Fundamentals of Nursing PDF

FUNDAMENTALS - PHILIPPINE NURSES ASSOCIATION \[PNA\] - PROFESSIONAL REGULATION COMISSION \[PRC\] Roles and Functions of a Nurse Caregiver \| Communicator \| Teacher Client Advocate\| Counselor Change agent Leader \|Manager \|Case manager Researcher Evidence-based practice (EBP) attempts...

FUNDAMENTALS - PHILIPPINE NURSES ASSOCIATION \[PNA\] - PROFESSIONAL REGULATION COMISSION \[PRC\] Roles and Functions of a Nurse Caregiver \| Communicator \| Teacher Client Advocate\| Counselor Change agent Leader \|Manager \|Case manager Researcher Evidence-based practice (EBP) attempts to cover gaps in patient care for better outcomes and a healthier population by blending clinical experience and evidence. 6 C's of Caring Care \|Compassion \|Competence Communication \| Courage \| Commitment Wellness aware of and making choices toward a healthy and fulfilling life. The Eight Dimensions of Wellness : Emotional \|Environmental \|Financial Intellectual \| Occupational \| Physical Social \| Spiritual Illness being unhealthy in your body or mind. Disease Alteration in body functions Common Causes of Disease - Biologic Agents (e.g. microorganisms) - Inherited Genetic - Developmental Defects - Physical Agents (hot/cold subs.,UV rays) - Chemical Agents (Lead, emissions - Tissue response to injury (fever, inflammation) - Faulty Chemical/Metabolic Process (↓Insulin=DM) - Emotional/ physical reaction to stress (anxiety,fear) Stages of Illness - Symptoms experience - Assumption of the sick role - Medical care contract - Dependent client role - Recovery and rehabilitation **Classification of Disease** A.According to Etiologic Factors HEREDITARY \| CONGENITAL \|METABOLIC DEFICIENCY \| TRAUMATIC \|ALLERGIC NEOPLASTIC \| IDIOPATHIC\| DEGENERATIVE \| ATROGENIC B. According to Duration or Onset Acute Illness \| Chronic Illness - Remission period - controlled and symptoms are not obvious. - Exacerbation disease becomes more active again at a future time, with recurrence of pronounced symptoms. - Sub-acute symptoms -pronounced but more prolonged than in acute disease. C. Others Class Organic \| Functional \| Occupational Familial \| Venereal \| Epidemic Endemic \| Pandemic \| Sporadic Primary prevention Ex ;immunization \|taking regular exercise. Secondary prevention Ex ; screening for high blood pressure\| BSE Tertiary prevention ---rehabilitation following significant illness Health promotion increase control over their own health -addressing and preventing the root causes of ill health, health maintenance. A systematic program or procedure planned to prevent illness, maintain maximum function, and promote health. NURSING DX- complications /associated problems PARTS 1.PROBLEM= existing or observable to client \[related to \] 2.ETIOLOGY=related factors \[ as evidence by\] 3.S/ SX = defining characteristics Types of Assessment 1. Initial assessment:/triage, 2. Problem-focused assessment: 3. Emergency assessment: 4. Time-lapsed assessment: SUBJECTIVE "as verbalize by the client " "as verbalize by the significant other " Nursing Diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Components of Nursing Diagnosis - 1^ST^-problem statement or diagnostic label (as listed in NANDA), - 2^nd^ etiology. - three part- Problem, Etiology and Sign, Symptoms (defining characteristics) Types Of Nursing Diagnosis Actual NDx \[characterized by \] Risk NDx \[ related to \] Wellness NDx \[Readiness for enhanced \] Planning 1\. Initial Planning 2\. On-going planning 3\. Discharge planning Elements of Planning SMART After\[time \] of nursing interventions , the client \[problem\] will\[goal\] ,\[measurable\] INDEPENDENT NURSING INTERVENTION = needing NO physicians order Ex; V.S taking, fix bed, rise the side rails /head of the bed , OTC meds DEPENDENT NURSING INTERVENTION =depends on the physician's order Ex; positioning the client/ assist the patient in drinking water in such cases if it is NPO, adminitered medications COLLABORATIVE NURSING INTERVENTION = referring your client to other multidisciplinary fields Ex; labs ,med tech, dietitians respiratory therapist Evaluation 1\. The goal was met 2\. The goal was partially met 3.The goal was not met SAFETY AND INFECTION CONTROL Infection invasion by microorganisms THE CHAIN OF INFECTION 1\. Etiologic/ Infectious Agent 2\. Reservoir 3\. Portal of Exit 4\. Mode of Transmission -- Biologic (animals like rats, and ,mosquito), \- mechanical ( inanimate objects infected with infected body fluids such as needles and syringes) 5\. Portal of Entry 6\. Susceptible Host STAGES OF INFECTIOUS PROCESS - Incubation Period - Prodromal Period - Illness Period - Convalescent Period BREAKING THE CHAIN OF Infection Asepsis absence of disease producing microorganisms (infection) 1\. Medical Asepsis "CLEAN technique" 2\. Surgical Asepsis "STERILE technique" OXYGENATION 1\. The Airways A. Upper Airways  Nasal Cavity \| Pharynx \| Larynx B. Lower Airways Trachea\| R. and L. mainstem bronchi Segmental bronchi \| Terminal bronchi C. Functions of the Upper Airway Transport of gases to the lower airways Protection of the lower airway Warming, filtration and humidification of air D. Functions of the lower airway  Clearance mechanism \- cough - mucociliary system \- macrophages -lympatics  Immunologic Responses \- Cell- mediated immunity in the alveoli Pulmonary Protection in injury \- Respiratory Epithelium - Mucociliary system Nares = the openings of the nose Vestibule = cavity inside the nostril Vibrissae = hairs that line the vestibule Carina = the biforcation of trachea\[ in between the inverted Y of the bronchi\] Goblet Cells = secretes mucous= 120 ml/day 2\. The Pleura Serous membranes that enclose the lungs. 3\. The lungs R. lung= 3 lobes,\[ higher/sucking pressure \] L. lung=2 lobes Mediastinum= separates the lungs 1\]Residual Volume = amt. Of air that remains in the lungs 2\]Tidal Volume = amt. of air that moves in and out of lungs= 500ml 3\]Expiratory reserve volume = amt. of extra air that can be exhaled after a normal breath. 4\]INSPIRATORY TOTAL LUNG CAPACITY- summation of 4 Pneumocytes= Type1= line the alveoli, Type 2= produce surfactant LS ratio 2;1\[lecithin &sphingomyelin \]- determine the capacity of the baby/ reediness of the baby to breath on its own. 4\. Thorax and Diaphragm Has 12 pairs of ribs\[ 1-7=true ribs , 8-10= false ribs, 11-12= floating ribs Diaphragm main respiratory muscle \[C1-C6= control the diaphragm -cervical and spinal nerve. 5\. Respiratory Control A. CNS Control - Medulla oblongata(central chemoreceptors)-\[vomiting center \] - Pons(apneustic center( APNEUSTIC B. Reflex Control  Cough reflex PLANNING 1\. Adequate supply of O2 from the environment. ↑ altitude=↓O2 concentration 2\. Deep breathing and coughing exercises 3\. Semi-fowler's and high fowler's 4\. Maintain patent airway 6\. Avoid environmental pollutants 7\. Chest Physiotherapy -expel phlegm s -  Percussion -  Vibration -  Postural drainage= expulsion of lung secretions from various lung segments through gravity. 8\. Bronchial Hygiene Measures A. Steam Inhalation \- to liquify mucous secretions \- to warm and humidify inspired air \- to soothe irritated airways \- to administer medications B. Aerosol Inhalation 9\. Suctioning: to clear airways from mucous secretions Oropharyngeal and Nasopharyngeal Suctioning 10\. Incentive Spirometry 11\. Administration of SupplementalOxygen Causes of Airway Obstruction \- tongue -increase salvation \- mucous secretions - edema of airways \- spasm of airways Clinical signs of Acute Hypoxia 1\. Nausea and vomiting 2.Oliguria, =urine formation \30cc/hr 3\. Headache 4. Apathy\[lack of emotion\] 5\. Dizziness 6. Irritability 7. Memory loss Clinical Signs of Chronic Hypoxia 1\. fatigue, lethargy= state of consciousness like feel sleepy. 2\. Pulmonary ventilation increases 3\. RBC count increases 4\. Hgb concentration increases 5\. Clubbing of fingers RHYTM \- Cheyne-stokes = from deep-shallow then apnea. \- Kussmaul's = HYPERVENTILATION \- Apneustic = prolonged gasping, then inefficient expiration \- Biot's = shallow breaths interrupted by apnea. CHON-PROTEINS 3-4HRS CHOO-FATS 4-6HRS CHO -CARBOHYDATE 1-2HRS 1\. The Mouth (Oral & Buccal Cavity) ⦁ Mechanical& Chemical digestion -amylase(ptyaline). Breaks starch=maltose. ⦁ Deglutition(swallowing) 2\. The Esophagus 3\. The Stomach ⦁ Capacity= 1500 ml Parietal cells-producing acid RUSH DIET-small frequent feeding BRAT DIET- banana, rice, apple ,toast FUNCTIONS OF THE STOMACH ⦁ Secretion 1500-3000 ml gastric juice= mucus+HCL 3\. The Small Intestine ⦁Majority of digestive process-duodenum 1\. Mucus Secretion ⦁ Goblet Cells & Duodenal (Brunner's) Gland = mucus to protect the mucosa 2\. Secretion of enzymes ⦁ Brush Border Cells= sucrase, maltase, enterokinase ⦁ Peptidase acts on polypeptides ⦁ Enterokinase activates trypsinogen from pancreas 3\. Secretion of Hormones ⦁ Endocrine cells secretes cholecystokinin, secretin and enterogastrone that regulate the secretion of the bile, pancreatic juice and gastric juice. FUNCTIONS OF LARGE INTESTINES ⦁ Motor Act. ⦁ Secretion.