fundamental of nursing-final

Fundamentals of Nursing Module

Acumen NURSING

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“Nursing is an art & a science. It is the diagnosis and treatment of human responses to actual and potential health problems. Earlier emphasis was on care of the sick; now promotion of health is being stressed ” -ANA, Alfaro,R. “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, its recovery, or to a peaceful death. The client will perform these activities unaided if he had the necessary strength, will or knowledge. Nurses help the client gain independence as rapidly as possible -Virginia Henderson,ICN THEORETICAL MODELS OF NURSING PRACTICE A. NIGHTANGLE’S THEORY (mid-1800) : Focuses on the patient and his environment. Developed and described the first theory of nursing. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. She believed that in the nurturing environment, the body could repair itself. Client’s environment is manipulated to include appropriate noise, nutrition, hygiene, socialization and hope. B. PEPLAU, HILDEGARD (1951) : Introduced the Interpersonal Model Defined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient relationship in which the nurse serves as a resource person, counselor and surrogate. 1. Orientation: the nurse and the client initially do not know each other’s goals and testing the role each will assume. The client attempts to identify difficulties and the amount of nursing help that is needed. 2. Identification: the client responds to help professionals or the significant others who can meet the identified needs. Both the client and the nurse plan together an appropriate program to foster health. 3. Exploitation: the clients utilize all available resources to move toward a goal of maximum health functionality. 4. Resolution: refers to the termination phase of the nurse-client relationship. It occurs when the client’s needs are met and he/she can move toward a new goal. Peplau further assumed that nurse-client relationship fosters growth in both the client and the nurse. C. ABDELLAH, FAYE G. : Introduced Patient – Centered Approaches to Nursing Model D. ORLANDO, IDA : Three elements–client behavior, nurse reaction & nurse actions – compose the nursing situation E. LEVINE, MYRA : Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing includes: conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity. F. JOHNSON, DOROTHY : Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery. G. ROGERS, MARTHA : Considers man as a unitary human being co-existing with in the universe, views nursing primarily as a science and is committed to nursing research. H. OREM, DOROTHEA : Developed the Self-Care Deficit Theory. She defined self-care as “the practice of activities that individuals initiate to perform on their own behalf in maintaining life, health well-being.” I. IMOGENE KING : Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Postulated the Goal Attainment Theory. Described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die with dignity. J. BETTY NEUMAN: Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention. K. SIS CALLISTA ROY (Adaptation Theory): Views the client as an adaptive system. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. L. LYDIA HALL: Introduced the model of Nursing: What Is it? It focuses on the notion that centers around three components of CARE, CORE and CURE. Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related to the physician’s orders. Core and cure are shared with the other health care providers. M. Virginia Henderson : Introduced The Nature of Nursing Model. She identified fourteen basic needs. She postulated that the unique function of the nurse is to assist the clients, sick or well, in the performance of those activities contributing to health or its recovery, the clients would perform unaided if they had the necessary strength, will or knowledge. N. Madaleine Leininger (1978, 1984): Developed the Trans-cultural Nursing Model. O. Ida Jean Orlando (1961) : Conceptualized the Dynamic Nurse – Patient Relationship Model.

Darius J. Candelario

Four Phases of the Nurse-Client Relationship:

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P. Ernestine Weidanbach (1964) : Developed the Clinical Nursing – A Helping Art Model. Q. Jean Watson (1979-1992): Introduced the theory of Human Becoming R. Joyce Travelbee (1966,1971) : She postulated the Interpersonal Aspects of Nursing Model. S. Josephine Peterson and Loretta Zderad (1976): Provided the Humanistic Nursing Practice Theory. T. Helen Erickson, Evelyn Tomlin, and Mary Ann Swain (1983) :Developed Modeling and Role Modeling Theory. U. Margaret Newman : Focused on health as expanding consciousness. She believed that human are unitary in whom disease is a manifestation of the pattern of health. She defined consciousness as the information capability of the system, which is influenced by time, space movement and is ever – expanding.

Freud (1961) Believed that the mechanism for right and wrong within the individual is the superego, or conscience. He hypnotized that a child internalizes and adopts the moral standards and character or character traits of the model parent through the process of identification. The strength of the superego depends on the intensity of the child’s feeling of aggression or attachment toward the model parent rather than on the actual standards of the parent. Erikson (1964) Erikson’s theory on the development of virtues or unifying strengths of the “good man” suggests that moral development continuous throughout life. He believed that if the conflicts of each psychosocial developmental stages favorably resolved, then an ‘ego-strength” or virtue emerges. Kohlberg Suggested three levels of moral development. He focused on the reason for the making of a decision, not on the morality of the decision itself. At first level called the premolar or the pre-conventional level, children are responsive to cultural rules and labels of good and bad, right and wrong. However, children interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. At the second level, the conventional level, the individual is concerned about maintaining the expectations of the family, groups or nation and sees this as right. At the third level, people make post-conventional, autonomous, or principal level. At this level, people make an effort to define valid values and principles without regard to outside authority or to the expectations of others. These involve respect for other humans and belief that relationships are based on mutual trust.

Moral Theories

Fowler (1979) : Described the development of faith. He believed that faith, or the spiritual dimension is a force that gives meaning to a person’s life. He used the term “faith” as a form of knowing a way of being in relation “to an ultimate environment.” To Fowler, faith is a relational phenomenon: it is “an active made-of-being-inrelation to others in which we invest commitment, belief, love, risk and hope.” ROLES AND FUNCTIONS OF THE NURSE 1. Caregiver 8. Decision-maker 2. Teacher 9. Protector 3. Counselor 10. Client Advocate 1. Coordinator 11. Manager 2. Leader 12. Rehabilitator 3. Role Model 13. Comforter 4. Administrator 14. Communicator CONCEPTS OF HEALTH AND ILLNESS HEALTH “A state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.A dynamic state in which the individual adapts to changes in internal and external environment to maintain a state of well-being” - World Health Organization (WHO) VARIABLES INFLUENCING HEALTH BELIEFS AND PRACTICES INTERNAL VARIABLES 1. Developmental Stage 2. Intellectual Background 3. Perception of functioning EXTERNAL VARIABLES 1. Family practices 2. Socioeconomic Factors 3. Cultural Background

Spiritual Theories

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4.
1.

Emotional and Spiritual Factors MODELS OF HEALTH AND ILLNESS a. The individual’s perception susceptibility to an illness. of

HEALTH-ILLNESS CONTINUUM (NEUMAN) Degree of client wellness that exist at any point in time--ranging from an optimal wellness condition, withavailable energy at its maximum--to death, which represents total energy depletion. - Dynamic state that continuously alters as a person adapts to changes in the internal & external environment to maintain a state of physical, emotional, intellectual, social, developmental & spiritual wellbeing.

2. HIGH-LEVEL WELLNESS MODEL (HALBERT DUNN) The high-level wellness model is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposely direction within the environment. It involves progress toward a higher level of functioning, an open-ended and ever-expanding challenge to live at the fullest potential. Last, there is continued integration of health practices by the individual at increasingly, higher levels throughout life. 3. AGENT-HOST-ENVIRONMENT MODEL (LEAVELL) The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment. a. AGENT – is any internal or external factor that by its presence or absence can lead to disease or illness. b. HOST – is the person or persons who may be susceptible to a particular illness or disease. Host factors are physical or psychosocial situations or conditions putting an individual or group at risk for becoming ill. c. ENVIRONMENT – consists of all factors outside of the host, physical environment includes economic level, climate, living conditions, and elements such as light and sound levels. Social environment consists of factors involving a person’s or group’s interaction with others, including stress conflicts with others, economic hardships and life crises such as the death of a spouse. 4. HEALTH-BELIEF MODEL (HBM) - Addresses the relationships between a person’s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies. FOUR COMPONENTS:

For example, a client’s needs to recognize the familial link for coronary artery disease. After this link is recognize, particularly when one parent and two siblings have died in their fourth decade from myocardial infarction, the client may perceive the personal risk of heart disease. b. The individual’s perception of the seriousness of the illness. - this perception is influenced and modified by demographic and sociophysiological variables, perceived threats of the illness and cues to action (for example, mass media campaigns and advice from family, friends, and medial professionals) c. The perceived threat of a disease. - this perception refers to beliefs a person holds about whether or not a disease poses a real threat to him. Perceived threat is influenced by certain cues to action in relation to health (e.g. mass-media campaigns, advice from others or a reminder a postcard from a dentist or physician). d. The perceived benefits of taking preventive action. - This perception refers to beliefs a person holds about the effectiveness of preventive action he might take to prevent illness. Perceived barriers to taking preventive action may relate, for example, to whatever the person believes stands in his way. For example, a barrier to seeing a dentist regularly to prevent tooth decay may be a person’s intense fear that the procedure is very painful. 5. EVOLUTIONARY-BASED MODEL - Illness and death serves as an evolutionary function. - Evolutionary viability reflects the extent to which individual’s function to promote survival and wellbeing. 6. HEALTH PROMOTION MODEL - A “complimentary counterpart to models of health protection” - Directed at increasing a client’s level of wellbeing. - Explains the reasons for client’s participation in health-promotion behaviors. - The model focuses on three functions: a.It identifies factors (demographic and social) that enhance or decrease the participation in health promotion.

