Fundamentals of Nursing Practice: Infection Control and IV Drips PDF

FUNDAMENTALS OF NURSING PRACTICE INFECTION CONTROL AND DISEASE PREVENTION o Nurses are directly involved in providing a biological safe – Meticulous use of medical and surgical asepsis is necessary to environment...

FUNDAMENTALS OF NURSING PRACTICE INFECTION CONTROL AND DISEASE PREVENTION o Nurses are directly involved in providing a biological safe – Meticulous use of medical and surgical asepsis is necessary to environment prevent transport of potentially infectious microorganisms. o Nurses are usually the ones in contact directly with patients. Therefore, if you are in contact with patient, nurses must provide safety for their patients. INFECTIOUS DISEASE is a major cause of death worldwide. – The control of the spread of microorganisms and the protection of people from communicable diseases and infections are carried out on international, national, state, community, and individual levels. i Infectious diseases usually comes from nosocomial infections or comes from transfer of microorganisms in hospital or clinical areas. ASEPSIS HANDWASHING/HAND HYGIENE – Asepsis is the freedom from disease-causing – It is considered one of the most effective infection microorganisms prevention measures. – If microorganisms migrate in a place where they are not – Wash hands for at least 15-20 seconds supposed to be, then that can certainly cause an infection because they are resident pathogens in that area. PURPOSES: – Ex: o E. coli is a resident pathogen/microorganism in the G.I To reduce the number of microorganisms on the hands tract but if this is ingested that it can cause problems in To reduce the risk of transmission of microorganisms to the body clients o Staphylococcus aureus, a gram-positive To reduce the risk of cross contamination among clients microorganism and it is a resident of the upper To reduce the risk of transmission of infectious organisms to respiratory tract. If they migrate into an open wound, oneself since it is expected to live in the upper airways if this migrates in the lower respiratory tract. Therefore, it can INDICATIONS: cause problems and diseases. Boyce et al. (2002) and the WHO (2009) as cited by Potter and Pery (2017) recommend the following hygiene ASEPTIC TECHNIQUE guidelines: – To decrease the possibility of transferring microorganisms from one place to another. 1. When hands are visibly dirty, when hands are soiled with blood – or other blood fluids, before eating, and after using the toilet, wash hands with water and either a nonantimicrobial or MEDICAL ASEPSIS SURGICAL ASEPSIS antimicrobial soap. All practices intended to Refers to those practices that 2. Wash hands if exposed to spore-forming organisms such as C. confine a specific keep an area of object free of difficile, Bacillus anthracis, or Norovirus microorganism to a specific all microorganisms; it area, limiting the number, includes practices that destroy If hands are not visibly soiled (WHO, 2009), use an alcohol-based, growth, and transmission of all microorganisms and waterless antiseptic agent for routinely decontaminating hands in microorganisms. spores. the following clinical situations: MEDICAL ASEPSIS Before, after, and between direct patient contact (e.g., taking Goal: To prevent the spread of the infection within and between a pulse, lifting a patient) individuals Before putting on sterile gloves and before inserting invasive devices such as a peripheral vascular catheter or urinary o If the patient is the cause of the infection, then nurses would catheter be protecting their selves and; After contact with the body fluids or excretions, mucous o If the health care provider is the source of infection, then you membranes, nonintact skin, and wound dressings (even if are protecting the patient from having such infection. gloves are worn) When moving from a contaminated to a clean body site during care After contact with surfaces or objects in the patient’s room (e.g., overbed table, IV pump) After removing gloves (CDC, 2008a) SURGICAL ASEPSIS PRINCIPLES OF SURGICAL ASEPSIS Performing sterile aseptic procedures requires a work area in which objects can be handled with minimal risk of contamination. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan 1  o Sterile field – work area wherein only sterile objects and supplies should be on use. The following principles are important: 1. A sterile object remains sterile only when touched by another sterile object. a) Sterile touching sterile remains sterile b) Sterile touching clean becomes contaminated c) Sterile touching contaminated becomes contaminated d) Sterile state is questionable i Sterile instruments or products which are often in packets. When there is breakage in that packet or packaging, it is considered unsterile already. Only sterile objects may be placed on a sterile field. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. A sterile object or field becomes contaminated by prolonged exposure to air. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. Fluid flows in the direction of gravity The edges of a sterile field or container are considered to be contaminated. APPLYING STERILE GLOVES – Gloves help to prevent the transmission of pathogens by direct and indirect contact. – This requires meticulous action and careful application of the glove to keep it sterile GLOVING METHODS 1. OPEN GLOVING – Gloves are usually used in regular or in general ward activities – Ex: Application of catheters, IV cannulas, insertion of catheters, cleaning of wounds, changing of bandages and etc. 2. CLOSED GLOVING – Usually utilized in the operating room areas and surgical procedures RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan 2  FUNDAMENTALS IN NURSING PRACTICE BASIC CALCULATIONS (CALCULATING IV DRIPS) INTRAVENOUS FLUID REGULATION SOLVE: When you have an order for an IV Infusion, it is the 3. Give 80ml IV in 4 hours. The drop factor is 60. nurse’s responsibility to make sure the fluid will infuse Determine the number of drops per minute. at the prescribed rate. IV fluids may be infused by gravity using a manual roller Solution: clamp or dial-a-flow, or infused using an infusion pump. 4 hours x 60 min = 240 mins 1hr KEY TERMS: (80ml) (60ugtts/ml) = 20 gtts/min Drop factor – Number of drops in one mL of solution, 240 mins and is printed on the IV tubing package. Macro drip and micro drip – Refers to the diameter of B. TO CALCULATE THE ML/HR the needle where the drop enters the drip chamber. Macro drip tubing delivers 10 to 20 gtts/mL and is used to infuse large volumes or to infuse fluids quickly. Micro drip tubing delivers 60 ugtts/mL and is used for small or very precise amounts of fluid, as with neonates or pediatric patients. Normal KVO rate delivers 10gtss/ml or 42 ml/hr 1. A physician ordered an IVF of PNSS 500 to run for 60ugtts/min for a 3 year old child who is suffering from DEFINING