Fundamentals of Nursing I Past Paper 2024-2025 (Mansoura National University)

Mansoura National University Faculty of Nursing FUNDAMENTALS OF NURSING I FIRST LEVEL FIRST SEMSETER ACADEMIC YEAR 2024-2025 2 Asepsis and Infection Prevention Learning outcomes 1. Explain the concepts of medical and surgical asepsis. 2. Identify signs of localized and systemic infections and inflammation. 3. Identify risks for nosocomial and healthcare-associated infections. 4. Identify causes of nosocomial and healthcare-associated infections 5. Identify factors influencing a microorganism’s ability to produce an infectious process. 6. Explain course of infection 7. Explain Chain of Infection 8. mention the recommended infection precaution in hospitals 3 Introduction Nurses are directly involved in providing a biologically safe environment. Microorganisms exist everywhere: in water, in soil, and on body surfaces such as the skin, intestinal tract, and other areas open to the outside (e.g., mouth, upper respiratory tract, vagina, and lower urinary tract). Most microorganisms are harmless and some are even beneficial in that they perform essential functions in the body. Infection: An infection is an invasion of the body by pathogens, or microorganism capable of producing disease. An infection is the growth of microorganisms in body tissue where they are not usually found. Infectious diseases are a major cause of death worldwide. The control of the spread of microorganisms and the protection of people from communicable diseases and infections are carried out on international, national, state, community, and individual levels. Types of infection:  Local or systematic; local is limited to the specific part of the body where the microorganism remains. If microorganisms spread and damage different parts of the body, it is a systemic infection.  Acute or Chronic infections: generally, appear suddenly or last a short time. A chronic infection may occur slowly, over long period, and May last month or years If the microorganisms spread and damage different parts of the body, the infection is a systemic infection. When a culture of the individual’s blood reveals microorganisms, the condition is called bacteremia. When bacteremia results in systemic infection, it is referred to as septicemia. Unfortunately, septicemia has become more common over time. Microorganism: A tiny living animal or plant that can cause disease, most are visible only with a microscope. Contamination: Means to make something unclean, such as area equipment ,if it contain microorganisms that cause disease. Disinfectant :A substance used to destroy pathogens but not necessarily their spores, in general not intended for use on persons. Antiseptic :A substance used to destroy pathogens on living object such as skin and mucous membrane Sepsis is the condition in which acute organ dysfunction occurs secondary to infection. 4 Asepsis: Is a freedom from disease- causing microorganisms. It is divided into medical asepsis and surgical asepsis.  Medical asepsis or clean technique includes procedures used to reduce the number of microorganisms and prevent their spread.  Surgical asepsis or sterile technique, includes procedures used to eliminated microorganisms from an area. Sterilization destroys all microorganisms including spores & viruses. Inflammation is a response of a tissue to injury, often injury caused by invading pathogens. It is characterized by:  increased blood flow to the tissue causing  increased temperature,  redness  swelling, and  pain. Nosocomial Infection What is a nosocomial infection? Nosocomial infections, also called health-care-associated or hospital-acquired infections (HAIs), are a subset of infectious diseases acquired in a health-care facility. To be considered nosocomial, the infection cannot be present at admission; rather, it must develop at least 48 hours after admission. These infections can lead to serious problems like sepsis and even death. Nosocomial infections can either develop during a client’s stay in a facility or manifest after discharge. Often, nosocomial infections are caused by multidrug-resistant pathogens acquired via invasive procedures, excessive or improper antibiotic use, and not following infection control and prevention procedures. In fact, many nosocomial infections are preventable through guidance issued by national public health institutes such as the Centers for Disease Control and Prevention (CDC). The CDC (2016) reports that central intravenous line–associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, and ventilator-associated pneumonia account for the majority of HAIs. 5 Who is at risk for a nosocomial infection?  Increasing age  Greater length of hospitalization  Excessive or improper use of broad-spectrum antibiotics  Higher number of invasive devices and procedures (for instance: central venous catheters, urinary catheters, surgical procedures, and mechanical ventilation)  Comorbid conditions o Diabetes o Chronic lung disease o Renal insufficiency o Malnutrition Causes of nosocomial infection  Urinary catheters o A urinary catheter is a tube inserted into the bladder to collect urine into a closed collection system. Urinary catheters can help patients who have difficulty controlling or emptying their bladder. As patients under anesthesia are unable to control their bladder, urinary catheters are typically placed during surgical procedures to keep the bladder empty. o Pathogens spread through an individual’s perineum or a contaminated urinary catheter can lead to urinary tract infections, which are the most common nosocomial infections.  Symptoms of urinary tract infections include painful urination, flank pain, and fever.  Surgical procedures 6 o Surgical site infections are the second most common type that can develop after surgery.  Length of operation, surgical technique, and operating room sterility are all factors that can affect the incidence of surgical site nosocomial infections. o Surgical site infections are caused by pathogens already prevalent on the skin or by organisms shed from members of the operating room staff, and often involve the skin, organs, or implanted materials.  Symptoms may include skin redness, tenderness, and drainage from surgical sites.  Central venous catheters o A central venous catheter (also known as a central line) is a tube placed in a large vein in the neck, arm, chest, or groin and can remain in place indefinitely. Central venous catheters can be used to give intravenous therapies such as total parenteral nutrition (TPN), which provides nutrients and fluids to patients. o Bloodstream infections can result from pathogens that may penetrate the skin during insertion of hubs of central lines. This is the third most common form of nosocomial infection and has the highest rate of mortality.  Symptoms of infection may include skin redness, tenderness, and drainage at insertion sites.  Mechanical ventilation o Ventilator-associated pneumonia is a respiratory infection caused by breathing in contaminated oropharyngeal flora during mechanical ventilation (machine-assisted breathing).  Together with central-line bloodstream infections, it is the third most common nosocomial infection.  Early-onset nosocomial pneumonia occurs within the first four days of admission and is commonly caused by community- acquired pathogens like Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.  Late-onset pneumonia is frequently caused by multi-drug resistant bacteria like MRSA, Pseudomonas aeruginosa, Klebsiella, and Acinetobacter.  Signs and symptoms include fever, increased mucus production, increased white blood cell count, and abnormal chest X-ray findings. The most common type of nosocomial infection Though various bacteria, viruses, and fungi can all cause nosocomial infections, the most common is the bacterium Staphylococcus aureus. Other common pathogens like Escherichia coli, Enterococci, and Candida are common culprits, and all can be normally found on the skin and mucous membranes. Antibiotic-resistant strains such as methicillin-resistant Staphylococcus aureus (MRSA) can be especially dangerous and difficult to treat. 7 Prevention of nosocomial infections  Implementation of infection control protocols to reduce exogenous and endogenous transmission in health-care facilities.  Exogenous transmission occurs due to person-to-person interactions and through environmental cross-contamination. o Frequent hand hygiene is the most important preventative measure to limit the spread of pathogens. o Compliance with isolation precautions o Proper use of personal protective equipment o Avoidance of unnecessary use of indwelling devices, and remove them as soon as advisable. o Practicing proper aseptic and/or sterile techniques during insertion and maintenance of devices.  Routine disinfection of surfaces, patient equipment, and medical devices  Appropriate waste management  Endogenous transmission o From excessive and improper use of broad-spectrum antibiotics.  Vancomycin affects the normal balance in the patient's own endogenous bacterial flora, ultimately leading to an overgrowth of some bacteria  Appropriate antimicrobial use with the correct agent, dose, and duration is needed to minimize the growth of antibiotic-resistant pathogens o Transfer from one part of the body to the other (as with urinary tract infections) o Depressed immune system from factors like malnourishment or chemotherapy Isolation technique refers to the precautions that are taken in the hospital to prevent the spread of an infectious agent from an infected or colonized patient to susceptible persons 8 Chain of Infection 1- Etiologic agent: The pathogenic organisms include bacteria, viruses, fungi and protozoa and more prevalent agent that are capable of causing infection.  Bacteria :The most significant and most commonly observed infection-causing agents in health care institutions  Virus I:s the smallest of all microorganisms, visible only with an electron microscope ,such as virus cause common cold and AIDS  Fungi : Plant-like organism (molds and yeasts) that also can cause infection ,are present in the air ,soil, and water. Example of disease cause by fungi include athlete's foot ,ringworm, and yeast infections. 2- Reservoir There are many reservoirs, or sources of microorganisms. Common sources are other humans, the client’s own microorganisms, plants, animals, medical equipment, or the general environment (e.g., soil and water). People are the most common source of infection for others and for themselves. A carrier is a human or animal reservoir of a specific infectious agent that usually does not manifest any clinical signs of disease. 