HEALTH

 State of complete physical, mental, and social well- 1. FLORENCE NIGHTINGALE:

being. (WHO)  Environmental Theory
 Healthcare Provider: Provide health through care.  Focused on clean air, clean water, light, drainage,
o Provide care through the needs (based on Maslow’s cleanliness
Hierarchy of Needs)  Born on May 12, 1820 (*May 12 is alson
 Self-Actualization: Contentment and satisfactions Internationa Nurses Day)
 Self-Esteem: Confidence and personality  Appointed at 34 years old during the Cremian War
 Love & Belonging: Family and relationship (1854-1856)
 Safety & Security: More on health prevention such  She was appointed as a superintendents
as immunization,handwashing, etc.  Lady with the lamp
 Physiologic Need: Thinck Airway, Breathing,  Notes in Nursing (Made after the mistakes)
Circulation  What it is and what it is not (Do’s and Dont’s)
 Made after realizing the mistake
SCOPE OF NURSING PRACTICE  Mother of Modern Nursing: Called as such as she
 Can be seen in The Philippine Nursing Act of 2002 was the first nurse to face the government
(RA 9173), Article 6, Sec 28  Death: August 1910
 It is our duty and responsibility from pregnancy,  Cause of Death: Old age but some sources says it is
labor, delivery, infant, and elderly, death and dying. due to syphillis
FOCUS OF NURSING 2. HILDEGARD PEPLAU
1. Promotion of Health: Health Education  Interpersonal Theory
2. Prevention of Illness: Ex. Immunization  Nurse-to-patient communication
3. Restore Health: You DO NOT TREAT cause 1. Orientation
nurses are not doctor. 2. Information/Identification
4. Care of Death and Dying: More on hospice care 3. Exploitation/Exploration
management. Hospice came from the Great Britain 4. Resolution
3. JOYCE TRAVELBEE
THEORETICAL FOUNDATION IN NURSING  Human-to-human relationship
Theory:  More on intimate relationship
 The basis of care 4. MYRA LEVINE
 Set of concepts that could explain a certain  4 Conservation Principles
phenomenon 1. Energy
Nursing Theory: 2. Personal
 Man: 3. Social
 Person: 4. Structural
 Nursing: 5. LYDIA HALL
 Health:  3C’s Theory (Care, Core, Cure)
1. Care
2. Core
THEORIES IN NURSING 3. Cure
1.) ENVIRONMENTAL THEORY 6. VIRGINAI HENDERSON
2.) INTERPERSONAL THEORY  14 Basic Needs
3.) HUMAN-TO-HUMAN RELATIONSHIP 7. FAYE-GLENN ABDELLAH
4.) 4 CONSERVATION PRINCIPLES  21 Nursing Problems
5.) 3C’S THEORY 8. JEAN WATSON
6.) 14 BASIC NEEDS  Human Caring Model
7.) 21 NURSING PROBLEMS 9. DOROTHEA OREM
8.) HUMAN CARING MODEL  Self-Care Deficit Model
9.) SELF-CARE DEFICIT MODEL  Hygiene, care for yourself, eating, feeding, etc
10.)DYNAMIC NURSING PROCESS 10. IDA ORLANDO
11.)BEHAVIORAL THEORY  Dynamic Nursing Process
12.)GOAL ATTAINMENT THEORY 11. DOROTHY JOHNSON
13.)SYSTEM MODEL  Behavioral Theory
14.)TRANSCULTURAL NURSING 12. IMOGEN KING
15.)ADAPTATION MODEL  Goal Attainment Theory
16.)HELPING ART THEORY 13. BETTY NEUMAN
17.)SCIENCE OF UNITARY HUMAN BEING  Systems Model
18.)HUMAN BECOMING 1. Primary
19.)LEVELS OF EXPERTISE 2. Secondary: Screenings, CBC, etc. prompt
management
3. Tertiary: May sakit with education that is
rehabilitation
14. MADELEIN LEININGER
 Transcultural Nursing
 Adopt and adjust to different cultures
15. SISTER CALLISTA ROY
 Adaptation Theory
16. ERNESTEIN WEIDEN BACK
  Helping-Art Theory
 Nursing is an art
17. MARTHA ROGERS
 Science of Unitary Human Being
18. PARZE
 Human Becoming
19. PATRICIA BENNER
 Levels of Expertise
 Stage:
1. Novice: No Experience
2. Advance Beginner: 6 months – 2 years
