GENERAL OBJECTIVES *At the end of the discussion, the learners shall be able to: ◦
Refresh their prior knowledge about concepts in Fundamentals Fundamentals of Nursing
◦
Discover certain topics which seem new to them
◦
Develop techniques that would help them in inculcating the concepts by heart and mind
◦
Evaluate the learning process they undergo by having simple quizzes and exercises
GENERAL OBJECTIVES *At the end of the discussion, the learners shall be able to: ◦
Refresh their prior knowledge about concepts in Fundamentals Fundamentals of Nursing
◦
Discover certain topics which seem new to them
◦
Develop techniques that would help them in inculcating the concepts by heart and mind
◦
Evaluate the learning process they undergo by having simple quizzes and exercises
CONTENT PREVIEW First day I. Historical and Contemporary Nursing Practice 1. Nursing Leaders 2. Definitions of Nursing 3. Roles and Functions of a Nurse II. Nursing Theories III. Paradigm: Definition of Terms 1. MAN: Levels of Clientele 2. NURSING PROCESS 3. HEALTH IV. Health Promotion 1. Levels of Prevention 2. Health Promotion and Health Protection
V.
Man and His Basic Human Needs
VI. Health and Illness VII. Asepsis and Infection Control VIII. Stress, Adaptation, Homeostasis IX. Physiologic Responses to Stress and Illness X.
Communication in Nursing
XI. The Nursing Process XII. Assessing Health
Information Overload Episodes of information overload
Student’s information processing capacity
Information Load
Grassroots of Nursing:
N-U-R-S-I-N-G- L-E-A-D-E-R-S Florence
Nightingale -first nursing scientist/ theorist for her work “ Notes on Nursing: What It Is, and What It Is Not (1860/1969)”
Clara
Barton -organized the American Red Cross
Lilian
Wald -founder of Public Health Nursing. Henry Street Settlement and Visiting Nurse Service
Lavinia
Dock -Nursing leader, protested for women’s rights
Margaret
Sanger -Nurse activist, founder of Planned Parenthood
Common Themes in Definition of Nursing Nursing
is caring. Nursing is an art. (“SKILLS”) Nursing is a science. (“THEORIES”) Nursing is client-centered. Nursing is holistic. Nursing is adaptive. Nursing is a helping profession. Nursing is concerned with health promotion, disease prevention, and health restoration.
NURSING as a science and an art. 1. Lewis introducing the topic “research” in class. 2. Jumbo inserting IV catheter. 3. Gerald washed his hands first before he introduced the NGT because he wanted to maintain aseptic technique. 4. Noel could easily recall all the definitions of nursing. 5. Regina promptly performed CPR after assessing that the patient doesn’t have a pulse and is not breathing.
Nursing as a caring profession Five Processes of Caring: 1.Knowing 2.Being with 3.Doing for 4.Enabling 5.Maintaining Belief Caring includes the ffg. factors: Providing presence“eye contact”’ Comforting“touch” Listening“attention” Knowing the client“uniqueness’ Spiritual caring- “transpersonally” Family Care“participants”
Is Nursing a vocation or a profession? Characteristics of a Profession 1.Education 2.Theory 3.Service 4.Autonomy 5.Code of Ethics 6.Caring
-the most unique characteristic of nursing
“The Nurse is basically a good person”. Four Virtues from the Practice of Charity 1.Justice 2.Prudence3.Fortitude4.Temperance-
being righteous cautious support sacrifice
Exercise: ____1. The nurse encourages the patient to verbalize. ____2. The nurse respects the autonomy of the patient. ____3. The nurse should stand even in unfavorable conditions. ____4. Before giving the medication, the nurse verified the dosage to the fellow nurse.
Attributes of Character Honesty Loyalty
Tolerance Reliability Judgment Motivation
Resourcefulness Moderation
1. Thinking of other alternatives. 2. Your boss has put a lot of trust in you because of this attribute. 3. You’re protecting the name of the hospital you’re working with. 4. You have to control your temper when undesirable events happen. 5. Informing the client about the medication you’re about to give. 6. Questioning an unclear doctor’s order. 7. Recognizing others because of a job well done. 8. Delaying your schedule of watching a movie because of an exam.