⦁ Absorption ⦁ Vitamin Synthesis ⦁ Defecation ⦁ fecal material is ¾ H2O and ¼ solid material VARIABLES AFFECTING INDIVIDUALS CALORIC NEEDS 1.Age and Growth 2. Gender 3. Climate 4\. Sleep 5. Activity 6. Fever 7.Illness FOOD AND FLUID INTAKE REGULATING MECHANISM 1\. Thirst 2. Hunger 3. Appetite 4. Satiety VITAMINS C ( Ascorbic Acid ) B1( Thiamine ) B2( Riboflavin ) B3( Niacin/Nicotinic Acid ) B6( Pyridoxine ) B9( Folacin/Folic Acid ) B12(cyanocobalamin Pantothenic Acid Biotin FAT SOLUBLE VITAMINS A ( Retinol ) D ( Ergocalciferol ) E ( Tocopherol ) K ( Menadione ) Hypokalemia = apathy, muscular weakness, mental confusion, abdominal distention, nausea, dysrhythmia Hyperkalemia = weakening of cardiac contraction, mental confusion, poor respiration ASSESSING NUTRIOTIONAL STATUS ABCD Approach ANTHROPOMETRIC MEASUREMENTS ⦁ Height ⦁ Weight ⦁ Skin folds (fat folds) ⦁ Arm muscle circumference (AMC) ⦁ BMI = wt in kg / (ht in meter x ht in meter) BMI: 20-25% Normal BIOCHEMICAL DATA ⦁ Hgb and Hct indices ⦁ Serum albumin ⦁ Transferrin (blood protein that binds with iron) ⦁ Total lymphocyte count ⦁ Nitrogen balance ⦁ Creatinine excretion Clinical Signs \- hair, skin, eyes, tongue, mucous membrane etc. Dietary Hx \[3 day recall/- 24 hr. diet recall. 1\. Clear Liquid. H2O lemonade \| Bouillon coffee/tea w/o milk Clear broth \| hard candy Gelatin carbonated drinks \| Popsicles \[KNORR CUBS /PINAPAKULUAN\] 2\. Full liquid. Plain Ice cream sherbet \| Milk pudding Strained soups strained veg. juices 3\. Soft. reduced fiber content wich requires less energy for digestion. (chopped/pureed foods) 4\. DAT. DIET AS TOLERATED Follows diet prescription. ALTERNATIVE FEEDING METHODS Nasogastric Feeding (gastric gavage) ⦁Levin tube=commonly used tube : ⦁ To provide feeding (gavage) ⦁ To irrigate stomach (lavage) ⦁ For decompression ⦁ Administration of medication ⦁ Administer supplemental fluids BOWEL AND BLADDER ELIMINATION contracting the abdominal muscles and by forceful expiration with gottis closed increase the abdominal pressure. (Valsalva Maneuver) The fecal matter may take 24-48 hrs. to pass through the large intestine. -  150-300 grams of feces - unabsorbed food residue, mucus, digestive secretions, water and microorganisms. -  75% H2O and 25% of solid. NORMAL CHARACTERISTIC OF THE STOOL - Color= yellow or golden brown (stercobilin/urobilinogen) - Odor =aromatic upon defecation (indole/scatole) - Amount =Approx. 150-300g/day - Consistency =soft, formed - Shape= cylindrical - Frequency= 1-2/day to 1 every 2-3 days. 1\. Alcoholic Stool = gray, pale or pale-colored stool 2\. Hematochezia = bright red blood. 3\. Melena = black tarry stool 4\. Steatorrhea = greasy, foul smelling stool d/t undigested fats 1\. Constipation = small, dry, hard stools or the passage of no stool a\. Adequate fluid intake, bet 1.5-2 L/ day b\. High fiber diet. bulk to the stool c\. Establish regular pattern of defecation d\. Respond immediately the urge to defecate. e\. Minimize stress. Stress triggers S N S causing decreased peristalsis. f\. Adequate activity and exercise promotes muscle tone and facilitate peristalsis. g\. Assume sitting or semi squatting. h\. Administer laxative as ordered. This stimulates peristalsis and promote defecation. TYPES OF LAXATIVES Chemical Irritants. \| Stool Lubricants. Stool Softener. \| Bulk Formers. \|Osmotic Agents. 2\. Fecal Impaction a\. Absence of bowel for 3-5 days b\. passage of fecal liquid seepage c\. Hardened fecal mass is palpated during digital examination of the rectum. d\. Nonproductive desire to defecate and rectal pain e\. Anorexia, body malaise f\. Subjective feeling of abdominal fullness or bloating, abdominal distention g\. Nausea and vomiting Nursing Intervention ; a\. Manual extraction or fecal disimpaction asordered. b\. Increase fluid intake c\. Sufficient bulk/fiber in the diet d\. Adequate activity and exercise 3\. Diarrhea a\. Replace fluid and electrolyte losses b\. Provide good perianal care. c\. Promote rest to reduce peristalsis. d\. Diet: small amts. Of bland foods Low fiber foods BRAT diet (banana, Rice am, apple, toast) Avoid execessive hot/cold fluids D. Potassium rich foods e\. Anti-diarrheal medications as ordered Demulcents: mechanically coat the irritated bowel and act as protectives Absorbents: absorbs gas or toxic substances frombowel Astringents: shrinks swollen tissues in the bowel 4\. Flatulence a\. Constipation b\. Codeine, barbiturates and other drugs c\. Anxiety d\. Eating gas-forming foods, cabbage, legumes, root crops, inions e\. Rapid food or fluid ingestion f\. Improper use of drinking straw g\. Excessive drinking of carbonated beverages h. Gum chewing, candy sucking, smoking i\. Abdominal surgery. Deceases peristalsis j\. Sipping hot beverages RN INTERVENTIONS FOR FLATULENCE a\. Avoid gas forming foods b\. Provide warm fluids to drink to increase peristalsis c\. Early ambulation for post-op clients d\. Adequate activity and exercise e\. Limit carbonated drinks use of drinking straws and chewing gums f\. Rectal tube as ordered place client left lateral position insert 3-4'' of lubricated tube gently in rotating motion.use rectal tube Fr. 22-30 retain rectal tube for max. 30 mins. carminative enema as ordered 5\. Fecal Incontinence voluntary elimination of bowel contents; Administering Enemas P-reparation for dx/surgery E- xpell flatus L- ubricate the colon S- often the stool S- timulate peristalsis S- timulate rectal wall nerve A.Cleansing- Non-retention P: for dx Stimulates peristalsis Ex: Hypertonic Sol'n. \| Hypotonic Sol'n. NSS+soap Suds \| Fleet enema \| Clean H2o A.Oil-based- Retention Carminative P: expel flatus gaseous distension Composition: MgSO4-30ml \| Glycerin- 60 ml \| H2O- 90 ml URINE FORMATION 1\. Glomerular Filtration 2. Tubular Reabsorption 3. Tubular Secretion Micturition = expelling urine from the bladder NORMAL CHARACTERISTICS OF URINE Color: amber/straw Odor: aromatic upon voiding Transparency: Clear pH: slightly acidic 4.6-8. average=6 Specific gravity: 1.002 and 1.030 (urinometer -URINARY TRACT INFECTION R B C \| W BC \| Pus \| Bacteria \| Hematuria Pyuria -DIABETIC KETOACIDOSIS Bacteriuria \| Albumin \| protein \|Glucose Ketones \| albuminuria \| Proteinuria Glycosuria \| Ketonuria 1\. Polyuria excessive amount of urine 100ml/hr=2.5L/day (diuresis) 2\. Oliguria decreased amount of urine 30ml/hr. or \< 500ml/day 3\. Anuria absence of production ofurine from 0 to 10ml/hr. (urine suppression) C. Altered Urinary Frequency 1\. Frequency 2\. Nocturia 3\. Urgency 4\. Dysuria-painful or difficulty in voiding 5\. Hesitancy=Difficulty initiating voiding. 6\. Enuresis=repeated involuntary voiding 7\. Pollakiuria=frequent, scanty urination 8\. Urinary Incontinence Retention. Accumulation of urine in the bladder w/ associated inability of the bladder to empty itself. (250-450ml=urine reflex) Legal Roles of Nurse 1\. Provider of Service 2\. Liability 3\. Standards of care 4\. Employee or Contractor for Service 5\. Contractual Relationship 6\. Citizen Rights = are privileges or fundamental powers Responsibilities = are the obligations associated with rights. i.e. to protect the rights of the recipient of care 1\. TORT is punishable by damages (i.e., monetary compensation) rather than imprisonment. A\] Intentional Torts \- a high degree of certainty \[ B\]Unintentional/negligent tort \- carelessness Assault: Tharmful, offensive or unauthorized contact ,a willful attempt or threat to injure. Battery: Is the harmful, offensive or unauthorized touching of another person. False imprisonment: Invasion of privacy: intrusion into the personal life of another, Defamation of Character: \- LIBEL AND SLANDER \- Accusing someone of a crime, having a horrible disease Using words which affect a person\'s profession or business -Misrepresentation and Fraud: -Infliction of Mental/Emotional Distress: -Negligent Torts; failure to act as a reasonable person to someone to whom s/he owes a duty, 1\. Ordinary negligence 2\. Gross negligence is more severe Malpractice includes four elements : 1\. Duty of care 2. Breach of duty 3\. element of injury 4. & proximal cause Data Privacy Act \[DPA\] Sensitive personal information 1.Race, ethnic origin, marital status , age ,color, and religious, philosophical or political affiliations 2.Health, education, genetic or sexual life of a person or to any preceding for any offense committed or alleged to have been committed by such person, the disposal of such proceedings, or the sentence of any court in such proceedings. 