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FUNDAMENTALS IN NURSING

EVOLUTION OF NURSING NURSING IN THE PAST (TRADITIONAL NURSING) –FOCUS WAS TAKING CARE OF SICK PEOPLE CONTEMPORARY NURSING EMPHASIZES CARE OF THE “WHOLE PERSON, “ OR HOLISTIC HEALTH CARE

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HISTORICAL PERSPECTIVES 1. INTUITIVE ▪ WOMEN WHO TOOK CARE OF THEIR CHILDREN, ELDERLY AND SICK MEMBERS OF THE FAMILY ▪ SHAMANS – INCANTATIONS, TREPHININGS • CONTRIBUTIONS TO MEDICINE AND NURSING 1. BABYLONIA – CODE OF HAMMURABI 2. EGYPT – ART OF EMBALMING; ID 250 RECOGNIZED DISEASES 3. ISRAEL – MOSES “FATHER OF SANITATION” 4. CHINA – MATERIA MEDICA (PHARMACOLOGY) 2. PERIOD OF APPRENTICE NURSING  EXTENDS FROM THE FOUNDING OF RELIGIOUS ORDERS IN THE 11TH CENTURY AND ENDED IN 1836  “ON –THE-JOB TRAINING”  HOSPITALS WERE ESTABLISHED IN THE 16TH CENTURY BUT WERE UNSANITARY, CHEERLESS, GLOOMY AND AIRLESS 3. DARK PERIOD OF NURSING  17TH TO 19TH CENTURY  NURSING CARE GIVEN BY CRIMINALS AND WOMEN OF LOW MORAL STANDARDS  ENDED IN 1836 WITH THE ESTABLISHMENT OF THE KAISERWERTH INSTITUTE FOR THE DEACONESSES IN GERMANY BY PASTOR FLIEDNER 4. EDUCATIVE PERIOD  ESTABLISHMENT OF NIGHTINGALE SCHOOL OF NURSING AT ST. THOMAS HOSPITAL IN LONDON ON JUNE 15, 1860  GUARDIAN ANGEL OR ANGEL OF MERCY IMAGE  DOCTOR’S HANDMAIDEN » FLORENCE NIGHTINGALE (May 12, 1820 - Aug. 13, 1920)  MOTHER OF MODERN NURSING  LADY WITH THE LAMP  ANGEL OF CRIMEA  NOTES ON NURSING  NOTES ON HOSPITAL

» NURSING LEADERS  CLARA BARTON (1812-1912) – AMERICAN RED CROSS  LILLIAN WALD (1867-1940) – FOUNDER OF PUBLIC HEALTH NURSING  MARY ADELAIDE NUTTING, ISABEL HAMPTON ROBB AND LAVINIA DOCKAMERICAN SOCIETY OF SUPERINTENDENTS OF TRAINING SCHOOLS FOR NURSES IN THE US & CANADA » CONTEMPORARY  DEFINITION OF NURSING BY FLORENCE NIGHTINGALE AND VIRGINIA HENDERSON  NIGHTINGALE, 1860 – NURSING IS “THE ACT OF UTILIZING THE ENVIRONMENT…”  VIRGINIA HENDERSON, 1960 – “TO ASSIST THE INDIVIDUAL, SICK OR WELL” Events and Trends  Establishment of WHO by UN  Atomic/ nuclear energy for dx and tx  Use of computers  Aerospace nursing  Laws amended perceiving health as a fundamental right  Disposable supplies and equipments  Development of the expanded roles of nurses.  Community health nursing intensified   ROLES AND FUNCTIONS OF THE NURSES I. Caregiver (Care Provider) » it includes those activities, which usually carried out by a professional, that assist the client physically and psychologically while preserving client’s dignity. It if often referred to as “Mothering Actions” II. Communicator » nurses identify client problems and then communicate these verbally or in writing to other members of the health team through coordination. III. Client Advocate » one who expresses and defends the cause of another. The nurse promotes what is best for the client, ensuring that the client’s needs are met and protects their rights. IV. Counselor » Helps a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships and to promote personal growth. Counseling requires therapeutic communication skills, and the nurse should be prepared to provide emotional, psychological and intellectual support appropriately. V. Leader

» Nursing leadership is defined as a mutual process of interpersonal influence through which the nurse helps a client make decision in establishing and achieving goals to improve the client’s well being VI. Manager » Ability to handle or control something successfully, which in this case applies on the nursing care of individuals, families and communities. Roles in nursing management includes planning, organizing, staffing, leading, communicating, decision making and controlling. VII. Nurse Administrator » manages client care, including the delivery of nursing services, making sure that the nursing services are organized, coordinated, and dispensed, to meet the patient’s needs. VIII. Nurse Educators » help to coordinate and assess the education needs of nurses in the institution. They coordinate internship and orientation programs to prepare newly hired function in special areas. IX. Role Model » Nurses serve as good models when they observe healthful practices of daily living. ♥ EXPANDED ROLES 1. NURSE-PRACTIONER – GRADUATE OF A NURSE-PRACTIONER PROGRAM 2. CLINICAL NURSE SPECIALIST – ADVANCED DEGREE, CONSIDERED AN EXPERT IN A SPECIALIZED AREA OF PRACTICE 3. NURSE-ANESTHETIST 4. NURSE-MIDWIFE 5. NURSE-RESEARCHER – DOCTORAL LEVEL 6. NURSE-ADMINISTRATOR-HEAD NURSES, SUPERVISORS 7. NURSE EDUCATORS 8. NURSE-ENTREPRENEUR 9. Nursing Informatics – the science of using computer information system in the practice of nursing. - a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information to support patients, nurses and other health professionals in their roles. - this is designed to enhance client care, education, management and nursing research. ▪ SCOPE OF NURSING ♥ R.A. 9173 Article VI Section 28 of the Philippine Nursing act of 2002 cites the Scope of Nursing. FOUR AREAS OF NURSING PRACTICE: 1. Promotion of Health & Wellness w Nurses promote wellness in clients who are both healthy & ill.

w As the nurse moves towards greater autonomy in providing client care. a thorough assessment of the client’s health status is essential to provide a meaningful data. Umbilical cord care. preventing drug & alcohol misuse. NUTRITION. use of first aid. such as nutrition & physical fitness. w This may involve individual & community activities to enhance healthy lifestyles. & safety. IMMUNIZATION. TERTIARY PREVENTION – FOCUS IS TO HELP REHABILITATE INDIVIDUALS (EX. w Nursing activities include the following:  Providing direct care to ill person such as administering medications. w Nursing activities that prevent illness include immunizations. 4. & specific procedures & treatment.  Rehabilitating clients to their optimal level following physical or mental illness. (such as measuring BP)  Consulting with other health care professionals about client problems  Teaching client about recovery activities. injury. baths. BSE) 3. pap smears. restricting smoking & preventing accidents & injury in the home & workplace. Restoration of Health w focuses on the ill client & it extends from early detection of disease through helping the client during the recovery period. such as exercises that will accelerate recovery after a stroke. routine physical examination. Prevention of Illness w The goal of illness prevention programs is to maintain optional health by preventing disease.2. STRESS MANAGEMENT 2. PRIMARY PREVENTION – FOCUS IS ON HEALTH PROMOTION EX. or addiction. w Prevention.  Performing diagnostic & assessment procedures. mammograms. in a narrow sense. SCREENING SURVEYS. FAMILY PLANNING SERVICES. w The nursing process is the best tool for the nurse in the health promotion role. SECONDARY PREVENTION – EMPHASIZES EARLY DETECTION. Alleviation of Suffering / Care of Dying  it involves comforting & caring for people of all ages who are suffering & dying.  It aims to restore maximum functional health pattern. . EARLY INTERVENTIONS (EX. consists of all interventions to limit progression of a disease. means avoiding the development of disease in the future. TEACHING CLIENTS WITH DM ABOUT SELF-MEDICATION & PREVETION OF COMPLICATIONS) 3. & in broader sense. TSE. prevention of sexually transmitted disease (use of condom). prenatal & infant care. ♥ 3 LEVELS OF PREVENTION 1.