9 3- Portal of exist: the exit from the reservoir is the point of escape for the organism cannot extend its influence unless it moves away from its original source. There are primary exist route for each type of organism. In human common escape routes are as follows: a- skin and mucus membrane. b- Respiratory tract c- Urinary tract. d- GI tract. e- Reproductive tract. f- Blood-serum hepatitis. 4-Modes of transmission: An organism may be transmitted from its reservoir by various means of routes. Some organisms can be transmitted by more than one route: 1. Direct transmission immediate and direct transfer of microorganisms from individual to individual through touching, biting, kissing, or sexual intercourse. Droplet spread is also a form of direct transmission but can occur only if the source and the host are within 1 m (3 ft) of each other. Sneezing, coughing, spitting, singing, or talking can project droplet spray into the conjunctiva or onto the mucous membranes of the eye, nose, or mouth of another individual. 2. Indirect transmission may be either vehicle borne or vector borne: a. Vehicle-borne transmission. A vehicle is any substance that serves as an intermediate means to transport and introduce an infectious agent into a susceptible host through a suitable portal of entry. Fomites (inanimate materials or objects), such as handkerchiefs, toys, soiled clothes, cooking or eating utensils, and surgical instruments or dressings, can act as vehicles. Water, food, blood, serum, and plasma are other vehicles. For example, food or water may become contaminated by a food handler who carries the hepatitis A virus. The food is then ingested by a susceptible host. b. Vector-borne transmission. A vector is an animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent. Transmission may occur by injecting salivary fluid during biting or by depositing feces or other materials on the skin through the bite wound or a traumatized skin area. 3. Airborne transmission Airborne transmission may involve droplets or dust. Droplet nuclei, the residue of evaporated droplets emitted by an infected host such as someone with tuberculosis, 10 can remain in the air for long periods. Dust particles containing the infectious agent (e.g., C. difficile, spores from the soil) can also become airborne. 5- Portal of entry: The portal of entry is the point at which organism enters the host. The entry route often is the same as the exits route. The urinary, respiratory, gastrointestinal, reproductive tract and the skin are common entry points. 6- Suspected host A susceptible host is any individual who is at risk for infection. A compromised host is someone at increased risk, an individual who for one or more reasons is more likely than others to acquire an infection. Impairment of the body’s natural defenses and a number of other factors can affect susceptibility to infection. Examples include age (the very young or the very old); clients receiving immune suppression treatment for cancer, for chronic illness, or following a successful organ transplant; and those with immune deficiency conditions. Course of infection: An infection progresses through the different phases which include: 1- Incubation period: is interval between the invasion of the body by the pathogen or into the body and the appearance of the first symptoms of the infection, e.g; chickenpox 2-3 weeks, common cold 1-2 days, tetanus 2 to 21 days. 2- Prodromal stage: is most infectious during this stage. It is an internal from onset of nonspecific signs and symptoms (malaise, low grade fever, fatigue) to more specific symptoms. During this time, microorganisms grow and multiply and client is more capable of spreading disease to others. 3- Full stage of illness: full stage of illness is an interval when client manifests signs and symptoms specific type of infection. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of illness and severity of manifestations. 4- Convalescent period: Convalescent period represents recovery from infection. It is an interval when acute symptoms of infection disappear and the person returns to healthy state-length of recovery depends on severity of infection and clients general state of health; recovery may take several days to months. 11 NURSING CARE Use frequent and effective hand hygiene before and after care. Educate the client about the required and recommended immunizations and where to obtain them. The target groups include children, older adults, those with chronic disease, and those who are immunocompromised and their families and contacts. Educate the client and ask for a return demonstration of good oral hygiene. Good oral hygiene decreases the protein (which attracts micro-organisms) in the oral cavity, which thereby decreases the growth of micro-organisms that can migrate through breaks in the oral mucosa. Encourage the client to consume an adequate amount of fluids. Adequate fluid intake prevents the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms. Adequate hydration also keeps the skin from breaking down. Intact skin prevents micro-organisms from entering the body. For immobile clients, ensure that pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) is done every 2 hr, or as prescribed. Good pulmonary hygiene decreases the growth of micro-organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance, and expanding the lungs. Use of aseptic technique and proper personal protective equipment (gloves, masks, gowns, and goggles) in the provision of care to all clients prevents unnecessary exposure to micro-organisms. Teach and use respiratory hygiene/cough etiquette. It applies to anyone entering a health care setting (clients, visitors, staff) with manifestations of illness, whether diagnosed or undiagnosed. This includes cough, congestion, rhinorrhea, or an increase in the production of respiratory secretions. The components of respiratory hygiene and cough etiquette include: ◯ Covering the mouth and nose when coughing and sneezing. ◯ Using facial tissues to contain respiratory secretions and disposing of them promptly into a hands-free receptacle. ◯ Wearing a surgical mask when coughing to minimize contamination of the surrounding environment. ◯ Turning the head when coughing and staying a minimum of 3 ft away from others, especially in common waiting areas. ◯Performing hand hygiene after contact with respiratory secretions and contaminated objects/materials 12 13 Vital Signs The most frequent and routine measurements obtained by health care providers are those of temperature, pulse, blood pressure (BP), respiratory rate, and oxygen saturation. As indicators of health status, these measures indicate the eﬀectiveness of circulatory, respiratory, neural, and endocrine body functions. Because of their importance, they are referred to as vital signs (VS). Pain, a subjective symptom, is often called another vital sign and is frequently measured with the others. Monitoring a client’s vital signs should not be an automatic or routine procedure; it should be a thoughtful, scientific assessment. Vital signs should be evaluated with reference to clients’ present and prior health status, their usual vital sign results (if known), and accepted standards. When and how often to assess a specific client’s vital signs are chiefly nursing judgments, depending on the client’s health status. 14 Body Temperature Objectives:  Determine times to assess vital signs.  Define body temperature.  List kinds of body temperature.  Enumerate most common sites for measuring bodytemperature.  Identify contraindication of body temperature from avarious site.  Identify normal range of body temperature.  List type of thermometer.  Measure body temperature using different scales.  Explain various Regulating factors of Body Temperature.  Describe heat loss mechanism.  Describe heat gaining mechanism.  Identify factors increasing heat production.  Identify factors decreasing heat production.  Define fever and hyper pyrexia.  Write type of fever.  Explain stages of fever.  Enumerate signs and symptoms of fever.  Plan nursing care for patient with fever.  Define hypothermia.  List causes of hypothermia.  List Signs and symptoms of hypothermia.  Plan nursing care of hypothermic patient. 15 Introduction Humans are warm-blooded creatures, which means they maintain a consistent internal body temperature independent of the outside environment. Despite extremes in environmental conditions and physical activity, temperature-control mechanisms of humans keep body core temperature (temperature of the deep tissues) relatively constant. However, surface temperature varies, depending on blood ﬂow to the skin and the amount of heat lost to the external environment. Definition of body temperature: Body temperature reflects the balance between the heat produced and the heat lost from the body. Two kind of body temperature: 1. Core temperature: Core body temperature is found in the blood supplying organs such as the brain and those in the abdominal and thoracic cavities. it remains relatively constant but may be affected by intrinsic factors and, to a lesser degree, extrinsic(environmental) factors 2. Surface temperature: is the temperature of the skin, the subcutaneous tissue and the fat. Thermoregulation (Temperature control) Thermoregulation is the process that allows the human body to maintain its core internal temperature. The heat of the body is measured in units called degrees. Temperature Scales Temperature can be measured on the Celsius or Fahrenheit scale. The scale used varies among agencies. Nurses do not routinely have to convert from one scale to the other; however, if conversion is necessary, use the simple formulas provided Celsius © = (Fahrenheit (F) temperature –32) X 5/9. Fahrenheit= (Celsius temperature X 9/5) + 32. How Does Thermoregulation Work? The hypothalamus, located between the cerebral hemispheres, controls body temperature. A comfortable temperature is the “set point” at which a heating system operates. The hypothalamus senses minor changes in body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. When nerve cells in the anterior hypothalamus become heated beyond 16 the set point, impulses are sent out to reduce body temperature. If the posterior hypothalamus senses that body temperature is lower than the set point, the body initiates heat-conservation mechanisms. Types of Thermoregulations When the brain receives a temperature warning from the body, it sends signals to various organs and body systems,which try to slow or increase heat production. If the body needs to cool down, these include:  Sweating: Sweating is one of the first methods the body will use to control temperature. Sweat cools the skin as it evaporates. This helps lower the internal temperature.  