3.Information issued by government agencies peculiar to an individual which includes nut not limited to social security numbers, previous current health records ,licenses, or its denials, suspension or revocation and tax returns 4.Information specifically established by an executive order or an act of congress to be kept classified Data subject individual whose personal information is processed PAIN-personal sensation a\. nociceptors= sensory pain receptors\[thermos,chemo or mechanical pressures\], -\[skin.blood vessels subq,tissue etc.\], -located on two types of peripheral nerve cells; 1\. A-delta fibers\[bright sharp\], 2.c-fibers\[dull poorly,persistent\] B. ORIGIN OF PAIN -cutaneous pain\[ skin/subq\] -deep somatic pain \[ligaments, tendons, bones, blood vessels, nerves \] -visceral pain \[abdominal cavity, cranium, thorax \] -referred pain -intractable pain\[resistant to cure or relief\] -phantom pain -radiating pain \[extends\] -psychogenic pain\[emotional\] -intermittent pain \[stops and starts\] c\. TYPES OF PAIN acute pain \| chronic pain d\. concepts associated with pain -pain threshold\[stimulation require to feel pain\] -pain reaction -pain tolerance \[maximum amount and duration of pain\] Neurosurgery for pain 🞇 Neurectomy 🞇 Rhizotomy 🞇 Cordotomy or Spinothalamic Tractotomy 🞇 Tractotomy 🞇 Gyrectomy 🞇 Hypophysectomy PHYSIOLOGY OF SLEEP RAS-state of wakefulness SEROTONIN-major neurotransmitter NREM stage 1-RR AND HR drops slowly stage 2-eyes are still stage3 &4 -skeletal muscles relaxed, diminished reflex Common Sleep Disorders 1\. Insomnia 2. Hypersomnia 3.Narcolepsy 4. Sleep Apnea 5\. Parasomnias - Somnambolism- Sleepwalking - Somniloquy. -Sleep talking - Night Terrors. \| Nocturnal Enuresis. - Nocturnal Emissions. \| Bruxism. LOSS =inaccessible, no longer valuable BEREAVEMENT =subjective response\[significant relationship\] GRIEF = thoughts, feelings, behaviors MOURNING =culture and customs The 5 Stages of Grief 1\. Denial 2. Anger 3. Bargaining 4\. Depression 5. Acceptance Signs of impending clinical death A. Loss of muscle tone B. Slowing of circulation C. Changes in vital signs D. Sensory impairment Indications of death Total lack of response to external stimuli No muscular movement No reflexes Flat encephalogram. VITAL SIGNS ASSESSMENT - Allow 5 minutes rest before taking the vital signs. - identify changes in the patient\'s condition. TEMPERATURE= 36.5 C-37.7 C. FACTORS THAT MAY INCREASE BODY TEMPERATURE: Strenuous exercise Stress Ovulation \[rases the temperature about one degree\] Body temperature is lowest in the early morning (4 am-6 am) Body temperature is highest late in the evening (8pm-midnight) hypothalamus \- producing hormones that regulate body temperature it becomes more active A. ORAL METHOD - Most accessible and convenient. - Allow 15 minutes to elapse between a client\'s intake of hot or cold food or smoking. - Place the thermometer under the tongue, directed toward the side. Take oral temperature for 2-3 minutes CONTRAINDICATIONS 1\. Oral lesion or surgery. 2. Dyspnea 3\. Cough 4. Nausea and vomiting 5\. Presence of oro-nasal contraptions eg nasal pack, nasogastric tube, endo-tracheal tube. 6\. Seizure prone 7. Very young children. 8\. Unconscious 9\. Restless, disoriented, confused A. RECTAL METHOD \- most accurate measurement. CONTRAINDICATIONS 1. Anal/rectal conditions or surgeries. \[Ex. Anal fissure, hemorrhoids, hemorrhoidectomy.\] 2. Diarrhea C.AXILLARY METHOD - safest and most non-invasive. - Place the arm tightly across the chest to keep the thermometer in place for 3 minutes in adults and for infants & children for 5 minutes TYMPANIC TEMPERATURE Place the probe very gently at the opening of the ear canal for 2-3 seconds until the temperature appears in the digital display, 1.CORE BODY TEMPERATURE \- I deep tissues of the body. 2\. SURFACE BODY TEMPERATURE -e skin, subcutaneous tissue and fat FACTORS THAT AFFECT THE BODY\'S HEAT PRODUCTION 1\. BASAL METABOLIC RATE. 2\. MUSCLE ACTIVITY 3\. THYROXINE OUTPUT 4\. EPINEPHRINE, NOREPINEPHRINE AND SYMPATHETIC STIMULATION 5\. INCREASED TEMPERATURE. Thyroxine \[T4\] LETRAIODOXTHYRONINE Crucial hormone produce by the thyroid gland Functions and roles; - Metabolism ;regulating the body's metabolic rate - Heart and muscle function - Brain development - Bone maintenance 1\. PYREXIA (Also called hyperthermia or fever). Febrile- whose body temperature is above the normal range 2\. HYPERPYREXIA Very high fever, ex. 41°C and above 3\. HYPOTHERMIA Subnormal core body temperature. Convulsions are a specific type of seizure TYPES OF FEVER 1\. INTERMITTENT FEVER \- has a fluctuating baseline between normal temperatures 2\. REMITTENT FEVER fluctuates within a wide range over 24 hours period but remains above normal body temperature. 3\. RELAPSING FEVER elevated for few days, alternated with 1 or 2 days of normal body temperature. 4\. CONSTANT FEVER Very high body temperature (Ex. 41-42°C) may cause irreversible brain cell damage or continuous fever is a body temperature greater than 37.7C (100F) that continues to persist for 24 hours or more. An acute fever lasts 4 days or less but may continue for up to 7 days in more severe infections. DECLINE OF FEVER 1.CRISIS - Elevated body temperature settles down to the baseline value immediately after starting treatment. - It is the sudden decline of fever. impairment of function of the hypothalamus. 2\. LYSIS It is the gradual decline of fever. FASTIGIUM- is the highest (peak) body temperature during the course of fever or illness PULSE \- regulated by the autonomic nervous system-\[ always active. even when you\'re asleep, and its key to continued survival\] PULSE SITES 1\. Temporal 2. Carotid 3. Apical 4\. Brachial 5. Radial 6. Femoral 7\. Posterior Tibial 8. Popliteal 9\. Pedal (dorsalis pedis)-Use the middle of the two to three fingertips to palpate the pulse. Do not use the thumb. ASSESSMENT OF THE PULSE Newborn to I month: 80 180 beats/ min. 1 year: 80 140 beats/min 2 years: 80 130 beats/ min. 6 years: 75 120 beats/min. 10 years 60 90 beats/min Adult: 60 100 beats/min. Pulse Deficit \- the difference between the apical and the radial pulse FACTORS AFFECTING THE PULSE RATE ARE AS FOLLOWS: 1\. Age 2. Sex/Gender. 3. Exercise, 4\. Fever. 5. Medications. 6. Hemorrhage. 7\. Stress. 8. Position. RESPIRATION Diffusion - There is a high concentration of oxygen in the alveoli and a low concentration of oxygen in the blood so oxygen diffuses from the alveoli into the blood. - There is a high concentration of carbon dioxide in the blood and a low concentration in the alveoli, so carbon dioxide diffuses from the blood into the alveoli. Three Processes: 1\. Ventilation. 2\. Diffusion. 3\. Perfusion. The availability and movement of blood for transport of gases, nutrients and metabolic waste products. TWO TYPES OF BREATHING Costal breathing, \- shallow breathing thoracic breathing or chest breathing \|rib cage expands outward Characteristics - Shallow= Minimal air enters the lungs - Limited Oxygen intake Stress and Tension - Causes =Anxiety, panic, breathing to chest or poor posture Diaphragmatic breathing, -or deep breathing, using the diaphragm, contracts and moves downward, - Deep Air reaches the lower parts of the lungs. - Increased Oxygen Intake: activates the body\'s natural relaxation response. - Recommended: Often recommended for stress reduction, relaxation, and overall health -have positive effects on y our physical and mental well being ASSESSING RESPIRATION Rate. Depth. = deep or shallow. Rhythm. = regularity of exhalations and inhalations. Quality or character. =effort and sound of breathing. RESPIRATORY CENTERS -in the medulla oblongata and pons, in the brainstem. q 1\. Medulla Oblongata -primary respiratory center. 2\. Pons contains the following: Pneumotaxic center \- rhythmic quality of breathing. \*Apneustic center \- deep, prolong inspiration Three types of respiration Extremal respiration \- inhalation and exhalation of gases. Internal respiration gas exchange between the blood and body cells Cellular respiration involves the conversion of food to energy, MAJOR FACTORS AFFECTING RESPIRATORY RATE - ALTITUDE; leading to increased respiratory rates to compensate for lower oxygen levels - Diseases and Conditions: -Pneumonia An infection that inflames the lungs air sacs (alveoli), resulting in symptoms fever, chills, and difficulty breathing. ke cough, - Influenza A viral infection causing fever, cough, sore throat, body aches, and a runny nose - \- Asthma and other lung conditions. - Anxiety and Stress, which can increase heart rate, blood pressure, and respiratory rate 1\. Exercise. 