3. Competent: Straight 2-3 years in an area
4. Proficient: 4-5 years of experiences in that area
5. Expert: More than 5 years in that area
HEALTH ASSESSMENT HEAD
 Skull and face: Normocephalic
Physical Examination:  Cranial Nerve 7: Facial expression and closing and
 Preparation: opening of the mouth
 Priority:  Cranial Nerve 5: Blinking and chewing
 Psychological: Patient needs to be informed  Nose and Sinuses:
 Physiological Structure:
 Note: Oral consent ony no written  Smell: Cranial Nerve 1: 9-12 inches below. Best
 Give Privacy to use is coffee
 Proper eqquipments and materials  Sinuses
 Phyical examining techniques:  Eyes and Vision
 Inspection: Sight and smell Structures:
 Palpation: Touch  Tear is released by the lacrimal gland (pinaka
 Percussion: Hearing lateral side sa mata)
 Ausculatation: Hearing  Pupil: Pupils equally round reactive light
Direct Ausculation: Ears directly on the site acaccommodationPERRLA)
Indirect Ausculation: Use of stethoscope.  Pupil is 3-7 mm
o Bell: Detects low pitch soun and best for  Reactive to light: use penlight. From outer to
hearing heart sound and blood vessel inner causing constriction
sound Accommodation (Near and far):
o Diaphragm: Detects high pitch sound  Normal: Constriction; Abnormal: Dilation
best for heart sounds, lung sounds,  Extraoccular muscle testing: Use the six cardinal
bowel movements gaze
Movement:
GENERAL SURVEY  Up: Cranial Nerve 3
 Vital Signs: Temperature, pulse, respirations, and  Down: Cranial Nerve 4
blood rpessure  Side: Cranial Nerve 6
 Temperature: Visual acuity:
 Oral temperature: below the tongue  20/20- use of snellen chart (CN 2)
 Rectal: most reliable  Hyperopia: Far sighted
 Heart Rate:  Myopia: Near sighted
 Child: Apical  CN 8 : Vestibulocochlear
 Adult: Radial Structures:
 Respiratory Rate:  Tympanic membrane:
 Rise and fall of chest i in adudlt  Color: Pearly gray, semi-transparent
 Rise and fall of the abdomen in pediatrics  Use of otoscope and Tuning Fork
 Blood Pressure:  Weber: N: (-) equal laterization
 Brachial  Rinne’s: N (+) Air conduction is greater than
 Popliteal bone conduction. Place the tuning fork at the
 Appearance: matoid
 Hygiene and grooming, height and weight  Mouth and Pharynx
 To assess BMI: N= 18.5-24.9 Structures:
 Attitude: Help us know the emotional status of the  Tongue
patients  CN 7: Anterior tongue
 CN 9: Posterior tongue
INTEGUMENTARY  CN 12: Tongue movement
 Hairs, Nails, etc  Gag reflex: CN 9
 Capillary refill  Tonsils: Use tongue depressor and penlight
 Equal or less than 2 secondes, angle is 160  Grade 1: No inflmmation and difficulty
degrees swallowing
 If 180: early clubbing; If 200: clubbing  Grade 2: Slight inflammation to the middle
 Pa bali na C is iron deficiency anemia  Grade 3: Almost touching uvula
 Diabetic patient: nail filing  Grade 4: Kissing tonsils
 Skin: NECK
 Assess the color, presence of wound, lesion,  Lymph nodes - check for enlargement, tenderness,e
skin turgor: Adults: sternal and claivcular, tc
Pedia: lateral abdomen  Thyroid gland
 Edema:Pitting (With identation), Non-  Central Vessels: Carotid and jugular veins: Assess:
Pitting (W/O identation) place pt in a semi-fowlers position
 Grading: NEUROLOGIC
0 = nonr  General Status:
+1= edema detected (1mm)  Language:
+2= 2-4 mm  Asking questions
+3=5-6 mm  Orientation:
+4= 8+mm  person, place, and time
 Memory:
 remote memory and immediate memory
 Attention span
  LOC(Use GCS)  Circular: Axillary to nipple
 Eyes – 4  Vertical: Up and down staring at the axially
