FUNDAMENTALS OF NURSING Vital Reparative Process By Florence Nightingale Man is passive in influencing the nurse or the environment
Man
Forms the Nursing
foundation
of
Four Components or Attributes of Man
Man is a whole. Man is complete
Capacity to think on an Abstract Level Establish a family Establish a territory Ability to use verbal symbols as language
By Virginia Henderson Man has fourteen fundamental needs
(14)
Human Needs Needs are physiologic and psychologic Both these needs must be met in order to maintain wellbeing.
Concept: Animals form a family by instinct Via hormonal scents
Key Concept: Basic Human Needs are equivalent to COMMON NEEDS
Nursing Concepts of Man Biopsychosocial Spiritual Being By Sister Calista Roy Man interacts with the environment
Characteristics of Human Needs Universal Interrelated One need is related to another need May be stimulated by internal or external factors May be deferred (but not indefinitely)
Open System By Martha Rogers Man interacts with the environment Exchanges matter with energy Exchanges energy with environment
Maslow’s Hierarchy of Needs
Unified Whole By Martha Rogers Man is composed of certain parts Total of those parts is more than the sum of all parts This is because man has attributes
Why do we study this? In order to prioritize nursing actions 1. Physiologic needs Food, maintenance homeostasis 2. Safety and security 3. Love and belongingness 4. Self-Esteem
1
of
Feeling good about one’s self Two factors affecting Selfesteem o Yourself Sense of adequacy Accomplishment o Others Appreciation Recognition Admiration Belongingness 5. Self-Actualization Able to fulfill needs and ambitions Maximizing one’s full potential 6. Aesthetics Beauty
Concept: Self-Actualization is very difficult to attain It is impossible to attain New needs come after getting one need Illness Highly subjective feeling of being sick or ill
Two Additional Needs by Maslow Need to know Need to understand
Two types of Illness: Acute Illness Sudden in onset (most of the time, but not always) Less than six (6) months
Richard Kalish Man needs stimulation Needs to explore o Sex o Activity o Novelty Stimulator Desire to come up something your own
Open to new ideas o Not adopts new ideas o Not one track mind Highly creative and flexible Does not need fame Problem-centered rather than self-centered
Chronic Illness Gradual in onset (most of the time, but not always) Types of Chronic Illness o Exacerbation Period characterized by
with of o
Characteristics of Self-Actualized Persons Judges people correctly Superior perception Decisive o Capable of making decisions Clear notion as to what is right and wrong
active signs and symptoms of the illness Remission Periods where no signs and symptoms are present
Disease Objective pathologic process Concepts:
2
Illness without disease is possible Disease without illness is possible Illness may or may not be related to a disease One can have a disease
Walter Cannon Ability to maintain homeostasis A dynamic equilibrium A state of balance of the internal environment while
without necessarily feeling ill
external changing
Deviance Any behavior that goes against social norms Shortens life span Results to disrupted family and community Concept: Deviant behavior can considered a disease
environment
is
Florence Nightingale Health is using one’s power to the fullest Being well Can be maintained by manipulating the environment Virginia Henderson Viewed in terms of ability to perform the fourteen (14) fundamental needs or components of nursing care UNAIDED
be
Rationale: Because it also shortens the life span like a disease
Martha Rogers Positive health symbolizes wellness Health is a value term defined by a certain culture
Example: Alcoholism o A disease rather than a social problem Wellness Feeling of being well
Sister Calista Roy A state and process of being
Definitions of Health
and becoming INTEGRATED PERSON
an
World Health Organization Health is the complete physical, mental, social (totality) well-being and not merely the absence of disease or infirmity A high-level wellness!
Dorothea Orem Characterized by soundness and wholeness of DEVELOPED HUMAN STRUCTURES and FUNCTIONS
Claude Barnard Ability to maintain internal milieu
Imogene King A dynamic state in the life cycle (contrasted with illness)
3
Illness is interference in the life cycle
Perceived seriousness Perceived threat Likelihood of Action influenced by: o Perceived benefit out of the action o Perceived barriers o o
Betty Neuman Wellness is that all parts and subparts are in harmony with each other and the whole system Dorothy Johnson Elusive dynamic state influenced by biologic, psychologic and social factors
Smith’s Four Levels of Health 1. Clinical Model Man is viewed as a Physiologic Being If there are no signs and symptoms of a disease, then you are healthy Against WHO definition of health This is the NARROWEST concept of health 2. Role Performance Model As long as you are able to perform SOCIETAL functions and ROLES you are healthy 3. Adaptive Model Health is viewed in terms of capacity to ADAPT. Therefore, goal of treatment is to restore capacity to adapt. Failure to adapt is disease 4. Eudaemonistic Model
Models of Health and Illness Health-Illness Continuum Dunn’s High Level Wellness and Grid Model X-axis is HEALTH Y-axis is environment Quadrant 1 High-level wellness in favorable environment Quadrant 2 Protected poor health in favorable environment Quadrant 3 Poor health in unfavorable environment Quadrant 4 Emergent high-level wellness
in unfavorable environment Health Belief Model By Rosentock Based on a motivational theory It assumed that good health is an objective common to all people Consider perceptions (influences individuals motivation toward results) o Perceived susceptibility
This is the BROADEST concept of health Because health is viewed in terms of Actualization
Leavell and Clark’s Agent, Host, Environment Model Also known as the Ecologic Model Expands to the MULTICAUSATION of a DISEASE Definitions of a disease as to its cause is expanded to a
4
multi-causation of a disease (i.e. cancer is a multi-factorial disease) Triad is composed of the agent, host and susceptible host Based on the interplay of three components model
of
Effects of Adrenalins Increases Cardiac Rate Response to increased metabolic rate and oxygen demand Increases Respiratory Rate
the
Concept of Health and Illness
Stress By Hans Selye Is a non-specific response of the body to any demand placed upon it. General Adaptation Syndrome (GAS) Local Adaptation Syndrome (LAS)
Adrenal Gland is composed of: 1. Adrenal Medulla Releases adrenalins 2. Adrenal Cortex Releases the following: Mineralocorticoids o Aldosterone Glucocorticoids Cortisol o A potent vasoconstrictor
General Adaptation Syndrome Involves two (2) body systems: Nervous System Endocrine System Nervous System involves: Sympathetic Nervous System Parasympathetic Nervous system Endocrine System involves: Adrenal Glands
Mineralocorticoids Increased Aldosterone levels Increases sodium retention and water retention Increases circulating blood volume Increases cardiac workload (due to vasoconstriction)
The Adrenal Gland is composed of: Adrenal Medulla Adrenal Cortex Adrenal Medulla Adrenalins or Fight Hormones: Epinephrine Norepinephrine
Response to increased metabolic rate and oxygen demand Bronchodilation Vasoconstriction Increased Peripheral Resistance Increased Cardiac Workload Increased Blood Pressure Decreased Renal Perfusion Decreased Renal Output Pale, Cool, Clammy Skin
releases or Flight
Glucocorticoids Increased (transient)
5
hyperglycemia
Increased glycogenolysis Increased neogenesis Increases blood sugar Increases osmotic pressure Increases fluid retention (glucose is a colloid which attracts water and adheres to it) Increases cardiac workload
Stress resulted from interaction of man with his environment and fellowman Therefore, Lazarus describes the SOCIAL ASPECT OF STRESS Also an adopted PHYSIOLOGIC RESPONSE
Key Concept! The most comprehensive concept of stress is the stress concept of LAZARUS as it combines Physiologic and Social aspects of stress.
Concept: Complications of Stress: Cerebrovascular Attack Increased Diabetic Ketoacidosis (if patient is diabetic) Hypertension leading to cardiac arrest
Statements about Stress Stress is NOT a nervous energy Man, whenever he encounters stress, tends to adopt Are you going around all stress? ANSWER IS NO!!! because stress is not always to be avoided and stress is not always undesirable Stress may lead to another stress A single stress does not lead to a disease
Local Adaptation Syndrome Also known as non-specific inflammatory response Bradykinin o Activates inflammatory response o Activates histamine Histamine o Activates the following: Prostaglandin Serotonin
Concepts:
Concept: Bradykinin, Histamine, Prostaglandin, and Serotonin all increase swelling
Key Concept! Hans Selye o Author of Physiologic Response to Stress
Lazarus Stress is a transaction
6
Adaptation stress comprises of toadjustments made in order to cope with a stressor Man is holistic in his adaptation to stress It involves the totality of man: o Physiologic o Psychologic o Social
Illness Behavior and Stages of Illness
Factors Affecting Compliance Client motivation Degree of required change in lifestyle Perceived severity of health problem Difficulty of understanding
Illness Behavior Pertains to any activity undertaken by a person who feels ill in order to
Define his state of health Discover a suitable remedy
IGUN – Eleven stages of Illness and Health-seeking Behaviors 1. Symptom Experience Client realizes there is a problem Client responds emotionally 2. Self-medication / Self-treatment (if not effective) 3. Communication to others 4. Assessment of symptoms Purpose is to verify the veracity of the complaint 5. Sick-Role Assumption 6. Concern Stage 7. Efficacy of treatment Assess sources of treatment Assess potential effectiveness of treatment 8. Selection of Treatment Stage Availability Cost of Treatment 9. Treatment Proper
instructions Belief about the effectiveness of the therapy Nature of the therapy itself o Adverse effects o Cost Cultural influences Degree of satisfaction with the relationship with health care providers
Suggested Nursing Actions in case Non-compliance of Assess the reasons
10. Assessment of Effectiveness of Treatment May go back to stage 7 (Efficacy of Treatment) if treatment is not effective May go to next stage if treatment is effective 11. Recovery and Rehabilitation Compliance Adherence to professional’s advice
Correct the misconception Demonstrate a caring attitude Encourage and provide positive reinforcement o Focusing on the positive rather than on the negative o Focus on things patient can still do and not on what the patient can no longer do Establish a therapeutic relationship of freedom and mutual responsibility o Make patient realize he is also responsible for his recovery o He is a partner with the health care team o He is an active participant
Guidelines Compliance
7
to
Enhance
Be sure patient understand procedure by giving information Make sure patient is capable of performing activity o Set realistic goals Ensure that he is a WILLING
Martha Rogers Nursing is a HUMANISTIC SCIENCE dedicated to compassionate concern for the promotion of health, prevention of illness and
participant o Look for buying signals Looking at wound Looking at materials needed
rehabilitation of the sick Sister Calista Roy Nursing is a THEORETICAL SYSTEM OF KNOWLEDGE that prescribes analysis and action related to the care of the sick or ill It is a set of knowledge
Definitions of Nursing: American Nurses Association Nursing is the diagnosis and treatment of human responses to illness (to actual and potential health problems)
Dorothea Orem Nursing is a helping service to any individual who is sick
Canadian Nurses Association The same definition plus… … includes the supervision of functions and services in collaboration with others to promote health
It comprises of wholly dependent or partly dependent care when the person is unable to do so. Defines nursing in terms of a NEED!