THE FORMULA dehydration. As a nurse you have to know how many ml/hour is the child receiving during the infusion. Calculate for the ml/hour using micro drip. Solution: 60ugtts/min x 60 mins = 60ugtts x 60 mins x ml VARIABLE DEFINITION 60ugtts/ml min hr 60ugtts Flow Rate The amount of liquid going into the = 60 ml/hr patient within a contain timeframe. Volume of liquid The amount of liquid measured in mLs 2. The physician ordered PNSS1L for a 65 year old or mcLs etc. patient to run for 25 gtts/min. She is high risk for cardiac Time The time measured in hours or overload, calculate for the number of ml/hr you are to minutes. administer for the client using macro drip. A. TO CALCULATE THE NUMBER OF DROPS/MINUTE Solution: TO GIVE THE PATIENT 25gtts/min x 60 mins = ml/hr 15gtts/ml 25gtts/min x 60 min = 25gtts x 60 min x ml 15gtts/ml min hr 15gtts 1500ml = 100 ml/hr 1. Dr. Park ordered an IVF for a CVA patient of D5LRS1L 15 hr to run for 8 hours, how many gtts/minute should the nurse regulate the flow of the IV? Calculate using a SOLVE: macrodrip. 3. Seo-Joon who is suffering from severe dehydration is Solution: receiving 50gtts/min of D5NM1L using macro drip as 100ml x 15 gtts/ml = gtts/min prescribed. How may ml/hour are you infusing to pt. x? 8 hours x 60 mins 1 hour Solution: 50 gtts/min x 15 gtts x 60 min = 200 ml/hr 15,000 gtts = 31.25 gtts/min or 31 gtts/min 15 gtts/ml hr 480mins C. TIME OF RUNNING FOR IV MEDS 2. Dr. Ik-jun ordered 500ml of 10% glucose to be administered IV in 8 hours. If the equipment has a drop factor of 15, what rate should the IV flow be adjusted? Solution: 500ml x 15 gtts/ml = gtts/min 480mins 1. The physician ordered 1L of D5W to be transfused in 200ml per hour. Calculate for the total number of hours 7500gtts = 15.6 or 15 to 16 gtts/min of infusion. 480mins Solution: 1000ml = 5 hours 200ml/hr RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan 2. Calculate for the total number of hours of infusion: 2000ml D5W to be infused at 125 ml/hr Solution: 2000ml = 16 hours 125ml/hr SOLVE: 3. The doctor ordered D5 O.3 NACL1L x 20 ugtts/min to a 3 year old child. How many hours will be the transfusion of the IVF? a. Get ml/hr first b. Get # of hours Solution: a) 20 ugtts/min x 60 min = 20 ml/hr 60 ugtts/ml hr b) 1000ml = 50 hours 20 ml/hr RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DRUG CALCULATIONS COMMON DOSAGE ADMINISTRATION SCHEDULES Solve: 300mcg x 1 tab = 3 tabs 100mcg AC, ac Before meals PC, pc After meals 2. The physician orders Dilantin in an oral suspension 0.1 Ad lib As desired gm p.o. The physician sends up a bottle labelled 125mg OD Once a day in 5ml. How many ml should the nurse administers? BID Two times a day TID Three times a day Solution: QID Four times a day Convert first: 0.1 gm x 1000mg = 100 mg PRN As needed 1gm h, hr Hour 100mg x 5ml = 4ml HS, hs At bedtime 125 mg qH Every hour q2H Every 2 hours 3. You have a syrup that contains 250mg in 5 ml. What q4H Every 4 hours volume contains 150mg? q6H Every 6 hours q8H Every 8 hours Solution: STAT Give immediately/ now 150mg x 5ml = 3ml 250mg SYSTEMS OF MEDICATION MEASUREMENT: SOLVE: VOLUME EQUIVALENTS 4. The physician orders 1000mg of Acetaminophen METRIC HOUSEHOLD (Tylenol) p.o. The only available tablets are 0.5gm 1 ml 15gtts each. How many tablets are needed to administer this 4-5ml 1 tsp dose? 15ml 1 tbsp 30m; 2 tbsp Solution: 240ml 1 cup 0.5 gm x 1000 mg = 500 mg 480ml (approx. 500ml) 1 pint (pt) 1gm 960ml (approx.. 1L) 1 qt 3840ml (approx.. 4L) 1 gallon 1000mg x 1 tab = 2 tabs 500mg WEIGHT EQUIVALENTS 5. The physician orders 0.125mg orally (po) of digoxin. METRIC APOTHECARY The medication is available in tablets containing 0.25 1mg 1/60 grain mg. Calculate how many tablet you are going to give? 60mg 1 grain Solution: 1g 15 grains 0.125mg x 1 tab = 0.5 tabs or ½ tabs 4g 1 dram 0.25mg 30g 1 ounce 500g 1.1 pound 6. The order states, “Erythromycin suspension 250mg 1000g (1 kg) 2.2 lb P.O. The pharmacy delivers 100-ml bottles with the labels stating, “5ml contains 125 mg of erythromycin.” ORAL MEDICATIONS Calculate how many ml are you going to administer? FORMULA: Solution: 250mg x 5ml = 10ml D xQ=X 125mg S 7. The doctor orders Catapres 300mcg p.o every 8 hours. D – desired dose You have 0.1 mg tablets on hand. How many tablets S – dose on hand (dosage in the packaging) would you administer? Q – quantity on hand X – amount to be administered Solution: 300mcg = 0.3mg x 1 tab = 3 tabs Examples: (Oral Medications) 1000mcg 0.1mg 1. The doctor order Catapres 300mcg p.o every 8 hours. Other way: You have 0.1 mg tablets on hand. How many would you 0.1mg x 1000mcg = 100mg administer? 1mg Solution: 300mg = 3 tabs Convert first: 0.1 mg x 1000mcg = 100mcg 100mg 1mg RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  IV MEDICATIONS 7. A diabetic patient has an order of regular insulin 5 units FORMULA: t.i.d a.c. The available regular insulin is 20 units per cc. How many ml would you give? D xQ=X S Solution: 5 units x 1cc = 0.25cc or 0.25 ml D – desired dose 20 units S – dose on hand (dosage in the packaging) Q – quantity on hand CALCULATE FOR INDIVIDUALIZED DRUG DOSAGE X – amount to be administered Body Weight Body Surface Area Examples: (IV Medications) CALCULATING DOSAGE ACCORDING TO BODY 1. Your patient needs to receive Demerol, 50mg IM (dose WEIGHT ordered). The medication is available only in ampules containing 100mg (dose on hand). Calculate how many The steps involved in calculating an individualized dose are ml are you going to give? as follows: Solution: 1. Convert pounds to kilograms 50mg x 1ml = 0.5ml 2. Determine the drug dose per body weight by multiplying 100mg drug dose x body weight x frequency 3. Choose a method of drug calculation to determine the 2. Drug A is available in 250mg/10 ml vials. The patient amount of medication to administer. needs a dose of 10mg IV. Calculate the volume required. Examples: Solution: 1. Calculate the dose of amoxicillin suspension in mLs for 10mg x 10 ml = 0.4ml otitis media for a 1-yr-old child weighing 22 lb. The dose 250mg required is 40 mg/kg/day divided BID and the suspension comes in a concentration of 400 mg/5ml. 3. Chlorpromazine injection is presented in a 1ml ampoule in a concentration of 50mg/ml. What volume contains Step 1: Convert pounds to 22 lb x 1 kg/2.2 lb = 10kg 30mg? kg Step 2: Calculate the dose 10 kg x 40 mg/kg/day = 400 Solution: in mg mg/day 30mg x 1ml = 0.6ml Step 3: Divide the dose by 400 mg/day ÷ 2 (BID) = 200 50mg the frequency mg/dose BID Step 4: Convert the mg 200 mg/dose ÷ 400 SOLVE: dose to mL mg/5mL = 2.5 mL BID 4. The physician orders Dilantin (phenytoin) in an oral 2. Calculate the dose of ceftriaxone in mLs for meningitis suspension 0.1 gm p.o. The pharmacy sends up a for a 5-yr-old weighing 18 kg. The dose required is 100 bottle labeled 125mg in 5ml. How many ml should the mg/kg/day given IV once daily and the drug comes nurse administer? prediluted