current.the building blocks of theories .focus on the exploration of concepts. hospitals. statements. diets. 4.directs links among theory. 3.a supposition or systems of ideas that is proposed to explain a given phenomenon. prosthesis) & future ( e. activity limitations.“meta” meaning “with” . characteristics. • Purposes of Nursing Theories : . or concepts. and control a phenomena.articulate a broad range of the significant relationships among the concepts of discipline.experts in each area helps to ensure that work in other areas remains relevant. research and clinical practice. THEORY . facilitation of strong self-image. Environment – the internal or external surroundings that affect the client. & extended care facilities. Nursing – the attributes. education. fear of pain) problems.• •  It includes helping clients adapt to altered health & function. and actions of the nurse providing care. live as comfortably as possible until death & helping support persons cope with death. Strategies to deal with current (e.easier to understand by example . . • METAPARADIGM . GRAND THEORY .g.used to describe.a group of related ideas. medications. • Theory that focus on environment: 1. Health – the degree of wellness or well-being that the client experiences.g. . or grief & bereavement counseling. • MIDLEVEL THEORY .  Nursing activities involve problem solving skills.a pattern of shared understandings and assumptions about reality and the world. adaptation to changing health status & lifestyle. . Client – the recipient of nursing care. predict. research and practice. Florence Nightingale Environmental theory . and ultimately influences health. • CONCEPT . 2. • PARADIGM .articulating relationships among major concepts Four major concepts in nursing: 1. useful.  Nurses carrying out these activities work in homes.guides knowledge development and directs education.something thought or imagined or perceived • CONCEPTUAL FRAMEWORK .

. . .holistic delivery of health care to meet the social.client is an individual with a need that when met diminishes distress. JOHNSON – BEHAVIORAL SYSTEM MODEL .IF THIS IS NOT POSSIBLE. . • Theories that focus on the inter-relationship between client and nurse: 1. pathologic state and treatment (cure) and body (care) 6.focus on how the client adapts to illness and how actual or potential stress can affect ability to adapt. 2. IMOGENE KING GOAL ATTAINMENT THEORY . DOROTHY E.ASSISTS INDIVIDUALS AND GROUPS IN SOCIETY TO ATTAIN. BETTY NEUMAN . developmental or social needs.3 NURSING SYSTEMS 1.. Faye Abdellah.the goal of nursing is to help the person adapt to this changes in physiological needs. LYDIA HALL .A PERSON IS A UNIFIED BIOPSYCHOSOCIAL SYSTEM IN CONSTANT INTERACTION WITH A CHANGING ENVIRONMENT. MAINTAIN. psychological. PARTIALLY COMPENSATORY – NURSE/CL ENGAGE IN MEETING SELFCARE NEEDS 3.Process by manipulation of env’t. 3. 5. Virginia Henderson.the typology of 21 nursing problems .clients’ basic needs are categorized according to behavioral subsystems.the client is composed of overlapping parts . .to facilitate the body’s reparative . role function during health and illness.14 Basic/ Fundamental Needs . SIS.focus on the independent satisfaction of human needs. .nurses interact with clients even when recovery may not be feasible.nursing care is necessary only if the client is unstable to fulfill biological. person (core).nurse is concerned with both healthy and ill individuals. self-concept. . Ida Jean Orlando . emotional and spiritual needs of the client and family.to identify problems and identify goals. physical. • Theories that focus on the client as an Individual / Holistic Approach: 1. SUPPORTIVE-EDUCATIVE – ASSISTS IN DECISION-MAKING AND ACQUISITION OF KNOWLEDGE AND SKILLS 4. increase adequacy and enhances well-being. DOROTHEA OREM – SELF CARE & SELF-CARE DEFICIT THEORY . intellectual.the goal of nursing is to ↓ stress. . CALLISTA ROY – ADAPTATION MODEL . AND RESTORE HEALTH.to work interdependently with other health caregivers. 3. NURSES HELP INDIVIDUALS DIE WITH DIGNITY 2. . WHOLLY COMPENSATORY – 100% CARE GIVEN TO THE CLIENT 2.

3. HILDEGARD PEPLAU INTERPERSONAL MODEL . ASSUMES THE POSITION OF DEPENDENCE. extrapersonal stressors – those that occur outside the person. ORIENTATION – THE NURSE AND THE CL DO NOT KNOW EACH OTHER’S GOALS. PERSONAL INTEGRITY AND SOCIAL INTEGRITY) LEGAL ASPECTS OF NURSING .promotes health & growth 4.based on the individual relationship to stress. STRUCTURAL INTEGRITY.use of therapeutic relationship between the nurse and the client .relationship between client and environment : 4.focus on the person’s wholeness .nurse enters into a personal relationship with an individual when a need is present .views client as an open system consisting of a basic structure or central core of energy resources.4 PHASES OF THE NURSE-CLIENT RELATIONSHIP: 1.MAN IS AN ENERGY FIELD IN CONSTANT INTERACTION WITH THE ENVIRONMENT.Caring promotes health more than does curing .categories of stress: a. Intrapersonal stressors – those that occur within the individual b. MARTHA ROGERS SCIENCE OF UNITARY HUMAN BEINGS . MYRA LEVINE FOUR CONSERVATION PRINCIPLES (CONSERVATION OF ENERGY.use of non-therapeutic touch to enhance the healing process 2. JEAN WATSON Human Caring Model . MADELEINE LEININGER – TRANSCULTURAL NURSING MODEL •HUMANISTIC & SCIENTIFIC MODE OF HELPING A CLIENT THROUGH SPECIFIC CARING PROCESSES (CULTURAL VALUES. NURSE ASSISTS CL TO UNDERSTAND THE PAST & EXTENT OF NEEDS) 2.Caring is central to nursing . . . the reaction to it and reconstitution factors. IDENTIFICATION – THE CLIENT RESPONDS TO THE PROFESSIONALS . RESOLUTION – TERMINATION PHASE 5. . CL TRIES TO SEEK HELP. INDEPENDENCE AND INTERDEPENDENCE 3. BELIEFS AND PRACTICES) TO IMPROVE OR MAINTAIN A HEALTH CONDITION • Theories that focus on the inter. PHASE WHERE CL TESTS THE NURSE. Interpersonal stressors – those that occur between individuals c. EXPLOITATION – CL UTILIZES ALL AVAILABLE RESOURCES TO MOVE TOWARD A GOAL OF MAXIMAL HEALTH 4.HEALTHCARE SYSTEM MODEL .

