not nursing intervention
8. Patient problem not goal of care
9. Professional not prejudicial judgments
10. Avoid illegally inadvisable statements
11. Problem and its cause to avoid a circular statement
12. Identify only one patient problem in the diagnostic statement

When initiating an original care plan, place the highest-priority nursing diagnosis
first.

The ordering of nursing diagnoses or patient problems using notions of urgency

and importance to establish a preferential order for nursing interventions.

3. PLANNING

- Third step of the Nursing Process

- This is when the nurse organizes a nursing care plan based on the nursing
diagnoses.

- Nurse and client formulate goals to help the client with their problems

- Expected outcomes are identified

- Interventions (nursing orders) are selected to aid the client reach these goals.

- Begin by prioritizing client problems

- Prioritize list of client’s nursing diagnoses using Maslow

- Set your priorities of care, what needs to be done first, what can wait.

- Apply Nursing Standards, Nurse Practice Act, National practice guidelines,

hospital policy and procedure manuals.
- Identify your goals & outcomes, derive them from nursing diagnosis/problem.

- Determine interventions, based on goals.

- Record the plan (care plan/concept map)

- Client specific Priorities can change

Developing a Goal and Outcome Statement

- Goal and outcome statements are client focused.

- Worded positively

- Measurable, specific observable, time-limited, and realistic

- Goal = broad statement

- Expected outcome = objective criterion for measurement of goal or Measurable

change that must be achieved to reach a goal

        EXAMPLE:

Goal:  Client will achieve therapeutic management of disease process….

Outcome Statement: as evidenced by BP readings of 110-120 / 70-80 and client

statement of understanding importance of dietary sodium restrictions by day of
discharge.

Types of Goals:

·         Short term- goal can be achieved in a reasonable amount of time ( few

hours to few days)

·         Long term-  goals  may take weeks/months to be achieved

·         Cognitive goals
·         Psychomotor goals

·         Affective goals

- Goals are patient-centered and SMART (Specific  Measurable 

Attainable Relevant  Time Bound)

Planning select interventions:

- Interventions are selected and written.

- The nurse uses clinical judgment and professional knowledge to select

appropriate interventions that will aid the client in reaching their goal.

- Interventions should be examined for feasibility and acceptability to the client

- Interventions should be written clearly and specifically.

Always partner with patients when setting their individualized goals.  Mutual goal
setting includes the patient and family (when appropriate) in prioritizing the goals
of care and developing a plan of action. Act as a patient advocate.

  

4. IMPLEMENTATION- The fourth step in the Nursing Process

- This is the “Doing” step

- Interventions will be collaborative, combining nursing actions and physician

orders.

- Carrying out nursing interventions (orders) selected during the planning step

-This includes monitoring, teaching, further assessing, reviewing NCP,

incorporating physicians orders and monitoring cost effectiveness of
interventions
 

INTERVENTION - are treatments or actions based on clinical judgment and

knowledge that nurses perform to enhance patient outcomes.

3 TYPES OF INTERVENTION

·         Independent ( Nurse initiated )- any action the nurse can initiate without
direct supervision

·         Dependent ( Physician initiated )-nursing actions requiring MD orders

·         Collaborative- nursing actions performed jointly with other health care

team members

EXAMPLE:

-Monitor Vital Sign q4h

-Maintain prescribed diet (2 Gm Na)

-Teach client amount of sodium restriction, foods high in sodium, use of nutrition
labels, food preparation and sodium substitutes

-Teach potential complications of hypertension to instill importance of

maintaining Na restrictions

-Assess for cultural factors affecting dietary regime

Factors to Consider When Selecting Interventions:

·         Desired patient outcomes

·         Characteristics of the nursing diagnosis.

·         Research-based knowledge for the intervention

·         Feasibility of the interventions

·         Acceptability to the patient

·         Nurse's competency

Model of Professional Nursing Practice Regulation

Tips for making decisions during implementation:

·         Review the set of all possible nursing interventions for a patient's problem

·         Review all possible consequences associated with each possible nursing

action

·         Determine the probability of all possible consequences

·         Judge the value of the consequence to the patient

 
5. EVALUATION - To determine effectiveness of NCP

-Final step of the Nursing Process but also done concurrently throughout client
care

-A comparison of client behavior and/or response to the established outcome

criteria

- Step of the nursing process that measures the client’s response to nursing
actions and the client’s progress toward achieving goals

-Data collected on an on-going basis

-Supports the basis of the usefulness and effectiveness of nursing practice

-Involves measurement of Quality of Care

- Evaluation of individual plan of care includes determining outcome

achievement

-Identify variables/factors affecting outcome achievement

-Decide where to continue/modify/terminate plan

-Continue/modify/terminate plan based on whether outcome has been met

(partially or completely)

Evaluation of Goal Achievement:

-Measures and Sources: Assessment skills and techniques

-As goals are evaluated, adjustments of the care plan are made

-If the goal was met, that part of the care plan is discontinued

-Redefines priorities

 
Reflection in Action:

Once you deliver an intervention, you continuously examine results by gathering

subjective and objective data from the patient, family, and health care team
members.
At the same time you review knowledge regarding a patient's current condition,
the treatment, and the resources available for recovery.
By reflecting on previous experiences caring for similar patients, you are in a better
position to know how to evaluate your patient.

Perform the following steps to objectively evaluate the degree of success in

achieving outcomes of care:

1. Examine
2. Evaluate
3. Compare
4. Judge
5. What is/are the barriers? Why did they not agree?

When do you discontinue a care plan?

- if the patient has met all goals and outcomes

Modifying a care plan

·         Reassessment

·         Redefining diagnoses

·         Goals and expected outcomes

·         Interventions
TEACHER’S INSIGHT:

Applying the concept of Nursing Process enhance the ability of the nurse in
problem solving and critical thinking. Nursing practice requires the proficient use
of the process in activities that contribute to the lasting growth of skills and
knowledge.

As a nurse it is a requirement that we must master every component of the

Process because it will   guide us in the delivery of health care especially in this
vibrant, intricate world of patient care.

The ability to execute the procedures in Nursing process will ensure quality and
continuous unique nursing care.

Nurses use their wise judgment to integrate assessment data to come up with
appropriate nursing diagnosis, correct plan and intervention and using feedback
mechanisms is a unifying philosophy of the process.

Before leaving this Chapter kindly proceed to Comprehension Assessment

page and complete the exercises provided.

CHAPTER 5

HEALTH AND ILLNESS

         This chapter covers concepts about different models of health and illness.

Duration: 2 hours

Intended Learning Outcomes:

1. Discuss Health definitions and different models.

2. Describe health promotion and illness prevention activities.

3. List and explain variables influencing a person’s health beliefs and practice and
illness behavior.

4. Discuss the 3 levels of preventive care

 
        

Definition of terms:

 Health – state of complete physical, mental, and social well-being and not
merely the absence of disease/infirmity (WHO 1947)
 Wellness – an integrated method of functioning which is oriented toward
maximizing the potential of which the individual is capable.

       - a state of well-being, it is a choice, a way of life.

 Well-being – subjective feeling of vitality and feeling well

 Illness -  absence of health; subjective; feeling of being ill
 Disease – alteration of body function resulting in a reduction of
capacities/shortening of its lifespan
 Health status – state of health at a given time
 Health Behaviors – health actions people take

Stages of sick role:

1.    Experiencing symptoms

2.    Assuming the sick role

3.    Assuming a dependent role

4.    Achieving recovery and rehabilitation

Models of Health:
- Theoretical way of understanding a concept or idea

1. Health Belief Model

  Three components:

 Individual’s perception of susceptibility to illness

 Individual’s perception of seriousness of illness
 Likelihood that person will take preventive action

2. Health Promotion Model

- Defines health as a positive, dynamic state

-Describes multidimensional nature of persons as they interact within their

environment

-Desired behavioral outcome is end point

- Result: improved health, enhanced functional ability, better quality of life

3. Basic Human Needs Model

- Provides a basis for nursing clients of all ages in all health settings…

certain human needs more basic than others; some needs must be met before
other needs

- ALWAYS: emergent physiological need takes precedence over a higher-level

need.

4. Holistic Health Models

- Considers emotional and spiritual well-being, as well as other dimensions of

individual, as important aspects of physical wellness.

- Involves clients in their healing process

5. Clinical Model/ Medical Model (Smith’s model of health)

– Health is a state of being free of signs and symptoms of disease and illness.

- Health is absence of illness

6. Needs-fulfillment Model

- Health is a state in which needs are being sufficiently met to allow an individual
to function successfuly in life with the ability to achieve the highest possible
potential.

7. Role-performance Model

-  Health is the ability to perform all those roles for which one has been socialized

Factors Affecting Health:

 Political – refers to one’s leadership, how he rules, manages and how other
people concerned are followed to actively participate in the decision
making process.
 Economic – refers to the production, distribution and consumption of
goods and services and how these affect health and development
 Socio-cultural – social and cultural variables influence a client’s health
practices, the dynamic of health care and the client-care provider
relationship
 Environment  – refers to the sum total of all the conditions and elements
that make up the surroundings and influence the health and health
practices of clients

Variables that influence beliefs and practices:

 Internal

§  Developmental stage
§  Intellectual background

§  Perception of functioning

§  Emotional factors

§  Spiritual factors

 External

§  Family practices

§  Socioeconomic factors

§  Cultural background

Dimensions of Wellness:

 Physical dimension

- Genetic make-up, age, developmental level, race, sex

- These strongly influence health status and health practice

 Psychological dimension

-Feelings, affect, and person’s ability to express these

-Beliefs in one’s worth

 Social dimension

-Concerns the sense of having support available for family and friends, practices,
values, beliefs that determine health

 Spiritual dimension

- Refers to the recognition and ability to practice moral or religious principles

  Sexual dimension

- Acceptance and ability to achieve satisfactorily expression of one’s sexuality

 Intellectual dimension

- Cognitive abilities, educational background, past experiences, sense of purpose

HEALTH PROMOTION- “…the science and art of helping people change their
lifestyle to move toward a state of optimal health.”

Levels of Preventive Care:

 Primary prevention

- Precedes disease or dysfunction

- known as wellness activities & focus on maintaining or improving general health

- directed toward promoting health and preventing the development of disease

processes.

- Health risk assessment

 Secondary prevention

-Directed at diagnosis and prompt intervention

-Reducing severity and enabling client to return to normal level of health as soon
as possible

-Goal: to reverse or reduce the severity of the disease or to provide a cure.

 Tertiary
– begins after an illness is diagnosed and treated to reduce disability and to
help rehabilitate  patients to a maximum level of functioning.

- Minimizing effect of long-term disease or disability

-Aimed at preventing complications and deterioration directed at rehabilitation

TEACHER’S INSIGHT:

 The role of a nurse in managing every aspect of man’s life to maintain healthy is
important. Model’s were provided to understand the health condition of each
person, using those models nurses can able to help his/her patient or client in
healing and curing process.

Nurses does not only deal with sick people it is covered in their responsibility to
promote health among well individuals, this varied field for nurses signifies the
value of nursing in different  health conditions of the population.

ILLNESS

- a state in which a person’s physical, emotional, intellectual, social,

developmental, or spiritual function is diminished or impaired compared with
previous experience.

Risk Factors:

 Genetic and physiological factors

 Age
 Environment
 Lifestyle

GOAL:  modify or eliminate

 
Acute Illness

-          Potentially life-threatening

-          Short duration

-          Severe

-          Abrupt onset

Chronic Illness

-          Potentially life-threatening

-          Usually >6 months

-          Similar to “disability”

Person’s Illness Behavior:

·         Internal variables:

-Client perceptions

-Nature of illness

-Coping skills

·         External  Variables:

-Visibility of symptoms

- Social group

-Culture & ethnic

-Socio-Economics

 
Impact of Illness:

 Behavioral and emotional changes

 Impact on body image
 Impact on self-concept
 Impact on family roles
 Impact on family dynamics

To supplement your understanding about the different topics covered in this

term you may use the flip classroom. Downloadable audio visual
presentations of concepts were provided.

CHAPTER 6: OXYGENATION
Oxygenation is the process of oxygen diffusing passively from the alveolus to
the pulmonary capillary, where it binds to hemoglobin in red blood cells or
dissolves into the plasma.

Related Terms:

TERM MEANING/DESCRIPTION
DYSPNEA Difficulty of breathing
HYPOXIA Insufficient oxygen in the tissues
HYPOXEMIA Insufficient oxygen in the arterial blood
KUSSMAUL’S Rapid and deep as an attempt to compensate acidosis by blowing off
Carbon dioxide
ORTHOPNEA Ease in breathing when in an upright position
ATELECTASIS Collapse of a portion of a lung
BIOT’s BREATHING Shallow breaths interrupted by apnea
EUPNEA Normal RR
BRADYPNEA Slow RR
TACHYPNEA Fast breathing
APNEA Absent breathing

Pleural contents:
 TERM PLEURAL CONTENT
CYCLOTHORAX Lymphatic fluids
HEMOTHORAX Blood
HYDROTHORAX Water
PLEURAL EFFUSION Fluids (water/blood)
PNEUMOTHORAX Air

RESPIRATORY-RELATED PROCEDURE

1. PULSE OXIMETRY

DESCRIPTION Simple non-invasive method of monitoring arterial blood

saturation (SaO2)
NORMAL RANGE Usually 95-100 %
  P: Poor peripheral blood flow
L: light that is bright (nurse must cover the probe during
CAUSES OF RESULT ALTERATION readings)
M: Manicure may cause false-low readings
NURSING RESPONSIBILITIES A: Assess pulse

B: Blanch test

C: Cleanse site

D: Detect o2 saturation

E: Expose: cover probe when exposed to bright or glaring

light

2. INCENTIVE SPIROMETER: LUNG EXPANSION THERAPY

OTHER NAME Sustained maximal inspiratory device

BASIC GOAL Patient will inhale large amount of air to fully expand the alveoli
to prevent lung collapse.
WHEN TO INSTRUCT Preoperatively
         
SPIROMETER POSITION Upright position
INSTRUCTION Seal lips tightly around the mouthpiece
BREATHING TECHNIQUE 1. Inhale slowly and deeply for 5 -10 seconds

 (2 seconds initially increasing to 6 seconds)

2. Hold breath for 5 seconds

3. Relax and exhale normally

COUGH After the incentive effort to facilitate removal of loosened
secretions
WHEN TO PERFORM 5-15 breaths per waking hour or as recommended by clinician
PISTON INDICATOR Will rise upon inhalation

