Assessment - First Step in the Nursing Process

It is systematic and continuous collection, validation and communication of client data as compared to wh It includes the clients perceived needs, health problems, related experiences, health practices, values and

Purpose
To establish a data base (all the information about the client):

nursing health history physical assessment the physicians history & physical examination results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment

1. Initial assessment assessment performed within a specified time on admission o Ex: nursing admission assessment 2. Problem-focused assessment use to determine status of a specific problem identified in an earlier asse o Ex: problem on urination-assess on fluid intake & urine output hourly 3. Emergency assessment rapid assessment done during any physiologic/physiologic crisis of the client t o Ex: assessment of a clients airway, breathing status & circulation after a cardiac arrest. 4. Time-lapsed assessment reassessment of clients functional health pattern done several months after in baseline data previously obtained.

Activities
1. 2. 3. 4. 5. Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data

Assessment

Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of

Collection of data

gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect clients health s includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing metho includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatm

Types of Data

1. Subjective data o also referred to as Symptom/Covert data o Information from the clients point of view or are described by the person experiencing it. o Information supplied by family members, significant others; other health professionals are conside o Example: pain, dizziness, ringing of ears/Tinnitus 2. Objective data o also referred to as Sign/Overt data o Those that can be detected observed or measured/tested using accepted standard or norm. o Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin Methods of Data Collection

1. Interview o A planned, purposeful conversation/communication with the client to get information, identify pro counseling. o it is used while taking the nursing history of a client 2. Observation o Use to gather data by using the 5 senses and instruments. 3. Examination o Systematic data collection to detect health problems using unit of measurements, physical examin o should be conducted systematically: 1. Cephalocaudal approach head-to-toe assessment 2. Body System approach examine all the body system 3. Review of System approach examine only particular area affected Source of data

1. Primary source data directly gathered from the client using interview and physical examination. 2. Secondary source data gathered from clients family members, significant others, clients medical reco literature/journals. o In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to co client. Components of a Nursing Health History:

o o o o o o o o o o

Biographic data name, address, age, sex, martial status, occupation, religion. Reason for visit/Chief complaint primary reason why client seek consultation or hospitalization. History of present Illness includes: usual health status, chronological story, family history, disab Past Health History includes all previous immunizations, experiences with illness. Family History reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, Review of systems review of all health problems by body systems Lifestyle include personal habits, diets, sleep or rest patterns, activities of daily living, recreation Social data include family relationships, ethnic and educational background, economic status, ho Psychological data information about the clients emotional state. Pattern of health care includes all health care resources: hospitals, clinics, health centers, family

Validation of Data

The act of double-checking or verifying data to confirm that it is accurate and complete.

Purposes of data validation 1. 2. 3. 4. 5. Cues

ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked avoid jumping to conclusion differentiate cues and inferences

Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, he

Inferences

The nurse interpretation or conclusion based on the cues. Example: o Red swollen wound = infected wound o Dry skin = dehydrated

Organization of Data
Uses a written or computerized format that organizes assessment data systematically. 1. Maslows basic needs 2. Body System Model 3. Gordons Functional Health Patterns:

Gordons Functional Health Patterns 1. Health perception-health management pattern. 2. Nutritional-metabolic pattern 3. Elimination pattern 4. Activity-exercise pattern 5. Sleep-rest pattern 6. Cognitive-perceptual pattern 7. Self-perception-concept pattern 8. Role-relationship pattern 9. Sexuality-reproductive pattern 10. Coping-stress tolerance pattern 11. Value-belief pattern

Analyze data

Compare data against standard and identify significant cues. Standard/norm are generally accepted measu o Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal

Communicate/Record/Document Data

nurse records all data collected about the clients health status data are recorded in a factual manner not as interpreted by the nurse Record subjective data in clients word; restating in other words what client says might change its origina

Assessment- Objective & Subjective Data

Review of clinical record

1. Client records contain information collected by many members of the healthcare team, such as demograp consultations 2. Reviewing the clients record before beginning an assessment prevents the nurse from repeating question information that needs clarification.

Interview

1. The purpose of an interview is to gather and provide information, identify problems of concerns, and prov 2. The goals of an interview are to develop a rapport with the client and to collect data 3. An interview has 3 major stages: 1. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achiev

handshake), and small talk about the weather, local sports team, or recent current event; th this time. 2. Body: during this phase, the client responds to open and closed-ended questions asked by 3. Closing: either the client or the nurse may terminate the interview, it is important fro the n developed thus far during the interview process. 4. Types of questions 1. Closed questions used in directive interview Re____ short factual answers; e.g. Do you have pain? Answers usually reveal limited amounts of information Useful with clients who are highly stressed and/or have difficulty communicating 2. Open-ended questions used in nondirective interview Encourage clients to express and clarify their thoughts and feelings; e.g. How have you b Specify the broad area to be discussed and invite longer answers Useful at the start of an interview or to change the subject 3. Leading questions Direct the clients answer; e.g. You dont have any questions about your medications, do Suggests what answer is expected Can result in client giving inaccurate data to please the nurse Can limit client choice of topic for discussion

Nursing History

1. Collection of information about the effect of the clients illness on daily functioning and ability to cope w 2. Subjective data o May be called covert data o Not measurable or observable o Obtained from client (primary source), significant others, or health professionals (secondary sourc o For example, the client states, I have a headache o Objective data o May be called overt data o Can be detected by someone other than the client o Includes measurable and observable client behavior o For example, a blood pressure reading of 190/110 mmHg. Physical assessment

1. Systematic collection of information about the body systems through the use of observation, inspection, a 2. A body system format for physical assessment is found below: o General assessement o Integumentary system o Head, ears, eyes, nose, throat o Breast and axillae o Thorax and lungs

o o o o o o o

Cardiovascular system Nervous system Abdomen and gastrointestinal system Anus and rectum Genitourinary system Reproductive system Musculoskeletal system

Psychosocial assessment 1. Helpful framework for organizing data 2. A suggested format for psychosocial assessment is found below: o Vocation/education/financial o Home and Family o Social, leisure, spiritual and cultural o Sexual o Activities of daily living o Health Habits o Psychological 3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding

Consultation

1. The nurse collects data from multiple sources: primary (client) and secondary (family members, support p 2. Consultation with individuals who can contribute to the clients database is helpful in achieving the most 3. Supplemental information from secondary sources (any source other then the client) can help verify infor and convey information about the clients status prior to admission

Review of literature

1. A professional nurse engages in continued education to maintain knowledge of current information relate 2. Reviewing professional journals and textbooks can help provide additional data to support or help analyz

ssist Patient from the Bed to Chair or Wheelchair

I. Purpose 1. To strengthen the patient gradually.

2. To provide a change in position. (In wheelchair to take her around for a change)

II. Equipment

Chair or wheelchair Patients robe and slippers Pillows Blanket, sheet or draw sheet

III. Procedure

1. See that the chair or wheelchair is in good condition. 2. Place the chair conveniently at night angles to the bedback of chair parallel to the foot of the bed and fa 3. Place pillow on the seat of the chair. If using wheelchair, line it with a blanket or sheet and arrange pillow lock the wheels. 4. Take the patients pulse 5. Assist the patient to a sitting position on bed, i.e., put one arm under the head and shoulders and the other the legs hanging over the side of the bed. 6. Watch the patient for a minute to defect any change in his color, pulse and respiratory rate. 7. Put on patients robe and slippers. Place the foot stool under the patients feet. 8. Stand directly in front of the patient and with a hand under each axilla, assist him to stand, step down and knees and lower body to seat him to the chair. Anchor chair with foot or have someone hold it on. (Or let your arm around his waist. Turn patient around with his back to the chair and seat him gently). Help him 9. Adjust the pillows and wrap blanket over patients lap. If in a wheelchair adjust the foot rests. 10. Observe frequently for changes in color and pulse rate, dizziness or sign of fatigue. 11. To put him back to bed, assist to stand, help to turn and stand on stool and back to bed. Support patient w Pivot to a sitting position in bed, supporting her head and shoulders with one arm and her knees with the 12. Draw up bedding. Take pulse after.

Back Care
After bathing and drying the back, it should be massaged or rubbed thoroughly. I. Purpose 1. To stimulate the circulation and give general relief. 2. To prevent bedsore 3. To give comfort to the patient.

II. Equipment

Alcohol 25% Talcum powder Bath towel

III. Procedure 1. Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. If the supine position is used and the patient is a woman, pillow under the abdomen removes pressure from the breasts and favor relaxation. 2. Raise the camisa and gown. 3. Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long strokes and kneading motions. The amount of pressure to exert depends upon the patients condition. Begun from neck and shoulders then proceed over the entire back. 4. Massage with both hands working with a strong stroke. In upward than in downward motions. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be used.) 5. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes. 6. Turn patient on his back and put on camisa or gown. 7. Fix and make patient comfortable.

Movements Used 1. Effleurage (strokingis a long sweeping movement with palm of hand conforming to the contour of the surface treated, over small surface (on the neck) the thumb and fingers are used. Strokes should be slow, rhythmical and gentle with pressure constant and in the direction of venous stream. 2. Kneadingperformed with the ulnar side palm resting on the surface and the fingers, and thumble grasping the skin and subcutaneous tissues which move with the hand of the operator. 3. Frictionis performed with the whole palmar surface of the hand or fingers and thumbs over limited areas. This movement is a circular from of kneading with pressure against the underlying part of tissue which cannot be grasped.

Blood Transfusion Therapy

Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction o consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII). Blood components include:

1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one un carrying capacity of blood with minimal expansion of blood. 2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic 3. Platelets, either HLA (human leukocyte antigen) matched or unmatched. 4. Granulocytes ( basophils, eosinophils, and neutrophils ) 5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors). 6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; th anticoagulation. 7. Albumin, a plasma protein. 8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.

9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-dry 10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-d 11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy 1. Avoids the risk of sensitizing the patients to other blood components. 2. Provides optimal therapeutic benefit while reducing risk of volume overload. 3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy

1. Whole blood transfusion o Generally indicated only for patients who need both increased oxygen-carrying capacity and resto obtain the specific blood components needed. 2. Packed RBCs o Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 ho into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of 1%, hemactocrit 3%. 3. Platelets o Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets s 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous tra destruction, and hypertension. 4. Granulocytes o May be beneficial in selected population of infected, severely granulocytopenic patients (less than expected to experienced prolonged suppressed granulocyte production. 5. Plasma o Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion i solutions (e.g., Ringers lactate) are preferred. Fresh frozen plasma should be administered as rapi unstable after thawing. 6. Albumin o Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circ large protein molecule is a major contributor to plasma oncotic pressure. 7. Cryoprecipitate o Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated intravascular co 8. Factor IX concentrate o Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling 9. Factor VIII concentrate o Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and H 10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Objectives

1. To increase circulating blood volume after surgery, trauma, or hemorrhage 2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia 3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

Nursing Interventions 1. 2. 3. 4. 5. Verify doctors order. Inform the client and explain the purpose of the procedure. Check for cross matching and typing. To ensure compatibility Obtain and record baseline vital signs Practice strict Asepsis At least 2 licensed nurse check the label of the blood transfusion o Check the following:

Serial number Blood component Blood type Rh factor Expiration date Screening test (VDRL, HBsAg, malarial smear) - *this is to ensure that the blood is free fr transfusion. 6. Warm blood at room temperature before transfusion to prevent chills. 7. Identify client properly. Two Nurses check the clients identification. 8. Use needle gauge 18 to 19. This allows easy flow of blood. 9. Use BT set with special micron mesh filter. To prevent administration of blood clots and particles. 10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occ 11. Monitor vital signs. Altered vital signs indicate adverse reaction. 12. Do not mix medications with blood transfusion. To prevent adverse effects o Do not incorporate medication into the blood transfusion o Do not use blood transfusion lines for IV push of medication. 13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose cau 14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse q 15. Observe for potential complications. Notify physician.

Complications of Blood Transfusion

1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with rec o Assessments: Flushing Rush, hives Pruritus Laryngeal edema, difficulty of breathing 2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma protei transfusion o Assessments: Sudden chills and fever Flushing Headache Anxiety 3. Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria. o Assessment: Rapid onset of chills Vomiting Marked Hypotension High fever 4. Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulato o Assessment: Rise in venous pressure

Dyspnea Crackles or rales Distended neck vein Cough Elevated BP 5. Hemolytic reaction. It is caused by infusion of incompatible blood products. o Assessment: Low back pain (first sign). This is due to inflammatory response of the kidneys to incompa Chills Feeling of fullness Tachycardia Flushing Tachypnea Hypotension Bleeding Vascular collapse Acute renal failure

Assessment findings 1. Clinical manifestations of transfusions complications vary depending on the precipitating factor. 2. Signs and symptoms of hemolytic transfusion reaction include: o Fever o Chills o low back pain o flank pain o headache o nausea o flushing o tachycardia o tachypnea o hypotension o hemoglobinuria (cola-colored urine) 3. Clinical signs and laboratory findings in delayed hemolytic reaction include: o fever o mild jaundice o gradual fall of hemoglobin o positive Coombs test 4. Febrile non-hemolytic reaction is marked by: o Temperature rise during or shortly after transfusion o Chills o headache o flushing

anxiety 5. Signs and symptoms of septic reaction include; o Rapid onset of high fever and chills o vomiting o diarrhea o marked hypotension 6. Allergic reactions may produce: o hives o generalized pruritus o wheezing or anaphylaxis (rarely) 7. Signs and symptoms of circulatory overload include: o Dyspnea o cough o rales o jugular vein distention 8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, d 9. Characteristics of GVH disease include: o skin changes (e.g. erythema, ulcerations, scaling) o edema o hair loss o hemolytic anemia 10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis 1. Ineffective breathing pattern 2. Decreased Cardiac Output 3. Fluid Volume Deficit 4. Fluid Volume Excess 5. Impaired Gas Exchange 6. Hyperthermia 7. Hypothermia 8. High Risk for Infection 9. High Risk for Injury 10. Pain 11. Impaired Skin Integrity 12. Altered Tissue Perfusion

Planning and Implementation 1. Help prevent transfusion reaction by:

Meticulously verifying patient identification beginning with type and cross match sample collectio identification prior to transfusion. o Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administratio o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly duri within 15 minutes after the start of transfusion). o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk o o Preventing infectious disease transmission through careful donor screening or performing pretest a o Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs (i.e., before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide. o Preventing hypothermia by warming blood unit to 37 C before transfusion. o Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate fi aggregates during transfusion. 2. On detecting any signs or symptoms of reaction: o Stop the transfusion immediately, and notify the physician. o Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for po o Send the blood bag and tubing to the blood bank for repeat typing and culture. o Draw another blood sample for plasma hemoglobin, culture, and retyping. o Collect a urine sample as soon as possible for hemoglobin determination. 3. Intervene as appropriate to address symptoms of the specific reaction: o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure asso o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocy subsequent transfusions. o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors o Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicat manifestation, transfusion can sometimes continue but at a slower rate.) o For circulatory overload, immediate treatment includes positioning the patient upright with feet de prescribed.