in a concentration of 400 mg/mL. Solution: Step 1. Calculate the dose 18 kg × 100 mg/kg/day = 1800 0.1gm x 100mg = 100 mg in mg: mg/day 1gm Step 2. Divide the dose by 1800 mg/day ÷ 1 (daily) = 1800 100mg x 5ml = 4ml the frequency: mg/dose 125mg Step 3. Convert the mg 1800 mg/dose ÷ 400 mg/mL = dose to mL: 4.5 mL once daily 5. If the stock atropine SO4 is 0.5mg (gr. 1/120) in a 1cc ampule and the ordered dose is gr. 1/150. We give how CALCULATING DOSAGE ACCORDING TO BODY many ml? SURFACE AREA Solution: Child’s Dose = surface area of child (m2) x normal adult dose 1/150 = 0.007 = 0.875cc or.9 cc 1.7 (m2) 1/120 = 0.008 Example: 6. The patient develops PVC’s, the doctor ordered 50mg Lidocaine 2% IV bolus. The stock in the unit is 1gm in 1. A child who weighs 10 kg and is 50 cm tall has a body 50cc vial. How many cc would you give to the patient? surface area of 0.4 m2. Therefore, the child’s dose of tetracycline corresponding to an adult dose of 250 mg Solution: would be as follows: 1gm x 100mg = 100mg 1gm 50mg x 50cc = 2.5cc 100mg RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  [LAB] FUNDAMENTALS OF NURSING PRACTICE ASSESSING RESPIRATIONS OBJECTIVES: Exercise o Define respiration and enumerate the function Sympathetic o Identify types of respirations Stimulation o Discuss factors affecting respiration Smoking o Identify normal respiratory rate for different age of – Causes constriction of blood vessels clientele Require more oxygen o Demonstrate proper technique in assessing Pyrexia respiration – If with fever COUNTING RESPIRATORY RATE DECREASES i Depth if in pain Pathologies Sedatives and analgesics – Decrease of Body activities Parasympathetic Relaxation Increased ICP (intracranial pressure) COMMON CAUSES OF AN INCREASED RESPIRATORY RATE RESPIRATION o Fever Respiration is the process of breathing in and out o Dehydration When we breath in we are inhaling oxygen (O2) o Heart conditions When we breathe out, we are exhaling carbon dioxide o COPD (CO2) o Overdose The function of the respiratory system is to supply o Hyperventilation blood with oxygen (O2) and rid the blood of carbon o Acidosis dioxide (CO2) o Asthma o Infection TYPES OF RESPIRATION o Lung Conditions External – Inhalation and Exhalation WHAT TO CHECK AND ASSESS Internal Rate – Happens inside Rhythm o Aerobic Pattern o Anaerobic Depth Sound NORMAL RESPIRATORY RATES FACTORS AFFECTING RESPIRATION INCREASES h rate if in pain h in BMR – Basal Metabolic Rate (increase the usage of body’s stored nutrients > functioning of body systems) RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  RESPIRATORY RHYTHM OR PATTERN c. Stridor Regular – Auscultated mainly in inspiration Irregular – Gasping sound 2. DISCONTINUOUS a. Coarse Crackles – Fluid/Phlegm accumulation in the lungs – Low pitched, wet bubbling sound – Auscultated mainly in inspiration (can extend in expiration) b. Fine Crackles – Auscultated mainly in inspiration – High pitched RESPIRATORY PATTERN AND DEPTH c. Pleural Friction Rub – Auscultated in inspiration and expiration – Low pitched/harsh/grating sound STEPS IN ASSESSING RESPIRATION 1. Review medical record (patient’s chart) for baseline data and factors that influence respiration 2. Introduce self 3. Identifies client using 2 identifiers 4. Explains the procedure and purpose to the client 5. Gather necessary equipment 6. Performs medical asepsis (hand wash) don gloves if necessary/if situation requires 7. Provides privacy for the client 8. Assist the patient to sitting or lying position. 9. Observe or palpate and count the respiratory rate a. Place a hand against the client’s chest to feel the chest movements with breathing, RESPIRATORY SOUNDS or place the client’s arm across the chest (Normal Lung Sounds) and observe the chest movements while supposedly taking the radial pulse 1. BROCHIAL b. Count the respiratory rate for 30 seconds if the respirations are regular. Count for 60 seconds – High pitched if they are irregular. An inhalation and an – Anteriorly exhalation count as one respiration 2. BRONCHOVESICULAR 10. Observe the depth, rhythm, and character of – Anteriorly and Posteriorly respirations 11. Observe the respirations for depth by watching the 3. VESICULAR movement of the chest. – Anterior between first and second intercostal space, 12. Observe the respirations for regular or irregular sternum, and shoulders rhythm. 13. Observe the character of respirations—the sound RESPIRATORY SOUNDS they produce and the effort they require. (Abnormal Lung Sounds) 14. Ensure that the patient is safe and comfortable. 15. Remove gloves and discard in appropriate receptacle. 1. CONTINUOUS 16. Perform medical asepsis (hand wash). a. High-pitched, polyphonic wheeze 17. Document findings in TPR sheet. – Auscultated mainly in expiration 18. Inform the doctor for abnormal findings. – More than 1 type – If nawala, nagclose na ang windpipe (tell the REFERENCES: doctor immediately) Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of nursing. Ninth b. Low-pitched, monophonic wheeze edition. St. Louis, Mo.: Mosby Elsevier. – Auscultated mainly in inspiration Weber, J. et al. (2014). Health Assessment in – One type Nursing. (5th Ed.). Philadelphia, Lippincott RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  [LAB] FUNDAMENTALS OF NURSING PRACTICE MEASUREMENT OF BODY TEMPERATURE OBJECTIVES: Fever (As a review) discuss temperature regulation in – Increases cellular metabolic rate and thus the human body increases body’s temperature. Discuss factors affecting body temperature Describe heat-loss mechanisms FACTORS AFFECTING THE BODY TEMPERATURE Discuss the different methods of measuring body Age temperature Diurnal Variations Identify the materials needed in measuring body – BT normally changes throughout the day. 3pm is temperature usually the warmest time of the day. Demonstrate proper technique in measuring and recording body temperature from the axilla (using Exercise digital thermometer) – Hard work or strenuous exercise can increase body temperature. BODY TEMPERATURE – It is the balance between the heat production by the Hormones body and the heat lost from the body – Estrogen and progesterone secretion at the time of ovulation raises body temperature. TWO KINDS OF BODY TEMPERATURE Stress A. SURFACE TEMPERATURE – Stimulation of the sympathetic nervous system – Is the temperature of the skin, the can increase the production of epinephrine and subcutaneous tissue and fat norepinephrine. B. CORE TEMPERATURE Environment – Is the temperature of the deep tissues of the – Extremes in environment can affect a person’s body, such as cranium, thorax, abdominal temperature regulatory systems. cavity and pelvic cavity. – It remains relatively constant 37 degree THE BALANCE BETWEEN HEAT PRODUCTION AND Celsius or 98.5 degree Fahrenheit. HEAT LOSS The body temperature is kept constant when the FACTORS AFFECTING THE BODY HEAT PRODUCTION rate of heat