Fundamentals of Nursing Notes

FUNDAMENTALS OF NURSING notes
Reference: Kozier & Erb’s Fundamentals of Nursing
PHYSICAL HEALTH EXAMINATION

- obtaining objective data (collected by professionals)
o Subjective data are complaints and experienced by patients
- Use of one’s senses
- To assess structure and functioning of an area (if functioning well or may abnormalities)
Considerations:
- Should be systematic (pattern)
o Head to toe (cephalocaudal)
o Sometimes focus assessment is done
 Focus and prioritize the area being complained or have problems (area of focus)
- Consider the age of patient
o Children are irritable
 Greatest fear – body mutilation
o Seeing instruments not familiar to them ex. Syringe, steth
o Has stranger anxiety – peaks at 8 mos but continues till toddler
o Ayaw nila iwananan sila ng mother nila
o For children like these: huwag pilitin, try mo munang itry sayo or if may doll
siya, don na muna
 Elderly – consider changing positions
- Consider the severity
4 basic techniques (IPaPeA)
(systematic way – mauuna muna yung di muna hahawakan pt.)
- Inspection – sight
o Visual examination of a nurse by naked eye or with lighted instrument
 Ex. Otoscope for ear
 Consider pt privacy
o Other senses may be considered
 Hindi lang puro sense of sight, siya lang yung main
 Kasama yung sense of smell cues (olfactory), auditory (if nakakairning ka ng hearing cues only,
like while you inspect, may naririning agad na sounds)
o Main focus are
 Overall appearance of health and illness (active, maputla, lethargic, responding)
 Signs of distress (pain, dob)
 Immediately, there are abnormalities)
 Facial expression, mood (is their facial expression/mood in tune with the situation, or if they
are crying or grimacing in pain
 Size (abnormalities), grooming, hygiene – reflects health of patient
- Palpation – touch
o Examination of body using sense of touch
o 2 types of palpation:
 Light (superficial) - uunahin lagi
 Dominant hand fingers presses gently downward
o In a circular manner
 Mild
 One hand
 Deep
 Bimanual (Two-hands) - deeper

o Non-dominant hand will press over the distal interphalangeal joint of the
middle 3 fingers of dominant hand
 One hand
o Isa lang nagpapalpate (dominant), the nondominant hand will support the
mass/organ
o
o Depends on the data that you want to assess, there a re specific ahnd aprts to use
 Fingertips – texture (Smooth, rogugh) and consistency (soft/hard)
 Dorsum of hand – temperature
 Vibrations - palm
 Pads – tactile discrimination
- Percussion – strike
o Surgeon discovered this: using barrels of alcohol first and tried in patients
o Act of striking the body surface of the area you want to assess to elicit sounds and produce vibrations
that can be felt
 Used whether to determine whether a structure is air filled (expected organs: lungs, stomach if
flatulent), fluid-filled (stomach), or solid (liver, bones, muscle).
o 2 types
 Direct – strike directly with finger pads of 2, 3, 4, or mag-isang middle finger lang
 Deretso sa structure
 Rapid
 Wrist moves
 Indirect
 middle finger of non-dominant hand (pleximeter) feels and placed mismo sa skin ng
patient, measures the vibrations/sounds
 finger of dominant hand (plexor) strikes onto the pleximeter
o percussion sounds
 flatness – extremely dull
 indicates: very dense
 ex. Muscles and bones
 dullness – dull, thud-like sound
 dense tissues, solid organ pero hindi matigas
 liver, spleen, heart
 resonance –hollow sound
 Filled with air
 Hollow organs - lungs
 Hyperresonance – abnormal; booming sound
 Overdistention of air sacs (patients with emphysema)
 Tympany – musical/drum-like sound
 Stomach is air-filled – flatulent patients, colic infants/nb
- Auscultation – hearing
o Listening for sounds
o Stethoscope – amplifies sound
 Other examples are: doppler technology, fetoscope (FHR)
o 4 properties:
 Frequency - measure of vibration which is heard as pitch
 Low pitched or high pitched
 Intensity – loudness of sound
 Duration – length of sound
 Quality – reflects musical characteristics

 Moaning/grunt quality
 Reflects several characteristics
2 considerations during physical assessment
1. Positioning
a. Considerations:
i. Structure - depends on the area assessing
1. Abdomen – supine/relaxed position para di tense and organs
ii. Age
iii. Energy level
iv. Physical condition
2. Privacy
a. Proper draping
b. Exposure is only to the area being assessed to prevent patient embarrassment
c. Rights of patients
GENERAL SURVEY
- Whole person
- Systematic
o Appearance
 Body built, height and weight – proportionate, or excessively thin or obese
 Posture and gait (standing, sitting, walking) – relaxed, erect posture, coordinated movement
or tensed, slouched, bent posture, uncoordinated movements, tremors
 Overall hygiene and grooming – clean and neat or dirty and unkempt
 Body and breath odor – no body/breath odor or foul, ammonia odor, aceton/foul breath odor
 Signs of distress in posture/facial expression – no distress or bending over due to abd pain,
wincing, labored breathing
 Signs of health/illness – healthy appearance or pallor, weakness, obvious illness
o Level of comfort (in pain, distress)
o Mental status – brain – LOA-AST
 LOC – responds to stimuli (healthy) or impaired/comatose(no consriousness), no response
 LOC – awareness and responsiveness to surrounding environment
 Glasgow Goma Scale (GCS) – detailed assessment for high risk paitents or those who
really have disturbed mental status
 Orientation – X3 (person, place, time) is N, X2 X1 are not oriented
 X1 – person
 X2 – person and place
 X3 – person, place, time
 Attitude – cooperative or negative, hostile, withdrawn
 Affect/mood – appropriate or inappropriate according to situation
 Speech, org., quality – understandable, moderate space, thought association or rapid or slow
pace, lacks association, exhibits confabulation (fills in gaps na hindi totoo/nangyari; not
technically nagsisinungaling) (brain functioning)
 Thoughts, relevance and organization – logical sequence, makes sense, sense of reality or
illogical sequence, flight of ideas (jumping from one topic to another), confusion
o Vital signs
o Height and weight
 Height - Measuring stick attached to wall/weighing scale

 Remove shoes
 Stand erect
 Heels together
 Heels, buttocks, back of head leans against measuring stick
 Eyes looking straight/ahead
 Weight
 Remove items in pocket (jewelries, gadgets, anything that could affect weight
 Regular:
o Same time – preferably before breakfast/before drinking and eating
o Same clothing
- There are body parts that does not need the complete IPaPeA
Assessment of Integument – usually kasabay ng ibang parts
o Using inspections and palpation
 Color
 Usual color – is pink, tan, brown, live, yellow undertone
 Abnormal:
o pallor – pale
 arterial insufficiency, decreased blood supply, anemic
o cyanotic – bluish color (white skin to blue tinge), possible O2 deficiency
 perioral, nailbed, conjunctiva
o erythema – red
 inflammation, allergy, injury/trauma
o jaundice - yellow discoloration
 due to bilirubin (babies: red blood cell breakdown/hemolysis)
 liver problems - immature liver
 Moisture – N: dry
 Abnormal:
o Increased dryness
o Increased sweating – diaphoresis, could indicate low O2 (cool skin also
indicates low O2, may shock or bleeding)
 Temperature – N: normally warm
 Abnormal
o Hot - fever
o Cool – decreased circulation
 Texture – generally soft, with rough areas (elbows, heels, knees)
 Turgor – once pinched, bounces back immediately
 Checks hydration status
 Assessed by pinching one area of skin and it bounces back (<3 sec)
o Adult - medial arm/anterior chest
o pedia – abdomen
o More than 3 secs – decreased blood circulation fluid retention, poor hydration
status
Scale for edema – pitting (PNLE Nov 2021)
Edema – accumulation of fluid in interstial spaces
- Normal in legs of pregnant women due to uterine pressure
- Can be seen in pt with cardiovascular, kidney problems
- Low albumin (oncotic pressure)