2\. Stress. 3.Environment. Increased temperature of the environment decreases RR ; decreased temperature increases RR 4\. Increased Altitude. 5\. Medications. (e.g. narcotics decreased RR) Hyperventilation. Deep rapid respiration. Carbon dioxide is excessively exhaled (respiratory alkalosis). Hypoventilation. Slow shallow respiration. Carbon dioxide is excessively retained (respiratory acidosis) BLOOD PRESSURE \- pressure of circulating blood against the walls of blood vessels. Systolic is the pressure in the artery as the heart contracts (squeezes) Diastolic is the pressure in the artery when the heart is refaxing and being filled with blood in both arms. Record whether the patient was lying, sitting, or standing at time the reading It is measure of the pressure exerted by the blood as it pulsates through the arteries. Systolic Pressure. Is the pressure of blood as a result of contraction of the ventricles of the heart (100-140mmHg) Diastolic Pressure. Is the pressure when the ventricles are at rest (60-90 mmHg) Pulse Pressure. Is the difference between the systolic and diastolic pressure (sp-dp=pp). Normal is 30-40 mmig Hypertension. Is an abnormally high blood pressure over 140 mmHg systolic and or above 90 mmHg diastolic for at least two consecutive readings. Hypotension, Is an abnormally low blood pressure. Systolic pressure below 90 mmHg and or below 60 mmHg of diastolic pressure. Primary Hypertension (essential HPN) An elevated blood pressure of unknown cause. Secondary Hypertension. An elevated blood pressure of known cause e g. atherosclerosis. cardiac diseases, aneurysm, kidney diseases etc. Orthostatic Hypotension, - falls when the client sits or stands. - postural hypotension, It can lead to symptoms such as dizziness, light headedness, fainting, and confusion. Prehypertension 120-139 \\ 80-89 Hypertension, Stage I 140-159 \\ 90-99 Hypertension. Stage 2 160 or above \\ 100 or above Symptoms: When rise from a lying or sitting position, may experience unexpected light headedness, blurred vision, tunnel vision, or dull pain in the back of your neck and shoulders. -In rare cases, fainting or loss of consciousness may occur. Risk of Falls: - may have an underlying severe condition on Gravity's Impact. when stand up gravity causes blood to g pool in legs. DETERMINANTS OF BLOOD PRESSURE 1\. Blood Volume. Hypervolemia raises BP. Hypovolemia lowers BP 2\. Peripheral Resistance. Vasoconstriction elevates BP. Vasodilatation lowers BP. 3\. Cardiac Output. If the pumping action of the heart is weak (decreased CO), BP decreases. 4\. Elasticity or Compliance of Blood Vessels. 5\. Blood Viscosity. Increased blood viscosity increases BP. Viscosity increases markedly when. - -refers to the thickness or stickiness of blood 11 the Hct is more than 60-65. influenced by factors such as the concentration of red blood cells (hematocrit), plasma proteins, and other cellular components, At a normal hematocrit of 40%, relative viscosity of blood is approximately. FACTORS AFFECTING BLOOD PRESSURE 1.Age. 2. Exercise. 3. Stress. Sympathetic nervous system stimulation increases BP 4\. Race. 5. Obesity. 6. Sex/Gender. After puberty and before age 65 year\'s, males have higher BP. After 65 years, females have higher BP due to hormonal variations in menopause 7\. Medications. 8. Diurnal Variations, BP is lowest in the morning and highest in the late afternoon or early evening ASSESSING BLOOD PRESSURE 1\. rested, 2\. Allow 30 minutes to pass 3\. Too narrow cuff causes false high reading. 5\. Position the arm at the level of the heart, with the palm of the hand facing up. 6\. inch antecubital space 7\. Determine palpatory BP before auscultatory BF to prevent auscultatory gap (temporary Sund). 8.Use the bell of the stethoscope since the BP is low frequency summit 9\. Inflate and deflate BP cuff slowly, 2-3 mmHg t a time. 10\. Wait 1-2 minutes before making further determination. 11\. Korotkoff\'s sound. 13\. The systolic pressure in the popliteal artery is usually 10-40 mmHg higher than that in the brachial artery; the diastolic pressure is usually the same. Hygiene --science of health & its maintenance. \- diseases or illness can be prevented \- feeling of comfort, well being, safety & self confidence. Personal hygiene -- is a self-care , bathing, toileting, general body hygiene & grooming. Two types of Sweat Glands: 1\. Apocrine glands ▪ axilla & anogenital areas ▪ at puberty under the influence of androgen. ▪ odorless, but may become musky/unpleasant when acted upon by microorganisms. 2\. Eccrine glands ▪ palms of the hands, the soles of the feet & forehead. ▪ The sweat is composed of water, sodium, potassium, chloride, glucose urea & lactate Common Problems of the Skin 1\. Abrasion -- scraped away. appears red, w/ localized bleeding or serous weeping. 2\. Excessive dryness -- scaly & rough. 3\. Acne around sebaceous glands, characterized by papules, pustules & comedones (black heads) 4\. Erythema -- redness 5\. Hirsutism \- excessive growth of the hair \[women.\] 6\. Hyperhidrosis -- is excessive & profuse perspiration. 7\. Bromhidrosis -- is foul smelling perspiration. 8\. Vitiligo \- are patches of hypopigmented skin caused by destruction of melanocytes Type of Skin Lesion 1\. Macule -- a flat, circumscribed area of color w/ no elevation of its surface. 2\. Patch -- same as macule but larger than 1cm.ex port birth mark. 3\. Papule -- a circumscribed, solid elevation of skin; less than 1cm ex. Warts, acne. 4\. Plaque -- same as papule butlarger than 1cm ex. Eczema. 5\. Nodule -- a solid mass that extends deeper into the dermis than that of a papule ex. Rheumatoid nodules 6\. Tumor -- a solid mass larger than a nodule. 7\. Vesicle -- a circumscribed elevation containing serous fluid or blood; less than 1cm ex. Blister, chicken pox. 8\. Bulla --a large fluid sac, or vesicle containing transparent watery fluid. 9\. Pustule -- a vesicle or filled w/ pus. Ex. Acne 10\. Wheal \- a relatively reddened, elevated, localized collection of edema fluid; irregular in shape. ex,. Mosquito bite. 11\. Cyst -- elevated, thick- walled lesion containing fluid or semisold matter. Ex. Sebaceous cyst, cervical cyst 12\. Telangiectasia --dilated capillary; fine red lines. Ex. Liver cirrhosis. 13\. Petechia -- pinpoint red spots. BATHING ▪TUB BATH ▪STAND-UP SHOWER ▪SIT-DOWN SHOWER W/SHOWER CHAIR ▪BED BATH Sponge Bath: \- therapeutic bath done by sponging the body with wash cloth from cold or tepid water to reduce body temperature & refresh Open Wound \- external or internal break -accidents involving sharp or rough objects that cut through the skin Types of Open Wound Abrasion rubs against a rough surface. Puncture hole-shaped wounds caused by pointy objects \[ if the wound is contaminated, antibiotics or a tetanus shot Incision clean and straight wound If tendons are affected, an incision will cause heavy bleeding Laceration \- deep and jagged cut that results Avulsion -partial or complete tear of the skin and tissues. \| some cases of avulsions can also lead to the loss or dislocation of limbs. Amputation loss of an extremity -can also be done in a medical procedure to manage certain diseases such as gangrene. Closed Wound -caused by blunt trauma, \- bleeding and damage to underlying muscle, internal organs and bones. Types of Closed Wound Contusions: painful bruise with reddish to bluish discoloration that spreads over the injured area of skin. Hematomas: -blood collecting and pooling in a limited space. \| painful, spongey rubbery lump-like lesion \| can be small or large, deep inside the body or just under the skin Wound Dressing A dressing or compress is a sterile pad applied to a wound Purpose: 1\. Stop bleeding 2\. Protection from infection 3\. Absorb exudate 4\. Ease pain compression or simply preventing pain from further trauma 5\. Debride the wound 6\. Reduce psychological stress FECAL ELIMINATION ▪ excreted waste products -feces or stool. ▪ colon's -absorption of water and nutrients, the mucoid protection of the intestinal wall, and fecal elimination. ▪ contents of the colon -foods ingested over the previous 4 days, although most of the waste products are excreted within 48 hours of ingestion. ▪ bowel movement= It is the expulsion of feces from the anus and rectum. ▪ Normal feces a=75% water and 25% solid materials ▪ brown,\[ presence of stercobilin and urobilin\],a red pigment in bile). ▪ Escherichia coli or staphylococci, which are normally present in the large intestine- affects fecal color, odor. FACTORS THAT AFFECT DEFECATION 1\. DEVELOPMENT a\. Newborns and infants Meconium \--up to 24 hours after birth \--black, tarry, odorless, and sticky Transitional Stool -after a week \--greenish yellow; they