Fundamental of Nursing PDF

Fundamental of Nursing  Fundamental of Nursing Table of contents No Topics Page 1. Medical asepsis 1 2. Body temperature 21 3. Pulse...

Fundamental of Nursing  Fundamental of Nursing Table of contents No Topics Page 1. Medical asepsis 1 2. Body temperature 21 3. Pulse 34 4. Blood pressure 46 5. Respiration 54 6. Medication administration 66 7. Nutritional needs 80 8. Basic Human needs 98 9. Professional nurse 106 10. Health and Illness 111 11. Ethical and Legal Aspects in Nursing 119 Practice 12. Comfort, rest and sleep 123 13. Sleep needs 141 14. Intestinal elimination 149 15. Urinary elimination 162  Medical Asepsis Medical Asepsis Out line  Introduction  Definition of terms.  Difference between medical and surgical asepsis  Chain of infection  Body defenses against infection.  Breaking the chain of infection  Specific medical asepsis practice in health care settings  Isolation techniques  Guidelines for preventing blood born disease.  Common practice of medical asepsis in everyday living. 1  Medical Asepsis Introduction The nurse’s efforts are directed toward minimize the onset & spread of infection, keep clients as free from exposure to infection- causing pathogens as possible based on the principles of aseptic technique. Aseptic technique implies all those procedures that eliminate pathogens or minimize their areas of existence. Definition of Terms Pathogens: They are microorganisms that can cause infectious diseases. Infection: It is the pathological condition resulting from the invasion of the body by pathogenic microorganisms. Carriers: Are people or animals that show no symptoms of illness but that have pathogens on or in their bodies that can be transferred to others. Nosocomial Infection (Hospital Acquired Infection): it is an infection acquired from health care settings. Contamination: the process by which something is unclean or un- sterile Disinfection: Process of eliminating pathogenic organisms on an inanimate object with the exception of spores. Disinfectant: Is a chemical substance that is used for disinfecting only an inanimate object (e.g. phenol, chlorine) it reduces the number of microorganisms, but does not eliminate them. 2  Medical Asepsis Antiseptic Solutions: a substance that can be applied to person's skin to reduce the number of microorganisms, inhibit its growth and activity, e.g. (alcohol, betadine). Infection Control Sterilization: is a destruction of all microorganisms and their spores. Asepsis: Refers to practices that minimize or eliminate organisms that can cause infection and disease. There are two types of asepsis medical asepsis and surgical asepsis. Differences Between them Discussed in the Following Table. Items Medical asepsis Surgical asepsis (Clean technique) (Sterile technique) Definition All procedures/ practices that Practices that keep an reduce possibility of disease by area or objects free from reducing the number, growth, all microorganisms (non transfer and spread of pathogenic and pathogenic microorganisms pathogenic) including spores and viruses. Emphasis based on maintaining Based on maintaining (focus) cleanliness to prevent spread of sterilization (free from microorganisms (freedom from all microorganisms). most pathogenic organisms). Purpose To reduce the number of To prevent introduction pathogenic organisms & of any organism into the prevents their spread. body. 3  Medical Asepsis Applications During daily routine care, the Surgical asepsis implies nurse uses medical aseptic the highest level of techniques to break the infection aseptic technique & chain. example changing client’s requires that all areas be bed linen daily, hand washing, kept as free as possible protective barrier clean mask, gown, gloves, over head and of infectious micro- shoes & routine environmental organisms. cleaning, disinfecting articles These techniques can be and use of antiseptics. practiced by nurses in the OR (surgical Clean technique is appropriate incision, delivery room, for: diagnostic Taking BP areas), invasive Examinin procedure as inserting g patients IV cannula, IV Feeding patients therapies, urinary catheter & sterile wound dressings) where sterile instruments& supplies are used Principle In medical asepsis, an area or In surgical asepsis, an object is considered area or object may be contaminated only if it is considered suspected of containing contaminated if touched pathogen (e.g., used bedpan, the by an object that is not floor & a wet piece of gauze). sterile (e.g., a tear in a surgical glove during a procedure, a sterile instrument placed on an un- sterile surface). Hand washing Hands and forearms are washed Hands and forearms are for 1 to 2 minutes to remove scrubbed for surface contaminants and soil. 5 minutes to reduce the Hands and arms are dried with bacterial count on the paper towels. skin surface. Hands and arms are dried with a sterile towel. 4  Medical Asepsis The Goal of Medical Asepsis 1) To prevent or reduce the transmission of microorganisms from one person (or source) to another. 2) To prevent re-infection of the patient. 3) To ensure patient's comfort, safety and psychological well- being 1. Practices That Reduce Pathogens Include; interrupts chain at level of causative agent and reservoir through; a. Hand washing b. Use of disinfectants and antiseptics as appropriate. 2. Practices That Interrupt Transmission; interrupts chain at level of portal of exit, transmission, and portal of entry a. Use of personal protective equipment latex gloves, gowns, mask, eye goggles b. Proper Equipment i.e. one-way valves b. Use of isolation procedures Chain of Infection It is a cyclic process explains how pathogen or infectious disease transmitted from person to another depending on six elements must be present before the development of infection take place. 5  Medical Asepsis 1. Causative agent. 2. Reservoir. 3. Portal of exit. 4. Means of transmission. 5. Portal of entry. 6. Susceptible host. 1. Infectious Agent: Infectious agents are microorganisms that can be grouped into 5 classifications (viruses, bacteria, fungi, protozoa, and rickettsia). In order for an infection to occur, an infectious agent must be present. 2. Reservoir The second ring in the chain of infection is the reservoir or the location of the infectious agent. Reservoirs (source) in which microorganisms live, possibly grow, and multiply. 6  Medical Asepsis People, animals and the environment (equipment, supplies, water, and food) all are reservoirs for microorganisms. 3. portal of exit: The infectious agent must leave the reservoir to infect another person (host); the portal of exit is the method by which an infectious agent leaves the reservoir. The blood, respiratory tract, skin and mucous membranes, genitourinary tract, gastrointestinal tract, and trans-placental route from mother to her unborn infant are some examples. 4. Mode of Transmission Are specific ways by which microorganisms travel from '' reservoir'' to "susceptible host'' 7  Medical Asepsis Routes of transmission include:  Direct contact: '' touching an infected person''  Airborne transmission:'' inhaling the microorganism into the susceptible host's respiratory system''  Blood born transmission: '' infected blood enters the susceptible host''  Ingestion: '' eating or drinking contaminated items''  Indirect contact: ''microorganisms are on a non-living object such as a table or piece of equipment that can absorb and transmit infection '' 5. Portal of entry: The portal of entry allows the agent access to the next person; common entrance sites to the human body include broken skin, mucous membranes and systems' respiratory, GIT and genitourinary'' 6. Susceptible host: a person who susceptible to the microorganism. Causes of susceptibility:  Presence of other diseases  Immunosuppressive disorders  Surgical procedures or trauma Susceptibility of the person depends on several factors: 1. Age (children and elders are more susceptible), and 8  Medical Asepsis 2. socioeconomic status 3. General physical condition 4. Occupation, life style, and living environment 5. Presence of underling disease or health problems Body defenses against infection The body has natural physical, chemical, and cellular defenses against invasion by pathogens as viruses, bacteria or other agents of disease. I- 1st Line of Defense: Body parts and mechanisms that preventing the pathogen from entering to the body include; 10  Medical Asepsis a. Skin (acts as a physical barrier against the entry of pathogens) b. Mucus membranes (inhibit the growth of most pathogenic microbes). c. Mucus and Cilia (Microorganisms are trapped in sticky mucus and expelled by cilia) d. Tears and saliva (wash bacteria away). e. Coughing or sneezing f. PH of body areas II- Second line of defense (non-specific response): If a pathogen get entrance into the body, the second line of defense takes place involving a range of defense mechanisms occur inside the body (Phagocytic white blood cells, inflammation and fever, antimicrobial substances) as a response to the presence of any pathogen to inhibit or destroy it. This is called active immunity. The white blood cells have key functions. III- Third line of defense ( specific immune response): It takes place when nonspecific methods are not enough defenses. It is directed against identifiable bacteria, viruses, fungi, or other infectious agents e.g., Macrophages, T lymphocytes. 11  Medical Asepsis How we can break the chain of infection Breaking the chain of infection at any point stops infection from spreading, however health care providers work directly toward breaking the chain of infection as early as possible. Preventing infection means looking at habits, lifestyles, and surroundings and assessing for those things that may promote infection to identifying risk factors. There are some steps to break the chain of infection:  Hand washing – the single most effective and important way to prevent spread of microorganisms. Wash hand before and after giving nursing care and after (handling equipment and supplies used for care, cleaning cuts, changing soiled linens handling, coughing, sneezing or blowing nose..