Pitting - Indent the finger
Scaling – grading of severity
1. Depth
2. Time of return
HAIR
A. Scalp
a. Inspect for:
i. Evenness
1. Alopecia – patches of hair loss, unless chemo pts
B. Thickness/Thinness of hair (abnormals)
a. Thick hair, esp. in women – hirsutism (cushing’s syndrome: increased androgen secretion)
b. Extremely thin hairs – hypothyroidism (less T3, T4, calcitonin)
C. Texture and oiliness
a. Brittle hair – hypothyroidism, low metabolism
D. Infections/infestations
a. Flakes
b. Nits – lice/eggs
c. Fungal infections such as ringworms
E. Body hair – hirsutism (increased hair in females) – adrenal gland problems (too much androgen)
a. Decreased hair in legs = decreased/poor leg circulation
NAILS
A. Degree of angle – not greater than 180
a. Clubbing - greater than 180 degrees, chronic (long term) low O2 (hypoxia – heart or lung problems such as
COPD)
Anxiety – ngatngat ng hair, this is a sign
THORAX – chest, responsible for oxygenation

a. Shape
a. Normal: AP diameter is ½ of transverse diameter (1:2) and deretso ang spine
b. Barrel-shaped: equal ratio of AP:Transverse
i. Lung problems ex. copd
c. Kyphosis – exaggerated convex of the spine (kuba)
i. Copd, emphysema, alveoli porblems
d. Lordosis - exaggerated concave of the spine (Liyad)
e. Scoliosis – lateral deviation/curvature of spine (Side)
f. Kyphoscoliosis – combination of kyphosis and scoliosis
b. Breathing patterns
a. Normal – eupnea “EU” = normal
i. 16-20 adults
b. Too fast – Tachypnea rate “tachy” = fast, “pnea” = lungs
c. Too slow – bradypnea rate “brady” = slow

d. Too shallow – hypoventilation depth
e. Too deep – hyperventilation depth
f. Absent – Apnea
i. NB -10 secs of apnea is normal, more than that, report. Time it always
g. Irregular – emergency breathing patterns so report
i. Cheyne-stoke – hypo, hyper, hypo, apnea….
1. Brain problems, nag-aagaw buhay
ii. biot’s (irreg)
1. hyper, apnea (because of the opioid), hyper
2. opioid overdose – (depressants) respiratory depression
3. lungs tries to compensates
iii. kussmaul’s
1. hyperventilation + tachypnea
2. want to expel more co2/air
3. DKA patients (CO2 is acidic, and body compensates by expelling c02)
a. Ketones – product of fat metabolism, releases co2/carbonic acid
b. Diabetic – sugar nasa blood, so naghihingalo ang cell, so gumagamit ng fats
c. Breathing effort
a. Normal – silent, effortless
b. Abnormal – problem with O2
i. Use of accessory muscles
ii. Nasal flaring – air hunger
iii. Facial straining – effort matindi
iv. Pursed lip breathing – increased effort in breathing
v. Chest retractions
d. Auscultation
a. Stethoscope
i. Tubing - have rubber so always check for latex allergy (emergency: severe allergic reaction)
ii. Chestpiece (ON)
1. Bell – low pitched
2. Diaphragm – high pitched
iii. Earpiece – away from ear
b. Inhale deeply and slow
c. Exhale normally/passively
e. Breath sounds
a. Vesicular – lungs, smaller airways (bronchioles/alveoli)
i. Soft intensity, low pitched

ii. Gentle sigh
b. Broncho-vesicular - bronchi
i. Moderate intensity, moderate pitched
ii. Blowing sound
c. Bronchial – trachea
i. High-pitched, loud
f. Adventitious Breath Sounds
a. Crackles (rales) – fine, short, interrupted crackling sounds
i. Hair rubbed, velcro
ii. There is moisture
iii. Pulmo edema - fluid volume excess (FVE), pneumonia - mucus
b. Gurgles (rhonchi) – continuous, low pitched, coarse, gurgling, harsh, louder sounds with moaning or
snoring quality
c. Friction Rub – superficial grating or creaking sounds
i. Leather grating
ii. pleuritis (outer layer of lungs is inflamed) – nagkikiskis
iii. during inspiration, sometimes in exhalation, cannot be expelled using cough
d. Wheeze -whistling
i. Continuous, high pitched, squeaky musical sounds
ii. Lower respiratory = bronchoconstriction
iii. Pag humihina ang wheezing, gumagaling if nagtatake ng bronchodilators. Pag hindi, totally na
nagcloclose na ang airways
iv. Complete airway obstruction – brain damage as fast as 3-5 minutes
v. exhalation
g. Thoracic Expansion
ASSESSING INFANTS THORAX AND LUNGS

- The thorax is rounded/barrel shaped (N)
- Tactile fremitus
o Feel vibrations (palpated)
o Infants: crying (hintaying umiyak)
o Adults: Words like “one two tree”, “blue moon”
o N: vibrations
o Ab: masyadong mahina or malakas
- Infants intend to breathe using their diaphragm (place hand in abdomen)
o If crying, rate is faster/irregular
o Adult: chest
- Right bronchial branch (pagnaka-apirate ng foreign object)
o Mas Malaki ang diameter
- Infants breathe exclusively thru nose
BREAST AND AXILLAE
A. Apperance
a. Round, essentially symmetrical (one breast is often slightly larger that the other – dominant hand is
connected to pectoralis muscle)
B. Skin
a. Smooth, intact, areola is darker, round
b. Abnormal: orange-peel skin

C. Nipple
a. Everted, without discharge/lesions.
b. Abnormal: flattening, redness, edema
Palpation of lymph nodes and breast – a week after menses (low estrogen)
1. Hands of the clock pattern
2. Spokes on a wheel pattern
3. Concentric circles pattern – walang mamimiss
4. Vertical strips pattern - walang mamimiss
a. Start in upper outer quadrant breast, near the axillae
CARDIOVASCULAR ASSESSMENT (CHEST AREA)

Anatomic Sites of Precordium/listening heart sounds (All People Enjoy Time Magazine/ Ang PET Mo)
A. Aortic area – R 2nd ICS
B. Pulmonic area – L 2nd ICS
C. Erb’s point – (S1 S2) L 3rd ICS
D. Tricuspid area – Lower L Sternal Border, 4th ICS
E. Mitral Area – L 5th ICS, medial to midclavicular line
a. Loudest, PMI, area of left ventricle (ventricles pumps blood systemically)
2 sounds – closure of valves (allows no regurgitation)
a. Lub – s1
a. Dull, low
b. AV valves (mitral/bicuspid, tricuspid valve)
b. Dub – s2
a. Higher pitched
b. Semilunar valves
c. S3 – ABNORMAL (Ken-Tucky) magkadikit s2 and s3
a. D
d. S4 – ABNORMAL (Mis-Si-Si-Ppi)
Extra heart sounds are normal in:
- Pregnant women
a. Increased volume in pregnancy
Relationship of heart sounds to systole and diastole
Heart
A. Inspect, palpate, auscultate
ABDOMINAL ASSESSMENT
IAPePa – Palpating and percussing first will elicit pain (can’t proceed with examination) and can disturb bowel sounds
(auscultation inaccurate as it activate bowel sounds)
4 quadrants (division by sternum - vertical and umbilicus - horizontal)

- RUQ -
- LUQ - kidney
- RLQ - right ovary, right spermatic cord,
- LLQ
9 abdominal regions (PNLE 2021, divided by midclavicular line – vertical; below rib/costal margin – 1 st horizontal and
midway between umbilicus and symphysis – 2nd horizontal)
- Regions
o RH
o Epigastric
o LH
o RL
o Umbilical
o LL
o RI
o Hypogastric
o LI
Too much pressure in aorta if visible pulsation in abdomen – prone to rupture