Imogene King Nursing is a helping profession that assists a person (same with Henderson) towards a DIGNIFIED DEATH
Florence Nightingale Nursing is the act of utilizing the ENVIRONMENT for the following purposes: o Recovery o Reparative process
Betty Neuman Nursing is a profession that is concerned with INTRAPERSONAL, INTERPERSONAL, and EXTRAPERSONAL VARIABLES affecting a person’s response to stressors
Virginia Henderson The unique function of the nurse is to assist individuals, sick or well, with the activities towards health that he would do unaided, if with strength and knowledge. If that is not possible, towards a PEACEFUL DEATH
8
Dorothy Johnson Nursing is an EXTERNAL REGULATORY FORCE that regulates the ACTION or BEHAVIOR of a person when such behavior constitutes a threat, in order to preserve his
2. Dorothy Johnson Behavioral Systems Model Seven Subsystems o Attachment and Affiliative o Dependency o Ingestive
organization
o o
Example: o In a COPD patient who remains a smoker, the nurse who encourages the patient not to smoke, serves as an external regulatory force
Faye Abdella Nursing
is
a
service
o
3. Virginia Henderson Fourteen (14) Fundamental Needs focusing on PHYSIOLOGIC SOCIAL RECREATION 4. Faye Abdella Problem Solving Approach to
to
individuals, families… and therefore, to society Conceptualized nursing as an ART and SCIENCE of MOLDING THE INTELLECT, ATTITUDE and SKILLS of the nurse Nursing in terms of providing education
Twenty-One (21) Nursing Problems Focus is on PROPER IDENTIFICATION of the problem Particularly about the proper nursing diagnosis
5. Marjorie Gordon Proposed the Human Functional Health Patterns used as a systematic framework for data collection
Hildegard Peplau Nursing is the INTERPERSONAL process of THERAPEUTIC INTERACTION between the nurse and the patient.
NURSING THEORIES Concept: First Nursing School Florence Nightingale
Eliminative Sexual Achievement Aggressive
–
1. Florence Nightingale Environmental Nursing Theory
9
Focus is on Eleven (11) Health Patterns Advantage to the nurse: o It enables the nurse to determine the client’s response as functional or dysfunctional Eleven Functional Health Patterns o Health perception o Nutritional / Metabolic o Elimination
o
o
o
o
o
o
Activity and Exercise Pattern Cognitive Perceptual Pattern Role Relationship Pattern Sexuality /
Reproductive Coping-StressTolerance Value Belief Patterns
of relationships
10. Dorothea Orem Self-care and Self-care Deficit Theory Three (3) Nursing Systems based on Art of Care of Patient Needs 1. Partial Compensatory o Patient performs some of nursing care needs 2. Wholly Compensatory or Total Compensatory o For paralyzed patients, for ICU patients 3. Supportive-Educative o For up and about patient
Interpersonal systems fraternity Social systems
7. Madeleine Lehninger Transcultural Nursing Theory / Model Nursing is a HUMANISTIC and SCIENTIFIC mode of helping through CULTURESPECIFIC PROCESS 8. Myra Levine
patient’s
9. Betty Neuman Health Care Systems Model The concern of nursing is to PREVENT STRESS INVASION
6. Imogene King Goal Attainment Theory Patient has three (3) interacting systems: o Individuals / Personal systems o Group systems /
o
3. Conservation of Personal Integrity o Example: maintain patient’s privacy 4. Conservation of Social Integrity o Example: maintenance
Four (4) Conservation Principles of Nursing 1. Conservation of Energy o Example: complete bed rest without bathroom privileges 2. Conservation of Structural Integrity o Example: turn patient from side to side every two hours to avoid bed sores
11. Hildegard Peplau Interpersonal Model Four (4) Phases of NursePatient Interaction 1. Orientation o Nurse and patient test the role each one assumes o Prepares patient for termination o Patient identifies areas of difficulty
10
2. Identification Phase o Patient identifies with the personnel who can satisfy his needs 3. Exploitation Phase o Nurse maximizes all the resources to benefit
the patient 4. Resolution Phase or Termination Phase o Occurs when patient’s needs have been met
Man is a BIOPSYCHOSOCIAL BEING Four (4) modes of Adaptation o Physiologic Mode Compatible with Hans Selye o Self Consent o o
Role Function Interdependence
14. Lydia Hall CARE, CORE, CURE Care o Comfort measures given by the nurse to a patient o Nurturance aspect of Nursing Core
Concepts: Various settings for application of: o Pre-Interaction Phase In psychiatric setting, this consists of gathering data o Pre-Entry Phase In community health nursing, this consists of a courtesy call 12. Martha Rogers Science of Unitary Human Beings Man is composed of energy fields, which are in constant interaction with the
o
Cure o
o
Therapeutic use of self Activities in relation to doctors’ orders Dependent orders
15. Jean Watson Human Caring Model Nursing involves the application of ART and HUMAN SCIENCE through TRANSPERSONAL TRANSACTIONS in order to help the person achieve mind, body and soul harmony
environment Concept: The most reliable method of identification is the Energy Field. This is better than the fingerprints as a person’s energy field is absolutely unique!
16. Rosemarie Rizzo Parse Theory of Human Becoming Emphasis is a FREE CHOICE (with personal meaning) Actions of patients may either be: o Revealing or concealing o Enabling or limiting
13. Sister Calista Roy Adaptation Model
11
17. Josephine Loretta Zderad
20. Margaret Newman Health as Expanding Consciousness Humans are Unitary Human Beings The nurse is a NOT A GOALSETTER or an OUTCOME
Therefore, there is a consequence o This pertains to behavior and action Patterson
and
Humanistic Nursing Practice Theory Nursing is an EXISTENTIAL EXPERIENCE between the nurse and the patient (nagkataon-nagkatagpo!) Nursing is a LIVE DIALOGUE between the patient who wants to be nursed and the nurse who has the skill to nurse
PREDICTOR, rather is a PARTNER OF THE PATIENT 21. Joyce Travelbee Interpersonal Process Theory Nurse needs to go beyond nursing roles to establish therapeutic relationship TRANSPERSONAL COMMUNICATION as the means to establish therapeutic relationship This implies that the nurse should not be rigid in the nursing role
18. Helen Tomlin, Evelyn Tomlyn and Mary Ann Swain Modeling and Remodeling Theory Focus is on the PERSON Emphasis is on the UNCONDITIONAL ACCEPTANCE of the PATIENT
22. Ida Jean Orlando Dynamic Nurse-Patient Relationship Model There is movement, the relationship is not static If the patient’s condition improved, then the intervention is effective and the patient moves on to new
19. Ann Boykin and Savina Schoenhofer Grand Theory of Nursing as Caring Theory Nursing is NOT BASED on a DEFICIT but rather it is an EGALITARIAN MODE of helping This theory is against the theory of OREM Nursing is an obligation towards humanity, whether there is a need or NOT!
problems 23. Nola Pender Health Promotion Model Motivation to participate in health care activities is influenced by COGNITIVE and PERCEPTUAL FACTORS, which are: o Importance of health to the person o Perceived control of health
12
o o o o
Self-efficiency Perceived health status Definition of health Perceived barriers to action
Patient’s illness is controlled o Patient may still be in the hospital 6. Unstable Phase o Patient is on a critical period o
24. Poppy Buchanan, Barker and
o
Phil Barker Tidal Model (Psychiatric Nursing) Helping patients recall their own personal stories of DISTRESS is the FIRST STEP in helping them regain control of their lives again!
25. Corbin and Strauss Trajectory Model The patient moves in a TRAJECTION of Eight (8) Phases Nurse needs to follow the patient along the eight phases of trajection: 1. Pre-Trajectory Phase o Patient shows no signs and symptoms of illness o No sickness
Signs and symptoms are present o Patient is NOT in the hospital o Patient is NOT under control o Patient is OUT of the hospital 7. Downward Phase o Patient is in a deteriorating phase 8. Death
26. Bonnie Weaver and Duldt Battey Humanistic Nursing Communication Theory Emphasis is on the interpersonal relationship between the nurse, the patient, the peers and colleagues 27. McGill Model of Nursing Emphasis is to encourage and
2. Trajectory Onset Phase o Patient now has signs and symptoms of illness 3. Crisis Phase o Patient is unstable o Patient is in a lifethreatening situation o Patient is critical 4. Acute Phase o Patient is in a state of active illness 5. Stable Phase
engage the patient and the family to actively participate in learning about health 28. Kathryn Barnard Parent-Child Interaction Model (Pediatric Nursing) In order to produce a healthy person, the baby’s need should be ADDRESSED AT ONCE! Application: Bonding
13
29. Alfred Adler The personality of an individual is affected by the BIRTH ORDER
o
o
30. Gladys Husted and James Husted
o
LEVELS OF PREVENTION:
1. Primary Prevention Emphasis on: o Generalized health promotion and specific protection o Recipients are GENERALLY HEALTHY PEOPLE When given: o Before onset of illness or before onset of disease Examples: o Generalized health education
o
Early detection / diagnosis o Prompt treatment o Health maintenance of persons already having health problems o Prevention of complications When given: o During illness Examples: o Screening survey o
o
o
o
o
and
2. Secondary Prevention Emphasis placed on:
Symphonological Bioethical Theory Symphono- means harmony and agreement Governed by ethical standards, which influence nursing actions.