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b. It organizes cues into a pattern to explain the likelihood of a client’s participation in health-promotion behaviors. c. It explains the reasons that individuals engage in health activities. THE THREE LEVELS OF PREVENTION PRIMARY PREVENTION Generalized health promotion specific protection against disease. It precedes disease or dysfunction and is applied to generally healthy individuals or groups. Health Promotion Specific Protection • Health Education • Use of specific immunizations • Attention to personal hygiene • Good standard of nutrition adjusted to developmental phases • Use of environmental of sanitation life • Protection against occupational • Provision of adequate housing & recreation hazards • Marriage counseling and sex education • Protection from accidents • Genetic screening • Use of specific nutrients • Periodic selective exams • Protection from carcinogens • Health education about accident and poisoning prevention, • Avoidance of allergens standards of nutrition and of growth and development for each stage or life, exercises requirements, stress management, protection against occupational hazards, and so on • Immunizations • Risk assessment for specific disease • Family planning services and marriage counseling • Environmental sanitation and provision of adequate housing recreation, and work conditions SECONDARY PREVENTION Emphasizes early detection disease, prompt intervention, and health maintenance for individuals experiencing health problems. Includes prevention of complications and disabilities. Early Diagnosis and Prompt Treatment Disability Limitations  Adequate treatment to arrest  Case – finding measures; individual and mass; selective disease process and prevent examinations further complications  Cure and prevention of disease process to prevent spread of  Provision of facilities to limit communicable disease, prevent complications and shorten disability and prevent death period of disability      Screening surveys and procedures any type (e.g., Denver Developmental Screening Test, hypertension screening) Encouraging regular medical and dental checkup Teaching self-examination for breast and testicular cancer Assessing the growth and development of children Nursing assessments and care provided in home, hospital, or other agency to prevent complications.

TERTIARY PREVENTION Restoration and Rehabilitation Begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Its focus is to help rehabilitate individuals & restore them to an optimum level of functioning within the constraints of the disability  Provision of hospital and community facilities for retraining and education to maximize use of remaining capacities  Education of the public and industries to use rehabilitated persons to the fullest possible extent  Selective placement  Work therapy in hospitals  Use of sheltered colony

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 Referring a client who has had a colostomy to a support group  Teaching a client who has diabetes to identify and prevent complications  Referring a client with a spinal cord injury to a rehabilitation center to receive training that will maximize use for remaining abilities

Difference between Health Promotion and Health Protection Health Promotion Health Protection Not disease oriented Illness or injury specific Motivated by personal, positive Motivated by “ avoidance” of illness “approach” to wellness Seeks to thwart the occurrence of insults to Seeks to expand positive potential health and well-being for health Factors Affecting the Nursing Shortage  Aging Nurse Workforce • Number of Nurses under 30 decreasing • Number of nurses age 40-49 increasing with 40% older than 50 by 2010 • New graduates entering workforce at an older age and will have fewer years to work  Aging of Nurses Faculty • As nursing faculty retire, nursing programs may have fewer faculty to educate future nurses  Aging Population • Individuals 65 and older to double between 2000 and 2030 • Increasing health care needs of aging population  Increased Demand for Nurses • Increased acuity of hospital clients requiring skilled and specialized nurses.

•
 • • • • •

Shorter hospital stays resulting in transfer of clients to long term care and community settings, creating increased demand for nurses in the community Workplace Issue Inadequate staffing Heavy workloads Increased use of overtime Lack of sufficient support staff Inadequate recruiting and retaining nurses

STRESS “Stress refers to tension resulting from changes in the internal and external environment either: physiologic, psychologic or social factors.” “Stress is the nonspecific response of the body to any demand made upon it” -Modern Stress Theory, Selye,H. *Str ess is always a part of the fabric of life *Str ess is not always something to be avoided *Str ess does not always lead to distress *Stress may lead to another stress *A stress, whenever prolonged or intense may lead to exhaustion *Man, whenever he encounter stress, he tends to adapt to it ADAPTATION The adjustments that a person makes in different situations; individuals’ reaction to and attempt to deal with stress Types of Adaptation A. General Adaptation Syndrome (GAS) Man, whenever he responds to stress, the entire body is involved There are many similar manifestations that characterize different disease conditions; and there are very few specific manifestations that characterize a particular disease. Fever, weakness fatigue, headache, anorexia, pain are examples of manifestations that characterize various disease conditions.

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1. Stage of Alarm (SA) • The person becomes aware of the presence of threat or danger. • Levels of resistance are decreased.

Stages of GAS

• •

Adaptive mechanisms are mobilized (fight-or-flight reaction).

If the stress is intense enough, even at the stage of alarm, death may ensure. Example: profuse bleeding in amputated limb due to vehicular accident. 2. Stage of Resistance (SR) • Characterized by adaptation & parasympathetic nervous system activity. • Levels of resistance are increased & hormonal levels return to normal. • The person moves back to homeostasis & stabilization. 3. Stage of Exhaustion • Results from prolonged exposure to stress and adaptive mechanisms can no longer persist. • Unless other adaptive mechanism will be mobilized, death may ensue. • Local Adaptation Syndrome (LAS) Man may respond to stress through a particular body part or body organ (e.g. inflammation, backache, headache, diarrhea). Modes of Adaptation Physiologic/Biologic Adaptive Mode e.g. enlargement of arm and chest muscles among men whose jobs include heavy lifting; people who live in countries with very hot/warm climate develop dark skin. This is due to overproduction of melanin to protect inner layers of the skin. Psychologic Adaptive Mode e.g. use of ego defense mechanism like denial, rationalization. Sociocultural Adaptive Mode e.g. talking, acting, dressing like to people in a particular place Technologic Adaptive Mode e.g. nurses learn how to use electronic devices and computers. Homeostasis “A state of dynamic equilibrium; stability; balance; constancy; uniformity. It is now more commonly referred to as “homeodynamics,” because it is characterized by constant change.” It is regulated by negative feedback mechanism.

B.

Concepts of Homeostasis (“homeodynamics”) (Systemic Physiologic Response to Stress)
A. Symatho-Adreno-Medullary Responses (Walter Cannon) (SAMR or Fight-or Flight Response) Stressors: a. physical injury b. elevated body temperature c. dehydration

SNS (norepinephrine)

Adrenal Medulla (Epinephrine & norepinephrine)

Hypothalamus

Brain: ↑ alertness; restlessness

Eyes: dilated pupils; ↑ visual perception

Mouth: ↓ salivary secretion, thirst&dryness

Heart: tachycardia; coronary vasodilation; ↑ force of cardiac contractility; ↑ cardiac output

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Lungs: hyperventilation, bronchodilation Blood vessels: peripheral vasoconstriction; ↑ BP

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Skin: pallor; diaphoresis; cold, clammy skin Liver: ↑ glycogenolysis, & gluconeogenesis; ↑ blood glucose level Muscles: ↑ glycogenolysis; ↑ muscle tension G.I. Tract:↓ gastric motility;↓ HCl secretion;↓ peristalsis;constipation;flatulence Spleen: contraction; ↓ hemolysis Pancreas: ↓ sec’n. of insulin and pancreatic enzymes

Urinary Bladder: relaxation of the detrusor muscles B. Adreno – Cortical Response

Stressor: Hypoglycemia (Blood glucose level = 60 mg/dl. And below)

Hypothalamus

activates
Anterior Pituitary

releases
ACTH

triggers

Adrenal Cortex

secretes
Glucocorticoid: Increases gluconeogenesis; Increases blood glucose levels Mineralocorticoid: Retention of sodium and water; Increase ECF volume; Increase BP.Androgen/Estrogen: (sex hormones) C. Neurohypophyseal Response Stressors: Blood loss (hemorrhage, excess loss of body

Hypothalamus

activates
Posterior ADH Kidneys Pituitary

releases
(antidiuretic) (renal)

hormone/vasopressin)acts on tubules)
Retention of water in the renal

tubules
Oliguria

Conservation of Circulating Volume

Prevention of Hypovolemic Shock

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Local Physiologic Responses to Stress Inflammation involves mobilization of specific and nonspecific defense mechanism in response to tissue injury or infection.