Landmarks commonly used to identify abdominal area (abnormalities)
1. Xiphoid process
2. Costal margins
3. Midline
4. Anterior superior
5. Iliac spines
6. Umbilicus
7. Inguinal (Poupart’s)
8.
Auscultation
- Bowel sounds: tinkling, gurgling noises (irreg)
- Every 5-20 secs.
- Normal: 5-30 BS/min
- Borborygmi sounds – Hyperactive bowel sounds, more than 30
- Others:
o Vascular sounds/blood vessel sounds
 Bruits – whooshing sound – aneurysm
o Peritoneal friction rub – grating of organ lining
- Considerations:
o Warm – if cold, abdomen will contract and auscultation is disrupted
o Diaphragm
Percussion
- Starts in RLQ-RUQ-LUQ-LLQ
- Systematic
- Percuss for presence of tympany (gas in stomach/intestine)
- Dullness – dense organs (liver, pancreas, spleen);
o Other areas should never be dull as it may indicate fluid or mass

o Abnormally large area of dullness: may indicate fluid or mass/tumor
PALPATION
- Light first before deep palpation
- Ensure pt position is relaxed – relaxed abdominal muscles
o Put pillow in the head
o Flex knee
- Warm hands – cold hands can make the abdomen tense and organs will contract
NEUROLOGIC SYSTEM
A. Mental status – reveals client’s general cerebral function
i. Intellectual (cognitive) – backwards counting
ii. Emotional (affective) functions – is mood appropriate to the situation
3. LOC – N: fully alert – responds to stimuli
a. Alertness to Coma - lowest (AVPU)
i. Alert (awake and enthusiastic)
ii. Verbal
iii. Pain
iv. Unresponsive
b. GCS – 3 indicators (EVM)
i. Lowest possible score – 3
ii. Highest possible score – 15
4. Cranial Nerves – specific nerve functions and assessment methods for each cranial nerve to detect abnormalities
(sometimes specific ang chinecheck, or high risk sila then lahat)
a. CN 1 – olfactory
i. Smell coffee, alcohol, and they can detect it (takpan yun isang butas while doing so)
b. CN 2 – optic
i. visual
c. CN 3 – oculomotor
i. Eye movement
ii. Look to left, r up down
d. CN 4 – trochlear
i. Eye movement
e. CN 5 – trigeminal (3 assessments)
f. CN 6 – abducens
i. Eye movement
g. CN 7 – facial
i. Ngiti po kayo?
h. CN 8 – vestibulocochlear/acoustic
i. Balance and hearing
i. CN 9 – glossopharyngeal
i. Dulo ng dila but near throat, swallowing, gag reflex (but not so much)
j. CN 10 – Vagus
i. Gag reflex (using tongue reflex) main
k. CN 11 – spinal/accessory
i. Motor
ii. Press balikat/side of head and papaangat, lagyan ng resistance
l. CN 12 – hypoglossal
i. Dulo ng dila
m. 2 functions:
i. Motor function – evaluates proprioception and cerebellar function
ii. Sensory function – touch, pain, temperature, tactile discrimination
1. Assessment:
A. light touch – touch various body areas with a wisp of cotton
B. vibration – tuning fork
C. pain - toothpick
5. Reflexes – automatic response of the body to a stimulus
a. Unconscious reaction
b. Deep tendon reflex is activated when a tendon is stimulated (tapped) and its associated muscle contracts
i. Patella, knee jerk
c. Hyperreflex – irritable brain
d. Hyporeflex – depression of brain
ASSESSMENT OF GENITALIA
Female
- Outer
o Examine labia minora, majora, clitoris, and vaginal opening – pink with brown pigmentations
o N vaginal sections – white, colorless, odorless
o Abnormal – foul-smelling, purulent discharge
- Development
o Stage 1: Pre-adolescent
 No pubic hair
o Stage 2: Puberty (11-12)
 Sparse hair
o Stage 3: 12-13
 Darker and curlier hair over symphysis
o Stage 4: 13-14
 Adult-like, none in thigh
o Stage 5: sexual maturity
 Adult appearance
 Appear aspect of thigh
Male
- Circumcised/not
o If not: gently retract the skin
- Smegma – normal white discharge (collected in foreskin if hindi tuli)
- Scrotal sac is mature if wrinkled
o Lower: left scrotal sac
- Tanner Stages (12-16)
o Same with female
ASSESSMENTS OF EXTREMITIES
Muscle strength
Grading scale:
- 0 – no detectable MC
- 1 – barely detectable MC
- 2 – complete ROM w/ gravity eliminated
- 3 – complete ROM against gravity
- 4 – complete ROM against gravity with some resistance
- 5 – complete ROM against gravity and full resistance (best/N)
Presence of tremors - abnormal
- Tremor – involuntary trembling of a limb or body part
o Intentional – more apparent when client attempts a voluntary movement ex. May hawak na phone
o Resting tremor – more apparent when resting
Arterial Pulses (artery – gives O2 bld)
Grading scale
- 0 – absent; no circu in the area
- 1 – diminished; thready; easily obliterated
- 2–N
- 3 – increased; full volume
- 4 – bounding hyperkinetic
Deep Tendon Reflex – because of the brain (sites: biceps, triceps, patellar, achilles)
Grading Reflect Response:
- 0 - no reflex
- +1 - minimal act
- +2 - normal response
- +3 - more act than normal
- +4 - Hyperactive response
o Electrolyte imbalances/CNS problems/cerebral irritation
Capillary Refill Time

- Simple test of circulatory status that uses nailbed
o Press down on the nailbed until it turns white
o Release
- Note time color returns after releasing pressure
- N refill time <2 sec (good circulation)
- More than that – poor circu
-
VITAL SIGNS (any deviations: can be life-threatening)

- No specific arrangements
- Or it depends on the focus of patient
- RR is concern of infants
Cardinal signs – important, essential, high level

- Important body organs are being assessed by it so vital
- Measures physiological stat
- Taken by health professionals
- Assess the most basic body functions of most vital rogans
1. Body temperature
a. 2 types
i. Surface temp – easily changes by the envi of pt; least invasive
1. Skin, SC, fat
ii. Core Temp – deep tissues; “thermisor”; accurate; measured also if life threatening like hyper and
hypothermia
1. Bladder (pelvic cavity)
2. Esophagus (abdominal cavity)
3. Rectal
b. Regulation of body temp
i. 3 main parts
1. Sensors in the periphery (skin – more sensitive to cold) and in the core
2. An integrator found in the HYPOTHALAMUS
3. An effector system (inuutusan ng brain to stabilize the body temp)
c. Factors affecting heat production
i. BMR – basic metabolic rate, will increase
1. Increased – during exercise
ii. Muscle activity – more activity, more heat
iii. Thyroxine T4 – from thyroid gland, responsible for BMR, and heat prodcuiton
iv. Catecholamines (epi, nore) – released from medulla, SNS (activated: increased epi and nore),
Stress response
v. Fever – body produces heat to fight infection
d. HEAT LOSS
i. Radiation – transfer of heat without contact
1. Ex. NB was put near wall in an air conditioned room. NB was warmer and smaller, wall is
bigger and radiates cold (extreme temp)
ii. Conduction – transfer of heat upon contact
1. Ex. Warmer baby is put into cold weighing scale without clothes on. There is a transfer of
temperature
iii. Convection – dispersion of heat by air currents, no surface
1. Ex. Baby is far from scale and wall but since we have warm air near us, baby release heat
iv. Evaporation – loss of moisture thru breathing and skin;
1. Continuous vaporization of moisture from the respi tract mucosa of the mouth and skin
e. Receptors in the skin
i. Most sensors are in the skin
ii. (peripheral receptors) Sensitive to cold than warm
f. 3 physiological processes to icrease body temp
i. Shivering/chills – increases heat production – tatas BMR- tataas heat production
ii. Sweating – inhibited to decrease heat loss (stopped)
1. Absence of sweating - anhydrosis
iii. Vasoconstriction – decreases heat loss
1. Causes discoloration in the skin
g. Hypothalamus integrator controls core temp = detects heat = send out signal to reduce body temp
h. Factors affecting body temperature
i. AGE
1. Infants – influenced by envi