Vasodilatation: the CNS may instruct the capillaries under the surface of the skin to dilate, or open. Vasodilatation, or enlarged capillaries, increases blood flow at the skin surface. This lets your body release heat through radiation. If your body needs to warm up, these include:  Stopping sweating: Your nervous system can lower sweat production to help maintain the heat your body generates.  Vasoconstriction: Your CNS may signal your capillaries to constrict, or become narrower. This decreases blood flow under the skin and reduces heat loss.  Thermogenesis: the body ‘s muscles, organs, and brain can produce heat when your internal temperature is sinking. This process is called thermogenesis. Muscles are especially effective at thermogenesis. They can produce large quantities of heat quickly. Shivering is one-way muscles generate heat.  Hormonal thermogenesis: the body can activate the thyroid gland if you are getting too cold. This releases hormones that increase your metabolism. An increased metabolism increases the energy your body creates and the amount of heat your body is able to make. Process of heat loss: Body heat is lost through the skin, lungs, and digestive and urinary tract. The loss through the skin accounts about 85% of the total. Heat is lost from the body through: Radiation: is the transferee of heat from the service of one object to another object without contact between the two objects. The heat is carried from one object to the other in the form of rays. For example, the use of heat lamp involves the transfer of heat by radiation 17 2- Conduction: is the transfer from one molecule to molecule of lower temperature, contact between materials,when body put on cold water. 3. Convection: is the dispersion of heat by air current. Heat is lost through convection when air currents pass over a warm object, carrying its heat away with them. 4. Vaporization: process whereby a substance in liquid state is changed to a vapor state. continuous evaporation of moisture from respiratory tract and from the mucosa of mouth and from the skin. E.g sponging a patient with alcohol and water provide for cooling by evaporation Factors increasing heat production: 1- Muscular activity: leads to an increase in tissue metabolism which in turn increases heat production e.g. shivering, muscular exercises. 2- Ingestion of food; by increasing the fuel supply, body heat is increased. 3- Time of day: body temperature tends to be at itshighest in the late afternoon or early evening. 4- Emotion: stimulate the sympathetic nervous system with release of epinephrine and nor epinephrine which increases the metabolic activates of body tissues which in turn increases heat production. 5- Hormones: increase in production of thyroxin by the thyroid gland increases basal metabolic rate thereby stimulates heat production. 6- Infection: causes increase in body temperature. 7- Increase temperature of the environment: high room temperature or hot water bath may increase body temperature. 8- Menstruation and pregnancy: at the time ofovulation a woman's body temperature may rise as much as 0.3C.it fall again one or two days before the onset of menstruation. the first 3 to 4 months of pregnancy are characterized by a slight rise of the temperature, then falls slightly below normal for the remainder of the pregnancy. it returns to normal after birth. Factors decreasing heat production: 1- Prolonged illness: muscular activity is diminished andless heat produced. 2- Fasting: an inadequate supply of food or fuel leads todecreased heat production. 3- Sleep: during sleep, when the body is less active, less heat is produced and body temperature is lowered. 4- Depression of the nervous system: mental depression , unconscious ness and the use of narcotic drugs, all act to lessen body activity and thus decrease heat production. 18 5- Time of the day: body temperature tends to be at its lowest in the morning. 6- Age: The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Children ‘s temperature continue to be more labile than those of adults until puberty. Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. Four most common sites for measuring bodytemperature: 1. Oral 2. Axillary 3. Rectal 4. Tympanic membrane Oral temperature: is considered to be reliable when the thermometer is placed posteriorly into the sublingual pocket. This landmark is close to the sublingual artery, so this site tracks changes in core body temperature. The oral cavity temperatures are influenced by drinking, chewing, smoking, and breathing with the mouth open. Cold drinks or food reduce oral temperatures; hot drinks, hot food, chewing, and smoking raise oral temperatures. Contraindications of oral temperature: 1- Infants and children 2- Unconscious patient 3- Inflammation or surgery of mouth 4- Mouth breathing patients 5- Very old 6- Very weak who cannot close his mouth well 7- Patient with seizure disorder 8- Persistent frequent cough 9- After drinking hot fluids or cold fluids (temporary, butcan measure after 15 min) Axillary temperature Temperature is measured at the axilla by placing the thermometer in the central position and adducting the arm close to the chest wall. Axilla is an unreliable site for estimating core body temperature because there are no main blood vessels around this area. Also, the axillary temperature can be affected by the environmental temperature and perspiration. 19 Contraindications of axillary temperature: 1. Skin disease 2. Axillary operation Rectal temperature Rectal temperature readings are considered to be very accurate. Contraindications of rectal temperature: 1- Patient with a surgery in rectum 2- Inflammation of rectum 3- Diarrhea 4- Clotting disorder 5- Hemorrhoids The tympanic membrane Nearby tissue in the ear canal, is a frequent site for estimating core body temperature. Normal body temperature: Normal human body temperature, also known as normothermia or euthermia. There is no single number that represents a normal or healthy temperature for all people under all circumstances using any place of measurement. 1- The average normal temperature for adult is 37c 2- The average normal rectal temperature for adult is 37.5c 3- The average normal axillary temperature for adult is 36.5c 4- The normal range of body temperature is 36.6 c : 37.2c Type of thermometer 1- Electronic thermometer. oral = blue rectal = red 2- Temperature sensitive tape. 3- Mercury in glass thermometer: - can be hazardous due to exposure to mercury which is toxic to human. a. oral = thin bulb b. rectal = blunt tip 4- Infrared thermometers: sense body heat in the form of infrared energy given off by a heat source like tympanic membrane in the ear canal, temporal artery of the forehead. a. Tympanic thermometer b. Temporal artery thermometers c. noncontact thermometers. 20 Heat balance: The amount of heat produced by body equal the amount of heat lost. Alteration in body temperature: 1- Pyrexia: it is common symptom of illness, a bodytemperature above the usual range is called pyrexia, hyperthermia or fever. Fever may be: a. low grade fever: is temperature, slightly elevated to approximately 37.3C to 38.2C b. high grade fever: temperature, above 38.3C to 40.5C c. hyperpyrexia: is a condition in which bodytemperature is above 41.6C febrile: client who has a fever A febrile a person who has not fever Causes of fever: 1- Damage to heat regulating center due to head injury, cerebrovascular accidents and abnormally high body temperature. this leads to disturbance in heat regulating mechanism. 2- Acute infectious disease e.g. malaria 3- Acute inflammatory conditions 4- Acute and prolonged pain 5- Extreme nervousness 6- Emotional stress 7- Trauma or injury to body tissue 8- Condition that increases heat production e.g., thyrotoxicosis there is increased metabolic rate which causes elevation of body temperature 9- Conditions that decrease heat loss e.g., dehydration which results in decreased in secretion of sweat. Clinical Signs of Fever Onset (Cold or chill stage): Chills 21 Feeling of coldness Cold skin Shivering Course. Defervescence (fever abatement): Excessive sweeting and a hot Flushed skin due to sudden vasodilation Decline period: it is a period when temperature fall tonormal Nursing Interventions for Clients with fever  Monitor vital signs.  Assess skin color and temperature.  Monitor white blood cell count, hematocrit value, andother pertinent laboratory records.  Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.  Provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration, if health permits. Clients who sweat profusely can become dehydrated  Measure intake and output.  Maintain prescribed intravenous fluids.  Reduce physical activity to limit heat producing, especially the flush stage.  Administer antipyretics as ordered.  Provide oral hygiene to keep the mucous membranes moist. They can become dry and cracked because of excessive fluid loss.  Provide a tepid sponge bath to increase heat loss through conduction.  Provide dry clothing and bed linens to increase heat loss through conduction 2- Hypothermia: a condition in which temperature is normally lower than normal Causes of hypothermia: 1- lowered metabolism 2- Decreased activity usually occurs in elderly. 3- Heavy sedation 4- Circulatory failure 5- Exposure to extremely cold environmental temperature Signs and symptoms of hypothermia: 22 1- Pale skin 2- Cold hand and feet 3- Cyanosed lips 4- Chilling 5- Drowsiness 6- Decreased mental and physical capabilities 7- Patient feels sleepy 8- Slow pulse rate Nursing care of pa ent with hypothermia: 1- Increase physical activities 2- Warm the patient by: Use of more blankets, extra clothes, heaters, hot application to the skin such as hot water bottles and heating pads to the skin, friction of body surface and warm food and drinks. 23 Pulse and Blood Pressure Background on Pulse and Blood Pressure The Circulatory System The heart is located in the center of the chest, protected by the rib cage. When the body ‘s circulatory needs change, the heart rate either accelerates or decelerates. The circulatory system is composed of:  Arteries: large vessels that transport systemic blood under high pressure to the tissues  Arterioles: the smallest branches of the arterial system that act as control valves to release blood into the capillaries  Capillaries: thin-walled vessels permeable to small molecular substances that exchange fluids, nutrients, electrolytes hormones, and other substances between the blood and interstitial fluid  Venules: vessels that collect blood from the capillaries and gradually coalesce into progressively larger veins  Veins: vessels that transport systemic blood from the tissues back to the heart and serve as a reservoir for extra blood. 