Inflammatory Response
Inflammants: Prevention of Hypovolemic Shock Mechanical Chemical Microbial Electrical

1.

Vascular Response • Transitory vasoconstriction followed immediately by vasodilation (due to the release of histamine, bradykinin, prostaglandin E)

Increased Capillary Permeability

Hyperemia: Redness (rubor) Heat (calor)

Fluid

/

Cellular

Exudation Edema (tumor)
C. • • • • • Exudates Serous Serosanguinous Sanguinous Purulent Mucoid/catarrhal

Pain (dolor) • Compression of nerve endings by edema fluids • Injury to nerve endings • Release of bradykinin Impaired function

Purposes of Inflammation 1. To localize tissue injury 2. To protect tissue from injury 3. To prepare tissue for repair Cellular Response • Neutrophils. First to be launched at the site of tissue injury. • Monocytes. Perform phagocytosis in chronic tissue injury. • Lymphocytes. Responsible for immune response. Processes Involved:

• Marginal/pavementation. Phagocytes line up at the peripheral walls of the blood vessels. • Emigration/diapedesis. Phagocytes line up at the peripheral walls of the blood vessels. • Chemotaxis. Injured tissues release substances, which exert magnet like force to the phagocytes
to bring them to the area of injury.

• Phagocytosis. Phagocytes ingest or engulf the antigens. Healing Process (Reparative Phase)

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• •

Regeneration. Involves replacement of damaged tissue cells by new cells which are identical in structure or function. Scar Formation. Involves replacement of damaged tissue cells by fibrous tissue formation. In the early stage, granulation tissue (pink or red, fragile gelatinous tissue) forms; later in the process, a cicatrix or scar forms because the tissue shrinks and the collagen fibers contract. Healing May also be classified as follows:

• • •

First Intention: Occurs in clean-cut wound (e.g. surgical wound). The wound edges are approximated, there is minimal or no scar tissue formation (also primary intention healing or primary union) Second Intention: Occurs when the wound is extensive and there is a great amount of tissue loss (e.g. decubitus ulcer). The repair time is longer; the scarring is greater (also, secondary intention healing). Third Intention: Occurs when there is delayed surgical closure of infected wound (also, tertiary intention healing)

a) Fever

The Systemic Manifestations of Inflammation:
endogenous pyrogens (prostaglandins, leukotrienes, bacterial endotoxins, interleukin 1)

act on Hypothalamus

Resetting of the body temperature set-point at a higher level Increasing heat production/decreasing heat loss (shivering; sweating is inhibited; vasoconstriction) Increased production of interferon (protects the cell from viral invasion) Increased phagocytic activity b) c) d) e) f) g) h) Leukocytosis (elevated WBC) Elevated ESR (erythrocyte sedimentation rate) Lymphadenopathy Anorexia Headache Body Weakness/Fatigue Body Malaise

STRESS MANAGEMENT a. Eat a well balanced diet b. Get sufficient amount of rest c. Exercise regularly d. Use relaxation methods & techniques 1. Deep breathing 2. Guided imagery 3. Progressive relaxation: various muscles groups progressively & systematically tensed & relaxed, from head to toe Suggested Steps: 1.Focus attention on a particular muscle group 2. Tense the muscle group upon which attention is focused 3. Maintain muscle tension for 5-7 secs.

in the body are

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4. Slowly relax the muscle group while continuing the focus 5. Repeat these steps for each muscle group in the body, from head to toe 4. Meditation: contemplative reflection & thought, & communication w/ self 5. Yoga: system of meditation & mental to attain a balance in the continuum of mend & body 6. Biofeedback: providing information to a subject about current status of some body function; goalgain & maintain control in real-life circumstances e. Engage in social support system Nursing Responsibilities in Stress Management I. To assist client & his family to adapt to stress & manage it wisely II. Recommended four guideposts when the nurse helps the client to manage stress A. Eliminate as many stressors as possible B. Teach about both the beneficial and detrimental effects of stress C. Teach how to cope & adjust with stress NURSING PROCESS “A deliberate, problem-solving approach to meeting the health care & nursing needs of patients” -Sandra Nettina The most efficient way to accomplish personalized care in a time of exploding knowledge and rapid social change. It assists in solving or alleviating both simple and complex nursing problems. Changing, expanding, more responsible role demands knowledgeably planned, purposeful, and accountable action by nurses Reasons for documentation of nursing care: 1. Provide evidence of comprehensive and systematic nursing care 2. Satisfy requirements of regulatory agencies 3. Provide a legal document that reflects the care given to and the progress of the patient 4. Provide a data base for continuous quality improvement programs Steps in the Nursing Process (ADPIE) 1. Assessment : Collection of personal, social, medical, and general data a. Sources: Primary (client and diagnostic test results) and secondary (family, colleagues, Kardex, literature) b. Methods b.1 Interviewing formally (nursing health history) and informally during various nurse-client interactions b.2 Observation b.3 Review of records b.4 Performing a physical assessment Types of Assessment Type Time Performed Purpose Example Initial Assessment Performed within To establish a complete Nursing admission specified time after database for problem assessment admission to health identification, reference, care agency and future comparison Problem-focused assessment Ongoing process integrated with care To determine the status of a specific problem identified in an earlier assessment To identify new overlooked problems Emergency assessment During a physiologic or psychologic crises of the client or Hourly assessment of client’s fluid intake and urinary in an ICU Assessment of client’s ability to perform self-care while assisting a client to bathe Rapid assessment of a person airway, breathing status, and circulation during a cardiac arrest Assessment of suicidal for violence Reassessment of a client’s functionally health patterns in a home care or outpatient setting or, in a hospital, at shift change

To identify life-threatening problems

Time-lapsed reassessment

Several month after initial assessment

To compare the client’s current status to baselines data previously obtained

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Examples of Subjective and Objective Data Subjective Objective “I feel weak all over when I exert myself.” Blood pressure 90/50 Apical pulse 104 Skin pale and diaphoretic Client states he has a cramping pain in his Vomited 100 mL green-tinged fluid abdomen. States “I feel sick to my stomach.” Abdomen firm and slightly distended Active bowel sounds auscultated in all four quadrants “I’m short or breath.” Lung sounds clear bilaterally; diminished in right Wife states: “He doesn’t seem so sad today” lobe “I would like to see the chaplain before surgery.” Client cried during interview Holding open Bible Has small silver cross on bedside table. 2. Nursing Diagnosis : Definition of client's problem: making a nursing diagnosis “A nursing diagnosis is a definitive statement of the client's actual or potential difficulties, concerns, or deficits that are amenable to nursing interventions .This step is to organize, analyze and summarize the collected data. There are two components to the statement of a nursing diagnosis joined together by the phrase "related to"” Part I: a determination of the problem (unhealthful response of client) Part II: identification of the etiology (contributing factors) 3. Planning: the nursing care plan, a blueprint for action remembering client is the center of the health team; client, family, and nurse collaborate with appropriate health team members to formulate the plan Guidelines: a. Planned intervention may include independent, interdependent,and dependent functions of the nurse; prescriptions made by physician or allied health professionals may be included b. New diagnoses should be noted on the nursing care plan and progress notes as they are identified c. Client outcomes (goals of nursing intervention) are reflected in expected changes in the client c.1 Expected client outcome is written next to each nursing diagnosis on nursing care plan c.2 These outcomes must be objective, realistic, measurable alterations in the client's behavior, activity, or physical state; a time period should be set for achievement of the outcome c.3 The outcome provides a standard of measure that can be used to determine if the goal toward which the client and nurse are working has been achieved d. Nursing interventions (nursing orders) are written for each nursing diagnosis and should be specific to the stated outcome or goal; each goal may have one or more applicable interventions 4. Implementation: the actual administration of the planned nursing care 5. Evaluation: Outcome and revision of nursing care plan a. Process is ongoing throughout client's treatment/hospitalization b. If outcome/goal is not reached in specified time, the client is reassessed to discover the reason c. Reordering of priorities and new goal setting may be necessary d. When diagnosis/problem is resolved, the date should be noted on care plan Examples of Critical Thinking in the Nursing Process Nursing Process Phase Critical Thinking Activities Assessing Making reliable observations Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating & Organizing data Categorizing data according to a framework Recognizing assumptions Findings patterns and relationships among cues Identifying gaps in the data & Making Inferences Suspending judgment when lacking data Making interdisciplinary connections Stating the problems Examining assumptions