 Verbal – 5  Clock method
 Motor – 6  BSE: 1 week after menstruation
 N= 15; Comatose: 3-7  Areola and nipples – press gently
 Sensory: Temperature and pain sensation ABDOMEN
 Tactile: more on sensation  Inspection
 Kinesthetic: more on movement  Ausculatation: M: 5-20 sec
 Motor:  Percussion: Tympanic sound
 FineL nose to finger, finger to finger, etc  Palpation: Liver and spleen
 Gross: Feet together standing, close eyes MUSKULOSKELETAL
 Deep tendon Reflex Bones
1. Babinski  Joint:
2. Achilles  Goniometer:
3. Patellar  Muscle strenght
4. Biceps 0 - 0%
5. Triceps 1- 10%
6. Brachioradialis 2- 25%
Scale: 0 – None 3- 50%
1= hypo 4- 75%
2= normal 5- 100%
3= above normal  Sternocleidomastoid – mu contract if iflex and neck
4= hyper on on the sides
Cranial Nerves  Trapezius – mu contract when hyperextendend ang
 I – Olfactory neck
 II – Optic GENITAL
 III – Oculomotor  Male: Structures
 IV – Trochlear  Testicles
 V – Trigeminal  TSE: Position: standing, same day every month
 VI Abducens  Female:
 VII Facial  Structutres
 VIII Vestivulocochlear  Bartholin glands
 IX Glossopharyngeal  N: Smooth
 X Vagus  A: Spongy
 Decrease heart trate, increase gastric secretion and RECTUM AND ANUS
motility  Rectum
 do not massage the carotid  Anus
 rectal stimulation  Standm feet wide apart
 XI Spinal Accessory  Prostate
 XII Hypoglossal  Normal: soft
Note:  Abnormal: Hard
 Sensory: 1, 2, 8
 Motor: 3, 4, 6, 11, 12
 Both: 5, 7. 9, 10
HEART
 Peripheral Vascular System
 Heart
 Poisition: Supine and left side lying
 Location: Apical pulse, Left 5th ICS MCL
 Heart Sound:
 S1 lub: cosing of the AV valve
 S2 dub: closure of the SLV
 Capillary reill test
 Pulses:
 Pedal pusle: dorsalis pedis, posterior tibia
CHEST AND THORAX
 Beathing patterin: Eupnea
 Breath sounds: bronchial: sternal area (harsh sound)
 Bronchovesicular: blowing tungs fields
 Vesicular: Sighing sounds
 Size and shape
 Tectile fremitus
 Respiratory excursion
BREAST AND AXILLA
 Lymph nodes
 Breast
 Position: Standing (best), sitting, lying down
 Methods: (*One hand is externally rotated)
  2pt Gait: Dungan ang left crutch with the
ACTIVITY right foot and advance together and vice verse
 Body movement (think single ladies)
 Exercise: a form of physical activity which is  3pt Gait:For patients with one weak leg (cast).
repetitive and structured Crutches then bad leg the good leg.
 Different body movements:  4pt Gait: Right crutch then left foot then left
RESPONSIBILITIES crutch then right foot. Most safe
Body Mechanics  Swing To: Crutches and swing toward but land
 Base of support on your heel in the midline of the crutches
 Center of gravity  Swing Through: Crutches and swing beyond yh
 Line of gravity emidline of the crutches
 You should not lift more than half of your body  Ang hawiranan sa crutches is the same height
weight and when lifitng it should be close to your lang sa cane
body as much as possible  Tapos 2 fingers below sa ilok ang resting pad to
 Use large muscles when lifting: biceps, thighs, and prevent brachial plexul damage
stomach Stairs
 Spread legs wide apart, knees flexion  Gamiton is crutches
 Avoid overstretching: Make sure bed is working  Going Up: With the good leg first (good leg,
area height (waist level) crutches, then bad leg)
 Avoid using back muscles  Going Down: With the bad leg first (Crutches then
Positioning bad leg, then good leg)
 Take note of the joint mobility  Note: Di pwede mag bulag si bad leg and crutches
Assist in exercises so if crutches una automatic na bad leg sunod.