2. Children – (fluctuate) vary more than those of adults until puberty (magiging stable)
3. Older adults – sensitive to extreme temp dur to decreased thermoregulatory controls
(heat stroke and hypothermia)
a. Over 75 years – risk of hypothermia (temp below 36 C or 96.8 F) due to problem
with heat production
b. In Ms, <35 C – life threatening
4. Diurnal variations (circadian rhythms)
a. Varies as much as 1 C (1.8 F) between early morning and later afternoon – body
prepares to sleep
b. Point of highest body tem – 4 PM – 6 PM
c. Lowest point – 4 AM – 6 AM
ii. EXERCISE – hard work/strenuous exercise can increase body temp to as high as 38 C (taken rectally
– core)
iii. HORMONES – ovulation raises body temp by 0.5 F – 1 F (progesterone has thermogenic effect)
iv. STRESS – stimulates SNS which increases production of epi and nore from adrenal medulla
v. ENVIRONMENT- temp cannot be modified in a very warm room – temp will be elevated
i. Alterations in body Temp
i. Cells are injured and dehydration – sobrang init
ii. Cell injury and poor circulation in hypothermia
iii. Hyperpyrexia – 41
iv. More than 42 – death
v. Below 35 – death
vi. Phases
1. Onset/cold/chill phase – low temp
a. Increased HR, RR, depth
b. Shivering
c. Pallid, cold skin
d. Feeling cold
e. Cyanotic naibed
f. Gooseflesh appearance
g. Cessation of sweating
h. Interventions: help client decrease heat loss by
2. Course/plateau (peak)
a. Absence of chills
b. Feels warm
c. Increases pulse and RR, thirst
d. Mild-severe dehydration
3. Deferescence/ flush phase/ fever abatement
a. Skin appears flushed and feels warm
b. Sweating
c. Decreased shivering
d. Possible dehydration
e. Interventions:
i. Monitor vs
ii. Remove excess blankets when feels warm, extra warmth when feling chills
iii. Adequate nutrition and fluids (2.5-3L)
j. 4 types of fever N: 36-37.5 C
i. One day (key word: TENT, ilan ang rate ng tent: 1 day)
1. Intermittent – on/off
2. Remittent – cont.
a. There are fluctuations, all of which are ABOVE NORMAL

ii. Several days
1. Relapsing – on/off
a. Days of on/off fever usually a day or 2
2. Constant – cont.
a. Always remains above normal in several days
b. Fluctuates minimally
iii. Fever spike – temp that rises to fever level rapidly following a normal temp then returns to normal
1. usually caused by bacterial infections
2. blood culture – obtained during fever spike to know the cause of infection
iv. Hyperthermia – NOT A FEVER! These are heat induced illnesses due to increased temp of
environement (39.2 C) and exertion
1. Heat exhaustion – papunta ng heat stroke (HATDOR Mnemonic)
a. Headache
b. Anxiety
c. Thirst/Temp below 38.8 C
i. Anything higher, papunta ng stroke
d. Diaphoresis
e. Orthostasis
f. Gooseflesh
2. Heat stroke – life threatening, stroke like features, CNS affectations (LOC, delirium, signs of
dehydration – can lead to shock)
k. Ways to measure body temo
i. Most common/accessible and convenient – oral (26.5-27.5 3-5 min)
1. Placement: Under tongue, either side of frenulum
2. Wait if took hot/cold beverafe for 30 mins
3. Accessible, convenient
4. Break if bitten, inaccurate if smoked, can cause injury after oral surgery,
ii. Most accurate/reliable – rectal (37 – 38.1 C, 1-2 min)
1. Apply clean gloves
2. Lubricate 2 inches
3. Instruct client to take a slow deep breath during insertion to ease pt
4. Never force thermos if resistance is felt
5. Insert in a circular/rotating motion
6. Insert 1 ½ inches in adults, 1 in for child, ½ inch infant
7. Least desirable for infant, last route to be used for infant
iii. Least accurate but most safe (noninvasive) – axilla (35.8-37 C, 5-10 min)
1. Pat axilla dry if very moist
2. Least accurate but safe
3. Bulb is placed in the center of axilla
4. Takes long time
5. Mostly ginagamit kasi isang priority natin is safety ng patient
iv. Most quick – tympanic (27 C, 2-5 sec)
1. Almost as accurate as rectal
2. Pull pinna slightly
a. Above 3 y.o: slightly upward and backward
3. Point the probe slightly anteriorly , toward eardrum
4. Insert the prob slowly and gently using circular motion until snug
5. Not touching eardrum
v. Safe non-invasive, very fast – temporal
1. Cons: expensive or NA
2. Pros: safe and non-invasive

3. Area: forehead (children), back of ear
4. More accurate, more invasive: temporal artery
l. Body temp in infanfts
i. Extremely labile – easily affected by envi
ii. Axillary - safest
1. Hold arms against chest
2. Not as accurate if with fever
iii. Tympanic route -fast and convenient
1. Lie them supine
2. Stabilize head
3. Pull pinna straight back and slightly down (below 3 yrs old)
4. Direct probe anteriorly, seal canal but do not touch typmpanic membrane
iv. Rectal – least desirable acc. Do kosher and ERb
v. Avoid tympanic route when + ear infections/drainage tube
vi. More accurate in febrile patient
vii. Temporal artery thermos – touch only the forehead/behind ear is needed
viii. Rectal route is LEAST DESIRABLE in INFANTS
2. PR/HR
a. When assessing pulse:
i. Rate (tachy/brady)
ii. Rhythm (patterns of beat and interval between beats)
1. N: equaly distributed
b. Pulse – created by the wave of blood created by heart contraction
i. Expressed in bpm
ii. 2 types
1. Central – near heart
2. Peripheral – extremities
c. Pulse sites
i. Superior lateral to the eye – temporal pulse
ii. Side of neck below the lobe of ear – carotid pulse
iii. Left of sternum at the 5th ICS – apical pulse, PMI, mitral (use of auscultation)
iv. Inner aspect of biceps of arm or medially in the antecubital space – brachial
v. Thumb side of the inner aspect of the wrist – radial
vi. Inguinal ligament – femoral
vii. Behind the knee – popliteal
viii. Medial surface of ankle – posterial tibial
ix. Dorsum of foot on imaginary line from middle of ankle to the space of bwtween big toe and
second toe – dorsalis pedis
d. Pulse assessment
i. Carotid
1. central
2. May cardiac arrest in adult
3. Supplies blood supply to the brain
4. Circu of blood central
ii. Apical
1. Auscultated
2. PMI
iii. Brachial
1. For BP checking
2. Infant arrest/CPR
iv. Radial
1. accessible
v. Femoral
1. Central
2. Determines circulation of lower extremities
vi. Popliteal
vii. Posterior and Dorsalis
1. If you want to know if blood is circulating until the ends of extremities
3. BP – measure of force blood exerts against blood vessel walls
a. Systolic pressure – maximum (VC) – pumping. First sound heard (Korotkoff sounds)
b. Diastolic – minimum (VR) – filling. Last sound heard (Korotkoff sounds)
c. Unit: mmHg use sphygmomanometer
d. Measuring BP
i. Not too tight, not too loose atleast 2 finger
1. Too tight/small/slow – erroneously high
2. Too loose/large/fast - erroneously low
3. Gaano kabilis: 1 mmHg = 2-3 seconds
ii. Rate of seconds: 220-90 = 130/2 = 65, 130/3 = 43;;;;;;; result: 43-65 seconds
iii. Should not smoke, did not walk far, mad, food (stimulants) – wait for 30 mins before assessing
iv. Left arm – more accurate, best site because it is connected directed to heart
v. Heart level
1. Too high - erroneously high (kasi nakaelevate)
2. Too low - erroneously low
vi. Fundamentals of Kosher and Erb
1. First time and walang base-line – systolic (Nawala pulsation) + 30 mmHg
2. Diastolic – minus 10 to diastolic (baseline)
vii. Auscultatory (listening for sounds; standard) or Palpatory (feel pulsations, first pulse – systolic.
Cannot feel diastolic (approx..) = only used during emergency when they cannot appreciate the
sounds)
viii. Invasive: arterial Line – Centrla venous pressure = measure specific mean arterial pressure
e. Infants BP
i. Not big deal but with dengue pts, must
ii. Pediatric steth
iii. Antecubital spance
iv. Systolic : 50-80
v. Diastolic – 25-55
f. Classification of BP: sys dias
i. N: <120 <80
ii. Pre-HPN: 120-139 80-89
iii. HPN Stage 1: 140-159 90-94
iv. HPN Stage 2: >160 >100
4. RR
a. Act of breathing, reflects lung function
b. Absorbs oxygen and expels co2
c. Intake of oxygen molecules and output of CO2
i. Inhalation/inspiration – intake
ii. Exhalation/expiration – breathing out
iii. Ventilation – in and out of air
d. 2 types of breathing
i. Costal breathing – from chest
1. Upward, outward
ii. Diaphragmatic breathing – movement in the abdomen

