NCMA113 LEC & LAB FROM DASH 10 – SUMMER FINAL 2021
Ito ung mga naturo samin ni Mam San Diego and Sir Dino.
(From Dash 10). Hiniwalay ko lang un reviewer na to sa video
lecture na pinopost sa FB cluster. Kayaaa kung gusto nyo ng
additional info, Pwede nyo rin to gamitin to as reviewer :))
 Oxygen Therapy
 Enema
 Hot and cold Application
 Death and dying
 Catheterization
- Aki
OXYGEN THERAPY
Oxygen
- Gaseous element essential to life.
- Prescribed as a medication.
- Administered under controlled conditions.
- Therapeutic (supplemental oxygen)
- Used when client is unable to obtain sufficient oxygen for
the body’s needs.
- Excess oxygen: can be harmful.
- (Kapag nasa ER it is imp. to assess the airway. To know DOB
difficulty of breathing look at the patients accessory muscles
in breathing, fingers nail bed if cyanotic and RR kung mataas)
 D – dry gas
 T – tasteless
 O – odorless
 C – colorless
 C – supports Combustion
Safety Precautions
 Place “No smoking: Oxygen in use” sign.
 Avoid use of oils, greases, alcohol, and acetone near the client.
 Avoid materials that generate static electricity.
 Make sure that the electric devices are in good working
conditions.
 (too much oxygen is dangerous malulunod sya mapupuno ng
hangin lungs nuya and it will not be able to function well)
Oxygen therapy
- Administration of oxygen at concentrations greater than that of
ambient air.
- Intent of treating or preventing the symptoms and
manifestations of hypoxia.
- 6 rights of medication administration also pertain to O2
administration.
- Goals of O2 Therapy
 Reverse’s hypoxemia.
 Decreases the work of the respiratory system
 Decreases the heart’s work in pumping blood (heart and
lungs are the important organs, circulation of the blood
enters the heart and then exchange of gases goes to the
lungs then oxygenated blood goes back to the heart and
then distributed throughout the body)
- Hazards of O2 Therapy
 Oxygen toxicity (too much of oxygen)
 Vision difficulties in newborns (premature) – retinopathy
 Hypoventilation (oxygen-induced)
AK 1 of 12
 Atelectasis – collapse of the lungs and the pt. will die. So
in giving o2 we need to know the amount.
 (for premature one of the problem is the respiratory
distress syndrome RDS dhil lungs func. is not fully
developed so management if pt. has RDS is giving of
oxygen kaya lang if premature bibigyan sya ng too much
oxygen and the effect of this is called retinopaty of
prematurity)
Sources of Oxygen
Wall outlets
– Permanent wall-piped system installed next to each bed.
Oxygen cylinders (O2 Tanks)
– Large cylinders: used when high flow rates are essential or
when a client requires oxygen for an extended period.
– Small cylinders: used when transporting clients or short-term
emergencies.
– Keep all cylinders away from heat.
Oxygen concentrator
- Used in home and extended care settings.
- Compresses room air and extracts oxygen.
- Provides concentrated oxygen flows in the range of 1 to 5
liters per minute (LPM).
- Requires periodic maintenance, needs electricity to operate.
- Not portable.
Oxygen Delivery System
Low-flow delivery system
- Do not provide exact oxygen concentrations.
- Client’s breathing pattern influences the concentration of
oxygen obtained.
- (hindi na inaadjust and it depends on breathing pattern of the
pt.)
Nasal Cannula
 Simple and comfortable.
 Used for precise oxygen delivery
 Use with caution for clients with
irregular breathing patterns.
 Use humidification to prevent drying
of nares.
 Flow rate ranging from 1 to 6 L/min
(24-44% FIO2)
Simple Facemask
 Used for short-term oxygen therapy.
 Contraindicated for patients with
carbon dioxide retention.
 Flow rate ranging from 5 to 8 L/min
(40-60% FIO2).
 (COPD pt. bawal bigyan ng o2)
Partial rebreather mask
 A simple mask with a reservoir bag.
 The reservoir bag should at least 1/3 to
½ full on inspiration.
 Flow rate ranging from 6 to 10 L/min
(40-70% FIO2).
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL

Non-rebreather mask 8. Observe for proper functioning of oxygen-delivery delivery

 A simple mask that has one-way valves device.
that prevent exhaled air from returning to 9. Verify setting on flowmeter and oxygen source for proper set-
the reservoir bag. up and prescribed flow rate.
 Flow rate should be a minimum of 10 10. Check cannula/ mask every 8 hours. Keep humidification
L/min (60- 80% FIO2) container filled at all times.
11. Wash hands.
12. Evaluate the client (response to oxygen therapy, respiratory
High-flow delivery system status, and O2 saturation)
- Oxygen percentage is constant 13. Document the procedure.
- Venturi mask Reminders:
 Delivers higher oxygen concentrations of 24% to 60% - DOB position pt. in high fowlers and semi-fowlers position.
with oxygen flow rates of 4 to 12 L/min, depending on the - Allow for deep breathing exrcise.
flow-control meter selected. - Monitor O2 saturation
- Say it to the doctor.