 Based on oxygen demand: Walkers
 Aerobic  Maximum support to both legs or one legs
 Anaerobic  Both legs: Waker, right foot, walker, left foot;
 Based on muscle contraction: alternate to exercise both legs
 Isotonic: Tanan mulihok joints, muscle, tendons  One leg: Walker woth the weaker legs
ex. walking
 Isometric: Muscle only ex. kegel exercise FLUIDS
 Isokinetic: combination of metric and tonic ex  Infants: 70-80%
weight lifiting  Adults: Males: 60% (more kay daghan sila muscles)
 Quadsetting exercise (isometric): exercise for Females: 50% (less kay daghan sila fats
cast patients. Place a roll below the cast and  Elderly: 50%
press.  ICF: Fluids inside the cells
Transferring patients  ECF
 From bed to stretcher : Kung aha itransfer gikan ang  Intrvascular: Inside the blood vessels/vasculatures.
patient mao ang tass. Ex. Tass and bed, ubos gamay The only one measurable
ang stretcher. If equal height sila there would be  Interstitial: Space between or outside the cell,
increase in friction usually site for fluid shifting/edema
 From bed to wheelchair : Place wheelchair at the  Transcellular: Fluids you can find in you cavity. Ex.
head part of the bed with an angle of 30 degress Peritoneum, sinovial joins, CSF
(pinaka duol sa parallel) place at the good side of RESPONSIBILITIES
the patient Fluid Replacement
 Priority: Look for the good side kay if ang good  More on IV therapy particulary infusion
side sa pt is at the foot then dadto sa ibutang ang  IV Fluids:
wheelchair  Hypotonic: Causes swelling. Less than 0.9%. Ex.
Assisting Ambulation 0.33 NaCL, 0.25% NaCl, 0.45% NaCL, More than
 Mild to moderate: weakness only. Place at the 200ml D5W
patients bad side para kay iyahang strenght ana na  Isotonic: No change. Ex. 0.9% NaCl, PLR, less than
side: hold patient at the belt support kay naa diha 200 D5w
iyahang center of gravity  Hypertonic: Causes shrinking. More than 0.9%. Ex.
 Sever: Position patient at the good side. Dapat naka D50W, D5LR, D50.45NaCl, D50.3NaCl
akbay ang patient, and then hold the belt support Fluid Transport and Shifting
 Ipsilateral (Cranial nerve; Same side) Intravenous Fluid
 Contralateral (Hemisphere; opposite)  From intrvascular to interstitial to intracellular
 Use of Assistive Devices (If di jud kalakaw ang  Hypotonic: ginapasulod ang fluids to cell causing
patient) sweeling. Intended for cellular dehydration
Canes  Hypertonic: Used for overhydrated cells. Solutes
 Minimal support and musulod then fluids inside the cell go out
 Do not use sa mga patient na ayha pa mag start ug leading to shrinking of te cell and fluids will shift to
lakw the interstitial.
 Make sure to exercise ang arms to prevent  If di makaya expand ang plasam it can lead to
Crutches increase BP
 Intended for walking  Plasma expanders: ex. albumin (main), hypertonic
 Best for patient na staring pa solution (alternative)
 Gaits:  Change the IV fluids every 24 hours as it can attract
microorganisms that can cause sepsis
 New IV Cannula  First hour, every 15 minutes
 Over the needle catheter  Secong hours, every 30 minutes
 The bigger the gauge the smaller the needle size  Third and fourth hours, every hour
 72 hours change for infection control
For Tubing Change
 Change every 72 hourse for infection control
Use Aseptic Technqiue For Crossmatching and Bloodtyping
 Ideal: alcohol then betadine and then dressing  There are 8 blood type
 Dressing: Since IV is considered as a puncture  Ma identify sa surface sa blood ang antigen