Diagnosing

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Comparing patterns with norms Identifying factors contributing to the problem Forming valid generalizations Transferring knowledge from one situation to another Developing evaluative criteria Hypothesizing & Making interdisciplinary connections Prioritizing client problems Generalizing principles from other sciences Applying knowledge to perform interventions Testing hypothesis

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Planning

Implementing Evaluating

Deciding whether hypotheses are correct Making criterion-based evaluation Advantages of nursing process 1. Encourages thorough individual client assessment by nurse 2. Determines priority of care 3. Provides comprehensive and systematic nursing care planning and delivery 4. Permits independent, creative, and flexible nursing intervention 5. Facilitates team cooperation by promoting: a. Contributions from all team members b. Communication among team members c. Coordination & Continuity of care 6. Provides for continuous involvement and input from client 7. Facilitates the "costing-out" of nursing services and care 8. Facilitates nursing research 9. Provides accurate legal document of client care

Basic Nursing Care

COMMUNICATION “Refers to reciprocal exchange of information, ideas, beliefs, feelings and attitudes between 2 persons or among a group. The need to communicate is universal. People communicate to satisfy needs. Clear and accurate communication among members of the health team, including the client, is vital to support the client's welfare” -Dolores Saxton Signs of Lack of Communication a. Efforts to change the subject-the client may not understand what the nurse is saying b. Lack of questions c. Non-Verbal Clues : Blank expression, lack of eye contact, etc. MAINTENANCE OF EFFECTIVE COMMUNICATION:THE NURSE'S ROLE A. Be aware that effective communication requires skill in both sending and receiving messages 1. Verbal: for example, words and tone of voice 2. Written 3. Nonverbal: for example, facial expression, eye contact, and body language B. Recognize the high stress-anxiety potential of most health settings created in part by: 1. Health problem itself, treatments and procedures 2. Exclusive behavior of personnel 3. Foreign environment 4. Change in lifestyle, body image, and self-concept 5. Inability to use normal coping skills such as exercise or talking with friends C. Recognize the intrinsic worth of each person 1. Listen, consider wishes when possible, and explain when necessary 2. Avoid stereotyping, snap judgments, and unjustified comparisons 3. Be nonjudgmental and non-punitive in response and behavior D. Be aware that each individual must be treated as a whole person E. Recognize that all behavior has meaning and usually results from the attempt to cope with stress 1. Be aware of importance of value systems & significance of cultural differences 2. Be sensitive to personal meaning of experiences to clients 3. Recognize that giving information may not alter the client's behavior 4. Recognize the defense mechanisms that the individual is using

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5. Recognize own anxiety and cope with it F. Maintain an accepting, open environment 1. Accept the client but set limits on inappropriate behavior 2. Identify and face problems honestly 3. Value the expression of feelings & be nonjudgmental G. Recognize the client as a unique person 1. Use names rather than labels such as room numbers or diagnoses & maintain the client's dignity 2. Be courteous toward the client, family, and visitors 3. Permit personal possessions where practical (e.g., own nightclothes, pictures, and toys) 4. Explain at the client's level of understanding and tolerance & encourage expression of feelings H. Support a social environment that focuses on client needs 1. Use problem-solving techniques that focus on the client 2. Be flexible in carrying out routines and policies Special Considerations in Communication Clients with Hearing Loss Signs of hearing Loss a. speech deterioration d. suspicion b. indifference e. tendency to dominate conversation c. social withdrawal Nursing Interventions: a. Face client directly, make sure your face is clearly visible b. Before discussion, tell the client the topic you are going to discuss c. Ensure that the client has access to hearing aid and that it is functional d. Speak slowly and distinctly; do not shout ; keep sentences short and simple e. Use written information to enhance spoken word ; resort to writing if unable to understand f. Pay attention when the person speaks;facial & physical gestures helps understand what the person is saying Clients with Aphasia Aphasia Syndromes a. Wernicke’s Aphasia : patient speaks readily but speech lacks clear content, information and direction b. Anomic or Amnesic Aphasia : speech is almost normal but marred by word-finding difficulty c. Conduction Aphasia : comprehension of language is good but has difficulty repeating spoken material d. Non-fluent Aphasia : speech is sparse and produced slowly and with effort and poor articulation e. Global Aphasia:severe disruption of all aspects of communication(verbal,written,reading,understanding) Nursing Interventions: a. Face client & establish eye contact b. Use gestures, pictures and communication boards c. Limit conversations to practical matters d. Keep background noise to a minimum; keep environment simple and relaxed e. Do not shout or speak loudly; speak at normal rate and volume (patient not hearing impaired!) f. Give client time to understand and respond; allow plenty of time to answer g. If clients has problems speaking, ask “yes” or “no” questions Client with Stroke “Refers to onset and persistence of neurologic dysfunction lasting for longer than 24 hours and resulting from disruption of blood supply to the brain” Nursing Interventions a. Approach the client from the side of intact vision b. Remind the client to turn head in the direction of visual loss to compensate for loss of visual field c. Explain location of object when placing it near the client d. Always put client care items in same places e. Put objects within client’s reach and on unaffected side f. Encourage client to repeat sounds of the alphabet g. Speak slowly and clearly h. Use simple sentences with questions or pictures i. Reorient client to time, place and situation j. Provide familiar objects & minimize distractions k. Repeat & reinforce instructions Clients with Dementia

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“Dementia is a disturbance involving multiple cognitive deficits including memory impairment.Primary dementias are degenerative disorders that are progressive, irreversible and not due to any other conditions.” Nursing Interventions a. Be calm & unhurried; identify yourself & address the person by name each meeting b. Keep conversations short & focused ; use simple words and phrases c. Do not ask the client to make decisions d. Be consistent e. Avoid distractions f. Use reality oriented techniques

ELIMINATION A. Promotion of normal elimination 1. Urination a. Adequate fluid intake b. Normal adult urinary output=80ml/hr 2. Bowel elimination a. Adequate fluid intake b. Regular exercise c. Regular fruit juices, raw fruits & vegetables as needed d. Normal bowel evacuation: varies in healthy individuals; no more than 3 mov’ts. /day--3X/wk. B. Urinary Incontinence: Involuntary release of urine Diagnosis of urinary incontinence a. History & physical examination b. Urinalysis-tells whether blood or infection present c. Cystoscopy- tells whether abnormalities are present d. Post-void residual-measures amount of urine remaining in bladder after voiding e. Stress test-determines if urine leaks after bladder is stressed due to coughing, lifting, etc. Treatment a. Drug therapy Antispasmodic & anticholinergic-relax &increase capacity of bladder • Alpha-adrenergic agonists-increase urethral resistance b. Kegel exercises-strengthen weak muscles around the bladder, *also very effective in preventing Perineal lacerations. b. Behavioral training-client learns different way to control urge to urinate c. Bladder retraining d. Surgery-repair of weakened or damaged pelvic muscles or urethra Nursing Interventions a. Provide skin care, protective undergarments b. Establish toileting schedule-provide easy access to bathroom & privacy c. Teach client Kegel exercises: • Stop & start urinary stream while voiding • Hold contraction for 10 secs. & relax fro 10 secs. • Work up to 25 repetitions 3X a day d. Prevent infection • Cleanse urethral meatus after each void • Acidify urine • Increase daily intake of fluids C. Catheterization Purposes a. Relieve acute urinary retention b. Relieve chronic urinary retention c. Drain urine preoperatively & postoperatively d. Determine amount of post-void residual e. Accurately measure output in the critically ill f. Obtain sterile urine specimen g. Continuous or intermittent bladder irrigation

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Types of Catheter & General Guidelines a. Indwelling Catheter • Use a closed drainage system • Advance catheter almost to bifurcation of catheter, esp. in male patients

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• Inflate
w/draw

balloon w/in guidelines of manufacturer only after urine is draining properly, then slightly catheter