EMEMA
- A technique used to stimulate stool
evacuation.
- It is a liquid treatment most used to
relieve severe constipation. The
process helps push waste out of the
rectum when you cannot do so on
your own.
- The administration of Enema
requires doctor's order.
Purposes of Enema
Oxygen administration procedure 1. Treat constipation
Administration of oxygen - Constipation is a common gastrointestinal condition. It
1. Identify the patient using two identifiers. occurs when the colon is unable to remove waste through
2. Assess the patients’ respiratory status (respiratory rate and the rectum.
depth, sputum production, and lung sounds) - People with this condition have three or fewer bowel
3. Explain the purpose and what will be done during the movements over a seven-day period.
procedure. - Mild constipation often occurs when you don’t eat enough
4. Wash hands fiber or drink enough water on a regular basis.
5. Fill the humidifier with sterile water. - Daily exercise also helps to prevent constipation.
6. Attach oxygen delivery device to oxygen tubing and attached - Kapag hindi nakapupu ang patient sa bibig lalabas yung
to oxygen source. baho
2. Cleanse the lower bowel in preparation for surgery or a
diagnostic procedure. (ex: barium enema, Colonoscopy)
- However, this is normally the last resort for constipation
treatment. If diet and exercise are not enough to keep you
regular, your doctor might recommend a laxative before
trying an enema.
7. Adjust to prescribed flow rate. - In some cases, laxatives are used the night before an
Note: enema administration to encourage waste flow.
2-3L lang ang ibinibigay so dpt iaadjust mo ung ball from 2-3L - Enemas may also be used before medical examinations of
only the colon. Your doctor may order an enema prior to an X-
Nasal Cannula ray of the colon to detect polyps so that they can get a
 Position tips of nasal cannula properly in patient’s nares clearer picture. This procedure may also be done prior to a
and adjust elastic headband or plastic slide on cannula. colonoscopy.
 Place gauze pad at ears to prevent skin irritation. Types of Enema
 (feel it at the back of your hands)
Simple Face Mask
 Position face mask fully covering the nose and mouth.
 Adjust elastic headband until mask fits comfortably.
 Place gauze pad at ears.
AK 2 of 12
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
Cleansing Enema
- Water-based and meant to be held in the rectum for a short
time to flush your colon.
- Once injected, they’re retained for a few minutes until your
body rids itself of the fluid, along with loose matter and
impacted stool in your bowel.
Carminative Enema
- A small volume enema given to release flatus. (maririnig na
nag fart si pt.)
- Consisted of two ounces of glycerin, one ounce of magnesium
sulfate (epsom salts) and three ounces of water combined to
stimulate peristalsis resulting in a bowel movement in which
feces and flatus are expelled.
- The advantage in times past of using the carminative enema
was that the low volume made it comfortable for the patient to
retain, and it took little time to administer.
- The enema is not in common use today since similar results
can be obtained using prepackaged small volume enemas such
as the Fleets saline enema,
- The Fleets bisacodyl enema or a bisacodyl suppository.
- When using the traditional carminative enema, instruct the
patient to try to retain the enema for five to ten minutes before
expelling.
Retention Enema
- A retention enema also stimulates the bowels, but the solution
that is used is intended to be “held” in the body for 15 minutes
or more.
Return-flow Enema
- or Harris flush, is used to remove intestinal gas and stimulate
peristalsis.
- A large volume fluid is used but the fluid is instilled in 100-
200 ml increments. Then, the fluid is drawn out by lowering
the container below the level of the bowel. This brings the
flatus out with the fluid.
Materials:
 Waterproof Pad
 IV Pole
 Enema Can/Bag
 Rectal Tube
 Water soluble lubricant
 Bedpan
 Towel
AK 3 of 12
 Clean Gloves
 Rectal Tube Sizes:
- Adult: Fr. 22-30
- Chidren: Fr. 14-18
- Infant: Fr. 12
Fleet- used for cleansing and para bumilis ang pagdumi pero too
much use mawawala ang normal na pagpupu.
Procedure:
1. Verify the doctor’s order of administering enema to the client.
2. Prepares the needed materials and solutions.
3. Performs handwashing before and after the procedure.
4. Identifies patient and explains the procedure.
5. Provides privacy to the client throughout the procedure.
6. Places the waterproof pad under the client’s buttocks.
7. Positions the client in left Sim’s position.
8. Prepares the irrigating can, tubing and solutions. Hangs the
enema can on the IV stand about 18-24 inches above the level
of the patient’s rectum.
9. Lubricates the rectal tube and allows a small amount of
solution to flow through the tubing into the bedpan.
10. Dons glove and lift the upper buttocks of the patient.
11. Inserts the tube slowly and smoothly around 3-4 inches into
the patient’s anus.
12. Administer the solution slowly. If the patient complains of
fullness or pain, use the clamp to stop the flow for 30 seconds,
and then restart the flow at a slower rate.
13. Closes the clamp after all the solutions has been administered
or when the client cannot hold anymore and wants to defecate.
14. Removes the rectal tube and places it in a disposable towel.
15. Encourages the patient to retain the enema solution.
16. Assist the patient to defecate.
17. Assists the patient with the necessary cleansing.
18. Makes the patient comfortable.
19. After care of the unit and materials used.
20. Document the procedure done. Record the kind and amount of
stool and solution used and the character of the return flow.
 