ETHICAL ASPECT OF NURSING  ETHICS – RULES OR PRINCIPLES THAT GOVERN RIGHT CONDUCT  BIOETHICS – THE ETHICS CONCERNING LIFE  MORALITY – CONCERNS BEHAVIOR WHICH INVOLVES JUDGEMENTS. FELONIES OR MISDEAMENOR ▪ FELONY – A SERIOUS CRIME SUCH AS MURDER. 2ND DEGREE MURDER ▪ MISDEAMENOR – AN OFFENSE OF A LESS SERIOUS NATURE ▪ TORTS – CIVIL WRONG COMMITTED AGAINST A PERSON OR A PERSON’S PROPERTY. ♥ Intentional Torts  Fraud – false presentation of some facts with the intention that it will be acted upon to another person. writing.▪ CRIME – ACT COMMITTED IN VIOLATION OF PUBLIC LAW. INTENTIONAL.  Invasion of Privacy  Defamation – false communication > Libel – print. ACTIONS AND ATTITUDES BASED ON NORMS • CODE OF ETHICS – PROVIDES A MEANS BY WHICH PROFESSIONAL STANDARDS OF PRACTICE ARE ESTABLISHED. pictures > Slander – spoken word  Assault – attempt or threat to touch another person unjustifiably  Battery – willful touching of a person (or clothing) that may or may not cause harm • False Imprisonment – unlawful restraint or detention of another person against his/her will ♥ Unintentional torts  NEGLIGENCE – COMMISSION OR OMISSION TO DO SOMETHING THAT A REASONABLE PERSON WOULD DO or would not do which cause injury  MALPRACTICE – “A PROFESSIONAL NEGLIGENCE” Improper or unskillful care of a patient ♥ MOST COMMON NURSING ERRORS THAT RESULT IN NEGLIGENCE  MEDICATION ERRORS  BURNING A CLIENT  FALLS  IGNORING A CLIENT’S COMPLAINTS OR FAILURE TO OBSERVE AND TAKE APPROPRIATE ACTION  MISTAKEN IDENTITY ♥ LEGAL DOCTRINES R/T NEGLIGENCE  RESPONDEAT SUPERIOR – “LET THE MASTER ANSWER”  RES IPSA LOQUITOR – “THE THING SPEAKS FOR ITSELF” No proof is needed. MAINTAINED AND IMPROVED .

DESCRIBING THE 5 STEPS OF THE NURSING PROCESS ♥ CHARACTERISTICS OF THE NURSING PROCESS:  CYCLICAL AND DYNAMIC. RATIONAL METHOD OF PLANNING AND PROVIDING INDIVIDUALIZED NURSING CARE. IT PROVIDES A FRAMEWORK FOR ACCOUNTABILITY AND RESPONSIBILITY IN NURSING AND IT MAXIMIZES RESPONSIBILITY FOR STANDARDS OF CARE. • GAINED LEGITIMACY IN 1973 WHEN ANA PUBLISHED STANDARDS OF NURSING PRACTICE. RATHER THAN STATIC  CLIENT CENTERED  OPEN AND FLEXIBLE  INTERPERSONAL AND COLLABORATIVE  IT IS PLANNED  GOAL DIRECTED  PERMITS CREATIVITY OF THE NURSE  EMPHASIZES FEEDBACK  UNIVERSALLY APPLICABLE ♥ BENEFITS FOR THE CLIENT  QUALITY OF CARE  CONTINUITY OF CARE  CLIENT PARTICIPATION IN THEIR HEALTH CARE ♥ BENEFITS FOR THE NURSE  CONSISTENT AND SYSTEMATIC NURSING EDUCATION  JOB SATISFACTION  PROFESSIONAL GROWTH  AVOIDANCE OF LEGAL ACTION NURSING PROCESS It was popularized by Lydia Hall in 1955 » It is both a problem solving process and a framework in which nurses can apply their knowledge and skills.♥ ETHICAL ISSUES IN NURSING  CARING FOR AIDS PATIENTS  ABORTION  CONFIDENTIALITY  TERMINATION OF LIFE-SUSTAINING TREATMENT  DNR ♥ NURSING PROCESS • SYSTEMATIC. » It is a GOSH approach G – oal oriented O – rganize S – ystematic H – umanistic Care .

technical skills ▬ knowledge . Pain. Physical Assessment. Objective (signs) – can be observed (by the use of senses) and measured Sources of data: 1. Diagnosis – identify the client’s status and health care needs. Methods of collecting Data: 1. dizziness) 2.36◦C – 37. ▪ Formulation of NCP which is used mainly as a guide to individualize care. ▪ Characteristics of a well stated goal: S. Collect.ealistic T.communication skills 5. Identifying the specific actions to be done.5◦C) . Primary Data – provided by the client 2.tiology S. Evaluating – measuring the client’s health achievements based on the goals specified. TEMPERATURE.1. Implementing. Actual – problem is present 2.to validate and confirm subjective and objective data.easurable A.roblem E. Subjective (symptoms) – apparent only to the client (e. » Phases / Steps in Nursing Process: Assessment ▪ Get the facts. Observation – use of 5 sense and instruments 3.the balance between heat produce by the body and heat loss from the body. ▪ Types of Nursing Diagnosis: 1. and record client data. VITAL SIGNS 1. Potential – problems may arise 3. Interview – a planned communication with the client.pecific M. 2.g. Types of Data: 1. ▪ Uses the PES format P. (normal. organize. Wellness – transition from a specific level of wellness to a higher level. 3. Planning – Determine goals and outcomes. Possible – problem may be present 4. validate.putting the NCP into action ▪ Requirement for implementation : ▬ TUOS . 2.igns and symtoms ▪ Prioritizing nursing diagnosis is based on what endangers life.ime framed 4.ttainable R. Secondary Data – provided by a source other than the patient.

6oF 36. lowest 4-6am Exercise Hormones – progesterone Stress Environment – elderly cl susceptible to heat stroke ▪ Four common types of fever ♥INTERMITTENT – ALTERNATES BETWEEN PERIODS OF FEVER AND PERIODS OF NORMAL TEMP ♥ REMITTENT – WIDE RANGE OF TEMP FLUCTUATION OCCURRING OVER THE 24HOUR PERIOD.temperature of the skin..deep tissue temperature of the body. 2 mins.4 o C– 97.▪ Types of Body Temperature: a.7o C– 99. ▪ Normal PR for adult – 60-100 bpm . 7 – 10 mins Automatic results Normal value 37o C– 98. and fats.taking Route oral Rectal Axilla Tympanic membrane No. Normal ranges from 36. ▪ it is regulated by the autonomic nervous sys. ▪ Routes of temperature.9 o F Description Most convenient and accessible Most accurate and invasive Least invasive and least accurate Directly reflects core temperature 2. Surface temp. subcutaneous tissue.7 o C– 99. ▪ FACTORS AFFECTING BODY TEMPERATURE AGE Infants – Elderly – hypothermia (lack of SC) Diurnal variables Highest temp – 8pm-12am. of minutes 2 .5 o F 37.6o F 37.3 mins.it is the wave of blood created by the contraction of the left ventricle. ALL OF WHICH ARE ABOVE NORMAL ♥ RELAPSING FEVER – TEMP IS ELEVATED FOR A FEW DAYS ALTERNATED WITH 1 OR 2 DAYS OF NORMAL TEMPERATURE ♥ CONSTANT FEVER – BODY TEMP IS CONSISTENTLY HIGH ▪ CONVERSION: Fahrenheit to Celsius = (o F-32) x 5/9 Celsius to Fahrenheit = (o C x 9/5) + 32 PULSE .7◦C -37◦C b. Core temperature.

To determine discrepancies with radial pulse Used to measure blood pressure Readily accessible and routinely use Determine the circulation of the legs PULSE SCALE SCALE FOR MEASURING PULSE STRENGTH 0 ABSENT 1+ PULSE IS DIMINISHED. if the cuff is too big for the patient. ▪ Diastolic Pressure – pressure when the ventricles are at rest. ▪ Normal Adult breathes 16-20 times per min. Cheyne – Stoke – alternate waxing and waning with temporary period of apnea. BLOOD PRESSURE BLOOD PRESSURE– it is the pressure exerted by the blood in the arteries. the BP reading may result to false measurement. Normal breathing – quiet. ▪ Pulse Pressure – the difference between the systolic and diastolic pressure ▪ the series of sounds during BP reading is called Korotkoff sounds. c. ▪ Characteristics : a. PULSE PRESSURE – DIFFERENCE BETWEEN SYSTOLIC AND DIASTOLIC WIDENED PULSE PRESSURE – WITH INCREASED ICP BP130/60 NARROWED PULSE PRESSURE – HYPOVOLEMIC SHOCK BP 70/60 ▪ If the BP cuff is too small for the patient. DEPTH (SEEN IN METABOLIC ACIDOSIS. ▪ Medulla Oblongata is the primary respiratory center of the body. . RESPIRATION – it is the act of breathing. regular. BOUNDING PULSE Pulse rate vary in different age levels 1 y/o – 80 – 100 bpm 10 y/o – 50 – 90 bpm 2 y/o – 80 – 140 bpm adult – 60 – 100 bpm 6 y/o – 75 – 120 bpm 3. BARELY PALPABLE 2+NORMAL 3+FULL PULSE 4+STRONG. the BP reading may result to false high measurement.Pulse Site Temporal Carotid Apical Brachial Radial Femoral Purposes Used when radial pulse is not accessible Used for infants and in cardiac arrest Used for infants and children up to 3 y/o. KAUSSMAUL’S – INCREASED RR. d. RENAL FAILURE 4. ▪ Normal Adult’s BP is 120/80 ▪ Systolic Pressure – pressure resulting from the contraction of ventricles. Biot’s – irregular respiration with period of apnea. rhythmic b.