…etc.)  Use of disinfectants for objects and antiseptics for people.  Treat all bodily fluids as potentially infectious.  Use protective barriers such as gloves, gown (aprons), masks.  Proper disposal of wastes, garbage, and used medical supplies.  Regular checkup and follow up, and protective vaccines. 12  Medical Asepsis Break Chain of Infection Common Practices of Medical Asepsis at health care settings:  Wash hands.  Maintain aseptic technique during providing nursing care  Keep the patient's room as clean, bright, dry and airy as possible because organisms do not grow well in such environment.  Cover breaks in the skin with sterile dressing. Breaks in the skin are a good portal of entry for many organisms. 13  Medical Asepsis  Use equipment and supplies for one patient only. If they are to reused by another patient, clean them thoroughly and then disinfect or sterilize them to prevent spreading organisms among patients.  Discard disposable equipment according to agency policy. All equipment used for patient care is considered contaminated after use.  Keep soiled equipment and supplies, especially linens away from your uniform so that you do not carry organisms from patient to patient and yourself.  Consider the floor heavily contaminated. Discard any item if it fall to the floor, or clean it before using it. Also disinfect or sterilize it as necessary.  Clean the least soiled areas first and the most soiled area last. This prevents having cleaner area soiled even more by material from dirtier area.  Pour liquids to be discarded, such as bath water and mouth wash rinsing directly into a drain or toilet. Avoid spilling and splashing these liquids on yourself, the floor or other equipment because they are very likely to contain pathogens.  Use of isolation practices. 14  Medical Asepsis Isolation Technique Definition Isolation refers to the precautions that are taken in the hospital to pre vent the spread of an infectious agent from an infected or colonized patient to susceptible persons (patients, staff, and visitors) Purposes  Isolation is a medical asepsis technique inhibits the spread and transfer of pathogenic organisms by limiting the contacts of the patient and creating some kind of physical barrier between the patient and others.  There are several common practices to help control the transmission organism by personal contact (hand washing – wearing gloves- gown – mask – hair& shoe covers). Types of Isolation Practices The centers of disease control (CDC) have categorized isolation techniques into groups to help health care personnel to prevent transmission of communicable illness. 1) Strict isolation:  Strict Isolation is used to prevent transmission of highly communicable diseases which can be spread by both the contact and airborne routes (eg. Diphtheria & chickenpox) 15  Medical Asepsis  Those who are kept in strict isolation are often kept in a special room at the facility designed for that purpose. Such rooms supplied with an ante-chamber, and a negative-airflow setup should be used and are equipped with a special lavatory and care giving equipment, and a sink and waste disposal are provided for workers upon leaving the area. The door of room must be kept closed at all times.   Visitation to patients on Strict Isolation should be limited to only family/caregivers. Visitors should follow the Strict Isolation Policy, report the station nurse before entering the room.  Gloves, face masks, gown must be worn by all persons entering the room  Hands must be washed on entering and after leaving the room.  Contaminated articles must be discarded or bagged and labeled before being sent for disinfection or sterilization. 16  Medical Asepsis 2) Contact isolation Contact isolation is used to prevent the spread of diseases that can be spread through contact skin to skin (pathogens can be spread by touching) for examples rabies, scabies, wound infection. 3) Respiratory Isolation. Used to prevent transmission of microorganisms spread by droplets such as measles, pneumonia, TB, meningitis 4) Body Substance Isolation (BSI) Avoidance of any contact with bodily fluids of a patient due to pathogens that can be transmitted via these fluids. Body substances include (blood, urine, feces, oral secretions, wound drainage, seminal fluid, and vaginal secretions). Blood isolation: precautions used to prevent transmission of blood borne disease examples of diseases that transmitted by blood (Malaria, viral Hepatitis c and B, AIDS) Blood born disease can be transmitted through - Injury with a needle or other sharp instrument, which has contaminated with blood or body fluids. - Exposure of open wounds to blood or body fluids from infected patients with an HIV & Viral Hepatitis B, C. - Splashes of infected blood or body fluids into mucous membranes & the eyes. 17  Medical Asepsis - Use of contaminated instruments (needles – syringes, tooth brush, shaving). - Transfusion with infected blood by (HIV & Viral Hepatitis B, C, & D) - Skin graft, organ transplants & sexual intercourse from an HIV & Viral Hepatitis B, C, & D infected donor Guidelines for preventing blood borne diseases in health care settings  Avoid contact with blood and other body fluids with barehanded. Use of personal protective barriers when you suspect contact with blood or body fluids. Also wear protective coverings, such as a mask, eyewear and a gown, if blood or other body fluids can splash.  Cover any cuts, scrapes or sores and remove jewelry, including rings, before wearing gloves.  Change gloves before providing care to a different victim.  Remove disposable gloves without contacting the soiled part of the gloves and dispose of them in a proper container.  Thoroughly wash your hands immediately after providing care. Wash hands upon arrival at hospital or returning to quarters.  Antiseptic hand cleaners should be available for special situations 18  Medical Asepsis  Ensure that articles are correctly cleaned and disinfected or sterilized before use. If possible, use as much disposable equipment as possible. Consider patient’s clothing / belongings as contaminated if soiled. Needles should not be recapped or manipulated by hand. Disposable sharps should be placed in a puncture-resistant container. Puncture-resistant containers should be readily available at all times. Common Practices of Medical Asepsis in Every Day Living: The following practices are examples of good medical asepsis that should be maintained in everyday living 1. Cover the nose and mouth when coughing and sneezing. Coughing and sneezing carry large numbers of organisms from mouth that may be inhaled by others. 2. Wash hands before handling food to prevent transferring organisms from your hands to the food, and after using bathroom to prevent spreading organisms found in excretions. 3. Use personal care items, such as towels, tooth brushes, combs, hair brushes, shaving gear and so on (change them frequently). This helps prevent spreading organisms from one person to another. 4. Use water fountains instead of public drinking cups to protect yourself and others from organisms lodged on cups 19  Medical Asepsis 5. Use pasteurized milk that has had many organisms removed. 6. License food handlers and inspect public eating places for protection from people carrying diseases and from poor practices of hygiene. 7. Control pests that may spread diseases, such as rats and mosquitoes. 8. Have regulations for immigrants and visitors who may enter the country with infectious diseases that can spread to others. 9. Teaching about maintaining good personal hygiene 10. Wash fruits and vegetables under running water. Store food properly. 11. Use liquid hand soap instead of bar soap 12. Use of T.V, Radio, newspaper in health teaching regarding sources of disease and ways of prevention. 13. Proper safe water supply. 14. Proper safe sewage disposable. 15. Maintain a clean home and environment. Improve home's air quality by increasing air circulation, and maintain good ventilation by opening windows. Control of air pollution. 16. Use of system of health insurance for every individual. 17. Pre employment medical examination to detect early any source of disease. 20  Body Temperature Body Temperature OUTLINES o Definition of Body Temperature o Variations in body temperature readings. o Normal Body Temperature. o Temperature Converting Formula o Temperature regulation o Assessing Body Temperature o Mechanisms of heat production and heat loss o Alteration in body temperature o nursing Strategies to lower and raise body temperature 21  Body Temperature Body Temperature Definition Body temperature is the difference between the amount of heat production and heat lost to the external environment. Variations in body temperature readings: Body temperature readings vary between temperature of the Core body and temperature of body surface at the same time. For example, nurse has measured the body temperature for Mr. Ahmed at 6 pm at 2 sites in the same time, from axilla (ie, body surface) was 36.5˚C, but from rectum (i.e., body core) was 37.5˚C Core body Temperature o It is the temperature inside the body; and humans maintain a consistent internal body temperature. o The 'core' is defined as the metabolically active organs (heart, lungs, liver, kidneys, brain and the blood). This may be increased by up to four degrees °C with maximal exercise (e.g. marathon runners). So, rectal temperature measurement is accurately predict a true core temperature measured o Sites to measure Core temperature are: - Rectum - Tympanic membranes - Temporal artery - Pulmonary artery - Urinary bladder - Esophagus But Surface temperature can be measured in the following sites o Oral o Axilla 22  Body Temperature – Taking temperature by mouth is only mildly uncomfortable, since must keep mouth closed and breathe through nose while the thermometer is in place. – Taking a rectal temperature can be slightly uncomfortable but should not be painful. – Taking your temperature with an ear thermometer causes little or no discomfort. It is not inserted very far into the ear, and it provides a reading in only a few seconds. For this reason, the ear thermometer is widely used in health professional's offices and hospitals. However, it may be less accurate than rectal thermometers. – Taking temperature with a plastic strip thermometer feels like having an adhesive bandage on your forehead. Although it causes very little discomfort, it is not as reliable as other methods, so another kind of thermometer should be used if the plastic strip shows an abnormal temperature. Normal Body Temperature o The average normal temperature for adults is 37˚C o The average normal rectal temperature is 37.5˚C o And the average normal axillary temperature is 36.5˚C o The normal range of body temperature is 36.5˚C:37.5˚C o Temperature of 34˚C to 41˚C is the approximate range within which body cells can function.  