Roles and Functions of a Professional Nurse Care Provider Leader Communicator Manager Teacher Researcher abnormal VS to the doctor Reporting Client Advocate Case Manager Continuing
Counselor Collaborator Change Agent
education to improve current practice Informing the patient about his rights Providing the client’s needs Gives health teachings Plans, gives directions, develops staff, monitors operations Interpersonal influence to promote the health of the client Helps the patient to cope with stressful emotional problems Initiates changes and assists the client to have modifications in lifestyle to promote health You meticulously wrote your SOAPIE method in the chart to inform others about the care you delivered to the patient. Coordinates the activities you planned for CVA patients to a nutritionist, physical therapist and speech therapist to properly manage the patient’s condition
Types of Nursing Interventions:
Independent
Dependent
Interdependent
1. The nurse providing 2-3LPM of O2. 2. Steam Inhalation 3. Oral Inhaler 4. Chest Physiotherapy 5. Purse-lip breathing 6. Deep Breathing Exercises 7. Cough Excercises 8. Health education 9. Calories needed by the client 10. For Chest X-ray
Nursing Care Delivery Models * to develop BEDSIDE NURSING and Total improve professional relationships b/n staff. Patient Care *RN is responsible for all aspects of care to one or more clients. *RNFunctional is the leader together with nursing assistants and health Nursing aides. *Coordinates and links health care services to clients and their Team Nursing families *Division of tasks, one nurse assumes a responsibility apart from others’ task Primary Nursing
Case Management
Nursing Theorists Florence Nightingale Virginia Henderson
-Environmental Theory -Assist the client to gain independence; 14 Basic Needs
Faye Abdellah Dorothy Johnson Imogene King
-21 Nursing Problems
-Behavioral System Model -Goal Attainment Theory
Madeleine Leininger -Transcultural Nursing Myra Levin
-Four Conservational Theory
Betty Neuman
-Health Care System Model
Cont… Dorothea Orem -Self-Care Deficit Theory Hildegard Peplau Martha Rogers
-Interpersonal Model
-Science of Unitary Human Beings
Sister Callista Roy
-Adaptation Model
Lydia Hall
-Core, Care and Cure
Ida Jean Orlando
-Dynamic Nurse-Patient Relationship
Jean Watson
-Human Caring Model
Joyce Travelbee -Interpersonal Aspects of Nursing Model Ernestine Weidenbach-Clinical Nursing- A Helping Art Model
Definition of Terms MAN -is a biopsychosocial and spiritual being who is in constant contact with the environment. (Roy) LEVELS OF CLIENTELE I. Individuals II. Families III. Social Group IV. Communities HEALTH- a complete state of physical, mental, emotional and social being of a person and not just merely the absence of disease or infirmity. (World Health Organization, 1947) -From an Old English “heal” which means “whole”
A Simple Paradigm MAN
NURSING PROCESS
Individuals Families Social Groups Communities
ADPIE
END GOAL
HEALTH
MAN’s Basic Needs: SelfActualization Self-Esteem
Love and Belongingness
Safety and Security Physiologic Abraham Maslow’s Hierarchy of Needs
Identify the following according to
Maslow’s Hierarchy of Needs: 1.Self-respect 2.The need to be fulfilled 3.Rest and sleep 4.Elimination 5.The need for shelter 6.The need to care and be cared for 7.Self-worth 8.Psychological safety 9.Oxygen 10.Spiritual fulfillment
Models of CLINICAL/MEDICAL Health MODEL ROLE
PERFORMANCE MODEL
ADAPTIVE
MODEL (Sister Callista Roy)
EUDOMONISTIC
MODEL
AGENT-HOST-ENVIRONMENT
MODEL
(Leavell & Clark) HEALTH-ILLNESS
CONTINUUM (McCann/Flynn & Heffron, 1984) DUNN’S
(1959)
HIGH- LEVEL WELLNESS GRID
A. Clinical Model hlt
practitioners used this model if their focus is on own relief of s/sx of dse & eliminate pain & malfunction. If there is less or absence of s/sx & pain health is restored.