24 The cardiac cycle has two phases: systole and diastole. Bloodwould flow to the tissues only during systole (phase in which the ventricles contract to eject blood) with an absence of blood flow during diastole (phase in which lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature, and because of the increased metabolic rate. 25 Factors affecting pulse rate 1. Medications: Some medications decrease the pulse rate, and others increase it. 2. Hemorrhage: Loss of blood from the vascular system normally increases pulse rate. 3. Stress: In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. 4. Position changes: When a person assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure reduction in blood pressure and increase in the heart rate. Characteristics of Normal Pulse: 1. Rate: A normal pulse rate for adults is between 60 and 100 beats per minute Bradycardia is a heart rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult 2. Pulse rhythm: is the regularity of the heartbeat. It describes how evenly the heart is beating: regular (the beats are evenly spaced) or irregular (the beats are not evenly spaced). Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early, late, or missed heartbeat. 3. Pulse volume: is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. It is described as normal (full, easily palpable), weak (thready and usually rapid), or strong (bounding). 26 Pulse sites: 1. Temporal, 2. Carotid 3. Apical 4. Brachial 5. Radial 6. Femoral, 7. Popliteal, 8. Posterior tibial 9. Pedal (dorsalis pedis), Recording and reporting pulse: Assessment of Normal Abnormal pulse Tachycardia or Rate 60-90b/m. bradycardia Rhythm Regular Irregular Force Strong Weak Deﬁni on of blood pressure: This is the force or the amount of pressure exerted by the blood against a vessel wall of arteries when the left ventricle contract. Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction. There are two blood pressure measures: 1. Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave. 2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries. Pulse pressure: is the difference between the diastolic andsystolic pressures. 27 Normal range of blood pressure: The average blood pressure of a healthy adult is 120/80 mmHg. Classification of blood pressure for adults aged≥18 years BP classification Systolic BP(mmHg)Diastolic BP(mmHg Normal > stimulate uterine contractions.  Contraindications: There have been conflicting studies in regards to pregnant women using ginger for morning sickness.  Nursing Considerations: 1. Do not give to patients with history of gallstones. 89 2. Watch for bleeding due to antiplatelet properties. 3. Possible interactions with Coumadin. 4. Avoid during chemotherapy or surgery. 3- Anise:  Uses: 1. Expectorant. 2. Coughs and Bronchitis 3. Parasite Repellant  Side effect: 1. Narcotic in large doses. 2. Anise seeds contain anethole, a plant hormone similar to human estrogen, avoid when pregnant and use with caution in very young babies. 3. The essential oil is for topical use only. 4- Green tea:  Uses: 1. Reduce Cancer incidence 2. Metabolism booster 3. Lowering Cholesterol 4. Relieve inflammation and itching of insect bites 5. Reduce Pink eye inflammation, Conjunctivitis  Side effect: Overuse of caffeine can affect sleep >> Insomia 5- Lavender: Uses: Reduce Anxiety & Stress Healing of Skin abrasions, Burns & scalds Anti-inflammatory and antiseptic Flea bites, rashes 90 Lowering blood pressure & relaxes cardiac spasms such as tachycardia Relive Arthritis & improve circulation Relaxation of nick & head muscle >> Nervous headache Effective for Leucorrhoea Relive Fibromyalgia 6- Thyme: Uses: Reduce Fever, bronchitis Fighting Toothache/ tooth infections Cough, flu & sore throat Insect repellent Side effect: Excessive amounts can affect menstrual cycles. Thymol is toxic and should be used with great care and in moderation. The essential oil should never be applied undiluted and is not suitable for use in small children. 7- Black seed: Uses: Relive Rheumatoid Arthritis, High Blood Pressure Anti-inflammatory, analgesic, antipyretic, antimicrobial and antineoplastic activity. Preventing Hair loss – Healthy Hair >> Aminoacids Side effect: Undiluted oil can cause skin irritation. Not to be used in pregnan women. 9- Nigella sativa‫ﺣﺒﮫ اﻟﺒﺮﻛﮫ‬ Nigella sativa has antihypertensive, anti-flatulent, and anthelmintic properties. It is recommended that the intake of one gram of Nigella Sativa twice daily is a very effective as an immune-modulator. 91 Nigella protects bronchospasm so it is used to relieve the symptoms of asthma, bronchitis, and coughing). 10- Cardamom ‫اﻟﺤﺒﮭﺎن‬ Contains volatile oil which is used as flavoring agent has anti-flatulent, anti-spasmodic, and anti-viral and gastroprotective effects Common side effect of cardamom is increasing the gastric acid secretion 12- Caraway ‫اﻟﻜﻤﻮن‬ Useful in strengthening the functions of stomach, and relieving intestinal gases. 13- Ginseng:  Uses: Improves concentration Fatigue, thus improves energy Stress relief Improve LDL & HDL levels Night sweats Headaches Palpitations 92  Action: They produce CNS depression.  Dosage: 100-300 mg/day/divided & Dried roots: - 2-4 grams  Precaution/Adverse Effects: Can produce diarrhea, sleep disturbance, hypertension and, skin rash. Limitations of Herbal Therapy: Although herbal medicines provide beneficial effects for a variety of conditions, a number of problems exist. Because they are not regulated, concentrations of the active ingredients vary considerably. Contamination with other herbs or chemicals, including pesticides and heavy metals, is also problematic. Some herbs also contain toxic products that have been linked to cancer. Some herbal substances contain powerful chemicals. Aromatherapy Aromatherapy is the therapeutic use of essential oils of plants in which the odor or fragrance plays an important part. The chemicals found in the essential oils are absorbed into the body, resulting in physiologic or psychologic benefit. Essential oils are extracted from plants and are massaged into the skin, inhaled, placed in baths, used as compresses, or mixed into ointments. Action essential oils Different oils may calm, stimulate, improve sleep, change eating habits, or boost the immune system. Precaution with Aromatherapy:  Essential oils, other than lavender or tea tree oil, are quite potent and can irritate the skin, so they should be diluted with a carrier oil before being used on the skin. Carrier oils such as sunflower oil, grapeseed oil, and soy oil contain vitamins, proteins, and minerals that provide added nutrients to the body.  Essential oils should not be ingested because even modest amounts can be fatal.  Pregnant women and individuals with epilepsy should consult a knowledgeable healthcare practitioner or qualified aromatherapist prior to the use of essential oils.  Some oils can trigger bronchial spasms, so individuals with asthma should consult their primary healthcare provider before using them. 93  Nutritional Therapy Nutritional therapy consists of the consumption of specific types of diets or supplements, including vitamins, minerals, amino acids, herbs and other botanicals, and miscellaneous substances such as enzymes and fish oils, for the purpose of preventing or treating illness. Some supplements cause adverse effects such as diarrhea or high blood pressure, yet others become dangerous when taken in combination with certain medications. Another safety concern with supplements is that they may be contaminated with dangerous substances such as mold, bacteria, pesticides, and metals.  Manual Healing Methods These healing practices include chiropractic, massage, acupuncture, acupressure, reflexology, and hand- mediated biofield therapies. Massage Massage therapy, the scientific manipulation of the soft tissues of the body, is a healing art, an act of physical caring, and a way of communicating without words. It is believed that massage aids the ability of the body to heal itself and is aimed at achieving or increasing health and well-being. Effect of massage 1. A skilled massage therapist not only stretches and loosens muscle and connective tissue but also greatly improves blood flow and the movement of lymph fluid throughout the body. 2. Massage speeds the removal of metabolic waste products resulting from exercise or inactivity, allowing more oxygen and nutrients to reach the cells and tissues. 94 3. The release of muscular tension also helps to unblock and balance the overall flow of life energy throughout the body. 4. On the physical level, massage relieves muscle tension, reduces muscle spasms, 5. improves joint flexibility and range of motion, improves posture, 6. lowers blood pressure, slows heart rate, promotes deeper and easier breathing, 7. and improves the health of the skin. 8. On the mental level, massage induces a relaxed state of alertness, reduces mental stress, and increases the capacity for clearer thinking. 9. On the emotional level, massage satisfies the need for caring and nurturing touch, increases feelings of well-being, decreases mild depression, enhances self -image, reduces levels of anxiety, and increases awareness of the mind–body connection Acupuncture, Acupressure, and Reflexology Acupuncture and acupressure are techniques in which pressure or stimulation is applied to specific points on the body, known as acupuncture points, to relieve pain, cure certain illnesses, and promote wellness. Acupuncture uses needles, whereas acupressure uses finger pressure. 95 Reflexology is a form of acupressure most commonly performed on the feet, but the hands or ears may also be manipulated. shows the foot reflex areas. Acupuncture, acupressure, and reflexology are treatments rooted in the traditional Eastern philosophy that qi, or life energy, flows through the body along pathways known as meridians. As vital energy flows through the meridians, it forms tiny whirlpools close to the skin’s surface at places called acupuncture points. These points function somewhat like gates to moderate the flow of qi. When the flow of energy becomes blocked or congested, individuals experience discomfort or pain on a physical level, may feel frustrated or irritable on an emotional level, and may experience a sense of vulnerability or lack of purpose in life on a spiritual level. The goal of care in wellness acupuncture is to recognize and manage the disruption before illness or disease occurs. Practitioners bring balance to the body’s energies, which promotes optimal health and well-being and facilitates individuals’ own healing capacity.  