If body temperature decreased than 34˚C or increased than 41˚C body cells cannot function  A Rectal tympanic or (ear) temperature reading is 0.5 to 1°F (0.3 to 0.6°C) higher than an oral temperature reading. A temperature taken in the armpit (axillary) is 0.5 to 1°F (0.3 to 0.6°C) lower than an oral temperature reading. Temperature Converting Formula To convert Fahrenheit to centigrade use the formula:- °C =f-32÷1.8 To convert centigrade to Fahrenheit use the formula: F= (°C ×1.8) +32 23  Body Temperature Temperature regulation There are various regulating factors that affect body temperature These are: 1. Physical control. 2. Chemical control. 3. Nervous system control. 1- Physical control The body gains heat from its environment, for example clothing, sun and ingestion of hot food 2- Chemical control The body produces heat through the metabolism of food. Body metabolism increases in order to produce more heat for the body as necessary. The rate at which metabolism take place affects and controls body temperature. An increase in the metabolism rate will result in an increase in body temperature and vice versa. 3- Nervous system control Body temperature is maintained by the hypothalamus in the central nervous system, located at the base of the brain. The anterior portion of the hypothalamus is concerned with heat dissipation (loss), and the posterior portion of the hypothalamus governs heat conservation (gain). Heat – Dissipating Mechanism The anterior part of the hypothalamus is stimulated by a very slight increase in the temperature of the blood above normal. It stimulates the sweat glands increase their rate of secretion. Evaporation of the large amount of sweat causes a greater heat loss which causes dilatation of surface blood vessels; so more heat is lost by radiation from the larger quantity of blood circulating near the surface in the dilated skin vessels. 24  Body Temperature Body heat is lost through the (skin, lungs, and excretion digestive and urinary tracts). The loss through the skin accounts about 85%of the total loss. Heat - Gaining Mechanism In a cold environment, the posterior portion of the hypothalamus is stimulated, this causes skin blood vessels constriction which decreases the volume of blood circulating near the surface and so decreases the heat loss by radiation. In addition there is decrease in activity of sweat gland. Thus, decreases heat loss by evaporation. Also shivering and voluntary muscle contraction occur, thereby, accelerating catabolism and heat production. Mechanisms of heat production and heat loss The temperature control mechanisms of human are keep the body's core temperature (temperature of the deep tissues) within the normal range. 25  Body Temperature Mechanisms of heat production and heat loss can be included in the following table: Heat production Mechanisms 1–vasoconstriction 2-shivering 3-increase activity 4-increase metabolism Heat loss Mechanisms 1-Radiation Means the transfer of heat from surface to the surface of another object without contact between two objects? Up to 85% of the human body's surface area radiates heat to the environment. 2-Conduction Means the transfer of heat from one object to another with direct contact. Conduction occurs when the warm skin touch an cooler. e.g. (patient contact with ice pack). 3-Convection Means the transfer of heat away by air movement a fan promoting heat loss. 4-Evaporation Is the conversion of a liquid to a vapor evaporation about (600 to 900) ml evaporated through skin (sweating, diaphoresis). Factors affecting heat production There are several factors can affect heat production can be categorized into intrinsic and extrinsic factors as the following: a) Extrinsic factors that influence temperature b) Intrinsic factors that influence temperature 26  Body Temperature (A) EXTRINSIC FACTORS THAT INFLUENCE TEMPERATURE Factor Effect Rationale Environment ▲or ▼ in body if the surround temperature is temperature temperature by high the temperature will be extremes of elevated. and if the surround Environment environment is low the body temperature temperature may be low Circadian ▲ In evening Means “day time factor” rhythm ▼ In early hours of morning (B) INTRINSIC FACTORS THAT INFLUENCE TEMPERATURE Factor Effect Rationale Thyroid ▲ Body temperature  Secretion of thyroxin leads to hormones  Metabolic rate Ovulation ▲Body temperature When progesterone level is low → body temperature is a low. When progesterone is high → body temperature above base line during ovulation and progesterone enter the circulation. Stress ▲Heat production stimulation of sympathetic and parasympathetic nervous system and production of epinephrine and nor epinephrine  metabolic activity Age Infant  adult  older. - old age person 75 yrs has inadequate diet, loss of subcutaneous tissue, reduced efficiency of thermo Exercise ▲ Body temperature Muscle activity an increased blood supply and an increased carbohydrate, fate breakdown  heat production Depression of ▼ Heat production due to use of narcotic drugs, all the nervous act to lessen body activity and System thus decrease Fasting ▼ Heat production due to inadequate supply of food. Sleep ▼ Heat production the body is less active Muscle mass ▼ Body temperature due to  heat loss 27  Body Temperature Assessing Body Temperature The four most common sites for measuring body temperature are oral, rectal, axillary, and the tympanic membrane and the skin. Orally: It reflects changing body temperature more quickly. Contra indication of oral temperature: - Breathing is difficult or rapid - Can't close mouth for any reason - Breathing through mouth - Persistent frequent coughing. - Mouth is inflamed - Infant or young children - Oral surgery/ broken jaw - Unconscious/agitated people - Very old and weak patient who cannot close his mouth well. - Patient with seizure disorder. - After drinking hot fluids or cold fluids. Rectally: are considered to be very accurate. Contra indication of rectal temperature - Diarrhea. - Rectal surgery. - Clotting disorders. - Hemorrhoids "pile" - Disease or inflammation of the rectum. Axillary: is the preferred site for measuring temperature newborn because it is accessible. Contraindication of axillary temperature - Thin patient. - Local inflammation. - Unconsciousness, shocked patients - Axillary operation. - Constricted peripheral blood vessels. Tympanic membrane: nearby tissue in the ear canal because the membrane has an abundant arterial blood supply. Temporal artery thermometer: are most useful for infants and children where a more 28  Body Temperature invasive measurement is not necessary. Types of thermometers 1- Glass thermometer (oral-rectal- axially ) 2- Digital thermometer 3-Electronic thermometer 4-Chemical dot thermometer 5-Infrared (tympanic thermometer) Alteration in body temperature There are main five medical problems of altered body temperature included in the following table: Term Definition Hypothermia Core temperature 40°C and body temperature is out of control. Associated with injury/damage to the head resulting in hypothalamic failure. Heat stroke is a potentially serious condition produced by prolonged exposure to excessive temperatures, which can lead to coma and death, Usually occurs around 41–42oC Death When body temperature = 43oC and above or = 20oC 1- Fever Fever is one of the most common medical signs and is characterized by an elevation of body temperature above the normal range of 36.5–37.5 °C (98– 100 °F) due to an increase in the temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering. causes unconsciousness and, if sustained leads to permanent brain damage. 29  Body Temperature Fever Classification Grade °F °C Low grade 100.4–102.2 38–39 Moderate 102.2–104.0 39–40 High-grade 104.0–106.0 40–41.1 Hyperpyrexia >106.0 >41.1 Emergency treatment Body temperature over 105.8°F (41°C) in an adult is a medical emergency and requires immediate treatment. The following indications in specific patient groups may require emergency treatment: o Newborns (three months or younger) with fever of 100.5°F (38°C) or higher o Infants or children with fever of 103°F (39.4°C) or higher o Adults with fever of 101°F or higher lasting longer than three days; or a temperature of 100.5°F lasting longer than three weeks without other symptoms Pattern of fever 1- Continuous Fever With a continuous fever, the person’s body temperature remains at a higher than normal temperature throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis 2- Remittent Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g. infective endocarditis. 30  Body Temperature 3- Intermittent fever is marked by a daily temperature drop into the normal range and then a rise back to above normal. Elevated temperature is present only for some hours of the day and becomes normal for remaining hours, e.g. malaria, pyaemia, or septicemia. 