any animal or insect 5. Portal of Entry and exit – provides the way for the pathogen to leave one host and enter another host. Infectious Agent – also known as pathogens ▪ Types of Infection-producing microorganism Virus – HIV.ASEPSIS AND INFECTION CONTROL ▪ Six Links in the Chain of infection: (SHARE ME) S-usceptible H-ost A-gent R-eservoir E-ntry M-ode of transmission E-xit 1. influenza. Susceptible Host – a carrier Body Defenses Against Infection: . 4. Modes of Transmission ▪ Direct Transmission – person to person Droplet Transmission – if the source and host are within 3 feet ▪ Vehicle-borne – any object or substance that provides a means of transport and introduce pathogen into a host. ▪ Vector – borne . Coli. protozoa. S.E. hepetitis Bacteria. worms 2. Reservoir – sources or places for growth of pathogens 3. Aureus Fungi – Candida Albicans Parasites – ticks.

Immune Response – immunity is the resistance of the body to a specific infection NOSOCOMIAL INFECTION – occurs when the client is in the hospital. 7. Hand washing 2. visitors and health care workers ▪ Standard Precaution – also known as universal precaution. 2. Exogenous – infection acquired from the environment or other people.such as cilia. Sterile objects become unsterile when touched by unsterile objects 2. 2. Enlarged lymph nodes. Alertness. prep. tears. Endogenous – infection acquired by microorganisms that the client himself harbors. Heat Medical Asepsis Terminologies: Clean – implies the absence of nearly all microorganism Dirty – presence of microorganism Sepsis – it is the state of being infected Disinfectant – chem. When sterile objects become unsterile. intact skin and mucous membrane. Remember: 1. Remove all jewelries 4. acidity of the stomach.1. Skin is unsterile and cannot be sterilized 6. and honesty are essential in maintaining sterile asepsis Isolation Precaution ▪ Isolation – describes measures taken to prevent the spread of microorganism to client.preparations Prevents growth and reproduction of some bacteria. Manifestations of Infection: ▪ General (LATENT) Loss of energy. All objects used in a sterile field must be sterile 4. Discomfort. The edges of the sterile field are considered unsterile 5. Iatrogenic – infection receives as the direct result of a treatment or diagnostic procedure. ▪ Local (RED Heat) Redness. ▪ Nosocomial infection can be: 1. Tachycardia and tachypnea. ▪ Handwashing – one of the most effective measures for preventing nosocomial infection. Wear latex gloves for dirty procedure Surgical Asepsis Sterile Technique – practice to keep an object or area free from all microorganism Principles: 1. Temperature is high. saliva. Edema. Keep fingernails short 3. Inflammatory Response – 3. ▪ Isolation Practices: . Anatomic and physiologic barriers. 3. Bactericidal – preparations that destroy bacteria Bacteriostatic. Used to inanimate obj. Sterile items are considered unsterile if it is out of vision or below waist level 3. it does not necessarily change appearance. conscientiousness. Anoxia. Nausea and vomiting.

Enteric Precaution – infectious diseases transmitted through direct or indirect contact with infected feces. . Example : Herpes Simplex. Pneumonia. influenza 3. Drainage / Secretion Precaution – patients with wound drainage or infected wounds. pupil dilation(mydriatic) ▪ Types: Liquid – 2gtts (conjunctival sac) Ointment – lower conjunctiva (inner to outer canthus) • Note: 1. 2. Universal / Blood and body fluids precaution – blood borne. immunocompromised patient MEDICATION ADMINISTRATION Terminologies: » Desired Effect – “therapeutic effect” » Adverse Effect – a harmful reaction. Example: Burns 6. offer oral hygiene. Varicella. √ If the drug has an offensive taste.opposite reaction » Drug Allergy – a hypersensitive response to an allergen which the individual has been exposed and developed antibodies. STD’s 7. Ex: Burns and open wounds. vaginal secretion. pleural fld. dysphagia or altered LOC √ Do not give if the client is on NPO. unexpected » Toxic Effect – plasma concentration of the drug reaches threatening level » Side Effect – a response that is unrelated to the desired action of the drug. don’t let the tip of canister touch any part of the eye. excessive response » Paradoxical reaction . Strict Isolation – indicated to highly transmissible diseases by direct contact and airborne routes of transmission such as Herpes Zoster. ▪ Sublingual – drugs are placed under the tongue. press the nasolacrimal gland 3. Examples : measles. ▪ Route of administration Oral Medication – most common method of drug administration and generally the safest route. no to cornea 2. Respiratory Isolation – indicated if the mode of transmission is droplet transmission. Eye Medication (optic) ▪ Effects: pupil constriction (miotics). Scabies. Hepa B. body fluids pathogens (blood. Reverse Isolation – patient is protected from pathogens and nosocomial infections. mumps. 1. Onset is slower. » Hypersensitivity – abnormal. Example: diarrhea.1.) Ex: AIDS. Contact Isolation – indicated for infectious diseases or multiple resistant microorganism that are spread by direct or close contact. typhoid fever 5. semen. Syphilis 4. expected » Drug dependence – the physical or psychological reliance on a chemical agent resulting from addiction. ▪ Buccal – drugs are placed in the inner cheek * Rule: Never swallow the drug and do not follow with water √ might cause aspiration and choking √ Assess for gag reflex.

Deltoid. non-irritating drug 2. ▪ Press the tragus of the ear 3x for absorption ROUTE : Intradermal Amount : < 1 cc Needle Gauge # 26-27 Angle of Insertion : 5 -15 ◦ Sites : ▪Anterior aspect of lower arm ▪Lateral aspect of upper arm ▪Upper aspect of the chest Others ▪ Used for mantoux test and allergy test ▪ Do not massage the bleb ▪ Bevel up ▪ No red ink Subcutaneous Sites ▪outer aspect of the upper arm ▪abdomen ▪thigh Amount : > 1 cc Needle Gauge # 25-26 Angle of Insertion : 45 ◦< Used for: ▪Insulin ▪Heparin ▪Do not massage ▪Do not aspirate Intramuscular Amount : 1-3cc Needle Gauge Child: # 24 – 25 Adult: # 23 .Ear Medication (otic) ▪ Position: lateral for 5mins.Below 7 months of age 3. Ventro Gluteal – 7 months and above 4. > 3y/o – pull the pinna up and back ▪ Solution: side of the ear and warm temp. ▪ Age: <3y/o – pull the pinna down and back. Dorso-gluteal – children 3 yrs and above ▪ used for large amounts of drug or highly irritating drug such as Dextran .24 Angle of Insertion: 90 ◦ Sites 1.1 ml. Vastus Lateralis.