 
 
 
 
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
HOT AND COLD APPLICATION
- Heat and cold are applied to the body for local and systemic
effects.
- When properly and correctly used, head and cold applications
are therapeutic modalities of treatment.
- R – Rest, I – Ice, C – Compression, E - elevation
o Vasodilation – lumalaki or lumuluwag un daanan
o Vasoconstriction – lumiliit un daanan
Local effects of heat
- Heat is an old remedy for aches and pains, and people often
equate heat with comfort and relief.
- It causes vasodilation and increases blood flow to be affected
area, bringing oxygen, nutrients, antibodies, and leukocytes.
Application of Heat
- Promotes soft tissue healing.
- Often used for clients with musculoskeletal problems such as
joint stiffness from arthritis, contractures, and low back pain.
Local effects of Cold
- Cold lowers the temperature of the skin and underlying tissues
and causes vasoconstriction
- Vasoconstriction reduces blood flow to the affected area and
thus reduces the supply of oxygen and metabolites, decreases
the removal of wastes and produces skin pallor and coolness.
- Prolonged exposure to cold results in impaired circulation, cell
deprivation, and subsequent damage to the tissues from lack of
oxygen and nourishment.
- The signs of Tissue Damage due to cold skin:
 Bluish purpled mottled appearance of the skin.
 Numbness
AK 4 of 12
 Blisters
 Pain
Cold compress
- Most often used for sports injuries to limit post injury swelling
and bleeding.
 Sprains (overstretch) a painful injury to the ligaments of a
joint caused by wrenching or overstretching.
 Strains (muscle tear)
 Fractures
Thermal tolerance
- Specific conditions necessitate precautions in the use of hot or
cold applications:
1. Neurosensory impairment – they are unable to perceive
hot and cold temperatures that can lead to burns or tissue
injuries. (ex. May tumor pt. sa brain kapag nilagyan ng
hot/cold application hindi nya mararamdaman)
2. Impaired mental status – they have altered level of
consciousness and need monitoring during applications to
ensure safety.
3. Impaired circulation – those with diabetes mellitus or
congestive heart failure lack the usual ability to dissipate
heat via blood circulation making them at risk for tissue
damage. (pt. na may mga ganitong sakit hindi pwedeng
lagyan ng hot/cold application)
4. Post-surgery – heat increases bleeding and swelling. (kaya
hindi tayo nag aapply sa operation site kase baka mag
cause un ng swelling or bleeding)
5. Open wounds – cold can decrease blood flow to the
wound and impair the healing process.
 Very hot or cold we put cloth.
Rebound Phenomenon
- Occurs at the time the maximum therapeutic effect of a hot or
cold application is achieved and the opposite effect begin
Therefore, thermal applications must be halted before this
phenomenon begins.
Applying heat
Dry heat is applied locally by means of:
 Hot water bag
- Common dry heat used at home.
- Convenient and relatively inexpensive.
- Considered safe and provide desired effect for normal
adult and child over 2 years is 46 C to 52 C (115 – 125 F)
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
- Debilitated or unconscious adult or child under 2 years:
40.5 to 46 C (105 to 115 F)
Aquathermia pad
- Aquamatic pad (also known as K-pad)
- The pad is attached to the tubing to and electrically powered
control unit that has an opening for water and temperature
gauge.
Hot and Cold Packs
- Commercially prepared hot and cold packs provide heat or
cold for a designated time.
- Directions on the package tell how to initiate the heating or
cooling process e.g., by striking, squeezing, or kneading the
pack.
- Kapag sobrang taas ng lagnat gumamit ng malamig na tubig
pero kapag may lagnat at giniginaw hindi pwedeng malamig
na tubig ang gamitin dpt tepid lng or ung galling sa gripo.
Electric Pad
- Provide constant, even heat, lightweight and can be molded to
a body part.
- Can burn if the setting too high.
Ice bags, Ice Gloves, and Ice Collars
- Are filled either with ice chips or with an alcohol-based
solution.
- They are applied to the body to provide cold to the localized
area.
Compresses
- Can either be warm or cold
- A hot compress is ordered, the solution is heated to the
temperature indicated by the order or according to agency
protocol.
Soak
- Refers to immersing a body part in a solution or to wrapping a
part in gauze dressings and then saturating the dressing with a
solution.
Sitz bath
- Or hip bath, used to soak a client’s pelvic area.
- The client sits in a special tub or chair and is usually immersed
from the midthighs to the iliac crests or umbilicus.
Therapeutic baths
- Usually ordered by a physician, given for physical effects such
as to soothe irritated skin or to treat an area.
- Medications maybe place in the water.
Cooling sponge bath
- Purpose: reduce a clients fever by promoting heat loss through
conduction and vaporization.
- Used with extreme caution and only for clients with very high
temperatures such as over 40 C, because rapid skin
temperature drop can cause chills that actually increase heat
production.
AK 5 of 12
FROM COURSE UNIT
Application of Moist Heat: Moist Compress and Sitz
Bath/Soak
FIRST: Introduce self and identify the client by asking for at least
2 identifiers (e.g. name, birthday, age, etc.)
Assessment:
1. Verify order for type of moist heat application, location
and duration, and desired temperature.
2. Review client’s chart for medical history and
contraindications that may prohibit the use of hot or warm
therapy.
3. Assess client’s vital signs and mobility.
4. Assess client’s skin around the area to be treated and
client’s temperature and pain sensitivity.
5. Inspect wound, if any, for size, color, odor, tenderness,
drainage.
6. Assess client and family’s awareness, understanding of
the procedure, and related safety factors.
Planning:
1. Identify expected outcomes
2. Assemble and prepare the equipment and supplies needed.
Implementation
Always provide privacy.
a. Applying moist sterile compress: Materials needed: Moist
compress (e.g. commercially prepared, aquathermia pad,
etc.); Sterile gauze pads or roll (size and number depends
on the body part of client to be treated); Heating
equipment (to warm the water to the needed temperature),
Water proof pad or clean dry towel, Water container/
basin), Gloves (1 pair clean and 2 pairs sterile)
1. Explain the procedure and purpose to the client, sensations the
client would feel and precautions to prevent burning.