o
Environmental Sanitation Recreation Housing
Prevention of accidents Standards of nutrition Immunizations Specific preventions Risk Assessment for specific disease Family Planning Services and Marriage Counseling
Encouraging regular check-ups Complying with regular check-ups Teaching Breast-selfexamination Teaching Testicularself-examination
Concept: o Most effective method of teaching is DEMONSTRATION
Additional Examples of Secondary Prevention o Assessment of growth and development o General nursing assessment and care at the hospital, community and the home
3. Tertiary Prevention Emphasis placed on:
14
o
Support of the client to achieve the following: Successful readaptation Optimal reconstitution Regain high-
o
to
the patient new coping
Concept: Do not give advice! o This is meant
level wellness Therefore, the purpose is more of REHABILITATION When given: o Begins after the illness or when a defect or disability is fixed or irreversible Examples: o Referring a client to support groups o Teaching a diabetic client insulin how
Helping develop skills
o
to
facilitate decisionmaking on the part of the client This is observed so that the client would not develop DEPENDENCY
3. Client Advocate Protects rights of patients Activity: o Speaking on behalf of the patient
inject 4. Change Agent Brings change or adjustments Nurse only influences a patient Nurse does not change the patient
ROLES OF A NURSE 1. Caregiver / Care Provider To convey understanding and support Activities: o Support and comfort measures (mothering aspect of nursing / nurturance aspect of
5. Teacher Teaching Imparting of knowledge
nursing)
6. Leader Application of interpersonal influence to bring out desired behavior (leadership)
2. Counselor Involves helping patient identify and avoid stressful and psychological problems Focuses on: o Helping client establish capacity for successful interpersonal relations
7. Manager Decision-making Planning Giving directions Monitoring operations Facilitating staff development
15
Therefore, this is done on the supervisory level of organization
4. Demonstration
He can only be a researcher after he receives his Master of Arts in Nursing (M.A.N) degree
TEACHING AND STRATEGIES
and
3. Answering Questions Cognitive
8. Researcher After graduation, nurse cannot yet be a researcher
Addresses affective cognitive learning
Motor
5. Discovery Cognitive and Affective
LEARNING
Concept: Learning is more effective if the learner discovers the content for himself. (That is, through experience!)
Basic Guidelines Develop a well-defined objective Assess client’s readiness to learn Start with what the client is concerned about Assess and start with what the client already knows; proceed from the known to the unknown Start with the simple proceeding to the complex Schedule a review of the content
6. Group Discussion Affective and Cognitive Sharing feelings during group dynamics 7. Practice Motor 8.Printed and Audiovisual Material 9. Role-playing For pediatric and psychiatric nursing settings
Concept:
Areas of Learning – Domain o Knowledge cognitive o Skills – motor o Attitude – emotional
10. Modeling What you say is what you do 11. Computer Assisted Learning Programs Online review
TEACHING STRATEGIES
THE NURSING PROCESS
1. Explanation and Description Address cognitive aspect of learning
Concept: The Nursing Process was introduced by LYDIA HALL!
2. One-to-one Discussion
Definition: 16
BENEFITS DERIVED FROM THE NURSING PROCESS
The Nursing Process is a systematic, organized, rational method of planning and providing individualized, humanistic nursing care
Concepts: Both the nurse and the patient benefit from the nursing process
Purposes of the Nursing Process:
To identify health status o Actual health problems o Potential health problems To establish plans To deliver specific nursing care
Patient obtains greater benefit Remember: Nursing process is CLIENTCENTERED or PATIENTCENTERED and NOT NURSE-CENTERED
Benefits from Nursing Process: Improves quality of care Ensures continuity and appropriate level of care Facilitates client participation through planning with patient Enables nurse to maximize resources Feedback allows nurse to evaluate care Serves as a framework for accountability through documentation Promotes a positive working atmosphere through collaboration Helps the nurse define roles to those outside the
Characteristics of Nursing Process (MEMORIZE THIS!!!) 1. Goal-oriented and clientcentered 2. Cyclical (no absolute beginning and end), dynamic (moving) rather than static 3. Plan of care organized according to client problems rather than nursing goals 4. Basis of prioritizing nursing activities would be the problems and not the goals 5. Follows a logical sequence 6. Universally applicable (to any type of patient) 7. Interpersonal and collaborative Work with patients and relatives Work with colleagues and other members of the health team 8. Adaptation of problem-solving techniques and principles 9. Problem-oriented, flexible, open to new information 10.Allows creativity of nurse and patient
profession For job satisfaction Facilitates professional growth Avoidance of legal action Meeting standards of accredited hospitals
PARTS OR COMPONENTS THE NURSING PROCESS
17
OF
ASSESSMENT PHASE OF THE NURSING PROCESS Nursing Activities Assessment Phase Data collection
in
the
o
Data Organization Data Validation Data Recording
IMPORTANT CONCEPT! No conclusion is developed in the assessment phase
To determine the status of a health problem (i.e. hydration status every fifteen minutes)
3. Emergency Assessment When done: o During acute physiologic and psychologic crisis Where done: o Emergency Room o Comfort Room o Anywhere!!! o On site!!! Purpose of Emergency Assessment o To identify lifethreatening condition Framework or Principle in Emergency Assessment o A – Airway o B – Breathing o C – Circulation o Utilize either Maslow’s Hierarchy of Needs or ABC principle
Purposes of the Assessment Phase To create a data base of the client’s response to health and illness To determine the nursing care needs of the patient Four (4) types of Assessment: 1. Initial Assessment When performed: o At specified time after admission Where done: o Done at the ward Where Admitted:
When performed: o Integrated throughout the nursing process Purpose of On-going Assessment: o To identify problems overlooked earlier
o At the ward Purpose of Initial Assessment: o To create a data base for problem identification o For reference and future comparison
4. Time-Lapsed Assessment When done: o Several months after initial assessment Purpose of Time-Lapsed Assessment o To compare current status of patient with base line data (initial
2. Focus Assessment or On-going Assessment
assessment) 18
ASSESSMENT PROCESS Concepts: Data is information
equivalent
3. Environment of the Patient Example: o Patient with diabetes mellitus exhibits
to
What is the initial output of the Assessment Phase? Data or Recorded Data Never validated data!!!
acetone breath Assess for diabetic ketoacidosis
Types of Data:
Methods of Data Collection Observing Interviewing Examining
1. Subjective or Covert Data Felt by the patient During the recording of data, this should be stated using the patient’s own words These are the symptoms felt by the patient
1. Observing It should be deliberate Exert effort Two (2) aspects of observation process: Noticing the stimuli Do an interpretation of the stimuli
2. Objective or Overt Data Capable of being observed by use of senses – sight, touch, smell, taste, hearing These are the signs which are observable
2. Interviewing Two (2) types of Interview:
Sources of Data:
Directive Type of Interview Structured
1. Primary Source
The person who brought the patient to the hospital
Patient himself except when: o He is unconscious o Patient is a baby o Patient is insane
2. Secondary Source Patient’s record Health care members Related literature or journals Significant others (they become primary source when patient is unconscious Family or relatives
Uses closed-ended questions calling for specific data When used: o When you need to elicit specific data o When there is little time available
Concept: Characteristics of Closed-ended questions: Yes or No questions
19
Asks when or asks for the time when event happened Asks how many Point with finger when asking to provide clarity Therefore, they call for highly specific answers
Non-Directive Type or RapportBuilding Interview Uses more open-ended questions Advantage is that it allows the patient to volunteer information
When is it done? o When patient available o When patient comfortable
is is
Recommended distance from the patient is three (3) to four (4) feet.
2. Body of the Interview Occurs when patient responds to questioning
3. Neutral Questions
An interview is a two-way process
Stages of the Interview 1. Opening Stage Key Concept!!! This is the most important part of the interview Rationale What was said and done during the opening stage sets the tone all throughout the interview
2. Closed-Ended Questions Questions answerable by “yes” or “no” Leading Questions Phrasing of question suggests what answer the interviewer is expecting
Types of Interview Questions: 1. Open-Ended Questions Questions not answerable by “yes” or “no” Questions that elicit information or explanation
you already know or what information is available An interview is a planned conversation with a purpose
Phrasing allows patient to answer with least pressure Usually NOT addressed to patient personally (i.e. what is your opinion about…) Raised as a general topic
3. Closing Stage How to close the interview: o Summarizing Technique Validation of Data Act of double-checking the data Purposes of Data Validation o To ensure the: Correctness Completeness
Planning the Interview Setting Concepts: Before the interview, determine what information
20
Accuracy of the data
Guidelines in Validating Data Compare subjective and objective data Be familiar with word usage
2. High-Risk Nursing Diagnosis A diagnosis that a patient is more vulnerable or susceptible compared with
(particularly if the patient is a child) Reassess / double-check data which are extremely abnormal Be sure that your data contains CUES and not INFERENCES Be sure that your data is FREE OF BIASES Avoid jumping to conclusions
others in the same situation 3. Possible Nursing Diagnosis There is an evidence of a health problem but the causes are NOT fully understood 4. Wellness Nursing Diagnosis A positive statement Indicates a healthy response Examples: o Potential for increased compliance related to increased level of knowledge o Potential for enhanced body image related to regular exercise o Potential for effective coping related to adequate support systems
Data Recording Concepts: Data Recording COMPLETES the Assessment Phase Initial Output of the Assessment Phase is DATA Final Output of the Assessment Phase is RECORDED DATA DIAGNOSING PHASE NURSING PROCESS
OF
Problem present at the time the statement was made
THE
Domains of Nursing Diagnosis Key Concept!