wounds use transparent film  If you have
Site Selection Type Antigen Antibody
 Bawal sa joint area, movable are, and sa movable na O X AB
ugat A A B
IV Equipment and Materials B B A
 Gloves: necessary to protect yourself from body AB AB X
fluid. Wash hands then gloves
 Tourniquet – place 2-4 inches above the site  O (-) is a universal donor
insertion. 1 tourniquest for 1 patients  AB (+) universal receiver
 Veiin finders  RH – if naay D-antigen then it is Rh positive but if
Observe Complication not then it is Rh negative
 Phelbitis: Redness, welling, heat, and pain on the  If mali ang nahatag it would lead to hemolysis which
site. Automatic terminate or stop infusion site. Do not is naay breakdown sa
reinsert on the same side.  RBC lifespan 120 days
 Infiltration: Wala sa ugat, na through and through.  Role of nurse is to verify the crossmatch. Best at
Pale, coll, clammy, painful, edematous, Automatic bedside
terminate or stop infusion site. Do not reinsert on the Use blood filters and gauge 18
same side.  Blood filter is needed aside for infection as maka help
 Overload: Slow down infusion into KVO rate. siya prevent ug clumping
Expect na ang pt is hatagan ug drugs sa DR such as  Gauge 18 para makasulod ang blood
diuretics. If naglisod ginhawa ang pt place pt in a Stay with the patient for the first 15 minutes or 50 ml
high fowlers position then KVO. na ang na transfuse
 Air Embolism: Position patient in a trendelenburg IV Fluids (0.9 NaCl ONLY)
positioning, para ang hangin di siya mudiritso saka sa Observe reactions
brain. Ma trap pa siya sa extremities to the RA, to  Allergic: can lead to anaphylaxis. Anaphylaxis pwede
RV, and into the lungs. Place pt for 20 minutes then ka mangatol dili tungod sa blood but tungod sa
30 minutes maximum. iyahang plasma contents
 Extravasation: Combination of phlebitis and  Sepsis: Naay gas bubbles in the bag indicating
infiltration. More likely to occur in vesicant meds ex. bacterial growth.
chemo meds. It can lead to necrosis if di ma remove.  Hemolytic Reaction: ABO incompatability may lead
Need i aspirate and contents/medications from the to death. Pag tan.awon nimo ang bag na cloudy siya,
patients veins to prevent necrosis. To stop buring meaning ana na hemolyze na so do not administer.
process, after na aspirate put ccold compress on site. This is caused by shaking the bag.
Not Delegated  Circulatory Overload: Remember you are giving
volume, musulod sa intravascular space. Banatyunon
BLOOD TRANSFUSION sa platelets.
Types of Blood Transfusion Not Delegate
 Whole Blood: Given in patient with or without active  Note: DO NOT MIX MEDS
bleeding. hgb is less than or equal to 9 Storage temperature
 PRBC: W/O active bleeding but hemoglobin is low  Whole blood and PRBC: 1-6 Celcius and can be
equal or less than 8 hgb. 1 unit = 1 hgb increase stored for 21-42 days. If ihatag sa patient at room
 Platelet: given if platelet is less than or equal to temp.
50,000; 1 unit can increase platelet from 5,000-  Platelet: Is not stored. Ayha ra ni siya makuha if naay
10,000 order/need na. It should be at 20-25 Celcius and only
 Fresh Frozen Plasma: For massive blood withn 72 hours.
transfusion  PFP and Cyro: 30 Celcius and can be stored for up to
 Cyroprecipitate: Treatment sa mga pt with problems 1 year
sa ilahang clotting factors. Management but not a  Thaw: 30-37 Celcius for FFP and cyro. Once thawed
cure. lifespan of 72 hours and they can be refreeze/restored
 Mas prefer and PRBC kay decrease and BP compred again once thawed.