4- Relapsing fever when fever reappears after a certain period of time, it is called relapsing fever. Not only once but fever may reappear a number of times. Those who have a weak immune system may have to face this problem. Hyperpyrexia Hyperpyrexia is a fever with an extreme elevation of body temperature greater than or equal to 41.5 °C (106.7 °F). Such a high temperature is considered a medical emergency as it may indicate a serious underlying condition or lead to significant side effects. The most common cause is an intracranial hemorrhage. Other possible causes include sepsis Phases of fever 1-Prodromal phase: Patients has nonspecific symptoms just before temperature rises. 2-Onset or invasion Observed mechanisms for increasing body phase: temperature (shivering) 3-Sationary phase: The fever sustained 4-Resolution: Temperature return to normal range. Signs and symptoms of fever -Pinkish (flushed) face. -Restlessness. -Poor appetite. -Eyes is sensitive to light. -Increased perspiration -Above normal pulse and respiration. -Disorientation and confusion. -Convulsion in infant and children. -Fever blister around nose or lips. 31  Body Temperature Hypothermia The three physiologic mechanisms of hypothermia are: - Excessive heat loss - Inadequate heat production to counteract heat loss - Impaired hypothalamic thermoregulation The clinical signs of hypothermia: - Decreased body temperature, pulse, and respiration, Severe shivering - Feelings of cold and chills - Pale, cool skin, Hypotension - Decreased urinary output - Lack of muscle coordination - Disorientation - Drowsiness progressing to coma Nursing Strategies to raise and lower body temperature Raising body temperature Lowering body temperature Generally: Monitor vital signs, Generally: Monitor vital signs, Assess skin color and temperature, Assess skin color and temperature, Measure intake and output Measure intake and output, assess WBCs count. 1. Add extra layers of thin 1. Remove layers of clothing or bedding. Multiple clothing/bedding. Do not remove all layers of thin clothing are more at once or you may cause the Patient effective than one or two thick to shiver, which will have the overall layers, as they trap the warm air. effect of increasing rather than Some man-made fibers can decreasing body temperature encourage wetness and thus may decrease temperature. Cotton is therefore preferable 2. Encourage the Patient to 2. Encourage the Patient to wear wear a hat or cover the head, as natural cotton fibers as these most heat is lost through the scalp absorb heat 3. If possible close any open 3. Use a fan positioned on the windows and Doors Patient’s back as this forms a larger surface area 32  Body Temperature Raising body temperature Lowering body temperature 4. Give the Patient warm drinks 4. Give the Patient cold drinks if if allowed allowed or ice to suck 5. If possible increase the room 5.If possible reduce the room temperature temperature or place the Patient near an open window but not in a draught 6. Adults and older children can 6. Adults and older children can be be helped or encouraged to wash helped or encouraged to wash their their hands and face in warm hands and face in tepid water. water provided that they have full Tepid sponging of the whole body sensation. Otherwise there is a risk where the Patient is allowed to dry by of burn injury. For this reason hot- the process of evaporation is not water bottles and high-temperature generally recommended as this can heat pads are not recommended and reduce the temperature too rapidly are indeed banned in most institutions 7. Monitor the Patient’s 7. Monitor the Patient’s temperature when actively temperature when actively intervening and ensure that it does intervening and ensure in the case of not rise more rapidly than 1oC adults that it does not fall more per hour as this can lead to shock. rapidly than 1oC per hour as this If the Patient requires their can lead to shock. In the case of temperature restoring more quickly, infants high temperatures can cause this should be undertaken in a febrile convulsions; it is therefore critical-care area where the Patient appropriate to reduce their can be closely monitored temperature more rapidly. This can be achieved by immersing them fully in a cool water bath 8.If the Patient is seriously 8.An antipyretic such as hypothermic (i.e. a temperature of paracetamol may be prescribed if 32.5oC or below) and continuously other methods of temperature monitored a foil blanket may be reduction have failed, though this used with caution, but again care should not be the action of first resort should be taken to ensure that the as it can interfere with the body’s body temperature does not increase natural defense mechanisms too rapidly. Warmed intravenous fluids may also sometimes be prescribed for this Patient group but again great care is needed 33  Pulse Pulse Outline o Anatomy and physiology of circulatory system. o Definition of pulse. o Sites for palpating pulse. o Assessment of normal and abnormal pulse rate, rhythm, volume and force. o Record and report pulse. o Factors affecting pulse and blood pressure. 34  Pulse Pulse Anatomy and physiology of circulatory system  The heart is a hollow, muscular organ located in the in the center of the thorax, where it occupies the space between the lungs (mediastenium) and rest on the diaphragm. It weight approximately 300g ;the weight and size of the heart are influenced by age, gender, body weight, extent of physical exercise and conditioning , and heart disease.  The heart composed of muscle which pumps blood to the tissues throughout the body supplying them with oxygen and other nutrients, beating approximately average 72 times per minute of our lives.  Heart is shaped like “Cone”  “top” of the heart is the base  “bottom” is the apex  Heart size = clenched fist  Precordium- area on anterior chest that covers heart and great vessels  Atria are tilted slightly toward the back and ventricles extend to left and toward anterior chest wall. 35  Pulse  Has Four chambers o 2 upper atria o 2 lower ventricles  Blood Circulation: Systemic circulation o left side of heart pumps blood through body o left ventricle pumps oxygenated blood into aorta o aorta branches into many arteries that travel to organs o arteries branch into many arterioles in tissue o arterioles branch into thin-walled capillaries for exchange of gases and nutrients o deoxygenated blood begins its return in venules o venules merge into veins and return to right atrium Pulmonary circulation o right side of heart pumps deoxygenated blood to lungs o right ventricle pumps blood to pulmonary trunk o pulmonary trunk branches into pulmonary arteries o pulmonary arteries carry blood to lungs for exchange of gases o oxygenated blood returns to heart in pulmonary veins 36  Pulse Pulse A pulse is when the left ventricle of the heart contracts. When this happens, blood is suddenly pushed from the ventricle to the main artery (aorta). This sudden forcing of blood from the heart into the arteries causes two things to happen. a. Artery Expansion. The sudden rush of blood increases the volume of blood in the arteries. In order to accept this increased volume, the arteries expand (stretch). As the arteries quickly contract (go back to normal size), blood is forced from the arteries, through the capillaries, and into the veins. b. Pulse. In addition to the expansion of the arteries, a "wave" travels through the arteries. This wave is the pulse. All arteries have a pulse, but the pulse is easier to feel (palpate) when the artery is near the surface of the body. Definition Pulse Pulse an alternate expansion and recoil of an artery as the wave of blood is forced through it by the contraction of the left ventricle. It is felt by palpating a superficial artery that has a bone behind it. The pulse rate is usually equal to heart rate, but may be lower if there is an obstruction of the artery or if the heart rhythm is weak or irregular. can feel it by placing fingers over one of the large arteries that lie close to the skin, especially if the artery runs across a bone and has very little soft tissue around it. Nursing consideration in measurement of pulse rate: o To measure heart rate, simply check pulse. With your palm facing upward, place two fingers on the thumb side of wrist — or place index and third fingers on neck to the side of your windpipe. When feel pulse, 37  Pulse count the number of beats in full one minute. Time the second hand on a clock or watch. o The hand being checked should be in normal relaxed position and not tense, held out straight or stretched by force. o Palm of the hand being checked should face upwards. o Hands should be kept stationary while checking. o Pulse of both hands should be checked. o Initially the fingers should be placed gently. Undue pressure should not be exerted unless it is necessary to find the pulse. o It should preferably be checked in the morning before eating or drinking anything. o If it becomes unavoidable to check at a time other than morning, it should not be checked immediately after eating or drinking unless there is no choice. o Do not check if you are feeling emotionally disturbed. Wait till you calm down. o Should not be checked when you have been walking and feeling somewhat out of breath. Rest for a while till you feel and breathe as you generally do. Normal resting heart rate For an adult, a normal resting heart rate ranges from 60 to 100 beats a minute. For a well-trained athlete, a normal resting heart rate may be closer to 40 beats a minute. For healthy adults, a lower heart rate at rest generally implies more efficient heart function and better cardiovascular fitness. 38  Pulse Resting Heart Rate Age or fitness level Beats per minute (B.P.M.) Babies to age 1: 100–160 Children ages 1 to 10: 60–140 Children ages 11 to 17: 60–100 Adults: 60–100 Well-conditioned athletes: 40–60 Assessment of the pulse o Palpate the artery wall with the tips of the index and middle fingers. The tips are very sensitive. Some recommend avoiding palpation with the thumb (misinterpreting your own radial pulse pulsating in examiners thumb). o Do not press too hard for fear of obliterating the pulse. o When the pulse is being counted, the rate, rhythm, volume and force should be noted. o Pulse rate: An average pulse rate for a resting adult is 72 bpm (beats per minute). Recording and Reporting of pulse o Pulse rhythm: means that beat are identical in force and separated by equal intervals and is evaluated as regular or irregular. - When intervals between beats are constant, the pulse is regular, and when intervals are not constant, the pulse is described as irregular. - o Pulse force refers to the pressure of the pulse wave as it expands the artery. Pulse force is determined as full or thready. 