B. Role Performance Model People who can fulfil their roles are healthy even if they appear clinically ill. Assumes in this model that “sickness” is the inability to perform one’s work.
C. ADAPTIVE MODEL (Sister Callista Roy) Adaptation
– it is the focus of this model Belief: health is a creative process. Therefore, disease is a failure in adaptation. (maladaptation) Treatment of a person: aim is to restore person by ability of a person to adapt, i.e. “to cope”
D. EUDOMONISTIC MODEL it
views that in this model, the highest aspiration of people is fulfilment & complete development which is “actualization” Illness is viewed as a condition that prevents selfactualization
E. AGENT-HOST-ENVIRONMENT MODEL (Leavell & Clark) also known as Ecologic Model; model was derived due to the community health work of authors model is used in predicting illness rather than in promoting wellness Env’t Host Agent
F. HEALTH-ILLNESS CONTINUUM (McCann/Flynn & Heffron, 1984) Wellness Model Premat ure Death
HighLevel Disability Symptoms Awareness Education Growth
Treatment Model
Signs
Wellnes s
G. DUNN’S HIGH- LEVEL WELLNESS GRID (1959) Very favorable environment C. Protected Poor Hlt (in favourable env t) thru social & cultural institutions ’
Death Death Death
A. High- Level Wellness (in favourable environment) Peak Peak Wellness Wellness
Poor Health Health D. D. Poor (unfavourable environment)
(unfavourable environment)
B. Emergent High-Level Wellness (in unfavourable environment)
Very unfavorable environment
Peak Wellness
Health Axis
Environmental Axis
Classification of Diseases According to Etiology 1.Hereditary 1.Hereditary 2.Congenital 2. Congenital 3.Idiopathic 3. Idiopathic 4.Metabolic 4. Metabolic 5.Deficiency 5. Deficiency 6.Neoplastic 6. Neoplastic 7.Degenerative 7. Degenerative 8.Iatrogenic 8. Iatrogenic 9.Traumatic 9. Traumatic 10.Allergic 10. Allergic
•DM •Alopecia after chemotherapy •Osteoarthritis •Uterine cancer •Fracture •Skin Allergy •Osteomalacia •Hyperthyroidism •Cleft Palate •HPN
According to Duration or Onset 1.Acute Illness- short duration 1.Acute 2.Chronic 2. Chronic Illnesslonger than 6 mos.
*remission -asymptomatic but with dse. *exacerbation -becomes active again with pronounced s/sx
Three Levels of Prevention 1. Primaryhealth promotion and protection 2. Secondary- early detection, diagnosis, screening 3. Tertiaryrehabilitation and adaptation
Identify the type of prevention: 1.Quit Smoking 1.Quit 2.Wear 2. Wear hazard devices 3.Physical 3. Physical Therapy after CVA 4.Attending 4. Attending Self-Management Self-Management education for DM pts. 5.Have 5. Have annual physical examination 6.Sputum 6. Sputum Exam for TB 7.Weighing 7. Weighing the children 8.Taking 8. Taking adequate fluids 9.Complete 9. Complete immunization 10.Speech 10. Speech therapy after laryngectomy
Activities to Promote Health and Prevent Illness 1. Have regular (yearly) PE -Papsmear and BSE 2. Men: regular testicular examination 3. Annual dental examination examination 4. Exercise regularly at least 3x per week for 30 mins. 5. Do not smoke. 6. Avoid alcohol 7. Reduce fat and increase fiber in the diet. 8. Sleep regularly 7 to 8 hours/ night 9. Eat breakfast 10. Maintain an ideal body weight
Health and Illness ASEPSIS and INFECTION CONTROL
InfectionAsepsisMedical
AsepsisSurgical AsepsisSepsisCarrierReservoir Resident floraSterilizationDisinfectantAntisepticBactericidal-
invasion by MOs free from infection clean technique sterile technique presence of infection asymptomatic but with infection habitat normally live on skin all MOs are destroyed remove pathogens on inanimate objects remove pathogens on persons but doesn’t necessarily destroy destroys bacteria
Cont… Communicable
Dse.-infectious agent that can be transmitted (direct, indirect, vehicle, airborne) Pathogena disease-producing microorganisms Pathogenicity-ability to cause a disease Virulencethe vigor of MOs in which they can grow and multiply Nosocomial infectionhospital-acquired infection Isolationseparation of persons with communicable disease Etiologythe study of the causes
Stages of Infectious Process 1.Incubation period time 2.Prodromal period non-specific to specific 3.Illness period s/sx 4.Convalescent period recovery
Chain of infection Agent
Reservoir Portal of exit
HOST Portal of entry transmission
Mode of
Mode of Transmission 1. Contact a. direct
body to body (bathing, feeding etc.)