e. Orthopnea – breathe better is sitting ot stangin; dob if supine
f. Respirations in infants
i. Crying – irreg rr
ii. Children – diaphragmatic breathing
1. Place hand in abdomen
iii. Complete nose breathings
iv. With periodic apnea (for about 10 sec)
1. More than 20 – report sa doctor
v. Have fewer alveoli
5. O2 sat – the percent of all hemoglobin binding sites occupied by o2 (there is a debate if this is the official VS, but in
books, pain is still the 5th cardinal sign) – cells need o2 molecules to continue functioning (which affects organ and
brain)
a. Hemogobin are protein inside RBC
b.
b. Can be obtained:
i. Externally – pulse oximeter (only measures percent of hemoglobin binding sites occupien by 02,
not the actual percentage of oxygen present in blood. They can’t distinguish what the hemoglobin
carries, whether it is o2 or carbon monoxide (poison, faster that o2 molecules to bind to
hemoglobin)
1. N: 95-100%
2. Use: pulse oximeter is everyday use – SaO2 –
a. Has sensors attached to pts finger, toe, earlobe
i. There are tape forms taped to forehead, nose, around hand/foot for
neonate
b. Has light (reflects the percentage of hemoglobin)
i. If room is too bright, it can interfere with results
1. If too much light, dim / cover the area w/ blanket
ii. Warm
c. Recheck readings if abnormal, patient chart
d. Infants
i. Earlobe/forehead
ii. spO2 – infant (95%) and neonate 0-28 days: (80%)
iii. pulse rate: 200 and 100
iv. keep it in place by – tape, elastic bandage, covered by stocking
ii. Blood test – Arterial Blood Gas (more reliable and specific), done by a nurse or pulmonary
therapists
th
6. PAIN – 5 VS, perceived (subjective) by the patient on a pain scale of 0-10
a. Is pain positive or negative experience? (PNLE)
b. 2 types of pain
i. Nociceptive pain – intact area, brain is properly functioning NS sends signals that tissues are
damaged, requiring attention and proper care
1. Somatic – skin, muscle, bone, connective tissue damage
2. Visceral – viscera “organ”
a. Ex. Labor pain, angina pectoris (heart: not enough o2), inflamed bowels – all of
these is associated with feelings of beign sick, pain in the whole body
ii. Neuropathic pain – assoc. w/ damaged or malfunctioning nerves due to illness (pathy-
abnormalities)
1. Peripheral - extremities
2. Central – trunk
c. Conditions of AB pain processing
i. “Hyper”algesia – too much pain, heightened response to pain

1. Normal stimuli/mild pain is severe for them ex. kurot
ii. Hyperpathia - heightened response to pain
iii. “A”llodynia – non painful stimulus produces pain, ex. Blanket, light touch
iv. “Dys”thesia – unpleasant abnormal sensation ex. Heart burn/pyrosis sensation (burning) feels
different
1. Characteristics feel different from usual
d. Pain scaling – 11 point rating scale (visual analogue scale – color/di makaappreciate ng numbers) (Numeric
rating scale – numeric)
i. 0 – no pain
ii. 2 - mild
iii. 4 – moderate
iv. 6 - severe
v. 8 - very severe
vi. 10 - worst possible pain
e. Wong-Baker’s pain scale/Face rating scale – pedia, graphic and uses emoticons
ADMINISTRATION OF MEDICINES
Prescription – doctors order (written, verbal, computerized in the hospital)
GENERIC NAME – general name ex. acetaminophen
TRADE NAME – registered name / brand name ex.
OFFICIAL NAME – PUBLISHED NAME
CHEMICAL NAME – chemists, atoms/molecules, drug constituents/components precisely
PHARMACOLOGY – study of the effect of drugs in the living organism
Licensed pharmacist – prepare and dispense drugs
Clinical pharmacist – specialist, guides physicians in prescribing
Pharmacy technician – assists licensed pharmacist, and in US – they can administer drugs
EFFECTS OF DRUGS
- Therapeutic effect – desired effect, primary effect intended
o Pain – analgesics, alleviates pain
- Side effect – predictable, may be harmless and tolerable, some are life threatening (should be stopped)
o Nurses should know the side effects, the s/s, and educate the pateint
 They might stop taking the drug due to side effects
o Adverse effect – harmful and needs to be discontinued, changed, opposite effect
- Drug toxicity – deleterious effects of drug to an org or tissue (PNLE: drug toxicity)
o Causes
 Overdosage
 Ingestion of drug for external use ex. Topical creams ingested
 Cumulative effect ex. Right dose and route but if they have kidney problems, hindi nae-
eliminate
 Increasing response to repeated doses of drug that occurs when rate of admini
exceeds the rate of metabolism and excretion (naiipon)
- Drug allergy – immunologic reaction to drug. Ex. When client is exposed to foreign substance (antigen). The
body may react to producing antibodies
o Anaphylactic reaction – severe allergic reaction, occurs anytime up to 2 minutes up to 2 weeks
 Occurs immediately after admini of the drug (fatal)
 1st symptoms – subjective (mouth swelling, SOB, inflamed airways, acute decrease of
BP/hypotension, increase PR - shock
- Drug tolerance
o Exists in person who has unusally low physicological response to drug
o Who requires increases in the dosage to maintain a given therapeutic effect
 Ex. Opiates (pain), barbiturates, drugs containing ethyl alcohol
- Cumulative
- Idiosyncratic effect – biglang lumitaw na hindi naman expected (unknown effect – idio)
o unexpected and may be individual to a client
o Underresponse and overresponse
Drug interaction – administration of drugs before, at the same time as, or another drug alters the ffect of one/both drugs
- Potentiating – palalakasin
o May be additive – same type of drugs increases the action of each other (1+1=2)
o Or synergistic – two different drugs increase the action of one or another drug, lalong lumakas ang
power (11=1=3)
- Inhibiting
IATROGENIC DISEASE – disease caused unintentionally by medical therapy (like drug therapy)
Ex. Iron for anemia but caused GI bleeding or NSAIDS for anti-inflammatory causing ulcers
DRUG ACTION ex. abx

Onset – time of admini until body initially responds -
Peak – peak plasma level – highest level of drug in the blood -

Half-life – elimination time: ½ T – liver deactivates the half and is elimminated
Plateau – maintained drug concentration (abx in scheduled doses) para masabayan yung half life
Pharmacokinetics – what the body does to the drug

- Absorption – drug passes into the bloodstream
o Absorption rate depends on the route (IV push, topical, oral etc)
- Distribution – transportation of drugs from site of absorption to site of action
o Brain has BBB
- Biotransformation – causes ½ t; detoxification/metabolism
o Liver detects foreign substance = coverts drug to less active form (active or inactive metabolites – wala
ng bisa)
- Excretion - metabolites/drug eliminated by the body
o Inactivated drugs detected by kidney and excreted in:
o Faces, breath, perspiration saliva, breastmilk
o Majority is eliminated in urine
Major concerns (long term drugs)

- 2 major organs – liver and kidney
- If prolonged, may harm liver or kidney
- Prone to cumulative effect and eventually, drug toxicity
MEDICAITON ADMINISTRATION ROUTES