Mind–Body Therapies In mind–body therapies, individuals focus on realigning or creating balance in mental processes to bring about healing. These therapies include yoga, meditation, hypnotherapy, guided imagery, biofeedback, qi gong, t’ai chi, and Pilates. Yoga Yoga has been practiced for thousands of years in India, where it is a way of life that includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. A typical yoga session lasts 20 minutes to an hour. Some individuals spend 30 minutes doing the poses and another 30 minutes doing breathing practices and meditations. Others spend the majority of the time doing poses and end with a short meditation or relaxation procedure. Even for those who are inactive and out of shape, sick, or weak, sets of easy exercises can help to loosen the joints and stimulate circulation. If practiced regularly, these simple exercises alone make a great difference in individuals’ health and well-being. Meditation Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Meditation is a process that all individuals can use to calm themselves, cope with stress, and for those with spiritual inclinations, feel as one with God or the universe. Meditation can be practiced individually or in groups and is easy to learn. It requires no change in belief system and is compatible with most religious practices. If practiced regularly, such as 20 minutes twice a day, meditation produces widespread positive effects on physical and psychologic functioning. The autonomic nervous system responds with a decrease in heart rate, lower blood pressure, decreased respiratory rate and oxygen consumption, and a lower arousal threshold. Meditation’s residual effects—improved stress-coping abilities—are a protection against daily stress and anxiety. Guided Imagery Imagery 96 refers to a two-way communication between the conscious and unconscious mind and involves the whole body and all of its senses. Most of us imagine frequently throughout the day. react to current stressors and anticipated dangers. Our bodies become aroused and tense, and we activate the fight-or-flight mechanism. Guided imagery can help us learn how to stop troublesome thoughts and focus on images that help us relax and decrease the negative impact of stressors. Imagery stimulates changes in many body functions, such as heart rate, blood pressure, respiratory patterns, brain wave rhythms and patterns, electrical characteristics of the skin, local blood flow and temperature, gastrointestinal motility and secretions, sexual arousal, and levels of various hormones and neurotransmitters. Imagery is used to promote healing; decrease pain and symptoms; minimize side effects; manage chronic illness; prepare for procedures, surgery, or childbirth; and access inner wisdom and resources.  Spiritual Therapy Faith and Prayer Faith refers to our beliefs and expectations about life, ourselves, and others. Prayer is most often defined simply as a form of communication and fellowship with the Deity or Creator. In directed prayer, the praying individual asks for a specific outcome, such as for the cancer to go away or for the baby to be born healthy. In contrast, in nondirected prayer, no specific outcome is asked. The praying individual simply asks for the best thing to occur in a given situation. 97  Miscellaneous Therapies  Some therapies do not fit into any of the previously described categories. These include music therapy, humor and laughter, bioelectromagnetics, detoxifying therapies, animal-assisted therapy, and horticultural therapy.  Nursing Role in Complementary & Alternative Therapy: Nurses work very closely with their patients and are in the unique position of becoming familiar with the patient’s spiritual and cultural viewpoints. They are often able to determine which complementary therapies are more appropriately aligned with these beliefs and oﬀer recommendations accordingly. Being knowledgeable about complementary therapies will help you provide accurate information to patients and other health care professionals. 1. All providers, including nurses, need to encourage open, honest dialogue with patients about the use of complementary therapies. 2. Providers also need to actively engage patients to accept integrative care to prevent disease, manage illness, and improve whole person well-being by employing the full spectrum of possible therapeutics rather than relying solely on surgery or drugs. 3. Nurse should have enough knowledge to discuss the full range of biomedical and complementary therapeutic options so that she can help patients make informed health care decisions. 4. Assess patients directly about their use of complementary therapies, including self-care activities such as yoga, meditation, or dietary supplements. 5. Be knowledgeable about the evidence for diﬀerent complementary therapies so that nurse can make appropriate recommendations about which therapies are possibly useful for patients. 6. Understand thoroughly the potential beneﬁts and risks so that information is clearly and fully disclosed. 7. Be knowledgeable, so nurse can give advice to patients about when to seek conventional care and when it is safe to consider complementary care services. For example, if a patient has right lower abdominal pain, nausea, and vomiting, be suspicious of conditions such as appendicitis or colitis and recommend consultation with a health care provider. However, if the patient has a chronic gastrointestinal disorder and has a diagnosis of irritable bowel syndrome, the patient may beneﬁt from relaxation and herbal therapy. 8. Be aware of the safety precautions for each complementary therapy, and incorporate these in the teaching plans. 9. Finally, understand your state Nurse Practice Act with regard to complementary therapies and practice only within the scope of these laws. 98 Health, Illness and Disparities Definition of health  Health: is the opposite of disease (Traditional View)  Health: is a state of complete physical, mental & social well- being, not merely the absence of disease. Being healthy: Able to function well; physically and mentally (World Health Organization (WHO))  Health: ability to lead socially and economically productive life (recent years)  Disease: an alteration in body functions resulting in a reduction of capacities or shortening of the normal life span. It is objective state, includes the following: Inherited, Congenital, & Idiopathic causes.  Illness: pathology affecting an organ or bodily system. It is subjective state. Resulted from response of a person to a disease. Also a highly personal state in which the person feels unhealthy or ill. Disease causes illness…  Continuum: graduated spectrum that can’t be divided  Wellness: an active state, oriented toward maximizing the potential of the individual. Wellness further describes health status. It allows health to be placed on a continuum from one’s optimal level (wellness) to a maladaptive state (illness). Wellness is a dynamic process that is ever changing. The well person usually has some degree of illness and the ill person usually has some degree of wellness. Human Dimensions of Health 1- Physical: The ability to carry out daily tasks, achieve fitness (e.g. pulmonary, cardiovascular, gastrointestinal), maintain adequate nutrition and proper body fat, avoid abusing drugs and alcohol or using tobacco products, and generally to practice positive lifestyle habits. 2- Intellectual: The ability to learn and use information effectively for personal, family, and career development 3- Emotional: The ability to manage stress and to express emotions appropriately, Emotional wellness involves the ability to recognize, accept, and express feelings. Enjoyment of creativity, the satisfaction of the basic need to love and be loved, the understanding of emotions, and the ability to maintain control over emotions. 4- Sociocultural : The ability to interact successfully with people and within the environment 99 5- Spiritual: manifests as inner strength and peace. It encompasses the beliefs that a person has that give meaning and purpose to their existence. Environmental aspects: The ability to promote healthmeasures that improve the standard of living and quality of life in the community Factors that disrupt health  Physical disease  Mental illness  Injury  Pain  Loss (self, permanent)  Impending Death  Competing Demands  Isolation Stages of Illness Behavior  Experiencing symptoms Sick role behavior- unable to maintain life schedule  Seeking professional care Dependence on others- depends on diagnosis and severity of illness  Recovery- final stage, resuming independence and returns to normal life 100 Nature of the Illness Acute Illness  Occurs suddenly  Limited time frame  Expected recovery Chronic Illness  Lasts six months or more  Requires life changes  Episode’s remission (symptoms are minimal to none) /exacerbation (flare-up), when symptoms intensify Impact of Illness on the Client Behavioral and emotional changes Anxiety about outcomes Loss of autonomy Self-concept and body image changes Lifestyle changes change in social customs Impact of Illness On the Family roles Depends on:  Member of the family who is ill  Seriousness and length of the illness  Cultural and social customs the family follows 1) Effect of chronic disease Role changes: if the wife gets sick or dies, the husband has to adjust (or vice-versa) Economic pressures: family member stops work to care for the sick, patient is unable to work, medical bills become high 2) Stress from taking care of sick family member e.g. Alzheimer‘s disease, serious mental illness, relative who is bed-ridden or incontinent 3) Stigmatizing diseases such as HIV/AIDS 101 Health promotion and illness prevention  Health promotion: - is a process undertaken to increase the levels of wellness in individuals, families, and communities. - It involves activities and programs provided by nurses and other health care providers to foster lifestyle behaviors conducive to optimum health status.  Health prevention: - Action aimed at eradicating, eliminating or minimizing the impact of disease and disability - The concept of prevention is best defined in context of levels, traditionally called primary, secondary, and tertiary levels. A fourth level, called primordial prevention, was later added.  