b. indirect exposure (contaminated objects) 2. Droplet (<3ft.)
secretions
3. Airborne (>3ft)
fine particles suspended in air
4. Vectorborne biologic and mechanical 5. Vehicle
mediator (food, water, milk, blood etc)
Types of Immunization ACTIVE
Natural
PASSIVE
Natural Artificial
Artificial
What type of immunity? 1.Recovery from mumps 2.Colostrum 3.Tetanus Immuniglobulin 4.Tetanus Toxoid 5.OPV 6.Recovery from Chickenpox
2 Types of Disinfection: a. Concurrent b. Terminal
Handwashing- is the single most important infection control practice. Soap,
water and alcohol are being used. Wash hands before and after every client care contact. It would be effective with adequate friction. Medical asepsis is done b holding hands lower than the elbows. Apply friction for 15 to 30 seconds on each hand. Clean under fingernails. Ideally, turn off the faucet with clean paper towel.
Health and Illness Stress, Adaptation, Homeostasis “Stress is always a part of the fabric of daily life”. -hans selye
Adaptation - the adjustments that a person make in different situations.
Types: 1.General Adaptation Syndrome (GAS)
a. Stage of Alarm b. Stage of Resistance c. Stage of Exhaustion 1.Local Adaptation Syndrome (LAS)
-man may respond to stress through a particular body part or organ. -examples: inflammation, backache, headache, diarrhea
-“homeodynamic”, Homeostasis because of constant change -a state of stability or equilibrium Sympatho-Adreno-Medullary Responses Stressors: Physical injury, (SAMR) dehydration etc. Hypothalamus
Adrenal Medullla (Norepinephrine and epinephrine)
Inflammatory Response • • • • •
Rubor Calor Tumor Dolor Loss of Function
Exudates ◦ ◦ ◦ ◦ ◦
Serous Serosanguinous Sanguinous Purulent Mucoid
Healing may be classified as: a. Primary/ First Intention - clean cut wound b. Second Intention - wound is extensive and there is a great amount of tissue loss. c. Tertiary/Third Intention - delayed surgical closure of infected wound Other responses to tissue injury: 1.Necrosis death of tissues 2.Hypertrophy increase in cell size 3.Hyperplasia increase in cell number 4.Metaplasia replacement of one mature cell type with another mature cell type
Nursing Interventions for Clients with Inflammation 1. Promote rest 2. Reduce swelling Position: Elevate part Cold and warm compress 3. Relieve pain 4. Increase hydration 5. Adequate nutrition: high calorie, CHON, Vit. C 6. Pharmacotherapy Analgesic/ antipyretic: Acetaminophen, Paracetamol, Aspirin, Mefenamic acid NSAIDS, Steroids Antimicrobials
Therapeutic Relationship
-directed towards helping a patient heal, physically
and emotionally.
-a professional relationship between a nurse,
physician or therapist and a client.
-Focused on helping the client solve problems and
achieve health-related goals.
-a means for smoothly implementing the five
processes of the nursing process.
-TRUST is the foundation of a positive nurse-client
relationship.
Phases of Therapeutic Nurse-Patient Relationship
I. Pre-interaction -review medical records -client’s history -speak with other HCP
II. Orientation -perform assessment -formulate patient outcomes -plan interventions -ESTABLISH RAPPORT AND TRUST
III. Working Phase -establish a contract -set limits -discuss the time frame of your relationship
IV. Termination -evaluate the pt.’s progress -review areas that need improvement -discuss any feelings (positive or negative) during termination
Stress- is an essential aspect of existence and has always been of human experience; it is something that every one has to cope.