2. Heat water to the desired temperature for moist compress. (For
aquathermia pad use, prepare and set the desired temperature.)
3. Perform hand hygiene and put on a pair of clean gloves
4. Keep client’s body part in proper alignment, drape client as
need, exposing only the body part to be treated.
5. Place a waterproof pad under the client’s body part, if
appropriate
6. Remove any wound dressing present, inspect condition of
wound and surrounding skin.
7. Dispose gloves and dressing into a biohazard bag. Then
perform hand hygiene.
8. Prepare the compress:
a) Pour the warm solution into a container: Follow
instructions for warming using commercially prepared
compress.
b) Wear sterile gloves
c) Using the sterile technique, open the gauze
d) Immerse gauze into the container of water
9. Pick up one layer of gauze, wring out excess water and apply
onto the wound and its surrounding skin
10. Lift gauze to initially assess for redness due to the moist heat
applied.
11. Pack the moist gauze snugly if client tolerates the compress
covering all wound surfaces.
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
12. Cover moist compress with dry sterile gauze and clean bath
towel. Secure as appropriate; use pin, tie, etc. (Apply
aquathermia or water-proof heating pad if available)
13. Dispose gloves properly and perform hand hygiene.
14. Check back with client after 15 minutes and assess. Change
moist compress using sterile technique if heat pad is not used.
15. After 30 minutes, or as ordered, remove the moist compress
using clean gloves.
16. Reassess wound and surrounding skin condition. (Replace
with dry sterile dressing, if ordered or as necessary, using
sterile technique, i.e. use sterile gloves and sterile gauze)
17. Help client to preferred comfortable position.
18. Dispose all soiled material and equipment appropriately and
perform hand hygiene.
Applying sitz bath or warm soak to sutured wound:
Materials: Sitz bath/tub equipment; Heating equipment (to warm
the water to the needed temperature), Clean and dry blanket or bath
towel, 3 pairs clean gloves
1. Heat water to the desired temperature in a separate container.
2. Perform hand hygiene and wear clean gloves.
3. Remove any existing dressing over the client’s wound and
inspect the condition of the wound and skin, especially the
suture line.
4. Dispose of the soiled dressing and gloves appropriately and
perform hand hygiene.
5. Apply clean gloves again and clean the suture and surrounding
skin.
6. In the client’s bathroom, fill the sitz bath container with the
warmed water. Check its temperature.
7. Assist client to the bathroom or to the bedside commode and
immerse body part into the bath and cover patient with blanket
or towel as needed. Remove and dispose gloves.
8. Assess client’s heart rate and ensure that client is not
lightheaded. Place the call button/ call light switch is within
reach.
9. After 20minutes, or as ordered, wear clean gloves, remove
client from the soak. Dry client, as necessary, and assist client
back to bed on position of comfort.
10. Drain the used sitz water and clean the equipment properly.
Place in the appropriate storage area. Dispose of soiled blanket
or towel and gloves and perform hand hygiene.
STOP the application immediately if any untoward incident or
problem(s) occur.
Evaluation:
1. Inspect the body part or wound condition for evidence of
effectiveness of therapy and sensitivity to touch.
2. Ask client to describe level of comfort and burning sensation
following the treatment.
3. Obtain vital signs and compare with baseline.
4. Identify any unexpected outcome.
Recording and Reporting: Record, document, and report all
pertinent information of the procedure performed.
Application of Cold
FIRST: Introduce self and identify the client by asking for at least
2 identifiers (e.g. name,
birthday, age, etc.)
AK 6 of 12
Assessment:
1. Verify order for type of moist heat application, location and
duration, and desired temperature.
2. Review client’s medical history and contraindications that may
prohibit the use of cold therapy
3. Assess client’s vital signs and mobility.
4. Assess client’s skin around the area to be treated and client’s
temperature and pain sensitivity.
5. Inspect wound, if any, for size, color, odor, tenderness,
drainage.
6. Assess client and family’s awareness, understanding of the
procedure, and related safety factors.
Planning:
1. Identify expected outcomes
2. Assemble and prepare the equipment and supplies needed.
Implementation:
Provide privacy at all times.
a) Applying a cold compress: Materials needed: Cold
compress may be commercially prepared, a towel, or
gauze pads or roll (size and number depend on the body
part of client to be treated); Ice, Container/basin,
Waterproof pad or clean dry towel, 1 pair clean gloves
1. Explain the procedure and purpose to the client, sensations the
client would feel and precautions to prevent complications.
2. Perform hand hygiene and put on a pair of clean gloves
3. Keep client’s body part in proper alignment, drape client as
need, exposing only the body part to be treated.
4. Place a waterproof pad or towel under the client’s body part, if
appropriate.
5. Place ice water into a basin and check the temperature.
6. Submerge gauze pad or towel into the water and wring out
excess moisture.
7. Apply compress to affected area, molded over the site.
8. Remove, remoisten, and reapply to maintain the cold
temperature as needed.
9. Check skin condition at appropriate and regular intervals.
10. After Remove gloves, dispose of properly, and perform hand
hygiene.
11. Help client to a comfortable position.
12. Remove, clean, dry, and store or dispose of supplies and
equipment accordingly.
Applying an ice pack or bag
Materials needed: Ice bag or commercially prepared ice gel pack;
Ice, Container/basin, Waterproof pad or clean dry towel, 1 pair
clean gloves
1. Explain the procedure and purpose to the client, sensations the
client would feel, and precautions to prevent complications.
2. Perform hand hygiene and put on a pair of clean gloves
3. Keep client’s body part in proper alignment, drape client as
need, exposing only the body part to be treated.
4. Place a waterproof pad or towel under the client’s body part, if
appropriate.
5. Fill bag with water (approximately 2/3 full) and ice.
6. Express excess air from bag, secure cap, and wipe the bag dry.
7. Apply over injury, mold and ensure it is secure in place.
*For commercially prepared ice gel pack, squeeze and knead
then wrap with towel.
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL

8. Check skin condition at appropriate and regular intervals.

9. After 30 minutes, or as ordered, remove gloves, dispose of
properly, and perform hand hygiene.
10. Help client to a comfortable position.
11. Remove, clean, dry, and store or dispose of supplies and
equipment accordingly.
STOP the application immediately if any untoward incident or
problem(s) occur.
Evaluation
1. Inspect the body part or wound condition for evidence of
effectiveness of therapy and sensitivity to touch.
2. Ask client to describe level of comfort and burning sensation
Signs of Impending Death
following the treatment.
Loss of Muscle Tone
3. Obtain vital signs and compare with baseline.
a. Relaxation of the facial muscles (jaw may sag)
4. Identify any unexpected outcome(s).
b. Difficulty speaking
Recording and Reporting: Record, document, and report all
c. Difficulty swallowing & gradual loss of the gag reflex.
pertinent information of the procedure performed.
d. Decreased activity of the GIT, with subsequent nausea,
accumulation of flatus, abdominal distention & retention of
DEATH & DYING
feces.
Terminal Illness
e. Possible urinary & rectal incontinence due to decreased
 a disease that will result in the death of the patient regardless
sphincter control
of any treatment intervention. A patient is considered
f. Diminished body movement
terminally ill when their estimated life expectancy is six
months or less, under the assumption that the disease will run
Slowing of the Circulation
its normal course.
a. Diminished sensation
 Dying- to pass away or transit to another world b. Mottling & cyanosis of the extremities
 Death- state when life ceases c. Cold skin, first in the feet and later in the hands, ears and
Stages of Death and Dying nose (however the client may feel warm due to elevated
(Elizabeth Kubler-Ross, 1969, 1974) temperature)
Denial Changes in Vital Signs
 It is the immediate response to loss experienced by most a. Decelerated and weaker pulse
people and it is a useful tool for coping. b. Decreased BP
Anger c. Rapid shallow, irregular, or abnormally slow respirations;
Cheyne strokes respirations; noisy breathing, referred to
 The client has no control over the situation and thus becomes
as death rattle due to collecting of mucus in the throat;
angry in response to this powerlessness.
mouth breathing, which leads to dry oral mucus
 The anger may be directed at self, God, and others.
membranes.
Bargaining
Sensory Impairment
 The anticipation of the loss through death brings about
a. Blurred vision
bargaining through which the client attempts to postpone or
b. Impaired sense of taste & smell (hearing is the last sense to
reverse the inevitable.
disappear)
Depression
 When the realization comes that the loss can no longer be Summary of Signs of Impending Death
delayed, the client moves to the stage of depression.
 It helps the client detach from life to be able to accept death.
Acceptance
 The final stage of acceptance may not be reached by every
dying client, however, “most dying persons eventually accept
the inevitability of death, many want to talk about their
feelings with family members:
 Verbalization of emotions facilitates acceptance.