Activities during the Diagnosing
Phase: This involves sorting, clustering, analyzing and interpreting data
It only that includes health problems a nurse is capable and licensed to treat
Parts of a Nursing Diagnosis 1. Problem Statement Example: o Fluid Volume Deficit 2. Presumed Etiology Example: o …related to frequent loss of bowel movement
Concept: The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!! Different Types of Nursing Diagnoses: 1. Actual Nursing Diagnosis
21
3. Defining Characteristics Example: o …as manifested by decreased skin turgor
o
2. On-going Planning Who are involved: o Done by all nurses who
Advantages of Using Standardized Diagnostic Terminology
Provides professional accountability and autonomy by defining and describing the independent areas of practice Provides effective vehicle of communication Provides an organizing principle for meaningful research Facilitates continuity and individualized care
PLANNING PHASE NURSING PROCESS
OF
At specified time upon or after admission of the patient
worked with the patient The patient himself o The family o But primarily, the NURSE Purposes of On-going Planning o To determine if the client’s health status has changed o To decide which problems to focus on during the shift o To set priorities for client care during the shift o To coordinate the patient care and activities so that more than one problem can be addressed at the same time o
THE
Concept: Planning means: Determining ahead of time Forecasting a course of action Key Concept!!! For your plans to be effective, involve the patient and the family
3. Discharge Planning Purpose of
IMPORTANT CONCEPT!!! Final output of the Planning Phase is a NURSING CARE PLAN or a WRITTEN CARE PLAN
Discharge
Planning o To ensure continuity of care Characteristics or the Planning Process S – Specific M – Measurable A – Attainable R – Realistic T – Time bound
Types of Planning 1. Initial Planning Done by the nurse When done:
Activities during Planning Process
22
Set priorities Set goals Identify alternatives of nursing care Select nursing measures Write nursing orders (supervisors do this) Write the nursing care plan
Requirements for Implementation Adequate knowledge Technical Skills Communication skills Therapeutic use of self Right attitude as a requirement Nursing Activities during the Implementation Phase Reassess the patient o Rationale To determine if the procedure is still needed Determine the need for nursing assistance Implement the nursing
Purposes of Goal-setting To set direction To provide a time span To have a criteria for evaluation To enable the nurse and the patient to determine whether the problem has been resolved or not To help motivate the client and theofpatient by providing a sense accomplishment
Key Concept!!! For your goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS
IMPLEMENTING PHASE OF THE NURSING PROCESS
strategies Communicate the procedure performed by documenting the procedure Understand orders o Clarify / verify doctors’ orders Encourage patient to participate actively
Guidelines for Implementation of the Nursing Strategies
Implementation
Putting the care plan into action
Key Concept!!! It should be based on scientific knowledge, research, professional standards of practice (care) o Rationale: This is done to ensure safe nursing care It should be adapted to the individual patient It should always be safe. Do not compromise
Purpose of Implementation To carry out planned activities To help the client Concept!!! The implementation phase ends upon recording of the care given and the response of the patient to that procedure
23
It should be holistic It should be accompanied by support, comfort and teaching
EVALUATION
PHASE
OF
o
THE
NURSING PROCESS
2. Intermittent Evaluation When done: o At a specified time Purpose: o It shows the extent of progress of the patient Importance: o Enables the nurse to correct deficiencies and modify the nursing care plan
Purpose of the Evaluation Phase To determine client’s progress To determine the effectiveness of the care plan To determine as to what extent the nursing goals have been met Importance of doing an Evaluation It determines if the care plan will be: o Continued o Modified o Discontinued
3.Terminal Evaluation When done: o At or immediately before discharge Importance: States the status of a health problem at the time of discharge It determines whether the goals are: o Met o Partially met
Activities during the Evaluation Phase Identify the OUTCOME CRITERIA to be used as measurement Gather information (data) relevant to the outcome criteria Compare outcome (data) with
Allows the nurse to decide and make onthe-spot modification/s in an intervention
o
the criteria Assess the reasons for the outcome Revise the nursing care plan as needed
Unmet
DOCUMENTATION It is a written, formal document A record of client’s progress
Types of Evaluation 1. On-going Evaluation When done: o During or immediately after the intervention Importance:
Purposes of Documentation Planning Care Communication For legal documentation purposes For research
24
For education Reimbursements For statistics, reporting, epidemiology Accreditation, licensing
Guidelines on Documentation
Timing o Document patient care as soon as possible Observe confidentiality Observe permanence o Use non-erasable ink o Do not use sign pen Signature o Sign full name and append R.N. Accuracy o Ensure that data is
Components of a Source Oriented Clinical Record Admission Sheet Face Sheet Medical History and Physical Examination Sheet Diagnostic Findings Sheet TPR Graphic Sheet Doctor’s Treatment and Order Sheet Therapeutic Sheet
correct Avoid biases o Avoid ambiguous terms Appropriateness o Write only appropriate information Completeness Use standard terminology Brevity o Make it concise yet meaningful Legal Awareness
Problem Oriented Clinical Record Same as Problem Oriented Medical Record Entry of data is based on CLIENT’S PROBLEM Example: o Problem No. 1: constipation Increase fluid intake: doctor Diatabs: pharmacist
o
assembled into an orderly or scientific manner Classification of information is based on SOURCE Each person or department maintains a different section on chart
o
o o
Cross entry out erroneous Write “Error” Countersign
TYPES OF RECORDS Source Oriented Clinical Record Accumulation of chronological, variative notations that are difficult to follow because they are not
NPO: Includes observations about the patient Example: o Radiologist’s notes are with doctor’s notes under one problem
Problem List Contains problems information problem)
25
only ACTIVE (and relevant about the
No potential problems (these are contained only in the progress notes)
Four (4) Basic Components of Problem Oriented Clinical Record
Purpose of the Kardex To make valuable information
1. Baseline Data All information gathered from a patient when he first entered the agency
2. Problem List
COMMUNICATION IN NURSING
4. Progress Notes Includes: o Nurses’ narrative notes
o
Concept: Communication is the basic component of Human Relationships
Formats: SOAPIE – for revisions COMMON METHODS OF COMMUNICATION AMONG NURSES
Elements of Communication 1. Message Data
1. Referring To endorse patient’s special concern to a higher authority or a specialized department or personnel
2. Sender Encoder 3. Receiver Decoder 4. Feedback 5. Context Setting Overall environment the communication place
2. Confer Verifying information
to
TECHNIQUES
Communication Exchange of ideas, information, feelings, data between two communicators
(SOAPIE) Flow sheets Discharge Notes and Referral Summaries
3. Reporting Giving information concerned person
readily available Allergies are written in red ink It is a reminder It is not a record
Concept: A Nursing Care Plan is not a record
3. Initial list of orders or Care Plans
o
Is the Kardex a part of the patient’s record? No, it is not!!! It is just a bulletin board
a
Modes of Communication 1. Verbal
KARDEX 26
where takes
Oral Spoken Written communication Texted communication Cable communication Telex communication Facsimile communication
o
o
2. Non-verbal communication Facial expression Grimacing Posture Gait Adornment Make-up Gestures
Perceptions Proxemics o Distances between communicators Intimate Distance Actual physical contact to 1.5 feet Personal Distance •
•
1.5 feet to 4 feet 3 feet to 4 feet for interview Social Distance 4 feet to 12 feet Public Distance 12 feet and beyond •
•
•
Roles and relationships
Therapeutic Communication in Nursing Using Silence o Supplement with nonverbal communication Provide General Leads o Examples: “…go on” “…tell me more” Open-ended questions
Factors Affecting Communication Ability of the communicator
One person believes that the space and all the things in that space belongs to him Do not enter abruptly; this may result in breach of privacy
Territoriality
27
UseoTouch But assess the culture of the patient o If the patient is a child, touch the patient on the top of the head o If the patient is an elderly, touch the patient on the hand o If the patient is of the same age level, touch the patient on the shoulder Offering yourself o For autistic child Stay nearby or stay beside the patient Presenting Reality o Example: “You are in the hospital” Reflecting o Example:
o
o
“What do you think will make you happy” Never agree nor disagree Reflect it back or throw it back
Non-therapeutic Communication Stumbling blocks to effective communication Stereotyping Generalizing Agreeing and Disagreeing No confrontation No argument Being defensive Moralizing or Passing Judgment
REM sleep is NOT AS RESTFUL as NON-REM sleep However, REM sleep is NEEDED Dreaming is a psychological outlet of pent up emotions
Nursing Alert! Deprivation of REM sleep results to: o Irritability o Restlessness o Poor concentration 2. Non-Rapid Eye Movement Sleep (Non-REM Sleep) Deep restful sleep Benefit is that it restores the body physically and psychologically (especially for post-operative patients)
Giving Common Advise Examples: “If I were you…” “You should have done it…”
Concept! Deprivation of Non-REM sleep causes: o Physical exhaustion o Decreased resistance against infection
PROMOTING REST AND SLEEP Circadian Rhythm A biological rhythm A biological clock Regulated from outside the person’s body
Wellness Teachings to Enhance or Promote Sleep
Types of Sleep 1. Rapid Eye Movement Sleep (REM sleep) Increased brain metabolism and activity Also called PARADOXICAL SLEEP Characterized by: o Vivid dreams o Easily recalled upon awakening
Establish a regular routine Have adequate exercise at daytime o Avoid stimulating activity by bedtime Avoid all types of stimulants o Caffeine-containing foods Coffee Cocoa Chocolate Tea
Concepts! 28
Cola
o o
Nicotine Alcohol Prolongs the REM stage of sleep It excites the patient like an
Concepts: Glucose is a ready source of energy for metabolic processes
anesthetic Not a stimulant
Carbohydrates When eaten are metabolized to glucose for energy Excess carbohydrates are converted to glycogen and stored in the liver Other excess carbohydrates go to the fat cells
Avoid shabu Use the bed mainly for sleep If unable to sleep, get up and pursue satisfying activity Drink something warm or hot (except stimulants) o Milk contains Ltryptophan o L-tryptophan is an amino acid with a
Key Concept! During starvation, stored glycogen is converted to glucose via a process called glycogenolysis
natural sedativeone effect that induces to sleep Do something HOT! o Twice-a-week masturbation is ideal o Facilitates release of tension of the day Side-to-side turning every two hours with back tapping Support bedtime rituals Remove all music in order to sleep
If glycogen is used up, fat resources are converted to glucose via a process called gluconeogenesis
Nursing Alert! Fat conversion to glucose produces waste products called KETONE BODIES These give rise to metabolic acidosis as Ketoacidosis
PROMOTING NUTRITION
in
Diabetic
Additional concepts! During starvation protein reserves are converted to glucose via process called gluconeogenesis
Proteins Macromolecules composed of o Carbon o Hydrogen o Oxygen o Nitrogen
Gluconeogenesis Production of glucose out of non-carbohydrate products
Basic Body Needs: Carbohydrates
Fats
Proteins
Lipoproteins 29
2. Non-essential Proteins Proteins that can be produced by the body
Substances composed of fats and proteins
Types of Lipoproteins 1. High Density Lipoproteins (HDL) High-grade lipoprotein
Functions of Protein Main element of our cells. o Building blocks of the
Good grade lipoprotein Good cholesterol Function of HDLs o Transports the bad cholesterol from systemic circulation to the liver for metabolism and eventual elimination
2. Low Density Lipoproteins (LDL) Low-grade lipoprotein Bad cholesterol Function of LDLs They clog the blood vessels
cells are proteins Resistance against infection o Formation of Immunoglobulins (globular proteins) Maintenance of normal intravascular fluid volume o Works with glucose and sodium o Albumin Main protein of blood
3. Very Low Density Lipoproteins (VLDL) Very bad cholesterol
Acts as a colloid Attracts water around it
Concepts!!! If protein levels are decreased, sodium and glucose will not be enough to hold plasma inside blood vessel resulting into edema
Functions of Fats Insulation Heat Conservation Source of Energy
Proteins Two (2) types in terms of needs of the body: 1. Essential Proteins Proteins that cannot be produced by the body itself To be sourced out from food eaten Animal protein is complete protein Plant protein is considered as incomplete protein
In liver hypoalbuminemia
cirrhosis, results to
edema VITAMINS Two (2) types of Vitamins Fat Soluble Vitamins Water Soluble Vitamins Fat Soluble Vitamins 1. Vitamin A Essential for normal vision For transmission of light stimulus via the optic nerve
30
2. Vitamin D Source is food Precursor is in the skin Sunlight is needed for Vitamin D to be converted to its active form
Function: o Influences calcium metabolism o To metabolize calcium
Concept! Without Vitamin D, there would be decreased calcium levels
Increased levels of Vitamin D leads to increased calcium levels
Forms: o Tablet o Liquid o Injectable Oral (tablet and liquid forms) o Take on an empty stomach o If there is GI distress (i.e. diarrhea), take with food o If GI distress subsides, take on an empty stomach Toxic effects: o Constipation (first option) Oral Liquid Iron o Use dropper and apply at the back of the tongue or use a straw
Vitamin E Anti-oxidant Promotes cell membrane integrity (like Vitamin C) Vitamin for the heart and skin Sources are meats and in vegetables Deficiency results to Vitamin E deficiency hemolytic anemia
Vitamin K
Synthesis of clotting factors Synthesis of prothrombin
Concept! Decreased levels of Vitamin K leads to prothrombin deficiency
Rationale: To avoid staining the teeth Health Teaching!!! o To enhance iron absorption, advice taking orange juice o Vitamin C in orange juice enhances iron absorption o Do not take milk o Milk inhibits absorption of iron o Too much fiber prevents absorption of iron o Thus, do not take oats when taking iron. Injectable Iron o Route is deep I.M. o Use Z-track technique o
Deficiency in prothrombin leads to bleeding
MICRONUTRIENTS Ferrous sulfate (FeSO4)
31
o
o
o
Gauge of Needle is at least 18 Length of Needle is 1.5” to 2.0” Site of administration is the GLUTEAL MUSCLE ONLY!!!