Successful prevention depends on: o knowledge of causation o Dynamic of transmission o Identification of risk factors o Availability of prophylactic or early detection and treatment measures o Continuous evaluation of applied procedure o Organization for applying this procedure 102 Primary level of prevention is to decrease the person‘s vulnerability to disease. Primary preventive measures include parenting education, attention to personal hygiene, and avoidance of toxins. Secondary level of prevention is early detection of disease to initiate early intervention. Secondary preventive activities are screening for particular diseases and preventing the spread of communicable disease. Tertiary level of prevention When a disease already exists, is used to minimize its effects and to prevent further disability. Nurses, who work in rehabilitation settings, including the home, are engaged in tertiary prevention. The focus is on restorative care, therapeutic interventions directed at helping clients reach and maintain their optimal level of functioning. primordial prevention: actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social, and behavioral condition and cultural pattern of living etc… 103 Models of health promotion and illness prevention Models of why and how people behave in ways to promote health and prevent illness help health care providers understand health related behaviors and adapt care to people from diverse economic and cultural backgrounds, to overcome barriers to health from disparities in care resulting from such factors I. The agent-host-environment model  Each factor constantly interacts with the others  When in balance, health is maintained  When not in balance, disease occurs The host reaction is influenced by family history, age,and health habits The environment includes physical, social, biologic,and cultural factors  Each of the agent-host-environment factors affects and is affected by the others. II. The health–illness continuum:  A person’s position moves back and forth on the continuum with physiological changes, lifestyle choices, and the results of various therapies. Continuum is personal and dynamic. Health changes over the course of time  view health as a constantly changing state, with high level of wellness and death at 104 opposite ends of a graduated scale, or continuum.  It illustrates the ever-changing state of health as a person adapt to changes in internal and external environments to maintain a state of well-being.  Measures a person ‘s level of health  Neuman’s Continuum- a balance of input and output. When energy output exceeds input, illness results. Wellness occurs when more energy is generated than expended The health belief model:  It focuses on what people perceive or believe to be true about themselves in relation to their health. This model based on three components of individual perceptions of threats of disease Underlying assumptions: Health actions are motivated by perceptions of: - Threat - Benefits - Costs - Concepts _ Perceived Susceptibility - Can I get the condition? _ Perceived Severity - How serious is this? _ Perceived Benefits - Will the advised actions work? _ Perceived Barrier - What are the costs III. The health promotion model: This model incorporates individual characteristics and experience, as well as behavior specific knowledge and beliefs, to motivate health promoting behavior. Nurses can use 105 the components of the model to design and provide intervention to promote health for people,families, and communities. Behavior specific knowledge, beliefs and relationships are considered major motivators for health promoting behaviors. Illustrates the ―multidimensional nature of persons interacting with their environment as they pursue health Incorporates individual characteristics and experiencesand behavior-specific knowledge and beliefs, to motivate health-promoting behavior Personal, biologic, psychological, and socioculturalfactors are predicative of a certain health-related habit Health-related behavior is the outcome of the model and is directed toward attaining positive health outcomes andexperiences throughout the lifespan Disparities in health care Although health care increasingly focuses on the promotion of health and the prevention of illness, there continue to be disparities that lead to different health outcome among different populations of people A health disparity is defined as a particular type of health difference that is closely linked with social, economic, and/orenvironmental Disadvantage health disparity is influenced by many different factors,including:  Racial and ethnic group  poverty  gender  age  mental health  educational level  disabilities  health insurance  and access to health care National trends in effort to prevent health disparities focus on vulnerable population, such as racial and ethnic minorities, those living in poverty, women, children, older adults, and people with disabilities and special health care needs Nursing role to promote health and prevent illness The current focus on health promotion and illness prevention at local, state, national, and global levels is important tonurse Major nursing goals related to health promotion Motivate clients to want to change. 106 Nurses identify high-risk individuals and determine and strengthen their social support, thus encouraging disease prevention. Clients who are attempting to adopt health-promoting behaviors must receive support and reinforcement for their attempts. 1. Nursing interventions to promote adolescent andmiddle adults health Teaching activities to promote health about safety, nutrition, growth and development, immunization, importance regular physical assessment, and importance of healthy family relationship Because independence and self-sufficiency are important to adolescents and young adults, they will not easily accept the dependent sick role so promoting health and preventing illness is very important by teaching, serving as role model, and encouraging self-care responsibilities 2. Nursing interventions to promote family health The nurse can help reduce risk factors with activities that promote health for all family members at any level of development. The nurse assists both the person and the family to meet their basic human needs Nurses may carry out such activities themselves or may refer the individual or family to other health care providers Health promotion activities and nursing action can reduce the risk for illness and facilitate healthy behaviors at any age within the family life cycle 3. Nursing interventions to promote community health Community health nurse focuses on whole populations within a community, community based nursing is centered onthe health care needs of individuals and families. Nurses practicing community based nursing provide interventions to manage acute and chronic health problems, promote health, and facilitate self-care. Nursing care provided within a community must be culturally competent and family centered. Nurses providing community-based care must know about the location and specialty of health care providers, the availability and accessibility of services and supplies andother public health services 107 Pain assessment and management "The fifth vital signs" Introduction: Pain is the most common reason patients seek health care. Research shows that under management of pain in hospitalized persons inhibit the ability and willingness to recover from illness. Statistics show that nationwide, we as healthcare providers tend to under medicate patients due to many factors. For these reasons, this is provided to enhance the healthcare providers’ skills and knowledge of assessment, management, and evaluation of pain. Recent literature has emphasized the importance of pain and recommended it being the fifth vital sign. Some states in the United States have passed laws necessitating the adoption of an assessment tool and documenting pain assessment in patient charts along with temperature, pulse, heart rate and blood pressure. Definition of pain: The International Association for the Study of Pain (IASP) defines pain as ―an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage, or both. Why pain is considered the “fifth vital sign? 1. Assessed in all patients 2. Patient/client right to appropriate assessment andmanagement of pain Pain is: 1. Subjective experience 2. Symptom of a condition – historically 3. Currently considered a condition 4. A protective physiological mechanism 5. The fifth Vital Sign Physiology of pain: I -Nociceptive Pain (noci=harm/pain) II- Neuropathic Pain III- Phantom Pain 108 I-. Nociceptive Pain Transduction of pain begins when a mechanical, thermal or chemical stimulus results in tissue injury or damage stimulating the nociceptors, which are the primary afferent nerves for receiving painful stimuli. Nociceptors are distributed in the body in the skin, subcutaneous tissue, skeletal muscles, and joints. Pain receptors are also located in the peritoneal surfaces, pleural membranes, Dura mater, and blood vessel walls rather than in the parenchyma of visceral organs. Noxious stimuli initiate a painful stimulus resultingin an inflammatory process, which leads to the release of cytokines and neuropeptides from circulating leukocytes, platelets, vascular endothelial cells, immune cells, and cells from within the peripheral nervous system. This results in the activation of the primary afferent nociceptors (A-delta and C- fibers). Furthermore, the nociceptors themselves release a substance P that enhances nociception, causing vasodilatation, increased blood flow, and edema with further release of bradykinin, serotonin from platelets, and histamine from mast cells. A-delta primary afferent fibers transmit fast pain to the spinal cord within 0.1 second, which is felt as pricking, sharp, or electric quality sensation and usually caused by mechanical or thermal stimuli. C-fibers transmit slow pain within 1 second, which is felt as burning, throbbing or aching and is caused by mechanical, thermal or chemical stimuli usually resulting in tissue damage. By the direct excitation of the primary afferent fibers, the stimulus leads to the activation of the fiber terminals. Pathway for transmitting pain 109 The transmission : Movement of pain impulses from the site of transduction to the brain. Transmission along the nociceptor fibers to the level of the spinal cord.Dorsal horn of spinal column processing. Transmission to the thalamus and the cortex of the brain Modulation: 'Body response" Activation of descending pathways that inhibit or facilitate the transmission of pain Neuropathic Pain Usually associated with dysfunction of the nervous system, specifically an abnormality in the processing of sensations. Pain receptors in the body become sensitive to stimuli and send pain signals more easily. In some cases the pain signal that normally moves from the periphery toward the brain reverses and is sent in the opposite direction. These changes are often associated with medical conditions rather than tissue damage e.g. cancer, HIV, diabetes, nutritional deficiencies (anorexia nervosa). III- Phantom Pain: Occurs after the loss of a body part from amputation, Patient feels pain in the amputated part for years after the amputation has occurred May be controlled Gate-Control Theory of Pain Gating mechanisms along the CNS, Can block transmission of impulses Pain relief measures to close the gate; Light touch [effleurage] Opening and closing of the gate was determined by; Amount of activity, Type of nerve fiber (myelinated is fast) and Selective cognitive processes Pain threshold: Level at which you feel pain Physiologic response to pain: Pain elicits a stress response in the human body triggering the sympathetic nervous system, resulting in physiologic responses such as the following: 110 1. Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide 2. Focus on pain, reports of pain, cries and moans, frowns and facial grimaces 3. Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilatedpupils. 4. Increased heart rate, peripheral, systemic, andcoronary vascular resistance, blood pressure 1. Increased respiratory rate and sputum retentionresulting in infection and atelectasis Decreased gastric and intestinal motility 2. Decreased urinary output resulting in urinaryretention, fluid overload, depression of all immune responses 3. Increased anti diuretic hormone, epinephrine, nor- epinephrine, aldosterone, glucagons, decreasedinsulin, testosterone 4. Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism 5. Muscle spasm resulting in impaired muscle function and immobility, perspiration Types of pain : Pain has many different classifications. Common categories of pain include acute, chronic non-malignant, and cancerpain. Pain Assessment: P: precipitating/Alleviating Factors: What causes the pain? What aggravates it? Has medication or treatment worked inthe past? Q: quality of Pain: Ask the patient to describe the pain usingwords like sharp, dull, stabbing, burningǁ R: Radiation: Does pain exist in one location or radiate toother areas? S: severity: Have patient use a descriptive, numeric or visual scale to rate the severity of pain. T: Timing: Is the pain constant or intermittent, when did itbegin, and does it pulsate or have a rhythm 111 Quality of pain Nursing management of pain: "Non-pharmacologic" 1. Massage 2. Acupuncture 3. Acupressure 4. Relaxation techniques 5. Hypnosis 6. Meditation 7. Distraction 8. Pharmacological pain relief Pharmacologic management: Administer analgesics as ordered/ reassess pain in 30minutes and hourly 1. Patient-controlled analgesia (PCA) 2. Local analgesic infusion pump 3. Topical analgesics and anesthetics 4. Local and regional anesthetics 112 Safety in Nursing care Delivery Introduction Safe care is a basic need of all clients regardless of the setting. Nurses are responsible for providing the client with a safe environment through the delivery of professional, quality nursing care that incorporates safetyprecautions, infection control practices, and hygiene assistance. Safe environment Safety has a positive association with health promotion and illness prevention. A safe environment reduces the risk of accidents, subsequent alterations in health and lifestyle, and the cost of health care services. There aremany factors in the environment that can threaten safety Factors Affecting Safety: 1. Developmental Considerations – Unborn: exposure to drugs, alcohol, or smoke – Children: increase in hazards as motor skillsdevelop – Adolescents: danger from drugs, alcohol, riskysexual activity – Older adults: risk of abuse & injury from falls Risk for injury varies with chronological age anddevelopmental stage. Health education about preventivemeasures can facilitate injury prevention for various agegroups. As infants mature, their potential for injury increases. Infants, toddlers, and preschoolers are explorers of their environment. Most accidents involvingthese age groups are preventable with careful adultsupervision to prevent falls from bed, burns, and electricalhazards, choking on small objects, and drowning. The older adult is prone to falls, especially in the bathroom, bedroom, and kitchen, because of a loss of agility and visual acuity, predisposition to dizziness and syncope, and side effects of medications. Prevention measures for this age group emphasize slow position changes, good lighting, hand rails, and skidproof strips inthe bathtub or shower and under rugs and carpets 2. Lifestyle Lifestyle practices can increase a person‘s risk for injury and potential for disease. Individuals who operate machinery; experience stress, anxiety, and fatigue; use alcohol and 113 drugs (prescription and nonprescription); andlive in high-crime neighborhoods are at risk for injury. 3. Sensory and Perceptual Alterations 4. Sensory functions are essential for accurate perception ofenvironmental safety. If one of the senses is altered, then the other senses compensate to facilitate perception of the environment. For instance, a blind person usually will develop a keen sense of touch and hearing. Clients who have visual, hearing, taste, smell, communication, or touch perception impairments are at increased 5. Mobility Clients who have impaired mobility are at increased riskfor injury, especially falls. Mobility impairments may bea result of poor balance or coordination, muscle weakness, or paralysis. Immobility may also precipitate physiological and emotional complications such as decubitus and depression, respectively. 6. Emotional State Emotional states such as depression and anger affect a client‘s perception of environmental hazards and degreeof risk-taking behavior. These emotional states alter a client‘s thinking patterns and reaction time. Usual safetyprecautions may be forgotten during periods of emotional stress. Self-confidence decreases when an elderly person falls; they tend to limit their activities because they fear falling again 7. Environmental Home Poor ventilation Gas leaks Faulty electrical systems & appliances Lack of smoke detectors Unlabeled toxic substances Workplace Dust Chemicals Noise Heights Dangerous machines Heavy lifting Repetitive motions 114 – Community Air pollution Crime Hazardous waste sites Dilapidated housing Poor sanitation Risk factors for fall : Definition of fall: A fall is an unintentional loss of balancecausing one to make unexpected contact with the ground or floor.  Incidence of fall in community  25% fall at age 70 y/o  35% fall after age 75 y/o  50% of older adults who fall, do so repeatedly Consequences of falls  Mortality: accounts for 1/3 of deaths in people overage 65  Injury and Disability: 10 - 15% of falls result in serious injury. Cause nearly 90% of fractures in theelderly, 42% require hospitalization, cause > 200,000 hip fractures each year. Health Care Costs: 3 million hospital days per year for hip fractures long-term care required for half of hip fracture survivors Risk factors for fall : 1. Internal risk factors: Internal conditions that affectone‘s ability to maintain his or her balance. 2. External risk factors: Safety hazards within theenvironment that predispose one to slipping and tripping  Stairway  Bathroom  Bedrails  Assistive Devices Improper Shoes  Poor lighting  Room Location  Decreased nursing staff  First week in different surroundings 115 Preventive measures for falls: 1. Identify high risk persons 2. Modify internal risk factors 3. Modify environmental risk factors 1. Identify high risk persons Obtain a fall History Symptoms Previous falls Location Activity Time 1. Evaluate age related changes:  Decrease vision  Decrease reaction time  Decrease bone density  Decrease physical activity level  Increase muscle atrophy. Assess mental status Assess environmental status  Adequate lighting?  Loose objects on floor?  Type of rugs/carpet?  Steps or stairs?  Wet surfaces?  Accessible telephone?  Clear path from bed to bathroom?  Ask provider to evaluate medications  Monitor BP & blood glucose  Teach to get up slower  Teach safe transfers  Provide strength training  Secure & use assistive devices  Flag chart and/or room  Avoid fluids & caffeine after 6 pm  Clear path to bathroom  Night lights 116  No throw rugs  Ambularm or Bed-Check systems  Answer call lights promptly  Provide adequate staff coverage during shift changeand at night TYPES OF ACCIDENTS In the health care setting, accidents are categorized by their causative agent: client behaviors, therapeutic procedures, or equipment: 1. Client behavior accidents occur when the client‘s behavior or actions precipitate the incident, for example,poisonings, burns, and self-inflicted cuts and bruises. 2. Therapeutic procedure accidents occur during the delivery of medical or nursing interventions, for example, medication errors, client falls during transfers, contaminationof sterile instruments or wounds, and improper performance of nursing activities. 