Nursing Interventions when complications occurs in Blood transfusion 1. 2. 3. 4. 5. 6. 7. 8.

If blood transfusion reaction occurs. STOP THE TRANSFUSION. Start IV line (0.9% Na Cl) Place the client in fowlers position if with SOB and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as e Notify the physician immediately. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroid Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RB Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory fo

Evaluation

1. 2. 3. 4. 5. 6. 7. 8.

The patient maintains normal breathing pattern. The patient demonstrates adequate cardiac output. The patient reports minimal or no discomfort. The patient maintains good fluid balance. The patient remains normothermic. The patient remains free of infection. The patient maintains good skin integrity, with no lesions or pruritus. The patient maintains or returns to normal electrolyte and blood chemistry values.

Bowel Elimination
The Large Intestine

Primary organ of bowel elimination Extends from the ileocecal valve to the anus

Functions

Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L) Manufacture of some vitamins Formation of feces Expulsion of feces from the body

The Small and Large Intestines Process of Peristalsis

Peristalsis is under control of nervous system Contractions occur every 3 to 12 minutes Mass peristalsis sweeps occur 1 to 4 times each 24-hour period One-third to one-half of food waste is excreted in stool within 24 hours

Peristalic Movements in the Intestine Colonic peristalsis is slow. Mass peristalsis is strong, few waves per da

Factors that influence Bowel Elimination 1. 2. 3. 4. Age Diet Position Pregnancy

5. Fluid Intake 6. Activity 7. Psychological 8. Personal Habits 9. Pain 10. Medications 11. Surgery/Anesthesia

Developmental Considerations

Infantscharacteristics of stool and frequency depend on formula or breast feedings Toddler physiologic maturity is first priority for bowel training (1 2 yrs) Child, adolescent, adultdefecation patterns vary in quantity, frequency, and rhythmicity Older adultconstipation is often a chronic problem

Foods Affecting Bowel Elimination

Constipating foods cheese, lean meat, eggs, & pasta Foods with laxative effectfruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foodsonions, cabbage, beans, cauliflower

Effect of Medications on Stool

Aspirin, anticoagulants pink, red, or black stool Iron saltsblack stool Antacids white discoloration or speckling in stool Antibioticsgreen-gray color

Physical Assessment of the Abdomen

Inspectionobserve contour, any masses, scars, or distension Auscultationlisten for bowel sounds in all quadrants Note frequency and character, audible clicks, and flatus Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussionexpect resonant sou Areas of increased dullness may be caused by fluid, a mass, or tumor Palpationnote any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

Inspection and palpation

Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection

Medical aseptic technique is imperative Wear disposable gloves Wash hands before and after glove use Do not contaminate outside of container with stool Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

Void first so urine is not in stool sample Defecate into the container rather than toilet bowl Do not place toilet tissue in bedpan or specimen container Notify nurse when specimen is available get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

Esophagogastroduodenoscopy (EGD) Colonoscopy Sigmoidoscopy Wireless capsule endoscopy

Indirect Visualization Studies

Upper gastrointestinal (UGI) Small bowel series Barium enema

Scheduling Diagnostic Tests

1 fecal occult blood test 2 barium studies (should precede UGI) make sure ALL barium is removed* 3 endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

Patient has a soft-formed bowel movement every 1-3 days without discomfort The relationship between bowel elimination and diet, fluid, and exercise is explained Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

Timing -attend to urges promptly Positioning have pt. sit up, gravity aids in BM Privacy close door & pull curtain Nutrition Exercise abdominal muscles & thighs Abdominal settings Thigh strengthening

Individuals at High Risk for Constipation

Patients Patients Patients Patients

on bed rest taking constipating medications with reduced fluids or bulk in their diet who are depressed with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) intrathoracic / intracranial pressure possible brain injur

Nursing Measures for the Patient With Diarrhea

Answer call lights immediately Remove the cause of diarrhea whenever possible (e.g., medication) If there is impaction, obtain physician order for rectal examination Give special care to the region around the anus After diarrhea stops, suggest the intake of fermented dairy products Fecal seepage may indicate impaction

Preventing Food Poisoning

Never buy food with damaged packaging Never use raw eggs in any form Do not eat ground meat uncooked Never cut meat on a wooden surface Do not eat seafood that is raw or has unpleasant odor Clean all vegetables and fruits before eating Refrigerate leftovers within 2 hours of eating them Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

Enemas Rectal suppositories Rectal catheters Digital removal of stool

Types of Enemas Cleansing high volume Retention - oil Return-flow bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

Oil-retentionlubricate the stool and intestinal mucosa easing defecation Carminativehelp expel flatus from rectum Medicatedprovide medications absorbed through rectal mucosa Anthelminticdestroy intestinal parasites Nutritiveadminister fluids and nutrition rectally

Bowel Training Programs

Manipulate factors within the patient's control Food and fluid intake, exercise, time for defecation Eliminate a soft, formed stool at regular intervals without laxatives When achieved, discontinue use of suppository if one was used

Types of Colostomies each has different stool consistency

Sigmoid colostomy Descending colostomy Transverse colostomy Ascending colostomy Ileostomy

Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy Location of an Ileostomy

Colostomy Care
Keep patient as free of odors as possible; empty appliance frequently Inspect the patient's stoma regularly Note the size, which should stabilize within 6 to 8 weeks Keep the skin around the stoma site clean and dry Measure the patient's fluid intake & output Explain each aspect of care to the patient and self-care role Encourage patient to care for and look at ostomy

Normal-Appearing Stoma
Patient Teaching for Colostomies

Community resources are available for assistance

Initially encourage patients to avoid foods high in fiber Avoid foods that cause diarrhea or flatus Drink two quarts of water daily Teach about medications Teach about odor control (intake of dark green vegetables helps control odor) Resume normal activity including work and sexual relations

Comfort Measures

Encourage recommended diet and exercise Use medications only as needed Apply ointments or astringent (witch hazel) Use suppositories that contain anesthetics

Characteristics of Normal Stool

1. 2. 3. 4. 5.

Color varies from light to dark brown foods & medications may affect color Odor aromatic, affected by ingested food and persons bacterial flora Consistency formed, soft, semi-solid; moist Frequency varies with diet (about 100 to 400 g/day) Constituents small amount of undigested roughage, sloughed dead bacteria and epithelial cells, f pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

1. Constipation abnormal frequency of defecation and abnormal hardening of stools 2. Impaction accumulated mass of dry feces that cannot be expelled 3. Diarrhea increased frequency of bowel movements (more than 3 times a day) as well as liquid co urgency, discomfort and possibly incontinence 4. Incontinence involuntary elimination of feces 5. Flatulence expulsion of gas from the rectum 6. Hemorrhoids dilated portions of veins in the anal canal causing itching and pain and bright red b

Care of the Dead

I. Purpose 1. To prepare the body for the morgue.

2. To prevent discoloration or deformity of the body. 3. To protect the body from post mortom discharge.

II. Equipments Tray with:

Basin of warm water, a basin of lysol solution 2% Soap in dish, pair of scissors, comb or brush Bath towel and wash cloth Surgical dressings p.r.n. Mortuary pack: should, diaper sheet 2 death tags, non-absorbent cotton, pins, bandages, forceps. Bed screen

III. Points to Remember 1. Respect the dead body. Avoid unnecessary exposure and irrelevant conversations. 2. The body should be identified properly. 3. Clothings, jewelry and other valuables or belongings must be kept and cared for properly.

IV. Procedure

1. The patient has pronounced dead by the doctor, place the body in dorsal position with only a small pillow 2. See that dentures are placed in the mouth if patient has any 3. Remove all appliances; catheters, drainage tubings, Venoclysis sets, etc. 4. Close the eves and mouth when open. 5. Eyesbring upper lid down to the lower and apply gentle pressure over it for a while. 6. Mouthbring the jaws together by placing a rolled towel under the chin. 7. Remove extra bed linen and camisa. Leave one sheet to cover the body. 8. Bathe the body using the Lysol solution to rinse. 9. Change surgical dressings p.r.n. Pack anus with cotton. Vagina (if female). If there is any discharge from 10. Place the diaper. 11. Full hands over the chest. Pad wrists with cotton and the tie the 2 wrists together with bandage. Attach on 12. Pad the ankles and tie them together. 13. Put on the shroud. Wrap body with a sheet well. Attach the other tag at the center 14. Cover the prepared body with a sheet and notify the head nurse or call for the messenger to take the body

Caring

Definition

Central to all helping professions, and enables persons to create meaning in their lives. Means that people, relationships, and things matter

Nursing Theories of Caring Culture Care Diversity and Universality Theory (Leininger)

Based on transcultural nursing model Transcultural nursing: a learned branch of nursing that focuses on the comparative study & analysis of beliefs, and values Goal of Transcultural Nursing: to provide care that is congruent with cultural values, beliefs, and practi Cultures exhibit both diversity and universality Diversity - perceiving, knowing, and practicing care in different ways Universality - commonalities of care Fundamental Theory Aspects - culture, care, cultural care, world view, folk health or well-being system

Theory of Bureaucratic Caring (Ray)

Rays theory focuses on caring in organizations (e.g. hospital) as cultures. The theory suggests that caring organizational structure. Example: ICU had a dominant value of technological caring (i.e., monitors, ventilators, treatments), Onco (i.e., family focused, comforting, compassionate). Furthermore, the meaning of caring was further influen valued caring in terms of its relatedness to client, while administrator valued caring as system related. Spiritual ethical caring influences each of the aspects of the bureaucratic system (political, legal, econom technological)

Caring, the Human Mode of Being (Roach)

Caring is the human mode of being, proposes that all persons are caring, and develop their caring abilities Develop the Six Cs of Caring in Nursing:

Six Cs of Caring in Nursing Compassion

Awareness of ones relationship to others, sharing their joys, sorrows, pain, and accomplishments. Partici

Competence

Having the knowledge, judgment, skills, energy, experience, and motivation to respond adequately to oth

Confidence

The quality that fosters trusting relationships. Comfort with self, client, and family.

Conscience

Morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility.

Commitment

Convergence between ones desires and obligations and the deliberate choice to act in accordance with th

Comportment

Appropriate bearing, demeanor, dress, and language, that is in harmony with a caring presence. Presentin respect.

Nursing as Caring (Boykin and Schoenhofer)

Suggests that the purpose of the discipline and profession of nursing is to know persons and nurture them Similar to Roach idea that all persons are caring. Caring in nursing is an altruistic, active expression of love, and is the intentional and embodied recognit

Theory of Human Care (Watson)

Human caring in nursing is not just an emotion, concern, attitude, or benevolent desire. Caring is a moral enhancement, and preservation of human dignity.

Theory of Caring (Swanson)

Caring involves 5 processes: Definition Striving to understand an event as it has meaning in life of the other Sub dimensions
Avoiding assumptions Centering on the one cared Assessing thoroughly Seeing cues Engaging the self of both Being there Conveying ability Sharing feelings Not burdening Comforting Anticipating Performing Competently/skillful Protecting Preserving dignity Informing/explaining Supporting/allowing Focusing Generating Alternative/thinking it through Validating/giving feedback Believing in/ holding in esteem Maintaining a hope-filled attitude Offering realistic optimism Going the distance

Process Knowing

Being With

Being emotionally present to other

Doing For

Doing for the other as he/she would do for the self if it were at all possible

Enabling

Facilitating the others passage through life transitions and unfamiliar events

Maintaining belief

Sustaining faith in the others capacity to get through an event or transition and face a future meaning

The Primacy of Caring (Benner and Wrubel)

Caring is central to the essence of nursing. Caring creates the possibilities for coping and creates possibili

Caring for Self

Caring for self means taking the time to nurture oneself. This involves initiating and maintaining behaviors that p

A balanced diet Regular exercise Adequate rest and sleep Recreational Activities Meditation and prayer

Changing a Central Line Catheter Dressing

Sample Central Line Dressing Checklist
Critical Performance Elements YES 1. Gather all necessary equipment: roll of tape, label, and central line line dressing kit. 2. Wash hands. Explain procedure to the patient and/or significant others. Check for providone-iodine or tape allergy. 3. Organize supplies and equipment at bedside to decrease the amount of time that site is open to air. 4. *** Open central line kit. Don mask. (Don gown if soiling is likely). 5. Place patient in supine position with head turned away from catheter insertion site to decrease potential for contamination by patients secretions. Place a mask over the patients mouth and nose or sterile drape over ventilated or trached patient. 6. *** Don a pair of clean gloves. 7. Remove present dressing carefully to minimize trauma and prevent accidental dislodgment of catheter. Discard soiled dressing in proper trash receptacle. 8. Visually inspect the skin and catheter site for signs of infection, leakage, or other mechanical problems. 9. *** Remove soiled gloves and don sterile gloves. 10. *** Working in a circular motion from insertion site outward to edge of dressing border cleanse skin, insertion site, and distal portion of catheter with : a. Providone-iodine scrub swabsticks x 3 to remove bacteria and fungi. b. Alcohol swabsticks x 3 to remove the betadine scrub. c. Betadine solution swabsticks x 3 to cover a 3 x 6 area from site to periphery- to provide protective barrier against pathogens. Blot excess or NO

pooled solution. Allow to dry. *** For patients with IODINE ALLERGY- If 4% chlorhexidine is used, remove it with alcohol swabs after a two to five minute dwell time. 11. If a tubing change is necessary: a. Instruct the patient to perform Valsalva maneuver or hold his/her breath (or immediately after a ventilator delivers a breath). b. Quickly disconnect and reconnect the IV tubing ensuring secure junction. 12. *** Dressing- may use elastoplast or occlusive dressing as follows: a. Elastoplast:

place folded 22 over insertion site to include sutures to prevent the tape/ elastoplast from sticking to the line and sutures. paint around the edges of the gauze with skin prep and allow to dry. cut elastoplast to fit over insertion site and sutures. apply elastoplast and secure edges with tape.

b. Occlusive Dressing- (Tegaderm):

do not use 22 skin prep is optional apply occlusive dressing according to manufacturers guidelines.

13. *** Loop and secure IV tubing to dressing and arm or chest. 14. *** Label dressing with time, date of dressing change and insertion, and initials. 15. Discard supplies used. Wash hands. 17. *** Document the dressing change, the condition of the insertion site on nursing note and flow sheet. Document any problems encountered in nursing progress notes on. NOTE: If 22 gauze used after initial insertion under occlusive (Tegaderm) dressing, dressing must be changed in 24 hours.
*** Must perform these critical elements for successful completion.