39  Pulse -A full pulse feels as if a strong wave has passed under your fingertips. When the pulse feels weak and thin, the pulse is described as thread Assessment of pulse Normal Abnormal Rate 60-100b./m. Tachycardia or bradycardia Rhythm Regular Irregular Force Strong Weak Volume Full Empty Common sits for palpating the pulse 1. Radial Artery: At the wrist, is the most commonly used for palpating the pulse rate, because it is easily accessible and can pressed against the radius bone. 2. The superficial temporal artery: in the temporal region. 3. The external carotid artery: in the neck. 4. The subclavian artery: behind the inner end of the clavicle against the first rib. 5. The brachial artery: on the inner aspect of the upper arm, about halfway between the shoulder and the elbow. 6. The femoral artery: in the mid-groin. 7. The popliteal artery: behind the knee. 8. The dorsalis pedis artery: below the ankle on the dorsum of the food. 9. Posterior tibial: just behind the ankle bone 10. Apical pulse: A more accurate estimate of the heartbeat, per minute. It is obtained by listening with a stethoscope over the apex of the heart between fifth and sixth rib about 3inches (8cm) to the left of the median line and slightly below the nipple. 40  Pulse There are Eight Common Arterial Pulse Sites. Abnormalities of pulse Rate a) Tachycardia: The pulse rate is abnormally rapid. An adult is considered to have tachycardia when his pulse rate is 100beat/m. or more. b) Bradycardia: The pulse rate is abnormally slow and below 60beat/m. II- Rhythm of pulse: Abnormalities in pulse Rhythm An irregular pulse rhythm is called arrhythmias 41  Pulse a- Intermittent pulse: a type of irregular pulse where a beat dropped either irregular or regular i.e. each 4beats there is a dropped beat or in the form of periods of normal rhythm broken by periods of abnormal rhythm. B-Bigeminal: It consists of two regular beats followed by longer than normal pause with no beat, and then two beats again followed by a pause. Bigeminal c- Premature beat (Extra systole) A premature beat occurs before the normal one. It is less intense than the normal one. Premature beats are sometimes called extra systole Premature beat III- Force and Volume of pulse Refers to the gush of blood that pumped by the ventricular contraction and pushed through the arteries where the blood is met by a certain degree. 42  Pulse Abnormalities of force and Volume a- Feeble, (weak) when the volume of blood is very little and it is easy to stop the feel of blood wave with slight pressure of the finger tips. b- Bounding pulse Occurs when it is very difficult to stop the feel of the pulse wave with mild pressure A bounding pulse is a powerful and strong pulse which is experienced for a short period. Some bounding pulses can be seen and felt just underneath the skin if there is an artery located there. Under normal conditions, a bounding pulse can be caused by strenuous exercise, anxiety, pregnancy, fever and alcohol use. The bounding pulse is generally a reflection of a rapid heartbeat. The sensation of a pulse is very obvious to the individual without even touching a pulse point. After a few minutes of rest, the pulse returns to normal, so this is not a cause for concern. Sometimes, however, a bounding pulse indicates serious medical conditions. The bounding pulse could mean that there is too much fluid in the circulatory system, this is called fluid overload. The bounding pulse is also an indicator of high blood pressure, aortic valve regurgitation, heart failure and chronic kidney failure. C-Water-hammer pulse This type of pulse is characterised by sudden expansion of the artery followed immediately by a sudden collapse. IV- Abnormalities of Pulse Rate and Force Thready pulse: This type of pulse is weak in force and is of a rapid rate. It occurs in shock. 43  Pulse V- Abnormalities of rate, Force and Rhythm Dicrotic pulse: Pulse wave feels double to touch. -A single pulse beat feels like double or 2 marked expansions for one beat. "Dicrotic pulse is experienced by nurse as if she is feeling a pulse beat followed by an echo of a beat." Pulse Deficit: It is difference between a peripheral pulse rate and an apical pulse rate If ventricular contractions are not strong or regular some of them may be so weak that the wave caused by the contraction does not reach the peripheral pulse site. In these instances the peripheral pulse counting is inaccurate. Therefore, apical rate should be counted before administering medication based on heart rate, such as digitals. Factors affecting Pulse Rate: 1) Sex. Women have a slightly faster pulse rate than men. 2) Age. The pulse rate gradually decreases from birth to adulthood then increases with advancing old age. 3) Body temperature: The pulse rate increase about10 b/m for each degree centigrade of temperature elevation. 4) Digestion: The increased metabolic rate during digestion will increase the pulse rate slightly. 5) Pain: Pain increases pulse rate. 6) Emotion: Fear, anger, anxiety, and excitement increase the pulse rate. 7) Exercise: The heart must beat faster during exercise to meet the increased demand for oxygen. 8) Blood pressure: In general, heart rate and blood pressure have an inverse relationship. When the blood pressure is low, there is an 44  Pulse increase in pulse rate as the heart attempts to increase the output of blood from the heart (cardiac output). 9) Decrease blood volume: When the blood volume decreases, heart rate increases to compensate. Heavy bleeding due to trauma or illness and dehydration are two common causes of decreased blood volume, which cause an increased heart rate. 10) Hormones: influence heart rate, especially epinephrine, norepinephrine, and thyroid hormones, all of which can increase the rate. 11) Medications and drugs: For example, digitalis slows the rate, while epinephrine (Adrenalin) increases it. Caffeine can also cause palpitations or extra beats 45  Blood Pressure BLOOD PRESSURE OUTLINES o Definition of blood pressure. o Factors controlling blood pressure. o Definition of systolic blood pressure. o Definition of diastolic blood pressure. o Normal range of blood pressure. o Definition of pulse pressure. o Definition of the abnormalities of blood pressure: hypertension, hypotension, and postural hypotension. o Factors affecting pulse and blood pressure. 46  Blood Pressure BLOOD PRESSURE Definition Blood pressure is the pressure of the blood against the walls of the arteries. Blood pressure results from two forces. One is created by the heart as it pumps blood into the arteries and through the circulatory system. The other is the force of the arteries as they resist the blood flow.  Blood pressure numbers: BP varies between two readings of a maximum and a minimum pressure for example: blood pressure reading is 120/80 mmHg o The higher (systolic) number which is 120 represents the pressure while the heart contracts to pump blood to the body. o The lower (diastolic) number which is 80 represents the pressure when the heart relaxes between beats. o Thus, the reading is recorded as fraction  Systolic/ Diastolic  The standard unites for measuring blood pressure: Is a millimeter of mercury (mmHg). The measurement indicates the height to which the blood pressure can raise a column of mercury in cardiac cycle blood pressure reaches the peak.  Blood pressure usually refers to: The pressure measured at a person's upper arm. It is measured on the inside of an elbow at the brachial artery, which is the upper arm's major blood vessel that carries blood away from the heart. 47  Blood Pressure A person's BP is usually expressed in terms of the systolic pressure and diastolic pressure (mmHg), for example 120/80. Definition of systolic pressure It is the greatest amount of pressure exerted by the blood against the walls of arteries during maximum ventricular contraction. Definition of diastolic pressure It is the lowest amount of pressure exerted by the blood against the walls of arteries during the resting period of the heart i.e. during the relaxation of the ventricle (refractory period) just before a new ventricular contraction. NB. Resting period of the heart: is the time of coronary filling. It is known also as the refractory period. Normal range Of 2 components: o Systolic … (= max press reached) = 110-130 mmHg. o Diastolic … (= min press reached) = 70-90 mmHg. 120 ± 20 o Normal Range of Blood Pressure: ‫ــــــــــــ‬ mm Hg. 80 ±15 Pulse Pressure Is the difference between systolic and diastolic blood pressure. pulse pressure =Volume of pulse beat. e.g. if blood pressure is 120/80 mm Hg. Pulse pressure is 120-80=40mm Hg. The pulse pressure is normally from 30-50 mm Hg. It gives an idea about the volume of pulse. 