contain mucus and are loose b\. Toddlers \(a) the discomfort caused by a soiled diaper \(b) the sensation - need for a bowel movement. c\. School-age children and adolescents ▪ in frequency, quantity, and consistency ▪may delay defecation because of an activity such as play d\. Older adults ▪ Toner and Claros (2012) state that "up to half of all older adults suffer from constipation". ▪ reduced activity levels, inadequate fluid and fiber intake, and muscle weakness. ▪ Adequate roughage in the diet, adequate exercise, and 6 to 8 glasses of fluid daily =l preventive measures for constipation. ▪ A cup of hot water or tea at a regular time in the morning is helpful for some 2\. DIET a\. Insoluble fiber --- movement of material t, increases stool bulk \| Sources ;whole-wheat flour, wheat bran, nuts,and many vegetables. b\. Soluble fiber --- gel-like material It can help lower blood cholesterol and glucose le.vels(Mayo Clinic, 2012). Sources ; oats, peas, beans, apples, citrus fruits, carrots, barley, and psyllium. ▪ SPICY FOODS can produce diarrhea and flatus in some individuals. EXCESSIVE SUGAR can also cause diarrhea GAS-PRODUCING FOODS, such as cabbage, onions, cauliflower, bananas, and apples. LAXATIVE-PRODUCING FOODS, such as bran, prunes, figs, chocolate, and alcohol. CONSTIPATION-PRODUCING FOODS, such as cheese, pasta, eggs, and lean meat. 3\. FLUID INTAKE AND OUTPUT \- daily fluid intake of 2,000 to 3,000 mL. 4\. ACTIVITY stimulates peristalsis, facilitating the movement of chyme along the colon. 5\. PSYCHOLOGICAL FACTORS anxious or angry experience increased peristaltic activity and subsequent nausea or diarrhea. people who are depressed may experience slowed intestinal motility, resulting in constipation 6\. DEFECATION HABITS If a person ignores this urge to defecate, water continues tobe reabsorbed, making the feces hard and difficult to expel. 7\. MEDICATIONS large doses of certain tranquilizers and repeated administration of morphine and codeine, cause constipation because they decrease gastrointestinal activity through their action on the central nervous system. 8\. DIAGNOSTIC PROCEDURE \- visualization of the colon (colonoscopy or sigmoidoscopy), the client is restricted from ingesting food or fluid. The client may also be given a cleansing enema prior to the examination. 9\. Anesthesia and Surgery ▪ cause the normal colonic movements to cease or slow by blocking parasympathetic stimulation to the muscles of the colon. ▪ cause temporary cessation of intestinal movement. This condition, called ileus, usually lasts 24 to 48 hours. 10\. Pathologic Conditions ▪ Spinal cord injuries and head injuries can decrease the sensory stimulation 11\. Pain ▪ hemorrhoid surgery) often suppress the urge to defecate to avoid the pain. 1\. Constipation ---fewer than three bowel movements per week. dry, hard stool or the passage of no stool. Insufficient fiber intake Insufficient fluid intake Insufficient activity or immobility Irregular defecation habits Change in daily routine Lack of privacy Chronic use of laxatives or enemas Irritable bowel syndrome (IBS) Pelvic floor dysfunction or muscle damage Poor motility or slow transit Neurologic conditions (e.g., Parkinson's disease), stroke, or paralysis Emotional disturbances such as depression or mental confusion Medications such as opioids, iron supplements, antihistamines, antacids, and antidepressants Habitual denial and ignoring the urge to defecate. Fecal impaction \--is a mass or collection of hardened feces in the folds of the rectum. 2\. Diarrhea \--the passage of liquid feces and an increased frequency of defecation. ▪ Often, spasmodic cramps are associated with diarrhea. ▪ Bowel sounds are increased. ▪ Fatigue, weakness, malaise, and emaciation 3\. Bowel Incontinence --- loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter. ▪ impaired functioning of the anal sphincter or its nerve supply, such as in some neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle. 4\. Flatulence --- excessive flatus in the intestines and leads to stretching and inflation of the intestines (INTESTINAL DISTENTION). ▪ The three primary sources of flatus are \(1) action of bacteria on the chyme in the large intestine, \(2) swallowed air, and \(3) gas that diffuses between the bloodstream and the intestine. ASSESSMENT INTERVIEW ▪ DEFECATION PATTERN ▪ DESCRIPTION OF FECES AND ANY CHANGES ▪ FECAL ELIMINATION PROBLEMS ▪ FACTORS INFLUENCING ELIMINATION Use of elimination aids. Diet. Fluid. Exercise. Medications. Stress. ▪ PRESENCE AND MANAGEMENT OF OSTOMY 1\. Cathartics ---drug that induce defecation, have a strong purgative effect 2\. Laxatives ---mild and it produces soft or liquid stools,accompanied by abdominal cramps 3\. Antidiarrheals --- slow the motility of the intestine or absorb excess fluid in the intestine 4\. Antiflatulents- -do coalesce the gas bubbles and facilitate their passage by belching through the mouth or expulsion through the anus. ADMINISTERING ENEMA ▪ distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus. ▪ The enema solution should be at 37.7°C (100°F) because a solution that is too cold or too hot is uncomfortable and causes cramping. 1\. Cleansing 2. Carminative 3\. Retention 4. Return-flow enemas. ▪ Cleansing enemas \- remove feces. Prevent the escape of feces during surgery. Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy). Remove feces in instances of constipation or impaction. 1\. High enema is given to cleanse as much of the colon as possible. 2\. Low enema is used to clean the rectum and sigmoid colon only. The client maintains a left lateral position. \(a) the height of the solution container \(b) size of the tubing \(c) viscosity of the fluid \(d) resistance of the rectum. ▪ A carminative enema \- expel flatus. ▪ For an adult, 60 to 80 mL of fluid is instilled. ▪ A retention enema introduces oil or medication into the rectum and sigmoid colon. ▪ The liquid is retained for a relatively long period (e.g., 1 to 3 hours). RETURN -FLOW ENEMA ▪ Harris flush, / expel flatus. ▪ Alternating flow of 100 to 200 mL ▪ repeated five or six times until the flatus is expelled and abdominal distention is relieved. ASSESSMENT Assess when the client last had a bowel movement and the amount, color, and consistency of the feces Presence of abdominal distention sphincter control ▪ doctors order (type of enema and the time to give it) ▪ Determine the presence of kidney or cardiac disease that contraindicates the use of a hypotonic or hypertonic solution. Large-Volume Enema with tubing of correct size and tubing clamp Correct solution, amount, and temp. Small-Volume Enema enema solution with lubricated tip Asepsis -The absence of disease-producing microorganisms, Being free from infection Medical Asepsis reduce the number & transfer ofpathogens Surgical Asepsis -Sterile technique Sepsis -The presence of infection Septicemia -Transport of an infection or the products of infection throughout the body or by blood. Carrier -person or an animal who is without signs of illness but who harbors pathogens within his body that can be transferred to another. Contact -A person or animal known or believe to have been exposed to a disease. Reservoir -The natural habitat for the growth and multiplication of microorganisms Transient flora or bacteria -The microorganism picked by the skin as a result of normal activities that can be removed readily. Antiseptic -A substance, usually intended for use on persons that inhibit the growth of pathogens but not necessarily destroy them. Communicable Disease -Results if the infectious agent can be transmitted to an individual by direct or indirect contact through a vector or vehicle, or as an airborne infection. Infectious Disease -Results from the invasion and multiplication of microorganisms in a host. Virulence -The vigor with which the organism can grow and multiply. Specificity -The organism's attraction to a specific host, which may include humans. Opportunistic Pathogens -Causes disease only in susceptible individual. Nosocomial Infection -Hospital-acquired infection. Stages of Infectious Process 01 Incubation Period. -entry of microorganisms into the body to the onset of signs and symptoms. 02 Prodromal Period onset of non-specific signs and symptoms to the appearance of specific signs and symptoms. 03 Illness Period. Specific signs and symptoms develop and become evident. 