Changing and flushing a central line access cap

Check clients chart and care plan to determine time of last access cap change.

Identify client Explain procedure to client and provide privacy Gather equipment Wash your hand and don gloves Repeat procedure with the remaining access caps Remove gloves and wash hands

Changing a Hospital Gown for a Client with an Intravenous Infusion

1. Slip the growth completely off the arm without the infusion and onto the tubing connected to the arm wi

2. Holding the container above the clients arm, slide the sleeve up over the container to rem ove the used g

3. Place the clean gown sleeve for the arm with the infusion over the container as if it were an extension of sleeve cuff. 4. Rehang the container. Slide the gown carefully over the tu bing toward the clients hand. 5. Guide the clients arm and tubing into the sleeve, taking care not to pull on the tubing. 6. Assist the client to put the other arm into the second sleeve of the gown, and fasten as usual.

7. Count the rate of flow of the infusion to make sure it is correct before leaving the bedside.

Changing Mainline IV Bag

Check physicians order. Wash Hands. Select correct solution (using 5 rights of drug administration). Remove outer wrap. Inspect bag carefully for tears or leaks by applying gentle pressure to the bag. Hold the bag up and examine for cloudiness, discoloration, or any foreign matter. Label bag with patients name, date, time or according to agency policy. Tape bag based on hourly flow rate and initial. Identify patient, explain procedure and asses IV site. Asses IV site again. Discard old bag according to agency policy Record I&O and IV solution according to agency policy.

Changing the Position of the Patient

I. In Dorsal Recumbent Position:

1. Arrange the pillows in the order to support the weight of the shoulders and head. 2. Relieve strain on the muscles of the back by supporting it, fill in the hollows with small pillows, small pa 3. Relieve strain on the abdominal muscles and on tendons under the knees. Support with the knee rest prov

II. Turning to One Side: A. To turn the patient toward you:

1. Move the patient to the side of the bed away from you by putting your forearms under the body then slidi across the bed. 2. Place one of your arms across the patients back reaching from the far side to the side nearer you and the 3. Lift and turn him gently toward you to the middle of the bed. 4. See that the head, shoulders and hips are properly adjusted, that the neck and shoulders are not cramped a 5. Flex the knees with the upper leg flexed a little more than the lower leg. 6. Support the legs by placing a pad or small pillow between them. 7. Support the whole length of the back with pillows so that the patient can relax comfortably.

8. A small pillow placed against the abdomen gives relief and comfort especially when the patient is sufferin B. To turn patient away from you:

1. From the side nearest you, slip one arm under the patients shoulder reaching the far shoulder and place th 2. Lift and draw his far side slightly toward you so that he is gradually turned away from you.

Charting
Purpose of Charting: To make record of 1. The significant observation of the patients condition both mental and physical. 2. The medication, treatment, diets and nursing care given and the reaction of the patient to this care. 3. The incident which might have some bearing on the patients condition.

General Rules for Charting: 1. All recording on the chart must be printed, except the written signature of the nurse. 2. The written signature of the nurse should consist of her initial of first name and fill last name. (a) The signature should stand alone on the line just below the notations recorded by her.

(b) The signature of the nurse should be of a size that will insure legibility without attracting attention. 3. A nurse making a series of statements or notations signs for the series and not for each individual stateme 4. The nurse should not go off duty without making the necessary notations on the charts of each patient a 5. All recording on the chart should be neat, legible, intelligent and meaningful. 6. Statements must be accurate, relevant and concise. (a) Terse statements instead of complete sentence are used. (b) Correct spelling and only acceptable and official abbreviations are to be used. 7. Authentic recording is essential as a chart often plays an important part in the presentation of court eviden 8. Print the proper headings for all new pages or sheets to be added to the chart using blue or black ink. 9. Keep all recordings within limits provided by the pale. Begin each separate notation on the horizontal line 10. Do not use ornamental lettering for recording on the chart. 11. Blue or black ink should be used for recording between the hours of 7:00am to 11:00pm. 12. Red ink should be used for recording between the hours of 11:00pm to 7:00am. 13. The midnight lines are to be drawn in red ink. Write the date and the day of the new day between the mid 14. In the hour column, record the time of treatment, medication, appearance of symptoms, doctors visit, etc 15. In the observations column: (a) Record any of all symptoms, complaints or change in the condition of the patient. (b) Record all start and p.r.n. treatments and medications given. (c) Record the results and effects of the medications and treatments. (d) Record routine nursing procedures involved in the care of the patient. (e) Record each time the attending physician visits the patient. 16. Never print the word patient when charting. The chart in itself is a record for the individual patient and al kept. 17. Do not write the orders of the doctor as Dr. Smith ordered backrest elevated two inches. 18. Arrange the different sheets on the chart in correct order. 19. Errors in charting: (a) Do not erase errors made in charting (b) When an error has been made, draw a line through the error from the upper left hand corner to the low containing the error and write the word ERROR under which the nurse signs her name. (c) An error in charting should not necessarily invoke recopying of the entire page. Consult the superviso made an error. It is necessary to recopy, the original page must be filed at the back of the chart.

General Rules for Printing: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Printing is the most consistently legible of all forms of writing for that reason should be used for recordin Print well formed, individual letters in each ward. Properly space all printed letters and words. Do not use more than one space for each letter, regardless of the shape of that letter. Separate printed words by a space the size of single letter. Do not use unnecessary curves tails or fancy strokes in making the printed letters. Make all printed letters stand erect. To avoid illegibility, do not make too much of a forward backward slant to the letters. Make all printed letters conform in appearance to those in the sample alphabet.

10. Make each printed letter rest on the line. 11. Always make the small letter 2/3 the height of capital ones. 12. Make the letter U curved at the bottom, make the letter V with art acute angle at the bottom. 13. Cross the letter t, horizontally at the upper third of its height. 14. Make the use of the word bed to remember on which side of the stem to make the loop for the letters b 15. For practice in printing use only those letters which are illustrated in the sample alphabet. 16. Print numbers that are to be used in charting as well as letters.

Example of Data to be Charted:

1. All doctors orders. (a) Medicines given, the time at which they are, and when, used to relieve a condition that should respond to trea (b) Inspections, or punctures done, time result, and by whom. (c) Treatment given, time and effect on patients condition during or after the treatment, or results of flow in case (d) Operation delivery, kinds, time, TPR after. 2. When recording the dressing of wound, state condition of the letter, if there is discharge, mention and change i 3. Symptoms a. Subjective b. Objectives: (b1)All conditions that call for particularly careful attention to their record e.g. following surgical operation or X accidents, chills, convulsions and when patient is very ill. (b2)Menstruation. (b3)Nature of excreta or order discharges, etc. 4. Amount of sleep. 5. Appetite and amount of food taken.

Cleaning Bedpans and Urinals

I. Equipment: 1. 2. 3. 4. 5. Tray with bedpan brush, bedpan swab Short-sleeved gown Can of disinfectant solution Soap or any cleanser Several pieces of dusting cloth

II. Procedure for Cleaning Bedpans and Urinals 1. 2. 3. 4. 5. 6. 7.

Put on the short-sleeved gown Collect the bedpans Empty the contents one by one into the hoper. Wash with clean cold water. Use brush p.r.n. Follow with h Put the bedpan in the scan of disinfectant Remove after, wash inside and outside with warm soapy water. Remove any stains using the cleanser Rinse with hot water Wipe to dry with the bedpan wiper and hang it at the bedpan rack.

Cleaning Sputum Cups

I. Equipment:

Tray with big basin of disinfectant solution. Creosol solution 5%. Medicine glass A pitcher of 1% creosol solution Sputum cup brush Several pieces of dusting cloth

Sapolio or Cleanser Short-sleeved gown

II. Procedure:

1. 2. 3. 4. 5. 6. 7. 8.

Put on the gown. Collect all the sputum cups in a tray. Empty their contents into the hopper. Wash with cold water. Rinse with hot water. Use brush p.r.n. Place cup in basin of disinfectant solution of 5% Creosol solution for 2 hours. Remove after, clean inside and out with soapy warm water. Remove stains. Rinse with hot water and dry the outside. Fill each sputum cup with 50 cc of 1% of Creosol solution and place in the trays, distribute back to each p For children and delirious patients, do not put Creosol solution inside their sputum cups.

Communication
Definition

It is the process of exchanging information or feelings between two or more people. It is a basic compone

The Communication process Referent

Or stimulus motivates a person to communicate with another. It may be an object, emotion, idea or act.

Sender

Also called the encoder, is the person who initiates the interpersonal communication or message

Message

The information that is sent or expressed by the sender.

Channels

It means, conveying messages such as through visual, auditory and tactile senses.

Receiver

Also called the decoder, is the person to whom the message is sent

Feedback

Helps to reveal whether the meaning of the message is received

Modes of Communication Verbal communication- uses the spoken or written word 1. Pace and Intonation

The manner of speech, as in the pace or rhythm and intonation, will modify the feeling and impact of the excited client may help calm the client.

2. Simplicity

Includes the use of commonly understood words, brevity, and completeness. Nurses need to learn to select appropriate, understandable terms based on the age, knowledge, culture and client, the nurses will be catheterizing you tomorrow for a urinalysis, I would be more appropriate to sa will collect it by putting a small tube into your bladder.

3. Clarity and Brevity

A message that is direct and simple will be more effective. Clarity is saying precisely what is meant, and The goal is to communicate clearly so that all aspects of a situation or circumstances are understood. To e slowly and enunciate carefully.

4. Timing and Relevance

No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure This involves sensitivity to the clients needs and concerns. E.g., a client who is enmeshed in fear of canc procedures before and after gallbladder surgery.

5. Adaptability

What the nurse says and how it is said must be individualized and carefully considered. E.g., a nurse who an enthusiastic Hi, Mrs. Jones! notices that the client is not smiling and appears distressed. It is importa

express concern in his facial expression while moving toward the client. 6. Credibility

Means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility by being consistent, Nurses should convey confidence and certainly in what they are saying, while being to acknowledge their find someone who does.

7. Humor

The use of humor can be a positive and powerful tool in nurse- client relationship, but it must be used wit clients perception of what is considered humorous.

Non-verbal Communication- uses other forms, such as gestures or facial expressions, and touch. 1. Personal Appearance

When the symbolic meaning of an object is unfamiliar the nurse can inquire about its significance, which How a person dresses is often an indicator of how person feels. E.g. For acutely ill clients n hospital or ho that the client is feeling better. A man may request a shave, or a woman may request a shampoo and some

2. Posture and Gait

The ways people walk and carry themselves are often reliable indicators of self-concept, current mood, an suggest a feeling of well being. Slouched posture and slow, shuffling gait suggest depression or physical The nurse clarifies the meaning of the observed behavior, e.g. You look like it really hurts you to move. something to make you more comfortable?

3. Facial Expression

No part of the body is as expressive as the face Although he face may express the persons genuine emotions, it is also possible to control these muscles feeling. When the message is not clear, it is important to get feedback to be sure of the intent of expressio Nurses need to be aware of their own expressions and what they are communicating to others. It is impos to control expressions of feelings such as fear or disgust in some circumstances. Eye contact is another essential element of facial communication

4. Gesture

Hand and body gestures may emphasize and clarify the spoken word, or they may occur without words to

Electronic Communication- many health care agencies are moving toward electronic medical records where nu E-mail

Most common form of electronic communication. Advantage: It is fast, efficient way to communicate and it is legible. It provides a record of the date and ti Disadvantage: risk of confidentiality When Not to Use Email:

a. When information is urgent b. Highly confidential information (e.g. HIV status, mental health, chemical dependency) c. Abnormal lab data

Agencies usually develop standards and guidelines in use of e-mail

Factors Influencing the Communication Process 1. Development

Language, psychosocial, and intellectual development move through stages across the lifespan.

2. Gender

Girls tend to use language to seek confirmation, minimize differences, and establish intimacy. Boys use la within a group.

3. Values and Perception

Values are the standards that influence behavior, and perceptions are the personal view of event.

4. Personal Space

Personal space is the distance people prefer in interactions with others. Proxemics is the study of distance between people in their interactions Communication 4 distances:

a. Intimate: Touching to 1 b. Personal: 1 to 4 feet c. Social: 4 to 12 feet d. Public: 12 to 15 feet 5. Territoriality

Is a concept of the space and things that an individual considers as belonging to the self

6. Roles and Relationships

Choice of words, sentence structure, and tone of voice vary considerably from role to role. (E.g. nursing s parent and child).

7. Environment

People usually communicate most effectively in a comfortable environment.

8. Congruence

The verbal and nonverbal aspects of message match. E.g., when teaching a client how to care for a colost with this. However, if the nurse looks worried or disgusted while saying this, the client is less likely to tr

9. Interpersonal Attitudes

Attitudes convey beliefs, thoughts, and feelings about people and events. Caring and warmth convey a feeling of emotional closeness Respect is an attitude that emphasizes the other persons worth and individuality. A nurse coveys respect disagrees.Acceptance emphasizes neither approval nor disapproval .The nurse willingly receives the clien

Communication in Nursing
Communication 1. 2. 3. 4.

Is the means to establish a helping-healing relationship. All behavior communication influences behavior Communication is essential to the nurse-patient relationship for the following reasons: Is the vehicle for establishing a therapeutic relationship. It the means by which an individual influences the behavior of another, which leads to the successful outc

Basic Elements of the Communication Process 1. 2. 3. 4.

Sender is the person who encodes and delivers the message Messages is the content of the communication. It may contain verbal, nonverbal, and symbolic languag Receiver is the person who receives the decodes the message. Feedback is the message returned by the receiver. It indicates whether the meaning of the senders mes

Modes of Communication 1. Verbal Communication use of spoken or written words.

2. Nonverbal Communication use of gestures, facial expressions, posture/gait, body movements, physica

Characteristics of Good Communication

1. Simplicity includes uses of commonly understood, brevity, and completeness. 2. Clarity involves saying what is meant. The nurse should also need to speak slowly and enunciate word 3. Timing and Relevance requires choice of appropriate time and consideration of the clients interest an answer before making another comment. 4. Adaptability Involves adjustments on what the nurse says and how it is said depending on the moods a 5. Credibility Means worthiness of belief. To become credible, the nurse requires adequate knowledge ab provide accurate information, to convey confidence and certainly in what she says.