3. Pureed Diet Osteorized diet 4. Full Liquid Diet
o
Whole grains and cereals
Rationale: To avoid staining the skin Concept: o Use an airlock o Place 0.5 ml of air in syringe so that medication would not leak into the subcutaneous tissues Nursing Alert! o Apply firm pressure for
Foods that melt or liquefy at body temperature
5. Clear Liquid Diet Given to surgical patients Limited to: o Water o Coffee o Tea o Cola o Clear stained broth o Gelatin o
at least five (5) minutes after injection Do NOT massage
SPECIAL DIETS 1. Light Diet Given for post-operative patients Plainly cooked No spices Large amounts of FAT omitted Avoid bran and high fiber
6. High Fiber Diet For patients constipation
at
risk
are
for
7. Candidiasis Diet Free of the following: o Fruits o Sugar o Yeast o Fermented foods
2. Soft Diet For people with difficulty with swallowing and chewing Generally low residue diet Nursing Alert! o Avoid the following: Nuts Seeds (tomato, guava, berry) Raw fruits and vegetables
Hard candies Nursing Alert! o Dairy products avoided
8. Low Residue Diet Reduced fiber To decrease GI irritation For patients with bowel inflammatory diseases: o Chron’s disease o Ulcerative colitis Acid-Ash Diet
Fried Foods 32
1. NASOGASTRIC TUBE FEEDING (NGT) Purpose of NGT insertion o For gastric gavage and lavage o For administration of food and medication
To alkalinize urine To soothe an irritated bladder and urethra Give citrus fruits Give vegetables Exceptions are: o Prune Juice o Cranberry Juice o Both produce ACIDIC URINE
o
Ash-Acid Diet Given to acidify urine To minimize or help control Urinary Tract Infections Give the following: o Protein o Meat o Poultry
ASSESSMENT OF NUTRITIONAL STATUS
Anthropometric Measurements
Skin Fold Test Derived from reserved fat of the body Mid-upper arm Measurement
Circumference
To keep the stomach empty o To prevent aspiration from regurgitation of gastric contents o For gastric decompression How to Insert NGT o Depth of Insertion Measure length from the tip of the nose to the ears to the tip of the xiphoid process Insertion: o Position the patient in semi-Fowler’s or Fowler’s position o While inserting to NASOPHARYNX Position the head in a hyperextended manner o
Obtains the muscle mass of the body This reflects the protein reserves of the body Laboratory diagnostic procedure for albumin
SUPPORTING NUTRITION OF PATIENT: ENTERAL AND PARENTERAL FEEDING ENTERAL FEEDING
33
When glottis, epiglottis are approached Flex the head o Rationale: To prevent entry of the tube into the trachea Nursing Alert! o Watch for signs and symptoms of RESPIRATORY DIFFICULTY
If there are signs, WITHDRAW TUBE o While inserting tube, observe for coughing or difficulty of breathing After inserting, ascertain proper placement on the o
therefore, from lung contents IMPORTANT CONCEPTS!!! o To insure safety of the patient prior to feeding, CHECK THE FOLLOWING:
stomach Concept! o Most accurate method to test for proper placement of the NGT is via X-RAY Other ways to test proper placement: o 1. Let patient hum If positive for humming, tube is in the esophagus and stomach If negative for humming, tube is in the trachea Nursing Alert! o Small-bore tube allows patient to hum o Therefore, this method is NOT RELIABLE o 2. Determine the pH of the aspirate Use litmus paper
Placement of the tube For patient safety To prevent LUNG aspiration of food Patency of the tube To insure successful introduction or administration of food o 3. By auscultating the epigastric region while insufflating 50 ml of air Hear gurgling sound TUBE FEEDING Never try to submerge the free end of the NGT to water •
•
•
o
Change of color from BLUE to RED indicates that the aspirate is acidic and, therefore, from stomach contents Change of color from RED to BLUE indicates that the aspirate is basic and,
34
This is potentially dangerous o If in trachea and submerging of free end to water coincides with inspiration, it will suck the water and lead to pulmonary aspiration Position during feeding: o Fowler’s Position Measure gastric residual volume
o
o
Subtract this from total feeding to introduce If aspirate is greater than 50 ml for adult or 10 ml for infant, then WITHHOLD FEEDING for 2 – 3 hours.
o
Rationale: Patient is not yet ready for next feeding. o If same occurs after 2 – 3 hours, NOTIFY DOCTOR. There is a problem with gastric emptying Watch out for COUGHING o Leakage to trachea If with DIFFICULTY OF BREATHING o Stop the procedure Flush with water after feeding to avoid clogging of the tube After the procedure o Do not place the patient on bed before 30 minutes have lapsed o Rationale: To prevent aspiration and
Important Concept!!! o Tube must reach two (2) centimeters before or above the RIGHT ATRIUM Nursing Responsibilities: o Watch out for signs and symptoms of embolism Care of Insertion Site o Application of sterile dressing with antibacterial ointment as ordered by doctor (prn)
GASTROSTOMY TUBE FEEDING (Enteral) No auscultation needed Assess for the patency of the tube Use water to do this PROMOTING OXYGENATION DEEP BREATHING Two (2) types of Deep Breathing: 1. APICAL DEEP BREATHING Done to expand the upper portion of the lungs Let the patient place palms on the upper chest Concentrate on that area Take a slow deep breath at a
regurgitation Average volume of feeding: o 300 ml to 400 ml
TOTAL PARENTERAL NUTRITION Introduced directly to the bloodstream Tube is inserted via the: o Subclavian vein o Internal jugular vein of the neck o External jugular vein of
the neck 35
count of 1,2,3 Release it slowly through the nose or a pursed lip at a count of 4,5,6,7 Therefore, expiration is longer than inspiration Rationale: o To prevent respiratory alkalosis Taught to patients who will undergo: o Upper abdominal surgery
o
Cholecystectomy Incision site on diaphragm Patient does not want to breathe Predisposed to hypostatic
o
Coughing is contraindicated in the following patients: With increased intracranial pressure (ICP) With increased
pneumonia
2. BASAL DEEP BREATHING Same procedure Area of concentration is the lower ribcage When to teach patient: o Before surgery o Before pain is present Rationale: o If pain is already present, it would be
Concepts!!! Deep Breathing and Coughing o Purpose is to stimulate surfactant production Yawning and sneezing also stimulate surfactant production
difficult follow for patient to When done: o Done q2 hours together with turning
OXYGEN INHALATION ADMINISTRATION
AND
Practical Application Concept! When administering oxygen, be sure to open the valve of the oxygen tank first. Be certain that the valve on the regulator is closed so that the flow meter would not break!
COUGHING EXERCISES Purpose o To expand the lungs o To facilitate expectoration of secretions
intraoptical pressure (IOP) With cardiac arrhythmias (but are allowed to do deep breathing)
How often done: o At least every two (2) hours Procedure o Teach the patient to inhale and exhale o Tell the patient to inhale and exhale a second time o Tell the patient to inhale and cough out NURSING ALERT!!!