48  Blood Pressure The mean arterial pressure (MAP) denotes the average pressure within the arteries. An electronic vital signs monitor can determine and display an accurate average pressure or MAP. Shock or other difficulty is usually indicated by a systolic reading of 80 or less. A diastolic reading over 100 is usually considered dangerously high. Abnormalities of blood pressure a- Hypertension: Abnormal elevation of blood pressure. The increase in blood pressure is symptom of a disease. It may be due to increase in the force of the heart, peripheral vascular resistance, loss of elasticity of the blood vessel. The blood pressure is increased more than 120+20/80+15 mm Hg. b- Hypotension: Abnormal decrease in blood pressure, it may be due to hemorrhage, shock wasting or debilitating diseases. The blood pressure will be less than 120-20/ 80-15 mm Hg c- Postural hypotension (orthostatic hypotension) Is a low blood pressure associated with weakness or fainting when rising to an erect position. It is the result of peripheral vasodilatation without a compensatory rise in cardiac output. This type of hypotension can usually be prevented by arising and moving the individual slowly especially after a period of bed rest. 49  Blood Pressure Classification of blood pressure for adults Category systolic, mmHg diastolic, mmHg Hypotension < 90 < 60 Normal 90 – 119 60 – 79 Prehypertension 120 – 139 80 – 89 Stage 1 Hypertension 140 – 159 90 – 99 Stage 2 Hypertension ≥ 160 ≥ 100 Factors controlling blood pressure 1- Pumping action of the heart (myocardial strength) (a) Weak pumping decrease in blood pressure. (b) Strong pumping action increase blood pressure +full and strong pulse. 2- Peripheral vascular resistance (a) Small blood vessel caliber increase blood pressure. (b) large caliber of blood vessel decrease blood pressure, and decrease in volume of pulse. 3- Elasticity of blood vessels (a) Decreased elasticity increase blood pressure, as in old age and arteriosclerosis, and weak pulse. (b) Relaxation of arteries as in case of shock decrease in blood pressure and rapid weak pulse. 4- Blood volume: Decrease volume as in hemorrhage decrease in blood pressure and weak pulse. 50  Blood Pressure 5- Viscosity of blood Viscosity of blood increase in case of decreased blood volume. Increase in viscosity of the leads to increase in blood pressure. Factors Affecting Blood Pressure o Sex … M ale > Female …due to hormones/ equal at menopause. o Age … Elderly > children …due to atherosclerosis. o Emotions … due to secretion of adrenaline & noradrenaline. o Exercise … due to  venous return. o Hormones … (e.g. Adrenaline, noradrenaline, thyroid H). o Gravity …  Lower limbs > upper limbs. o Race … Orientals > Westerns … ? dietary factors, or weather. o Sleep …  due to  venous return. o Pregnancy … due to  metabolism. o Nutrition… according to dietary pattern o Diurnal variation… day time variation typically lowest the in the early morning, It gradually rises during the morning and afternoon ,peaking in late afternoon or evening. Smoking … due to narrowing of peripheral vascular disease and hardening of the arteries Assessment of blood pressure: Blood pressure may be measured directly or in directly. The direct Method: - Requires the insertion of a thin intervenes catheter into an artery ,tubing connects the catheter with an electronic sensor. Pressure within in the artery transmits pressure along the fluid filled tubing to the sensor which then displays a blood pressure reading on an electronic display. 51  Blood Pressure - Measured in (mmHg), & sometimes in (cmH2O), where (1 mmHg = 1.36 cmH2O). The indirect method: - Requires use of the sphygmomanometer. The nurse may use auscultation, palpation or both assessing the blood pressure indirectly by auscultation is the most common technique. Nursing consideration for Auscultation: o The best environment for blood pressure measurement by auscultation is a quiet room at comfortable temperature. o Try to control the patient /patient pain anxiety or exertion and ask patient / patient to refrain from eating or smoking before the assessment because these factors can cause false reading. o Although the patient /patient may lie or stand, sitting is the preferred position 52  Respiration RESPIRATION Outline o Body needs oxygen o Definition of respiration, ventilation, diffusion, and perfusion o Conditions essential for normal respiratory functions o Mechanism of respiratory control o Normal respiration o Abnormalities related to rate, depth, rhythm, and sound o Methods to assess respiratory functions o Factors affecting respiration o Nursing measures to promote normal respiration o Problems related to respiration o Assess cough o Nursing intervention for cough o Assess difficult respiration o Nursing intervention for difficult respiration o Nursing intervention for bronchial secretion 53  Respiration Respiration Introduction; The primary function of the respiratory system is to supply the blood with oxygen in order for the blood to deliver oxygen to all parts of the body. The respiratory system does this through breathing. Breathing is essential to life. Oxygen is required by the body to release energy at cell level so that the individual can participate in activities. The release of such energy through metabolism produces carbon dioxide as a waste product that must be expelled from the body. Without oxygen, for even short period some of the body cells will suffer irreversible damage and quickly die. A constant supply of oxygen through respiratory channel is needed because it cannot be stored in the body. Oxygen intake and elimination of carbon dioxide is achieved through respiration. Pathway of air: nasal cavities (or oral cavity) pharynx trachea primary bronchi (right & left) secondary bronchi tertiary bronchi bronchioles alveoli (site of gas exchange) o Respiration: Is the gas exchange between the individual and the environmental air in which the individual takes in oxygen (inspiration) and eliminates carbon dioxide and water vapor (expiration). o Breathing is an active process - requiring the contraction of skeletal muscles. The primary muscles of respiration include the external intercostal muscles (located between the ribs) and the diaphragm (a sheet of muscle located between the thoracic & abdominal cavities). 54  Respiration o Normal breathing is slightly observable, effortless, quiet, automatic, and regular. It can be assessed by observing chest wall expansion and bilateral symmetrical movement of the thorax o Normal resting respirations are 12 to 20 breaths per minute, with a time period of 2 seconds Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific. Costal (thoracic) breathing occurs when the external intercostal muscles and the other accessory muscles are used to move the chest upward and outward; diaphragmatic (abdominal) breathing occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen. o Average respiratory rates, by age:  Infants: 20–40 breaths per minute  Adults: 12–20 breaths per minute The basic activities occur during normal respiration 1. Ventilation exchange of air between the atmosphere and the alveoli within the lung. 2. Diffusion of gases between the alveoli and the blood. 3. Perfusion Transport of gases between blood and body cells. 1- Ventilation o Is the exchange of air between the atmosphere and the alveoli within the lung. o It consists of inspiration and expiration (respiratory cycle). o This is achieved by pressure changes within the lung. Air moves from higher pressure to lower pressure. o Ventilation occurs under the control of the autonomic nervous system from parts of the brain stem, the medulla oblongata and the pons. This area 55  Respiration of the brain forms the respiration regulatory center, a series of interconnected brain cells within the lower and middle brain stem which coordinate respiratory movements  During inspiration (Inhalation) The external intercostals plus the diaphragm contract to bring about inspiration:  Contraction of external intercostal muscles elevation of ribs & sternum increased front- to-back dimension of thoracic cavity lowers air pressure in lungs and alveoli air moves into lungs  Under normal conditions, the diaphragm is the primary driver of inhalation.  During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support because forced inhalation aid in further expanding the thoracic cavity  During expiration (Exhalation )  Natural elasticity of the lungs and relaxation of external intercostal muscles & diaphragm return of diaphragm, ribs, & sternum to resting position restores thoracic cavity to preinspiratory volume increases pressure in lungs and alveoli air is exhaled  Exhalation is generally a passive process; however, active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out. 2- Diffusion of gases between the alveoli and the blood o Is the exchange of the carbon dioxide (co2) and oxygen (o2) between the lung alveoli and the blood: O2 diffusing from the alveoli into the blood & 56  Respiration CO2 from the blood into the alveoli. Diffusion requires a concentration gradient. So, the concentration (or pressure) of O2 in the alveoli must be kept at a higher level than in the blood & the concentration (or pressure) of CO2 in the alveoli must be kept at a lower lever than in the blood. o Alveoli have very thin walls, but they have amazingly large surface area. This allows the oxygen in the alveoli to diffuse across the surface as much and as quickly as possible. Survival is dependent upon this process being reliable, sustained and efficient, even when challenged by disease or an unfavorable environment. o As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. 3- Transport of gases between blood and body cells (perfusion) It is the transport and utilization of oxygen by cells and the exchange of carbon dioxide or oxygen in the blood capillaries. The body cells utilize oxygen for the production of heat through oxidation and liberation of energy from food we eat. Conditions essential for normal respiratory functions 1. The airway passage (nose, pharynx, trachea and bronchial tree) must remain clear and free from any obstruction such as: o Foreign body e.g. a piece of food, toy or any other small objects. o Liquid as in cases of drowning. o Secretion, tumor or edema in the respiratory tract and lung tissues. 2. The muscles of respiration (intercostal muscles and diaphragm) and abdominal muscles should be maintained in good condition, free from any abnormalities. 57  Respiration 3. Adequate hydration is essential for respiratory function. 4. The circulatory system and blood which is the carrying system of oxygen should be in good condition and free from any abnormality. Respiratory Regulation (control) The mechanism of respiration is controlled by 1- Nervous control: through the respiratory center in the medulla which initiate control and the action of respiratory muscles. 