 Used to administer IM medication that are highly irritating to subcutaneous and skin tissues  Attach a new sterile needle to the syringe after drawing up the medication  Retract the skin to the side before piercing the skin with the needle to prevent tracking. Intermittent injection ports have either a resealable latex injection site for needle access. 5. They are small fluid containers (100-150ml) attached below the primary infusion container. Secondary IV setups are the tandem and piggyback. Frequently used to infuse solutions into children. introduced directly into a vein by venipuncture. IV Push (bolus). Volume. 2. Intravenous Medications ▪ IV meds enter the client’s bloodstream directly by the way of a vein. Volutrol and Pediatrol.Lactated Ringers 5% dextrose in water 0. Intermittent IV infusions – a method of administering a medication mixed in a small amount of IV solution such as 50 or 100ml. Large volume infusion – the safest and easiest way to administer IV meds. The drugs are diluted in volumes of 1. they are appropriate when a rapid effect is required ▪ Medications are administered intravenously by the following methods: 1.Z-TRACK METHOD  Do not massage the site after injection to prevent tissue irritation.may be affixed to an IV catheter or needle to allow medications to be administered intravenously.000ml or 500 ml of compatible fld.control Infusions – intermittent meds may also be administered by a volume-control infusion set such as Soluset. It is used in emergency cases.9% NaCl. Intermittent Infusion Devices. 4.the IV administration of an undiluted drug directly into the systemic circulation. Type of Fluid Isotonic -SHOCK Hypotonic -Dehydration Hypertonic -Use to treat metabolic acidosis IV Fluid 0. Ringer’s Solution . Normal Saline or LR are frequently used. 3.45 NaCl 10-15% Dextrose in water 3% NaCl Sodium Bicarbonate .

Bld glucose < 60 mg/dL Shakiness .FORMULA FOR DOSAGE COMPUTATION ♦ ORAL MEDICATIONS: Solids (D/S=Q) Desired dose = quantity of Stock dose drug ♦ ORAL/PARENTERAL MEDICATIONS: Liquids (D/S X DILUTION = Q) Desired dose x dilution = quantity of Stock dose drug ♦ IV FLUID FLOW RATE:  gtts/min = volume in cc x gtt factor no. Right Dosage 3. of hours x 60 min. Right Drug 2.Right Preparation PROCEDURES 1. Right Approach 7. Right Time 5. Right Route 4. ▪ Capillary blood glucose is monitored by using commercial glucose meter such as Glucometer. Right Patient 6.  cc/hr = volume in cc or gtts/min x 4 no. Blood Glucose Screening ▪ The glucose value measures the effectiveness of the treatment of the client with diabetes. Right Action 1O. Protect test tips from exposure to light. Right Documentation 8. of hours  duration in hours = volume in cc cc/hr » The following is a method to calculate drops per minute: Volume to be infused (cc/hour) X gtt/ml 60 minutes • 10 Rights in giving medications: 1. ▪ Measurement is done 30 minutes before meal. ▪ Normal Blood Glucose is 60-120 mg/dl Signs and Symptoms of Abnormal Blood Glucose Level Hypoglycemia. Right Frequency 9.

Gavage – gastric feeding b. Saline) 90-120 ml. Hypertonic solution – increased osmotic pressure will draw fluid from the interstitial space into the colon (e. For decompression d. Solution. Medication and supplemental fld. » Remember to stop and remove if the client cannot talk. ▪ Purpose : Bowel training program to establish bowel fxn Eliminate feces and flatus Avoid contamination of the sterile field Treat constipation and impaction Support visualization of intestine ▪ Principles: » lubricate tube 3 -4 inches » Position: left lateral position or sims position » Administration: deliver slowly to minimize discomfort » Height of container: 12” above the rectum » Temperature: not more than 42◦C ▪ Solutions commonly used: 1. and sometimes by irritating the intestinal mucosa. ▪ Principles: » Position: High Fowler’s Position » Length of tube to inserted: (NEX) from the tip of the nose to the earlobe down to the xiphoid process. is coughing. or becomes cyanotic. Adm.Hunger Rapid Pulse Irritability Loss of concentration Seizure Hyperglycemia – Bld glucose > 120 mg/dL Weakness Polydipsia Dry skin and mouth Nausea and Vomiting Glucosuria Thirst Kussmaul breathing (late) 2. Lavage – stomach irrigation c. increases peristalsis and expulsion of the feces and flatus.g. . ▪ Purposes: a. Draws water into the colon 3. Insertion of NGT ▪ NGT is inserted through the nose and into the stomach . » Fr 12 (36 inches) for adult Enema – act by distending the intestine.

no movement of fluid in or out of the colon. single lumen c.#8 or #10. Cleansing – used to cleanse the bowel * instruct the client to hold the fluid for 10 -15 mins. External Urine Drainage Device (condom cath) MALE Position Length Length to be inserted FEMALE Supine / flaccid penis at 90◦ Dorsal Recumbent angle 22 cm catheter 40 cm catheter 2 – 3 inches 6 – 9 inches . Hypotonic solution – lower osmotic pressure will cause water to move from the colon to the interstitial space (e.2. Oil retention – given to soften feces and lubricate the rectum and anal canal. » Client should void within 4 – 6 hrs after an indwelling catheter is removed » Acidify the urine – offer food such as cranberries. clamp the tube for 30 secs. • 60-80 ml. it distends the rectum and colon and stimulates peristalsis. Carminative – release gas. Stimulates peristalsis and soften feces * watch out for circulatory overload 3. usually with 2 lumens b. 2. The volume of solution stimulates peristalsis (e.g. Suprapubic catheter – small insertion is made above the pubic area and the tube is directly inserted into the baldder. male adult #18 » do not allow the catheter bag to lie on the floor. 500-1. Straight Catheter – for short-period catheterization. Isotonic solution . Urinary Catheterization – introduction of a catheter into the urethra towards the urinary bladder. Indwelling catheter (foley.#14 or #16.000 ml. Normal saline) ▪ Types of Enemas : 1. Tap water). d. ▪ the force of the solution is controlled by REST Resistance of the rectum Elevation of the solution container Size of the tubing Thickness of the fluid 4. Of fluid is instilled 3. retention) – for long period catheterization. plums and prunes » Increase fluid intake to 3L/day to prevent urinary stasis ▪ Types of catheter : a. . Introduce oil or meds into the rectum and sigmoid colon. * If client complains of cramping. Do not allow the drainage spout to touch the collection receptacle. female adult . ▪ Principles : (sterile technique is a must) » Size : children.g. The fluid is retained for 1-3 hrs.

20 – 30 secs 2 – 3 inches Saline solution 5 – 10 secs. bubbling breath sound c. Oxygenation ▪ Oxygen is a clear.5 mins. 2 – 3 minutes Length of tube to be inserted Lubricant Duration Resting pd bet. Facilitate ventilation . Decreased breath sound ROUTE Position ORO PHARYNGEAL Conscious. suctioning 3 – 5 inches water 5 – 15 secs. ▪ 3 . Tract » it is normal for suctioning to cause coughing. Suctioning – is aspirating secretions through a catheter connected to a suction machine or ▪ wall suction outlet. pallor and cyanosis b. » performed to clear the airways » irritates mucosa and removes oxygen from the resp. sneezing and gagging ▪ Manifestations of the need for suctioning: 4D a. 20 – 30 secs 6.5. odorless gas that constitutes approximately 21% of the air we breathe. Drooling. Decreased oxygen saturation d. ▪ Principles : (sterile technique is a must) » Suction Catheter size : Adult: #12-#18 Children: #8-#10 Infant: #5-#8. absence of oxygen in the brain may cause permanent damage. is necessary for all living cells. Dyspnea.semifowler’s Unconscious – side lying 110-150 mmHg NASO PHARYNGEAL Semi fowler’s with neck hyperextended TRACHEOSTOMYENDOTRACHEAL Semi fowler’s unless contraIndicated Pressure Depends upon the age 90 – 110 mmHg and type of suction apparatus 3 – 5 inches Water-soluble 5 – 15 secs. ▪ Therapeutic Nursing Intervention for Oxygenation : a.