sa whole blood Should Assess Blood Bag
 Blood is given 2-4 hours due to increased risk for  Assess blood for: Type, component, Rh, serial #, date
infection and to prevent sepsis of collection, date of expiry,
 Platelet, FFP, and cryoprecipotate – administer as fast  Test blood for: HIV, Hepatitis B & C, Malaria,
as the patient can tolerate to prevent clumping VDRL
 Requires D.O and consent If there is transfusion reaction
Requires Aseptic Techniques  Stop blood transfusion
A Nurse: 2 RN’s to verify  Transfuse PNSS
Should take Vitals signs before, during, and after  Assess patient
  Notify PHCP and blood bank (ilahang icheck ang o Need to expel more CO2
problem sa blood) o Inhale sa ilong, exhale na murag pa sigarilyo
 Send the blood bag and tubing to the blood bank o Best in respiratory acidosis
 Submit a urine sample to the hospital lab (Tung first  Hyperventilation
na ihi gikan sa pagtransfuse) o There is decrease CO2, give bag, use hand if
 Earliest sign of ABO incompatability is back pain. walay bag
 Hypoventilation
o Increased CO2, management is pursed lip
OXYGENTATION breathing
 500 ml of air and musulod sa atuang body during SMI: Sustained Maximal Inhalation
inhalation. If athletic it can range from 1-2L ang Inhale nad exhale to nose - steam inhalation
musulod  Incentive Spirometry
 21% of oxygenation  Mouthpiece sustain maximal inspiration, then
 Intrapleural pressure is negative (less than the INHALE then HOLD
atmospheric pressure which is 760mmHg)  Tanawon kung unsa ka taas ang bola
 The diaphragm and external intersotal muscles  10x per hour (If dili ma achieve sa goal. Pwede ni
contract to create negative pleural pressure to mutaas depende sa doctors order)
increase the size of the thorax for inspiration  May or may not have an order
 Relaxation of the diaphragm and contraction of the  Suctioning
internal intercostal muscles allows the air to escape  Necessaru when patients are unable to clear
from the lungs. respiratory secretions
 Ventilation: moving of gases into and out the lungs  Set suction pressure:
 Perfusion: ability of the cardiovascular system to o Portable: 15 mmHg in adults and
pump oxygenated blood to tissues and return o Wall unit: 120 mmHg
deoxygenated blood to the lungs
 Use Aseptic techniques
 Inspiration: an active process stimulated by the
 Catheter Tipped
chemical receptors in the aorta.
o Open: Massive Secretion
 Expiration: a passive process that depends on the
elastic recoil of the lungs o Whistle: Less secretion
 Surfactant: chemical produced in the lungs to  To suction during withdrawal (5-10 seconds;
maintain surface tension if the alveoli circular motion)
 Atelectasis: collapse of the alveoli  Insertion: Use luubricant
 WOB: effort required to expand and contract lungs  Oxygenate: 100% before and after suctioning
 Compliance is the ability of the lungs to distend or  Not delegate:
expand in response to increase intraalveolar pressure o Endotracheal
 Airway resistance: increase in pressure that occurs as o Tracheostomy
the diameter of the aiways decrease from mouth/nose  Oxygen Therapy
to alveoli  Types of:
 Diffusion is the process for respiratory gas exchange o Delivery:
and it occurs in the alveolar capillary membrane Cocentrators: equipment that gather O2 and
 Oxygen transport depends on the: concetrate it and gives it to the patient.
 Amount of oxygen entering the lungs Cylinders: Oxygen tank
(ventilation) o Delivery:
 Blood flow to the lungs and tissue (perfusion) Nasal Cannula
 rate of diffusion Tent:
 Oxygen carrying capacity Mask:
 Carbon dioxide is a product of cellular metabolism Simple
that diffue RBC and is rapidlu hydrated into carbonic Venturi: Precise control of low flow
acid oxygenation. Best for COPD. Facemask with
 Neural regulation: cerebral cortex regulates the adaptor
voluntary control of respiration by delivering impulse Partial Rebreather: Has plastic bag and buslot
to the respiratory motro neurons by the way of spinal Nonrebreather: w/o buslot. Can give 100%
cord. oxygenation.
Responsibilities  Home:
 Breathing Exercises o No smoking signs.
 Deep breathing exercises: o Dili butanagan ug no smoking signs and CR
o Goal is lung expansion  Evaluate respiratory status every hour
o Place patient in a high or semo fowlers position.  Requires Doctors order
Bawal higda. o No consent
o Inhale sa ilong, breath out sa mouth o Pwedeand nurse ang mag order in emergency
o 5 minutes lang per session and repeat for 4-5x a cases but lowest possible lang which is 2L/min.
day post op However, need isecure ang doctor’s consent
o Teach during post op (at least 3 days before within 24 hours.