Communicating With Clients Who Have Special Needs 1. Clients who cannot speak clearly (aphasia, dysarthria, muteness)

a. Listen attentively, be patient, and do not interrupt. b. Ask simple question that require yes and no answers. c. Allow time for understanding and response. d. Use visual cues (e.g., words, pictures, and objects) e. Allow only one person to speak at a time. f. Do not shout or speak too loudly. g. Use communication aid:Pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm 2. Clients who are cognitively impaired a. Reduce environmental distractions while conversing. b. Get clients attention prior to speaking c. Use simple sentences and avoid long explanation. d. Ask one question at a time e. Allow time for client to respond f. Be an attentive listener g. Include family and friends in conversations, especially in subjects known to client. 3. Client who are unresponsive a. Call client by name during interactions b. Communicate both verbally and by touch c. Speak to client as though he or she could hear d. Explain all procedures and sensations e. Provide orientation to person, place, and time f. Avoid talking about client to others in his or her presence g. Avoid saying things client should not hear

4. Communicating with hearing impaired client a. Establish a method of communication (pen/pencil and paper, sign-language) b. Pay attention to clients non-verbal cues c. Decrease background noise such as television d. Always face the client when speaking e. It is also important to check the family as to how to communicate with the client f. It may be necessary to contact the appropriate department resource person for this type of disability 5. Client who do not speak English a. Speak to client in normal tone of voice (shouting may be interpreted as anger) b. Establish method for client o signal desire to communicate (call light or bell) c. Provide an interpreter (translator) as needed d. Avoid using family members, especially children, as interpreters. e. Develop communication board, pictures or cards. f. Have dictionary (English/Spanish) available if client can read.

Reports

Are oral, written, or audiotape exchanges of information between caregivers.

Common reports 1. Change-in-shift report 2. Telephone report 3. Telephone or verbal orders only RNs are allowed to accept telephone orders. 4. Transfer report 5. Incident report

Documentation

1. Is anything written or printed that is relied on as record or proof for authorized person. 2. Nursing documentation must be: o accurate o comprehensive o flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and ref 3. Effective documentation ensures continuity of care saves time and minimizes the risk of error. 4. As members of the health care team, nurses need to communicate information about clients accurately an 5. If the care plan is not communicated to all members of the health care team, care can become fragmented omitted. 6. Data recorded, reported, or communicated to other health care professionals are CONFIDENTIAL and m

Confidentiality 1. 2. 3. 4. 5. 6.

Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients Only staff directly involved in a specific clients care has legitimate access to the record. Clients frequently request copies of their medical record, and they have the right to read those records. Nurses are responsible for protecting records from all unauthorized readers. When nurses and other health care professionals have a legitimate reason to use records for data gathering authorization must be obtained according to agency policy. 7. Maintaining confidentiality is an important aspect of profession behavior. 8. It is essential that the nurse safe-guard the client right to privacy by carefully protecting information of a 9. Sharing personal information or gossiping about others violates nursing ethical codes and practice standa 10. It sends the message that the nurse cannot be trusted and damages the interpersonal relationships.

Guidelines of Quality Documentation and Reporting 1. Factual

a. A record must contain descriptive, objective information about what a nurse sees, hears, feels, and smells. b. The use of vague terms, such as appears, seems, and apparently, is not acceptable because these words suggest Example: The client seems anxious (the phrase seems anxious is a conclusion without supported facts.) 2. Accurate

a. The use of exact measurements establishes accuracy. (example: Intake of 350 ml of water is more accurate t b. Documentation of concise data is clear and easy to understand. c. It is essential to avoid the use of unnecessary words and irrelevant details 3. Complete a. The information within a recorded entry or a report needs to be complete, containing appropriate and

Example: The client verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 1 rates pain as 8 on a scale of 0-10. 4. Current

a. Timely entries are essential in the clients ongoing care. To increase accuracy and decrease unnecessary duplic clients bedside, which facilitate immediate documentation of information as it is collected from a client 5. Organized

a. The nurse communicates information in a logical order.

Example: An organized note describes the clients pain, nurses assessment, nurses interventions, and the clients respons

Legal Guidelines for Recording

1. Draw single line through error, write word error above it and sign your name or initials. Then record note 2. Do not write retaliatory or critical comments about the client or care by other health care professionals. o Enter only objective descriptions of clients behavior; clients comments should be quoted. 3. Correct all errors promptly o Errors in recording can lead to errors in treatment o Avoid rushing to complete charting, be sure information is accurate. 4. Do not leave blank spaces in nurses notes. o Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your na 5. Record all entries legibly and in blank ink o Never use pencil, felt pen. o Blank ink is more legible when records are photocopied or transferred to microfilm. o Legal Guidelines for Recording 6. If order is questioned, record that clarification was sought. o If you perform orders known to be incorrect, you are just as liable for prosecution as the physician 7. Chart only for yourself o Never chart for someone else. o You are accountable for information you enter into chart. 8. Avoid using generalized, empty phrases such as status unchanged or had good day. o Begin each entry with time, and end with your signature and title. o Do not wait until end of shift to record important changes that occurred several hours earlier. Be s 9. For computer documentation keep your password to yourself. o Maintain security and confidentiality. o Once logged into the computer do not leave the computer screen unattended.

Diagnosis - Second Step in the Nursing Process

Definition

Is the 2nd step of the nursing process. the process of reasoning or the clinical act of identifying problems

Purpose

To identify health care needs and prepare a Nursing Diagnosis. To diagnose in nursing It means to analyze assessment information and derive meaning from this analysis.

Nursing Diagnosis

Is a statement of a clients potential or actual health problem resulting from analysis of data. Is a statement of clients potential or actual alterations/changes in his health status. A statement that describes a clients actual or potential health problems that a nurse can identify and for w health status, to reduce, eliminate or prevent alterations/changes. Is the problem statement that the nurse makes regarding a clients condition which she uses to communic It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health prob independent nursing interventions. o Analysis separation into components or the breaking down of the whole into its parts. o Synthesis the putting together of parts into whole

Three Activities in Diagnosing: 1. Data Analysis 2. Problem Identification 3. Formulation of Nursing Diagnosis

Characteristics of Nursing Diagnosis 1. 2. 3. 4. It states a clear and concise health problem. It is derived from existing evidences about the client. It is potentially amenable to nursing therapy. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE) 1. Problem statement/diagnostic label/definition = P 2. Etiology/related factors/causes = E 3. Defining characteristics/signs and symptoms = S

*Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis

1. Actual Nursing Diagnosis a client problem that is present at the time of the nursing assessment. It is based o Examples:

Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea. Disturbed Sleep Pattern r/t cough, fever and pain. Constipation r/t long term use of laxative. Ineffective airway clearance r/t to viscous secretions Noncompliance (Medication) r/t unknown etiology Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis Acute Pain (Chest) r/t cough 2nrdary to pneumonia Activity Intolerance r/t general weakness. Anxiety r/t difficulty of breathing & concerns over work

2. Potential Nursing diagnosis one in which evidence about a health problem is incomplete or unclear therefo factors are unknown but a problem is only considered possible to occur. Examples:

Possible nutritional deficit Possible low self-esteem r/t loss job Possible altered thought processes r/t unfamiliar surroundings

3. Risk Nursing diagnosis is a clinical judgment that a problem does not exist, therefore no S/S are present, bu problem is only is likely to develop unless nurse intervene or do something about it. No subjective or objective c be more vulnerable to the problem are the etiology of a risk nursing diagnosis. Examples:

Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. Risk for interrupted family processes r/t mothers illness & unavailability to provide child care. Risk for Constipation r/t inactivity and insufficient fluid intake Risk for infection r/t compromised immune system. Risk for injury r/t decreased vision after cataract surgery.

Formula in writing nursing diagnosis (PES or PE)

1. Actual nursing diagnosis = Patient problem + Etiology replace the (+) symbol with the words RELAT 2. Risk Nursing diagnosis = Problem + Risk Factors 3. Possible nursing diagnosis = Problem + Etiology Qualifiers words added to the diagnostic label/problem statement to gain additional meaning.

deficient - inadequate in amount, quality, degree, insufficient, incomplete impaired made worse, weakened, damaged, reduced, deteriorated decreased lesser in size, amount, degree ineffective not producing the desired effect

Activities during diagnosis: 1. 2. 3. 4. 5. 6.

Compare data against standards Cluster or group data Data analysis after comparing with standards Identify gaps and inconsistencies in data Determine the clients health problems, health risks, strengths Formulate Nursing Diagnosis prioritize nursing diagnosis based on what problem endangers the clients

Situation: Functional Health Pattern Activity/Exercise

Anna, 35 years of laundry woman seeks consultation at the Philippine General Hospital due to fever 2 day ako giniginaw, masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. laundry). She has 3 children she walks off to school everyday before she goes to work

Vital Signs

Temperature (T) =39.2C Respiratory Rate (RR) = 35 P = 96; with flush skin and warm to touch, teary ey

Nursing Diagnosis

Hyperthermia [related to (r/t)] environmental condition AMB T = 39C, flush skin, warm to touch, teary

Situation: Functional Health Pattern = Nutritional/Metabolic 1. 2. 3. 4. States, No appetite since having cough Has not eaten today; last fluids at noon today Has lost 8 lbs in past 2 weeks Nauseated x 2 days

Nursing Diagnosis

Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease p

Situation: Functional Health Pattern = Activity/Exercise

1. Difficulty sleeping because of cough 2. States, Cant breath lying down 3. Report pain on chest when coughing Nursing Diagnosis

Disturbed Sleep Pattern r/t a disease process, orthopnea and pain. Acute Pain (chest) r/t pathologic condit

Situation: Functional Health Pattern = Coping/Stress 1. 2. 3. 4. 5. Anxious State, I cant breath Facial muscles tense, trembling Expresses concern and worry over leaving daughter with neighbors Husband out of town, will be back next week.

Nursing Diagnosis

Anxiety r/t difficulty of breathing and concerns over parenting roles.

Diagnostic Tests
PPD test 1. Read result 48 72 hours after injection. 2. For HIV positive clients, in duration of 5 mm is considered positive

Bronchography 1. 2. 3. 4. Secure consent Check for allergies to seafood or iodine or anesthesia NPO 6-8 hours before the test NPO until gag reflex return to prevent aspiration

Thoracentesis (Aspiration of fluid in the pleural space.) 1. Secure consent, take V/S 2. Position upright leaning on over bed table 3. Avoid cough during insertion to prevent pleural perforation

4. Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity 5. Check for expectoration of blood. This indicate trauma and should be reported to MD immediately.

Holter Monitor 1. It is continuous ECG monitoring, over 24 hours period 2. The portable monitoring is called telemetry unit

Echocardiogram

1. Ultrasound to assess cardiac structure and mobility 2. Client should remain still, in supine position slightly turned to the left side, with HOB elevated 15-20 deg

Electrocardiography 1. 2. 3. 4.

If the patients skin is oily, scaly, or diaphoretic, rub the electrode with a dry 4x4 gauze to enhance electro If the area is excessively hairy, clip it Remove client`s jewelry, coins, belt or any metal Tell client to remain still during the procedure

Cardiac Catheterization

1. Secure consent 2. Assess allergy to iodine, shellfish 3. V/S, weight for baseline information 4. Have client void before the procedure 5. Monitor PT, PTT, and ECG prior to test 6. NPO for 4-6 hours before the test 7. Shave the groin or brachial area 8. After the procedure : bed rest to prevent bleeding on the site, do not flex extremity 9. Elevate the affected extremities on extended position to promote blood supply back to the heart and preve 10. Monitor V/S especially peripheral pulses 11. Apply pressure dressing over the puncture site 12. Monitor extremity for color, temperature, tingling to assess for impaired circulation.

MRI 1. Secure consent, 2. The procedure will last 45-60 minute 3. Assess client for claustrophobia

4. 5. 6. 7. 8. 9.

Remove all metal items Client should remain still Tell client that he will feel nothing but may hear noises Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI. Client with cardiac and respiratory complication may be excluded Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedur

UGIS Barium Swallow 1. 2. 3. 4. 5. 6. 7. Instruct client on low-residue diet 1-3 days before the procedure Administer laxative evening before the procedure NPO after midnight Instruct client to drink a cup of flavored barium X-rays are taken every 30 minutes until barium advances through the small bowel Film can be taken as long as 24 hours later Force fluid after the test to prevent constipation/barium impaction

LGIS Barium Enema 1. 2. 3. 4. 5. 6. Instruct client on low-residue diet 1-3 days before the procedure Administer laxative evening before the procedure NPO after midnight Administer suppository in AM Enema until clear Force fluid after the test to prevent constipation/barium impaction

Liver Biopsy 1. 2. 3. 4. 5. 6. 7. 8.

Secure consent, NPO 2-4 hrs before the test Monitor PT, Vitamin K at bedside Place the client in supine at the right side of the bed Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD Right lateral post procedure for 4 hours to apply pressure and prevent bleeding Bed rest for 24 hours Observe for S/S of peritonitis

Paracentesis 1. Secure consent, check V/S 2. Let the patient void before the procedure to prevent puncture of the bladder

3. Check for serum protein. Excessive loss of plasma protein may lead to hypovolemic shock.

Lumbar Puncture 1. 2. 3. 4. 5. Obtain consent Instruct client to empty the bladder and bowel Position the client in lateral recumbent with back at the edge of the examining table Instruct client to remain still Obtain specimen per MDs order

Documenting and Reporting

Guidelines for Good Documentation and Reporting

1. Fact information about clients and their care must be factual. A record should contain descriptive, objective smells 2. Accuracy information must be accurate so that health team members have confidence in it 3. Completeness the information within a record or a report should be complete, containing concise and thorou are easy to understand 4. Currentness ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following: a. Vital signs b. Administration of medications and treatments c. Preparation of diagnostic tests or surgery d. Change in status e. Admission, transfer, discharge or death of a client f. Treatment fro a sudden change in status 5. Organization the nurse communicate in a logical format or order 6. Confidentiality a confidential communication is information given by one person to another with trust and disclosed

Documentation

Anything written or printed that is relied on as a record of proof fro authorized persons.

Purposes of Records 1. Communication 2. Planning Client Care 3. Auditing Health Agencies

4. 5. 6. 7. 8.