BRAINSTICKER: 555 -  Inhale 5 seonds, hold breath 5 seconds, 5 breaths every

waking hour

3. OXYGEN THERAPY

DESCRIPTION Administration of oxygen at a concentration greater than that found in the

environmental atmosphere
EARLIEST Change in patient’s RR and pattern
INDICATOR
FIRE Oxygen supports combustion; it does not support/ start a fire
NURSING No smoking
ACTIONS
Use cotton blankets

Check wirings during oxygen therapy

STEPS Connect, Adjust, Apply (Connect the tubing to the tank, Adjust humidifier,
Apply to patient)
 

TANK COLOR SUBSTANCE

Green Oxygen
Light Blue Gasul
Yellow Air, flurane
Red Fire extinguisher
 Dark Blue Nitrous Oxide
Black Nitrogen
Gray Carbon Dioxide
Brown Helium
Red Halothane
Orange Cyclopropane

LOW FLOW DELIVERY SYSTEM:

EQUIPMENT LITERS/MIN. DETAILS

Nasal Cannula 1-6 ·         AKA Nasal prongs

·         For COPD patient (2-3 L/min); for long-term use

·         For claustrophobic patient

·         For nasal-breather patients

·         Allows mealtime use

Simple face 5-8 ·         For short-term use
mask
·         For emergency use

·         Effective for mouth breathers

Partial 6-11 ·         Bag is 2/3 full
rebreather
·         Patient rebreathes 1/3 of exhaled air conserves oxygen

·         Useful when oxygen concentrations must be   raised

·         Not recommended for COPD patients

·         Should NEVER be used with a nebulizer

Non-rebreather 10-15 ·         Highest in low flow

·         For unstable respiration

HIGH FLOW DELIVERY SYSTEM:

EQUIPMENT LITERS/MIN DESCRIPTION

Venturi mask 4-11 ·         Most accurate and reliable in delivering oxygen

·         Can deliver precise, high flowrates

T-piece 8-10 ·         Connected to endotracheal tube
Tracheo  collar 8-10 ·         Connected to tracheostomy
4. OROPHARYNGEAL AIRWAY

CUE DETAIL
Purpose ·         To keep the upper air passage open
Position ·         Supine/semi-fowler’s during insertion

·         Side-lying to drain secretions after insertion

Reminder ·         Do not tape airway in place
When to remove ·         Remove immediately when patient gags or coughs

·         Keep suction available at bedside

Mouthcare ·         Every 2-4 hours

·         Remove every 8 hours to assess mouth and provide oral care

ARTIFICIAL AIRWAYS

ARTIFICIAL AIRWAY OROPHARYNGEAL

Point of insertion Mouth
Patient Unconscious
Length of insertion From tip of mouth to earlobe or

From the center of the mouth to the angle of the jaw

Sizes 80 mm, 90 mm, 100 mm
Contraindication -          Nausea and vomiting

-          Consciousness

-          Aspiration

5. OROPHARYNGEAL SUCTIONING

- Aspirating secretions through a catheter connected to a suction machine or wall

suction outlet

SUCTION CATHETER TYPES

 CATHETER DETAILS
Whistle tipped Less irritating on respiratory tissues
Open-tipped More effective for removing thick mucus plugs
Yankaeur Used to suction oral cavity

SUCTION CATHETER SIZES

PATIENT CATHETER SIZE

Adult 12-18 Fr
Child 8-10 Fr
Infant 5-8 Fr

SUCTION PRESSURES

PATIENT WALL PRESSURE PORTABLE PRESSURE

Adult 100-120 mmHg 10-15 mmHg
Child 95-110 mmHg 5-10 mmHg
Infant 50-95 mmHg 2-5 mmHg

SUCTION COLOR PRESSURES

CATHETER COLOR FRENCH  (SIZE) CATHETER COLOR FRENCH  (SIZE)

R: Red 18 B: Black 10
O: Orange 16 B: Blue 8
G: Green 14 Y: Yellow green 6
W: White 12 Y: Yellow (gray) 5

PROCEDURAL STEPS:
 CUE DETAIL
Assess suction needs ·         Noisy breathing

·         Respiratory distress

·         Inability to cough up and expectorate secretions

Prevent hypoxemia ·         Hyperoxygenation: increase oxygen flow up to 100 % before
suctioning  (12-15 LPM)

·         Hyperinflation: delivering 3-5 breaths before and after each pass

of suction catheter
Patient’s position ·         Conscious for oral suctioning: semi-fowler’s with head turned to
one side

·         Conscious for nasal suctioning: semi-fowler’s with neck

hyperextended

·         Unconscious: side lying (lateral), facing the nurse

Gloves ·         Sterile in dominant

·         Nonsterile in nondominant
Dominant Hand ·         Kept sterile

·         Used to hold the suction catheter

Non dominant ·         Kept clean

·         Used to press the suction valve

Test suction ·         Use normal saline solution or apply your sterile gloved finger or
thumb to the port or open branch of the y-connector(suction control) to
create suction

·         Check if it works
Suctioning depth ·         From the tip of the nose to the earlobe or 4-6 inches

·         Insert along one side of the mouth to the oropharynx

Lubricate ·         Catheter tip with sterile water, saline or water-soluble lubricant
When to suction ·         Upon removal of catheter
Method ·         Intermittent with gentle rotation; twisting motion; quickly but
gently
Suction time ·         5-10 seconds (should not exceed 10-15 seconds)
Interval time ·         For regular suctioning: 20-30 seconds
Total time ·         5 minutes
Success Indicator ·         Clear breath sounds
 BRIEF COMPARISON:

OROPHARYNGEAL NASOPHARYNGEAL OROTRACHEAL                 

Depth 3-5 in 3-5 in >5 in

Landmark Mouth to earlobe Tip of the nose to earlobe Mouth to earlobe to side of
neck
Duration 5-10 seconds 5-10 seconds 5-10 seconds
Suction interval 20-30 seconds 20-30 seconds 20-30 seconds

NASOTRACHEAL TRACHEOSTOMY

Depth 3-5 in 3-5 in

Landmark Nose to earlobe to midsternum 3 inches below circoid carilage
Duration 5-10 seconds 5-10 seconds
Suction interval 20-30 seconds 2-3 minutes

6. CHEST PHYSIOTHERAPY

CHEST DETAIL
PHYSIOTHERAPY
Description ·         Pulmonary toilet: POPE VICOS

·         Postural drainage + adjunctive techniques (Percussion, vibration,

Coughing, Suctioning)
Percussion ·         Gentle tapping/clapping motions on the back of the patient (1-2
minutes)

·         Used cupped hands

Vibration ·         Series of vigorous quivering produced by hands that are placed
flat against pt’s chest wall.
Coughing ·         Perform two huff cuffs; cough at the peak of inspiration.
 VIBRATION

PURPOSE To loosen thick secretions; often done alternately with percussion

Hand Position Palms down, on chest area to be drained, with one hand over the
other.
Breathing technique Inhale and exhale slowly
Vibration Vibrate during 5 exhalations over 1 affected lung segment (1-2
minute per lobe)
Post-vibration Encourage patient to cough and expectorate secretions.

POSTURAL DRAINAGE

CUE DETAIL
Description Drainage by gravity of secretions from various lung
segments.
Schedule 2-3 times per day
Best times Hours before breakfast to prevent vomiting and before
bedtime.
Time per position 10-15 minutes
Sequence Positioning, percussion and vibration
Principle Affected lung is positioned highest to drain secretions
Contraindications Pregnant, fractures, fatigue
Important Assessments Assess for tolerance to perform the activity.

TEACHER’S INSIGHT:

Oxygen is one of the most important chemical in our body to survive. Our ability
to acquire sufficient amount of oxygen and excrete carbon dioxide is vital process
to meet our physiologic need, interventions enumerated in this chapter aims to
assist our patients to achieve such. Nursing responsibilities must be considered
by the care provider in performing each procedure to deliver appropriate care
and avoid untoward incidence. Also, nurses must be fully aware in the
contraindications of each procedure to ensure the safety of the patient.
CHAPTER 7: FLUIDS & ELECTROLYTES
I. CONCEPTS OF FLUID AND ELECTROLYTE BALANCE

A. Electrolytes

- A substance that is dissolved in solution and some of its molecules split or

dissociate into electrically charged atoms or ions

  Measurement:

a. The metric system is used to measure volumes of fluids—liters (L) or milliliters

(mL).

b. The unit of measure that expresses the combining activity of an electrolyte is

the milliequivalent (mEq).

c. One milliequivalent (1 mEq) of any cation always reacts chemically with 1mEq
of an anion.

d. Milliequivalents provide information about the number of anions or cations

available to combine with other anions or cations.

B. Body fluid compartments

-Fluid in each of the body compartments contains electrolytes.

- Each compartment has a particular composition of electrolytes, which differs

from that of other compartments.

- To function normally, body cells must have fluids and electrolytes in the right
compartments and in the right amounts.

- Whenever an electrolyte moves out of a cell, another electrolyte moves in to

take its place.

- The numbers of cations and anions must be the same for homeostasis to exist.
- Compartments are separated by semi permeable membranes.

  Intravascular compartment- Refers to fluid inside a blood vessel

Intracellular compartment -The intracellular compartment refers to all fluid inside

the cell.

     -Most bodily fluids are inside the cell.

The extracellular compartment -  Refers to fluid outside the cell.

- The extracellular compartment includes the interstitial fluid, which is fluid

between cells (sometimes called the third space), blood, lymph, bone, connective
tissue, water, and transcellular fluid

Extracellular Intracellular fluid (70%) fluid (30%)  Intravascular (6%)  Interstitial

(22%) Transcellular (cerebrospinal canals, lymphatic tissues, synovial joints, and the
eye) (2%)

C. Third-spacing

-Third-spacing is the accumulation and sequestration of trapped extracellular

fluid in an actual or potential body space as a result of disease or injury.

- The trapped fluid represents a volume loss and is unavailable for normal
physiological processes.

- Fluid may be trapped in body spaces such as the pericardial, pleural, peritoneal,
or joint cavities; the bowel; or the abdomen, or within soft tissues after trauma or
burns.

- Assessing the intravascular fluid loss caused by third-spacing is difficult. The

loss may not be reflected in weight changes or intake and output records, and
may not become apparent until after organ malfunction occurs.

D. Edema- Edema is an excess accumulation of fluid in the interstitial space.

-  Localized edema occurs as a result of traumatic injury from accidents or
surgery, local inflammatory processes, or burns.

- Generalized edema, also called anasarca, is an excessive accumulation of fluid in

the interstitial space throughout the body and occurs as a result of conditions
such as cardiac, renal, or liver failure.

E. Body fluid

- Body fluids transport nutrients to the cells and carry waste products from the
cells.

- Total body fluid (intracellular and extracellular) amounts to about 60% of body
weight in the adult, 55% in the older adult, and 80% in the infant.

- Thus infants and older adults are at a higher risk for fluid-related problems than
younger adults; children have a greater proportion of body water than adults and
the older adult has the least proportion of body water.

Constituents of body fluids:

o   Body fluids consist of water and dissolved substances.

o   The largest single fluid constituent of the body is water.

o   Some substances, such as glucose, urea, and creatinine, do not dissociate in

solution; that is, they do not separate from their complex forms into simpler
substances when they are in solution.

o   Other substances do dissociate; for example, when sodium chloride is in a

solution, it dissociates, or separates, into two parts or elements. Infants and older
adults need to be monitored closely for fluid imbalances.

F. Body fluid transport

  Diffusion
-Diffusion is the process whereby a solute (substance that is dissolved) may
spread through a solution or solvent (solution in which the solute is dissolved).

- Diffusion of a solute spreads the molecules from an area of higher

concentration to an area of lower concentration.

-A permeable membrane allows substances to pass through it without restriction.

- A selectively permeable membrane allows some solutes to pass through

without restriction but prevents other solutes from passing freely.

- Diffusion occurs within fluid compartments and from one compartment to

another if the barrier between the compartments is permeable to the diffusing
substances.

Osmosis

- Osmotic pressure is the force that draws the solvent from a less concentrated
solute through a selectively permeable membrane into a more concentrated
solute, thus tending to equalize the concentration of the solvent.

-If a membrane is permeable to water but not to all the solutes present, the
membrane is a selective or semipermeable membrane.

- Osmosis is the movement of solvent molecules across a membrane in response

to a concentration gradient, usually from a solution of lower to one of higher
solute concentration.

- When a more concentrated solution is on one side of a selectively permeable

membrane and a less concentrated solution is on the other side, a pull called
osmotic pressure draws the water through the membrane to the more
concentrated side, or the side with more solute.

 
Filtration

- Filtration is the movement of solutes and solvents by hydrostatic pressure.

-The movement is from an area of higher pressure to an area of lower pressure.

Hydrostatic pressure

- Hydrostatic pressure is the force exerted by the weight of a solution.

- When a difference exists in the hydrostatic pressure on two sides of a

membrane, water and diffusible solutes move out of the solution that has the
higher hydrostatic pressure by the process of filtration.

-At the arterial end of the capillary, the hydrostatic pressure is higher than the
osmotic pressure; therefore fluids and diffusible solutes move out of the capillary.

- At the venous end, the osmotic pressure, or pull, is higher than the hydrostatic
pressure, and fluids and some solutes move into the      capillary.

-The excess fluid and solutes remaining in the interstitial spaces are returned to
the intravascular compartment by the lymph channels.

Osmolality

- Osmolality refers to the number of osmotically active particles per kilogram of

water; it is the concentration of a solution.

- In the body, osmotic pressure is measured in milliosmoles (mOsm).

-The normal osmolality of plasma is 270 to 300 milliosmoles/kilogram (mOsm/kg)

water.

G. Movement of body fluid

-  Cell membranes separate the interstitial fluid from the intravascular fluid.

- Cell membranes are selectively permeable; that is, the cell membrane and the
capillary wall allow water and some solutes free passage through them.

- Several forces affect the movement of water and solutes through the walls of
cells and capillaries.

-The greater the number of particles within the cell, the more pressure exists to
force the water through the cell membrane.

- If the body loses more electrolytes than fluids, as can happen in diarrhea, then
the extracellular fluid contains fewer electrolytes or less solute than the
intracellular fluid.

- Fluids and electrolytes must be kept in balance for health; when they remain out
of balance, death can occur.

Isotonic solutions

- When the solutions on both sides of a selectively permeable membrane have

established equilibrium or are equal in concentration, they are isotonic.

- Isotonic solutions are isotonic to human cells, and thus very little osmosis
occurs; isotonic solutions have the same osmolality as      body fluids.