Palpation – examination of the body using the sense of touch. Simple face mask – delivers oxygen concentration 60 – 90%. ▪ Safety Precaution 1. Cannula – tubes with two prongs for insertion into the nostrils.25-50%. Promote patent airway d. Palpation: . Preferably used for patient with COPD. » Tympany – sound produced from an air-filled stomach. 4. b. partial rebreather – delivers oxygen concentration. b. No objects that cause static electricity 3. Ensure adequate hydration. 2. No volatile subs. No smoking sign on the door 2. Flows. Auscultation – is the process of listening to sounds produced within the body. heart. Percussion – the act of striking a body surface to elicit sounds that can be heard or vibrations that can be felt. Oxygen flow rate1-6L/min. Face Masks – the mask covers the client’s nose and mouth 1. Non-rebreather – 95 -100 %. flow 10-15 L/min. Venturi mask .5-8L/min. The pads of the fingers are used 3.» position in semi or high fowler’s » Incentive spirometer provides an “incentive” to breath deeply. » Resonance – produced by lung filled with air » Hyperresonance – booming sound that can be heard over an emphysematous lung. near the patient PHYSICAL ASSESSMENT ▪ Methods of Assessment: 1. Administer oxygen Oxygen Delivery Devices : a. that is assessing by using the sense of sight. flows : 6-10 L/min 3. flow 4-10L/min. 4. 2. Inspection – is the visual examination. » flatness – produced by very dense tissue such as muscle or bone » dullness – produced by dense tissue such as liver. c.

p p percussion .

miosis. SKULL AND FACE a. nodule. b. shape and symmetry b. within normal e. symmetric facial movement Lack of symmetry: increased skull size. erythema +1 barely detectable +2 indentation of 2-4mm +3 indentation of 5-7mm +4 indentation >7mm Papule. some birthmarks Moisture in skin folds Uniform . pallor (poor arterial circulation) Delayed return of color (circulatory impairment) DEVIATION FROM NORMAL Normocephalic and symmetrical Slightly asymmetric facial feature.) NORMAL FINDINGS 180◦ or greater (clubbing). Nail bed color b. angle of nail plate . NAILS a. color b. jaundice. moisture Freckles. myxedema Mydriasis. Skin a. Longer mandible (may indicate excessive growth hormone) Exophthalmos.ASSESSMENT NORMAL FINDINGS Varies from light to deep brown No edema DEVIATION FROM NORMAL Pallor. anisocoria Absent response Strabismus. Edema c. Curvature and angle b. HAIR a. Thickness or thinness c. Pupil size When pinched skin springs back to previous state Evenly distributed thick variable Very thin hair (hypothyroidism) Hirsutism in women Convex. Skin turgor 2. spoon nail Bluish (cyanosis). c. nystagmus 3 – 7mm in dm Illuminated pupils constrict and when looking at near objects . generalized hypothermia (shock) Skin stays pinched or tented or moves back slowly Alopecia 1.160◦ Highly vascular and pink Prompt return of pink or usual color (1-2 secs. Temperature f. Distribution b. Perform blanche test ASSESSMENT 4. EYES a. vesicle. Amount of body hair 3. cyanosis. pustule Excessive moisture (hyperthermia) Excessive dryness (dehydration) Localized hyperthermia (infection) . Facial features and movement 5. Skin lessions d. Size.

   ABDOMEN  SUPINE  INSPECT.PERCUSS AND PALPATE  BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND INTERVALS( 5-25/MIN NORMAL)  IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5 MINS MORE. SEQUENCE IS CLOCKWISE FROM RLQ HYPOACTIVE < 3 HYPERACTIVE =CONTINOUS.FREQUENT TINKLING SOUND – BOWEL OBSTRUCTION RUQ         RLQ o o o o o o o LUQ    Liver and Gall Bladder Pylorus Duodenum Head of the Pancreas Right Adrenal Gland Portion of the Right Kidney Hepatic Flexure of Colon Portions of Ascending and Transverse Colon Cecum and Appendix Portion of Ascending Colon Bladder (usually if distended) Lower pole of Right Kidney Right Ovary Right Spermatic Cord Right Ureter Left lobe of Liver Spleen Stomach .AUSCULTATE.LOUD.

RECENT MEMORY AND REMOTE MEMORY  ATTENTION SPAN AND CALCULATION (SERIAL 7S/3S TESTS) CEREBELLAR FUNCTION. VI – ( Abducens) – visual pathways – pupil size. PROPRIOCEPTION-POSITION SENSE. papillary reactions. POINT TO POINT TOUCHING.ARTICULATION > TASTE – CN VII – Ant. 1/3 CN X – region of epiglottis . facial sensation • CN VIII – Vestibulocochlear/ Auditory – nystagmus.PERSON)(CONFUSION)  MEMORY. hearing capacity • CN VII – Facial. extraocular movements • CN V – Trigeminal – mm of mastication.g.IMMEDIATE RECALL. XII.GAIT SENSORY FUNCTION(e.     LLQ         Body of Pancreas Left Adrenal Gland Portion of the Left Kidney Splenic portion of Colon Portions of transverse and descending colon Lower pole of Left Kidney Sigmoid Colon Portion of Descending Colon Bladder (usually if distended) Left Ovary Uterus (if enlarged) Left Spermatic Cord Left Ureter 9 Regions of the Abdomen Right Hypochondriac R Lumbar Right Iliac Epigastric Umbilical Hypogastric Left Hypochondriac Left Lumbar Left Lumbar NEUROLOGIC TESTS MENTAL STATUS LANGUAGE-CEREBRAL CORTEX-APHASIA  ORIENTATION(TIME. X – Vagus. 2/3 CN IX – Post.ROMBERG’S TEST) CRANIAL NERVE FUNCTIONS Cranial Nerves • CN I – Olfactory – sense of smell • CN II – Optic – visual field testing • CN III – Oculomotor.COORDINATION . IV – (Trochlear).PLACE.Hypoglossal . IX – Glossopharyngeal.ALTERNATING MOVEMENTS.

1 depressed GCS : 3-8 = Severely depressed/comatose • DEEP TENDON REFLEX – 0 .Spinal Accessory – SCM and Trapezius mm Glasgow Coma Scale > Eye Opening >Best Motor Response Spontaneous ---.4 Obeys -----------------.3 Localizes ------------. CATHETERIZED URINE SPECIMEN 2. XII > FACIAL EXPRESSION – CN VII • CN XI .1 Abnormal Flexion --.SPUTUM SPECIMEN • GROSS APPEARANCE OF THE SPUTUM • SPUTUM CULTURE & SENSITIVITY TEST ACID-FAST BACILLI STAINING 4. X. the serum creatinine rises.NO REFLEX – +1 – MINIMAL ACTIVITY(HYPOACTIVE) – +2 – NORMAL RESPONSE – +3 – MORE ACTIVE THAN NORMAL – +4 – MAXIMUM ACTIVITY ( HYPERACTIVE) – PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY • LABORATORY AND DIAGNOSTIC EXAMINATIONS 1.3 GCS : 13-15 = Normal Incomprehensible sounds --. reflects the degree . URINE A.1 >Verbal Response Oriented -------------------------.> SWALLOWING – CN IX. SECOND-VOIDED URINE SPECIMEN D. SERUM CREATININE (0.4 (E + M + V) = 3 to 15 Inappropriate Words ---------. MIDSTREAM URINE SPECIMEN B.2 GCS : 9-12 = Moderately Nil ---------------------------------.5-1.6 To Speech ----.5 mg/100 ml) • Most accurate measure of GFR. STOOL • ROUTINE FECALYSIS – TO ASSESS GROSS APPEARANCE OF STOOL & PRESENCE OF OVA/PARASITES • STOOL CULTURE & SENSITIVITY TEST • GUIAIC STOOL EXAM – BLEEDING IN THE GIT 3.5 To Pain ----------. 24-HR URINE SPECIMEN C.4 Nil ------------------.5 Coma score: Confused conversation ------.2 Withdraws -----------. CLEAN-CATCH.3 Extensor response ---2 Nil ------------------. If GFR fails.