Research Education Reimbursement Legal Documentation Health Care Analysis

Documentation Systems 1. Source Oriented Record a. The traditional client record b. Each person or department makes notations in a separate section or sections of the clients chart c. It is convenient because care providers from each discipline can easily locate the forms on which to record d. Example: the admissions department has an admission sheet; the physician has a physicians order sheet, a e. NARRATIVE CHARTING is a traditional part of the source-oriented record 2. Problem Oriented Medical Record (POMR) a. Established by Lawrence Weed b. The data are arranged according to the problems the client has rather than the source of the information. The four (4) basic components: i. Database consists of all information known about the client when the client first enters the health care history, social & family data

age

ii. Problem List derived from the database. Usually kept at the front of the chart & serves as an index to the in the order in which they are identified & the list is continually updated as new problems are identified & othe iii. Plan of Care care plans are generated by the person who lists the problems. Physicians write orders or nursing care plans iv. Progress Notes chart entry made by all health professionals involved in a clients care; they all use the problems on the problem list and may be lettered for the type of data Example: SOAP Format or SOAPIE and SOAPIER S Subjective data O Objective data A Assessment P Plan I Intervention E Evaluation R- Revision

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Advantages of POMR:

It encourages collaboration Problem list in the front of the chart alerts caregivers to the clients needs & makes it easier to track Disadvantages of POMR:

Caregivers differ in their ability to use the required charting format Takes constant vigilance to maintain an up-to-date problem list Somewhat inefficient because assessments & interventions that apply to more than one problem mus

3. PIE (Problems, Interventions, and Evaluation) a. Groups information in to three (3) categories b. This system consists of a client care assessment floe sheet & progress notes c. FLOW SHEET uses specific assessment criteria in a particular format, such as human needs or functional d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes 4. Focus Charting a. Intended to make the client & client concerns & strengths the focus of care b. Three (3) columns fro recording are usually used: date & time, focus & progress notes 5. Charting by Exception a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded b. Incorporates three (3) key elements: i. Flow sheets ii. Standards of nursing care iii. Bedside access to chart forms 6. Computerized Documentation

a. Developed as a way to manage the huge volume of information required in contemporary health care b. Nurses use computers to store the clients database, add new data, create & revise care plans & document clien 7. Case Management a. Emphasizes quality, cost-effective care delivered within an established length of stay b. Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

Nursing Care Plan (NCP) Two Types:

1. Traditional Care Plan written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & 2. Standardized Care Plan based on an institutions standards of practice; thereby helping to provide a high

KARDEX

Widely used, concise method of organizing & recording data about a client, making information quickly cards kept in a portable index file or on computer generated forms.

Information may be organized into sections: 1. Pertinent information about the client 2. List of medications 3. List of IVF 4. List of daily treatments & procedures 5. List of Diagnostic procedures 6. Allergies 7. Specific data on how the clients physical need is to be met 8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries

Completed when the client is being discharged & transferred to another institution or to a home setting w Regardless of format, it includes some or all of the following:

1. Description of clients physical, mental & emotional state 2. Resolved health problems 3. Unresolved continuing health problems 4. Treatments that can be continued (e.g. wound care, oxygen therapy) 5. Current medications 6. Restrictions that relate to activity, diet & bathing 7. Functional/self-care abilities 8. Comfort level 9. Support networks 10. Client education provided in relation to disease process 11. Discharge destination 12. Referral Services (e.g. social worker, home health nurse)

Enemas
Cleansing Enemas

Stimulate peristalsis through irrigation of colon and rectum and by distention 1. 2. 3. 4.

Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 100 Tap water: Give caution o infants or to adults with altered cardiac and renal reserve Saline: For normal saline enemas, use smaller volume of solution Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require fu

Oil-Retention Enemas

Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass

Carminative Enema

Provides relief from gaseous distention

Astringent Enema

Contracts tissue to control bleeding

Key Points: Administering Enema

1. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less are too hot or too cold, or solutions that are instilled too quickly, can cause cramping and damage to recta 2. Allow solution to run through the tubing so that air is removed 3. Place client on left side in Sims position 4. Lubricate the tip of the tubing with water-soluble lubricant 5. Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for childr 6. Raise the water container no more than 12 to 18 inches above the client 7. Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client wil solution 8. After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes 9. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.

Ethico-Moral Aspects in Nursing

Ethos - comes from Greek work w/c means character/culture - Branch of Philosophy w/c determines right and wrong Moral - personal/private interpretation from what is good and bad.

Ethical Principles: 1. 2. 3. 4. 5. 6.

Autonomy the right/freedom to decide (the patient has the right to refuse despite the explanation of the Nonmaleficence the duty not to harm/cause harm or inflict harm to others (harm maybe physical, financ Beneficence- for the goodness and welfare of the clients Justice equality/fairness in terms of resources/personnel Veracity - the act of truthfulness Fidelity faithfulness/loyalty to clients

Moral Principles: 1. Golden Rule 2. The principle of Totality The whole is greater than its parts 3. Epikia There is always an exemption to the rule 4. One who acts through as agent is herself responsible (instrument to the crime) 5. No one is obliged to betray herself You cannot betray yourself 6. The end does not justify the means 7. Defects of nature maybe corrected 8. If one is willing to cooperate in the act, no justice is done to him 9. A little more or a little less does not change the substance of an act. 10. No one is held to impossible

Law - Rule of conduct commanding what is right and what is wrong. Derived from an Anglo-Saxon term that m Court - Body/agency in government wherein the administration of justice is delegated. Plaintiff - Complainant or person who files the case (accuser) Defendant - Accused/respondent or person who is the subject of complaint Witness- Individual held upon to testify in reference to a case either for the accused or against the accused.

Written orders of court Writ legal notes from the court 1. Subpoena

a. Subpoena Testificandum a writ/notice to an individual/ordering him to appear in court at a specific time b. Subpoena Duces Tecum- notice given to a witness to appear in court to testify including all important

Summon notice to a defendant/accused ordering him to appear in court to answer the complaint against him Warrant of Arrest - court order to arrest or detain a person Search warrant - court order to search for properties. Private/Civil Law - body of law that deals with relationships among private individuals

Public law - body of law that deals with relationship between individuals and the State/government and governm general public. Private/Civil Law :

1. Contract law involves the enforcement of agreements among private individuals or the payment of com
o o

Ex. Nurse and client nurse and insurance Nurse and employer client and health agency An agreement between 2 or more competent person to do or not to do some lawful act. It maybe written or oral= both equally binding

Types of Contract:

1. Expressed when 2 parties discuss and agree orally or in writing the terms and conditions during the creation o

Example: nurse will work at a hospital for only a stated length of time (6 months),under stated conditions allowance)

2. Implied one that has not been explicitly agreed to by the parties, but that the law considers to exist.

Example: Nurse newly employed in a hospital is expected to be competent and to follow hospital policies written or discussed. Likewise: the hospital is expected to provide the necessary supplies, equipment needed to provide compe

Feature/Characteristics/Elements of a lawful contract:

1. Promise or agreement between 2 or more persons for the performance of an action or restraint from certain act 2. Mutual understanding of the terms and meaning of the contract by all. 3. A lawful purpose activity must be legal 4. Compensation in the form of something of value-monetary Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

Tort law

Is a civil wrong committed against a person or a persons property. Person/persons responsible for the tort are sued for damages Is based on: o ACT OF COMMISSION something that was done incorrectly o ACT OF OMMISION something that should have been done but was not.

Classification of Tort Unintentional Tort 1. Negligence

Misconduct or practice that is below the standard expected of ordinary, reasonable and prudent person Failure to do something due to lack of foresight or prudence Failure of an individual to provide care that a reasonable person would ordinarily use in a similar circums An act of omission or commission wherein a nurse fails to act in accordance with the standard of care.

Doctrines of Negligence: a. Res ipsa loquitor the thing speaks for itself the injury is enough proof of negligence b. Respondeat Superior let the master answer command responsibility c. Force majuere unforeseen event, irresistible force 2. Malpractice

stepping beyond ones authority

6 elements of nursing malpractice:

a. Duty the nurse must have a relationship with the client that involves providing care and following an acce b. Breach of duty

the standard of care expected in a situation was not observed by the nurse is the failure to act as a reasonable, prudent nurse under the circumstances something was done that should not have been done or nothing was done when it should have been done

c. Foreseeability a link must exist between the nurses act and the injury suffered d. Causation it must be proved that the harm occurred as a direct result of the nurses failure to follow the have known that the failure to follow the standard of care could result in such harm.

e. harm/injury physical, financial, emotional as a result of the breach of duty to the client Example: physical i

suffering f. damages amount of money in payment of damage/harm/injury Intentional Tort

Unintentional tort do not require intent bur do require the element of HARM Intentional tort the act was done on PURPOSE or with INTENT o No harm/injury/damage is needed to be liable o No expert witnesses are needed

Assault

An attempt or threat to touch another person unjustifiably Example: o A person who threatens someone with a club or closed fist. o Nurse threatens a client with an injection after refusing to take the meds orally.

Battery

Willful touching of a person, persons clothes or something the person is carrying that may or may not ca without consent, is embarrassing or causes injury. Example: o A nurse threatens the patient with injection if the patient refuses his meds orally. If the nurse gave committing battery even if the client benefits from the nurses action.

False Imprisonment

Unjustifiable detention of a person without legal warrant to confine the person Occurs when clients are made to wrongful believe that they cannot leave the place Example: o Telling a client no to leave the hospital until bill is paid o Use of physical or chemical restraints o False Imprisonment Forceful Restraint=Battery

Invasion of Privacy

intrusion into the clients private domain right to be left alone

Types of Invasion the client must be protected from:

1. use of clients name for profit without consent using ones name, photograph for advertisements of HC a 2. Unreasonable intrusion observation or taking of photograph of the client for whatever purpose without cl 3. Public disclosure of private facts private information is given to others who have no legitimate need for t

4. Putting a person in a false/bad light publishing information that is normally considered offensive but whi Defamation

communication that is false or made with a careless disregard for the truth and results in injury to the repu

Types:

1. Libel defamation by means of print, writing or picture o Example: 1. o writing in the chart/nurses notes that doctor A is incompetent because he didnt respond 2. Slander defamation by the spoken word stating unprivileged (not legally protected) or false word by wh o Example: Nurse A telling a client that nurse B is incompetent Person defamed may bring the lawsuit The material (nurses notes) must be communicated to a 3rd party in order that the person Public Law: Criminal Law deals with actions or offenses against the safety and welfare of the public. 1. 2. 3. 4. 5. 6. homicide self-defense arson- burning or property theft stealing sexual harassment active euthanasia illegal possession of controlled drugs

Homicide killing of any person without criminal intent may be done as self-defense Arson willful burning of property Theft act of stealing

Evaluation
Definition

Is assessment the clients response to nursing interventions and then comparing that response to predeterm

Purpose:

To appraise the extent to which goals and outcome criteria of nursing care have been achieved.

Activities: 1. Collect data about the clients response. 2. Compare the clients response to goals and outcome criteria. 3. The four possible judgments that may be made are as follows: o The goal was completely met. o The goal was partially met. o The goal was completely unmet. o New problems & nursing diagnosis have developed. 4. Analyze the reasons for the outcomes. 5. Modify plan of care as needed.

Evening Care of Patient

I. Purpose 1. To refresh the patient and prepare line him for sleep 2. To promote muscular relaxation 3. To prevent bedsore

II. Preparation of Patient and Environment A try containing:

Basin of warm water Alcohol 70% Soap in soap dish Talcum powder Hair comb or brush Bath towel & wash cloth Pitcher of warm water Mouth wash tray with Mouth wash solution Tooth brush Kidney basin Linen required

III. Procedure

1. Allow patient to brush his teeth, wash his face, hands and forearms. If patient is unable to help himself do 2. Turn patient to her side, unfasten her camisa and bath her back. Massage back with alcohol 700/0 or (skin and other reddish pots on the back. Dust with powder 3. If the patient is wearing a binder, remove it when giving care to the back. Inspect dressing for bleeding or in place. 4. Brush and comb hair. Protect back and camisa with towel 5. Fasten patients camisa Move patient to one side brush crumbs or dirt from the bed. 6. Tighten beddings. 7. Fluff up pillows and replace 8. Replace ice cap or hot water bag p.r.n 9. Give bedtime medicine if any. Attend to all patients request 10. Place signal cord or bell within the reach of the patient. 11. Remove all unnecessary things from the room: trays, dishes, etc. Empty waste basket. 12. Adjust screen or blinds and light.

Family Structure
Traditional Family

It is composed of a father, a mother and their children. These people, married and living together in one h uncles, cousins and grandparents, who may or may not live with the nuclear family, are part of the extend geographic proximity to members of the extended family, who provided a sense of stability and belongin

Single Parent Families

Single parents may be never married, separated, divorced or widowed. Most often, the single parent is d married men and women are choosing to become parents.

Alternate Family Structure

Cohabiting Families

It includes those individuals who choose to live together for a variety of reasons: relationships, financial n

Although the single person is not living with others, he or she is a part of a family of origin, usually has a social n living alone are found in to age groups: the young adult who has achieved independence and enters the work forc

spouse. (Taylor, et.al., 1989)

Hair Care
I. Purpose 1. 2. 3. 4. 5. To ass to the comfort of the patient. To remove tangles from the hair. To preserve or keep the hair in good condition during illness. To observe the presence of lice without the patients being aware of it. To prevent infection.

II. Equipment

Patients bath towel Hair comb Hairbrush Vaseline Clips Rubber bands or tapes

III. Procedure 1. 2. 3. 4. 5.

Move the patients head near the edge of the bed, her face turned away from you. Place towel under the head of the patient extending down the chest rind shoulders. Loose the hair and part of the middle. Brush hair thoroughly. In combing or brushing, comb small stands at a time. Hold the strand at a time wrapping around the foref the pull comes on your baud, not on the hair roots and comb the tangles from the end first. 6. Comb gently. But remove all tangles. If the hair is badly tangled, apply vaseline or oil or wet hair with alc 7. If the hair is long, part down and middle and plaid into two braids shirting towards the front so that a pati across the front of the head or let them freely down helding the ends with ribbon or tape or rubber bands. 8. Gather all used articles. Clean and disinfect brush and comb and return them into their proper places.

IV. Instructions 1. Never allow an ill patient to comb her hair. 2. If the hair is too tangled, alcohol or vaseline may be use to remove the tangles. 3. The nurse should never cut the patients hair without the patients permission

Hand Washing Technique

Hanging Main Line IV and Tubing

Wash hands. Compare type and amount of solution with physicians order. Check pharmacy label for clients identification, solution type, additives and expiration date. Select appropriate IV tubing. Obtain needle-less cannula or adapter for the established infusion site. Remove the outer wrapper around the IV bag. Inspect the bag carefully for tears or leaks by applying gentle pressure to bag. Examine for discoloration, cloudiness or foreign matter. Time-tape and label bag.

Head-To-Toe Assessment
Preview

Head (Skull, Scalp, Hair) Face Eyebrows, Eyes and Eyelashes Eye lids and Lacrimal Apparatus Conjunctivae Sclerae Cornea Anterior Chamber and Iris Pupils Cranial Nerve II (optic nerve) Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens) Ears Nose and Paranasal Sinuses Cranial Nerve I (olfactory Nerve) Neck Thorax ( Cardiovascular System) Breast Abdomen Extremities

_____________________________________________________________________________________

Skull, Scalp & Hair

Observe the size, shape and contour of the skull. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about te Observe and feel the hair condition.