Hypotonic solutions

-When a solution contains a lower concentration of salt or solute than another

more concentrated solution, it is considered hypotonic.

- A hypotonic solution has less salt or more water than an isotonic solution; these
solutions have lower osmolality than body fluids.

- Hypotonic solutions are hypotonic to the cells; therefore osmosis would

continue in an attempt to bring about balance or equality.
 

  Hypertonic solutions

-A solution that has a higher concentration of solutes than another less

concentrated solution is hypertonic; these solutions have a higher osmolality than
body fluids.

Solution Tonicity:

0.9% sodium chloride (normal saline); (0.9% NS -) Isotonic

5% dextrose in water (D5W) -Isotonic

5% dextrose in 0.225% saline (D5W/¼ NS) -Isotonic

Lactated Ringer’s (LR) -Isotonic

0.45% sodium chloride (normal saline); (½ NS) -Hypotonic

0.225% sodium chloride (normal saline); (¼ NS-) Hypotonic

0.33% sodium chloride (normal saline); (⅓ NS) -Hypotonic

3% sodium chloride (normal saline); (3% NS) -Hypertonic

5% sodium chloride (normal saline); (5% NS) - Hypertonic

10% dextrose in water (D10W) -Hypertonic

5% dextrose in 0.9% sodium chloride (normal saline); D5W/NS -Hypertonic

5% dextrose in 0.45% sodium chloride (normal saline); (D5W/½ NS) - Hypertonic

5% dextrose in lactated Ringer’s (D5LR) - Hypertonic

Osmotic pressure
- The amount of osmotic pressure is determined by the concentration of solutes
in solution.

- When the solutions on each side of a selectively permeable membrane are

equal in concentration, they are isotonic.

-A hypotonic solution has less solute than an isotonic solution, whereas a

hypertonic solution contains more solute.

- A solvent moves from the less concentrated solute side to the more
concentrated solute side to equalize concentration.

Active transport

-If an ion is to move through a membrane from an area of lower concentration to

an area of higher concentration, an active transport system is necessary.

- An active transport system moves molecules or ions against concentration and

osmotic pressure.

- Metabolic processes in the cell supply the energy for active transport.

- Substances that are transported actively through the cell membrane include
ions of sodium, potassium, calcium, iron, and hydrogen, some of the sugars, and
the amino acids.

H. Body fluid intake and output

1. Body fluid intake

- Water enters the body through three sources— orally ingested liquids, water in
foods, and water formed by oxidation of foods.

-About 10 mL of water is released by the metabolism of each 100 calories of fat,

carbohydrates, or proteins.
2. Body fluid output

- Water lost through the skin is called insensible loss (the individual is unaware of
losing that water).

- The amount of water lost by perspiration varies according to the temperature of

the environment and of the body, but the average amount of loss by perspiration
alone is 100 mL/day.

- Water lost from the lungs is called insensible loss and is lost through expired air
that is saturated with water vapor.

-The amount of water lost from the lungs varies with the rate and the depth of
respiration.

- Large quantities of water are secreted into the gastrointestinal tract, but almost
all this fluid is reabsorbed.

-A large volume of electrolyte-containing liquids moves into the gastrointestinal

tract and then returns again into the extracellular fluid.

- Severe diarrhea results in the loss of large quantities of fluids and electrolytes.

-The kidneys play a major role in regulating fluid and electrolyte balance and
excrete the largest quantity of fluid.

-Normal kidneys can adjust the amount of water and electrolytes leaving the
body.

-The quantity of fluid excreted by the kidneys is determined by the amount of

water ingested and the amount of waste and solutes excreted.

- As long as all organs are functioning normally, the body is able to maintain
balance in its fluid content.

The client with diarrhea is at high risk for a fluid and electrolyte imbalance.

 
 

I. Maintaining fluid and electrolyte balance

a. Homeostasis- is a term that indicates the relative stability of the internal

environment.

b. Concentration and composition of body fluids must be nearly constant.

c. When one of the substances in a client is deficient—either fluids or electrolytes

—the substance must be replaced normally by the intake of food and water or by
therapy such as IV solutions and medications.

d. When the client has an excess of fluid or electrolytes, therapy is directed

toward assisting the body to eliminate the excess.

 e. The kidneys play a major role in controlling balance in fluid and electrolytes.

f. The adrenal glands, through the secretion of aldosterone, also aid in controlling
extracellular fluid volume by regulating the amount of sodium reabsorbed by the
kidneys.

g. Anti-diuretic hormone from the pituitary gland regulates the osmotic pressure
of extracellular fluid by regulating the amount of water reabsorbed by the kidney.

Fluid intake:

Ingested water - 1200-1500 mL

Ingested food - 800-1100 mL

Metabolic oxidation - 800-1100 mL

TOTAL: 2300-2900 mL

Fluid output:
Kidneys - 1500 mL

Insensible loss through skin - 600-800 mL

Insensible loss through lungs - 400-600 mL

Gastrointestinal tract - 100 mL

TOTAL: 2600-3000 mL

II. FLUID VOLUME DEFICIT

-  Dehydration occurs when the fluid intake of the body is not sufficient to meet
the fluid needs of the body.

-The goal of treatment is to restore fluid volume, replace electrolytes as needed,

and eliminate the cause of the fluid volume deficit.

Types of fluid volume deficits:

1. Isotonic dehydration

a. Water and dissolved electrolytes are lost in equal proportions.

b. Known as hypovolemia, isotonic dehydration is the most common type of

dehydration.

c. Isotonic dehydration results in decreased circulating blood volume and

inadequate tissue perfusion.

2. Hypertonic dehydration

a. Water loss exceeds electrolyte loss.

b. The clinical problems that occur result from alterations in the concentrations of
specific plasma electrolytes.

c. Fluid moves fromthe intracellular compartment into the plasma and interstitial
fluid spaces, causing cellular dehydration and shrinkage.

3. Hypotonic dehydration

a. Electrolyte loss exceeds water loss.

b. The clinical problems that occur result from fluid shifts between compartments,
causing a decrease in plasma volume.

c. Fluid moves from the plasma and interstitial fluid spaces into the cells, causing
a plasma volume deficit and causing the cells to swell.

 Causes of fluid volume deficits:

1. Isotonic dehydration

a. Inadequate intake of fluids and solutes

b. Fluid shifts between compartments

c. Excessive losses of isotonic body fluids

2. Hypertonic dehydration—conditions that increase fluid loss, such as excessive

perspiration, hyperventilation, ketoacidosis, prolonged fevers, diarrhea, early-
stage renal failure, and diabetes insipidus

3. Hypotonic dehydration

a. Chronic illness

b. Excessive fluid replacement (hypotonic)

c. Renal failure
d. Chronic malnutrition

  Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and

gastrointestinal status.

2. Prevent further fluid losses and increase fluid compartment volumes to normal
ranges.

3. Provide oral rehydration therapy if possible and IV fluid replacement if the

dehydration is severe; monitor intake and output.

4. Generally, isotonic dehydration is treated with isotonic fluid solutions,

hypertonic dehydration with hypotonic fluid solutions, and hypotonic
dehydration with hypertonic fluid solutions.

5. Administer medications as prescribed, such as antidiarrheal, antimicrobial,

antiemetic, and antipyretic medications, to correct the cause and treat any
symptoms.

6. Administer oxygen as prescribed.

7. Monitor electrolyte values and prepare to administer medication to treat an

imbalance, if present.

III. FLUID VOLUME EXCESS

1. Fluid intake or fluid retention exceeds the fluid needs of the body.

2. Fluid volume excess is also called overhydration or fluid overload.

3. The goal of treatment is to restore fluid balance, correct electrolyte imbalances

if present, and eliminate or control the underlying cause of the overload.

 Types:
1. Isotonic overhydration

a. Known as hypervolemia, isotonic overhydration results from excessive fluid in

the extracellular fluid compartment.

b. Only the extracellular fluid compartment is expanded, and fluid does not shift
between the extracellular and intracellular compartments.

c. Isotonic overhydration causes circulatory overload and interstitial edema; when

severe or when it occurs in a client with poor cardiac function, congestive heart
failure and pulmonary edema can result.

2. Hypertonic overhydration

a. Occurrence of hypertonic overhydration is rare and is caused by an excessive

sodium intake.

b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid
volume expands, and the intracellular fluid volume contracts.

3. Hypotonic overhydration

a. Hypotonic overhydration is known as water intoxication.

b. The excessive fluid moves into the intracellular space, and all body fluid
compartments expand.

c. Electrolyte imbalances occur as a result of dilution.

  Causes:

1. Isotonic overhydration

a. Inadequately controlled IV therapy

b. Renal failure

c. Long-term corticosteroid therapy

2. Hypertonic overhydration

a. Excessive sodium ingestion

b. Rapid infusion of hypertonic saline

c. Excessive sodium bicarbonate therapy

3. Hypotonic overhydration

a. Early renal failure

b. Congestive heart failure

c. Syndrome of inappropriate antidiuretic hormone secretion

d. Inadequately controlled IV therapy

e. Replacement of isotonic fluid loss with hypotonic fluids

f. Irrigation of wounds and body cavities with hypotonic fluids

Assessment Findings: Fluid Volume Deficit and Fluid Volume Excess

Fluid Volume Deficit Fluid Volume Excess
CARDIOVASCULAR • Bounding, increased pulse rate

• Thready, increased pulse rate • Elevated blood pressure

• Decreased blood pressure and orthostatic
(postural) hypotension
• Flat neck and hand veins in dependent
positions
• Distended neck and hand veins
• Elevated central venous pressure
• Dysrhythmias
• Diminished peripheral pulses

• Decreased central venous pressure

• Dysrhythmias
RESPIRATORY Increased respiratory rate (shallow
respirations)
• Increased rate and depth of respirations
• Dyspnea
• Dyspnea
• Moist crackles on auscultation
NEUROMUSCULAR • Altered level of consciousness

• Decreased central nervous system activity, • Headache

from lethargy to coma
• Visual disturbances
• Fever, depending on the amount of fluid loss
• Skeletal muscle weakness
• Skeletal muscle weakness
• Paresthesias
RENAL Increased urine output if kidneys can
compensate; decreased urine output if kidney
• Decreased urine output damage is the cause
INTEGUMENTARY • Pitting edema in dependent areas

• Dry skin • Pale, cool skin

• Poor turgor, tenting

• Dry mouth
GASTROINTESTINAL • Increased motility in the gastrointestinal tract

• Decreased motility and diminished bowel • Diarrhea

sounds
• Increased body weight
• Constipation
• Liver enlargement
• Thirst
• Ascites
• Decreased body weight
LABORATORY FINDINGS Decreased serum osmolality

• Increased serum osmolality • Decreased hematocrit

• Increased hematocrit • Decreased BUN level

• Increased blood urea nitrogen (BUN) level • Decreased serum sodium level

• Increased serum sodium level • Decreased urine specific Gravity

• Increased urinary specific gravity

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and

gastrointestinal status.

2. Prevent further fluid overload and restore normal fluid balance.

3. Administer diuretics; osmotic diuretics typically are prescribed first to prevent

severe electrolyte imbalances.

4. Restrict fluid and sodium intake as prescribed.

5. Monitor intake and output; monitor weight.

6. Monitor electrolyte values, and prepare to administer medication to treat an

imbalance if present.

A client with renal failure is at high risk for fluid volume excess.

IV. HYPONATREMIA

- Hyponatremia is a serum sodium level lower than 135 mEq/L.

- Sodium imbalances usually are associated with fluid volume imbalances.

Causes:
1. Increased sodium excretion

a. Excessive diaphoresis

b. Diuretics

c. Vomiting

d. Diarrhea

e. Wound drainage, especially gastrointestinal

f. Renal disease

g. Decreased secretion of aldosterone

2. Inadequate sodium intake

a. Nothing by mouth

b. Low-salt diet

3. Dilution of serum sodium

a. Excessive ingestion of hypotonic fluids or irrigation with hypotonic fluids

b. Renal failure

c. Freshwater drowning

d. Syndrome of inappropriate antidiuretic hormone secretion e. Hyperglycemia

f. Congestive heart failure

Normal Value: 135 to 145 mEq/L

Nursing Interventions:
1. Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and
gastrointestinal status.

2. If hyponatremia is accompanied by a fluid volume deficit (hypovolemia), IV

sodium chloride infusions are administered to restore sodium content and fluid
volume.

3. If hyponatremia is accompanied by fluid volume excess (hypervolemia),

osmotic diuretics are administered to promote the excretion of water rather than
sodium.

4. If caused by inappropriate or excessive secretion of antidiuretic hormone,

medications that antagonize antidiuretic hormone may be administered.

5. Instruct the client to increase oral sodium intake and inform the client about
the foods to include in the diet

6. If the client is taking lithium (Lithobid), monitor the lithium level, because
hyponatremia can cause diminished lithium excretion, resulting in toxicity.

Common Food Sources:

Bacon, Butter, Canned food, Cheese, such as American or cottage cheese

Frankfurters, Ketchup, Lunch meat, Milk, Mustard, Processed food, Snack food,
Soy sauce, Table salt, White and whole-wheat bread

V. HYPERNATREMIA

- Hypernatremia is a serum sodium level that exceeds 145 mEq/L (see Box 9-2).

Causes:

1. Decreased sodium excretion

a. Corticosteroids

b. Cushing’s syndrome

c. Renal failure

d. Hyperaldosteronism

2. Increased sodium intake: excessive oral sodium ingestion or excessive

administration of sodium -containing IV fluids

3. Decreased water intake: nothing by mouth

4. Increased water loss: increased rate of metabolism, fever, hyperventilation,

infection, excessive diaphoresis, watery diarrhea, diabetes insipidus.

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and

integumentary status.

2. If the cause is fluid loss, prepare to administer IV infusions.

3. If the cause is inadequate renal excretion of sodium, prepare to administer

diuretics that promote sodium loss.