production in the body is equal to the rate of heat loss. Basal Metabolic Rate – It is the rate of energy utilization in the body HEAT LOSS MECHANISMS required to maintain essential activities such as breathing. HEAT TRANSFER BY CONDUCTION – It means heat exchange between objects at different Metabolic rate temp. that are in contact with one another. Example – Decrease with age. TSB when you have fever. Or taking a bath when you have fever. Muscle activity – Including shivering Thyroxine Output – Increases the rate of cellular metabolism throughout the body (hormone produced by the thyroid gland, which acts to increase MR and so regulating GD. Chemical Thermogenesis HEAT TRANSFER BY RADIATION – The stimulation of heat production in the body – It means transfer of heat as infrared electromagnetic through increased cellular metabolism. rays from one object to another at a different temp. Epinephrine, norepinephrine and sympathetic with which it is not contact. Human body radiates heat stimulation rays in all directions but is also exposed to heat rays – Directly affect muscle cells, thereby increasing radiated from the surrounding. Staying in an air- cellular activity. conditioned room or staying under the heat of the sun RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  DONTs (AXILLARY) a. No to patients without upper extremities, with axillary mass DONTs (Rectal) a. With hemorrhoids b. Rectal Cancer c. Diarrhea Pacifier Thermometers HEAT TRANSFER BY EVAPORATION – The pacifier thermometers are used to check the – Even when a person is not sweating a certain amount body temperature of babies or infants. of water still evaporates from the skin and lungs at a – They help measure the body temperature without rate of about 600 ml/day. This is known as the irritating the baby. insensible water loss. – The thermometer is held in the mouth of the baby – Sweating provides a very important way of heat loss and the baby's natural sucking instinct is used to from the body which can be regulated. check its body temperature. – The pacifier thermometers are very safe for CONVECTION checking the body temperature of babies. – It is the removal of heat from the body by convection air currents. Underarm or Oral Thermometers – Heat must first be conducted to the air and then – The underarm thermometers are kept in the carried away by the convection current. Example is underarms to measure the body temperature of sitting in front of the fan or having the wind blow on the patient. you. – Likewise, the oral thermometers are held in the mouth for temperature measurement. TYPES OF THERMOMETER – there are three types of clinical thermometers depending on the body part used to measure the temperature 1. Ear (Tympanic) Thermometer – Don’t use it if the patient has an ear problem (otitis media) – Human ear is located near the brain. This makes is an accurate point to measure the body TIPS ON MEASURING BODY TEMPERATURE temperature The most accurate way to measure an infant’s – The temperature of the eardrum is measured by temperature is rectally with a digital thermometer. the ear thermometers. The most accessible area for measurement is the – However, the eardrum is most fragile and axilla. delicate body part. Therefore, the body o Measuring body temperature through the armpit temperature cannot be measured by touching is probably the most inaccurate, in comparison the eardrum to oral or rectal measurements. – For temperature measurement, infrared sensors Invest in two thermometers, one for oral measurement are used to remotely sense the temperature of and one for rectal measurements. Do not use one the eardrum. thermometer for both purposes. Ear thermometers are not recommended for infants, as earwax buildup or a curved, tiny ear canal may yield inconsistent temperature readings. If taking the temperature orally, do not move the mouth around and make sure the thermometer is in one place, under the tongue. Also, do not open the mouth until the temperature is verified. If taking the temperature orally, wait at least 15 minutes after food or beverage consumption before 2. Digital Thermometer measuring for accuracy. DONTs (ORAL) If body temperature needs to be recorded over a a. If patient is with gingivitis, oral thrush, stomatitis period of time, it is best to take the temperature at the (foot and mouth disease), same time every day with the same thermometer for b. No to young children, patients with seizure disorder, optimal comparison. This is especially important when post stroke patients. Only to adult patients who are using basal thermometers for female fertility conscious and coherent purposes. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  Before using the thermometer, make sure the contact tip of the mechanism, as well as the intended contact surface, are clean and debris free. It doesn’t hurt to wipe both with some rubbing alcohol, just in case, before use. STEPS IN MEASURING BODY TEMPERATURE (AXILLA) 1. Review medical record (patient’s chart) for baseline data and factors that influence vital signs. 2. Introduce self. 3. Identify the patient using two (2) identifiers. 4. Explain the procedure and the purpose of assessment. 5. Assess the patient’s toiletting needs. 6. Gather necessary equipment and check that the thermometer is working or functional. 7. Perform medical asepsis (hand wash) and don dispossable gloves (as necessary). 8. Provide privacy. 9. Assist the patient to sitting or lying position. 10. Expose the axilla by rolling the sleeve of the patient’s gown. Make sure to keep the chest covered. o **Note: Avoid taking the temperature in the axilla if it is with lesions. 11. Pat dry the armpit as necessary with tissue. 12. Prepare the thermometer: a. Remove from storage container or protective case. b. Hold the far end opposite the probe (rounded tip) or sensor. c. Clean (wipe) with alcohol swab (or cotton ball with alcohol) from the probe to the center near the display window. d. Discard the used cottonball in proper receptacle. e. Press the “ON” button and wait for the signal. 13. Lift the patient’s arm. 14. Place the probe (sensor) at the center of the armpit (directed towards the patient’s back). 15. Instruct the patient to fold the arm across the chest and keep still. 16. Leave the thermometer in place until the alarm (beeping sound) sets off. 17. Lift patient’s arm and remove the thermometer. 18. Roll back the sleeve of the patient’s gown. 19. Read the temperature as displayed. 20. Inform the patient. 21. Press the “OFF” button. 22. Clean (wipe) the thermometer with alcohol swab (or cotton ball with alcohol) from the center to the probe. 23. Discard used cotton ball to proper receptacle. 24. Return the thermometer inside storage container. 25. Ensure that the patient is safe and comfortable. 26. Remove gloves and discard in appropriate receptacle. 27. Perform medical asepsis (hand wash). 