3. Equipment accidents result from the malfunction or improper use of medical equipment, for example, electrocution and fire. National and institutional policies establish safety standards; for example, the risk for equipment accidents can be reduced by having the biomedical engineering department check the equipment inspection label prior to use. All accidents and incident reports must be fully documented according to institutional protocol. POTENTIAL OCCUPATIONAL HAZARDS Nurses and other health care providers are at risk for injury in the workplace. The Occupational Safety and Health Administration (OSHA), a division of the Department ofLabor, has the power to enforce safety standards and to cite and discipline agencies that are not in compliance with the standards. Numerous hazards exist in today‘s workplace, such as latex allergies, blood borne pathogens, work-related musculoskeletal disorders (MSDs), chemotherapeutic agents, environmental pollution, and violence. Nurses who prepare or administer chemotherapeutic agents are exposed tooccupational hazards from dermal absorption, ingestion, and inhalation from aerosolization of powder or liquid during reconstitution or from spillage. Latex Allergy The National Institute for Occupational Safety and Health (NIOSH, 1997) issued an Alert titled Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Latex products are manufactured from a milky fluid derived from the Brazilian rubber tree, Hevea brasiliensis. The allergicresponse is attributed to the proteins contained in the milky fluid and to the chemicals that are added during the processing and manufacture of commercial 117 latex. There are three types of latex reactions: irritant contact dermatitis; allergic contact dermatitis, the most common type of reaction; and immediate hypersensitivity, a systemicreaction, also called type I IgE–mediated reaction. Niosh recommendations to prevent latexexposure employers EMPLOYERS Provide workers with non- latex gloves. Provide appropriate barrier protection for workers handling infectious materials; if latex gloves are chosen, provide reduced-protein, powder-free gloves to protect workers from infectious materials. Provide good housekeeping to remove latex-containing dust, and ensure that workers change ventilation filters and vacuum bags frequently in latex- contaminated areas. Provide education programs regarding latex allergy. Periodically screen high-risk workers for latex allergy symptoms. Evaluate current policies whenever a worker is diagnosed with a latex allergy. Work-Related Musculoskeletal Disorders Work-related back pain affects 38% of nurses. The predominant cause of nurse back pain is lifting clients. OSHA has recommendations for nursing home employers to help reduce the number and severity of MSD conditions such as low back pain, sciatica, rotator cuff injuries, and carpal tunnel syndrome. SAFETY HAZARDS IN THE HOME Poisoning Poisoning death rates have more than quadrupled in the past 20 years. Although young children are frequent victims, the increase has been mainly among adults. In many cases, the person does not die but becomes ill or suffers other effects. Carbon Monoxide Exposure Carbon monoxide (CO) is a colorless, tasteless, odorless toxic gas. Exposure can cause headaches, weakness, nausea, and vomiting; prolonged exposure leads to seizures, dysrhythmias, unconsciousness, brain damage, and death Scalds and Burns The following are common causes of scalds and burns:  Scald injuries (e.g., from hot water, steam, or grease)are the most common cause of burns in children younger than age 3.  wming food or formula in the microwave 118  Sunburn can cause a first- or second-degree burn.  Contact burns may occur from contact with metal surfaces and vinyl seats when cars are parked in thesun.  Chemical agents, such as acid, alkali Fires Home fires are a major cause of death and injury. Olderadults and children younger than age 5 years have the greatest risk of fire death. Suffocation/Asphyxiation Suffocation by smothering is the leading cause of death for infants younger than 1 year. Suffocation may also be caused by drowning, choking on a foreign object, or inhaling gas or smoke. Take-Home Toxins Take-home toxins are hazardous substances transported from the workplace to the home. These toxins are most likely transported to workers’ homes on the workers themselves, on their clothing, or on objects brought from the workplace. SAFETY HAZARDS IN THE COMMUNITY  Motor Vehicle Accidents  Pathogens  Foodborne Pathogens  Vectorborne Pathogens  Waterborne Pathogens  Pollution  Electrical Storms Safety hazards in the health care facility Never events can cause serious injury or death to a patient,and should never happen in a hospital › Foreign object (such as a sponge) left in patients aftersurgery › Air embolism › Administering the wrong type of blood Severe pressure ulcers Falls and trauma 119 Injuries from burns, restraints, or bedrails Infections associated with urinary catheters Infections associated with intravenous catheters Symptoms resulting from poorly controlled blood sugarlevels Surgical site infections following certain elective procedures (e.g., certain orthopedic surgeries, bariatricsurgery for obesity) Deep vein thrombosis or pulmonary embolism followingtotal knee and total hip replacement procedures. Equipment-Related Accidents Equipment-related accidents usually occur when equipmentmalfunctions or is used improperly Fires and Electrical Hazards Because most institutions promote a smoke-free environment, fire in a healthcare agency is more often related to anesthesia or improperly grounded or malfunctioning electrical equipment. Restraints A restraint is a device or method used for the purpose of restricting a patient‘s freedom of movement or access to his body, with or without his permission. Mercury Exposure Mercury is a heavy, odorless, silver-white liquid metal. Mercury is toxic in both acute and chronic exposure. It can be inhaled, ingested, or absorbed through the skin. It accumulates in muscle tissue and can cause renal and neurological disorders, especially in fetuses and neonates. The health effects that can be caused by breathing mercury depend on how much mercury vapor you breathe and how long you breathe the vapors. Health problems can result from short-term or long-term mercury exposure Health effects caused by short-term exposure to highlevels of mercury vapors  Cough, sore throat  Shortness of breath  Chest pain  Nausea, vomiting, diarrhea  Increase in blood pressure or heart rate 120  A metallic taste in the mouth  Eye irritation  Headache  Vision problems Health effects caused by long-term exposure to mercury vapors  Anxiety  Excessive shyness  Anorexia  Sleeping problems  Loss of appetite  Irritability  Fatigue  Forgetfulness  Tremors  Changes in vision  Changes in hearing Biological Hazards As a nurse, you will place a high priority on the biological safety of patients. Institutionalized patients are at especially high risk from infectious microorganisms, some of which arehighly resistant to antibiotics. Hazards to Healthcare Workers Nursing is an active profession, and workplace injuries areall too common Back Injury Nursing personnel are consistently listed in the top 10 occupations for work-related musculoskeletal disorders (MSDs). The American Nurses Association (ANA) reports that 52% of nurses report chronic back pain (ANA, 2013), likely because many nursing tasks require bending and twisting of the torso, activities that can cause injury when the nurse does not use correct body mechanics. Needlestick Injury Healthcare workers, mostly nurses and housekeeping staff, suffer up to 1 million injuries 121 per year from needles and other ―sharps, putting them at risk for infectious diseases such as hepatitis B and AIDS. The operating room is a high-risk area; surgeons experience about a quarter of all ―sharpsǁ injuries Radiation Injury Radiation is the process of emitting radiant energy in theform of waves or particles. Take precautions to avoid excessive radiation exposure for the patient and yourself during x-ray procedures Violence The impact of violent acts on healthcare workers is widespread and includes injuries, higher- than-average staff turnover, increased requests for medical leaves, unusually high time-off and attendance issues, and stress-relatedillnesses Promoting Safety in the Healthcare Facility The following interventions will help you to prevent common accidents in the healthcare setting. Preventing Falls in Healthcare Facilities Provide a Safe Environment Determine the appropriate use of side rails based on the patient‘scognitive and functional status. Keep the bed in a low position,except when giving care, with wheels locked. Make sure to lock wheels ofwheelchairs, especially duringtransfer. Provide nonskid slippers Keep water, urinal, bedpan, andtissues within easy reach of the patient. Place the call light within reach.Have the patient demonstrate the ability to call for the nurse. Provide a night light. Keep floors dry and free ofclutter. For patients at risk for falls,place a warning sticker on thechart or door. 122 Assess, Teach, and Support Provide review and modification of medications,especially psychotropic medications. Provide gait training and adviceon the use of assistive devices. Orient the person to surroundings (e.g., bathroom,chairs; you may need to labelitems). Offer to assist with toileting andtransfer activities. Educate the patient and familyregarding fall prevention strategies. Policies, Procedures,Routines Consider instituting hourlyrounds on your unit. This has proven effective in reducing the number of falls. Place disoriented patients inrooms near the nurses’ station. Provide regular nursing surveillance of hospitalized older adults. Research suggests that this can reduce their falls rate by about 50% (Shever, Titler, Kerr, et al., 2008) Ask patients at risk for falling to wear red or brightly colored socksto alert caregivers. Communicate falls risk statusduring handover and transfer reports. Document changes in the patient‘s condition in the patientrecord What to Do If There Is a Mercury Spill Do not touch mercury droplets. Mercury vaporizes; the toxicvapors can be inhaled or absorbed through the skin. In the Healthcare Agency If you are not trained in the procedure, do not attempt to clean up a mercury spill. Notify the environmental servicesdepartment. Keep people and animals away from the area. Clean the spill promptly. If you are trained, use a commercially made mercury spill kit. All healthcare facilities should have them. Spill kits should contain gloves, protective glasses, mercury-absorbing powder, special mercury sponges, and a disposal bag. Some kits have filtered vacuum equipment. 123 Follow agency guidelines and instructions in the kit. Clean beads off skin, clothing, and disposable items. Placecleaning materials and disposable items in the disposal bag and seal. Follow agency policy for laundering clothing. On hard surfaces, use a flashlight to search for beads. Change clothing that has been contaminated. Wash well. Shower and wash your hair as soon as possibleso you do not unknowingly carry mercury home. Ventilate the area well to reduce the concentration of mercury vapors. Promote exhaust ventilation if possible. Complete an occurrence report. In the Home and Community If you do not have a spill kit, wear rubber gloves and eye protection; use paper towels for cleanup and a plastic bag fordisposal. Keep people and pets away from the area. Wipe beads off skin, clothing, and disposable items. Placedisposable items in the plastic bag and seal with tape. On hard surfaces, use cardboard to scrape up the beads andpour them into a can or jar with a lid. Then wash the area. Shower or wash well. Keep the area well ventilated for several days. Do not use a broom or vacuum cleaner. These will justspread the mercury around and be contaminated by it. Do not flush mercury or cleaning materials down a toilet ordrain. Do not wash and reuse contaminated materials 124 125 126 127 128

Fundamentals of Nursing I Past Paper 2024-2025 (Mansoura National University)

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