4. Restrict sodium and fluid intake as prescribed

ASSESSMENT FOR HYPONATREMIA VS HYPERNATRIMIA

HYPONATREMIA HYPERNATREMIA
CARDIOVASCULAR • Heart rate and blood pressure responds to
vascular volume status
• Symptoms vary with changes in vascular volume

• Normovolemic: rapid pulse rate; normal blood

pressure

• Hypovolemic: thready, weak, rapid pulse rate;

hypotension; flat neck veins; normal or low central
venous pressure

• Hypervolemic: rapid, bounding pulse; blood

pressure normal or elevated; normal or elevated
central venous pressure
RESPIRATORY • Pulmonary edema if hypervolemia is
present
• Shallow, ineffective respiratory movement is a
late

manifestation related to skeletal muscle weakness

NEUROMUSCULAR • Early: spontaneous muscle twitches;
irregular muscle contractions
• Generalized skeletal muscle weakness that is
worse in the extremities • Late: skeletal muscle weakness; deep
tendon reflexes diminished or absent
• Diminished deep tendon reflexes
CENTRAL NERVOUS SYSTEM • Altered cerebral function is the most
common manifestation of hypernatremia
• Headache
• Normovolemia or hypovolemia: agitation,
• Personality changes confusion, seizures

• Confusion • Hypervolemia: lethargy, stupor, coma

• Seizures

• Coma
GASTROINTESTINAL • Extreme thirst

• Increased motility and hyperactive bowel sounds

• Nausea

• Abdominal cramping and diarrhea

RENAL  

• Increased urinary output • Decreased urinary output

INTEGUMENTARY Dry and flushed skin

• Dry mucous membranes • Dry and sticky tongue and mucous

 membranes

• Presence or absence of edema, depending

LABORATORY FINDINGS
• Serum sodium level less than 135 mEq/L
• Decreased urinary specific gravity
on fluid volume changes
• Serum sodium level that exceeds 145
mEq/L
• Increased urinary specific gravity

Monitor the client closely for signs of a potassium imbalance. A potassium

imbalance can cause cardiac dysrhythmias that can be life-threatening!

VI. HYPOKALEMIA

- Hypokalemia is a serum potassium level lower than 3.5 mEq/L.

- Potassium deficit is potentially life-threatening because every body system is

affected.

  Causes:

1. Actual total body potassium loss

a. Excessive use of medications such as diuretics or corticosteroids

b. Increased secretion of aldosterone, such as in Cushing’s syndrome

c. Vomiting, diarrhea

d. Wound drainage, particularly gastrointestinal

e. Prolonged nasogastric suction

f. Excessive diaphoresis

g. Renal disease impairing reabsorption of potassium

2. Inadequate potassium intake: nothing by mouth

3. Movement of potassium from the extracellular fluid to the intracellular fluid

a. Alkalosis

b. Hyperinsulinism

4. Dilution of serum potassium

a. Water intoxication

b. IV therapy with potassium-poor solutions

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, gastrointestinal, and renal

status, and place the client on a cardiac monitor.

2. Monitor electrolyte values.

3. Administer potassium supplements orally or intravenously, as prescribed.

4. Oral potassium supplements

a. Oral potassium supplements may cause nausea and vomiting and they should
not be taken on an empty stomach; if the client complains of abdominal pain,
distention, nausea, vomiting, diarrhea, or gastrointestinal bleeding, the
supplement may need to be discontinued.

b. Liquid potassium chloride has an unpleasant taste and should be taken with
juice or another liquid.

5. Intravenously administered potassium

6. Institute safety measures for the client experiencing muscle weakness.

7. If the client is taking a potassium-losing diuretic, it may be discontinued; a
potassium sparing diuretic may be prescribed.

8. Instruct the client about foods that are high in potassium content.

Potassium is never administered by IV push, intramuscular, or subcutaneous routes.

IV potassium is always diluted and administered using an infusion device!

VII. HYPERKALEMIA

- Hyperkalemia is a serum potassium level that exceeds 5.1 mEq/L.

  Causes:

1. Excessive potassium intake

a. Overingestion of potassium-containing foods or medications, such as

potassium chloride or salt substitutes

b. Rapid infusion of potassium-containing IV solutions

2. Decreased potassium excretion

a. Potassium-sparing diuretics

b. Renal failure

c. Adrenal insufficiency, such as in Addison’s disease

3. Movement of potassium from the intracellular fluid to the extracellular fluid

a. Tissue damage

b. Acidosis

c. Hyperuricemia
d. Hypercatabolism

Normal Value: 3.5 to 5.1 mEq/L

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal

status; place the client on a cardiac monitor.

2. Discontinue IV potassium (keep the IV catheter patent), and hold oral

potassium supplements.

3. Initiate a potassium-restricted diet.

4. Prepare to administer potassium-excreting diuretics if renal function is not

impaired.

5. If renal function is impaired, prepare to administer sodium polystyrene

sulfonate (Kayexalate), a cation exchange resin that promotes gastrointestinal
sodium absorption and potassium excretion.

6. Prepare the client for dialysis if potassium levels are critically high.

7. Prepare for the IV administration of hypertonic glucose with regular insulin to

move excess potassium into the cells.

8. Monitor renal function.

9. When blood transfusions are prescribed for a client with a potassium

imbalance, the client should receive fresh blood, if possible; transfusions of stored
blood may elevate the potassium level because the breakdown of older blood
cells releases potassium.

10. Teach the client to avoid foods high in potassium

11. Instruct the client to avoid the use of salt substitutes or other potassium-
containing substances.

Common Food Sources:

Avocado, Bananas, Cantaloupe, Carrots, Fish, Mushrooms, Oranges, Potatoes,

Pork, beef, veal, Raisins, Spinach, Strawberries, Tomatoes

ASSESSMENT FOR HYPOKALEMIA VS. HYPERKALEMIA

HYPOKALEMIA HYPERKALEMIA
CARDIOVASCULAR • Slow, weak, irregular heart rate

• Thready, weak, irregular pulse • Decreased blood pressure

• Weak peripheral pulses

• Orthostatic hypotension
RESPIRATORY • Profound weakness of the skeletal muscles
leading to respiratory failure
• Shallow, ineffective respirations that result
from profound

weakness of the skeletal muscles of respiration

• Diminished breath sounds

NEUROMUSCULAR • Early: muscle twitches, cramps, paresthesias
(tingling and burning followed by numbness in
• Anxiety, lethargy, confusion, coma the hands and feet and around the mouth)

• Skeletal muscle weakness, eventual flaccid • Late: profound weakness, ascending flaccid
paralysis paralysis in the arms and legs (trunk, head, and
respiratory muscles become affected when the
• Loss of tactile discrimination serum potassium level reaches a lethal level)

• Paresthesias

• Deep tendon hyporeflexia

GASTROINTESTINAL  Increased motility, hyperactive bowel sounds

• Decreased motility, hypoactive to absent • Diarrhea

bowel sounds

• Nausea, vomiting, constipation, abdominal

distention

• Paralytic ileus
LABORATORY FINDINGS • Serum potassium level that exceeds 5.1
mEq/L
• Serum potassium level lower than 3.5 mEq/L
• Electrocardiographic changes: tall peaked T
• Electrocardiogram changes: ST depression, waves, flat P waves, widened
shallow, flat
QRS complexes, and prolonged PR intervals
or inverted T wave, and prominent U wave

Monitor the serum potassium level closely when a client is receiving a potassium-
sparing diuretic!

VIII. HYPOCALCEMIA

-Hypocalcemia is a serum calcium level lower than 8.6 mg/dL.

  Causes:

1. Inhibition of calcium absorption from the gastrointestinal tract

a. Inadequate oral intake of calcium

b. Lactose intolerance

c. Malabsorption syndromes such as celiac sprue or Crohn’s disease

d. Inadequate intake of vitamin D

e. End-stage renal disease

2. Increased calcium excretion

a. Renal failure, polyuric phase

b. Diarrhea

c. Steatorrhea

d. Wound drainage, especially gastrointestinal

3. Conditions that decrease the ionized fraction of calcium

a. Hyperproteinemia

b. Alkalosis

c. Medications such as calcium chelators or binders

d. Acute pancreatitis

e. Hyperphosphatemia

f. Immobility

g. Removal or destruction of the parathyroid glands

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, and gastrointestinal status;

place the client on a cardiac monitor.

2. Administer calcium supplements orally or calcium intravenously.

3. When administering calcium intravenously, warm the injection solution to body

temperature before administration and administer slowly; monitor for
electrocardiographic changes, observe for infiltration, and monitor for
hypercalcemia.

4. Administer medications that increase calcium absorption.

a. Aluminum hydroxide reduces serum phosphorus levels, causing the
countereffect of increasing calcium levels.

b. Vitamin D aids in the absorption of calcium from the intestinal tract.

5. Provide a quiet environment to reduce environmental stimuli.

6. Initiate seizure precautions.

7. Move the client carefully, and monitor for signs of a pathological fracture.

8. Keep 10% calcium gluconate available for treatment of acute calcium deficit.

9. Instruct the client to consume foods high in calcium

IX. HYPERCALCEMIA

- Hypercalcemia is a serum calcium level that exceeds 10 mg/dL.

  Causes:

1. Increased calcium absorption

a. Excessive oral intake of calcium

b. Excessive oral intake of vitamin D

2. Decreased calcium excretion

a. Renal failure

b. Use of thiazide diuretics

3. Increased bone resorption of calcium

a. Hyperparathyroidism

b. Hyperthyroidism
c. Malignancy (bone destruction from metastatic tumors)

d. Immobility

e. Use of glucocorticoids

4. Hemoconcentration

a. Dehydration

b. Use of lithium

c. Adrenal insufficiency

Normal Value: 8.6 to 10 mg/dL

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal

status; place the client on a cardiac monitor.

2. Discontinue IV infusions of solutions containing calcium and oral medications

containing calcium or

vitamin D.

3. Discontinue thiazide diuretics and replace with diuretics that enhance the
excretion of calcium.

4. Administer medications as prescribed that inhibit calcium resorption from the

bone, such as phosphorus, calcitonin (Calcimar), bisphosphonates, and
prostaglandin synthesis inhibitors (aspirin, nonsteroidal anti inflammatory drugs).

5. Prepare the client with severe hypercalcemia for dialysis if medications fail to
reduce the serum calcium level.
6. Move the client carefully and monitor for signs of a pathological fracture.

7. Monitor for flank or abdominal pain, and strain the urine to check for the
presence of urinary stones.

8. Instruct the client to avoid foods high in calcium. A client with a calcium
imbalance is at risk for a pathological fracture. Move the client carefully and
slowly; assist the client with ambulation.

Common Food Sources:

Cheese, Collard greens, Milk and soy milk, Sardines, Spinach, Tofu, Yogurt

ASSESSMENT FOR HYPOCALCEMIA VS. HYPERCALCEMIA

HYPOCALCEMIA HYPERCALCEMIA
CARDIOVASCULAR • Increased heart rate in the early phase;
bradycardia that can lead to cardiac
• Decreased heart rate arrest in late phases

• Hypotension • Increased blood pressure

• Diminished peripheral pulses • Bounding, full peripheral pulses

RESPIRATORY • Ineffective respiratory movement as a
result of profound skeletal muscle
• Not directly affected; however, respiratory failure or weakness
arrest can result from decreased respiratory movement
because of muscle

tetany or seizures
NEUROMUSCULAR • Profound muscle weakness

• Irritable skeletal muscles: twitches, cramps, tetany, • Diminished or absent deep tendon
seizures reflexes

• Painful muscle spasms in the calf or foot during • Disorientation, lethargy, coma
periods of inactivity
• Paresthesias followed by numbness that may affect
the lips,

nose, and ears in addition to the limbs

• Positive Trousseau’s and Chvostek’s signs

• Hyperactive deep tendon reflexes

• Anxiety, irritability
RENAL  

• Urinary output varies depending on the cause • Urinary output varies depending on the
cause

• Formation of renal calculi; flank pain

GASTROINTESTINAL • Decreased motility and hypoactive
bowel sounds
• Increased gastric motility; hyperactive bowel sounds
• Anorexia, nausea, abdominal
• Cramping, diarrhea distention, constipation
LABORATORY FINDINGS  

• Serum calcium level less than 8.6 mg/dL Serum calcium level that exceeds 10
mg/dL
• Electrocardiographic changes: prolonged ST interval,
prolonged • Electrocardiographic changes:
shortened ST segment, widened
QT interval
T wave
 

Tests for hypocalcemia. A, Chvostek’s sign is contraction of facial muscles in

response to a light tap over the facial nerve in front of the ear. B, Trousseau’s sign
is a carpal spasm induced by inflating a blood pressure cuff (C) above the systolic
pressure for a few minutes. (From Lewis, S., Heitkemper, M., & Dirksen, S. [2007].
Medical-surgical nursing [7th ed.]. St. Louis: Mosby.)

X. HYPOMAGNESEMIA

-Hypomagnesemia is a serum magnesium level lower than 1.6 mg/dL.

 Causes:

1. Insufficient magnesium intake

a. Malnutrition and starvation

b. Vomiting or diarrhea

c. Malabsorption syndrome

d. Celiac disease

e. Crohn’s disease

2. Increased magnesium secretion

a. Medications such as diuretics

b. Chronic alcoholism

3. Intracellular movement of magnesium

a. Hyperglycemia

b. Insulin administration

c. Sepsis

Normal Value: 1.6 to 2.6 mg/dL

Nursing Interventions:

1. Monitor cardiovascular, respiratory, gastrointestinal, neuromuscular, and

central nervous system status; place the client on a cardiac monitor.

2. Because hypocalcemia frequently accompanies hypomagnesemia,

interventions also aim to restore normal serum calcium levels.
3. Administer magnesium sulfate by the IV route in severe cases (intramuscular
injections cause pain and tissue damage); monitor serum magnesium levels
frequently.

4. Initiate seizure precautions.

5. Monitor for diminished deep tendon reflexes, suggesting hypermagnesemia,

during the administration of magnesium.

6. Oral preparations of magnesium may cause diarrhea and increase magnesium

loss.

7. Instruct the client to increase the intake of foods that contain magnesium.

XI. HYPERMAGNESEMIA

- Hypermagnesemia is a serum magnesium level that exceeds 2.6 mg/dL.

  Causes:

1. Increased magnesium intake

a. Magnesium-containing antacids and laxatives

b. Excessive administration of magnesium intravenously

2. Decreased renal excretion of magnesium as a result of renal insufficiency

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, and central nervous system

status; place the client on a cardiac monitor.

2. Diuretics are prescribed to increase renal excretion of magnesium.

3. Intravenously administered calcium chloride or calcium gluconate may be
prescribed to reverse the effects of magnesium on cardiac muscle.