Concept! Humidifier moistens the oxygen administered Purpose o To avoid drying and irritation of the mucosal lining o Also traps particulates from the tank
36
2. High Flow Administration Uses a venturi mask
Iron oxide may be present in the tank (iron plus oxygen produces iron oxide or rust)
NEBULIZATION With sodium chloride salbutamol A physiologic solution
Concept! Fire Precaution o Place ‘NO SMOKING’ sign at the door or at the head part of the patient Tank and oxygen do not explode They merely support combustion
and
Water liquefies secretions Sodium chloride stimulates coughing Salbutamol is a bronchodilator Purpose: o For expectoration of secretions
Nursing Pre-therapy Assessment Prior to Nebulization Have baseline data of patient’s breath sounds
Other Concepts! Do not use volatile substances Acetone and alcohol can react with oxygen and lead to toxicity of patient Do not use oil based or grease on any part of the oxygen set Do not allow the patient to use an electric razor as sparks may trigger combustion
Assess after nebulization again to assess effectiveness of the procedure
SPIROMETRY Purpose is to expand the lungs Done when inhaling Instruction to the patient: o Inhale from the spirometer and NOT blow to the spirometer Procedure:
Nursing Alert! Retrolental Fibroplasia occurs if there is excess oxygen administration in infants. Excess oxygen leads to destruction of the retina and blindness
o
Inhale – exhale Inhale – exhale fully o Place mouthpiece between teeth o Hold breath for four (4) seconds o Then inhale, fully rising the ball Upon inhalation, the ball rises o
Modes of Administration 1. Low Flow Administration Utilizes nasal cannula or nasal prongs or nasal catheters Given to COPD patients
CHEST PHYSIOTHERAPY This is a dependent procedure
37
There are no absolute contraindications to this procedure Contraindicated for the following patients with: o Pacemakers o Lung abscess o o o
o
Hemoptysis Dangerous Arrhythmias Active PTB (which goes to the other lobe) Lung CA (malignancy goes to other lung)
Three components of Physiotherapy Vibration Percussion Postural Drainage
Assess breath sounds to know which lung fields have secretions Then assess again after procedure to check effectiveness of the procedure.
Concepts!!! Vibration and percussion are done to mechanically dislodge secretions Nebulization is done to liquefy secretions Suctioning is done to clear secretions Postural Drainage is done to drain secretions using gravity
Chest
Postural Drainage When done: o Before meals o Two (2) hours after meals Before doing the procedure, the following baseline data are needed: o Breath sounds o Vital signs o Continuous ECG monitoring During the procedure:
Vibration Palms of your hand are placed on chest or back of patient giving quivering motions Palms remain in contact with the chest or back Percussion Use cupped hands Hands alternate in rising and coming into contact with chest or back of patient
o
Postural Drainage Drain secretions by gravity Change positions IMPORTANT CONCEPT!!! o Rule out contraindications before performing chest physiotherapy Pre-therapy Assessment Vibration and Percussion
for
38
Ensure the comfort of the patient o Provide a kidney basin and tissue paper Nursing Alert! o Watch out for signs of symptoms which may require stopping of the procedure: Sudden dyspnea Cyanosis Extreme diaphoresis
Sudden alteration of blood pressure, respiratory rate, pulse rate Appearance of arrhythmias
SUCTIONING Purpose is secretions
to
seek
out
Concepts!!! Question: o
Hemoptysis General intolerance of the procedure
Important Concept! If any of the above occurs, STOP THE PROCEDURE and inform the physician Concepts! After the procedure assess the following: o Breath sounds o Vital signs o Quantity and quality of sputum o Overall response of the patient to the procedure Give oral hygiene o Rationale: To eliminate phlegm from the mouth
If you have only one (1) suction catheter, which will you suction first, the nose or the mouth? Answer: o If the patient is an infant or a newborn: Start on the mouth then proceed to the nose Rationale: o If you start on the nose, you will trigger the sneezing reflex and this would result into aspiration Answer: o If the patient is an adult, suction the mouth first, then proceed to the nose Rationale: o This is done for aesthetic reasons
Important Concept!!! Patients with cystic fibrosis benefit much from postural drainage TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning
Depth
Oropharyngeal
39
Duration
Interval with each Pass of Suction
Total Time
Suctioning If patient conscious
is
Fowler’s (high 10 – 15 or moderate); centimeters Head turned to one side (towards the
Not more 20 – 30 than 10 – seconds 15 seconds
Not more than 5 minutes
Not more 20 – 30 than 10 – seconds 15 seconds
Not more than 5 minutes
Not more 20 – 30 than 10 – seconds 15 seconds
Not more than 5 minutes
nurse)
If the patient is unconscious
Place on one 10 – 15 side (facing the centimeters nurse); Tilt neck to move head slightly forward towards the basin to avoid aspiration during suctioning
Nasopharyngeal Suctioning If the patient is conscious
Neck should be hyperextended; Fowler’s position
From tip of the nose to tip of the earlobe
If the patient is unconscious
Flat with
From tip of Not more 20 – 30 the nose to than 10 – seconds
on
bed head
turned to the the tip of 15 nurse the earlobe seconds Lateral position may be assumed TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning Orotracheal Suctioning
Depth
Duration
40
Interval with each Pass of Suction
Not more than 5 minutes
Total Time
If patient conscious
is Low to semifowler’s position
Measure Not more 20 – 30 from mouth than 10 seconds to mid- seconds sternum
Not more than 5 minutes
If the patient Flat on is bed; unconscious Suction trachea through the mouth Nasotracheal Suctioning
Measure Not more 20 – 30 from mouth than 10 seconds to mid- seconds sternum
Not more than 5 minutes
If the patient Low to is conscious semifowler’s position
From tip of Not more 20 – 30 the nose to than 10 seconds earlobe to seconds dominating
Not more than 5 minutes
side of neck to the thyroid cartilage If the patient Flat on is bed; unconscious Suction trachea through the nose
From tip of the nose to earlobe to dominating side of neck to the thyroid cartilage
41
Not more than 10 – 15 seconds
20 – 30 seconds
Not more than 5 minutes
TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning
Depth
12.5
Duration
Endotracheal
Semi-Fowler’s
Tube Suctioning
if not centimeters seconds contraindicated or 6 inches; Insert as far as it goes until you meet resistance or until patient coughs
42
5 – 10
Interval Total with Time each Pass of Suction 2 – 3 Not minutes
more than 5 minutes
Tracheostomy Tube Suctioning
Semi-Fowler’s Insert as 5 – 10 if not far as it seconds contraindicated gets until you meet resistance or until the patient
2 – 3 Not minutes more than 5 minutes
coughs
Important Concepts!!! For Endotracheal Suctioning o NO TUBE IS USED HERE o This is suctioning of the
trachea through the mouth or through the nose Two (2) types of Endotracheal Suctioning o Orotracheal Suctioning Oral approach o Nasotracheal Suctioning Nasal approach
For Endotracheal and Tracheostomy (Naso and Oral and Tube) o Before suctioning, HYPEROXYGENATE the patient During intervals, HYPEROXYGENATE the patient For ET, Tracheostomy, ET Tube o Nursing Alert! During insertion, if you encounter resistance, withdraw the catheter about one centimeter o
General Conditions for Suctioning
43
o
o
o
o
o
(1 cm) before applying suction Rationale: To avoid trauma on the mucous membrane Do suctioning
o
o
intermittently Suctioning should not be continuous Rotate the catheter (between the thumb and the index finger) as you withdraw Apply suction only when you are ready to withdraw (i.e. keep finger away from suction port if you are still not ready)
Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy the mucous plug Instill 2.0 ml Normal Saline Solution for children to liquefy the
mucous plug Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the mucous plug
VITAL SIGNS TEMPERATURE Oral Axillary Rectal Oral Method Most convenient Most accessible Nursing Alert! o Applicability is for children aged six (6) years and above o Not applicable for children below six (6) years old Contraindicated in patients with: o Oral surgery
How to Hyperoxygenate the Patient Give two (2) to three (3) blows by ambubag Increase flow rate and concentration of oxygen Nursing Alert! o If the patient has thick, tenacious secretions, DO NOT USE AN AMBUBAG o
o
Use an OXYGEN INSUFFLATION SUCTION CATHETER instead!!! o This is a two-lumen catheter (one lumen brings oxygen to the patient, the other lumen brings out secretions from the patient) In the event of encrustations, PERFORM TRACHEAL LAVAGE
Mouth breathers History of convulsive seizures o Unconscious o Incoherent o Irrational o Mentally disrupted o Insane Procedure o Nothing Per Orem for about thirty (30) minutes before taking o
temperature 44
No food intake No drinks o No smoking o No chewing gum o No whistling o No gargling Rationale: o Any of the above would alter the result Placement: o Under the tongue, beside the frenulum (right or left) Total Time: o Two (2) to three (3) minutes o
Rectal Method Most reliable (except for tympanic thermometer) Most accurate (except for tympanic thermometer) Concept!
o
o
Axillary Method Least realiable
Safest method Nursing Alert! o During application, be sure that axilla is dry o Dry using a patting motion Nursing Alert! o Do NOT RUB!!! Rationale: o This increases heat due to friction o Rubbing increases blood supply to the area o Therefore, there will be increase in temperature reading o Rubbing provides a false-positive elevation of temperature reading Duration: o In adults – nine (9) minutes o In children – five (5) minutes
If tympanic method is used using a tympanic thermometer, the rectal method is only second most reliable and second most accurate Disadvantage: o Placement on a different site yields a different reading o Therefore, ensure that the bulb of the rectal thermometer rests on the mucous membrane Contraindications: o Hemorrhoids o Rectal Surgery o Certain Cardiac ailments due to stimulation of the vagus nerve; valsalva maneuver leads to arrhythmias Position of Patient when taking the reading: o
Sim’s left position Sim’s right position o For Newborn, lift up ankles to keep buttocks up o In Toddlers, set on prone position on adult’s lap Duration: o Two (2) minutes o
Conversion Fahrenheit
45
of
Centigrade
to
Centigrade = (5/9)F – 32 Centigrade = (F/1.8) – 32 o
Conversion of Fahrenheit Centigrade Fahrenheit = (9/5)C + 32 Fahrenheit = (1.8)C + 32
to
Concepts!!! Peak body temperature occurs at 12NN to 3PM or 4PM Lowest body temperature occurs in the early morning hours of the day
FEVER Normally, the hypothalamus is able to adjust body temperatures between 37 C to 40°C But due to the presence of pyrogenic materials like the following: o Pathogenic microorganisms o Toxins o Foreign substances o Any substance capable of increasing body temperature Creates a deficiency of -3°C,
°
making a person enter the FIRST STAGE OF FEVER
First Stage of Fever Typical signs and symptoms indicate the body’s compliance mechanism to increase and conserve heat: o Chills o Shivering o Gooseflesh Contraction of arectores
46
pilorum or pilo arecti muscles Vasoconstriction Decreases blood supply to the skin Pallid Skin
o Cyanotic nail beds Key Concept!!! o Patient complains of feeling cold o Sweating will stop because body will minimizes heat loss Also called: o Onset Stage o Chill Stage o Cold Stage This stage is characterized by
low febrile temperatures Nursing Management o Key Concept Aim is to minimize heat loss o Key Concept Do NOT apply TEPID SPONGE BATH because this would make patient progress to SHOCK Provide additional clothing as necessary Provide additional blankets as necessary Provide something warm to drink These measures would result to a gradual increase in body temperature Question: o When will you start application of TSB? Answer:
o
If there is a 1°C to 2°C increase in body temperature
o
Second Stage of Fever Also called: o Coarse Stage of Fever
Loss of appetite Myalgia or muscle pains due to increased catabolism Nursing Management o Tepid Sponge Bath o Cooling Bed Bath o
o Peak Stage of Fever Key Concept! o Patient does not feel hot or cold o Skin is warm to touch o Skin is flushed o Fever blisters are present Herpetic lesions o Absence of shivering o Possible dehydration Important Concept!!!