Normal Findings:
Skull Scalp Hair Can be black, brown or burgundy depending on the race. Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry. Lighter in color than the complexion. Can be moist or oily. No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness or masses on palpation. Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation.

__________________________________________________________________________________________ Face

1. Observe the face for shape. 2. Inspect for Symmetry. o Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes. o Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the ang is normal. o If both are met, then the Face is symmetrical 3. Test the functioning of Cranial Nerves that innervates the facial structures CN V (Trigeminal) 1. Sensory Function

Ask the client to close the eyes. Run cotton wisp over the fore head, check and jaw on both sides of the face. Ask the client if he/she feel it, and where she feels it. Check for corneal reflex using cotton wisp. The normal response in blinking.

2. Motor function

Ask the client to chew or clench the jaw. The client should be able to clench or chew with strength and force.

CN VII (Facial) 1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).

Place a sweet, sour, salty, or bitter substance near the tip of the tongue. Normally, the client can identify the taste.

2. Motor function

Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks.

Normal Findings

Shape maybe oval or rounded. Face is symmetrical. No involuntary muscle movements. Can move facial muscles at will. Intact cranial nerve V and VII.

_______________________________________________________________________________________ Eyebrows, Eyes and Eyelashes

All three structures are assessed using the modality of inspection.

Normal findings Eyebrows

Symmetrical and in line with each other. Maybe black, brown or blond depending on race. Evenly distributed.

Eyes

Evenly placed and inline with each other. None protruding. Equal palpebral fissure.

Eyelashes

Color dependent on race.

Evenly distributed. Turned outward.

__________________________________________________________________________________________ Eyelids and Lacrimal Apparatus 1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands. a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the clients upp b.Inquire for any pain or tenderness.

3. Palpate for the nasolacrimal duct to check for obstruction. a.To assess the nasolacrimal duct, the examiner presses with the index finger against the clients lower inner o NOSE. b. In the presence of blockage, this will cause regurgitation of fluid in the puncta Normal Findings Eyelids

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. No PTOSIS noted. (Drooping of upper eyelids). Meets completely when eyes are closed. Symmetrical.

Lacrimal Apparatus

Lacrimal gland is normally non palpable. No tenderness on palpation. No regurgitation from the nasolacrimal duct.

__________________________________________________________________________________________ Conjunctivae

The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the clien the examiner should exert NO PRESSURE against the eyeball; rather, the examiner should hold the lids a

In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:

1. Ask the client to look down but keep his eyes slightly open. This relaxes the levator muscles, whereas clo eversion. 2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward or upward; th

3. 4. 5. 6.

Place a cotton tip application about I can above the lid margin and push gently downward with the applic Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the eyebrow, neve Examine the lid for swelling, infection, and presence of foreign objects. To return the lid to its normal position, move the lid slightly forward and ask the client to look up and to b

Normal Findings:

Both conjunctivae are pinkish or red in color. With presence of many minutes capillaries. Moist No ulcers No foreign objects

__________________________________________________________________________________________ Sclerae

The sclerae is easily inspected during the assessment of the conjunctivae.

Normal Findings

Sclerae is white in color (anicteric sclera) No yellowish discoloration (icteric sclera). Some capillaries maybe visible. Some people may have pigmented positions.

__________________________________________________________________________________________ Cornea

The cornea is best inspected by directing penlight obliquely from several positions.

Normal findings

There should be no irregularities on the surface. Looks smooth. The cornea is clear or transparent. The features of the iris should be fully visible through the cornea. There is a positive corneal reflex.

__________________________________________________________________________________________ Anterior Chamber and Iris

The anterior chamber and the iris are easily inspected in conjunction with the cornea. The technique of ob chamber.

Normal Findings:

The anterior chamber is transparent. No noted any visible materials. Color of the iris depends on the persons race (black, blue, brown or green). From the side view, the iris should appear flat and should not be bulging forward. There should be NO cr from one side.

__________________________________________________________________________________________ Pupils

Examination of the pupils involves several inspections, including assessment of the size, shape reaction to constriction. Simultaneously, the other eye is observed for consensual response of constriction.

The test for papillary accommodation is the examination for the change in papillary size as it is switched from a d

Ask the client to stare at the objects across room. Then ask the client to fix his gaze on the examiners index fingers, which is placed 5 5 inches from the Visualization of distant objects normally causes papillary dilation and visualization of nearer objects caus

Normal Findings

Pupillary size ranges from 3 7 mm, and are equal in size. Equally round. Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual. Pupils dilate when looking at distant objects, and constrict when looking at nearer objects.

If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to l

__________________________________________________________________________________________ Cranial Nerve II (optic nerve)

The optic nerve is assessed by testing for visual acuity and peripheral vision. Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the western al different directions, maybe used. The chart has a standardized number at the end of each line of letters; these numbers indicates the degree The numerator 20 is the distance in feet between the chart and the client, or the standard testing distance. eye can read the lettering, which correspond to the number at the end of each letter line; therefore the larg Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder.

In testing for visual acuity you may refer to the following:

The room used for this test should be well lighted.

A person who wears corrective lenses should be tested with and without them to check fro the adequacy o Only one eye should be tested at a time; the other eye should be covered by an opaque card or eye cover, Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand perceive the light of the penlight directed to their yes.

Peripheral Vision or visual fields

The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vis areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide The performance of this test assumes that the examiner has normal visual fields, since that clients visual

Follow the steps on conducting the test:

1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level w 2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client 3. Instruct the client to stare directly at the examiners eye, while the examiner stares at the clients open eye periphery. 4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the pe below. 5. Normally the client should see the same time the examiners sees it. The normal visual field is 180 degrees

__________________________________________________________________________________________ Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)

All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or th

Follow the given steps: 1. 2. 3. 4. 5. 6. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the clients eyes. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is The nurse moves the object in a clockwise direction hexagonally. Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal gazes. The examiner should watch for any jerky movements of the eye (nystagmus). Normally the client can hold the position and there should be no nystagmus.

__________________________________________________________________________________________ Ears

1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when 3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodie o For adult pull the pinna upward and backward to straiten the canal.

For children pull the pinna downward and backward to straiten the canal 4. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks. Normal Findings

The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal. On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color.

__________________________________________________________________________________________ Nose and Paranasal Sinuses The external portion of the nose is inspected for the following: 1. 2. 3. 4. Placement and symmetry. Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing) Flaring of alae nasi Discharge

The external nares are palpated for: 1. Displacement of bone and cartilage. 2. For tenderness and masses

The internal nares are inspected by hyper extending the neck of the client, the ulnar aspect of the examiners hard the tip of the nose upward while shining a light into the nares. Inspect for the following:

1. Position of the septum. 2. Check septum for perforation. (Can also be checked by directing the lighted penlight on the side of the no 3. The nasal mucosa (turbinates) for swelling, exudates and change in color. Paranasal Sinuses

Examination of the paranasal sinuses is indirectly. Information about their condition is gained by inspecti maxillary sinuses are accessible for examination.

By palpating both cheeks simultaneously, one can determine tenderness of the maxillary sinusitis, and pre tenderness of the frontal sinuses.

Normal Findings

Nose in the midline No Discharges. No flaring alae nasi. Both nares are patent. No bone and cartilage deviation noted on palpation. No tenderness noted on palpation. Nasal septum in the mid line and not perforated. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy). No tenderness noted on palpation of the paranasal sinuses.

__________________________________________________________________________________________ Cranial Nerve I (Olfactory Nerve) To test the adequacy of function of the olfactory nerve: 1. 2. 3. 4. The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. (E.g. coffee). Ask the client to identify the odor. Each side is tested separately, ideally with two different substances.

Mouth and Oropharynx Lips Inspected for: 1. Symmetry and surface abnormalities. 2. Color 3. Edema Normal Findings: 1. 2. 3. 4. With visible margin Symmetrical in appearance and movement Pinkish in color No edema

Temporomandibular Palpate while the mouth is opened wide and then closed for:

1. Crepitous 2. Deviations 3. Tenderness Normal Findings: 1. Moves smoothly no crepitous. 2. No deviations noted 3. No pain or tenderness on palpation and jaw movement. Gums Inspected for: 1. Color 2. Bleeding 3. Retraction of gums. Normal Findings: 1. Pinkish in color 2. No gum bleeding 3. No receding gums Teeth Inspected for: 1. 2. 3. 4. 5. 6. 7. Number Color Dental carries Dental fillings Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth). Tooth loss Breath should also be assessed during the process.

Normal Findings: 1. 2. 3. 4. 5. 28 for children and 32 for adults. White to yellowish in color With or without dental carries and/or dental fillings. With or without malocclusions. No halitosis.

Tongue

Palpated for: 1. Texture Normal Findings: 1. 2. 3. 4. 5. 6. 7. Uvula Inspected for: Pinkish with white taste buds on the surface. No lesions noted. No varicosities on ventral surface. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue. Gag reflex is present. Able to move the tongue freely and with strength. Surface of the tongue is rough.

1. Position 2. Color 3. Cranial Nerve X (Vagus nerve) Tested by asking the client to say Ah note that the uvula will move up Normal Findings: 1. 2. 3. 4. Positioned in the mid line. Pinkish to red in color. No swelling or lesion noted. Moves upward and backwards when asked to say ah

Tonsils Inspected for: 1. Inflammation 2. Size A Grading system used to describe the size of the tonsils can be used.

Grade 1 Tonsils behind the pillar. Grade 2 Between pillar and uvula. Grade 3 Touching the uvula Grade 4 In the midline.

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Neck

The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jug

Normal Findings: 1. 2. 3. 4. The neck is straight. No visible mass or lumps. Symmetrical No jugular venous distension (suggestive of cardiac congestion).

The neck is palpated just above the suprasternal note using Normal Findings: 1. The trachea is palpable. 2. It is positioned in the line and straight.

the thumb and the index finger.

Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements. Describ tenderness and fixation to surrounding tissues.

Normal Findings:

May not be palpable. Maybe normally palpable in thin clients. Non tender if palpable. Firm with smooth rounded surface. Slightly movable. About less than 1 cm in size. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Pa anterior approach.

Posterior Approach: 1. 2. 3. 4.

Let the client sit on a chair while the examiner stands behind him. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the ist Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to b 5. Ask the patient to swallow as the procedure is being done. 6. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the fingers are placed deep to and in front of the muscle. 7. Then the procedure is repeated on the other side. Anterior approach:

1. The examiner stands in front of the client and with the palmar surface of the middle and index finge 2. Ask the client to swallow while palpation is being done.

3. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is other of the lobe to be examined. 4. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined. 5. Again, the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid Normal Findings: 1. Normally the thyroid is non palpable. 2. Isthmus maybe visible in a thin neck. 3. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner may hear bruits, an enlarged thyroid. Check the Range of Movement of the neck.

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Thorax (Cardiovascular System)

Inspection of the Heart

The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsatio

Normal Findings: 1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size). 2. There should be no lift or heaves. Palpation of the Heart

The entire precordium is palpated methodically using the palms and the fingers, beginning at the ap base of the heart.

Normal Findings: 1. No, palpable pulsation over the aortic, pulmonic, and mitral valves. 2. Apical pulsation can be felt on palpation. 3. There should be no noted abnormal heaves, and thrills felt over the apex. Percussion of the Heart

The technique of percussion is of limited value in cardiac assessment. It can be used to determine b

Auscultation of the Heart Anatomic areas for auscultation of the heart:

Aortic valve Right 2nd ICS sternal border. Pulmonic Valve Left 2nd ICS sternal border. Tricuspid Valve - Left 5th ICS sternal border. Mitral Valve - Left 5th ICS midclavicular line

Positioning the client for auscultation:

If the heart sounds are faint or undetectable, try listening to them with the patient seated and learn heart closer to the surface of the chest. Having the client seated and learning forward s best suited for hearing high-pitched sounds related t The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems

Auscultating the heart: 1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral 2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound the aortric valve. 3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs. 4. Count heart rate at the apical pulse for one full minute. Normal Findings: 1. S1 & S2 can be heard at all anatomic site. 2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4). 3. Cardiac rate ranges from 60 100 bpm.

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Breast
Inspection of the Breast

There are 4 major sitting position of the client used for clinical breast examination. Every client should be e 1. 2. 3. 4. The The The The client client client client is is is is seated seated seated seated

with her arms on her side. with her arms abducted over the head. and is pushing her hands into her hips, simultaneously eliciting contraction of th and is learning over while the examiner assists in supporting and balancing her.

While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bu An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through i them from upward movement in position 2 and 4. Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory

Normal Findings: 1. The overlying the breast should be even. 2. May or may not be completely symmetrical at rest.

3. 4. 5. 6. 7. 8. 9.

The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown dependin Nipples are rounded, everted, same size and equal in color. No orange peel skin is noted which is present in edema. The veins maybe visible but not engorge and prominent. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. No retractions or dimpling.

Palpation of the Breast

Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the p the breast is adequately surveyed. Breast examination is best done 1 week post menses. Each areolar areas are carefully palpated to determine the presence of underlying masses. Each nipple is gently compressed to assess for the presence of masses or discharge.

Normal Findings: No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples.

NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the var _____________________________________________________________________________________

Abdomen

In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the clie relax abdominal muscles.

Inspection of the abdomen Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour (flat, rounded, scapold) Distension Respiratory movement. Visible peristalsis. Pulsations

Normal Findings: Skin color is uniform, no lesions. Some clients may have striae or scar. No venous engorgement. Contour may be flat, rounded or scapoid Thin clients may have visible peristalsis. Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen

This method precedes percussion because bowel motility, and thus bowel sounds, may be increased The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds a exploring arterial murmurs and venous hum.

Peristaltic sounds

These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Pe motility of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

1. Divide the abdomen in four quadrants. 2. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of This direction ensures that we follow the direction of bowel movement. 3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 concluding that no bowel sounds are present. 4. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 15 se may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound Some factors that affect bowel sound: 1. 2. 3. 4. 5. 6. 7. Presence of food in the GI tract. State of digestion. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis). Bowel surgery Constipation or Diarrhea. Electrolyte imbalances. Bowel obstruction.