COFFEE. OR IN THE ACUTE STAGES OF INFX. FOUND IN GREEN LEAFY VEG • • • • • • • • • SPECIAL DIET • CLEAR LIQUID – PROVIDED FOR CL POST-OP. POULTRY. PEAS. female: 35-45 . IMPAIRED IMMUNE RESPONSE (FOUND IN CITRUS FRUITS.000 – 10. NUTS. PREVENTS CELL MEMBRANE DAMAGE. BROCCOLI. LIGHTLY SEASONED. OSTEOMALACIA. FOUND IN GREEN.ESSENTIAL FOR BLOOD CLOTTING. NTDs. GINGER ALE. FOUND IN DEEP ORANGE FRUITS AND VEG D (CHOLECALCIFEROL) – RICKETS. TOMATO. GREEN BEANS C/I TO PX TAKING L-DOPA • VIT B9 (FOLIC ACID) – MEGALOBLASTIC ANEMIA. FOUND IN MEAT. WATER.000 / mm³ • WBC (Leukocytes) – 5.000 mm³ • Hct – male: 38-54 vol%. BLEEDING. APPLE JUICE) • FULL-LIQUID DIET – LIQUIDS OR FOODS THAT TURN TO LIQUID AT ROOM TEMP (EX. FOUND IN MILK AND MILK PRODUCTS. NUTS.000 – 450. MILK. SKIN SPOTS. CHEESE. TEA. LIVER. DERMATITIS. ORGAN MEATS VIT B3 (NIACIN) – PELLAGRA (DIARRHEA. TUNA. COMMONLY SEEN IN ALCOHOLICS VIT B2 (RIBOFLAVIN) – SKIN LESIONS. SEEN IN PATIENTS TAKING INH.of renal impairment KEY INFO ABOUT VITAMIN • • WATER-SOLUBLE – NOT STORED IN THE BODY. HEART FAILURE. DELAYED WOUND HEALING. FOUND IN MILK AND DAIRY PRODUCTS E (TOCOPHEROLS) – ANTIOXIDANT. CLEAR BROTHS. EGGS. LIVER.0000 / mm³ • Platelets – 150. CUSTARD • PUREED DIET – MODIFICATION OF THE SOFT DIET IN WHICH LIQUID IS ADDED AND BLENDED TO A SEMISOLID CONSISTENCY Normal values: • RBC (Erythrocytes) – 5. SPAG SAUCE. LEAFY VEG. EDEMA. COTTAGE CHEESE VIT B12 (COBALAMIN) – PERNICIOUS ANEMIA. EX. EGGS. PUDDING. FOUND IN BEEF. MEATS. LOW-RESIDUE (LOW-FIBER DIET). DEMENTIA). FOUND IN ANIMAL PRODUCTS FAT-SOLUBLE VITAMINS A (RETINOL) – NIGHT BLINDNESS. PARTICULARLY GI (EX.000. LIVER. FISH. FOUND IN PORK. CHEILOSIS. MILK) • SOFT DIET – FOR CL WHO HAVE DIFFICULTY CHEWING AND SWALLOWING. MUSCLE WEAKNESS). FOUND IN VEG OILS K . POTATOES) VITAMIN B1 (THIAMINE) – BERIBERI (NERVE CHANGES. PORK. NEEDS DAILY SUPPLY IN THE DIET VITAMIN C – DEF WILL RESULT IN SCURVY. WHOLE GRAINS VIT B6 (PYRIDOXINE) – NERVOUS AND MUSCULAR PROBLEMS.

2 mg/ dl > Serum uric acid : 2.5 – 5. Gr.80. Prothrombin – 10-15 mg/100 ml plasma Bld.5 – 8.5 – 8 mg/dl > Albumin : 3.108 mEq / L • Calcium – 4. Fibrinogen – 350 mg/ 100 ml plasma Prothrombin time – 11 -16 sec PTT – 60 – 70 secs APTT – 30 – 45 sec Bleeding time – 3.5 mEq / L • Potassium – 3.0 • Spe.4 – 1.5 mEq / L • • • • • • • • • • • • .120 mmHg ESR – male : 15-20 ml/hr.145 mEq / L • Chloride – 98.5 mins Clotting time – 8 – 15 mins GFR – 125 ml/ min MAP. – 1.3 % > Lymphocytes: 30 – 40% > Monocytes : 0 -5 % • Blood Studies: > BUN : 10 -20 mg/dl > Serum Creatinine: .Hgb – 12-17 g/ dl Bld.5 – 5 mEq / L • Phosphorus – 3.5 mg/ dl > Cholesterol : 150 – 250 mg/dl > Triglycerides – 140 – 200 mg/dl Genito.2 – 5.025 • Protein – Absent • RBC – 0-5 hpf • WBC – 0-5 hpf • Pus – absent • Glucose – absent • Ketones – absent • Cast – 0-4 Serum Electrolytes: • Sodium – 135.5 – 5.010 – 1.urinary • Color – amber/ straw • Ph – 4. female: 20-30 Differential counts: > Neutrophils: 60 – 100% > Eosinophils : 0 – 5 % > Basophils : 0.

to determine the type of bacteria Sensitivity.6-1.5 • Laboratory Test • Total Cholesterol: Overnight Fast Result: Optimal: <200mg/dL. High: >239mg/dL • LDL/ HDL Fast for 12-14 hrs • BUN/ Creatinine Test • To determine renal functioning BUN 8-25 mg/dl Values affected by protein intake.to determine what type of antibiotics will be used Stool Guaiac Test to determine the presence of occult blood and bleeding in the GI tract Ova and parasite tests to determine the presence of parasitic infection of the intestine • • • BLOOD TRANSFUSIONS • PURPOSES: • To restore circulating blood volume • To stop bleeding due to platelet deficiencies/ defects and coagulation factor deficiencies • To increase oxygen carrying capacity of the blood • To combat infection due to decreased and defective white cells or antibodies • TERMINOLOGIES: • ANTIGENS.5 – 2.complex proteins on the red cells surface – may stimulate the formation of antibodies – if antigen is present in the red cell.5 g/day (NPO 8 hrs) High Hypothyroidism Low • • Renal disease/ shock Sputum Examinations Sputum Culture and Sensitivity Culture. the immune system recognizes it as “self” and not produce antibody . fluid volume changes High Renal Disease Excessive protein intake/catabolism Low Severe liver damage • • Creatinine Normal Values: 0. tissue breakdown.• Magnesium – 1.