Tepid Sponge Bath Temperature of water is 32°C o This temperature is maintained throughout the procedure How to apply: o Done by patting Rationale: o To avoid friction,
o
For every increase of temperature, there is a corresponding increase in pulse rate Rationale: o Increase in temperature results in an increase in pulse rate due to increased metabolic rate o Increased metabolic rate increases oxygen demand o Due to increased oxygen demand of susceptible brain cells, CONVULSIVE SEIZURES may occur. These may also be due to irritation of nerve cells – FEBRILE CONVULSIONS Increased oxygen demand also leads to an increase in respiratory rate Patient complains of:
which increases temperature Important Concept! o Do NOT use ALCOHOL when applying TSB Rationale: o Alcohol dries the skin and leads to irritation Key Concept! o TSB should not be done hurriedly Rationale: o When done hurriedly, TSB will stimulate shivering o Shivering would lead to increased muscle activity o Increased muscle activity would lead to increased temperature
Cooling Bed Bath
47
Water temperature will start at 32°C Procedure will go on with gradual decrease in water temperature until it is maintained at 18°C Therefore, to achieve this
drop in temperature, utilize ice Same procedure of application as in Tepid Sponge Bath Types of Fever 1. Intermittent Fever A fever that is alternated at regular intervals by periods of normal and subnormal temperature
If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by two (2). This is legal!
If pulse is irregular, count or monitor the pulse for one (1) FULL minute
Assessment of the Pulse Deficit This is the most accurate method Involves two nurses using one watch Starts at the same time Ends at the same time Comparison of results ensues Count is done for one (1) full minute
2. Remittent Fever Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE NORMAL. Duration is within a 24hour period
Scale in Pulse Assessment 0 - Absent or cannot be felt 1+ - Weak or thready 2+ - Normal 3+ - Grounding BLOOD PRESURE
3. Relapsing Fever Short periods of febrile episodes alternated by one (1) to two (2) days of normal temperature
Systolic Produced by ventricular contraction Pressure on blood vessels during depolarization ventricular contraction
4. Constant Fever Minimal fluctuations of temperature, all of which are ABOVE NORMAL
or
Diastolic Pressure that remains in the walls of the blood vessels during relaxation or repolarization or resting
5. Staircase or Spiking Fever Common in patients with TYPHOID FEVER
Broadly two (2) types: Direct o By insertion catheter
PULSE ASSESSMENT Concepts!
48
of
a
Indirect Method o Auscultatory method o Palpatory method o Flush Method
o
Concepts!!! Take systolic on loudest sound if patient is an adult If patient is pediatric or up to ten (10) years old, take the
Auscultatory Method Uses Korotkoff sound o A popping sound o NOT the heart beat o It is a phenomenon – an unknown phenomenon!
Determining Amount of Inflation Using auscultatory method o Ask patient what is his last BP reading and then add 30 – 40 mmHg from last
systolic reading. – rate Deflate gradually is approximately 2 – 3 mmHg per second Alternative auscultatory method o Auscultate for the last sound as you go up. Then add 30 – 40 mmHg o Then deflate o
first sound, whether it is faint or loud If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then there is a sound at 130 mmHg down to 80 mmHg then… Use the PALPATORY METHOD in combination with the AUSCULTATORY METHOD because there is an auscultatory gap
Repeat using: Auscultatory method Palpatory method How to do the Palpatory Method Inflate o Determine up to what point to inflate o Palpate pulse o If pulse is absent, add 30 – 40 mmHg
Tripartite Blood Pressure
160 / no muffling / 110
Done if patient is an adult. Example: 140 mmHg systolic – first loudest sound 100 mmHg 1st diastolic – muffling 70 mmHg 2 nd diastolic – last sound o Therefore, the tripartite blood pressure is 140 / 100 / 70 If there is no muffling, an example would be:
Deflate o First palpable pulse is true systolic pressure For diastolic pressure, proceed using the auscultatory method
Flush Method Represents the mean blood pressure Represents the average of the systolic and diastolic pressures
49
When done: o When you have a BP apparatus without a stethoscope o Used for pediatric patients How done:
Stage 1 Involves the epidermis Manifestation o Non-blanchable erythema of INTACT SKIN
o
o
Inflate up to the poin t where extremity becomes pale o Deflate slowly and look for a REBOUND FLUSH – when extremity becomes red again This is the true reading!! Note that there is only ONE reading!!!
Stage 2 Partial Thickness Skin Loss Involves epidermis and dermis Manifestation o Blister formation o Shallow craters o Shallow abrasion and ulceration
SKIN INTEGRITY Decubitus ulcers are caused by: o Unrelieved, sustained pressure o Localized ischemia o Shearing force o Pressure plus friction Predisposing Factors: o Unconsciousness o Incontinence o Loss of Sensation o Hypoproteinemia Decreased lean muscle mass Increase in fluid shifting leads to edema Dependent position is the skin attached to or facing the bed o Emaciation Stages
of
Decubitus
This is the first heralding sign of decubitus ulceration
Stage 3 Full Thickness Skin Loss Ulceration There is skin loss already Involves necrosis of the skin and subcutaneous tissues EXTENDING TO but NOT THROUGH the underlying fascia Stage 4 Formations
and
manifestations of Stage 3 plus… o Involvement of bones, supporting structures (tendons), joint capsules o Massive damage Tools to Assess Risk of Ulceration Norton’s Pressure Area Risk Assessment Form Shannon’s Scoring System
Ulcer
Formation 50
Branden Scale of Predicting Ulceration Waterlow Risk Assessment Cards o Most important tool o Most common tool o Most often used tool
3+ 4+ 5+
-
3 cm induration 4 cm induration 5 cm induration
PAIN MANAGEMENT Pain
EDEMA Caused by shifting of fluid into the interstitial tissues
A noxious stimulation of actual or threatened / potential tissue damage
Categories of Pain according to Origin Cutaneous o Skin Deep Somatic o Tendons, ligaments o Bones o Blood Vessels
Management of Edema 1. Elevation of the edematous part Nursing Alert! If edema is due to Congestive Heart Failure (Right Sided), NEVER ELEVATE THE LOWER EXTREMITIES Rationale: This increases the workload of the right side of the heart
Visceral Pain of the body o Organs
Categories of Pain based on Cause Acute o Due to trauma or surgery o Persists for less than six (6) months Chronic Malignant Pain o Related to cancer o On and off o Persists for more than six (6) months Chronic Non-malignant Pain o Persists for more than six (6) months
Concept! If edema is due to prolonged standing, DO THE ELEVATION 2. Wear elastic stockings 3. Use warm compress alternated with cold compress Rationale: Vasoconstriction and vasodilation causes recirculation of fluid Concept! This is contraindicated if there is inflammation
Categories of Pain according to Where It Is Experienced Radiating Pain o Felt on the source and is extending to nearby tissues
Assessment of Edema Induration 1+ 1 cm induration 2+ 2 cm induration
51
Referred Pain
o
o o
Felt on other parts detached from the source Example: Pain on a lacerated liver may be felt on the right shoulder and not
o
on the right upper quadrant Intractable Pain o Highly resistant to painrelief methods Phantom Pain o Pain that is felt on a MISSING BODY PART or a PART THAT IS PARALYZED by SPINAL CORD INJURY.
Pain Threshold Amount of pain stimulation that is required in order to feel pain
Large diameter nerve fibers close the gate – prevents the transmission of impulses through the spinal cord o Therefore, when LARGE DIAMETER NERVE FIBERS ARE STIMULATED, THE GATE IS CLOSED Pain management operates on the principle of how to stimulate the Large Diameter Nerve Fibers to close the gate.
Pain Management Strategies
Pain Tolerance Maximum amount of pain and duration that a person is willing to endure
Pharmacologic Methods Narcotics NSAIDs Adjuvants or Co-analgesics
Gate Control Theory Concept!