04 Convalescent Period. Signs and symptoms start to abate until the client returns to normal state of health. The Chain of Infection \(1) Etiology/Infectious Agent: (microorganisms): Bacteria, fungi, virus, parasites 2\) Reservoir (source): Human beings, inanimate objects, plants, general environment such as air, water and soil. \(3) Portal of Exit; Sputum, emesis, stool, blood \(4) Modes of Transmission Contact, vehicle, airborne, vetorborne \(5) Portal of Entry Mucous membrane, non-intact skin, GI tract, GU tract, respiratory tract \(6) Susceptible Host Immunosuppressed children/elderly, chronically ill, those with trauma or surgery 1\. Etiologic Agent depends on its pathogenicity, virulence, invasiveness and specificity. 2\. Reservoir (source) Humans (clients, visitors, health care personnel) \| Animals (insects, rats) Plants \| General Environment (Water, air, food and soil) 3\. Portal of Exit from Reservoir Respiratory Tract: droplets, sputum Gastrointestinal Tract: vomitus, feces, saliva, drainage tubes Urinary Tract: urine, urethral catheters Reproductive Tract: semen, vaginal discharge Blood: open wound, needle puncture site 4\. Mode of Transmission a\. Contact Transmission. - Direct contact immediate and direct transfer from person to person (body surface -- to -- body surface). - Indirect contact exposed to a contaminated object such as dressing, needle and surgical instrument. b\. Droplet Transmission. mucous membrane of the nose, mouth, or conjuctiva \| within a distance of 3 feet. c\. Vehicle Transmission. contaminated items Examples: food, water, milk, blood, eating utensils, pillows, mattress. d\. Airborne Transmission. suspended in the air for a long time or when dust particles contain pathogens. e\. Vector bone Transmission. - Biological vectors are animals, like rats, snails, mosquitos. - Mechanical vectors are inanimate objects that are infected with infected body fluids like contaminated needles and syringes. Factors Influencing the Host's Susceptibility - Intact skin and mucous membrane - The normal ph levels of secretions - The body's WBC influence resistance - The age, sex, and race have been shown to influence susceptibility. - Immunization. (natural/acquired), - Fatigue, climate, general health status, presence of pre- existing illness, previous/current treatments and some kind of medications may play a part in the susceptibility of a potential host. VENTILATION Movement of air in and out of the lungs RESPIRATION Gas exchange that occurs at the alveolar level where the blood is oxygenated and carbon dioxide is removed CARBON INTOXICATION High level of carbon dioxide in the body CARDIAC OUTPUT Amount of blood that the heart pumps in 1 full minute PERFUSION Passage of blood through arteries to an organ / tissue HEMATOLOGICAL SYSTEM Amajority of oxygen molecules are transported throughout the body by attaching to hemoglobin with RBC - SPO2 -oxygen saturation - Normal; adult -- 94-98% - CHRONIC OXYGENATION condition; lower 88-92% - Acute bronchitis -- chronic cough COPD- CHRONIC OBSTRUCTIVE PULMONARY DISEASE Emphysema -- too much accumulation due to phlegm which narrows airways \[ bronchodilators = dilate airways \] ABG - Indicates ; O2 , CO2 , p H and bicarbonate levels - More specific measurement of oxygen and carbon dioxide in the blood - Used for patients who have deteriorating or unstable respiratory status requiring emergency treatment. - Drawn from radial artery by r HYPOXIA Reduced level of oxygenation Early signs ; anxiety, confusion,restlessness Late signs ; consciousness and vital signs High RR and HR \| LOW SPO2 HYPOXEMIA Specific type of hypoxia Decreased partial pressure of oxygen in the blood indicated in the ABG result HYPERCAPNIA or hypercarbia Elevated level of C02 in the blood Mucuos membrane -gums/eyes/mouthc SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS SOB \[ DYSPNEA\] RESTLESSNESSS =Early sign of hypoxia TACHYCARDIA =Early sign of hypoxia TACHYPNEA = respiratory distress SPO2 -OXYGENATION SATURATION LEVEL =Below 94-respiratory condition NOISY BREATHING =Audible noises with breathing =ADVENTITOUS SOUNDS-Wheezing, ratels, crackles =SECRETION- plug airway =Low oxygen FLARING OF NOSTRILS \[NASAL FLARING \] =Sign of respiratory distress in infants - SKIN COLOR =Cyanosis-Late sign of hypoxia - POSITION OF PATIENT TRIPOD POSITION -enhanced lung expansion \[ sit up and lean over by resting arms on their legs - HYPOXIC -Avoid supine position it will worsen - ABILITY OF PATIENT TO SPEAK IN FULL SENTENCES - CONFUSION OR CHANGE IN LEVEL OF CONSIOUSNESS \[ LOC\] =Confusion -early sign f hypoxia LOC- worsening sign of hypoxia INTERVENTIONS TO MANAGE - High fowlers position promotes effective chest expansion and diaphragmatic descent - TRIPOD POSITION - ENCOURAGE ENCHANCED BREATHING AND COUGHING TECHNIQUE - MANAGE OXYGEN THERAPHY AND EQUIPMENT - ASSESS THE NEED FOR RESPIRATORY MEDICATIONS BRONCHODILATORS =relax smooth muscle and open airways GLUCOCORTICOIDS =relieve inflammation and assist in opening air passages MUCOLYTICS =decrease the thickness of pulmonary secretions \[expel mucus \] PROVIDE SUCTIONING IF NEEDED Brief only ;10-15 sec Check V.S during \[PR-before and after suctioning\] Trivia- vagus-largest cranial nerve -unable to clear secretions from mouth and pharynx History of patient; muscle disorder or CVA -stroke For risk of aspirations -pneumonia and hypoxia PROVIDE PAIN RELIEF IF NEEDED =Pain; high level of anxiety , and metabolic demand s, which in turn high need more of 02 supply. - CONSIDER SIDE EFFECTS OF PAIN MEDICATIONS =Common side effect; respiratory depression - CONSIDER OTHER DEVICES TO ENHANCE CLEARANCE SECRETIONS - PLAN FREQUENT RES PERIODS BETWEEN ACTIVITIES - CONSIDER OTHER POTENTIAL CAUSES OF DYSPNEA =Review most recent hemoglobin and hematocrit lab result and diagnostic test - CONSIDER OBSTRUCTIVE SLEEP APNEA \[OSA\] =Snores with pauses in breathing while snoring has decreased oxygen saturation level while sleeping or awakens feeling not rested LOW SPO2 WHILE SLEPPING unable to maintain an open airway while sleeping ,resulting in periods of apnea or hypoxia CIPAP&BIPAP while sleeping to prevent adverse outcomes - MONITOR PATIENT ANXIETY =Breathing and coughing techniques encourage relaxation ENCHANCED BREATHING AND COUGHING TECHNIQUES PURSED-LIP BREATHING Inhale through nose and exhale through mouth at slow and controlled flow. For COPD INCENTIVE SPIROMETRY For post op patients Medical device prescribed after surgery. 1.To expand the lungs 2.,\[ THORACENTESIS \] reduce build up of fluid in the lungs and 3.prevent pneumonia SIT UPRIGHT Repeat the technique 10 times every hour as deep as possible. to Expel the mucus place in the mouth the mouthpiece and create a tight seal expect coughing encourage the patient to expel the mucus and not swallow COUGHING AND DEEP BREATHING - Take deep breath ,slow breath and exhale slowly - After each set of breath expect the patient to cough. - Repeat the technique 3-5 times every hour Steps ; Sit/stand with elbows slightly back Inhale a deep breath \| Hold your breath \| Exhale HUFFING TECHNIQUE Inhale with medium-sized breath and make a sound like Ha to push the air out quickly with the mouth slightly open VIBRATORY POSITIVE EXPIRATORY PRESSURE \[PEP\] THERAPHY Prescription with doctors Handheld device such as flatter valves or acapella devices for patients Assistance in Cleaning the mucus in airways NASAL CANNULAE Delivers 24-30% oxygen Flow rate ; 1-4L/min 4L will dry nose 2L -more comfortable Used in non-acute situations or if only mildly hypoxic HUDSON MASK Delivers 30-40% oxygen Flow rate ; 5-10L/min Mild to moderate hypoxia VENTURI MASK Delivers 24-60% oxygen Different colors delivers different rate Color Flow rate Oxygen level \[O2\] Blue 2-4L/min 24% White 4-6L/min 28% Yellow 8-10L/min 35% Red 10-12L/min 40% Green 12-15L/min 60% Used in COPD\[ Emphysema / acute bronchitis \] Don't over oxygenate the NON REBREATHER Delivers 85-90% oxygen Flow rate ; 5L/min Bag on mask with valves stopping almost all rebreathing of air For acute conditions Note; SPO2 should maintain at 94-98% not 100% Over oxygenation result in SOB Do not keep patient on 15L for longer than necessary NON-INVASIVE VENTILATION CPAP- CONTINOUS POSITIVE AIRWAY PRESSURE High pressure air / oxygen with tight-fitting mask Positive pressure all the time to help keep airways open\[split them\] while you sleep. For acute pulmonary edema, sleep apnea. BIPAP-BILEVEL POSITIVE AIRWAY PRESSURE High positive pressure on respiration and lower positive pressure on exhalation For COPD AND ARDS- ACUTE REPIRATORY DISTRESS SYNDROME INVASIVE VENTILATION MECHANICAL VENTILATOR Fully controlled oxygen delivery up to 100% Ventilation by machine attached to an artificial airway to ventilate lungs -icu NASOGASTRIC TUBE remove the contents of the stomach, including air, to decompress the stomach, or to remove small solid objects and fluids, such as poison from the stomach Types of NG Tube - Levin Tube =Single Lumen - Salem Sump Tube = Double Lumen - Moss Tube = Triple Lumen - Sengstaken-Blakemore Tube =Quadruple Lumen LEVINE TUBE  rubber or plastic or silicon tube  holes at the tip and along the side. SALEM SUMP TUBE Double lumen tube (one for suction and drainage and a second -- smaller one for ventilation. Made of clear plastic Has a blue sump (pigtail) that allows air to enter the patient's stomach Larger port (121.9 cm) serves as the main suction conduit The tube floats freely and doesn't adhere to or damage gastric mucosa MOSS TUBE Has a radiopaque tip and three lumens Usually inserted during surgery - First lumen -- positioned and inflated in the crdi -- serve as a balloon inflation port - Second lumen -- is an esophageal aspiration port - Third lumen -- is a duodenal feeding port SENGSTAKEN-BLAKEMORE TUBE designed for management of upper gi hemorrhage due to esophageal varices, Usually the result of liver cirrhosis.  