surgery). Do not teach the day before operation  Application: position, turn on, regulate, apply
kay di masabtan sa patient due to anxiety.  Position:
o Need more O2 o Elevate HOB: High fowlers to promote lung
 Purse lip breathing: expansion
 Yes to cotton cloth
 o No to woolen cloth: concentrates static
electricity causing irritation
o No to synthetic fibers
CHEST PHYSIOTHERAPY
 Requires doctors order
 A group of therapies for mobilizing pulmonary
secretions
 Recommended for patients who produce sputum
greater than 30ml of sputum per day or evidence of
atelectasis on chest x-ray examination
 Sequence is
1.) Postural drainage
o A component of pulmonary hygiene and consist
of drainage, positioning, and turning
o Improves secretion clearance and oxygenation
o Involves draining affected lung segments and
help drain secretions from those segments of the
lungs and trachea
o Not all patient needs postural drainage to all lung
segment.
o Position: Segment to drain upwards
o If upper lobe: high fowler
o If lower lobe: trendelenburg
2.) Percussion
o Rhythimcally clapping on the chest wall over the
are being drained to force secretions into larger
airways for expectoration
o How: Use cushioned blow
o Cup hands because it conform the hands to the
chest wall while trapping a cushionof air to soften
the intensity of clapping
o Should not be painful
o Contraindicated in patients with bleeding
disorders, osteoporosis, and fractured ribs
o Avoid percussing over burns, open wounds, and
skin infections
o Take precaution to percuss on the lung fields
under the ribs and not voer the spine
o Perform percussion over a single layer of cloth
which prevents slapping the patient skin. Thicker
or multiple layers can dampen vibrations
o Should be with cloth and towel: cup hands and
percuss
o During exhalation: instruc patient to inhale
deeply then ipa exhale then while nag exhale pag
percuss.
o Duration: 1 minute per segment
3.) Vibrations
o Gentle, shaking pressure applied to the chest wall
to shake secretions into larger airways
o Place a flattened hand or two firmly on the chest
wall over the appropriate segment and press the
top and bottom hand in each other to vibrate
o Tense the muscles of the arms to provide shaking
motions
o This technique help increase the velocity and
turbelance of exhaled air, facilitating secretion
removal. This also increases the exhalation of
trapped air, shakes mucus loose, and induced
ccough.
o Shaking downwards
o How: Ipa inhale ang patient. pag exhale dayun is
shake downwards
o Duration: 1 minute
4.) Coughing exercise
o Few deep breaths, then during exhalation instruct
patient to cough
5.) Oral Care
 High frequency chest wall oscillation or oscillating
vest: helps clear airways fromexcessive secretions tor
educe WOB and to improve a patients ability to
cough up secretion
CHEST TUBE DRAINAGE SYSTEM
 Role: Maintain integrity and patency
 Indicated in patients with pneumothorax,
hemothorax, after surgery in the lungs, etc
 Focus on the chest tube not the patient
 Upper part removes air
 If basal part: blood and fluid remove
 X-ray: used if need ba mag chest tube and patient or
need na ba iremove ang chest tube
 Bottle system: to remove air and fluids to have
negative pressure to lead for the expansion of the
lungs
 3 way bottle system: has water seal chamber
 Drainage chamber: dari gina drain iyahang drainage.
May change in color, level, etc
 Water seal chamber: Focus if okay ra ab ang patient
 observe if there is continuous bubbling: indicates
air leak. Clamp the tube then check ang
connector kung aha ang leak
 Irregular/intermittent bubbling: normal
 No bubbling: either obstrution or nag expand na
ang lungs sa patient. If obstruction usually after a
few hours sa pag insert sa chest tube mag stop na
siya. If expansion, dugay na ang chest tube sa
patient.
 Suction Chamber:
 Continuous bubbling is normal
 If ipalakaw lakaw ang patient with chest tube,
ioff ang suction machine then open the air vent. If
mana siya ug lakaw then close the air vent and
turn on suction
 Have available at bedside
 bottle with sterile water (if mabuak ang glass
diritso dani ibutang)
 Petrolatum gauze/ vaselinized gauze: if
matangtang ang tube this will prevent na magka
tension pneumothorax ang patient.
 Tension pneumothorax mag occur if ma ipit ang
tube or wala natabunan diritso kung na tang tang
ang CTT. life threatening
 Evaluate respiratory ststus every hours
 Should position bottle system: always downhill
 Teaching
 Removal instructions: Valsalva maneuver. Take a
deep breath, close mouth/hold your breath, bear
down.