AK 7 of 12
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
Clinical Signs of Death
 Cessation of the apical pulse, respirations and blood pressure.
1. Total lack of response to external stimuli.
2. No muscular movement, especially breathing.
3. No reflexes.
4. Flat encephalogram for 24 hours.
Cerebral Death
 Occurs when the higher brain center, the cerebral cortex, is
irreversibly destroyed.
 Brain death (also known as brain stem death) is when a person
on an artificial life support machine no longer has any brain
functions. This means they will not regain consciousness or be
able to breathe without support.
Body Changes
Rigor Mortis
 Stiffening of the body that occurs about 2 to 4 hours after
death due to lack of Adenosine Triphosphate (ATP), which is
not synthesized because of a lack of glycogen in the body.
 Starts in the involuntary muscles (heart, bladder, etc.) then
progresses to head, neck, trunk and finally reaches the
extremities.
 Leaves the body about 96 hours after death.
Algor Mortis
 Gradual decrease of the body’s temperature after death.
 When blood circulation terminates and the hypothalamus
ceases to function, body temperature falls about 1 degree
Celsius per hour until it reaches room temperature.
Livor Mortis
 Bluish discoloration of the skin after death.
 After blood circulation has ceased, skin becomes discolored.
 The RBC breakdown, releasing hemoglobin, which discolors
the surrounding tissues.
Embalming
 Injection of chemicals in the body to destroy the bacteria.
 Tissues after death become soft & eventually liquefied by
bacterial fermentation.
 The hotter the temperature, the more rapid the change,
therefore, bodies are often stored in cool places to delay the
process.
Nursing Responsibilities
Promotion of Comfort
a. Relief of pain is critically important, the sooner the dying
client obtains pain relief, the more energy the client can direct
toward maintaining quality in the remainder of his life.
b. Provide personal hygiene measures, control pain, relief
respiratory difficulties, assists with movements, nutrition,
hydration and elimination, provide measures related to sensory
changes.
c. Facilitate expression of feeling, prayer, meditation, reading,
and discussion with appropriate clergy/spiritual advisor.
Promotion of Spiritual Comfort
a. Support client in his expression of the philosophy he has
chosen for his life.
AK 8 of 12
b. Attentive listening encourages client to express feelings,
clarify them, and accept his fate.
c. Praying silently with the client.
d. Make referral for spiritual counseling.
Care of the body
1. Place in supine position with arms at the side, palms down, or
across the abdomen (to make the body look as natural and
comfortable as possible).
2. Place a small pillow or folded towel under the heads (to
prevent discoloration from blood pooling).
3. Gently hold eyelids close for a few seconds to make it remain
close.
4. Insert client’s dentures to maintain the normal facial features.
5. Place a rolled-up towel under the chin to keep mouth closed.
6. Wash any soiled body parts, dress the body in a clean gown,
and cover the body up to the shoulders with clean linen.
7. Place absorbent pads under the perineal and rectal area to
collect any oozing feces or urine.
8. Remove all jewelries and present it and any valuables to the
family
9. If the wedding band is left in place, tape it securely to the
finger.
10. Allow family members to enter the room when body is
prepared never allow a single family member to enter the
room alone (for emotional support).
11. Special tags containing the deceased’s name, hospital number,
and name of the attending physician are placed on the wrist
and ankles and on the outside of the shroud.
12. In the morgue, body is placed in a special cooling unit to slow
decomposition.
Death Certificate
 Made out when a person dies, usually signed by the attending
physician and filled with a local health or other government
office.
 Family is given a copy to use for legal matters.
Labeling of the Deceased
 If appropriately identified and prepared incorrectly can create
legal problems.
 Placed on the wrist, ankle, and on the shroud.
 Contains name of deceased, Hospital number and name of
attending physician
Autopsy or Postmortem Examination
 An examination of the body after death and is performed only
in certain cases:
 When death is sudden or occurs within 48 hours of admission
to a hospital, the organs and tissues of the body are examined
to establish the exact cause of death.
 To learn more about the disease.
 To assist in the accumulation of statistical data.