• Secure

catheter to patient’s thigh, allowing for some slack to accommodate movement & to lessen drag on patient • Ensure tubing is over patient’s leg • Care of indwelling catheter  Cleanse around area where catheter enters urethral meatus  Do this w/ soap & water during the daily bathing routine & after defecation



Don’t pull on catheter while cleansing  Don’t use powder or spray around perineal area  Don’t open the drainage system  Avoid raising the drainage bag above the level of the bladder  Avoid clamping the drainage tubing Catheter is only irrigated when an obstruction, usu. Following prostate or bladder surgery (e.g., potential blood clots) is anticipated b. Suprapubic Catheter • Placed to drain the bladder • Achieved via a percutaneous catheter or by way of an incision through the abdominal wall c. Intermittent Self-catheterization • Purpose: to drain the bladder yrs. • Procedure:  Gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container  Wash hands  Cleanse urethral meatus & surrounding area  Lubricate tip of catheter  Insert catheter until urine flows  W/draw catheter when urine flow stops  Clean off residual lubricant from meatus  Dispose of urine  Wash hands D. Ostomies Types of ostomies a. Ileostomy to semi-formed stool, dependent upon amount of bowel removed • May skew fluid & electrolyte balance, especially potassium & sodium • Digestive enzymes in stool irritate skin • Do NOT give laxatives • Ileostomy lavage may be done if needed to clear food blockage • May not require appliance set; if continent ileal reservoir or Koch pouch b.Colostomy • Ascending-must wear appliance--semi-liquid stool • Transverse-wear appliance--semi-formed stool • Loop stoma  Proximal end-functioning stoma  Distal end-drains mucous  Plastic rod used to keep loop out  Usually temporary • Double barrel  Two stomas



• Employed by the client w/ Spina Bifida & other neuromuscular diseases; can be taught to children

7-8

• Liquid

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 Similar to loop but bowel is surgically severed • Sigmoid • Formed stool • Bowel can be regulated so appliance not needed • May be irrigated Stoma assessment a. Color-should be same color as mucous membranes (normal stoma color- Red not dusky or pale: sign of infection) b. Edema-common after surgery c. Bleeding-slight bleeding common after surgery

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MOBILITY
Prevent complications of mobility 1. Skin changedecubitus ulcer a. Turn client q 2 hrs. b. Use heel/elbow protectors c. Use alternate pressure mattress or sheepskin 2. Musculoskeletal changes a. Start ROM exercises to affected joints b. Provide foot board &/or foot cradle (best for gout) c. Position & turn q 2 hrs. 3. Respiratory changes-pneumonia, atelectasis a. Instruct client to cough & deep breathe q 2 hrs. b. Turn q 2 hrs. c. Suction if needed (tracheostomy suctioning ADULT- maximum 15 seconds; therapeutic 10 seconds, INFANTS – 5 to 10 secs.) d. Chest physiotherapy as needed 4. Cardiovascular system changes a. Orthostatic / Postural hypotension(sign & symptoms- dizziness, headache & pallor): Instruct client to change position slowly; especially prone to supine or standing. This is commonly seen as a SIDE EFFECT of Vasodilators , Anti-hypertensives & Anti-cholinergics. b. Increased cardiac workload: discourage Valsalva maneuver c. Thrombus/embolus formation

•
•

Apply anti-embolic stockings Turn q 2 hrs. • Start anti-coagulation therapy if indicated • Initiate exercise 5. Urinary changes: renal calculi, UTI a. Increase fluid intake (2000-3000 cc/day) 6. Psychosocial changes: Provide stimuli to maintain orientation B. Types of exercise 1. Passive-carried out by the nurse w/out assistance from client; purpose is to retain joint mobility &circulation 2. Resistive-carried by the client working against resistance; purpose is to increase muscular strength 3. Isometric-carried out by the client w/ no assistance; purpose is to increase muscular strength 4. Range of Motion (ROM)-joint is moved through entire range; purpose is to maintain joint mobility 5. Active-performed by the patient;purpose is to maintain mobility, muscle strength & muscle size C. Use of mechanical aids to promote mobility 1. Crutches

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a. Support feet and legs during walking b. Adjust hand bars to allow 15-20 degrees of elbow flexion c. Use well-fitting shoes with non-slip soles d. Use rubber suction tips on crutches e. May be used temporarily or permanently f. Teach client crutch walking

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2. Cane a. Provides stability when walking and relieves pressure on weight-bearing joints b. Adjust cane w/ handle @ level of greater trochanter: elbow flexed at 30-degree angle c. Teach client to hold cane close to body, & hold in hand on stronger side d. Move cane @ same time as the weaker leg 3. Walker a. to assist in weight-bearing mobility b. Teach client how to sit & turn D. Prosthetic devices-used to replace a missing body part E. Brace-support for weakened muscles “A feeling of distress, suffering or agony caused by stimulation of specialized nerve endings” -Patricia Novac

PAIN

Theories of Pain

a. Specificity theory proposes that pain can be initiated only by painful stimuli. b. Pattern theory-stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and muscles to respond c. Gate Control Theory-pain impulses can be altered or regulated by gating mechanisms along nerve pathways. This theory explains how past and present experiences can influence the perception of pain.

1.

Pain Assessment

2.

Influencing factors • Past experience with pain • Age (tolerance generally increases with age) • Culture and religious beliefs • Level of anxiety • Physical state (fatigue or chronic illness may decrease tolerance) Characteristics of pain • Location • Aggravating factors • Quality • Alleviating factors • Intensity • Interference with Activities of Daily Living • Timing and duration • Patterns of response • Precipitating factors

Types of Pain

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1. Acute: Self-Limited, has a beginning and an end lasting up to 6 mos. 2. Chronic: Persistent or episodic pain lasting >6 mos.

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Medical Treatment
• Pharmacologic • Nonpharmacologic Intervention a. Acupuncture • Oriental method: insert fine needles at specified body sites • How acupuncture works physiologically: Unknown b. Relaxation Techniques-biofeedback, visualization, meditation, hypnosis-to help client control anxiety c. Electronic Stimulation such as Transcutaneous Electric Nerve Stimulation (TENS)-electrodes applied over the painful area or along nerve pathway d. Distraction-focusing client’s attention on something other than pain e. Massage-generalized cutaneous stimulation of the body; makes the client more comfortable due to muscle relaxation f. Ice and Heat Therapies-effective in some circumstances; ice may decrease the prostaglandins which intensify the sensitivity of pain receptors g. Guided Imagery-using one’s imagination in a guided manner to achieve a specific positive effect

Type of intravenous pump that allows the client to administer his own narcotic analgesic (e.g., morphine) on demand within preset dose and frequency limits. Goal: To achieve more constant level of analgesia as compared to PRN IM injection. In general, causes less sedation and lower risk of pulmonary depression. Used most often for postoperative pain management; also used for intractable pain in terminal illness. PCA pump may be used solely on PCA mode or may be combined with a continuous basal mode where client is receiving continuous infusion of narcotic in addition to self-administered bolus injections. Nursing Interventions 1.Instruct client in use of PCA pump a. Demonstrate how to push control button. b. Explain concept of patient-controlled analgesia. 2. Frequently assess client’s level of consciousness (LOC), RR, and degree of pain relief.

Patient-Controlled Analgesia (PCA)

Nursing Assessment & Interventions for Pain

Noninvasive alternative to traditional methods of pain relief Used in treating acute pain (e.g., post-op pain) and chronic pain (e.g., chronic low back pain chronic) 1. Consists of impulse generator connected by wires to electrodes on skin ; produces tingling, buzzing sensation in the area 2.Mechanism based on gate-control theory: electrical impulse stimulates large diameter nerve fibers to “close the gate” a. Don’t place electrodes over incision site, broken skin, carotid sinus, eyes, laryngeal or pharyngeal muscles. b. Don’t use in client with cardiac pacemaker. c. Provide skin care. • remove electrodes once a day; wash area with soap & water, & air dry • wipe area with skin prep pad before reapplying electrode • assess area for signs of redness; reposition electrodes if redness persists for more than 30 mins.