Stress Management 1. Supporting protective mechanism -rest, massage, relief of pain 2. Exploration of feelings 3. Facilitating problem solving 4. Regular pattern of exercise 5. Relaxation techniques
Advanced Stress Management and Relaxation Techniques Autogenic training Visualization and Imagery Affirmation Meditation Therapeutic touch Massage Yoga Music therapy Anti-anxiety medications
Communication Techniques 1.Use silence. 2.Accepting. 3.Giving recognition. 4.Offering self. 5.Giving broad opening. 6.Offering general leads. 7.Making observations 8.Encouraging comparison 9.Restating 10.Focusing 11.Reflecting 12.Exploring 13.Giving information 14.Seeking clarification 15.Presenting reality 16.Asking direct questions
What type of coping mechanism was used? 1.The adolescent decides to take up nursing because she greatly admires her mother who is a nurse. 2.The girl who is not as beautiful as her sisters, studies very hard and she achieves high grades. 3.The teacher who really wants to be the principal of the school states that she wouldn’t take the position if it were offered because it is a lot of work and no commensurate compensation. 4.The father shouts at his children as he arrives home because he was reprimanded by his boss at work. 5.The six year old child thumbsucks as he is confined in the hospital. 6.The nursing student vomits after a very difficult situation. 7.The client with cancer consults other physicians because he refuses to accept his diagnosis. 8.The student who hates her teacher, frequently tells the teacher that she admires her teaching.
Documenting and Reporting Documenting- serves a permanent record. Reporting- when two or more people share information about the client care, either face to face or by telephone. Purposes: 1.Communication 2.Legal Documentation 3.Research 4.Statistics 5.Education 6.Audit and Quality Assurance 7.Planning Client Care 8.Reimbursement
Types of Records A.Source-Oriented Medical Record (Traditional) - Each department makes notes on the chart. Five Basic Components 1.Admission Sheet 2.Physician’s Order Sheet 3.Medical History 4.Nurses’ Notes 5.Special Records and Reports (referrals, x-ray, VS, I&O)
B. Problem-Oriented Medical Record (POMR) -integrates all data about the problem gathered by the HCP. -records are recorded and arranged according to the source of information. Four Basic Components 1.Databaseall initial information 2.Problem List 3.Plan of care 4.Progress notes
(SOAPIE, Flow Sheets, Discharge notes)
Kardex -makes information readily accessible to all members of the HCP. -series of flip cards -tool for change-of-shift-report (use a pencil only)
Data included in KARDEX: • • • • • • •
Personal data Basic needs Allergies Diagnostic tests Nursing procedures Medications and IV therapy, BT Treatments like oxygen supply, steam inhalation, suctioning, change of dressing, mechanical ventilation
Characteristics of a Good Recording 1. Brevity (concise and complete) 2. Use of ink/ permanence 3. Accuracy (chart objective facts) Incorrect: Ate with poor appetite. Correct: Ate 50% of the food served. Incorrect: Depressed Correct: Seen crying *Place quotation marks if it’s a client complain *Objective data (VS, I&O etc.) *Describe behaviors rather than feelings *Refusal of medications and treatments- documented 4. Appropriateness
Cont… 5. Completeness and chronology *Notes should appear on succeeding line. *Date and time are included. *Avoid time changes in the text of other nurses. *Avoid double charting. *Avoid squeezing an information into a space. The following information should be charted: 1. Physician’s visits 2. Medication- immediately 3. Treatment- immediately
Cont… 6. Use of Standard Terminology (include grammar) 7. Signed (Bernard M. Lapuz, SN/ Bernard M. Lapuz, RN) 8. In case of ERROR -draw a horizontal line, write “ERROR”, initials/ signature 9. Confidentiality 10. Legal Awareness 11. Legible 12. Do not use the word “patient” or “pt.”; the chart belongs to the patient. 13. A horizontal line drawn to fill up a partial line -to prevent others from adding information e.g. Bernard M. Lapuz, RN
Types of Reporting 1. Change-of-Shift Report -endorsement (KARDEX) 2. Telephone Reports a. when the call was made b. who made the report c. who was called d. to whom information was given e. what information was given f. what information was received 3. Telephone orders *ONLY RNs may receive telephone orders *The order must be verified; have a witness if possible *Should be countersigned by the physician within 24 hours 4. Transfer reports- when transferring a pt. to another unit.