flexible plastic tube containing several channels and two inflatable balloons  minnesota tubes -- a modern form of sb tube -- have an opening near the upper Esophagus  esophageal and gastric balloons are inflated in the esophagus and stomach  1 kg is applied to the tube so that gastric balloon will compress gastro-esophageal junction and reduce the blood flow to esophageal varices to aid esophageal balloon to stop bleeding INDICATIONS FOR NG TUBE 1 DIAGNOSTIC PURPOSE - Evaluation of upper gastrointestinal Bleeding (presence and volume) - Aspiration of gastric fluid content to Be analyzed - Identification of the esophagus and Stomach on a chest radiograph - Administration of radiographic Contrast to the GI tract - Identification of cancer cells (gastric Lavage) 2 THERAPEUTIC PURPOSE - Gastric decompression, including Maintenance of a decompressed State after endotracheal - Intubation, often via the Oropharynx. - Relief of symptoms and bowel Rest in the setting of small bowel Obstruction - Aspiration of gastric content from Recent ingestion of toxic material - Administration of medicine - Feeding - Bowel irrigation - NG tube can be kept following Corrosive ingestion for the Development of a tract in the - Esophagus that subsequently Can be used for balloon Dilatation CONTRAINDICATION FOR NG TUBE Absolute contraindications Severe face trauma or skull base fracture Recent nasal surgery Esophageal trauma or obstruction Relative contraindications  coagulation  abnormality  recent banding of  esophageal varices  esophageal varices (usually sengtaken blakemore tube is introduced, but an ng tube can be used for lower grade varices) or stricture Alkaline ingestion (the tube may be kept if the injury is not severe) INSERTING A NASOGASRIC TUBE SAFETY CONSIDERATION Perform hand hygiene Introduce yourself to the patient Confirm patient ID using two patient identifiers Explain the process to the patient Listen and attend to patient cues Ensure patient's privacy and dignity Assess abcs/suction/oxygen Apply principles of asepsis and safety Check vital signs Complete necessary focused assessmentssteps 3\. Assess for the best nostril before you begin (Do this by occluding one Side and asking the patient to sniff. Ask the patient about Previous injuries or history of a deviated septum) If either nostril is equally suitable. Select The nostril closest to the suction 4\. Palpate the patient's abdomen for distension, pain, and or rigidity. Auscultate for bowel sounds 7\. Check doctor's orders to determine whether the ng tube is to be attached to suction or a drainage bag 8\. Position patient sitting up at 45 to 90 degrees(unless contraindicated by the patient's Condition), with pillow under the head and shoulders. To pass more easily 14\. Measure the distance of the tube from the tip of the nose, to...The earlobe, to... The xiphoid process and then mark the tube at this point. 17\. Curve 10 to 15 cm of the end of the ng tube around your gloved finger, and then release it. METHODS OF CONFIRMING NG TUBE POSITION Measurement of NG aspirate ph using ph Indicator paper Chest X-ray Methods which should never be used to confirm NG tube position include:¹ Auscultation of air insufflated through the feeding tube ('whoosh' test) Testing the acidity/alkalinity of aspirate using blue litmus paper Interpreting the absence of respiratory distress as an indicator of correct Positioning Monitoring bubbling at the end of the tube Observing the appearance of NG tube aspirate COMPLICATIONS OF NG TUBE - Injury to the esophagus, throat, sinuses, or stomach - Ng tube can cause further problems when it gets blocked or if it comes out of place - Regurgitation and aspiration - It may cause some symptoms such as diarrhea, nausea, vomiting or abdominal cramps Heat regulation takes place in the hypothalamus. Many factors affect body temperature, including body rhythms, menstrual cycle, muscle action, age, environmental conditions, medications, etc. Cover dry heat/cold applications with cloth/ towel before applying them. Observe the skin for any problem, discontinue immediately. Carefully watch the time. Heat/Cold should not be applied for more than 30 minutes. Special precautions during heat and cold therapy: Neurosensory impairment. Impaired mental status Impaired circulation. Open wounds. \[ more sensitive to heat and cold.\] Determine the presence of any conditions contraindicating the use of heat: The first 24 hours after traumatic injury. Heat increases bleeding and swelling. Active hemorrhage. Heat causes vasodilation and increases bleeding. Noninflammatory edema. Heat increases capillary permeability and edema. Skin disorder that causes redness or blisters. Determine the presence of any conditions contraindicating the use of cold: Open wounds. Impaired circulation. Allergy or hypersensitivity to cold. COLD APPLICATIONS Uses of Cold Application: - To provide topical anesthesia; - prevent edema after bruises, spasms - lessen hemorrhage; - reduce pain, - slows bacterial growth and decreases inflammation; - lower body temperature, - Vasoconstriction - sprains and fractures;sports injuries, to limit post-injury swelling and bleeding. 1.Dry cold applications A.) Ice Bags and Ice Collars \- filled with crushed ice, b\) Cold packs left in place no longer than 30 minutes. 2.Moist Applications 1\) Cold compress Large basin - Tub with ice. Small basin! Tub with cold water Change the compress when it warms. changed every 5 minutes. Remove the compress after 20 minutes. 2\. Cool Sponge bath \- (tap water ) reduce body temperature HEAT APPLICATION To relieve pain; \| reduce swelling, congestion \| inflammation; relieve muscle spasm; \|provide comfort;\| raise the body temperature;\| vasodilation, increase the blood supply to the injured part - with musculoskeletal problems such as joint stiffness from arthritis, contractures, and low back pain. 1\. Dry heat a\) Hot water bottle: b\) - Heating pads: contains electric wires that produce heat; you plug them \- Hot packs: dry heat applications. contain chemicals. 2\. Moist Heat a.)Hot soaks -- foot bath/Hip bath. Putting body parts into water for 15- 20 minutes. Hip Bath: - is also known as Sitz bath i. Purpose: to clean perineal or anal wounds, b.) Hot Compresses \- placed in a basin of hot water. - Fill the basin one-half to two - thirds full with hot water. - Check the area every 5 minutes. Check for redness and complaints of pain, discomfort, or numbness. Remove the compress if any occur. - Remove the compress after 20 minutes Desired Temperature: Infants under 2 years - 105-115 0F (40.50 - 460 C) Children over 2 years and adult - 1150-1250F (460 - 510 C) - Maximum therapeutic effects ; within 20--30 minutes. - (beyond 45 minutes) results in tissue congestion and vasoconstriction. Cold works best when applied within the first 24 hours of injury or condition, - while heat is primarily used to treat the chronic phase of an injury or condition, usually 48 hours after an acute injury. - 3x a day for 10-15mins. not exceeding 30 minutes - Exercise-induced - Cold -- 4-6 hours -- Heat therapy (max. 15-20 mins) Definitions and Signs of Death cessation of the apical pulse, respirations, and blood pressure, also referred to as HEART-LUNG DEATH In 1968, THE WORLD MEDICAL ASSEMBLY (GILDER, 1968) -indications of death: Total lack of response to external stimuli No muscular movement, \[breathing\] No reflexes Flat encephalogram (brain waves). - artificial support, absence of brain waves for at least 24 hours indicates death. - cerebral death or higher brain death, \[ the higher brain center, the cerebral cortex, is irreversibly destroyed\] "a clinical syndrome characterized by the permanent loss of cerebral and brainstem function, manifested by absence of responsiveness to external stimuli, absence of cephalic reflexes, and apnea. An isoelectric electroencephalogram for at least 30 minutes in