Electrical Stimulation Technique for Pain Control Transcutaneous Electrical Nerve Stimulator (TENS)

1. Evaluate objectively the nature of the patient’s pain: location, duration, quality, & impact on daily activities.

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2. Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain). Take careful history of prior & present medications, response, & side effects. 3. Assess relief from medications & duration of relief. (Use the same measuring scale every time). 4. Base the initial analgesic choice on the patient’s report of pain. 5. Administer drugs orally whenever possible; avoid intramuscular injection. 6. Administer analgesia “around the clock” rather than PRN. 7. Convey the impression that the patient’s pain is understood & that the pain can be controlled. 8. Take a careful pain history. Explore pain interventions that have been used & their effectiveness. Determine if the intensity of the pain correlates w/ the prescribed analgesic. 9. Reevaluate the pain frequently. The requirement for analgesia should decrease if other treatment is given, including radiation/chemotherapy. 10. Use alternative measures to relieve pain such as imaging, relaxation, & biofeedback. 11. Provide ongoing support & open communication. 12. Consider referral to a pain specialist for intractable pain. 13. Provide education. a. Method of administration of medications & importance of maintaining prescribed schedule b. Need to call health professionals if pain has increased or occurred in another area of the body c. Side effects of medication (1) Constipation-best treated prophylactically (2) Nausea-antiemetic therapy helpful (3) Tolerance-increasing doses often required achieving the same effect. This is a normal physiologic response to opioids. Patient reports shorter duration of effect. There is no maximum opioid dose as long as side effects are tolerable. (4) Addiction usually isn’t a problem to needed narcotics.

SLEEP
A state of consciousness in w/c the individual’s perception & reaction to the environment are decreased A. Physiology 1. Reticular Activating System (RAS)-maintains a state of wakefulness & mediates some stages of sleep. Sleep is an active process involving the RAS & a dynamic interaction of neurotransmitters. 2. Serotonin is a major neurotransmitter associated w/ sleep. It is derived from its precursor Tryptophan, a naturally occurring amino acid. It decreases activity of RAS, thereby inducing & sustaining sleep. Other neurotransmitters-acetylcholine & norepinephrine appear to be required for the REM sleep cycle. B. Theories 1. Active Theory of Sleep: proposes that there are centers that cause sleep by inhibiting other brain centers. 2. Passive Theory of Sleep: states that the RAS simply fatigues & therefore becomes inactive thus, sleep occurs. C. Stages 1. NREM (Non-Rapid Eye Mov’t.) Stage a. Very light sleep; drowsy, relaxed; readily awakened-Stage (St.) 1

Deep sleep; difficult to arouse; ↓ V/S; ↓ metabolism, brain waves, muscles relaxed-St. 4 2. REM (Rapid Eye Mov’t.) Stages a. Eyes appear to roll b. “Paradoxical Sleep” c. Close to wakefulness but difficult to arouse d. Dream state of sleep e. Sympathetic Nervous System dominates f. Flow of gastric acid increases g. Restores a person mentally-learning, psychological adaptation & memory h. The sleeper reviews the day’s events & processes & restores information D. Functions 1. NREM-body restoration 2. REM-increases synthetic processes in the brain

b. c. d.

Light sleep; eyes are still; HR & RR decrease slightly; body temperature falls-St. 2 Domination of PNS; body process slows further; difficult to arouse-St. 3

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E. Sleep-promoting Nursing Interventions 1. Warm bath- relaxes muscles, which induces sleep. 2. Drink Milk – rich in tryptophan, which induces sleep. 3. Attend to individual’s bedtime rituals that promote sleep 4. Emphasize adequate exercise. *Exercise at least 2 hrs. Before sleep to enhance NREM, not immediately before sleep. 5. Give or advise high protein food; they contain tryptophan, w/c is a CNS depressant. 6. Assess habits of sleep rhythm & wake-up time. 7. Avoid caffeine & alcohol in the evening. 8. Make sure client goes to bed when sleepy. 9. Use the bed mainly for sleep. 10. Be judicious in using minor tranquilizers. F. Common Sleep Disorders 1. Insomnia: *difficulty in falling asleep *intermittent sleep *premature awakening 2. Hypersomnia: *excessive sleep (daytime or night time) *r/t psychologic problems, CNS damage, metabolic disorders 3. Narcolepsy/Sleep Attack: *overwhelming sleepiness *REM uncontrolled 4. Sleep Apnea: periodic cessation of breathing during asleep; characterized by snoring 5. Parasomnias a. Somnambolism/Sleep Walking b. Night Terrors: After having slept for few hrs., the child bolts upright in bed, shakes & screams, appears pale & terrified. c. Nocturnal Enuresis/Bedwetting d. Soliloquy/Sleep-talking e. Bruxism: clenching & grinding of teeth during sleep; may erode & diminish the height of dental crowns & may cause the teeth to become loose

Use the following techniques of examination as appropriate for eliciting findings: Inspection a.Begins with first encounter with the patient and is the most important of all the techniques b.Is an organized scrutiny of the patient’s behavior and body c. With knowledge and experience, the examiner can become highly sensitive to visual clues. d.The examiner begins each phase of the examination by inspecting the particular part with the eyes. Palpation a.Involves touching the region or body part just observed and noting what the various structures feel like. b.With experience comes the ability to distinguish variations of normal from abnormal. c. Is performed in an organized manner from region to region. Percussion a.By setting underlying tissues in motion, percussion helps in determining whether the underlying tissue is air filled, fluid filled, or solid. b.Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner. There are five basic notes produced by percussion, which can be distinguished by differences in the qualities of sound, pitch, duration, and intensity. These are: Relative Intensity 1. 2. 3. 4. Flatness Dullness Resonance Hyper resonance Soft Medium Loud Very loud Tympany Relative Pitch High Medium Low Lower * Relative Duratio n Short Medium Long Longer * Example Location Thigh Liver Normal lung Emphysematous lung Gastric air bubble or puffed out cheek

Physical Assessment

5. Tympany

*Distinguished mainly by its musical timbre.

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c.

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The technique for percussion may be described as follows: 1. Hyperextend the middle finger of your left hand, pressing the distal portion and joint firmly against the surface to be percussed. • Other fingers touching the surface will damp the sound. • Be consistent in the degree of firmness exerted by the hyperextended finger as you move it from area to area or the sound will vary. 2. Cock the right hand at the wrist, flex the middle finger upward, and place the forearm close to the surface to be percussed. The right hand and forearm should be as relaxed as possible. 3. With a quick, sharp, relaxed wrist motion, strike the extended left middle finger with the flexed right middle finger, using the tip of the finger, not the pad. (A very short fingernail is a must!) Aim at the end of the extended left middle finger (just behind the nail bed) where the greatest pressure is exerted on the surface to be percussed. 4. Lift the right middle finger rapidly to avoid damping the vibrations. 5. The movement is at the wrist, not at the finger, elbow, or shoulder; the examiner should use the lightest touch capable of producing a clear sound.

Auscultation a. This method uses the stethoscope to augment the sense of hearing. b. The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 25 to 38 cm (10-15 inches), and the head should have a diaphragm and a bell. • The bell is used for low-pitched sounds such as certain heart murmurs. c. The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breath sounds. d. Extraneous sounds can be produced by clothing, hair and movement of the head of the stethoscope. Equipment • Thermometer • Cotton applicator stick • Sphygmomanometer • Stethoscope • Oto-ophthalmoscope • Reflex Hammer • Flashlight • Tuning Fork • Tongue Depressor • Safety Pin • Additional items include disposable gloves and lubricant for rectal examination and a speculum for examination of female pelvis VITAL SIGNS Importance—Many major therapeutic decisions are based on the vital signs; therefore, accuracy is essential. C. Technique Temperature • Routinely, where accuracy is not crucial, an oral temperature will suffice. • A rectal temperature is the most accurate. • Unless contraindicated (as in a patient with a severe cardiac arrhythmia), a rectal temperature is often preferred. D. Findings

 May vary with the time of day. o Oral: 370C (98.60F) is considered normal. May vary from 35.80C to 37.30C (96.40-99.10F) o Rectal: Higher than oral by 0.40C to 0.50C (0.700.90F).

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Pulse • Palpate the radial pulse and count for at least 30 seconds. I f the pulse is irregular, count for a full minute and note the number of irregular beats/min.  Normal adult pulse is 60 to 80 beats/min; regular in rhythm. Elasticity of the arterial walls, blood volume, and mechanical action of the heart muscle are some of the factors that affect strength of the pulse wave, which normally is full and strong.

•

Note: Whether the beat of the pulse against your finger is strong or weak, bounding or thread.

Respiration • Count the number of respirations taken in 15 seconds and multiply by 4.  Normally 16 to 20 respirations/min.