Give the meaning of commonly used abbreviations…
a.c OD DOMAINS of LEARNING ADL OU a. Cognitive Ax. OS (Knowledge) BID QID BMR AD b. Affective BP AU (Emotions, Feelings and Interests) c.c. AS Cap prn c. Psychomotor Gtt s.s. (Skills) h.S s.c IM stat IV TID Mcgtt Od
THE NURSING PROCESS
Assessing Health a. Head-to-Toe Framework
General: General Health State, VS, weight, nutritional status Head, hair, scalp, eyes, ears, oral cavity, cranial nerves Neck Chest Abdomen Extremities Genitals Rectum
Body Systems Framework Respiratory Cardiovascular Musculoskeletal Gastrointestinal Integumentary Endocrine Genitourinary Reproductive Neurologicc Sensory Psychosocial
1. Body Temperature -balance between heat produced and heat loss in the body. Types: a.Core- deep tissues (oral and rectal) b.Surface- skin and subQ (axilla) Heat regulating center- HYPOTHALAMUS
Factors affecting body’s heat: a. Basal Metabolic rate *younger-higher the BMR *olderlower the BMR b. Muscle Activity- exercises increases BMR c. Thyroxine output- increases BMR d. Catecholamines- increases BMR e. Fever
Factors affecting temperature: 1. Age 2. Diurnal variationhighest from 8-12MN lowest from 4-6AM 3. Exercise 4. Hormones 5. Stress- Sympathetic stimulation
PROCESSES in HEAT LOSS Radiation Conduction
Convection Evaporation
1.Application of moist wash-cloth over the skin 2.Exposure of skin towards electric fan 3.Continuous vaporization of moisture from the skin, oral mucous, respiratory tract 4.It feels warm in a crowded area.
Alterations in Body Temperature 1.Pyrexia/ Hyperthermia- above normal 2.Hyperpyrexia- very high, >41C 3.Hypothermia- low temp.
Types of Fever 1.Intermittent Fever2.Remittent Fever3.Relapsing Fever4.Constant Fever-
fluctuates to normal and abnormal within 24 hours fluctuates within 24 hours of abnormal temperature fluctuates to normal and abnormal few days in between remains very high
ORAL
Most accessible and convenient to use
c/I: Oral Lesions, dyspnea, cough, seizure, chills, unconscious
2-3 minutes
AXILLA
Safest and most noninvasive method
C/I: none
10 minutes
Fastest
TYMPANIC
C/I: Mastoiditis and ear infection
2-3 seconds
Most accurate Assume lateral position
RECTAL 2 minutes
C/I: Hemmohoidectomy, diarrhea, anal fissures, quadriplegic clients
Pulse 1. Rate: Newborn 120-180bpm Adult 60-100bpm *Tachycardia- above 100bpm *Bradycardia- below 60bpm 2. Rhythm- the pattern and intervals of beats. *Dysrhythmia- irregular rhythm 3. Volume- the strength of the pulse. *Normal pulse can be felt with moderate pressure *Full/ bounding- great pressure *Thready pulse- weak 4. Presence/ ansence of bilateral equality * radial, ulnar, femoral etc.