Percussion of the abdomen

Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, an abdomen. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and du Tympany will predominate because of the presence of gas in the small and large bowel. Solid masse the 6th or 9th rib just posterior to or at the mid axillary line on the left side. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver The palms of the left hand are placed over the region of liver dullness. 1. The area is strucked lightly with a fisted right hand. 2. Normally tenderness should not be elicited by this method. 3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. Renal Percussion

1. Can be done by either indirect or direct method. 2. Percussion is done over the costovertebral junction. 3. Tenderness elicited by such method suggests renal inflammation. Palpation of the Abdomen Light palpation

It is a gentle exploration performed while the client is in supine position. With the examiners hands The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, b This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding

Tensing of abdominal musculature may occur because of: 1. The examiners hands are too cold or are pressed to vigorously or deep into the abdomen. 2. The client is ticklish or guards involuntarily. 3. Presence of subjacent pathologic condition. Normal Findings: 1. No tenderness noted. 2. With smooth and consistent tension. 3. No muscles guarding. Deep Palpation

It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of The abdominal wall may slide back and forth while the fingers move back and forth over the organ b Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be fel In the absence of disease, pressure produced by deep palpation may produce tenderness over the c

Liver palpation

There are two types of bi manual palpation recommended for palpation of the liver. The first one is the sup

1. Ask the patient to take 3 normal breaths. 2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation. 3. Press hand deeply over the RUQ The second methods: 1. 2. 3. 4. 5.

The examiners left hand is placed beneath the client at the level of the right 11th and 12th ribs. Place the examiners right hands parallel to the costal margin or the RUQ. An upward pressure is placed beneath the client to push the liver towards the examining right hand, Ask the client to breath deeply. As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise we When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tend

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Extremities
Inspection 1. Observe for size, contour, bilateral symmetry, and involuntary movement. 2. Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration. 3. Always compare both extremities. Palpation 1. 2. 3. 4. Feel for evenness of temperature. Normally it should be even for all the extremities. Tonicity of muscle. (Can be measured by asking client to squeeze examiners fingers and noting for Perform range of motion. Test for muscle strength. (performed against gravity and against resistance)

Table showing the Lovett scale for grading for muscle strength and functional level Functional level No evidence of contractility Evidence of slight contractility Complete ROM without gravity Complete ROM with gravity Complete range of motion against gravity with some resistance Complete range of motion against gravity with full resistance Normal Findings Both extremities are equal in size. Have the same contour with prominences of joints. No involuntary movements. No edema Color is even. Temperature is warm and even. Has equal contraction and even. Can perform complete range of motion. No crepitus must be noted on joints. Can counter act gravity and resistance on ROM. Lovett Scale Zero (Z) Trace (T) Poor (P) Fair (F) Good (G) Grade Percentage of normal 0 0 1 10 2 25 3 50 4 75 100

Normal (N) 5

Health and Illness

Health

As defined by the World Health Organization (WHO): state of complete physical, mental and social well-

Characteristics 1. A concern for the individual as a total system 2. A view of health that identifies internal and external environment 3. An acknowledgment of the importance of an individuals role in life

*A dynamic state in which the individual adapts to changes in internal and external environment to maintain a sta

Models of Health and Illness

1. Health-Illness Continuum (Neuman) Degree of client wellness that exists at any point in time, ranging fro maximum, to death which represents total energy depletion.

2. High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing the health potential of an i continuum of balance and purposeful direction within the environment.

3. Agent Host environment Model (Leavell) The level of health of an individual or group depends on the

Agent any internal or external factor that disease or illness. Host the person or persons who may be susceptible to a particular illness or disease Environment consists of all factors outside of the host

4. Health Belief Model Addresses the relationship between a persons belief and behaviors. It provides a wa in relation to their health and how they will comply with health care therapies. Four Components

The individual is perception of susceptibility to an illness The individuals perception of the seriousness of the illness The perceived threat of a disease The perceived benefits of taking the necessary preventive measures

5. Evolutionary Based Model Illness and death serves as a evolutionary function. Evolutionary viability refl survival and well-being. The model interrelates the following elements:

Life events

Life style determinants Evolutionary viability within the social context Control perceptions Viability emotions Health outcomes

6. Health Promotion Model A complimentary counterpart models of health protection. Directed at increasin clients participation health-promotion behaviors. The model focuses on three functions:

It identifies factors (demographic and socially) enhance or decrease the participation in health promotion It organizes cues into pattern to explain likelihood of a clients participation health-promotion behaviors It explains the reasons that individuals engage in health activities

Illness

State in which a persons physical, emotional, intellectual, social developmental or spiritual functioning i deviation from a normal, healthy state.

3 Stages of Illness

1. Stage of Denial Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness. 2. Stage of Acceptance Turns to professional help for assistance 3. Stage of Recovery (Rehabilitation or Convalescence) The patient goes through of resolving loss or imp

Rehabilitation

1. A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest pos economical functioning. 2. Abilities not disabilities are emphasized. 3. Begins during initial contact with the patient 4. Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of functio 5. Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process. Focuses of Rehabilitation 1. 2. 3. 4. 5.

Coping pattern Functional ability focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dress Mobility Integrity of skin Control of bowel and bladder function

Indwelling Catheter Insertion

Inserting an Indwelling Catheter to a Female

Check physicians order.

Check clients identaband and if able have client state name. Explain procedure to client. Provide privacy. Gather equipment. Assist client to position, knees up and out. o *Be careful to not contaminate sterile field Cleanse clients perineum of antiseptic solution. Remove drapes. Reposition client for comfort; put bed in low position. Remove and discard disposable supplies in appropriate container. Wash hand. Document procedure, measure and record urine output on I&O bedside record.

Inserting an Indwelling Catheter to a Male

Check physicians order. Check clients identaband and if able have client state name.

Explain procedure to client. Provide privacy. Gather equipment. Prepare client by placing client in supine position with knees slightly apart. Fan fold top linen down to lower extremities exposing only perineal area. Prepare equipment in the same manner as demonstrated for female catheterization. Tape catheter to abdomen with 1 inch tape. Attach drainage bag to bed frame, not side rails. Cleanse clients perineum of antiseptic solution. Remove drapes. Reposition client for comfort; put bed in low position with side rails up. Remove all equipment, including gloves & discard trash in the appropriate container. Wash hand. Document procedure. Measure and record urine output on I&O bedside record.

Intradermal Injection (Test for Drug Sensitivity)

Purpose:

To introduce drugs, bacteria or their toxins and other organic preparations to test whether the body is sensitive to

Site of Injection:

Inner aspect of forearm or upper arm

Points to Remember:

1. A positive test consists of a wheal formation with redness which appears in 10-15 minutes. 2. Precaution in all patients being injected with penicillin for the first or second time even if the sensitivity t

3. Watch patient for at least 30 minutes after the injection for signs of reaction. At all times the following m anaphylaxis or generalized reactions: o Epinephrine Hcl 1:10 00 for immediate IM o I.V. antihistaminics o 50/0 Dextrose in Water 1 liter and venosel.

Equipment:

Hype tray: Alcohol sponge Sterile tuberculin syringe 2 sterile needles gauge 25-27 Drug to be tested diluted to the strength which will be injected to the patient

Procedure:

1. Prepare the drug in the same manner as for hypodermic injection. 2. Explain to the patient. Make him comfortable. Support forearm on a firm surface. 3. Cleanse the skin area about 3 inches (diameter) on the inner aspect of the forearm midway between the w

4. 5. 6. 7.

with other, and allow to dry.) Insert the needle, into the skin as superficially as possible by the needle only as far as the level edge to be Inject the solution enough to make a wheal or circumscribed elevation of the skin. Inject no more than 0.1 Withdraw the needle gently, do not press. Do not cleanse or massage site of injection. Wait for 10-15 minutes. Evaluate results.

Charting: Record drug, time injected, reaction observed, and usually by whom it was evaluated.

Intramuscular (IM) Administration

Here are the steps needed to accomplish administering IM injections. Feel free to read through the steps and watc

1. You will be needing all these supplies. Prepare the medication to be given, syringe, alcohol prep pad, gau and 1 1/2 long. 2. Wash your hands. 3. Prepare/Mix the medication accordingly and put it into the syringe. 4. Attach the new needle into the syringe. 5. Medication can be given into the: o Ventrogluteal Patient may lie on back or side with hip and knee flexed. o Vastus lateralis Patient may lie on the back or may assume a sitting position. o Deltoid Patient may sit or lie with arm relaxed. o Dorsogluteal Patient may lie prone with toes pointing inward or on side with upper leg flexed an 6. The site should be free of bumps and scars. 7. Clean the site with an alcohol pad. Allow the alcohol to dry. Do not use a blower or fan to quicken the dr 8. Spread the skin with your fingers and inject the needle straight down in a dart-like motion all the way. 9. Pull back on the plunger a little. If you see blood enter the syringe, pull the needle out a little and inject th 10. Pull the needle out and dispose of properly in a sharps container. Do not put medical or sharp waste in the 11. Use the gauze to dab up any blood, if necessary, and cover with a bandage. 12. Wash your hands.

Laboratory and Diagnostic Examination

Urine Specimen 1. Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test a. Best time to collect is in the morning, first voided urine b. Provide sterile container c. Do perineal care before collection of the urine d. Discard the first flow of urine

e. Label the specimen properly f. Send the specimen immediately to the laboratory g. Document the time of specimen collection and transport to the lab. h. Document the appearance, odor, and usual characteristics of the specimen. 2. 24-hour urine specimen a. Discard the first voided urine. b. Collect all specimens thereafter until the following day c. Soak the specimen in a container with ice d. Add preservative as ordered according to hospital policy 3. Second-Voided urine required to assess glucose level and for the presence of albumen in the urine. a. Discard the first urine b. Give the patient a glass of water to drink c. After few minutes, ask the patient to void 4. Catheterized urine specimen

a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen c b. Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary

Stool Specimen 1. Fecalysis to assess gross appearance of stool and presence of ova or parasite

a. Secure a sterile specimen container b. Ask the pt. to defecate into a clean, dry bed pan or a portable commode. c. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth and the test result. 2. Stool culture and sensitivity test

To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.

3. Fecal Occult blood test

Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer, detectin

a. Hematest- (an Orthotolidin reagent tablet) b. Hemoccult slide- (filter paper impregnated with guaiac) *Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours. c. Colocare a newer test, requires no smear

Instructions 1. 2. 3. 4. 5. 6. Advise client to avoid ingestion of red meat for 3 days Patient is advice on a high residue diet Avoid dark food and bismuth compound If client is on iron therapy, inform the MD Make sure the stool in not contaminated with urine, soap solution or toilet paper Test sample from several portion of the stool.

Venipuncture Pointers 1. 2. 3. 4. 5.

Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or blood a Never collect venous sample from an infectious site because it may introduce pathogens into the vascular Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury. Dont wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine. If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy, maintain pressure on

Arterial puncture for ABG test 1. 2. 3. 4.

Before arterial puncture, perform Allens test first. If the patient is receiving oxygen, make sure that the patients therapy has been underway for at least 15 m Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the patient is hav If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample.

Blood specimen 1. No fasting for the following tests: o CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes 2. Fasting is required: o FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)

Sputum Specimen 1. Gross appearance of the sputum a. Collect early in the morning b. Use sterile container c. Rinse the mount with plain water before collection of the specimen d. Instruct the patient to hack-up sputum

2. Sputum culture and sensitivity test a. Use sterile container b. Collect specimen before the first dose of antibiotic 3. Acid-Fast Bacilli a. To assess presence of active pulmonary tuberculosis b. Collect sputum in three consecutive mornings 4. Cytologic sputum exam a. To assess for presence of abnormal or cancer cells.

Leavell and Clarks Three Levels of Prevention

Primary Prevention

Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening.

Health Promotion

health education marriage counseling genetic screening good standard of nutrition adjusted to developmental phase of life

Specific Protection

use of specific immunization attention to personal hygiene use of environmental sanitation protection against occupational hazards protection from accidents use of specific nutrients protections from carcinogens avoidance to allergens

Secondary Prevention

Also known as Health Maintenance. Seeks to identify specific illnesses or conditions at an early stage w prevent catastrophic effects that could occur if proper attention and treatment are not provided

Early Diagnosis and Prompt Treatment

case finding measures individual and mass screening survey prevent spread of communicable disease prevent complication and sequelae shorten period of disability

Disability Limitations

Adequate treatment to arrest disease process and prevent further complication and sequelae. Provision of facilities to limit disability and prevent death.

Tertiary Prevention

Occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt the d an optimal health status. To establish a high-level wellness. To maximize use of remaining capacities

Restoration and Rehabilitation

Work therapy in hospital Use of shelter colony

Making a Recovery or Anesthetic Bed (Post-Operative Bed)

I. Purpose

1. To provide warmth and comfort for the patient. 2. To provide protection for the bed. 3. To arrange the bed and other furniture in order to facilitate the transfer of the patient from stretcher to bed

II. Equipment

The same linen as those used for making on occupied bed plus the following Bath towel Small robber sheet

Woolen blanket 3 hot water bags w/cover p.r.n.

On the Bedside Table:

Stethoscope Sphygmomanometer Kidney basin Swipes Padded tongue depressor p.r.n. Observation Sheet

In the Room

Oxygen tank with complete Tubbings, humidifier and nassal catheter Suction apparatus Stand Drainage bottles

III. Procedure:

1. Strip on the bed and turn the mattress. 2. Make an ordinary bed with the top sheet untucked at the foot part. (If weather is cold, place bath blanket o inches and the bottom side folded back even with the foot of the mattress. 3. Fanfold together the top sheet and blanket towards the side away from the door. 4. Place the small rubber sheet across the hood part of the bed. 5. Place the bath towel over the small rubber sheet. 6. Slip the pillowcase and put the pillow upright against the bars of the head of the bed. 7. Put the hot water bags at the foot and center of the bed if the weather is cold. 8. Place the necessary articles on the bedside table and the irrigating stand, suction machine and oxygen set9. Arrange unit.

Maslows Hierarchy of Basic Human Needs

Definition

Each individual has unique characteristics, but certain needs are common to all people. A need is something that is desirable, useful or necessary. Human needs are physiologic and psychologica of health or well-being.