- Oral
o Least painful, least expensive, most convenient, safe, do not cause stress or any break in skin barrier
o Claritin - Melt rapidly in the tongue
o Absoption is in small intestine
o Cons:
 n/v
 pt cannot swallow
 unconscious pt
 oral surgery/injury
- Sublingual
o Same as oral
o More potent because it bypasses the liver and directly enters the blood – buo pa ang amount when
enters blood (sa liver lang madedeactviate yung half)
- Buccal
o Cheek, mucus membrane
o Same as sublingual
o Do not drink water (can be swallowed and enter oral route)
o Before taking the drug, ask pt to drink to moisten mucus membrane or under tongue
- Rectal
o Provides local therapeutic effect
o Drugs released at slow, steady rate
o Used when drug has objectionable taste or odor
o Cons:
 Unpredictable dose (not sure kung ilan ang naaabsorb sa bloodstream)
 Unpleasant
 Limited forms
- Vaginal
o Local effect,
o Slow, steady
o Cons:
 Uncomfortable
 Messy (soiling of cloth/underwear)
 Limited
- Topical – skin, kinikiskis so local
o Few side effects
o local
o Ointments, cream, lotion, liniment
o Nurse are expected to wear gloves or use tongue depressors or cotton tip applicators
o Cons:
 Abrasion, injury cause systemic (blood) effect
 Leaves residue which soils clothes
- Transdermal – matagal, mabagal ang effect (usually 24 hrs)
o Prolonged systemic effect – reach blood faster
 Ex. Nitrogrycerin patch (for angina pectoris)
o Few side effects
o Avoids GI absorption problems
o Onset of drug faster than oral; faster absorption
- PARENTERAL ROUTE - needle (other possible meanings: needle, GI/alimentary and respi tract)
o SC/hypodermic – sq tissue, below the skin, above muscle
 Absorption is slower
 Heparin and insulin administration – hindi Maganda pag biglaan and could make the pt.
hypoglycemic
 25 G needle, 3/8 or 5/8 inches
 Cons:
 Sterile
 More expensive
 For small volume only
 Some can irritate tissue and cause pain
 Cause pain and anxiety
 Degree: 40-45 degrees;;;;; small needle(ex. Insulin) or if obese si pt = 90 degrees
o IM – muscle;
 Administer larger vol than SQ
 Rapidly absorbed
 Deltoid: 1 mL max, 1mL syringe ex. Tuberculin syringe (23-25 G, 1 in)
 Ventrogluteal: preffered site for IM acc. to the reference book 3-5 mL syringe (21-22 G, 1.5 in)
 Accommodate large amoutns
 Far from nerves and blood vessels
 Vastus lateralis: NB/infants – (deltoid and ventro are not mature)
 Breaks skin barrier
 Pain and anxiety
 Breaks skin barrier
 sterile
 90 degrees
 Z-track technique (ganon yung degree) for iron prep
 Lesser irritation
 Lesser leakage
 Lesser staining
 Technique/prcess
o Slightly pulls and hold pressure on skin
o Give injection
o This leaves zigzag path behind when needle is removed and release skin
o ID – dermis
 Absorption is SLOW (advantage for testing allergy – Skin test)
 Rabies also have ID, although in Phil. mostly IM
 Small amts (0.05 mL)
 Breaks skin barrier
 Syringe: 1 mL
 Gauge: 25-27 G
 Needle length: ¼ to 5/8 long
 Degree: less than 15 degrees; almost parallel to skin level; 5-10 degrees
 More than 15 – SC na
 Should create a bleb/wheal (if not, SQ siya napunta)
o IV – vein
 Rapid effect, directly into the blood
 Drug distribution inhibited by poor circu
 Intnravenous prep
 Intermittent IV infusion/piggy back
o Meds mixed in small amt (50 or 100 mL)
o Put label on an IV intermittent med to be designed to prevent medication
error
o Piggyback set separate from main line
o Less common parenteral routes
 Intra-arterial – artery
 Intra-cardiac – into heart muscle
 Intra-osseous – injected to bone directly, when they cannot access vein in an emergency
situation
 Common: anterior proximal tibia
 Intra-thecal – into spinal canal ex. Spinal anesthesia
 Intra-pleural – pleural space (space bet. Lungs and wall)
 Epidural – epidural space
 Intra-articular - joints
MEICAITON ORDERS
- STAT – given immediately, at once now, ngayon lang.
o Ex. Valium 10 mg IV stat
- Single – one time order, once at a SPECIFIED time
o Ex. Plasil 1 mg IV 1 hr before O.R
- Standing order – current order
o May/may not have termination date
 ex. Enervon OD, ampicillin 250 mg IV BID x 7 days – standing order pa lang
o May be carried out indefinitely ex. Multiple vitamins daily
o Carried out for specified number of days
- Standard order – protocol
o Give insulin sliding scale IV according to protocols
o According to hospitals
o Some physicians have their own standard order, for any specific patient with the same situation, they
have order
- PRN order – as needed, if there are assoc. s/s
o Ex. Give Morphine 10 mg IV PRN q6H (if may pain lang)
Parts of prescription
- Descriptive information
o Name
o Age
- Date (up-to-date) to prevent recycling prescription
- Rx symbol – “take thou”
o Ex. Rx paracetamol
 You take paracetamol 1g tab
- Medication
o Name, dose, strength
- Route
- Dispensing instreuctions
o Ex. Dispense 15 capsules
- Directions for administration
o Ex. One tablet with meals
- Refill and/or special labelling
o Ex. Refill #5
- Prescriber’s signature w/ licensed
o (s2 drugs – delikado, only those who are S@ can prescribe these type of drugs)
PRACTICE GUIDELINES/competency.safety precautions/always safety of patient

- Cloudy medication
o If there are changes (consistency and color), do not give and ask pharmacist
- Double check drugs, name,
o 3 checks (medication administration record)
 1st check: read MAR (if ito exactly),
 find kung anong drug, verify client name and room number matches in MAR,
 compare it to patient chart and label of med
nd
 2 check: while preparing
 Is this the right drug being ordered by the AP
rd
 3 check:
 before returning it to storage place
o Recheck label on container
 Before opening package at the bedside
o Check label on medication against MAR
- Should be personally prepared

o If someone asked you to inject, we can help but we have to personally prepare another drug
- Appropriate identification
o Check IV bracelets, confirming the patient record
o 2 identifiers: name and date of birth, or IV band and chart of pt, asking pt while reading IV band
- Bedside medications (check policy)
o Refrain from leaving medications bedside, always check for hospital policy
o Pwedeng iniiwan – cough syrup, nitroglycerin but check policy
- Vomits medication
o Document
o Report to AP or nurse-in-charge
o Either they give it in diff route or give anti-nauseous
- Special Precautions (high risk drugs)
o Anticoagulants, insulin, IV drugs
 Signs of bleeding, hypoglycemia with glucose source, check for reaction
- New orders post surgery –
o usually may bagong orders, so may update na ang doctor
o some hospital require their doctors to prescribe new orders after surgery
- Medication omitted (PNLE 2021)
o Dapat tugma, sundin policy of every hospi,
o Document (not in a way na nakabigay ka) w/ reaos in nursing notes
o Do not sign MAR and explain in nursing notes but it depends on hospital policies
- Medication error
o Assess for adverse effects
o Report immediately to charge nurse and physician
o Incident report – not a part of patient chart, usually collected by risk management/nurse manager
(chart is only for ongoing care of pt)
- Always check expiration date
10 R of Medication Admininstration
1. Right medication – med given was med ordered
2. Right dose – appropriate to height, weight, age, body weight
1. Multiple pills/tablets or large quantity of liquid medication – cue of wrong calculation
a. Ex. Order: give 90 mg TID: and 1 tablet is 9 mg so you need to
2. Double check the questionable
a. Call doctor to confirm
3. Right time
1. Right frequency ex. OD, BID, TID, QID/q6H
2. Time ordered acc. to policy
3. Within 30 mins before/after the scheduled (only allowance), acc. to policy
4. Right route
1. As ordered
2. Safe (ex. Order: Rectal: is it safe if may lesions sa rectum? Or if was infant ordered tablets
3. appropriate
5. Right client
1. Given to inended client
2. Identification band
a. Confirm to patient also
3. Name alert procedure

a. Hospi have protocols for same names ex. In UAE, 4 names = ask 3-4 names (given
name, father’s name, grandfather’s name, clan name) +birthday is not big deal+
6. Right client education
1. Explain info
2. Why
3. Expectation (side effects)
4. Warn precautions
7. Right documentation
1. Not document, not done
2. Document after giving the drug, not before (bawal advanced charting)
3. If time differes from prescribed time (late)
a. Note the time on MAR, document
b. Explain reason in nursing notes
4. If not givern
a. Follow the agency’s policy for documenting the reason
b. Document, note time
c. Explain reason in nursing notes
8. Right to refuse
1. Adult clients have right to refuse
a. PNLE July 2021: what to do when patient refused:
i. Inform patient of the potential consequences of refusal
b. Communicate refusal to MD
c. If pushed despite refusal: battery (unconsented touch to patient) – intentional tort
9. Right Assessment
1. There are specific assessments prior to admini
a. Anti hypertensives – BP
2. Specific parameters
a. Drug orders sometimes have parameters
i. Ex. Captopril to control BP IF 160/110 above
10. Right Evaluation
1. Appropriate follow-up (check if goal was met)
2. Side effects or adverse reactions
F. Avoiding puncture injuries esp. If pt has blood-borne infections/diseases

a. Puncture proof disposal containers/sharps’ box
1. Do not throw sharps in norma bins, waste hand;ers cound be injured
2. Anything that are sharp: needles, surgicall blades, lancets, razords, broken glass of ampules,
broken capillary pipettes (samples), exposed dental wires, hooks, IV spikes/rasps
3. Huwag binabali ang needle ng syringe, no de-aattaching needle from syringe
4. Only 2/3 full to fully closed
b. No recapping: only recap if still unused by pt, or transporting blood sample to lab
c. One-handed scoop method – uses one hand to recap, scoop and secure with two hands
PROMOTING OXYGENATION/respi function