 Consent should be obtained by the physician from the decent
(before death) or by the next of kin (surviving spouse, adult
children, parents, siblings)
 Hospitals cannot retain any tissues or organs without the
permission of the person who consented to the autopsy
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL
Loss
 An actual or potential situation in which something that is
valued is changed, no longer available or gone.
 Parting with an object, person, belief or relationship that one
values.
 Loss of body image, significant other, a sense of well-being, a
job, personal possessions, beliefs, a sense of self. etc.
Grief
 The total response to the emotional experience related to loss
which is usually resolved within 6 months to 2 years.
Types
1. Abbreviated grief
 Grief which is brief but genuinely felt; lost may not have
been sufficiently important to the grieving person or may
have been replaced immediately by another, equally
esteemed object.
2. Anticipatory grief
 Process of accomplishing part of the grief work before an
actual loss; grief response in which the person begins
grieving process before an actual loss.
3. Dysfunctional grief
 Occurs when there is prolonged emotional instability,
withdrawal from usual task or activities that previously
gave pleasure & lack of progression from one level to
successful coping with the loss.
a. Unresolved – extended in length and severity, no
resolution
b. Inhibited – repressed>>>>somatic manifestations
Grieving process
 Sequence of affective, cognitive & physiological states
through which the person responds to and finally accepts an
irretrievable loss.
Bereavement
 The subjective response experienced by the surviving loved
ones after the death of a person with whom they have shared a
significant relationship.
 Experience alterations in libido, concentration, patterns of
eating, sleeping, activity and communication.
Concepts which help the Nurse to Plan for Interventions
Mourning
 The behavioral process through which grief is eventually
resolved or altered.
 Process by which people adapt to a loss which is
influenced by cultural, customs, rituals, and society’s
rules for coping with loss.
Hope
 Characterized by a confident, yet uncertain expectation of
achieving a goal.
Closure
 The point at which the loss has been resolved and the grieving
individual can move on with life without focusing on the loss.
AK 9 of 12
URINARY CATHETERIZATION
Urinary system Anatomy
- Urinary Elimination depends on effective functioning of four
urinary tract organs: kidneys, ureters, bladder and urethra.
- The paired kidneys are situated on either side of the spinal
column, behind the peritoneal cavity. They are primary
regulators of fluid and acid base balance in the body. (ex.
There is excessive vol. in the body mag do-double work si
kidneys if there is excess fluid in the body. If there is problem
in the acid and base balance in the body kidneys is working by
retaining some acid and bases, base on the needs of the body.
Kapartner ng kidneys ang lungs in regulating the fluid and
acid base balance. If pt. has problem in kidneys may pain sa
plank area niya where kidneys are located)
- Once the urine is formed in the kidneys, it moves through the
collecting ducts into calyces of the renal pelvis and from there
into the ureters.
- The urinary bladder is a hollow muscular organ that serves
as a reservoir for urine and as the organ of excretion. Used to
excrete or expel the urine outside the body. (hollow means
there is space inside. Muscular organ means it is made of
muscle and if it is made out of this it has the ability to contract
and relax or expand. Organs composed of muscle like womb.
Reservoir means makes storage. Amount of urine that
stimulates urinary process. Residual urine this is the remaining
amount of urine in the bladder because we don’t excrete all of
the urine in the body.)
- The urethra extends from the bladder to the urinary meatus.
Notes:
 Kidneys- filters blood so that waste
will be excreted through urethra.
 Ureters- pair of tubes from kidneys
to bladder.
 Bladder- located at the center, reservoir or storage.
 Urethra- from the bladder to urinary meatus. One tube
extending to the meatus.
 Meatus- is the opening outside the body, found in both male
and female. Located on top of the penis and vulva.
 UTI- is common in women because of the length of urethra.
So if male have UTI there is something wrong because it is not
common in men.
 Front to back- In washing perineal are for woman.
Urinary Elimination
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL

How do we eliminate urine?