4. Instruct the client to restrict dietary intake of magnesium-containing foods.

5. Instruct the client to avoid the use of laxatives and antacids containing
magnesium.

Common Food Sources:

Avocado, Canned white tuna, Cauliflower, Green leafy vegetables such as spinach
and broccoli, Milk, Oatmeal, Peanut butter, Peas, Pork, beef, chicken, Potatoes,
Raisins, Yogurt

ASSESSMENT FOR HYPOMAGNESEMIA VS. HYPERMAGNESEMIA

HYPOMAGNESEMIA HYPERMAGNESEMIA
CARDIOVASCULAR • Bradycardia, dysrhythmias

• Tachycardia • Hypotension

• Hypertension
RESPIRATORY • Respiratory insufficiency when the skeletal
muscles of respiration are involved
• Shallow respirations
NEUROMUSCULAR • Diminished or absent deep tendon reflexes

• Twitches; paresthesias • Skeletal muscle weakness

• Positive Trousseau’s and Chvostek’s signs

• Hyperreflexia

• Tetany, seizures
CENTRAL NERVOUS SYSTEM • Drowsiness and lethargy that progresses to
coma
• Irritability
• Confusion
LABORATORY FINDINGS • Serum magnesium level that exceeds 2.6
mg/dL
• Serum magnesium level less than 1.6 mg/dL
• Electrocardiographic changes: prolonged PR
• Electrocardiographic changes: tall T waves, interval, widened QRS complexes
depressed ST segments
 

Calcium gluconate is the antidote for magnesium overdose!

XII. HYPOPHOSPHATEMIA

1. Hypophosphatemia is a serum phosphorus level lower than 2.7 mg/dL.

2. A decrease in the serum phosphorus level is accompanied by an increase in the

serum calcium level.

Causes:

1. Insufficient phosphorus intake: malnutrition and starvation

2. Increased phosphorus excretion

a. Hyperparathyroidism

b. Malignancy

c. Use of magnesium-based or aluminum hydroxide–based antacids

3. Intracellular shift

a. Hyperglycemia

b. Respiratory alkalosis

  Assessment:

1. Cardiovascular
a. Decreased contractility and cardiac output

b. Slowed peripheral pulses

2. Respiratory: shallow respirations

3. Neuromuscular

a. Weakness

b. Decreased deep tendon reflexes

c. Decreased bone density that can cause fractures and alterations in bone shape

4. Central nervous system

a. Irritability

b. Confusion

c. Seizures

5. Hematological

a. Decreased platelet aggregation and increased bleeding

b. Immunosuppression

Nursing Interventions:

1. Monitor cardiovascular, respiratory, neuromuscular, central nervous system,

and hematological status.

2. Discontinue medications that contribute to hypophosphatemia.

3. Administer phosphorus orally along with a vitamin D supplement.

4. Prepare to administer phosphorus intravenously when serum phosphorus
levels fall below 1 mg/dL and when the client experiences critical clinical
manifestations.

5. Administer IV phosphorus slowly because of the risks associated with

hyperphosphatemia.

6. Assess the renal system before administering phosphorus.

7. Move the client carefully, and monitor for signs of a pathological fracture.

8. Instruct the client to increase the intake of the phosphorus-containing foods

while decreasing the intake of any calcium-containing foods.

A decrease in the serum phosphorus level is accompanied by an increase in the

serum calcium level and an increase in the serum phosphorus level is accompanied
by a decrease in the serum calcium level.

XIII. HYPERPHOSPHATEMIA

1. Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dL

2. Most body systems tolerate elevated serum phosphorus levels well.

3. An increase in the serum phosphorus level is accompanied by a decrease in the

serum calcium level.

4. The problems that occur in hyperphosphatemia center on the hypocalcemia

that results when serum phosphorus levels increase.

Causes:

1. Decreased renal excretion resulting from renal insufficiency

2. Tumor lysis syndrome

3. Increased intake of phosphorus, including dietary intake or overuse of
phosphate-containing laxatives or enemas

4. Hypoparathyroidism

Normal Value: 2.7 to 4.5 mg/dL

Nursing Interventions:

1. Interventions entail the management of hypocalcemia.

2. Administer phosphate-binding medications that increase fecal excretion of

phosphorus by binding phosphorus from food in the gastrointestinal tract.

3. Instruct the client to avoid phosphate-containing medications, including

laxatives and enema

4. Instruct the client to decrease the intake of food that is high in phosphorus.

5. Instruct the client in medication administration: take phosphate-binding

medications, emphasizing that they should be taken with meals or immediately
after meals.

Common Food Sources:

Fish, Organ meats, Nuts, Pork, beef, chicken, Whole-grain breads and cereal

 CHAPTER 8: NUTRITION
NUTRITION

- Study of nutrients and the processes by which they are used by the body

TERMINOLOGIES:

a. Digestion
-process by which food is broken down for the body to use in growth,
development, healing and prevention of diseases

b. Absorption

-process by which digested CHO, CHON, fats, minerals and vitamins are actively
and passively transported into organs and tissues

c. Metabolism

-process by which nutrients are converted to energy to support cellular growth

and repair

STANDARD DIETS:

DIET CLEAR FULL SOFT

Liquid Form Yes
Solid Form Yes (melts at body temp)
Contents Carbohydrates
Examples Hard candy, coffee, tea,
broth, popsicle, soft drinks,
bouillon, gelatin, ginger
ale, water, apple/grape
juice
Yes No
Yes (melts at body temp) Yes
CHO, fats, vitamins Almost all nutrients
Milk, custard, pudding, ice Mashed potato,
cream, strained vegetable juice, oatmeal
sherbet, breakfast drinks,
strained soup, butter

DIET & DISORDERS:

DISORDER DIET DETAIL

Celiac Gluten-free No BROW: banana, rye, oats and wheat
GI upset BRATY diet Banana, rice am, apple sauce, toasted bread, yogurt
Gouty arthritis Purine (no-no) No organ meats, alcohol, chocolate and seafoods
Immune-low Well-cooked Well-cooked foods are considered low bacteria food
(no fresh foods)
MAOI regimen No tyramine A: avocado, aged cheese

B: banana, beer

C: chicken liver, canned and processed foods  

Ostomy No BAG diet B: blockers-celery, foods with seeds, tough coatings:
 nuts

A: aromatics-garlic, egg, onion and fish

G: gas-forming- asparagus, beer, broccoli, cabbage,

carbonated drinks
 

MACRONUTRIENTS: CHO, CHON, FAT

MICRONUTRIENTS: VITAMINS AND MINERALS

CALORIE (KILOCALORIE)

- 1 g (CHO) - 4 CAL

- 1 G (CHON) - 4 CAL

- 1 G (FAT) - 9 CAL

Variable affecting Caloric Needs

·         Age and growth

·         Gender (higher BMR in males)

·         Climate (cold=higher BMR)

·         Sleep (lower BMR)

·         Activity

·         Fever

·         Illness

Food and Fluid Regulatory Center: HYPOTHALAMUS

I. MINERALS
A. CALCIUM

- necessary for bone and teeth formation

-promotes muscular contraction

- promotes blood coagulation

- activates other enzymes for biological reactions

- deficiency: rickets, osteomalacia, tetany

- excess: calcium rigor (tonic contraction)

SOURCES: milk and dairy prod, green and leafy vegetables, whole grains, nuts,
legumes, carrots, seafood, tofu

B. POTASSIUM

-promotes fluid and electrolyte balance

-major cation in the intracellular fluid

-affects muscular and cardiac activities

Hypokalemia: loss of K; manifested by apathy, muscular weakness, mental

confusion, abdominal distention, nausea, lack of appetite, nervous irritability,
dysrhythmias

Hyperkalemia: excess K; weakened cardiac contraction, mental confusion,

numbness of extremities

SOURCES: Banana, Avocado, Oranges, Strawberries, Cantaloupe, Raisins, Raw

tomatoes, Carrots, Mushroom, Pork, Beef, Fish

C. SODIUM
-maintains fluid balance

-major extracellular cation

-maintain acid-base balance

-allows passage of glucose through the cell wall

-maintains normal muscle excitability

D. IRON

- most abundant trace element

- constituent of hemoglobin and myoglobin necessary in maintaining adequate

oxygenation in the blood

- contributes to antibody formation, collagen synthesis

SOURCES: pork liver, organ meats, enriched rice, kamote leaves, soybeans, sea
weeds, clams, malunggay, ampalaya leaves, peanuts, pechay, sitaw leaves, eggs

- Iron deficiency leads to anemia

- excess Fe leads to hemosiderosis

E. IODINE

-synthesis of thyroxine (thyroid gland)

-Cretinism: congenital disorder due to decrease Iodine during pregnancy

-Hypothyroidism/Hyperthyroidism

SOURCES: iodized salt, seafood, milk, eggs, bread

 
II. ASSESSMENT OF NUTRITIONAL STATUS

A. ANTHROPOMETRIC MEASUREMENTS

-height

-weight (best indicator of nutritional status)

-Skin folds (Fat folds)

-Arm Muscle circumference

-BMI = wt in kg / (ht in meter)2

BMI result:
-

20-25%- Normal

27.5-30%- mild obesity

30-40%- moderate obesity

Above 40%- severe obesity

B. BIOCHEMICAL DATA

- Hgb and Hct indices

-Serum Albumin

-Nitrogen Balance

-Creatinine Excretion

C.CLINICAL SIGNS

- hair, skin, tongue, mucous membrane, abdominal girth

D. DIETARY HISTORY

- 24 hr diet recall; 72 hr diet recall

III. MEASURES TO STIMULATE APPETITE

-          Serve food in pleasant and attractive manner

-          Place patient in a comfortable position (SF/HF to prevent aspiration)

-          Provide good oral hygiene measures

-          Promote comfort

-          Remember that color affects color

-          Engage in pleasant conversation

-          Assist weak patient in feeding

IV. NURSING INTERVENTIONS FOR NAUSEA AND VOMITING

-          Position conscious clients in SF or HF position; unconscious patients in

lateral position to prevent aspiration

-          Provide good oral hygiene measures

-          Suction the mouth as needed if the client is unable to expel vomitus

-          Relieve nausea by offering the client:

o   ice chips

o   hot tea with lemon/ lime

o   hot ginger ale

o   dry toast or crackers

o   cold cola beverage

-          Replace loss fluid by hydration and IV therapy

-          Observe for potential complications:

DEHYDRATION

-          Thirst (first sign)

-          dry mouth and mucous membrane

-          warm, flushed, dry skin

-          fever, tachycardia, low bp

-          weight loss

-          sunken eyeballs

-          oliguria

-          dark, concentrated urine

-          high urine SG

-          poor skin turgor

-          altered LOC

-          elevated BUN, Crea

-          elevated Hct

ACID-BASE BALANCE

-          Metabolic Alkalosis: excessive vomiting

-          Metabolic Acidosis: excessive diarrhea

ADMINISTER ANTIEMETIC AS ORDERED BY THE PHYSICIAN FOR VOMITING

-          Metoclopramide (Plasil)

-          Trimethobenzamide (Tigan)

-          Promethazine (Phenergan)

-          Prochlorperazine maleate (Compazine)

CHAPTER 9: ELIMINATION
Defecation- expulsion of feces from the rectum

Characteristics of Stool:

Color: yellow or golden brown (due to bile pigment)

Odor: aromatic upon defecation

Amount: depends on the bulk of the food intake (150-300 g/day)

Consistency: soft, formed

Shape: cylindrical
Frequency: variable; usual range 1-2 per day to 1 every 2-3 days

Alteration on the characteristics of Stool:

Alcoholic Stool

- gray, pale or clay colored stool due to absence of stercobilin caused by biliary
obstruction

Hematochezia

-passage of stool with bright red blood due to lower GI bleeding

Melena

-passage of black,tarry stool due to UGIB

Steatorrhea

-greasy, bulky, foul-smelling stool due to undigested fats like in hepato-biliary

obstructions

COMMON FECAL ELIMINATION PROBLEMS:

1. CONSTIPATION

-       passage of small, dry, hard stools

-       Nursing interventions:

-       increase OFI (1500-2000 ml/day)

-       increase fiber intake to provide bulk of the stool (fresh or cooked fruits and
vegetables, whole grain, breads and cereals, fruit and vegetable juices)

-       establish regular pattern of defecation

-       respond stat to urge to defecate

-       minimize stress. SNS activation decreases peristalsis

-       maintain exercise to promote muscle tone and stimulate peristalsis

-       assume sitting or semi-squatting position. Allows gravity to assist the

elimination of feces and easier contraction of abdominal and pelvic muscles

-       administer laxatives as ordered

TYPES OF LAXATIVES:

a. CHEMICAL IRRITANTS

-       provide chemical stimulation to intestinal wall thereby increasing peristalsis.

Ex. Dulcolax (Bisacodyl), castor oil, Senokot (Senna)

b. STOOL LUBRICANT

-       lubricates feces and facilitates expulsion (mineral oil)

c. STOOL SOFTENERS

-       Sodium Docussate

d. BULK FORMERS

-       increases bulk of stool, increasing mechanical pressure and distention of the

intestine, thereby increasing peristalsis (ex. Psyllium)

e. OSMOTIC AGENTS

-       attract fluids from the intestinal capillaries (Lactulose, Magnesium

Hydroxide)

 
2. FECAL IMPACTION

-       mass or collection of hardened, putty-like feces in the folds of the rectum.