- Changing positions = prevents pneumonia (infection/inflammation of lower parenchyma)
o Assists patient who have difficulty
o EVERY 2 HRS (the more frequent the better)
- Ambulating – promotes respi function
 Earlier ambulation, mas okay respi function

- Exercise – adequate ventilation promotes gas exchange
- APE Mnemonic
DEEP BREATHING AND COUGHING (post-op, naiilang sa positioning, afraid to exercise due to pain) – if APE was not done,
preferably teach patients earlier/before surgery. (should be return demo to really see its effectiveness) (anxious si pt if
malapit na and disoriented after surg)
Purposes: 3R
- Remove accumulation of secretions
- Raise secretions for expectoration/swallow
- For restricted lung expansion/functioning
o Splinting – pillow (support to perform deep breathing and coughing)
ABDOMINAL (diaphragmatic) and PURSE-LIP BREATHING (show demo, and return demo)
- Semi-sitting/fowler position (or if hindi makaupo, lying position w/ 1 pillow)
- Flex knees – for relaxed abdominal muscles
- Hand on abdomen – just below the ribs (diaphragmatic)
- Feel rise/expansion of abdomen (straight back, no arching)
- Purse lips (like whistle), breath out slowly and gently (without cheek puffing)
- Feel abdomen fall/sink, and tighten abdominal muscles (contract for expanded exhalation)
- Use if short of breath
- Increase gradually 5-10 mins/4x a day
HYDRATION – maintain moist mucus membrane to prevent drying of mucus membranes and prevent irritation, loosen
tenacious (thick) secretions
- Humidifier are devices that add water vapor to inspired air
- Nebulizer are used to deliver humidify and medications. They may be used w/ oxygen delivery systems to
provide moistened air directly to the client
MEDICAITONS (BAE)
- Bronchodilators – reduce bronchospasm, open airways, facilitate breathing and oxygenation (given first before
steroids to open airways)
- Anti-inflammatory (steroids) – reduce inflammation, for restricted airways
o Orally, IV, inhalers
- Expectorants – break-up mucus, easy to expectorate
o Ex. Guaifenesin
“INCENTIVE” SPIROMETRY – (incentive – gift – benefit) aka Sustained Maximal Inspiration Device (SMI)
- Main purpose: Benefits patient/intervention; help the lungs recover after surgery or had lung problems
- Can determine the flow of air
- Ituro before pa when they are oriented and can understand (return demo)
- 2 types:
o Cylinder and ball
 Inhale to move them
- C-LIFE Mnemonic: PURPOSES
o Counteract hypoventilation (shallow breathing) from anesthesia
 Anesthesia are depressants and causes respi depression/hypoventilation
o Loosen secretions
o Improve ventilation
o Facilitate gas exchange
o Expand collapsed alveoli (atelectasis) – helps to expand collapsed air sacs
- DEMO
o Position: upright sitting/standing (spirometry needs to be upright)
o Exhale normally
o Seal lips on mouthpiece
o Take IN slow deep breaths
o To elevate the balls/cylinder and then hold the breath for 2 sec (initially) up to 6 sec (optimum)
 The more matagal, the more Maganda
 If they can elevate balls – ensure adequate ventilation of alveoli
o If w/ difficulty breathing only in the mouth, a nose clip can be used
o Remove mouthpiece and exhales normally
o Cough – remove secretions
o Relax and take several normal breaths
o Repeat several times and then (until) 4-5 times every hour
o Clean mouthpiece w/ water
o Shake it dry
PERCUSSION, VIBRATION AND POSTURAL DRAINAGE (dependent nursing intervention) – loosen/dislodge tenacious
secretions
- Check doctor’s order. Needs doctors order for frequency and for postural drainage. Doctor will determine the
area needed to be percussed
o Positioning
o Frequency
- Consider: (PNLE) before PVD
 Time of meal – special consideration
 Before meal – can induce vomiting (due to positioning) which can lead to aspiration,
tiring for pts (note that they have high o2 demand)
 Position – automatic due to postural, it it appropriate or tolerable?
- PERCUSSION (with palms) to dislodge tenacious secretions in alveoli walls
o “CLAPPING”
o Forceful striking using cupped hands; two hands alternate
o Concentrated to congested lung area
o Steps:
 Cover w/ towel/gown – para di masakit
 Pt breathe slow and deep to relax
 Wrist flexed rapidly
 1-2 min/segment (doctors will be the one to know the segment)
 Avoid: over the breast, sternum, spinal column, kidney (KBSS)
- VIBRATIONS –
o Series of vigorous quivering-produce vibration by using hands
o Hands placed flat in the chest wall or at the back of patient (para mayani and malaglag ang thick
secretions)
o Sometimes, alternated with percussion
o Steps:
 Placed hand, palm down in chest area with one hand over the other
 Fingers together, extended
 Deep slow breathing (mabagal exhalation para masabayan ny)

 During exhalation: tense hand (heel) > vibrate >go downward >stop when patient inhales
 One affected segment: vibrate w/ 5 exhalations
 Cough after vibration
 Put secretions in sterile container
- POSTURAL DRAINAGE – use positioning to drain secretions (after meals)
o Drainage of secretions by gravity (opposite of the affected area)
 Ex. Upper lobe (w/ secretions) – upright
 Lower lobe – Trendelenburg
 Left lung – right
 Right lung – left position
o 2-3x day (depends on degree of lung congestion)
o Monitor v/s (RR and PR) – before and after
- After PVD – cough out / suction
- Document:
o characteristics of sputum (color, amount, thick/thin)
- Put secretions in sterile container
OXYGEN THERAPY
OXYGEN – drug; needs doctor order
Too much can lead to blindness
- HUMIDIFIERS
o O2 can be drying and irritate mucus membrane (esp. of long term)
o Prevent drying of mucus membrane
o Prevent irritation
o Loosen secretion
o The more bubbles, the more vapor
o Very low o2 (1-2 Lpm) – do not require usually because patient is only low in oxygen but can breathe
atmospheric air (which already has vapor)
- OXYGEN CYLINDERS/wall mounted
o Green coding (PNLE dati with tank ng compressed air)
o Safety precautions:
 Careful handling
 Strapped securely
 Wheeled transport devices – safe
 Rolling is unsafe
 Placed away from traffic areas and heaters
- REGULATOR
o Released O2 at safe level or desirable rate
o In cylinder:
 Content gauge – measure pressure and amount of oxygen left in the tank
 Regulator – determine and control gas flow in L/min
o Wall-mounted:
 Flow meter – controls gas flow
SAFETY PRECAUTIONS (PNLE)
- Place “NO-SMOKING” sign (door, foot/head) – in visible area
- Electric device – works properly (to prevent short circuit spark > fire)
- avoid woolen blankets/synthetic fibers - cause static electricity
o use cotton
- avoid placing volatile/flammable inside pt room (oils, alcohol, grease, acetone)
- FIRE EXTIGUISHER – nurses should be trained. Each department should have several in strategic locations
o PASS
 Pull the pin
 Aim at base of fire
 Squeeze
 Sweep side to side
o If there is fire: RACE
 Rescue patient
 Alarm
 Confine/close (the fire)
 Extinguish the fire/escape
OXYGEN DELIVERY SYSTEM

- CANNULA / nasal prongs
o Most common
o Inexpensive
o For low flow/concentration
 2-6 LPM / 24-45% of O2
o Can’t deliver high O2 (if more than 6)
o Cause irritation and drying of mucus membrane
o with humidifier
- FACE MASK
o Mas mataas ang order compared to cannula
o Covers mouth & nose
 Exhalation port – to let CO2 escape
o SIMPLE FACE MASK – most basic
 delivers 40-60%, 5-10 L/min
 Limited eating, drinking interruption
 Patients sometimes do no tlike close areas
o PARTIAL REBREATHER MASK
 Level-up ng simple
 May reservoir (rebreather) – bag attached where air is
 Client is able to rebreathe the 1st third (1/3) of exhaled air
 Delivers up to 60-90%
 6-10/LPM
o NONREBREATHER MASK
 Delivers the highest O2 concentration
 95-100%
 10-15 LPM
 For emergency
o VENTURI MASK
 Most precise / accurate
 24-40% or 50%
 4-10 LPM
 Ex. Patients with COPD (has distended alveoli) – to N persons: ang drive to breathe is high CO2,
but with COPD: and drive nila is LOW O2
 CO2 retention
 Hypoxic drive can cause
 Color depends on the concentration needed
o FACE TENT
 Over the nose and in mouth, replace typical face mask if poorly tolerated
 30-50%
 4-8 LPM
 Client’s facial skin is kept dry
TRACHEOSTOMY – “ostomy” opening