28. Document findings in TPR sheet. REFERENCES Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of nursing. Ninth edition. St. Louis, Mo.: Mosby Elsevier. Weber, J. et al. (2014). Health Assessment in Nursing. (5th Ed.). Philadelphia, Lippincott RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  [LAB] FUNDAMENTALS OF NURSING PRACTICE ASSESSING THE PULSE FACTORS AFFECTING PULSE RATE OBJECTIVES: o Discuss factors affecting pulse Age – As age increases, the pulse rate gradually o Identify pulse sites decreases o Discuss different areas of assessment Gender – after puberty, the average male’s pulse rate o Identify materials needed for the procedure is slightly lower than the female’s o Demonstrate proper technique in assessing pulse Exercise – increases with activity. Athletes have less pulse rate than the average person because of PULSE greater cardiac size, strength and efficiency – It is a wave of blood created by contraction of the left Fever – increases because of ventricle of the heart a. In response to the lowered blood pressure that – Generally, the pulse wave represents the stroke results from peripheral vasodilation volume output and the amount of blood that enters b. Because of increased metabolic rate the arteries with each ventricular contraction. In a healthy person, the pulse reflects the heartbeat. That Medications is, the pulse rate is the same as the rate of ventricular – Cardiotonics – decrease the heart rate; contraction of the heart. epinephrine increases it. – Cardiac output – is the volume of blood pumped into Hypovolemia – loss of blood in the vascular system the arteries by the heart and equals the result of the normally increases the heart rate stroke volume times heart rate. 5 liters of blood is Stress – sympathetic nervous system stimulation – normally pumped by an adult heart when at rest. increase Position changes APICAL PULSE – Standing or sitting – causes pooling and consequently results in transient decrease of venous return and subsequent lowering of BP – Compensatory mechanism Pathology PULSE SITES Temporal – Passes over the temporal bone of the head – Superior and lateral to the eye PERIPHERAL PULSE – Used when radial pulse is not accessible Carotid – Side of the neck where the carotid artery runs between the trachea and sternocleidomastoid muscle – Used during cardiac arrest/shock in adults – Used to assess for circulation to the head Apical – At the apex of the heart; before the age of 4 apex is at the left of the midclavicular line (4th ics), bet 4-6, it is at the mcl, for 7-9 either 4th or 5th ics. – Routinely used for infants and children up to 3 yrs of age – Used determine discrepancies with radial pulse – Used in conjunction with some medications. Brachial – At the inner aspect of the biceps muscle of the arm or medially in the antecubital space – Used to measure bp – Used in cardiac arrest of infants RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  Femoral – Where the femoral artery passes alongside the In some clients, the rate changes with position because inguinal ligament of changes in blood flow volume and autonomic nervous – Used in cases of cardiac arrest system activity – Determines circulation to the leg AREAS OF ASSESSMENT Popliteal – Where the popliteal artery passes at the back of Rate the knee Volume – Determines circulation to the lower leg Elasticity Equality Posterior tibial Rhythm – On the medial aspect of the ankle – Circulation to the foot PULSE RATE Pedal (dorsalis pedis) Normal Ranges (beats per minute, bpm): – an imaginary line drawn from the middle of the ü Newborns – 80-180 ankle to the space between the big toe and the ü 1 year – 80-140 second toe ü 5-8 years – 75-120 – Circulation to the foot ü 10 years – 50-90 ü Teen – 50-90 Radial ü Adult – 60-100 – On the thumb side of the inner aspect of the wrist – Readily accessible PULSE RATE DEVIATIONS Tachycardia- excessive physical activity; respiratory problems (COPD, ARDS) Bradycardia – Post anesthesia, CAD Pulse Deficit – Caused by inefficient contraction of the heart; the heart fails to transmit a pulse wave to the peripheral site – To assess for pulse deficit, a nurse and a colleague assess the radial and apical pulse simultaneously and then compares it. The difference between the radial and apical pulse is the pulse deficit. PULSE RHYTHM – Equal time elapses between beats of a normal pulse – Pattern of the beats and the intervals between the beats Dysrhythmia/Arrhythmias – An interval interrupted by an early or late beat or a missed beat – It may consist of random, irregular beats or a predictable pattern of irregular beats – When this is detected, the apical pulse is assessed. – An ECG is needed to define the dysrhythmia further. ASSESSING THE PULSE PULSE VOLUME – Also called PULSE STRENGTH or AMPLITUDE, Considerations refers to the force of blood with each beat. Usually, – Any medication the pulse volume is the same with each beat. – If the client has been physically active – Any baseline data about the client’s normal heart Normal – can be felt with a moderate pressure of the rate fingers and can be obliterated with greater pressure. – Positional variations Weak/Thready – readily obliterated with pressure from fingers; it is also characterized as feeble If the client has been physically active, wait for 10-15 Full/Bounding – is obliterated only with difficulty minutes until the client has rested RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  4. Select pulse site. Normally, the radial pulse is taken, PULSE STRENGTH SCALE unless it cannot be exposed or circulation to another body area is assessed SCALE DESCRIPTION 5. Assist the client in a comfortable position. When the 0 Absent, not palpable radial pulse is assessed, with the palm facing 1+ Pulse diminished, barely downward, the client’s arm can rest along the side of palpable the body or the forearm can rest at 90º angle across 2+ Easily palpable, normal the chest 3+ Full pulse, increase 6. Palpate and count for the pulse. Place two or three 4+ Strong, bounding pulse, middle fingertips lightly and squarely over the pulse cannot be obliterated point. 