-       inability to evacuate stool voluntarily

SIGNS & SYMPTOMS:

-       absence of bowel movement for 3-5 days

-       passage of liquid fecal seepage

-       hardened fecal mass palpated during DRE

-       nonproductive desire to defecate and rectal pain

-       anorexia, body malaise

-       subjective feeling of abdominal fullness or bloating

-       apparent abdominal distension

-       Nausea & Vomiting

MANAGEMENT:

-       manual extraction or fecal disimpaction as ordered

-       Increase fluid intake

-       Sufficient bulk in the diet

-       Adequate activity and exercise

3. DIARRHEA

-       frequent evacuation of watery stool due to increased gastric motility

MANAGEMENT:

-       replace fluid and electrolyte losses

-       provide good perianal care. Diarrheal stool is oftentimes acidic and can
cause soreness and irritation in the area

-       promote rest

-       eat small amount of bland food

-       low fiber diet

-       BRAT diet (Banana, Rice Am, Apple, Toast)

-       avoid excessively hot or cold fluid

-       increase intake of K-rich food

-       administer antidiarrheal drugs as ordered

-       Demulcents: mechanically coat the irritated bowel and act as protectives

-       Absorbents: absorbs gas or toxic substances from the bowel

-       Astringents: shrink swollen or inflamed tissues in the bowel

Note: Do not administer antidiarrheal at the start of diarrhea as it is the body’s

protective mechanism to get rid of toxins or bacteria

4. FLATULENCE

-       presence of excessive gas in the intestines

COMMON CAUSES:

-       constipation
-       codein, barbiturates and other meds that decrease intestinal motility

-       anxiety

-       eating gas forming food (cabbage, onions, rootcrops, legumes)

-       rapid food or fluid ingestion

-       excessive drinking of carbonated drinks

-       gum chewing, candy sucking, smoking

-       abdominal surgery

MANAGEMENT:

-       avoid gas forming food

-       provide warm liquids to drink to increase peristalsis

-       promote early ambulation among post op pts

-       promote adequate rest and activity

-       limit carbonated beverages

-       Rectal tube insertion as ordered

-       position: left lateral

-       insert 3-4 inches of lubricated tube in rotating motion

-       use appropriate size (Fr. 22-30)

-       retain rectal tube for 30 minutes

-       administer carminative enema as ordered

-       administer cholinergic as ordered (neostigmine)

 

5. FECAL INCONTINENCE

-       involuntary elimination of bowel contents often associated with neurologic,

mental or emotional impairments

-       seen in patients with injury to cerebral cortex (pt is unable to perceive that
rectum is distended or unable to initiate the motor response required to inhibit
defecation voluntarily)

-       patient with spinal cord injury (sacral region)

RELATED PROCEDURES:

1. ENEMA

Mechanism -       Distend the intestines

-       Irritate the intestinal mucosa

-       Increase peristalsis
Temperature -       100-105 F (37.8 to 40.6 C)
Child -       Enema temperature: 37.8 C to prevent burning the rectal tissues
Pt’s position -       Left-lateral Sim’s position
Insertion -       ½ inches for infant

-       2-3 inches for children

-       3-4 inches for adult

Note -       High-flow (large-volume) enema is given to cleanse as much as the
colon as possible.

-       Low-flow (small-volume) enema is given to cleanse the rectum and

sigmoid colon only.
 

ENEMA ADMINISTRATION

CLUE DETAIL
 Lubricate 2 inches of the rectal tube
Patient’s position Left lateral with the right leg acutely flexed
Insert Smoothly and slowly into the rectum towards the umbilicus
Depth 3-4 inches
Resistance -       If there is resistance, instruct the patient to take a deep breath
and run small amount of solution to relax the rectal and anal
sphincter
Height -       12 inches: low enema

-       18 inches: high enema

Complaint -       If patient complains of fullness or pain:

-       Lower the container or

-       Use the clamp to temporarily stop the flow fro 30 seconds

-       Then restart the flow at a slower rate

Retention -       At least 5-10 minutes for cleansing enema

-       At least 30 minutes for retention enema

 

TYPES OF ENEMA:

CLEANSING ENEMA
Purpose Promote bowel evacuation by softening the feces and stimulating peristalsis.
Solution Tap water, weak soapsuds 9with any mild soap) and saline 91 teaspoon salt
to 500 mL tap water)
Amount Children: 500 mL

Adult: 1 Liter
 

OIL-RETENTION ENEMA
Purpose -       Lubricate the rectal mucosa

-       To apply absorbable or local medicaments

-       Antibiotic enemas are used to treat  infections locally

Instruction -       Retain solution for 1-3 hours or retain solution within the
rectum until the next bowel movement takes place.
 
 FLEET ENEMA
Purpose Hypertonic enema solution that exerts osmotic pressure, which draws fluids
from the interstitial space of the colon then stimulates peristalsis and
defecation, reducing constipation.
 

URINARY ELIMINATION

- maintains homeostasis by maintaining body fluid composition and volume

MICTURITION

-       act of expelling urine from the bladder

-       urination, voiding

-       initiated by parasympathetic nervous system activation

URINALYSIS:

TEST DETAILS NORMAL VALUE

Specific Measures the density of a solution compared to 1.010-1.030
gravity the density of water.
Osmolality Is the most accurate measurement of the 250-900 mOsm/kg
kidney’s ability to dilute and concentrate urine.
pH Alkaline urine can be a sign of UTI 4.6-8.0 (6.0 is the average)
Odor Foul smelling urine is a usual sign of infection Mildly aromatic
Turbidity Cloudy urine can be a sign of infection Transparent when freshly
voided
Color Yellow to amber

Volume Report to physician if output is <30 mL/hour 1-2 liters

 

URINE COLOR:

COLORS DETAILS
Blue/green Amitriptyline, pseudomonas species
Bright yellow Multivitamins
Dark brown Metronidazole, methyldopa, sinemet
Pale yellow Diluted urine, excessive fluid intake
Pink Phenothiazine, phenytoin
Red- orange Rifampicin, RBCs
 

PROBLEMS IN URINARY ELIMINATION:

1. ALTERATION IN URINE COMPOSITION

RBC in the urine - hematuria

Pus in the urine - pyuria

Bacteria - bacteriuria (sign of UTI)

Albumin in the urine: Albuminuria

Protein in the urine: Proteinuria

Glucose:         - Glycosuria

Ketones:         - Ketonuria

2. ALTERED URINE PRODUCTION

Polyuria - excessive urine production; more that 100 ml/hr or 2500 ml/day;
diuresis

Oliguria - decreased amount of urine; less than 30 ml/hr or less than 500ml/day

Anuria - little to no urine production; 10 ml/hr; urinary suppression

 
3. ALTERED URINARY FREQUENCY

Frequency -Voiding at frequent intervals

Nocturia -Increased frequency at night

Urgency -Strong feeling that the person wants to void

Dysuria -painful or difficult voiding

Hesitancy -difficulty initiating voiding

Enuresis -repeated involuntary voiding beyond 4-5 years of age

Pollakuria -Frequent, scanty urination

4. URINARY INCONTINENCE

Total Incontinence - continuous and unpredictable loss of urine

Stress Incontinence - leakage of less than 50 ml of urine as a result of a sudden

increase in intra-abdominal pressure

Urge Incontinence - follows a sudden strong desire to urinate and leads to

involuntary detrusor contraction

Functional Incontinence - involuntary unpredictable passage of urine

Reflex Incontinence - Involuntary loss of urine occurring at somewhat predictable

intervals when specific bladder volume is reached

Retention - accumulation of urine in the bladder with associated inability of the

bladder to empty itself

RELATED PROCEDURES:
1.  CONDOM CATHETERIZATION

PURPOSES:

-       To relieve bladder distention or to provide gradual decompression of a

distended bladder 

-       To instill medication into the bladder 

-       To irrigate the bladder 

-       To measure hourly urine output accurately

-       To collect urine specimen

-       To measure residual urine Residual Urine (is the amount of urine retained in
the bladder after forceful voiding)

-       To maintain continence among in continent clients

-       To prevent urine from contracting an incision after perineal surgery

-       To promote healing of the genito-urinary structures postoperatively

CLUE DETAILS
Preparation Drape the patient, inspect and cleanse the penis.
Secure condom Leave 1 inch space between penis and the plastic connecting
tube.
Tape the condom Secure elastic tape around the base of the penis over the
condom.

Check for penile oxygenation within 30 minutes.

Connect Connect condom to the urinary drainage system.
Attach Ambulatory patient: attach the bag to the patient’s leg.

On complete bedrest; attach the bag to the bedframe.

Changing time Change the condom catheter every day, wash penis with soap
and water, then dry.
 
2. CATHETERIZATION

Description Introduction of a catheter into the urinary bladder.

Sizes of catheter CHILD          ADULT          MALE

Fr 8-10        Fr 14-16        Fr 18
Length of catheter Female: 22 cm                  Male: 40 cm
Types of catheter Straight: inserted to drain the bladder and then removed immediately.

Retention: remains in the bladder to drain urine.

COUDE’: more rigid than straight catheters, has tapered and curved
tip. (commonly used for men with prostatic hypertrophy; it is more
easily controlled and less traumatic on insertion)

3-way catheter: for patients who may require bladder irrigation.

 

MATERIALS USED:

MATERIAL DURATION
Plastic catheter 1 week or less (inflexible)
Rubber/silastic 2-3 weeks
Siliconized rubber 2-3 months

They create less encrustation at the meatus but is expensive.

Polyvinyl chloride 1-1 1/2 months

They soften at body temperature to conform with urethra

 

PROCEDURE IN USING:

STEP DETAILS
Right-right, left-left -       Stand on the right side of the patient if you are right-handed.

-       Stand on the left side of the patient if you are left-handed.

Position Male: supine     Female: dorsal recumbent
Topical anesthesia -       Apply xylocaine gel into the urethra of a male patient 5 minutes
before catheter insertion.

-       Wear clean cloves.

Open kit Apply waterproof drape under patient’s buttocks.
Wear gloves Observe sterile technique
Test balloon Inflate and deflate the balloon and lubricate catheter.
Meatal cleaning -       Use nondominant hand

-       Male: grasp 90 degrees just below the glans firmly upright with
slight tension.

-       Female: spread the labia and locate the urethral meatus during
cleaning process.
Catheter insertion -       Grasp catheter: 2-3 inches from the tip

-       Ask the patient to take slow deep breath and insert as the client
exhales.

-       (+) urine outflow: add 2 inches more

-       Inflate the balloon: sterile water is preferred over NSS.

Secure catheter -       Male: upper thigh/lower abdomen

-       Female: inner thigh

Common mistakes -       Catheter slips into the vagina: discard, use a new sterile catheter

-       Catheter contacts the labia: discard, use a new sterile catheter

-       Vaginal entry: retain the catheter to serve as a landmark, get a new

sterile catheter, and insert it above the previously mistakenly inserted
catheter.
 

DIFFERENCE IN MALE-FEMALE CATHETERIZATION

PATIENT MALE FEMALE

Position Supine: thighs slightly abducted Dorsal recumbent: feet at about 2
feet apart
Depth of insertion 6-9 inches 2-3 inches
RN’s 1 hand Grab the penis 90 degrees Retract the labia
Cleaning method Circular Front to back
Insertion instruction Inhale through the mouth and exhale Inhale through the mouth and
as the nurse inserts the catheter. exhale as the nurse inserts the
catheter.
Attach Lower abdomen Inner thigh
CHAPTER 10: MOBILITY, ACTIVITY AND EXERCISE
BODY MECHANICS The coordinated efforts of the musculoskeletal and nervous
systems to maintain balance, posture, and body alignment during lifting,
bending, and moving to perform activities safely.

PRINCIPLES OF BODY MECHANICS FOR HEALTH WORKERS:

o   When planning to move a client, arrange for adequate help. Use mechanical
aids if help is unavailable.

o   Encourage the client to assist as much as possible.

o   Keep the back, neck and pelvis, and feet aligned. Avoid twisting.

o   Flex knees, and keep feet wide apart.

o   Position self close to the client (or object being lifted).

o   Use arms and legs (not back).

o   Slide client toward yourself using a pull sheet.

o   When transferring a client onto a stretcher, a slide board is more appropriate.

o   Set (tighten) abdominal and gluteal muscles in preparation for the move.

o   Person with the heaviest load coordinates efforts of team involved by

counting to three.

GUIDELINES IN BODY MECHANIC

GUIDELINE DETAIL
Alternate Work-rest-work to prevent muscle strain.
Avoid R-S-T Reaching, stretching and twisting
Belly Objects carried should be close to the belly
Contract Contract muscles before use
Face Always face the direction of movement.
Knees Bend with your knees and not with your waist is proper.
Lower The lower the center of gravity to the ground, the greater the stability.
Waist Level of working area at waist decreases the workload and energy
consumption
Wider The wider the base of support, the greater the stability.
 

PHYSIOLOGIC RESPONSES TO IMMOBILITY

o   Decrease in muscle strength

o   Muscle atrophy

o   Disuse osteoporosis

o   Fibrosis and ankylosis

o   Contracture

EXERCISES - planned, structured and repetitive body movements done to

improve or maintain fitness.

TYPE DESCRIPTION EXAMPLE

ISOTONIC Muscle contraction and active movement. Running, walking, swimming

Dynamic Purpose: muscle tone, mass, strength, joint

flexibility
ISOMETRIC Muscle tension with no change in length Gluteal, abdominal and
quadriceps muscle
Static or setting No joint movement contractions, kegel’s exercise

Purpose: maintain muscle tone

ISOKINETIC Muscle contraction against resistance weight-lifting

Resistive Purpose: increases muscle size

AEORBICS Oxygen taken is greater than oxygen used Aerobic dancing

Done continuously and rhythmically

 

ALIGNMENT DEVICES

DEVICE DESCRIPTION
Bed board Plywood board placed under the entire surface of the mattress.
Hand roll Maintains the thumb slightly adducted and in opposition to the fingers.

Maintains fingers in a slightly flexed position.

Side rails Bars positioned along the sides of the length of the bed.

Always raised up to prevent falls.

Trapeze Descends from a securely fastened overhead bar attached to the bed frame.

Allows patient to use upper extremities to raise the trunk off the bed.

Purpose: to assist in transfer from bed to wheelchair and to perform upper

arm-strengthening exercises and movements.
Trochanter Rolls used to prevent external rotation of legs when clients are in supine
position.
Wedge pillow Or abductor pillow: triangular-shaped pillow made of heavy foam.

Purpose: maintains the legs in abduction following total hip replacement.

CHAPTER 11: COMFORT, REST AND SLEEP

REST- diminished state of activity, calmness, relaxation without emotional stress;
freedom from anxiety

SLEEP -state of consciousness in which the individual’s perception and reaction

to the environment are decreased

RETICULAR ACTIVATION SYSTEM: maintains wakefulness

Serotonin: neurotransmitter associated with sleep

STAGES OF SLEEP:

1. NREM (NON-RAPID EYE MOVEMENT) STAGE (body restoration)

STAGE 1

-       very light sleep

-       drowsy, relaxed

-       readily awakened

  STAGE 2

-       light sleep

-       eyes are still

-       HR and RR decreases slightly

-       body temperature falls

STAGE 3

-       domination of PNS

-       body process slows further

-       difficult to arouse

    STAGE 4

-       deep sleep

-        difficult to arouse

-        decrease BP, RR, PR, Temp

-       decrease metabolism, brain waves, muscles relaxed

2. REM (RAPID EYE MOVEMENT) STAGE (increase in systhetic processes in the

brain)
-       Eyes appear to roll

-       Close to wakefulness but difficult to arouse

-       Dreamstate of sleep

-       SNS dominates

-       Flow of gastric acid increases

-       Sleeper’s reviews the day’s events and processes and stores information

Nursing interventions to Promote Sleep:

-       Promote comfort and relaxation

-       Create a restful environment

-       Attend to bedtime rituals

-       Provide adequate exercise atleast 2 hours before sleep to enhance NREM

-       Encourage intake of high Protein food. It contains Tryptophan which

enhances sleep

-       Avoid caffeine and alcohol in the evening

-       Go to bed when sleepy

-       Use the bed mainly for sleep

Common Sleep Disorders:

o      Insomnia

-       difficulty in falling asleep

-       premature awakening

o      Hypersomnia

-       excessive sleep

-       related to psychological problems, CNS damage

o      Narcolepsy

-       sleep attack

-       overwhelming sleepiness

-       REM uncontrolled

o      Sleep Apnea

-       periodic cessation of breathing during asleep characterized by snoring

o      Parasomnias

-       Somnambulism - sleep walking

-       Night Terrors - child bolts upright in bed, shakes, screams, appears pale and
terrified

-       Nocturnal Enuresis- bed wetting

-       Soliloquy - Sleep talking

-       Nocturnal Erections - “wet dreams”

-       Bruxism - clenching and grinding of teeth during sleep

CHAPTER 12: SAFETY, SECURITY AND PRIVACY

A safe environment is one in which basic needs are met, physical hazards are
reduced or eliminated, transmission of organisms is reduced and sanitary
measures are carried out.