the absence of hypothermia and poisoning by central nervous system depressants supports the diagnosis" People who support this definition of death believe the cerebral cortex, which holds the capacity for thought, voluntary action, and movement, is the individual. stages of decomposition Pallor mortis Paleness within twenty minutes or less. Algor Mortis gradual decrease of the body's temperature after death. falls about 1°C (1.8°F) per hour until it reaches room temperature., the skin loses its elasticity - After blood circulation has ceased, the red blood cells break down, releasing hemoglobin, which discolors the surrounding tissues. This DISCOLORATION, - LIVOR MORTIS, Cool of death -an hour post mortem (after death) - decreased around 2 degrees Celsius ,and will continue to decrease one degree Celsius until it reaches the temperature of the environment around it Embalming injection of chemicals into the body to destroy the bacteria. Rigor Mortis stiffening of the body - 2 to4 hours after death \| leaves the body about 96 hours after death. - One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it. Putrefaction Decomposition of proteins in a process that results in the eventual breakdown of cohesion between tissues and the liquefaction of most organs. Mortician (a undertaker),care of the dead Post mortem care Straighten limbs before death, if possible Place head on pillow \| Remove tubes Note on chart -what personal artifacts were released with the body \- what belonging were released -who received the belongings IMPLEMENTATION 1. proper alignment of body. 2. if possible, place dentures in the mouth 3\. remove any external objects causing pressure or injury to the skin 10\. ID tags- big toes, wrist and morgue bag\[shroud\] MEDICAL ADMINISTRATION BRAND NAME: Tylenol GENERIC : Paracetamol (Acetaminophen) CHEMICAL : N-Acetyl-Aminophenol (APAP) Pharmacology study of the effect of drugs on living organisms. Pharmacy art of preparing, compounding, & dispensing drugs. pharmacist- prepares, makes, and dispenses drugs as ordered Aerosol spray or foam \- A liquid, powder, or foam Aqueous solution -dissolved in water Aqueous suspension \- finely divided in a liquid such as water Caplet \- capsule, coated and easily swallowed Capsule gelatinous to hold a drug in powder, liquid, or oil form Cream \- A non-greasy, semisolid Elixir \- A sweetened and aromatic solution of alcohol Extract \- made from vegetables or animals Gel or jelly \- A clear or translucent semisolid that liquefies when applied to the skin Liniment \- mixed with alcohol, oil, or soapy emollient and applied to the skin Lotion \- liquid suspension applied to the skin Lozenge (troche) \- A flat, round, or oval preparation that dissolves and releases a drug when held in the mouth Ointment (salve, unction) \- A semisolid preparation , \[the skin and mucous membrane \] Paste \- thicker and stiff, \[penetrates the skin less than an ointment \] Pill \- drugs mixed with a cohesive material, Powder \- A finely ground drug or drugs; Suppository \- gelatin and shaped for insertion ; the base dissolves gradually at body temp. Syrup \- An aqueous solution of sugar Tablet -powdered drug compressed in hard small disk; Tincture alcoholic or water-and-alcohol solution Transdermal patch \- A semi-permeable membrane shaped ROUTES OF ADMINISTRATION ORAL \| SUBCUTANEOUS \| SUBLINGUAL \| INTRAMUSCULAR \| BUCCAL \|RECTAL INTRADERMAL\| INTRAVENOUS \| TOPICAL VAGINAL\| INHALATION TRANSDERMAL PARENTERAL Intra-arterial (artery) Intracardiac (heart muscle) Intraosseous (bone) Intrathecal or intraspinal ( spinal canal) Intrapleural ( pleural space) Epidural ( epidural space) Intra-articular ( joint) Tips of syringes: - L uer-Lok syringe (note threaded tip) - Non--Luer-Lok syringe (note the smooth graduated tip) 60-mL non--Luer-Lok syringe, -irrigation of tubes or wounds. 1\. Stat Order \- to be given immediately and only once 2\. Single Order \- one time order, to be given once at specified time 3\. Standing Order \- may or may not have a termination date. May be carried out indefinitely until an order is written to cancel it. 4\. PRN Order \- as needed order, permits the nurse to give a medication when Essential Parts of a Medication Order Full name of the client Date and time the order is written Name of the drug to be administered Dosage of the drug Frequency of administration Route of administration Signature of the person writing the order Parts of a Prescription client: name, address, age Date- prescription was written Rx symbol, ="take thou" Medication name, dosage, and strength Route of administration Dispensing instructions -pharmacist, Directions for administration to be given to the client, \[ "take on an empty stomach"\] Refill and/or special labeling, Prescriber's signature Basic Formula for Calculating Drug Dosages D/S X Q \[ D= DESIRED DOSE \| S= STOCK DOSE Q= QUANTITY \] Ten "Rights" of Medication AD. MEDICATION \| DOSE \| TIME \| ROUTE CLIENT \| EDUCATION \| DOCUMENTATION \| REFUSE \| ASSESSMENT \|EVALUATION PURPOSE OF URINARY CATHETERIZATION - Relieve urinary retention. - Obtain a sterile urine specimen - Measure residual urine. - Empty the bladder before, during, or after surgery - Allows accurate measurement of urine output URINARY CATHETER SIZES The FRENCH SCALE (FR) Each unit = 0.33 mm in diameter (18 Fr. =a diameter of 6 mm). larger sized - male \[stiffer\], thus easier to push the distance of the male urethra. No. 8 Fr. And 10 Fr.- for children No. 14 Fr. And 16 Fr. - for female adults. No. 20 Fr. And 22 Fr. - for male adults Urinary Size - size of the urethral canal - expected duration of catheterization - any allergies to latex or plastics - indications for catheterizing the patients (clot retention, child) TYPES OF URINARY CATHETERS Intermittent Catheter. - drain the bladder for short period (5-10 minutes). Indications: - Collection of the sterile urine sample - relief of discomfort from bladder distention - Measure residual urine - Management of patients with spinal cord injury, neuromuscular degeneration or incompetent bladders Retention/Indwelling Catheter \- secured there for a period of time. Indication (Long Term) - Refractory bladder outlet obstruction and neurogenic bladder with urinary retention - Prolonged and chronic urinary retention - promote healing of perineal ulcers where urine may cause further skin breakdown Indication Short term - a\. Post surgery and in critically ill patients to monitor urinary output - b.Prevention of urethral obstruction from blood clots with continuous or intermittent bladder irrigations - c\. Instillation of medication into the bladder - d\. Surgical procedures \[pelvic or abdominal surgery repair of the bladder, urethra, and surrounding structure \] - e\. Urinary obstruction (enlarged prostate) acute urinary retention Supra Pubic Catheter small incision above the pubic area. \| for continuous drainage. Indications:  Unable to catheterize per urethra  Traumatic urethral disruption  Full bladder Contraindications: Empty bladder \| Known bladder cancer Clot hematuria \| Extensive scarring Fem fem bypass \| traumatic urethral injury \| History of urethral strictures Resistance to passage \| High riding prostate \| Blood at meatus Risk associated with CATHETERIZATION -Urethral trauma and bleeding inappropriate catheter size or -use of force Urinary tract infections related to poor sterile technique or long term catheterization. \- Bladder spasms and pain False passage. - Evaluate catheter FUNCTION AND AMOUNT, COLOR, ODOR, AND QUALITY OF URINE. Report any of the following: 1\. inability to void within 8 to 10 hours 2\. Frequency, burning, dribbling, or hesitation in starting the stream of urine. 3\. cloudiness or any other color or characteristic of the urine. Perineal Care : To prevent or eliminate infection, odor and promote healing. \| Remove secretions, and provide comfort. Assess Presence Of: +-----------------------------------+-----------------------------------+ | Irritation, excoriation Recent | , inflammation, swelling | | rectal or perineal surgery | | | | Indwelling catheter | +-----------------------------------+-----------------------------------+ | Excessive discharge | pain or discomfort | | | | | Urinary or fecal incontinence | Odor | +-----------------------------------+-----------------------------------+ ASSESSMENT; Assess ; client's tolerance for perineal care; activity tolerance, comfort level during movement, cognitive ability, musculoskeletal function, presence of shortness of breath. - visual status, ability to sit without support, hand grasp, ROM of extremities. - presence of equipment (foley catheter, condom catheter). - for allergy or sensitivity to Clorhexidine gluconate (CHG).