Pulse Sites 1.Temporal 2.Carotid 3.Apical 4.Brachial 5.Radial 6.Femoral 7.Posterior tibial 8.Popliteal 9.Pedal (Dorsalis Pedis)
Respiration -the act of breathing. Three processes: 1.Ventilation – movement of gases in and out of lungs 2.Diffusion – exchange of gases 3.Pefusion – movement of blood for transport Two types: a.Costal (thoracic)- movement of chest b.Diaphragmatic (abdominal)- movement of abdomen Respiratory centers a.Medulla Oblongata- primary respiratory center b.Pons *Pneumotaxic- rhythmic quality of breathing *Apneustic- deep prolonged breathing
Assessing Respiration Rate: 12-20 RR/min Depth- observe for movement of chest Rhythm- observe for regularity of exhalation and inhalation Quality- respiratory effort and sound of breathing
Terminologies: Eupnea- normal respiration Tachypnea- >20RR/ min Bradypnea- <12RR/ min Hyperventilation- Deep, rapid respiration (alkalosis) Hypoventilation- slow, shallow respiration (acidosis) Dyspnea- DOB Orthopnea- ability to breath only in upright position Apnea- absence of respirations
Blood Pressure - The pressure exerted by blood against the walls of the arteries
*Systolic Pressure- pressure of blood as a result of contraction of the ventricles *Diastolic Pressure- pressure when ventricles are at rest. *Pulse Pressure- difference between the systolic and diastolic pressures (30-40mmHg) *Hypertension- >140/90mmHg *Hypotension- <90/60mmHg
Determinants of BP 1.Blood Volume 2.Peripheral Resistance (dialte and constrict) 3.Elasticity or compliance of blood vessels 4.Blood Viscosity
Assessing BP 1.Allow to rest. 2.Sitting or supine 3.Left arm is preferred over the right. 4.Snugly fit 5.Inflate 6.Deflate- “Korotkoff sound’ 7.If Mercurial, read lower meniscus 8.Prevent “Error of Parallax”
Nursing Health History -gathered through interview Components of Nursing Health History 1.Biographic Data 2.Chief Complaint 3.History of Present Illness 4.Past Health History 5.Family History of Illness 6.Review of Systems 7.Lifestyle 8.Social data 9.Psychologic data 10.Patterns of health care
Physical Health Examination -head to toes -determine the mental status and LOC -protect the client’s privacy during the examination -prepares the needed articles and equipment Modes of Examination 1.Inspection 2.Palpation 3.Percussion 4.Auscultation
-sight -touch -tapping -stethoscope (hear)
Positions 1.Dorsal recumbent 2.Dorsal/ supine 3.Sitting 4.Fowler’s- semi (45 degrees) and high (90 degrees) 5.Lithotomy 6.Lateral 7.Sim’s/ Semi-prone position 8.Prone
Pointers: 1. Sequence of assessment in abdomen? IAPERPAL 2. Sequence of quadrants? RLQ, RUQ, LUQ, LLQ 3. Best position when examining the chest? Sitting 4. Position when examining the back? Standing 5. How do we check for neck lymphadenopathy? Stand behind the client and palpate the neck 6. If you’ll use vaginal instrument, pour warm water first to ensure comfort.
Supplemental Data a.Urine b.Stool c.Sputum d.Blood e.Body secretions
Urine specimen 1.Clean-catch, mid-stream specimen for routine urinalysis, C&S - Best time to collect is AM (concentrated) - Discard the first flow urine. - Sterile container. Wash first before getting the specimen. - 30-50ml - Send to the laboratory immediately
2. 24-hour urine specimen -Discard first voided urine - Collect all specimen thereafter, until the same day the ffg. day. - Soak the specimen in a container with ice.
3. Catheterized urine specimen -clamp the catheter for 30 mins. to 1hour. -cleanse the drainage port of the two-way FC -Use sterile needle and syringe to aspirate from the drainage port. -don’t collect urine from the urinary drainage bag.
Stool a.Routine fecalysis –determine ova/ parasites b.Stool Culture- etiologic agents c.Guaiac Stool Exam/ Occult Blood- bleeding Test of Glucose in the urine *Benedict’s Test -collect specimen before meals -Heat 5ml of Benedict’s solution in a test tube -Add 8-10 drops of urine Interpretation: Blue (-) Green + Yellow - ++ Orange - +++ Red ++++
Test for Albumin in the urine *Heat and Acetic Acid Test -collect urine specimen before meals -imaginary divide the test tube into three parts -fill the 2/3 part with urine, heat the test tube -add 1/3 acetic acid or just few drops, don’t boil -CLOUDINESS indicates albuminuria Sputum Specimen: 1. Sputum Culture and Sensitivity Test 2. Acid-fast bacilli (AFB) staining (3 consecutive mornings)