7. Count the pulse rate PULSE ELASTICITY 8. Assess the pulse rhythm and volume. Normal – feels straight, smooth, soft and pliable 9. Document pulse rate, rhythm and volume and other pertinent related data. Older people often have inelastic arteries that feel twisted and irregular upon palpation. o Thumb is not used because the thumb has a pulse Elasticity – reflects its expansibility or its deformities. that can be mistaken for the client’s own pulse. Pliable – easily bent or shaped o Count for 15 seconds and multiply by 4. PULSE EQUALITY/BILATERAL EQUALITY o IF the pulse is irregular, count for one full minute. o AN irregular pulse requires the taking of apical Pulses on both sides of the peripheral vascular pulse. system should be assessed. All symmetrical pulses should be assessed EVALUATION simultaneously except for the carotid pulse. Compare the pulse rate to baseline data or normal The carotid pulse should NEVER be assessed range for age of client simultaneously because it will occlude the circulation blood circulation to the brain. Relate pulse rate and volume to other vital signs; pulse rhythm and volume to baseline data and health ASSESSMENT status Clinical signs of cardiovascular alterations other than If assessing peripheral pulses, evaluate equality, rate pulse rate, rhythm or volume and volume in corresponding extremities Fatigue Conduct appropriate follow-up such as notifying the physician or giving medication Pallor Cyanosis VARIATION: USING A DUS Palpitations Syncope 1. If used, plug the stethoscope headset into one of the Impaired peripheral tissue perfusion two output jacks located next to the volume control. Factors that may affect pulse rate 2. Apply transmission gel either to the probe at the Site most appropriate for assessment narrow end of the plastic case housing the transducer, or to the client’s skin. EQUIPMENT 3. Press “on” button Watch with second hand or indicator 4. Hold the probe against the skin over the pulse site. Stethoscope (for apical pulse assessment) Use a light pressure and keep the probe in contact Doppler Ultrasound (if needed) with the skin 5. Adjust the volume if necessary. Distinguish artery PREPARATION sounds from vein sounds. If arterial sounds cannot be If the client has been physically active, wait for 10-15 easily heard, reposition the probe. minutes for the client to rest. Warm the stethoscope (if to be used) For number 5. Arterial sounds are distinctively pulsating Check functionality of DUS (if to be used) and have a pumping quality. The venous sound is intermittent and varies with respirations. Both artery PERFORMANCE sounds and vein sounds are heard simultaneously through DUS because major arteries and veins are 1. Explain to the client what you are going to do, why it situated close together throughout the body. is necessary and how she or he can cooperate. Discuss how the results will be used for planning 6. After assessing the pulse, remove all gel from the further care or tx probe to prevent damages to its surface. Clean the 2. Wash hands and observe appropriate infection control transducer with aqueous solutions. procedures – Alcohol or other disinfectants may damage the 3. Provide for client privacy face of the transducer. 7. Remove all gel from the client. VARIATION: ASSESSING THE APICAL PULSE RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  Performance 1. Explain the procedure to the client 2. Observe appropriate infection control procedures. 3. Provide for client privacy. 4. Position comfortably and expose the area of the chest over the apex of the heart. 5. Locate the apical impulse. This is the point over the apex of the heart where the pulse can be most clearly heard. 5.1 Palpate the angle of Louis (between manubrium and top of the sternum, and the body of the sternum). It is palpated just below the suprasternal notch and is felt as a prominence. 5.2 Slide your index finger just to the left of the client’s sternum, and palpate the second intercostal space, and continue palpating downward until the 5th ICS. 5.3 Move your index finger laterally along the 5th ICS toward the MCL. Normally, the apical impulse is palpable at or just medial to the MCL. 6. Auscultate and count heartbeats. 6.1 Use antiseptic wipes to clean the earpieces and diaphragm 6.2 Warm the diaphragm by holding it in the palm of the hand for a moment. 6.3 Insert earpieces of the stethoscope into your ears in the direction of the ear canals. or slightly forward to facilitate hearing 6.4 Make sure the diaphragm is active 6.5 Place the diaphragm over the apical impulse and listen for S1 and S2 heart sounds, which are heard as “lubb-dubb” 6.6 If rhythm is regular, count for 30 seconds and multiply by two. If irregular, count for one full minute. 7. Assess the rhythm and strength 8. Document REFERENCES Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of nursing. Ninth edition. St. Louis, Mo.: Mosby Elsevier. Weber, J. et al. (2014). Health Assessment in Nursing. (5th Ed.). Philadelphia, Lippincott RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  [LAB] FUNDAMENTALS OF NURSING PRACTICE PHYSIOLOGY OF CIRCULATION (FLOW, PRESSURE, AND RESISTANCE) BLOOD FLOW BLOOD VESSEL DIAMETER – Volume of blood flowing through vessels, organs, or – Has the greatest influence on resistance the entire circulation in a given time – Frequent changes alter peripheral resistance. – Measured in mL/min – Viscosity and blood vessel length are relatively – Equivalent to cardiac output (CO) for the entire constant. vascular system – Relatively constant when at rest, but may vary at any given moment BLOOD PRESSURE – Force per unit area exerted on the wall of the blood vessel by the blood – It is expressed in mmHg – Fluid close to the walls moves more slowly than in the – It is measured as the systemic arterial blood pressure middle of the tube (laminar flow). in large arteries near the heart – The pressure gradient provides the driving force that keeps blood moving from higher- to lower-pressure areas. – Resistance varies inversely with the fourth power of RESISTANCE (PERIPHERAL RESISTANCE) vessel radius: – Resistance of the blood vessels to blood flow If the radius increases, resistance decreases, – Opposition to flow and vice versa. – Measurement of the amount of friction that blood Example: If the radius is doubled, resistance encounters with the vessel walls, generally in the drops to 1/16 as much. peripheral (systemic) circulation BLOOD VISCOSITY – Volume of blood flowing through vessels, organs, or the entire circulation in a given time – Small-diameter arterioles are major determinants of – The greater the viscosity, peripheral resistance. the less easily molecules are able to slide past each The radius changes frequently, in contrast to other. larger arteries that do not change often. – Increased viscosity equals increased resistance. TOTAL BLOOD VESSEL LENGTH – The longer the vessel, the greater the resistance encountered. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan – Abrupt changes in vessel diameter or obstacles SYSTOLIC PRESSURE dramatically increase resistance. – This pressure is exerted in the aorta during ventricular contraction. – Pressure due to contraction – The left ventricle pumps blood into the aorta, imparting kinetic energy that stretches the aorta. – It averages 120 mm Hg in a normal adult. RELATIONSHIP BETWEEN FLOW/PRESSURE/RESISTANCE Blood flow (F) is directly proportional to blood pressure gradient (P). – If △P increases, blood flow speeds up. Blood flow is inversely proportional to peripheral resistance (R). DIASTOLIC PRESSURE – If R increases, blood flow decreases – This pressure is the lowest level of aortic pressure when the heart is at rest. R is more important in influencing local – Pressure at rest blood flow because it is easily changed by altering the blood vessel diameter. SYSTEMIC BLOOD PRESSURE – The pumping action of the heart generates blood flow. – Pressure results when flow is opposed by resistance. – Systemic pressure is the highest in the aorta and declines throughout the pathway. – The steepest drop occurs in the arterioles. PULSE PRESSURE – The difference between the systolic and diastolic blood pressure PULSE – Throbbing of the arteries due to the difference in pulse pressures, which can be felt under the skin MEAN ARTERIAL PRESSURE (MAP) – This pressure that propels blood to the tissues. – Pulse pressure phases out near the end of the arterial tree. – Flow is non pulsatile with a steady MAP pressure. ARTERIAL BLOOD PRESSURE 🛈 The heart spends more time in diastole, so MAP is – Arterial blood pressure is determined by 2 factors: not just a simple average of diastole and systole. MAP IS CALCULATED BY: 🛈 The blood pressure nearest to the heart is pulsatile it rises and falls with each heartbeat. *SBP: systolic blood pressure; DBP: diastolic blood pressure RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  🛈 Pulse pressure and MAP both decline with increasing distance from the heart. CLINICAL MONITORING OF CIRCULATORY EFFICIENCY Vital signs: Pulse, blood pressure, respiratory rate, and body temperature Taking a pulse: Pressure points: areas where arteries are close to the body surface can be compressed to stop blood CAPILLARY BLOOD PRESSURE flow in the event of hemorrhaging. REGIONS TO CHECK THE PULSE Low capillary pressure is desirable because: …high blood pressure would rupture fragile, thin- walled capillaries. … most capillaries are very permeable, so low pressure would force filtrate into the interstitial spaces. VENOUS BLOOD PRESSURE – It changes little during the cardiac cycle. – There is a small pressure gradient, only ~15 mm Hg If the vein is cut, the low pressure of the venous system causes the blood to flow out smoothly. MEASURING BLOOD PRESSURE – Systemic arterial blood pressure is measured indirectly by auscultatory methods using a sphygmomanometer. 1. Wrap the cuff around the arm superior to the elbow. 2. Increase the pressure in the cuff until it exceeds the systolic pressure in the brachial artery. 3. Pressure is released slowly, and the examiner listens for Korotkoff sounds with a stethoscope. – Low pressure is due to the cumulative effects of peripheral resistance. SYSTOLIC PRESSURE The energy of the blood pressure is lost as heat It is usually ~120 mmHg during each circuit. Sounds first occur when blood starts to flow through the artery. – The low pressure of the venous side requires adaptations to help with venous return. DIASTOLIC PRESSURE It is usually less than80 mmHg. FACTORS AIDING VENOUS RETURN Sounds disappear when the artery is no longer constricted blood is flowing freely. 1. Muscular pump: Contraction of the skeletal muscles “milks” blood back toward the heart – valves prevent backflow 2. Respiratory pump: Pressure changes during breathing move the blood toward the heart by squeezing the abdominal and thoracic veins. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan 3. Sympathetic venoconstriction: Under sympathetic FACTORS THAT AFFECT REGULATION OF BLOOD control, smooth muscle constricts, pushing blood back PRESSURE: toward the hear Short-term regulation: neural controls Short-term regulation: hormonal controls Long-term regulation: renal controls IN A NUTSHELL: The blood vessels of the body work with lymphatic vessels to circulate fluids. There are 3 types of blood vessels in the body: arteries, veins, and capillaries. Structurally, blood vessels contain 3 tunics: the tunica intima, the tunica media, and the tunica externa. Capillaries are microscopic blood vessels associated with tissues, where nutrient exchange occurs. They contain fenestrations and/or intracellular clefts that make them leaky. REGULATION OF BLOOD PRESSURE The arteries are high-pressure vessels, and veins are – Maintaining blood pressure requires coordination low-pressure vessels. between the heart, the blood vessels, and the Blood pressure is a measure of the pressure that kidneys. All are directed by the brain blood exerts on the wall of the blood vessels. – Blood pressure varies directly with CO (Cardiac Blood pressure and flow are related to cardiac output, Output), PR (Peripheral resistance), and blood peripheral resistance, and blood volume. volume Blood pressure is regulated by hormonal, neural, and renal controls. 3 MAIN FACTORS THAT REGULATE BLOOD At the capillaries, fluid and molecule movement can PRESSURE: be driven by bulk flow and by both osmotic and 1. Cardiac output (CO) hydrostatic pressures. 2. Total peripheral resistance (TPR) The circulatory pathways of the body include the 3. Blood volume pulmonary and systemic circulation. This equation shows that blood pressure (MAP) is directly proportional to CO (cardiac output) and TPR. Changes in 1 variable are quickly compensated for by changes in other variables. Anything that increases SV, HR, or TPR will also increase MAP. – SV is effected by venous return (EDV). – The heart rate is maintained by the medullary centers. – TPR is effected mostly by vessel diameter. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  [LAB] FUNDAMENTALS OF NURSING PRACTICE CHANGES AND ABNORMALITIES IN VITAL SIGNS VITAL SIGNS REVIEW NORMAL VITAL SIGNS – Vital signs measure the body’s functions. Temperature – They provide staff with a picture of what is going on An oral temperature range of 36° to 38° C (96.8° to inside of a patient’s body. 100.4° F) is acceptable. The average is 37° C (98.6° F). REVIEW NORMAL VITAL SIGNS Rectal temperatures are usually 0.5° C (0.9° F) Pulse higher than oral temperatures. – As with all vital signs there is no exact normal, every Axillary and tympanic temperatures are usually patient will have a different and unique baseline to be 0.5° C (0.9° F) lower than oral temperatures. used as comparison. NURSING INTERVENTIONS FOR ABNORMAL VITAL NURSING INTERVENTIONS FOR ABNORMAL VITAL SIGNS SIGNS Temperature Pulse Hypothermia and Hyperthermia Brachycardia, Tachycardia, and Dysrhythmia HYPOTHERMIA BRACHYCARDIA – An abnormally low body temperature. – An abnormally low pulse rate, usually slower than 60/min. Nursing Interventions - create a warm environment, provide blankets, oral and IV fluids, Nursing Interventions - Assess patient for injury, assess vital signs regularly, be prepared for life- positioning, chronic pain, medications that may have saving measures. Notify provider and document decreased the pulse, assess and monitor vital findings. signs, notify provider and document findings. TACHYCARDIA – An abnormally high body pulse rate usually higher than 100/min. HYPERTHERMIA – An abnormally high body temperature. Nursing Interventions - Assess patient for injury, pain, allergic reaction positioning, or medications. Nursing Interventions - Provide oral and IV fluids, Assess and monitor all vital signs. Notify provider administer fever reducing medications as ordered, and document findings. keep linens and clothing dry, prevent shivering but do not warm the patient. Notify provider and document findings. DYSRHYTHMIA – An irregular heart rhythm sometimes found while assessing radial pulse. A fever alone is typically not harmful in adults unless it Nursing Interventions - Assess patient for injury, exceeds 102° F. assess and monitor vital signs. Administer appropriate medications as ordered to maintain heart rhythm. Notify the provider and document findings. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  REVIEW NORMAL VITAL SIGNS Recheck abnormal vital signs to ensure abnormal Respirations results Rate, Depth, and Rhythm QUICK WAYS TO REMEMBER CONTENT The expected rate for adults is 12 to 20/min. o Say information out loud, practice talking to Newborns have rates of 30 to 60/min. friends or in the mirror as if you are the nurse School-age children have respiratory rates of 20 to explaining it to a patient. 30/min. o Make up funny or quirky acronyms about Altered depths are described as deep or shallow medications or processes that will help you A regular rhythm is expected in adults. Occasional remember them. changes in rhythm are not abnormal § For example, the nursing process can be Oxygen saturation is typically between 90%-100% but remembered as ADPIE (assess, diagnose, may vary due to illness plan, implement, and evaluate) o Visualize information HYPOXEMIA § In the example ADPIE, visualize an apple – Abnormally low oxygen in the blood, Oxygen pie with the letters AD on it. Saturation below 90%. TIPS FOR SUCCESS Nursing Interventions - Confirm the vital sign When in Doubt... abnormal and not equipment error, assess patient Assess, diagnosis, plan, then implement positioning, oxygen equipment and environmental factors, assess and monitor vital signs, encourage Always Assess Before Action deep breathing, notify provider and document If two answers feel correct, choose the best answer Opposites Attract! If two answers are complete findings. opposites, one is usually the correct answer REVIEW NORMAL VITAL SIGNS Blood Pressure Normal BP is 120/80 Infants BP is much lower but increases with age HYPOTENSION – Abnormally low blood pressure. Nursing Interventions - Confirm the vital sign abnormal and not equipment error, assess patient positioning, asses for related symptoms and abnormal vital signs, educate patient about calling for assistance to avoid falling, assist with ambulation. HYPERTENSION – Abnormally high blood pressure. Nursing Interventions - Confirm the vital sign abnormal and not equipment error, assess patient positioning, administer medications as ordered, educate patient on lifestyle, diet changes, and stress reduction. REVIEW NORMAL VITAL SIGNS Pulse – As with all vital signs there is no exact normal, every patient will have a different and unique baseline to be used as comparison. IMPORTANT TIPS Gather all the appropriate equipment ready before beginning Know which abnormal vital signs are an emergency and what require further monitoring Always document findings and interventions RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTAL OF NURSING PRACTICE CONCEPT OF MAN, HEALTH AND ILLNESS The person is he to whom this nature is given and who has to use it for his purposes (Palmiano, 2019). B. OBLIGATIONS NURSING METAPARADIGM (PEHN) Person 1. The sick person is expected to see being sick as Environment undesirable and so are under the obligation to try Nursing and get well as quickly as possible. Health 2. After a certain period of time, the sick person must PERSON seek technically competent help (usually a doctor) – Recipient of Nursing Care and cooperate with the advice of the doctor in – Central to the nursing care provided order to get better. – Provide individualized, patient-centered care o Patient-centered care have to identify what the WELLNESS actual need of a certain individual and that – Wellness refers to a state of wellbeing. nurses should provide appropriate care for them. – The basic aspects of wellness include self- responsibility; an ultimate goal; a dynamic growing Nurses are in the unique position to help patients achieve process and maintain optimal levels of health (Potter & Perry, et al., – This includes daily nutrition, stress management, 2018) physical fitness, preventive health care, emotional o Unique position in a sense that they have the health and most importantly, the whole being of an knowledge, skills, and attitude to provide all the care individual. that is necessary for the patient in order for them to meet their health needs and that will enable them to SEVEN COMPONENTS OF WELLNESS perform all their maximum level of functions and thus their optimal levels of health. 1. PHYSICAL – Ability to carry out daily task, achieve fitness, HEALTH, WELLNESS AND ILLNESS maintain adequate nutrition and proper body fat, avoid abusing drugs and alcohol or using HEALTH tobacco products and generally practice a – WHO (1947) defines health as “a state of complete positive lifestyle habits. physical, mental, and social wellbeing and not merely – More particular on how an individual do things in the absence of disease of infirmity” using the body and maintaining the physical health. i o It also places their health in the context of 2. INTELLECTUAL environment. – Ability to learn and use information effectively for o People’s lives, and therefore their health, are personal, family and career development. It affected by everything they interact with. involves striving for continued growth and o This equates health being productive and create a learning to deal with new challenges effectively. living. It focuses on the living state rather on – Uses the mental power category of disease that may cause illness or – Includes the decision-making, critical thinking, death. and make use of the brain. – Nightingale, describe it as “a state of being well and 3. SOCIAL using every power the individual possesses to the – Ability to interact to successfully with people and fullest extent.” within the environment of which each person is a – Parson (1951) defined health as the ability to part, develops and maintains intimacy with maintain normal roles. significant others and develop respect and tolerance for those with different opinions and CONCEPT OF SICK ROLES beliefs. – This includes beings able to build relationship, A. RIGHTS friendship, and able to interact successfully with the people around an individual and the 1. The sick person is temporarily exempt from environment. performing ‘normal’ social roles (such as going to work or housekeeping). The more severe the 4. OCCUPATIONAL sickness, the greater the exemption. – Ability to achieve a balance between work and