To ensure patient safety

The nurse should conduct a focus assessment during every nurse-patient

encounter which includes:

          -  A visual scan of the environment for potential hazards

          -  A quick appraisal of patient related factors

1. FALL- Fall risk, especially in the elderly, is growing.  In hospitalized patients, 4-

12 falls occur per 1,000 bed days, ranking them among the 10 most common
claims presented to insurance agencies.

Strategies to help reduce falls:

A. Physical environment

-       Appropriate furniture and lighting

-       Call bell easily accessible/personal items within reach

-       Traffic areas free from obstruction

-       Secure/remove loose carpets or runners

-       Eliminate clutter

-       Grab bars in appropriate areas in washroom

-       Handrails in the halls

-       Keep bed in a low position – lock bed/wheelchairs/stretcher

-       Identify clients at risk for falls.

-       If a client experienced falls at home, they will likely continue to be at risk for
falls in the hospital setting.    

-       Place them close to nursing station.

B. Communication/Assessment

-       Orient client to physical surroundings

-       Explain use of call bell

-       Assess client’s risk for falling

-       Alert all personnel to the client’s risk for falling

-       Instruct client and family to seek assistance when getting up

-       Maintain client’s toileting schedule

-       Observe/assess client frequently

-       Encourage family participation in client’s care

2. RESTRAINTS Device used to immobilize a client or an extremity

-A temporary means to control behavior

Restraints are used to:

-       Prevent falls & wandering

-       Protect from self-injury (pulling out tubes)

-       Prevent violence toward others

Restraints deprive a fundamental right to control your own body.

Cautious Use of Restraints:

-While restraint-free care is ideal, there are times that restraints become
necessary to protect the patient & others from harm.

ü  Highly agitated, violent individual – Physical/Chemical restraints

ü  Intubated patient – pulling out endotracheal tube

ü  Suicide patient - Chemical restraints

Use of Restraints:

-       Use only when absolutely necessary.

-       Attending physician is responsible for the assessment, ordering &

continuation of restraint.

-       Can be instituted on your nsg judgment – must have a doctors order ASAP.

-       Continued use of restraints must be reviewed daily by the RN &

documented on the health record.

-       Always explain what you do & why, to reduce anxiety & promote
cooperation.

Goals of Restraint Use:

-       To avoid the use of restraints whenever possible.

-       Encourage alternatives

·         Family member to sit with patient

·         Geriatric  chair vs. bed       

·         Non restraint measures – safety belt, wedge pillows, lap tray

·         Consider restraints as a temporary measure – decrease likelihood of injury

from restraint use.

Remove restraints as soon as the patient is no longer at risk for injury.

                            

Complications assoc. with restraints:

-       Hazards of immobility

-       Death

-       Pressure sores, pneumonia, constipation, incontinence, contractures,

decreased mobility, decreased muscle strength, increased dependence

-       Altered thought processes

-       Humiliation, fear, anger & decreased self-esteem

-       Strangulation

-       Compromised circulation

-       Lacerations, bruising, impaired skin integrity

•            Must release restraint every 2 hours for assessment & ROM

Physical Restraints – device that limits a client’s ability to move

-       Side rails – stop patient from rolling out, but does not stop them from
climbing out – side rail down when working on that side.

-       Jackets & Belts – patient who is confused & climbing over rails may need a
jacket or belt to restrain them to bed.  Sleeveless with cross over ties, allows
relative freedom in bed.

-        Arm & Leg – Undesirable, limits patients movement, injury to wrist/ankle

from friction rubbing against skin – use extra padding.  Restrain in a slightly
flexed position, if too tight could impair circulation.  Never tie to a bed rail.

-       Mitts are used for those confused & pulling at edges of dressings, tubes,
IV’s, wounds.  Doesn’t limit arm movement, soft boxing glove that pads the hand,
remove, wash & exercise.

-Ensure not too tight

-Use quick release tie for all restraints

Chemical Restraints- Medication

-       Patient must be closely observed and assessed frequently post medication.

-       Remains a high risk for injury.

Supporting Documentation:

-       Rationale for the use of restraints, including a statement describing the

behavior of the patient.

-       Previous unsuccessful measures or the reason alternatives are not feasible.

-       Decision to restrain with the type of restraint selected and date & time of
application.

-       Observations regarding the placement of the restraint, its condition and the
patient’s condition, including the frequency of observation (not just at the end of
your shift)
-       Assessment of the need for ongoing application of restraint.

-       Care of the patient which may include re-positioning, toileting, mobilization

and/or skin care

Measures designed to promote client safety are the result of individualized

assessment findings.  Often it is the conclusion of the nurse that a client’s safety is
at risk, and subsequent nursing interventions are implemented.  Assessment of a
client’s safety should occur in the home, healthcare facility, and community
environment.

3. STANDARD PRECAUTIONS

COLONIZATION, INFECTION, AND DISEASE

Colonization

- The term colonization is used to describe microorganisms present without host

interference or interaction. Understanding the principle of colonization facilitates
interpretation of microbiologic reports. Organisms reported in microbiology
results often reflect colonization rather than infection.

Infection

-  indicates a host interaction with an organism. A patient colonized with S.

aureus may have staphylococci on the skin without any skin interruption or
irritation. If the patient had an incision, S. aureus could enter the wound, with an
immune system reaction of local inflammation and routing of white cells to the
site.

-  Clinical evidence of redness, heat, and pain and laboratory evidence of white
cells on the wound specimen smear suggest infection.  Infection is recognized by
the host reaction and by organism identification.

Disease
It is important to recognize the difference between infection and disease.
Infectious disease is the state in which the infected host displays a decline in
wellness due to the infection. When the host interacts immunologically with an
organism but remains symptom free, the definition of disease has not been met.

-  M. tuberculosis is an example of an organism that often persists as infection

without producing disease. The host may become infected after exposure to the
tubercle bacillus. The person is infected when bacteria are first detected by
nonspecific immunologic recognition and later as newly sensitized T cells
propagate daughter lines of defense.

INFECTIOUS PROCESS

A complete chain of events is necessary for infection to occur.

The necessary elements of infection include the following:

• A causative organism

• A reservoir of available organisms

• A portal or mode of exit from the reservoir

• A mode of transmission from reservoir to host

• A susceptible host

• A mode of entry to host

ELEMENTS OF INFECTION

1. Causative Organism

The types of microorganisms that cause infections are bacteria, rickettsiae,

viruses, protozoa, fungi, and helminths.
2. Reservoir is the term used for any person, plant, animal, substance, or location
that provides nourishment for microorganisms and enables further dispersal of
the organism. Infections may be prevented by eliminating the causative
organisms from the reservoir.

3. Mode of Exit

The organism must have a mode of exit from a reservoir. An infected host must
shed organisms to another or to the environment before transmission can occur.
Organisms exit through the respiratory tract, the gastrointestinal tract, the
genitourinary tract, and the blood.

4.  Mode of Transmission

A route of transmission is necessary to connect the infectious

source with its new host. Organisms may be transmitted through sexual contact,
skin-to-skin contact, percutaneous injection, or infectious particles carried in the
air. A person who carries, or transmits, an organism and who does not have
apparent signs and symptoms of infection is called a carrier.

- It is important to recognize that different organisms require specific routes of

transmission for infection to occur.

5. Susceptible Host

For infection to occur, the host must be susceptible (ie, not possessing immunity

to a particular pathogen). Previous infection or vaccine administration may render
the host immune (ie, not susceptible) to further infection with an agent. Many
infections are prevented because of the powerful human immune defense.
Although exposure to potentially infectious microorganisms occurs essentially on
a constant basis, our elaborate immune systems generally prevent infection from
occurring. The immune-suppressed person has much greater susceptibility than
the normal, healthy host.

6. Portal of Entry

A portal of entry is needed for the organism to gain access to the host. For
example, airborne M. tuberculosis does not cause disease when it settles on the
skin of an exposed host. The only entry route for the bacterium that is of concern
is through the respiratory system.

STANDARD PRECAUTIONS

The tenets of Standard Precautions are that all patients are colonized or

infected with microorganisms, whether or not there are signs or symptoms, and
that a uniform level of caution should be used in the care of all patients.

THE ELEMENTS OF STANDARD PRECAUTIONS:

include hand hygiene, use of gloves and other barriers (eg, mask, eye protection,
face shield, gown), handling of patient care equipment and linen, environmental
control, prevention of injury from sharps devices, and patient placement.

 
1.  Hand Hygiene

- The most frequent cause of infection outbreaks in health care institutions is

transmission by the hands of health care workers. Hands should be washed or
decontaminated frequently during patient care.

Comparing Hand Hygiene Methods

Hand Decontamination with Alcohol-Based Product

• After contact with body fluids, excretions, mucous membranes, nonintact skin,
or wound dressings as long as hands are not visibly soiled.

• After contact with a patient’s intact skin (as after taking pulse or blood pressure
or lifting a patient)

• In patient care, when moving from a contaminated body site to a clean body
site

• After contact with inanimate objects in the patient’s immediate vicinity

• Before caring for patients with severe neutropenia or other forms of severe
immune suppression

• Before donning sterile gloves when inserting central catheters

• Before inserting urinary catheters or other devices that do not require a surgical
procedure.

• After removing gloves

Hand Washing

• When hands are visibly dirty or contaminated with biologic material from
patient care

• When healthcare workers do not tolerate waterless alcohol product

 

2.  Glove Use

-  Gloves provide an effective barrier for hands from the microflora associated
with patient care. Gloves should be worn when a health care worker has contact
with any patient’s secretions or excretions and must be discarded after each
patient care contact.

- Latex gloves are often preferred over vinyl gloves because of greater comfort
and fit and because some studies indicate that they afford greater protection
from exposure.

3.  Needlestick Prevention

- The most important aspect of reducing the risk of blood borne infection is
avoidance of percutaneous injury.

-Extreme care is essential in all situations in which needles, scalpels, and other
sharp objects are handled. Used needles should not be recapped. Instead, they
are placed directly into puncture resistant containers in the vicinity of their use. If
a situation dictates that a needle must be recapped, the nurse must use a
mechanical device to hold the cap or use a one-handed approach to decrease the
likelihood of skin puncture.

4.  Avoidance of Spray and Splash Exposure.

- When the health care provider is involved in an activity in which body fluids
may be sprayed or splashed, appropriate barriers must be used. If a splash to the
face may occur, goggles and facemask are warranted.

-  If the health care worker is handling material that may soil clothing or is
involved in a procedure in which clothing may be splashed with biologic material,
a cover gown should be worn.
 

USE STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS.

1. Airborne Precautions

- In addition to Standard Precautions, use Airborne Precautions for patients

known or suspected to have serious illnesses transmitted by airborne droplet
nuclei. Examples of such illnesses include the following:

Measles, Varicella (including disseminated zoster), Tuberculosis

2. Droplet Precautions

- In addition to Standard Precautions, use Droplet Precautions for patients known

or suspected to have serious illnesses transmitted by large particle droplets.
Examples of such illnesses include Invasive Haemophilus influenzae type b
disease, including meningitis, pneumonia, epiglottitis, and sepsis
Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and
sepsis

- Other serious bacterial respiratory infections spread by droplet transmission,

including Diphtheria (pharyngeal), Primary atypical pneumonia (Mycoplasma
pneumoniae), Pertussis, Pneumonic plague, Streptococcal (group A) pharyngitis,
pneumonia, or scarlet fever in infants and young children, Serious viral infections
spread by droplet transmission, including:, Adenovirus Influenza. Mumps
Parvovirus B19, Rubella

3. Contact Precautions

 - In addition to Standard Precautions, use Contact Precautions for patients

known or suspected to have serious illnesses easily transmitted by direct patient
contact or by contact with items in the patient’s environment.
Examples of such illnesses include Gastrointestinal, respiratory, skin, or wound
infections or colonization with multidrug-resistant bacteria judged by the infection
control program, based on current state, regional, or national recommendations, to
be of special clinical and epidemiologic significance Enteric infections with a low
infectious dose or prolonged environmental survival, including  Clostridium difficile,
for diapered or incontinent patients: enterohemorrhagic,  Escherichia
coli  O157:H7,  Shigella  species, hepatitis A, or rotavirus

- Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in

infants and young children.

-Skin infections that are highly contagious or that may occur on dry skin,
including, Diphtheria (cutaneous), Herpes simplex virus (neonatal or
mucocutaneous), Impetigo, Major (noncontained) abscesses, cellulitis, or pressure
ulcers, Pediculosis, Scabies, Staphylococcal furunculosis in infants and young
children, Zoster (disseminated or in the immunocompromised host)*, Viral and
hemorrhagic conjunctivitis, Viral hemorrhagic infections (Ebola, Lassa, or
Marburg).

PREVENTING INFECTION IN THE HOSPITAL

Specific organisms with Nosocomial infection potential

-          Clostridium difficile

-          Methicillin-resistant staphylococcus aureus

-          Vancomycin-Resistant Enterococcus

1.  DISINFECTING SKIN

2. USING GUIDE WIRES

- Guide wires should not be used routinely when replacing central venous
catheters. However, they may be used if there is no evidence of infection and
insertion risk is unacceptably high, as when the patient has a coagulopathy or is
obese.
3.  CHANGING INFUSION SETS, CAPS, AND SOLUTIONS

Infusion sets and stopcock caps should be changed no more frequently than
every 4 days, unless an infusion set is used for the delivery of blood or lipid
solutions. Infusion sets and tubing for blood, blood products, or lipid emulsions
should be changed within 24 hours of initiating the infusion. Blood infusions
should finish within 4 hours of hanging the blood; lipid solutions should be
completed within 24 hours of hanging.