•
• • • • •

Note: Rhythm and depth of breathing. Blood Pressure Measure the blood pressure in both arms. Palpate the systolic pressure before using the stethoscope in order to detect an auscultatory gap.* Apply cuff firmly; if too loose, it will give a falsely high reading. Use cuff in appropriate size: a pediatric cuff for children; a leg cuff for obese people. The cuff should be approximately 2.5 cm (1 inch) above the antecubital fossa.

• Normal range: Systolic—95-140 mm Hg Diastolic—60-90 mm Hg • A difference of 5 to 10 mm Hg between arms in common. • Systolic pressure in lower extremities is usually 10 mm Hg higher than reading in upper extremities. • Going from a recumbent to a standing position can cause the systolic pressure to fall 10 to 15 mm Hg and the diastolic pressure to rise slightly (by 5 mm Hg).

Principles and Practices of Surgical Asepsis Principles All objects used in a sterile field must be sterile.

Selected Nursing Procedures

Practices All articles are sterilized appropriately by dry or moist heat, chemicals, or radiation before use. Always check a package containing a sterile object for intactness, dryness, and expiration date. Any package that appears already open, torn, punctured, or wet is considered unsterile. Storage areas should be clean, dry, off the floor, and away from sinks Always check chemical indicators of sterilization before using a package. The indicator is often a tape used to fasten the package or contained inside the package. The indicator changes color during sterilization, indicating that the contents have undergone a sterilization procedure. If the color change is not evident, the package is considered unsterile. Commercially prepared sterile packages may not have indicators but are marked with the word sterile. Handle sterile objects that will touch open wounds or enter body cavities only with sterile forceps or sterile gloved hands. Discard or resterilize objects that are considered questionable, assume the article is unsterile. One left unattended, a sterile field is considered unsterile. Sterile objects are always kept in view. Nurses do not turn their backs on a sterile field. Only the front part of a sterile gown (from the waists to the shoulder) and 2 inches above the elbows to the cuff of the sleeves are considered sterile.

Sterile objects become unsterile when touched by unsterile objects. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile.

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Always keep sterile gloved hands in sight and above waist level; touch only objects that are sterile. Sterile draped tables in the operating room or elsewhere are considered sterile only at surface level. Once a sterile field becomes unsterile, it must be set up again before proceeding. Sterile objects can become unsterile by prolonged exposure to airbone microorganisms. Keep doors closed and traffic to a minimum in areas where a sterile procedure is being performed because moving air can carry dust and microorganisms. Keep areas in which sterile procedures are carried out as clean as possible by frequent damp cleaning with detergent germicides to minimize contaminants in the area. Keep hair clean and short or enclose it in a net to prevent hair from failing on sterile objects. Microorganisms on the hair can make a sterile field unsterile. Wear surgical caps in operating rooms, delivery rooms, and burn units. Refrain from sneezing or coughing over a sterile field. This can make it unsterile because droplets containing covering the mouth and the nose should be worn by anyone working over a sterile field or an open wound. Nurses with mild upper respiratory tract infections refrain from carrying out sterile procedures or wear masks. When working over a sterile field, keep talking to a minimum. Avert the head from the field if talking is necessary. To prevent microorganisms from failing over a sterile field, refrain from reaching over a sterile field unless sterile gloves are worn and refrain from moving unsterile objects over a sterile field. Unless gloves are worn, always hold wet forceps with the tips below the handles. When the tips are held higher than the handles, fluid can flow onto the handle and become contaminated by the hands, When the forceps are again pointed downward, the fluid flows back down and contaminates the tips. During a surgical hand wash, hold the hands higher than the elbows to prevent contaminants from the forearms from reaching the hands. Sterile moisture-proof barriers are sued beneath sterile objects. Liquids (sterile saline or antiseptics) are frequently poured into containers on a sterile field. If they are spilled onto the sterile field, the barrier keeps The liquid from seeping beneath it. Keep the sterile covers on sterile equipment dry. Damp surfaces can attract microorganisms in the air. Replace sterile drapes that do not have a sterile barrier underneath when they become moist. A 2.5-cm (1-in) margin at each edge of an opened drape is considered unsterile because the edges are in contact with unsterile surfaces. Place all sterile objects more than 2.5 cm (1 in.) inside the edges of a sterile field. Any article that falls outside the edges of a sterile field is considered unsterile. Use sterile gloves or sterile forceps to handle sterile items. Prior to a surgical aseptic procedure, wash hands to reduce the number of microorganisms on them When a sterile object becomes unsterile, it does not necessarily change in appearance.The person who sees a sterile object become contaminated must correct or report eh situation.Don’t a set up a sterile field ahead of time for future use.

Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action.

The edges of a sterile field are considered unsterile.

The skin connot be sterilized and is unsterile. Conscientiousness, alterness, and honesty are essential qualities in maintaining surgical asepsis.

Nosocomial Infections
Most Common Microorganisms Urinary Tract Escherichia coli (80%) Enterococcus species Causes Improper catheterization technique Contamination of closed drainage system

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Pseudomonas aeruginosa Surgical Sites Staphylococcus aureus Enterococcus species Pseudomonas aeruginosa Bloodstream Coagulase-negative staphylococci Staphylococcus aureus Enterococcus species Inadequate hand washing Inadequate hand washing Improper dressing change technique

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Inadequate hand washing Improper intravenous fluid, tubing, and site care technique

Pneumonia Inadequate hand washing Staphylococcus aureau Improper suctioning technique Pseudomonas aeruginosa Enterobacter species Steps to follow other Exposure to Bloodborne Pathogens • Report the incident immediately to appropriate personnel within the agency. • Complete an injury report. • Seek appropriate evaluation and follow-up. This includes:  Identification and documentation of the source individual when feasible and legal  Testing of the source for hepatitis B, hepatitis C, and HIV when feasible and consent is given  Making results of the test available to the source individual’s health care provider  Testing of blood of exposed nurse (with consent) for hepatitis B, hepatitis C, and HIV antibodies  Postexposure prophylaxis if medically indicated • For a puncture / laceration:  Encourage bleeding  Wash / clean the area with soap and water  Initiate first-aid and seek treatment if indicated.

•
HIV: •

For a mucous membrane exposure (eyes, nose, mouth), saline of water flush for 5 to 10 minutes.

Postexposure Protocol (PEP)

For “high-risk” exposure (high blood volume and source with a high HIV titer): three-drug treatment is recommended. Must be started within 1 hour. • For “increased risk” exposure (high blood volume or source with a high HIV titer): three-drug treatment is recommended. Must be started within 1 hour. • For “low-risk” exposure (neither high blood volume nor source with a high HIV titer): two-drug treatment is considered. Must be started within 1 hour. • Drug regimens vary. Drugs commonly used are zidovudine, lamivudine, didanosine, and indinavir. • HIV antibody test done shortly after expsosure (baseline), and 6 week, 3 months, and 6 months after ward. Hepatitis B Anti-HBs testing 1 to 2 months after last vaccine close. • Anti-BHs testing 1 to 2 months after last vaccine close. Hepatitis C • Anti-HVC and ALT at baseline and 34 to 6 months after exposure Selected Safety Hazards throughout the Life Span

  

Developing fetus: Exposure to maternal smoking, alcohol consumption, addictive drugs, x-rays (first trimester), certain pesticides Newborns and infants: Falling, suffocation in crib, choking from aspirated milk or ingested objects, burns from hot water or other spilled hot liquids, automobile accidents, crib or playpen injuries, electric shook, poisoning Toddlers: Physical trauma from falling, banging into objects, or getting cut by sharp objects; automobile accidents; burns; poisoning; drowning; and electric shock

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  
     

Preschoolers: injury from traffic, playground equipment, and other objects; choking, suffocation, and obstruction of airway or ear card by foreign objects; poisoning; drowning fire and burns; harm from other people or animals Adolescents: substance abuse Vehicular (automobile, bicycle) accidents, recreational accidents, firearms,

Older adults: Falling, burns, and pedestrian and automobile accidents

Applying Restraints
Obtain consent from the client or guardian. Ensure that a physician’s order has been provided or, in an emergency, obtain one within 24 hours after applying the restraint. Assure the client and the client’s support people that the restraint is temporary and protective. A restraint must never be applied as punishment for any behavior or merely for the nurse’s convenience. Apply the restraint in such a way that the client can move as freely as possible without defeating the purpose of the restraint. Ensure that limb restraints are applied securely but not so tightly that they impede blood circulation to any body area or extremity. Pad bony prominences (e.g., wrists and ankles) before applying a restraint over them. The movement of a restraint without padding over such prominences can quickly abrade the skin. Always tie a limb restraint with a knot (e.g., a clove hitch) that will not tighten when pulled. Tie the ends of a body restraint to the part of the bed that moves to elevate the head. Never tie the ends to a side rail or to the fixed frame of the bed if the bed position is to be changed. Assess the restraint every 30 minutes. Some facilities have specific forms to be used to record ongoing assessment. Release all restraints at least every 2 to 4 hours, and provide range-of-motion (ROM) exercises and skin care. Reassess the continued need for the restraint at least every 8 hours. Include an assessment of the underlying cause of the behavior necessitating use of the restraints. When a restraint is temporarily removed, do not leave the client unattended. Immediately report to the nurse in charge and record on the client’s chart any persistent reddened or broken skin areas under the restraint. At the first indication of cyanosis or pallor, coldness of a skin area, or a client’s complaint of a tingling sensation, pain, or numbness, loosen the restraint and exercise the limb. Apply a restraint to that it can be released quickly in case of an emergency and with the body part in a normal anatomic position. Provide emotional support verbally and through touch.