2- Chemical stimulation: The chemical regulator of respiration is the carbon dioxide level in the blood. As carbon dioxide accumulates in the blood, it has stimulating effect mainly on central chemoreceptors present in the medulla, and peripheral chemoreceptor present in the carotid bodies and aorta. This lead to stimulation of medullary respiratory center and so rate and depth of respiration is increased. Receptors: carotid (mainly) and aortic oxygen-sensitive chemoreceptors in carotid and aortic bodies Note: Oxygen receptors (sensory nerve endings) are chemoreceptors separate from the carotid sinus baroreceptors (pressoreceptors) Assessment of respiratory functions It can be achieved through physical assessment and laboratory investigations. 1- Physical assessment: A) Assessment by observation: Normal respiration must be normal rate, depth and rhythm, noiseless, painless and without effort. 58  Respiration 1- Respiratory rate Abnormalities of respiratory rate Tachypnea or It is a rapid breathing, the respiratory rate is above polynea the normal level Bradypnea It is a slow breathing. The respiratory rate is below normal level 2- Respiratory depth The depth is described as deep or shallow breathing depending on whether the volume of air taken in, is above or below normal. Normally the average volume of exchanged air is about 500 milliliter and depth of each respiration is the same. Abnormalities of respiratory depth Hyperpnea Increased depth of breathing with or without increase of its rate. Abnormalities in rate and depth Hyperventilation Abnormal increase in rate and depth of respiration. Hypoventilation Abnormal decrease in rate and depth of respiration. 3- Respiratory rhythm Normal respiration is rhythmic or regular e.g. time interval for each breath (inspiration, expiration and short period of rest) is equal approximately 4 seconds. Abnormalities in rhythm and depth Cheynestokes Gradual increase in depth of respiration followed respiration by a gradual decrease in its depth and then a period of no breathing (apnea).it is a serious symptom Biot’s respiration Repeated sequences of deep gasps. 59  Respiration Abnormalities of sound Stertorous Noisy respiration or snoring sound respiration. breathing Wheezy breathing Wheezy associated with each expiration or inspiration or both. This occurs when the air forced through narrow lumen (passage). Abnormalities related to effort Dyspnea Difficulty in breathing in any position. Orthopnea Difficulty in breathing in horizontal dorsal (lying) position. General appearance A person who has difficulty in breathing, attempts to find a position of comfort. Distress may be evident by facial expression. Skin color Observe the color of skin and mucous membrane, Normally is pink. Cyanosis: blue discoloration of skin and mucous Membrane 60  Respiration It is seen on lips, tips of the lopes of the ears, nail beds and at the ends of fingers or toes. It is due to defective oxygenation of the blood. Chest Notice whether chest contour is symmetrical right and left. contour A collapsed lung may be revealed by a smaller appearing chest cavity on that side or a deviated trachea. Fingertip Observe fingers. Clubbing may denote decrease oxygen assessment supply to the body cells. Speech People with normal respiratory function are able to finish pattern long sentences without pausing for breath. Breath odor Normally breath is odorless –Bad odor generally denote poor oral hygiene or respiratory infection. B-Assessment by palpation and percussion o By placing the palms of hands on the person’s chest: Normally, small vibration can be felt (fremitus); Due to air passage through the bronchi. When fluids is present, this vibration is increased. C-Assessment by auscultation : For listening to the sound of respiration and assessing the depth and rhythm. Normally respiration makes a quite sound. The nurse places the diaphragm of the stethoscope firmly against the chest wall as the patient breathes slowly and deeply through the mouth. Investigation To determine any problems in the respiratory system such as: -Pulmonary function tests. -Blood gas analysis, PH. -Sputum culture. -Bronchoscopy. -A biopsy. -A radiograph of chest. 61  Respiration Respiration is automatically controlled by the brain. A variety of factors can influence respirations. Factors affecting respiration 1. Age: Rate of respiration is increased in infancy 40 c/m. 2. Sex: Females have more rapid rate. 3. Exercises: Cause temporary increase in respiratory rate. 4. During digestion: respiratory rate is increased. 5. Emotion : increase respiratory rate and changes its depth 6. Discomfort and pain: increase respiratory rate. 7. Drugs: e.g. – Morphine, depress in respiratory rate. General anesthesia slow rate and depth of respiration.Co2, Caffeine and atropine stimulate respiration. 8. Changes in atmospheric pressure: In high places, respiratory rate is increased. 9. Hemorrhage: Increase respiratory rate. 11. Fever: Increase respiratory rate. 1°C 4 cycles. Ideally, the respirations are observed for a full minute and reported as "RR=16 c/min." (meaning respiratory rate equals 16 respirations per minute). Common nursing measures to promote Normal Respiration Maintenance of normal oxygenation is important as a preventive measures for patients who have a tendency to respiratory difficulties e.g., inactive patients, post – operative patients, patients receiving certain drugs which affect respiration, patients in pain or individuals working in certain vocations. 1- Deep breathing exercises; 62  Respiration This is done in the form of inhalation slowly and to the greatest chest expansion possible, holding breath for 3 seconds, and exhale slowly, this should be done frequently. 2- Effective Coughing; The nurse places the diaphragm of the stethoscope firmly against the chest wall as the patient breathes slowly and deeply through the mouth. 3- Proper positioning; Having patient assume a position that allow for free movement of the diaphragm and expansion of the chest wall, promotes easy respiration. As fowler, sitting, and semi-sitting positions. 4- Postural drainage; Gravity drainage of the lung by special positions depends on the area of the lung needs to be drained. 5- Percussion and vibration of the chest wall; To loosen the thick secretion from the bronchi. 6- Adequate hydration An adequate or an above-normal fluid intake helps to minimize the viscosity of respiration secretions, thus make it watery and easily expelled out. 7- Humidification In some circumstances in which the air is dry, a humidification is necessary. Room humidification or direct humidification is used. Drug may be used. 63  Medication administration MEDICATIONS ADMINISTERATION Outline: o Definition of medicine. o The purpose of medicine. o Factors affecting the action of prescribed drugs. o Medication effect. o Routes for administering drugs. o Nurse's roles in giving medication. 64  Medication administration MEDICATIONS ADMINISTERATION Definition: Drug is a chemical substance intended for use in the diagnosis, treatment, cure, mitigation, or prevention of a disease. The purpose of drugs o Drugs given for diagnostic purposes -To determine the cause of physical impairment as barium for x-ray. o Drugs used in treatment of diseases -To relief distressing symptoms. -To restore normal functions as digitalis. -To supply deficient substances in the body as insulin. o Drugs used to cure disease (specifics) as quinine to cure malaria. o Drugs used to prevent diseases as vaccines (small box vaccine typhoid Serum). Factor affecting the action of prescribed drugs o Age: The dosage may vary according to the age of patients. Infants, Children and aged require a smaller dosage of drug than adult Dose. o Weight: The dosage may vary with underweight or overweight. o Sex: The dosage may need to be modified according to sex (males 65  Medication administration and Females). o Physical condition: as degree and severity of symptoms. o Method of administration: Drug given by rectum is absorbed slowly. Intravenous (I.V.) drugs have a very quick action. Subcutaneous (S.C.) Absorbed in shorter period of time than orally. o Excretion of the drugs: Some drugs have a commutative action as Digitalis. It is important to observe patient for toxicity. Food and Drug Interactions 1. Certain drugs may interfere with the absorption, excretion, or use in the body of one or more nutrients. 2. Certain foods may increase or decrease the absorption of a drug into the body. 3. Certain foods may alter the chemical actions of drugs, preventing their therapeutic effect on the body. Common Food and Drug Interactions Drug Effects on Nutritional Status Abuse of antacids can lead to phosphate depletion, which can cause a vitamin D deficiency, resulting in osteomalacia, or softening of the bones due to loss of calcium. Excessive use of diuretics may result in the loss of electrolytes, especially potassium, that places Patients with cardiac conditions at a higher risk for serious rhythm problems. Potassium loss is greatest in Patients taking digitalis as well as diuretics, making the heart more sensitive to the drug. 66  Medication administration Prolonged use of oral contraceptives by women may cause folacin and vitamin C deficiencies if their diets are inadequate in these nutrients. Hydralazine (antihypertensive drug) can deplete the body’s supply of vitamin B6. Medication Effects Local Effect Is just affecting the body tissue at the site of medicine administration. E.g. cough drops exert a soothing effect on the mucous membranes of the mouth and throat only. Systemic Effect Is a total body effect. The medicine is absorbed into the blood stream and distributed to distant sites, generalized body effects occur. Side Effect In addition to the therapeutic effect of the drug, it may have additional effects, known as side effects. E.g. although the Medicine's therapeutic effect (increase the heart rate) would be desirable, the medicine side effect (increase the blood pressure) Would be occurring. Toxic Effect In an effect caused by an over dose or an excessive accumulation of medicine. It may occur suddenly or slowly over a period of time. E.g. Dioxin has the effect of slowing and strengthening the heart Beat. A toxic effect is a cardiac arrhythmia such as Bradycardia. Synergistic Effect 67  Medication administration Administered together and effect is produced by their combination that is greater than the effect of either drug if given separately. This Can be a harmful effect. (A magnified reaction). Antagonistic Effect Is a lessened effect that occurs when two drugs are administered simultaneously (the resulting action is less than of either drug when given separately). Many drugs cannot be mixed in intravenous fluid for this effect. Untoward Effect Is an undesirable but predictable effect of a medicine e.g Choramphenicol is effective against gram positive bacteria, a long Term use of it leads to destruction of red blood cells. Adverse Effect Is an unpredictable effect of medicine such as allergic or idiosyncratic effects. Penicillin e.g. is capable for causing this kind of reaction (skin rash, hypotension, and laryngeal spasm). Tolerance Effect A person has developed tolerance to a drug when he must take larger and larger dosage in order to achieve therapeutic action e.g. Morphine sulfate, effective for pain relief, commonly become ineffective over a period of time as tolerance to it occur. Cumulative effect It occur due to gradual accumulation of a drug in a person's body Because of inadequate liver function. It leads to toxic effects or sometimes synergistic or antagonistic effects. 68  Medication administration Routes of Drugs Administration - Parenteral - Non-Parenteral Parenteral 1- An intravenous injection: It is a liquid administered directly into the bloodstream via a vein. It is advantageous when a rapid onset of action is needed. 2- Intramuscular injection: - It is the injection of a substance directly into a muscle. - Many vaccines are administered intramuscularly. - Depending on the chemical properties of the drug, the medication may either be absorbed fairly quickly or more gradually. - Intramuscular injections are often given in the deltoid, vastus lateralis, ventrogluteal and dorsogluteal muscles. 3- Subcutaneous injection: Subcutaneous injections are given by injecting a fluid into the layer of skin directly below the dermis and epidermis. Subcutaneous injections are highly effective in administering vaccines and such medications as insulin. 4- Intradermal injection: -used for diagnostic purposes as skin test specific allergic reaction. Non-Parenteral (1) Orally: Giving drugs by mouth. Forms of oral drugs: Tablet, pills, capsules, powder, liquid and oily drugs. Advantages: It is the simplest and most economical method used for local or systemic effect. 69  Medication administration Disadvantages: -Nausea and vomiting from stomach irritation. -Ineffective by digestive juices in the stomach. -Inadequate absorption of the drug from intestine. -Discolor the teeth. (2) Rectally: Drugs administrates by rectum. In the form of enemas or suppositories. (3)Vaginal: Drugs administered in the vagina, such as suppositories or vaginal douches. (4) Inhalation: o By respiratory tract. o In the form of: -Amyl nitrite to relive asthmatic attacks. o Ammonia and smelling salt as respiratory stimulants. o Oxygen therapy. (5) Instillation: Pouring a liquid medicine drop into a body cavity as in eye, nose, ear and throat. (6) Local application to the skin: In the form of: antiseptic solution, ointments, solvent and lotions. The nurse's role in giving medication A- Before administrating drugs 1. A written physician order is required before a nurse administers any therapeutic agent. Types of medicine orders They may vary depending on the patient's condition and the circumstances present at the time of the order. 70  Medication administration Standing Order: Is order that will apply to all patients who are admitted to a particular nursing care unit or meet certain criteria, it is carried out for a specified number of days or until canceled by another order. Standing orders are also referred to as scheduled orders because they are administered routinely as specified until the order is canceled by another order. The standing orders stay in effect until the health care practitioner discontinues or modifies the dosage or frequency with another order or until a prescribed number of days has elapsed as determined by agency policy. The purpose of a standing medication order is to maintain the desired blood level of the medication. Agency policy determines the actual times for administering medications for a 24-hour time interval. Stat Order: The term STAT is Latin for "immediately". Is one to be carried out as soon as possible e.g. furosemide 20 mg IV stat. Stat order is an order for a single dose of medication to be given immediately. Stat drugs are often prescribed in emergency situations to modify a serious physiological response; a stat dose of nitroglycerin may be ordered for a Patient experiencing chest pain. The nurse should assess and document the Patient’s response to all stat medications. Single Order: Is given only when the patient needs it e.g. an analgesics hypnotics and laxatives. Single-dose Orders Single-dose orders are one-time medications or may require the administration of drops or tablets over a short period of time. The nurse should administer single-dose orders only once, either at a time specified by the health care practitioner or at the earliest convenient time. These drugs are often prescribed 71  Medication administration in preparation for a diagnostic or therapeutic procedure; for example, radiopaque tablets may be administered in preparation for a gallbladder test, or a one-time order may be given for a preoperative medication. PRN Orders PRN- Order (as needed) basis as circumstances indicate. The drug is administered when, in the nurse’s judgment, the Patient’s condition requires it. Before administering a prn medication, the nurse must thoroughly assess the Patient, using both objective and subjective data in determining the appropriateness of administering the medication. This type of order is commonly written for analgesics, antiemetic, and laxatives. 2. Observe the "Six Rights" of Medication Administration -The Right Patient. -The Right Medicine. -The Right Dose. -The Right Time. -The Right Route. Right Documentation - Date - Time - Signature 3. Drug knowledge: Before the nurse can safely administer a drug, she Needs to become acquainted with different form and types of this drug. She must know range of safe dosage, methods of administration, expected therapeutic effect, side effects and symptoms of overdose (toxicity). 4. be sure if medication is to be delayed or omitted for a specific length of time. 72  Medication administration Labeling of drugs o Give medication only from clearly labeled containers. o For preparing a dose, read the three times. Each time that you give a medication, you also need to remember to do the "Three Checks". This means that you are going to do a "triple-check" to make sure that the six rights are present each time that you give a medication. You must: 1. Remove the medication from the locked area and check the prescription label against the medication log to make sure that they match: this is the 1st check. 2. Before pouring the medication, check the prescription label against the medication order to make sure that they match: this is the 2nd check. 3. After you pour the medication, but before you give it, check the prescription label against the medication log entry again to make sure that they match: this is the 3rd check. o Never give a drug from unmarked bottle or box. o Pour medicine from the bottle on the side opposite the label. o Only the pharmacist should change labels on medicine containers. o If a drug has two commonly used names, both names should appear on the label. Nurses can avoid a serious mistake if: 1. Prepare medication for one individual at a time. 2. Give the medication to the individual as soon as nurse prepare it. 3. Do not talk to others and ask them not to talk to nurse when nurse are giving medication. 4. Do not stop to do something else in the middle of giving medications. 5. Pay close attention at all times when nurse are giving medications. 73  Medication administration Preparing drugs o Wash hands before measuring or preparing a medication. o Make certain that all equipment is clean. o Do not touch the medicine with your hands. o Do not return excess medicine or medicine refused by a patient to stock supply. o Do not pour a drug from one bottle to another. o Never leave the medicine cabinet unlocked. Measuring drugs o *The nurse must know the different systems of weights and measures of drugs. o *The metric system: The most commonly used division is milliliter. o This measurement is identical to the cubic centimeter so ml and cc o Are interchanged terms. o *Household measurement: are not accurate because manufactures of items such as teaspoons, table spoons and cups are not o Required to meet measurement unless the tool is specifically designed as a measuring device. o *Measure the exact amount of drug ordered, using a calibrated measure. o *Make sure that medicine glasses are dry before pouring or measuring a medication. o *Holding the medicine glass at eye level and place thumbnail of the handholding the class at the height to which medicine is to be poured. o *Do not converse with a person who is preparing a medication. 74  Medication administration Metric Household 1 mL 15 drops 5 mL 1teaspoon 15 mL 1table spoon 30 mL 1ounce (2 table spoon) 500 mL 1 pint (half quart) 1000 mL 1quart (3, 7853) L B-G iving Medications o Give the medication at the time for which it is ordered. o Identify the patient before giving the medication by name o Administer only those medicines, which you have measured and Poured. o Do not permit one patient to carry medicine to another. o Never mix