needle gauge 18 or 19 and NSS as a main line. add 50-100ml 0.  RED BLOOD CELL ( ERYTHROCYTE) – the major cellular element of the circulating blood. • Start infusion slowly @ 10 gtts/min. • Observe for potential complications or reactions.sensitive to plasma protein or donor antibody which react with recipients antigen. to prevent platelets from clumping and sticking to the side of the bag.9% NaCl. usually 4 units/hr. Adm. • Use BT set with filter. • obtain and record vital signs as baseline data. Allergic reaction. Remain at bedside for 15-30 mins. the serial no.9% NaCl.000 cubic ml. after it is taken from the blood bank.000-10. granulocytes (60%) & mononuclear cells (40%). check the label of the blood. malaria) • Warm blood at room temperature before transfusion to prevent chills. • Platelets > administer as rapidly as tolerated. > If necessary to help cells infuse.  PLATELETS – play an essential role in the control of bleeding. During administration. Notify physician. • Identify client properly. Inform the client and explain the purpose of the procedure. Its principal function is to transport oxygen. • BLOOD COAGULATION – is the process whereby the components of the liquid blood are transformed into a semisolid material TRANSFUSION TECHNIQUE Packed red cells > administer only with 0. • Documentation. COMPLICATIONS OF BLOOD TRANSFUSION 1. Altered VS indicates adverse reaction.ANTIBODY – protein circulating in the plasma produced in response to an antigen that the individual is lacking • AGGLUTINATION – clumping of blood cells • HEMOLYSIS – destruction of RBC • CROSSMATCHING – compatibility testing. • Monitor vital signs every 30 mins. • . Hepatitis B.  Total leukocyte count is 5. and screening tests ( STD’s. accomplished by incubating a sample of the patient’s plasma with the donor red cell to detect sign of incompatibility. • Do not mix medications with BT to prevent adverse effects.9% Na Cl (dextrose hemolyzes RBC and LR causes coagulation) > squeeze bag to mix cells every 20-30 mins. • Blood should be transfused 30 mins.. expiration date.000-400.  WHITE BLOOD CELL (LEUKOCYTE) – its function is to protect the body from invasion of bacteria and other foreign entities. Normal value – 150. 1unit over 1-2 hrs. • Check for cross matching and blood typing. blood type. add 50-100ml 0. > If necessary to help cells infuse.000 cells/ cubic ml. blood component. • NURSING INTERVENTION • Check and verify doctor’s order. To ensure compatibility. • Practice strict aseptic technique • At least 2 nurses . It is divided into 2 general categories. To observe any untoward reaction. Rh factor.

tachypnea. 2. Assist client in semi-fowler’s position . (4) insert indwelling catheter to monitor hourly urine output. (3) give antipyretics as ordered . acute renal failure.laryngeal edema. (2) low back pain. (4) anxiety. (3) feeling of head fullness. • Nursing Actions: (1) stop infusion. It is kept at the bedside in case the tube becomes dislodged and needs to be reinserted. • Signs: (1) rapid onset of chills. (2) notify the physician & the blood bank. • Mild. • Nursing Actions: (1) Stop the infusion. (5) observe for anaphylaxis or severe reaction.hypersensitivity to donor white cells. • a curved tracheostomy tube is inserted to extend through the stoma into the trachea • • Outer cannula – inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with a tape or ties. (5) hypotension. hives. (2) place the patient in upright with feet in dependent position. (6) bleeding. urticaria. (2) monitor temp. (3) administer diuretics and oxygen as prescribed. (1) chills & fever.. Septic reaction. • This seal prevents aspiration of oropharyngeal secretions and air leakage between the tube and trachea. Can accommodate. (2) headache. platelets. • Signs: (1) rise in venous pressure. rashes. (3) maintain BP with IV colloid solution. (3) obtain culture of patient’s blood and return blood bag with administration set for culture. Tracheostomy Care 1. (4) marked hypotension. • Signs: (1) sudden chills. (3) Give diuretics as prescribed to maintain urine flow.caused by transfusion of blood contaminated with bacteria. glomerular filtration. (3) vomiting & diarrhea. (2) distended neck veins. • Nursing actions: (1) stop infusion & notify the doctor. • Signs.fluid administered at a rate or volume greater than the circulating sys.(antibody-antigen reaction). • Essential when ventilating a tracheostomy client with a mechanical ventilator. Febrile / Non-hemolytic. (5) muscle pain.flushing. itching. • Hemolytic Reaction. • Nursing Actions: (1) stop infusion and KVO with NSS. Tracheostomy • a surgical incision in the trachea just below the larynx. Obturator – used to insert the outer cannula and then removed. • for clients who need long-term airway support. crackles. (4) tachycardia. chest pain.infusion of incompatible blood products. dyspnea. • Circulatory Overload. cardiac arrest. asthmatic wheezing • Severe. (2) high fever. (7) death. cough.  Cuffed tracheostomy tubes • Surrounded by inflatable cuff that produces an airtight seal between the tube and the trachea. (3) give anti-histamine as directed. (3) dyspnea. (4) monitor VS. or plasma proteins. (2) treat shock if present. (3) flushing. flushing. (2) KVO with NSS. (4) give antibiotics & intravenous fluids. renal blood flow. • Nursing Actions: (1) discontinue transfusion.

” or purple. Remove soiled tracheostomy dressing. Discard the glove and dressing. Odor is minimal because fewer bacteria are present. Pour hydrogen peroxide and normal saline in separate sterile basins 3. Suitable time selected: preferably after meal and same time each day Irrigating reservoir: 500-1500 ml of luke warm tapwater. Suction the tracheostomy tube 4. using a brush or pipe cleaners moistened with sterile normal saline. 8. cleanse the lower intestinal tract and establish a regular pattern of evacuation. Gastrostomy – an opening through the abdominal wall into the stomach. Lock the cannula in place. 6. 12. An ileostomy produces liquid fecal drainage. 2. Change the tracheostomy ties. gas or mucus. Remove from the soaking solution. “blackish. mushy drainage because some of the liquid has been reabsorbed. 14. 5. Hydrogen peroxide may be used to remove crusty secretion.2. Place the inner cannula in hydrogen peroxide. Transverse colostomy – produces a malodorous. It contains digestive enzymes. 13. Colostomy • • • • • • • • • First few days: beefy red and swollen Gradually swelling recedes and color is pink or red Notify physician immediately if stoma is dark blue. 9. 7. • Stoma – an end or terminal colostomy • • • • • 1. Clean the inner cannula. hung 45 to 50 cm (18 to 20 in) Lubricate the catheter/ cone gently insert into the stoma. Unlock the inner cannula and remove it gently pulling it out toward you. which are damaging to the skin. Suction the outer cannula 10. Descending colostomy produces increasingly solid fecal drainage. Clean the incision site and tube flange using sterile applications or gauze dressings moistened with NS. Apply sterile dressing. Rinse the inner cannula thoroughly in the sterile normal saline. No more 8 cm or 3 in . Ileostomy – opens into the ileum (small bowel) Colostomy – opens into the colon (large bowel) The location of ostomy influences the character and management of the fecal drainage. After rinsing. using a pipe cleaner folded in half to dry only the inside of the cannula.indicates insufficient blood supply BEGINS TO FUNCTION 3-6 DAYS POSTOPERATIVELY Colostomy Care and Irrigation Colostomy is irrigated to empty the feces. gently tap the cannula. Thoroughly rinse the cleaned area using gauze moistened with sterile NS. Jejunostomy – opens through the abdominal wall into the jejunum. 3. ensure thatthetracheostomy tube is securely supported. 11. Insert the inner cannula by grasping the outer flange.

In applying appliance. about 0. beans and high-cellulose products such as peanuts. eggs. cutting or trauma to the stoma) Use skin barrier to protect skin Cleanse skin gently and pat dry. rn MAN . Empty the contents of the pouch through the bottom opening into a bedpan (prevents spillage of effluent onto the client’s skin) Use warm water.3 cm (1/8 in) larger than the stoma. fish. Carmela perez. (to prevent rubbing. Do not lose hope if a door was locked. mild soap to clean the stoma and skin. do not rub The patient can lightly dust nystatin (Mycostatin) powder on the peristomal skin if irritation or yeast growth is present. Patients avoid foods that cause excessive odor and gas such as cabbage family. YOU CAN! Believe in yourself! GOOD LUCK AND GOD BLESS! Ms. Allow 10 to 15 mns most of the return and also ambulation stimulates peristalsis and completion of the irrigation. Pouches need to be emptied when they are one-third to one-half full.• • • • • • • • • • • Never force the catheter! A slow flow helps to relax the bowel and facilitates passage of the catheter Water should flow in over 5 to 10 minute pd. God holds the key and He’ll open it on the right time! If you think YOU CAN DO IT….