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Process  To remove transient microorganisms, body secretions and excretions, and dead skin cells  To stimulate circulation to the skin  To produce a sense of well-being  To promote relaxation and comfort  To prevent or eliminate unpleasant body odors Assessment  Condition of the skin (color, texture and turgor, presence of pigmented spots, temperature, lesions, excoriations, and abrasions)  Fatigue  Presence of pain and need for adjunctive measure (e.g., an analgesic) before the bath  Range of motion of the joints  Any other aspect of health that affect the client’s bathing process (e.g., mobility, strength, cognition)  Need for use of clean gloves during the bath Equipment  Basin or skink with warm water (between 43 and 46C or 3110 and 115F)

Bathing an Adult or Pediatric Client

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Soap and soap dish Linens: bath blanket, two bath towels, washcloth, clean grown or pajamas or clothes as needed, additional bed linen and towels, if required Gloves, if appropriate (e.g., presence of body fluids or open lesions) Personal hygiene article (e.g., deodorant, powder, lotions) Shaving equipment for male clients Table for bathing equipment Prepare the bed and position the client appropriately.

FOR A BED BATH

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Position the bed at a comfortable working height. Lower the side rail on the side close to you. Keep the other side rail up. Assist the client to move near you. This avoids undue reaching and straining and promotes good body mechanics. Place bath blanket over top sheet. Remove the top sheet from under the bath blanket by starting at client’s shoulders and moving linen down toward client’s feet. Ask the client to grasp and hold the top of the bath blanket while pulling linen to the foot of the bed. The bath blanket provides comfort, warmth, and privacy. Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be changed, place it in the linen hamper.

Remove client’s gown while keeping the client covered with the bath blanket. Place gown in linen hamper. Make bath mitt with the washcloth. A bath mitt retains water and heat better than a cloth loosely held and prevents ends of washcloth from dragging across the skin. Wash the face. Circular Motion. Begin the bath at the cleanest area and work downward to-ward the feet. • Place towel under client’s head.

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Wash the client’s eyes with water only and dry them well. Use a separate corner of the washcloth for each eye. Using separate comers prevents transmitting microorganisms from one eye to the other. Wipe from the inner to the outer canthus. This prevents secretions from entering the nasolacrimal ducts.

Ask whether the client wants soap used on the face. Soap has a drying effect, and the face, which is exposed to the air more than other body parts, tends to be drier. • Wash, rinse, and dry the client’s face ears, and neck. • Remove the towel from under the client’s head. Wash the arms and hands. (Omit the arms for a partial bath.)

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Place a towel lengthwise under the arm away from you. It protects the bed from becoming wet. Wash, rinse, and dry the arm by elevating the client’s arm and supporting the client’s wrist the elbow .Use long, firm strokes from wrist to shoulder, including the axillary area. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. Apply deodorant or powder if desired. (Optional) Place a towel on the bed and put a washbasin on it. Place the client’s hands in the basin. Many clients enjoy immersing their hands in the basin and washing themselves. Soaking loosens dirt under the nails. Assist the client as needed to wash, rinse, and dry the hands, paying particular attention to the spaces between the fingers. Repeat for hand and arm nearest you. Exercise caution if an intravenous infusion is present, and check its flow after moving the arm.

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Wash the chest and abdomen. (Omit the chest and abdomen for a partial bath. However, the areas under a woman’s breast may require bathing if this area is irritated or if the client has significant perspiration under the breast.)

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Place bath towel lengthwise over chest. Fold bath blanket down to the client’s public area. Keeps the client warm while preventing unnecessary exposure of the chest. Lift the bath towel off the chest, and bathe the chest and abdomen with your mitted hand using long, firm strokes . Give special attention to the skin under the breasts and any other skin folds particularly if the client is overweight. Rinse and dry well. Replace the bath blanket when the areas have been dried.

Wash the legs and feet. (Omit legs and feet for a partial bath.)

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Expose the leg farthest from you by folding the bath blanket toward the other leg being careful to keep the perineum covered. Covering the perineum promotes privacy and maintains the client’s dignity. Lift leg and place the bath towel lengthwise under the leg. Wash, rinse, and dry the leg using long, smooth, firm strokes from the ankle to the knee to the thigh. Washing from the distal to proximal areas promotes circulation by stimulating venous blood flow. Reverse the coverings and repeat for the other leg. Wash the feet by placing them in the basin of water Dry each foot. Pay particular attention to the spaces between the toes. If you prefer, wash one foot after that leg before washing the other leg. Obtain fresh, warm bathwater now or when necessary. Water may become dirty or cold. Because surface skin cells are removed with washing, the bathwater from dark-skinned clients may be dark, however, this does not mean the client is dirty. Raise side rails when refilling basin. This ensures the safety of the client.

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Wash the back and then the perineum.

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Assist the client into a prone or side-lying position facing away from you. Place the bath towel lengthwise alongside the back buttocks while keeping the client covered with the bath blanket as much as possible. This provides warmth and undue exposure. Wash and dry the client’s back, moving from the shoulders to the buttocks, and upper thighs, paying attention to the gluteal folds Perform back massage now of after completion of bath. Assist the client to the supine position and determine whether the client can wash the perineal area independently. If the client cannot do so, drape the client and wash the area.

Assist the client with grooming aids such as powder, lotion, or deodorant.

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Use powder sparingly. Release as little as possible into the atmosphere. This will avoid irritation of the respiratory tract by powder inhalation. Excessive powder can cause caking, which leads to skin irritation. 1. 2. 3. 4. 5. 6. 7. Eyes (inner to outer) Face (circular) Ears & Neck (circular) Arms & Hands (distal to proximal) Chest & Abdomen (long firm strokes-longitudinal) Legs & Feet (distal to proximal) Back & Perineum (shoulders to buttocks then upper thighs - distal to proximal)

Systematic Way for Bed Bath

Using a Metered – Dose Inhaler
• Make sure the canister is firmly and fully inserted into the inhaler.

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Remove the mouthpiece cap and, holding the inhaler upright; shake the inhaler vigorously for 3 to 5 seconds to mix the medication evenly. • Exhale comfortably (as in a normal full breath. • Hold the canister upside down. a. Hold the MDI 2 TO 4 cm (1 to 2 in) from the open mouth b. Put the mouthpiece far enough into the mouth with its opening toward the throat. Close the lips tightly around the mouthpiece. An MDI with a spacer or extender is always placed in the mouth. Administering the Medication  Press down once on the MDI canister (which release the dose) and inhale slowly and deeply through the mouth.

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Hold your breath for 10 seconds. This allows the aerosol to reach deeper airways. Remove the inhaler from or away from the mouth. Exhale slowly through-pursed lips. Controlled exhalation keeps the small airways open during exhalation.

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Repeat the inhalation if ordered. Wait 20 to 30 second between inhalations of bronchodilator medications so the first inhalation has a chance to work and the subsequent dose reaches deeper into the lungs. After the inhalation is completed, rinse mouth with tap water to remove any remaining medication and reduce irritation and risk of infection. Clean the MDI mouthpiece after each use. Use mild soap and water, rinse it, and let it air dry before replacing it on the device. Store the canister at room temperature. Avoid extremes of temperature. Report adverse reactions such as restlessness, palpitation, nervousness, or rash to the physician. Many MDIs contains steroids for an anti-inflammatory effect. Prolonged use increases the risk of fungal infections in the mouth.

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