- Opening of trachea through the neck to breathe
- Prone to infection so body secretes due to foreign device
- Responsibilities:
o Should be open and patent
o Prevent development of infection
- TRACHEOSTOMY CARE
o Semi-fowler position / Fowler
o Suction pt if needed – to make sure airway is patent
o Sterile gloves
o Suction the tube – make sure na walang plema
o Soak catheter to solution (NSS) for rinsing;
o Soiled dressings removed
o Sterile NSS – to rinse inner cannula (tube na nasa loob) and dry by shaking
o Secure inner cannula in place
o Secure flange of inner cannula to outer cannula
o Site cleaned – using sterile applicator w/ nss
o Same manner cleaning to the flange – using sterile applicator w/ nss
o Skin dried
o Securely supported
 4by4 v shaped gauze
SUCTIONING (suck – negative pressure)

- Aspirating secretions through a catheter connected to suction machine
- 2 types
o Wall mounted
o Portable
- Preferably, sterile technique (in all suctioning: standard) to avoid introducing foreign
- Parts:
o 2 types of catheter
 Open tipped
 More effective to remove thick secretions
 Whistle tipped
 Less irritating to respiratory tissues
o Yankauer suction cath

 Oral suction tuble
 Rigid (but will mostly do not cause injury)
o Wall suction unit
 Controls suction
 Connect catheter into suction machine
 Turn on
 To elicit negative/sucking pressure
 80-100 mmHg
 Gauge:
- Secretions and oxygen are both suctioned
- Considerations:
o HYPERINFLATION
 Give client breaths that are 1-1.5 x tidal volume set on the ventilator (hyperinflate)
 Use ventilator circuit or manual resuscitation bag
 3-5 breaths delivered BEFORE and AFTER each suctioning
o HYPEROXYGENATION
 Done before suctioning also
 Increase oxygen flow
 Done w/ a manual resuscitation bag or thru the ventilator
 Increase O2 flow (100%) BEFORE and BETWEEN suctioning
o HYPERVENTILATION
 Increase number of breaths the client is receiving
 Ventilator (increase the set RR) or using manual resus bag
- SUCTION CATHETER SIZED
o Adults: F 12-18
o Children: F 8-10
o Infant: F 5-8
- CONSIDERATIONS:
o INFANTS
 Bulb syringe to remove secretions from infant’s nose/mouth
 Press (to remove air) before ipasok sa baby
 Avoid stimulating gag reflex (CN 10)
o CHILDREN
 Catheter is used to remove secretions from an older child’s mouth or nose
o ADULT
 Often have cacrdiac/respi disease
 Prone to hypoxemia related to suctioning
 WOF signs of hypoxemia
 Stop suctioning
 Hyperoxygenate
- OSOPHARYNGEAL, NASOPHARYNGEAL, NASOTRACHEAL, SUCTIONING

o STEPS: 6 Ps
 Position: w/ gag reflex: Semi-fowlers (PNLE: SATA)
 Head turned to one side – for oral suctioning
 Hyperextend the neck – nasal
 If unconscious: lateral facing you
 Pressure: set pressure and turn on
 Wall Unit:
o Adult 100-120 mmHg
o Child: 95-110
o Infant: 50-95 mmHg
 Portable unit:
o Adult: 10-15 mmHg
o Child: 5-10
o Infant: 2-5 mmHg
 Point and Position (point to point – gaano ang length ng catheter na ipapasok)
 Measure distance between the tip of the nose to earlobe or 13 cm (5 in)
 Mark the position on tube w/ fingers
 Pressure and Patency
 Test pressure of the suction and the patency of catheter by
o Pressure: closing tip w’ thumb
o Patency: dip w/ NSS + moistens catheter
 Put catheter (no pressure) and suction (dito na may pressure up to withdrawal – circular
motion)
 Apply suction 5-10 secs and gently rotate the cath. The whole suction attempt should
only LAST 10-15 sec max.
 Rinse and flush cath and tubing w/ sterile water or saline
 Relubricate the cath
 Repeat suctioning until air passage is clear
 Allow sufficient time between each suction for venti and oxygenation.
 Limit suctioning 5 mins total
 Patient breath and cough
 Encourage client to breathe deeply and cough between suctions
 Assist client to position that facilitates breathing
 Assist client togargle/ nasal and oral hygiene
 Document
o OROPHARYNGEAL
 Adnvacne 10-15 sm along one side of mouth
 Apply suction
Suctioning tracheostomy/endotracheal tube
 3 purpose:
 Ppatent airway (prevent obstruction)
 Promote respi function
 Prevent pneumonia
 10 steps: 10 ps
 Position: semi-fowlers
 Paracetamol – analgesia para di uncomfortable, depends on doctor’
 Put 100% - hyperoxygenation – adjust O2
 Place sterile towel client’s chest below tracheostomy
 Pressure set (or portable, wall mounted, age)
 Put on PPE (sterile gloves)
 PNSS (check pressure and patency, moisten, lubricate)
 Place catherter to moisten and clean (without pressure)
 Put suction (5-10 sec, max is 10-15) duration of 5 mins
 Provide hyper O2
o Turn to 12-15 LPM if receiving o2

o Attach resus to tracheostomy or ETT
o Ambubag 3-5 breath (sabay/press as client inhale) x as the client inhales
 Before and after suctioning
 Considerations in infants and children
 Have an assistant to gently restrain the child to keep the child;s hands out of the wt
o Fear of Body mutilation
 Assistant will maintain the child’s HEAD in the midline position
 Older adults – cardiac/respi
 Do a thorough LUNG ASSESSMENT before and after to determine effectiveness and to
be aware of special problems

Fundamentals of Nursing Notes

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Fundamentals of Nursing Notes

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FUNDAMENTALS OF NURSING notes

Reference: Kozier & Erb’s Fundamentals of Nursing

PHYSICAL HEALTH EXAMINATION

 Bimanual (Two-hands) - deeper

 Quality – reflects musical characteristics

 Height - Measuring stick attached to wall/weighing scale

- Low albumin (oncotic pressure)

THORAX – chest, responsible for oxygenation

c. Too slow – bradypnea rate “brady” = slow

i. Soft intensity, low pitched

ASSESSING INFANTS THORAX AND LUNGS

b. Abnormal: orange-peel skin

CARDIOVASCULAR ASSESSMENT (CHEST AREA)

4 quadrants (division by sternum - vertical and umbilicus - horizontal)

Too much pressure in aorta if visible pulsation in abdomen – prone to rupture

o Other areas should never be dull as it may indicate fluid or mass

Capillary Refill Time

VITAL SIGNS (any deviations: can be life-threatening)

Cardinal signs – important, essential, high level

1. Infants – influenced by envi

a. There are fluctuations, all of which are ABOVE NORMAL

2. Pros: safe and non-invasive

ii. Diaphragmatic breathing – movement in the abdomen

i. “Hyper”algesia – too much pain, heightened response to pain

DRUG ACTION ex. abx

Peak – peak plasma level – highest level of drug in the blood -

Pharmacokinetics – what the body does to the drug

Major concerns (long term drugs)

MEDICAITON ADMINISTRATION ROUTES

PRACTICE GUIDELINES/competency.safety precautions/always safety of patient

- Should be personally prepared

3. Name alert procedure

F. Avoiding puncture injuries esp. If pt has blood-borne infections/diseases

PROMOTING OXYGENATION/respi function

 Earlier ambulation, mas okay respi function

 Deep slow breathing (mabagal exhalation para masabayan ny)

OXYGEN DELIVERY SYSTEM

TRACHEOSTOMY – “ostomy” opening

SUCTIONING (suck – negative pressure)

o Yankauer suction cath

- OSOPHARYNGEAL, NASOPHARYNGEAL, NASOTRACHEAL, SUCTIONING

o Turn to 12-15 LPM if receiving o2

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