-  There are no guidelines for the appropriate intervals for the hang time of other
solutions.

4.  Isolation Precautions

Isolation precautions are guidelines created to prevent transmission of

microorganisms in hospitals.

ASEPSIS

- Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and
other microorganisms that can cause disease. Healthcare professionals use
aseptic technique to protect patients from infection.

- Aseptic technique is a standard healthcare practice that helps prevent the

transfer of germs to or from an open wound and other susceptible areas on a
patient’s body.

- Aseptic techniques range from simple practices, such as using alcohol to

sterilize the skin, to full surgical asepsis, which involves the use of sterile gowns,
gloves, and masks.

- Healthcare professionals use aseptic technique practices in hospitals, surgery

rooms, outpatient care clinics, and other healthcare settings.

- Using aseptic technique prevents the spread of infection by harmful germs.

Healthcare professionals use aseptic technique when they are:
ü  performing surgical procedures

ü  performing biopsies

ü  dressing surgical wounds or burns

ü  suturing wounds

ü  inserting a urinary catheter, wound drain, intravenous line, or chest tube

ü  administering injections

ü  using instruments to conduct a vaginal examination

ü  delivering babies

ASEPTIC TECHNIQUE VS CLEAN TECHNIQUE

-The aim of using aseptic technique is to eliminate germs, which are disease-

causing microorganisms. Clean technique focuses on reducing the number of
microorganisms in general.

- Healthcare professionals learn both aseptic and clean techniques and use them
in different situations. They will use aseptic technique during surgical operations
or when inserting a foreign object, such as a catheter, into a person’s body.

- Clean technique is often sufficient for long-term care, in-home care, and some
outpatient clinical settings. Healthcare professionals use clean technique for
people who are not at high risk of infection. For example, they may use clean
technique when changing the dressing on a wound that is healing.

DIFFERENT ASPECTS OF ASEPTIC TECHNIQUE PRACTICES:

1. BARRIERS
Barriers prevent the transfer of germs between healthcare professionals, patients,
and the environment. Aseptic barriers include:

·         sterile gloves

·         sterile gowns

·         sterile masks

·         sterile drapes

·         protective wrappers on sterilized instruments

2. PATIENT AND EQUIPMENT PREPARATION

- Healthcare professionals must thoroughly prepare both the patient and the
equipment before a medical procedure takes place.

Aseptic preparation may involve:

·         disinfecting a patient’s skin using antiseptic wipes

·         sterilizing equipment and instruments before a procedure

·         keeping sterilized instruments inside plastic wrappers to prevent

contamination before use

3. ENVIRONMENTAL CONTROLS

- It is essential to maintain an aseptic environment before and during procedures.

The designated procedural area is also called an aseptic field.

Maintaining an aseptic field involves:

·         keeping doors closed

·         minimizing movement in and out of the aseptic field

·         limiting entry to necessary personnel only

·         permitting only one patient per aseptic field

4. CONTACT GUIDELINES

- These guidelines prohibit any contact between sterile and non-sterile items.
Healthcare professionals can only touch sterile objects and surfaces, and they
must avoid touching nonsterile items and surfaces at all costs.

- The same guidelines apply to sterile devices. If a sterile instrument falls on the
ground and the wrapper sustains damage, a healthcare professional must remove
the instrument and re-sterilize it before use.

ISOLATION

- Isolation refers to the precautions that are taken in the hospital or department
to prevent the spread of an infectious agent from an infected or colonized
patient to susceptible or uninfected patient.

TYPES OF ISOLATION:
Strict isolation
-is used for diseases spread through the air and in some cases by contact.  Those who are
kept in strict isolation are often kept in a special room at the facility designed for that
purpose. Such rooms are equipped with a special  lavatory  and caregiving equipment, and
a sink and waste disposal are provided for workers upon leaving the area.

Contact isolation
-is used to prevent the spread of diseases that can be spread through contact
with open wounds. Health care workers making contact with a patient on contact
isolation are required to wear gloves, and in some cases, a gown.

Respiratory isolation
- is used for diseases that are spread through particles that are exhaled. Those
having contact with or exposure to such a patient are required to wear a mask.

Reverse isolation

- is a way to prevent a patient in a compromised health situation from being

contaminated by other people or objects. It often involves the use of laminar air
flow and mechanical barriers (to avoid physical contact with others) to isolate the
patient from any harmful pathogens present in the external environment.

High isolation
-  is used to prevent the spread of unusually highly contagious, or high consequence,
infectious diseases (e.g., smallpox, Ebola virus). It stipulates mandatory use of: (1) gloves
(or double gloves if appropriate), (2) protective eyewear (goggles or face shield), (3) a
waterproof gown (or total body Tyvek suit, if appropriate), and (4) a  respirator  (at least
FFP2 or N95 NIOSH equivalent),  not  simply a surgical mask. Sometimes  negative pressure
rooms  or  powered air-purifying respirators  (PAPRs) are also used.

Self-isolation  or  home isolation

- is the act of voluntarily quarantining oneself to prevent infection of oneself or

others. The practice became notable during the 2019–20 coronavirus pandemic.
Key features are:

ü  staying at home
ü  separating oneself from other people—for example, trying not to be in the
same room as other people at the same time

ü  asking friends, family members or delivery services to carry out errands, such
as getting groceries, medicines or other shopping

ü  asking delivery drivers to leave items outside for collection.

 FUNCTIONS OF THE IMMUNE SYSTEM:

-       The immune system provides protection against invasion by

microorganisms from outside the body.

-       The immune system protects the body from internal threats and maintains
the internal environment by removing dead or damaged cells.

IMMUNITY

A. Natural immunity

-       Natural immunity is also called native or innate immunity.

-       It is present at birth and includes biochemical, physical, and mechanical

barriers of defense, as well as the inflammatory response.

B. Acquired immunity

-       Acquired or adaptive immunity is received passively from the mother’s

antibodies, animal serum, or antibodies produced in response to a disease.

-       Immunization produces active acquired immunity.

4. ENVIRONMENTAL SAFETY
A. Fire safety

1. Keep open spaces free of clutter.

2. Clearly mark fire exits.

3. Know the locations of all fire alarms, exits, and extinguishers

4. Know the telephone number for reporting fires.

5. Know the fire drill and evacuation plan of the agency.

6. Never use the elevator in the event of a fire.

7. Turn off oxygen and appliances in the vicinity of the fire.

8. In the event of a fire, if a client is on life support, maintain respiratory status

manually with an Ambu bag (resuscitation bag) until the client is moved away
from the threat of the fire and can be placed back on life support.

9. In the event of a fire, ambulatory clients can be directed to walk by themselves

to a safe area and, in some cases, may be able to assist in moving clients in
wheelchairs.

10. Bedridden clients generally are moved from the scene of a fire by stretcher,
their bed, or wheelchair.

11. If a client must be carried from the area of a fire, appropriate transfer
techniques need to be used.

12. If fire department personnel are at the scene of the fire, they will help
evacuate clients.

Actions to Take in the Event of a Fire

1. Rescue clients who are in immediate danger.

2. Activate the fire alarm.

3. Confine the fire.

4. Extinguish the fire: obtain the fire extinguisher.

5. Pull the pin on the fire extinguisher.

6. Aim at the base of the fire.

7. Squeeze the extinguisher handle.

8. Sweep extinguisher from side to side to coat the area of the fire evenly.

Remember the mnemonic RACE to prioritize in the event of a fire. R is rescue

clients in immediate danger, A is alarm (sound the alarm), C is confine the fire by
closing all doors, and E is extinguish. To properly use the fire extinguisher,
remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P is
pull the pin, A is aim at the base of the fire, S is squeeze the handle, and SS is
sweep from side to side to coat the area evenly.

B. Electrical safety

1. Electrical equipment must be maintained in good working order and should be

grounded; otherwise it presents a physical hazard

2. Use a three-pronged electrical cord.

3. In a three-pronged electrical cord, the third longer prong of the cord is the
ground; the other two prongs carry the power to the piece of electrical
equipment.

4. Check electrical cords and outlets for exposed, frayed, or damaged wires.

5. Avoid overloading any circuit.

6. Read warning labels on all equipment; never operate unfamiliar equipment.

7. Use safety extension cords only when absolutely necessary, and tape them to
the floor with electrical tape.
8. Never run electrical wiring under carpets.

9. Never pull a plug by using the cord; always grasp the plug itself.

10. Never use electrical appliances near sinks, bathtubs, or other water sources.

11. Always disconnect a plug from the outlet before cleaning equipment or
appliances.

12. If a client receives an electrical shock, turn off the electricity before touching
the client.

Any electrical equipment that the client brings into the health care facility must be
inspected for safety before use.

C. Radiation safety

1. Know the protocols and guidelines of the health care agency.

2. Label potentially radioactive material.

3. To reduce exposure to radiation, do the following:

a. Limit the time spent near the source.

b. Make the distance from the source as great as possible.

c. Use a shielding device such as a lead apron.

4. Monitor radiation exposure with a film (dosimeter) badge.

5. Place the client who has a radiation implant in a private room.

6. Never touch dislodged radiation implants.

7. Keep all linens in the client’s room until the implant is removed.
 

D. Disposal of infectious wastes

1. Handle all infectious materials as a hazard.

2. Dispose of waste in designated areas only, using proper containers for

disposal.

3. Ensure that infectious material is labeled properly.

4. Dispose of all sharps immediately after use in closed, puncture-resistant

disposal containers that are leakproof and labeled or color-coded. Needles
(sharps) should not be recapped, bent, or broken because of the risk of accidental
injury (needle stick).

E. Physiological changes in the older client that increase the risk of accidents

·         Musculoskeletal Changes

-       Strength and function of muscles decrease.

-       Joints become less mobile and bones become brittle.

-       Postural changes and limited range of motion occur.

·         Nervous System Changes

-       Voluntary and autonomic reflexes become slower.

-       Decreased ability to respond to multiple stimuli occurs.

-       Decreased sensitivity to touch occurs.

·         Sensory Changes

-       Decreased vision and lens accommodation and cataracts develop.

-       Delayed transmission of hot and cold impulses occurs.

-       Impaired hearing develops, with high-frequency tones less perceptible.

·         Genitourinary Changes

-       Increased nocturia and occurrences of incontinence may occur.

F. Poisons

1. A poison is any substance that impairs health or destroys life when ingested,
inhaled, or otherwise absorbed by the body.

2. Specific antidotes or treatments are available only for some types of poisons.

3. The capacity of body tissue to recover from a poison determines the

reversibility of the effect.

4. Poison can impair the respiratory, circulatory, central nervous, hepatic,

gastrointestinal, and renal systems of the body.

5. The toddler, the preschooler, and the young school-age child must be
protected from accidental poisoning.

6. In older adults, diminished eyesight and impaired memory may result in

accidental ingestion of poisonous substances or an overdose of prescribed
medications.

7. A Poison Control Center phone number should be visible on the telephone in

homes with small children; in all cases of suspected poisoning, the number
should be called immediately.

8. Interventions

a. Remove any obvious materials from the mouth, eyes, or body area
immediately.

b. Identify the type and amount of substance ingested.

c. Call the Poison Control Center before attempting an intervention.

d. If the victim vomits or vomiting is induced, save the vomitus if requested to do

so, and deliver it to the Poison Control Center.

e. If instructed by the Poison Control Center to take the person to the emergency
department, call an ambulance.

f. Never induce vomiting following ingestion of lye, household cleaners, grease,

or petroleum products.

g. Never induce vomiting in an unconscious victim.

The Poison Control Center should be called first before attempting an intervention.

CONFIDENTIALITY AND INFORMATION SECURITY

1. In the health care system, confidentiality refers to the protection of privacy of

the client’s PHI.

2. Clients have a right to privacy in the health care system.

3. A special relationship exists between the client and nurse, in which information
discussed is not shared with a third party who is not directly involved in the
client’s care.

4. Violations of privacy occur in various ways

B. Nurse’s responsibility

1. Nurses are bound to protect client confidentiality by most nurse practice acts,
by ethical principles and standards, and by institutional and agency policies and
procedures.

2. Disclosure of confidential information exposes the nurse to liability for invasion

of the client’s privacy.
3. The nurse needs to protect the client from indiscriminate disclosure of health
care information that may cause harm.

C. Medical records

1. Medical records are confidential.

2. The client has the right to read the medical record and have copies of the
record.

3. Only staff members directly involved in care have legitimate access to a client’s
record; these may include physicians and nurses caring for the client, technicians,
therapists, social workers, unit secretaries, client advocates, administrators (e.g.,
for statistical analysis, staffing, quality care review). Others must ask permission
from the client to review a record.

4. The medical record is sent to the records or the health information department
after discharge of the client from the health care facility.

D. Information technology/computerized medical records

1. Health care employees should have access only to the client’s records in the
nursing unit or work area.

2. Confidentiality/information security can be protected by the use of special

computer access codes to limit what employees have access to in computer
systems.

3. The use of a password or identification code is needed to enter and sign off a
computer system.

4. A password or identification code should never be shared with another person.

5. Personal passwords should be changed periodically to prevent unauthorized

computer access.

E. When conducting research, any information provided by the client is not to be

reported in any manner that identifies the client and is not to be made accessible
to anyone outside the research team.
The nurse must always protect client confidentiality.

Violations and Invasion of Client privacy:

-       Taking photographs of the client

-       Release of medical information to an unauthorized person, such as a

member of the press, family, friend, or neighbor of the client, without the client’s
permission

-       Use of the client’s name or picture for the health care agency’s sole
advantage

-       Intrusion by the health care agency regarding the client’s affairs

-       Publication of information about the client

-       Publication of embarrassing facts

-       Public disclosure of private information

-       Leaving the curtains or room door open while a treatment or procedure is

being performed

-       Allowing individuals to observe a treatment or procedure without the

client’s consent

-       Leaving a confused or agitated client sitting in the nursing unit hallway

-       Interviewing a client in a room with only a curtain between clients or where

conversation can be overheard

-       Accessing medical records when unauthorized to do so

Maintenance of Confidentiality:

-       Not discussing client issues with other clients or staff uninvolved in the
client’s care
-       Not sharing health care information with others without the

-       Client’s consent (includes family members or friends of the client)

-       Keeping all information about a client private, and not revealing it to

someone not directly involved in care

-       Discussing client information only in private and secluded areas

-       Protecting the medical record from all unauthorized readers