Pain signals are carried to the spinal cord by the small diameter nerve fibers Large diameter nerve fibers also pass through the substancia gelatinosa o
Non-Pharmacologic Methods Physical Interventions Cognitive / Behavioral Interventions
This is in the most widely used theory pain management
Concepts! At the dorsal horn of the spinal cord is a gate. This gate is called the SUBSTANCIA GELATINOSA A series of nerves pass through this gate Small diameter nerve fibers pass through the substancia gelatinosa
Non-Pharmacologic Physical Interventions 1. Cutaneous Stimulation Massage o Effleurage o Soft massage o Gentle stroking Petrissage o Hard massage
52
Large and quick pinches o Also done by striking Application of Counter-Irritant o Bengay o Menthol o Omega Pain Killer o Flax Seeds o Poultices Heat and Cold Application o Nursing Alert! o Rebound Phenomenon When you apply heat (usually done for 20 minutes), vasodilation is produced If heat is applied o
for more than 20 minutes, there is vasoconstriction This is an inherent defense mechanism from burning of tissues Cold Application o Maximum vasoconstriction is reached when skin reaches 15°C
certain chemical pathways o Origin is also Ancient china Contralateral Stimulation o Example: Injury on left side and massage is done on the right side o Useful when patient cannot be accessed: For patients in a cast For patients with burns For patients with phantom pain
2. Immobilization Application of splints 3.Transcutaneous Electrical Nerve Stimulation Composed of electrodes Operated by battery Electrodes are applied on
o
natural analgesic effects o This started in Ancient China Accupuncture o Insertion of long slender needles on
If there is further drom in temperature, there is vasodilation (skin becomes reddish) o This is the inherent defense mechanism from being frozen Accupressure o Pressure on certain points of the body o Stimulates release of endorphins, which have
painful site or over the spinal cord 4.Administration of a Placebo Relieves pain because of its intent and not because of physical or chemical properties Cognitive or Behavioral NonPharmacologic Interventions Purpose: o To alter pain perception
53
o o
To alter pain behavior To provide client with a greater sense of control over the pain
URINARY ELIMINATION Oliguria Renal output of less than 500 ml per day
Specific Interventions 1.Distraction
Purpose is to divert attention from pain Slow Rhythmic Breathing o Stare at a certain object o Take deep breath slowly o Release or exhale slowly o Concentrate on breathing o Picture a peaceful scene o Establish a rhythmic pattern
2.Massage Breathing
and
Slow
Anuria Renal output of less than 100 ml per day Retention Positive for distended bladder May also occur in the absence of bladder distention
Altered Urinary Elimination Enuresis
Rhythmic
3.Rhythmic Singing and Tapping Key Concept! o Faster beat music is more preferable 4.Guided Imagery
Imagine that you are walking along a peaceful shore Eyes are closed and suggestions are given
Common among pediatric patients Age 4 – 5 years old child has adequate bladder control Primary Enuresis o Never had a dry period Secondary Enuresis o Acquired enuresis o At age 7, bladder control is present for at least one year o Then, enuresis comes o
back Urinating could NOT be controlled again
Incontinence Involuntary passage of urine
5.Hypnosis The success of hypnosis depends on the ability of the patient to concentrate and the capacity of the hypnotist to suggest Based on suggestion Progressive relaxation
Types of Incontinence 1.Functional Incontinence Involuntary passage Unpredictable time
54
2.Reflex Incontinence Occurs at somewhat predictable times when specific bladder volume is reached No awareness of bladder filling
Advise patient to stand with legs slightly apart o Concentrate on perineum o Draw perineum upward slowly Alternative way: o
o
No urge to void It may be related to neurologic impairment
3.Stress Incontinence Loss of urine is less than 50 ml occurring with increased intra-abdominal pressure o Occurs when laughing o Occurs when sneezing o Occurs when smiling Total Incontinence Continuous flow of urine No bladder distention No bladder spasm No awareness of bladder filling
o
o
o
When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing Advantage of Kegel’s Exercises Increases muscle tone of the pelvis Increases muscle control
2.Clean Intermittent Self Catheterization Applicable for Reflex Incontinence How done: o Use a mirror for: Obese male patients Female patients Concept! o Possible Board Question: Is your Clean Intermittent Self
Urge Incontinence Urine flows as soon as a strong sense of feeling to void occurs Strong bladder spasm Management of Incontinence 1.Kegel’s Exercises Also called: o Pubococcygeal Muscle Exercises o Pelvic Floor Muscle Exercises Applicable for: o Functional Incontinence o Stress Incontinence How done:
o
Catheterization procedure a sterile procedure? Answer: No, it is just a clean procedure. Therefore, you can just wash the catheter for the next use.
3.Crede’s Maneuver
55
Application of a steady but gentle pressure on the suprapubic region to force urine out of the bladder Nursing Alert! o Do not use if there is OBSTRUCTION (i.e.
o
Let patient wash genitals o Dry the genitals o Get to bed Place patient in semi-Fowler’s position when she is ready to void o
renal obstruction in the form of renal stones) This is done only for patients who are no longer expected to regain control (Reflex incontinence and retention)
Clean and spread labia with two fingers Remain holding labia Then let patient urinate Let go of first flow Collect next flow
CATHETERIZATION
4.Prompted Voiding or Scheduled Toileting For Reflex Incontinence
5.Application of Adult Catheter and External Condom Catheter For elderly with Total Incontinence
6.Catheterization
MIDSTREAM CLEAN CATCH URINE SPECIMEN How is this done? If patient is a Male… o Clean the penis o Do this from the meatus down to the shaft o Let the patient urinate o Discard the first or the initial urine o Collect midstream urine o Purpose is to attain sterile specimen for urine culture and sensitivity testing If patient is a Female…
Coude Catheter o Elbowed catheter for Benign Prostatic Hypertrophy Robinson Catheter patients o Straight catheter Multi-Lumen Retention Catheter o Foley catheter One lumen is for inflation One lumen is for drainage of urine One lumen is for irrigation A three-way catheter Aspirate using syringe and needle This is made with a selfsealing rubber
Concepts!!! See to it that penis is perpendicular to body to straighten up the urethra to bladder While inserting the catheter, ask the patient to breathe through the mouth Cleanse the penis before insertion 56
Grasp penis firmly to avoid stimulating erections Where to tape catheter o Tape it upward on the abdomen Rationale: o To avoid scrotal
Concepts! For Flatulence o Avoid
excoriation Tape on the inner thigh (with penis sideways either on left or right and follow the normal contour of the penis Length of Catheter o 40 centimeters Depth of Insertion o While inserting, the point at which urine starts to flow, insert
o
o
o o
carbonated
drinks Do not use straw Avoid chewing gum Avoid gas-forming foods: Camote Cabbage Cauliflower Onions
For Constipation: Increase fluid intake
further by and five then (5) centimeters inflate the balloon – KOZIER o Insert up to a the Ypoint, retract after inflating (this method is more prone to infection For females o Insert at female Urethra Length of Catheter o 22 centimeters Depth of Insertion o
Avoid ignoring the urge to defecate Do not abuse laxatives
Prune juice Papaya Increase fiber in the diet Use METAMUCIL (natural fiber) instead of laxatives
Special Laboratory Procedures 1.Guiac Test To determine the presence of occult blood Concepts!!! o Have a meat-less diet three (3) days before examination o Withhold oral iron supplements o Injectible iron is allowed o Avoid any food that discolors the stool.
Point at which urine starts to flow, insert further by five (5) centimeter before inflating balloon
GIT – FECAL ELIMINATION Wellness Teachings Fluid intake of at least 2,000 ml per day Regular exercise High fiber diet
2.GI SERIES Upper GI Series – Barium Swallow Nursing Considerations:
57
o
Elimination of contrast medium
How: Increase fluid intake o Increase fiber in the diet Rationale: o To offset the risk of constipation o Inform patient that the color of the stool will be WHITE
Rationale: o Can lead to rupture of the appendix
o
2. Carminative Enema Used to expel out flatus Burned sugar
3. Oil Retention Enema Purpose: o To lubricate the colon and to soften the feces o Retention time is one (1) to three (3) hours
Lower GI Series – Barium Enema Done at the radiology department Nursing Concern: o Elimination of Barium How:
4. Retention Flow Enema Also called Harish Enema
o
Cleansing may be needed enema after barium enema
Flush
Solution continually administeredisuntil what comes out of the body is clear.
Positions in Enema Cleansing Enema High Cleansing Enema o Clean as much of the colon as possible o On introduction, Sim’s Left position facilitates flow of enema to sigmoid colon
Different Types of Enema 1. Cleansing Enema Soap suds enema Alkaline solution Nursing Alert! o Contraindicated patients with cirrhosis and
Now commercially available
in liver with
o
increased ammonia in the blood Rationale: o Alkaline solution facilitates transfer of ammonia from the GI tract to the bloodstream Therefore, use lemon juice or dilute vinegar instead!!! Nursing Alert! o Also contraindicated in possible appendicitis or appendicitis patients
Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse colon o Then, Right Side-Lying position to facilitate flow of enema to the descending colon Low Cleansing Enema o For cleaning of rectum and colon only
SEXUALITY
58
Human Sexual Response
Excitement / Physical Stimulation Erotic stimuli causes sexual stimulation Lasts for a few minutes to several hours Types of Stimulation Physical Stimulation Oral stimulation o Fellatio Oral stimulation of the penis using the mouth o Cunningulus Oral stimulation of the vagina o Anningulus Oral stimulation of the anus In homosexual male, typhoid fever may be obtained from anningulus Male and Female oral sex is called SOIXANTE NEUF
o Erection of the penis Females o Redness near the ear o Nipples, breasts move up o Fourchette retracts o Clitoris becomes visible o Increased vaginal secretion o If female is unaroused, there is backpain as penis hits the cervix If the female is wellstimulated, the cervix rises
Plateau Stage Lasts thirty (30) seconds to three (3) minutes In males: o
Scrotum rises Shaft of upward penis increases in length and width In females: o Cervix rises In both sexes: o There is increased muscle tone o Myotonia o
Orgasmic Phase or Orgasmic Stage Climax of sexual tension Peak of sexual experience Lasts three (3) to ten (10) seconds
Physiological Sexual Stimulation Stimulation by: o Smell o Sight o Hearing o Fantasy o Spoken words o Mental imagery
Resolution Stage Key Concepts! o Females have longer resolution phase o Males have shorter resolution phase
During stimulation or Period of Excitement Males
PERIOPERATIVE NURSING 59
Stages of Perioperative Nursing Pre-operative Phase Intra-operative Phase Post-operative Phase
Pre-operative Phase
Begins upon decision of patient to undergo the operation Ends when patient is placed on the operating table
1. Clean Wound Uninfected No inflammation Respiratory, Alimentary and Urinary tracts are not entered 2. Clean Contaminated Wound A surgical wound No evidence of infection Respiratory, GI, Urinary tracts are entered
Post-operative Phase Begins upon admission to the PACU Ends upon the discharge of the patient Skin Preparation Purpose: o To reduce postoperative infection by: Removing soil and transient
Where is shaving done? o Not at the Operating Room!
TYPES OF WOUNDS
Intra-operative Phase Begins when patient is placed on the operating table Ends when client is admitted to the Post-Anesthesia Care Unit or PACU
If hair needs to be removed, the best method would be through the use of: o Clippers o Depilatory cream Shaving is NOT ADVISED. This is the last choice
3. Contaminated Wound Involves large spillage of content from the GI, Urinary and Respiratory tracts Positive for inflammation
microbes Reducing microbial count to subpathological level in a short period of time with minimal skin irritation.
Positive for infection Dirty Infected Wound Old wounds Necrotic, gangrenous wound
Modes of Dressing
Applying
Gauze
1. Dry to Dry A wide mesh of cotton applied to the surface of the wound A second layer is applied over it
Concepts! Hair on the skin should not be shaved if it does not interfere with the procedure
60
2. Wet to Dry Inner layer is saturated with NSS or anti-microbial agent On top is a moist absorbent material 3. Wet to Damp A variation of wet to dry It is removed before it is completely dried 4. Wet to Wet Inner layer is saturated with NSS or anti-microbial solution Second layer is a wide mesh It is kept moist with a wetting agent
61