 For every movement in the body it has to start with a stimulus.
 Stimulus (should have adequate amount to urinate) to urinate
should occur first at the urinary bladder. When bladder is full
it will serve as stimulus for the stretch receptors located in the
bladder to send signal to the braid that you need to void. Once
that is stimulate your internal sphincter will relax and you will
start to void.
Altered Urine Production (Abnormalities)
 Polyuria
- (or diuresis) refers to the production of abnormally large
amounts of urine by the kidneys. 2.5L/day.
- Poly- many, Uria- urine
- If we ingested a lot of fluids or some medications that can
cause this.
 Oliguria
- low urine output, usually <400 ml a day.
- Olig- low, Uria- urine
- If we are dehydrated or some medications that can cause
this.
 Anuria
- refers to a lack of urine production; >50ml/day.
- A- absence, Uria- urine
 Polyuria, oliguria and anuria
- refers to the production of the urine.
-  next words will be about how we expel urine.
 Urinary Frequency
- Voiding at frequent intervals more than the usual.
- Ihi ng ihi, common in weather conditions.
 Nocturia
- Voiding more than two times at night.
- Noct- night, Uria- urine
 Urinary Urgency
- feeling that the person must void immediately.
 Dysuria
- painful urination.
- Dys- difficult or painful.
 Enuresis
- repeated involuntary urination in children at night.
- Urinate ka na hindi mo controlled.
 Urinary retention
- Results from over distention of the bladder.
- Urine accumulates.
 Neurogenic bladder
- Unperceived bladder fullness
- Bladder is full but you cannot feel that it is full.
Note: Micturition- means process of urinating, process of
production or release of urine or void.
Urine components
 Normal urine consists of 96% water
and 4% solutes.
 Organic solutes include urea,
ammonia, creatinine, and uric acid. Notes:
 Urea is the chief organic solute.  Dark amber- have problem in fluids.
Sodium chloride is the most  Cloudy- problem in UTI cause may puss or nana.
abundant inorganic salt.  Dark orange- if dehydrated.
 Red- presence of blood.
AK 10 of 12
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL

Notes: According to Catheter Material Used

 Urine should be colorless to pale yellow or we call it amber.  Plastic catheters
 Dragon fruit na red can cause pink urine. - Used for short periods because of inflexibility
Catheterization - 1 week or less
- It is the insertion of a hollow tube through the urethra into the  Rubber catheters
bladder to urethra to drain urine. (lumen means space in the - Used for 2-3 weeks
tube. This is a STERILE PROCEDURE so wear sterile gloves. - Assess client for latex-allergy. (to test latex allergy, wear
- Purposes: latex gloves and kapag kumati ito mean u have latex
 To relive discomfort due to bladder distention or provide allergy)
gradual decompression of distended bladder. (for pt. who - Common in hospital
cannot expel urine)  Silicone catheters
 To assess the amount of residual urine if the bladder - For long term use (2-3months)
empties incompletely. - Expensive
 To obtain urine specimen - Common in hospital
 To empty the bladder completely prior to surgery.  PVC catheters
 To facilitate accurate measurement of urinary output for - Used for 4-6 weeks
critically ill clients whose output needs to be monitored - Soften at body temperature and more comfortable to use.
hourly. (if pt. is in the ICU there should be strict
monitoring of input and output- amt. of urine excreted)
 To provide for intermittent or continuous bladder drainage
and irrigation. (specially for client who undergo surgical
procedure. Male procedure that you have to provide
continual bladder drainage in the urethra and it is called
BPH benign prostatic hyperplasia)
 To prevent urine from contacting an incision after perineal
surgery.
 To manage incontinence when other measure has failed.  This is two way silicon catheter.
(for elderly clients they cannot control urination anymore  Injection port- this is where we introduce fluids
so they use condom catheter common in soldiers)  Ball- where fluids goes, used to anchor
Types of catheters  Don’t pull if pinaalis ang catheter inflate first
According to the number of lumens:
 Straight catheter (non-retention)
- Single lumen tube
- Used in surgery or laboring
 Two-way Catheter (foley, Retention)
- Double lumen catheter
- Most common catheter in ward.
 Three-way Catheter
- Triple lumen catheter used in bladder irrigation.
- For continuous bladder urination.

AK 11 of 12
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY (DASH 10): 1ST YEAR SUMMER FINAL

Positions in Catheterization

Sterile Drapes Position

Male Female

 Put lubricant first, if naka pasok na inflate the balloon

 

AK 12 of 12