Physiologic 1. 2. 3. 4. 5. 6. 7. Oxygen Fluids Nutrition Body temperature Elimination Rest and sleep Sex

Safety and Security 1. Physical safety 2. Psychological safety 3. The need for shelter and freedom from harm and danger

Love and belonging 1. 2. 3. 4. The need to love and be loved The need to care and to be cared for. The need for affection: to associate or to belong The need to establish fruitful and meaningful relationships with people, institution, or organization

Self-Esteem Needs 1. 2. 3. 4. Self-worth Self-identity Self-respect Body image

Self-Actualization Needs 1. 2. 3. 4. The need to learn, create and understand or comprehend The need for harmonious relationships The need for beauty or aesthetics The need for spiritual fulfillment

Characteristics of Basic Human Needs 1. 2. 3. 4. 5. Needs are universal. Needs may be met in different ways Needs may be stimulated by external and internal factor Priorities may be deferred Needs are interrelated

Maslows Characteristics of a Self-Actualized Person 1. Is realistic, sees life clearly and is objective about his or her observations 2. Judges people correctly 3. Has superior perception, is more decisive 4. Has a clear notion of right or wrong 5. Is usually accurate in predicting future events 6. Understands art, music, politics and philosophy 7. Possesses humility, listens to others carefully 8. Is dedicated to some work, task, duty or vocation 9. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes 10. Is open to new ideas 11. Is self-confident and has self-respect 12. Has low degree of self-conflict; personality is integrated 13. Respect self, does not need fame, and possesses a feeling of self-control 14. Is highly independent, desires privacy 15. Can appear remote or detached 16. Is friendly, loving and governed more by inner directives than by society 17. Can make decisions contrary to popular opinion 18. Is problem centered rather than self-centered

19. Accepts the world for what it is

Metro Manila Development Screening Test (MMDST)

Definition

Simple and clinically useful tool To determine early serious developmental delays Dr. William K. Frankenburg Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST Developed for health professionals (MDs, RNs, etc) It is not an intelligence test It is a screening instrument to determine if childs development is within normal Children 6 years and below

Purposes

Measures developmental delays Evaluates 4 aspects of development

Aspects of development

In the care of pediatric clients, growth and development are not in isolation. Nurses being competent in the aspe theories and milestones are in best position to counsel clients on these aspects. Having background knowledge o assessment skills to determine developmental delays through the aid of screening tests.

The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for normalcy of the child children 6 years old and below. Modified and standardized by Dr. Phoebe Williams from the original Denver Frankenburg, MMDST evaluates 4 sectors of development:

Personal-Social tasks which indicate the childs ability to get along with people and to take care of him Fine-Motor Adaptive tasks which indicate the childs ability to see and use his hands to pick up objects Language tasks which indicate the childs ability to hear, follow directions and to speak Gross-Motor tasks which indicate the childs ability to sit, walk and jump

MMDST KIT. Preparation for test administration involves the nurse ensuring the completeness of the test mate be followed as specified:

MMDST manual test Form

bright red yarn pom-pom rattle with narrow handle eight 1-inch colored wooden blocks (red, yellow, blue green) small clear glass/bottle with 5/8 inch opening small bell with 2 inch-diameter mouth rubber ball 12 inches in circumference cheese curls pencil

EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the procedure to the pare is not a diagnostic test but rather a screening test only. When conducting the test, the parents or caregivers of th test as it may be misinterpreted by them. The nurse should also establish rapport with the parent and the child to

AGE & THE AGE LINE. To proceed in the administration of the test, the nurse is to compute for the exact age date itself. The age is the most crucial component of the test because it determines the test items that will be app computing by subtracting the childs birth date with the test date. After computing, draw the age line in the test f

TEST ITEMS. There are 105 test items in MMDST but not all are administered. The examiner prioritizes items to explain to the parent or caregiver that the child is not expected to perform all the tasks correctly. If the sequen personal-social then progressing to the other sectors. Items that are footnoted with R can be passed by report.

SCORING. The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor Opportunity (NO). F age is considered a developmental delay. Whereas, failure of an item that is completely to the right of the childs CONSIDERATIONS:

Manner in which each test is administered must be exactly the same as stated in the manual, words or dire If the child is premature, subtract the number of weeks of prematurity. But if the child is more than 2 yea If the child is shy or uncooperative, the caregiver may be asked to administer the test provided that the ex directed in the manual If the child is very shy or uncooperative, the test may be deferred

Moral Theories
Freud (1961)

Believed that the mechanism for right and wrong within the individual is the superego, or conscience. He standards and character or character traits of the model parent through the process of identification. The strength of the superego depends on the intensity of the childs feeling of aggression or attachment to the parent.

Erikson (1964)

Eriksons theory on the development of virtues or unifying strengths of the good man suggests that mor if the conflicts of each psychosocial developmental stages favorably resolved, then an egostrength or vi

Kohlberg

Suggested three levels of moral development. He focused on the reason for the making of a decision, not

1. At first level called the premolar or the preconventional level, children are responsive to cultural rules and interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. 2. At the second level, the conventional level, the individual is concerned about maintaining the expectation 3. At the third level, people make postconventional, autonomous, or principal level. At this level, people ma regard to outside authority or to the expectations of others. These involve respect for other human and bel

Peter (1981)

Proposed a concept of rational morality based on principles. Moral development is usually considered to one feels), moral judgment (how one reason), and moral behavior (how one act). In addition, Peters believed that the development of character traits or virtues is an essential aspect or mo learned from others and encouraged by the example of others. Also, Peters believed that some can be described as habits because they are in some sense automatic and chastity, tidiness, thrift and honesty.

Gilligan (1982)

Included the concepts of caring and responsibility. She described three stages in the process of developing

1. Caring for oneself. 2. Caring for others. 3. Caring for self and others.

She believed the human see morality in the integrity of relationships and caring. For women, what is righ On the other hand, men consider what is right to be what is just.

Spiritual Theories
Fowler (1979)

Described the development of faith. He believed that faith, or the spiritual dimension is a force that gives He used the term faith as a form of knowing a way of being in relation to an ultimate environment. T

made-of-being-in-relation to others in which we invest commitment, belief, love, risk and hope.

Nasogastric and Intestinal Tubes

Nasogastric Tubes 1. Levin Tube single lumen a. Suctioning gastric contents b. Administering tube feedings

2. Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents suction on the gastric muco source) a. Suctioning gastric contents b. Maintaining gastric decompression Key Points

1. Prior to insertion, position the client in High-Fowlers position if possible. 2. Use a water-soluble lubricant to facilitate insertion 3. Measure the tube from the tip of the clients nose to the earlobe and from the nose to the xiphoid process reach the stomach 4. Flex the clients head slightly forward; this will decrease the chance of entry into the trachea 5. Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress 6. Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares 7. Validating placement of tube. o Aspirate gastric contents via a syringe to the end of the tube o Measure ph of aspirate fluid o Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A ch should be heard 8. Characteristics of nasogastric drainage: o Normally is greenish-yellowish, with strands of mucous o Coffee-ground drainage old blood that has been broken down in the stomach o Bright red blood bleeding from the esophagus, the stomach or swallowed from the lungs o Foul-smelling (fecal odor) occurs with reverse peristalsis in bowel obstruction; increase in amou

Intestinal Tubes

Provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention.

allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstructio 1. Types of Intestinal Tubes a. Cantor and Harris Tubes i. Approximately 6-10 feet long ii. Single lumen iii. Mercury placed in rubber bag prior to tube insertion b. Miller-Abbot Tubes

i. Approximately 10 feet long ii. Double lumen iii. One lumen utilized for aspiration of intestinal contents iv. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stom 2. Nursing Implications

a. Maintain client on strict NPO b. Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray c. After the tube has been placed in the stomach, position client on the right side to facilitae passage through th d. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician e. Encourage activity, to facilitate movement of the tube through the intestine f. Evaluate the type of gastric secretions being aspirated g. Do not tape or secure the tube until it has reached the desired position h. Tubes may attached to suction and left in place for several days i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst j. Removal of the tube depends on the relief of the intestinal obstruction k. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth l. May be allowed to progress through the intestines and expelled via the rectum.

How to Insert a Nasogastric (NG) Tube

Check physicians order. Check clients identaband and if able have client state name. Discuss procedure to client. Provide privacy. Gather equipment. Position client at 45 degree angle or higher with head elevated. Wash hands and don clean gloves. Provide regular oral and nasal hygiene. Remove gloves and wash hands.

Position client for comfort. Document procedure.

Nasal Gavage
I. Definition:

In this method of feeding, liquid is introduced into the stomach through a rubber catheter which is passed the esophagus. When forced feeding is necessary, this method is less exhausting as the mouth does not ha

II. Therapeutic Uses: 1. When a patient is weakened and cannot swallow food.

2. 3. 4. 5. 6.

Sometimes in the operation of the mouth such as carcinoma of the tongue, a cleft palate or fracture of the In the operation of the throat and sometimes after tracheotomy. In tetanus or meningitis with a locked jaw. In forced feeding for irrational and violet patients. In very weak patient who cannot swallow food vary well.

III. Equipment: Tray with:

Medium size rubber catheter

Sterile (No.2 French catheter for adult) Sterile glass syringe or a small glass funnel attached O.S Kidney basin Dressing rubber Draw sheet Lubricant A flask containing the nourishment ordered at temperature of 104 to 105F

IV. Procedure

Food consists of any liquid for which will readily pass through the tube. The temperature should be warm, not hot, as the lining of the nose is much sensitive than that of the mout The danger of burning the patient is greater when feeding by this method

1. The position of the patient may be lying down with the head turned to one side or sitting up with the head nurse with head turned away from the nurse. 2. Expel the air and lubricate the tube. 3. Insert the curve thru the nose and backward inward the septum. Instruct the patient to make motion of sw 4. Tell patient to open the mouth and look if the catheter has passed if patient coughs, wait before moving d 5. Introduce 6 to 8 inches. Wait until the patient is accustomed to the presence of the tube. 6. Connect the funnel to the catheter; then pour the liquid slowly at the sides. Raise 3 to 4 inches above the n 7. Wait for a few minutes then pinch the tube and withdraw. In some cases the tube is left and hold in place

VI. Precautionary Measures While Doing the Nasal Gavage The following precautions should be strictly observe during a nasal gavage:

1. The catheter should first be lubricated and in inserting it should be directed toward the septum of the nose removed and inserted again in the other nostril. 2. As the catheter is small, there is considerable danger of its passing into the larynx therefore the patients c pouring in the solution which if the tube should be in the larynx would down the patient. 3. Even a small amount of food in the lungs would cause a severe irritation, and dyspnea and if, allowed to r probably lead to a lung abscess or septic pneumonia, if the tube is in the trachea a whistling sound will be esophagus probably a gurgling sound will be heard. 4. As the tube is soft it may become coiled upon itself in the mouth or in the throat. If the fluid, is poured in checking and gasping. And will almost certainly enter the larynx causing dyspnea, cyanosis and later a po pass the finger to the back of the throat to sea the tube is in position. 5. Before pouring in the solution, wait until the patient is at rest, until all distress has subsided and normal b the esophagus. 6. Pour in only few drops at first, then pour the balance in very slowly, if there are not symptoms of checkin 7. After all the fluid has left the funnel, pinch the catheter and quickly withdraw.

Normal Values

Bleeding time

1-9 min

Prothrombin time

10-13 sec

Hematocrit

Male

42-52% ;

Female 36-48%

Hemoglobin

Male

13.5-16 g/dl;

Female 12-16 g/dl

Platelet

150,000- 400,000

RBC

Male

4.5-6.2 million/L;

Female 4.2-5.4 million/L

Amylase

80-180 IU/L

Bilirubin(serum)

direct

0-0.4 mg/dl;

indirect 0.2-0.8 mg/dl; total 0.3-1.0mg/dl

pH

7.35- 7.45

PaCo2

35-45

HCO3

22-26 mEq/L

Pa O2

80-100 mmg

SaO2

94-100%

Sodium

135- 145 mEq/L

Potassium

3.5- 5.0 mEq/L

Calcium

4.2- 5.5 mg/dL

Chloride

98-108 mEq/L

Magnesium

1.5-2.5 mg/dl

BUN

10-20 mg/dl

Creatinine

0.4- 1.2

CPK-MB

Male

50 325 mu/ml;

Female 50-250 mu/ml

Fibrinogen

200-400 mg/dl

FBS

80-120 mg/dl

Glycosylated Hgb (HbA1c)

4.0-7.0%

Uric Acid

2.5 8 mg/dl

ESR

Male

15-20 mm/hr;

Female 20-30 mm/hr

Cholesterol

150- 200 mg/dl

Triglyceride

140-200 mg/dl

Lactic Dehydrogenase

100-225 mu/ml

Alkaline phospokinase

32-92 U/L

Albumin

3.2- 5.5 mg/dl

Nursing Theorist
Nursing As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia Henderson.

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activ death the client would perform unaided if he had the necessary strength, will or knowledge. Help the client gain independence as rapidly as possible.

Nursing Theory

Over the years, nursing has incorporated theories from non-nursing sources, including theories of systems, huma Barnum defines theory as a construct that accounts for or organizes some phenomenon. A nursing theory, then, With the formulation of different theories, concepts, and ideas in nursing it:

It guides nurses in their practice knowing what is nursing and what is not nursing. It helps in the formulations of standards, policies and laws. It will help the people to understand the competencies and professional accountability of nurses. It will help define the role of the nurse in the multidisciplinary health care team.

Four Major Concepts

Nurses have developed various theories that provide different explanations of the nursing discipline. All theories human beings. People are the recipients of nursing care; they include individuals, families, communities, and gro internally and externally. It means not only in the everyday surroundings but all setting where nursing care is pro being. The concept of Nursing is central to all nursing theories. Definitions of nursing describe what nursing is, nursing theories address each of the four central concepts implicitly or explicitly. Betty Neuman (1972, 1982, 1989, 1992) Health Care System Model

The Neuman System Model or Health Care System Model

Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary To address the effects of stress and reactions to it on the development and maintenance of health. The con clients basic structure and to obtain or maintain a maximum level of wellness. The nurse helps the client to adjust to environmental stressors and maintain client stability.

Metaparadigm Person

A client system that is composed of physiologic, psychological, sociocultural, and environmental variable

Environment

Internal and external forces surrounding humans at any time.

Health

Health or wellness exists if all parts and subparts are in harmony with the whole person.

Nursing

Nursing is a unique profession in that it is concerned with all the variables affecting an individuals respo

Dorothea Orem (1970, 1985) Self-Care Deficit Theory

Self-Care Deficit Theory

Defined Nursing: The act of assisting others in the provision and management of self-care to maint effectiveness. Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-b Has a strong health promotion and maintenance focus. Identified 3 related concepts:

1. Self-care - activities an Individual performs independently throughout life to promote and mainta 2. Health - results when self-care agency (Individuals ability) is not adequate to meet the known sel 3. Nursing System - nursing interventions needed when Individual is unable to perform the necessa

Wholly compensatory - nurse provides entire self-care for the client. Example: care of a new born, care of client recovering from surgery in a post-anest Partial compensatory - nurse and client perform care; client can perform selected self-car needs the client cannot meet independently. Example: Nurse can assist post operative client to ambulate, Nurse can bring a mea Supportive-educative - nurses actions are to help the client develop/learn their own selfencouragement. Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychia

Dorothy E. Johnson (1980) Behavioral System Model

Behavioral System Model

Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can mo Viewed the patients behavior as a system, which is a whole with interacting parts. The nursing process is viewed as a major tool. To reduce stress so the client can recover as quickly as possible. According to Johnson, each person as a b 1. Ingestive. Taking in nourishment in socially and culturally acceptable ways. 2. Eliminated. Riddling the body of waste in socially and culturally acceptable ways. 3. Affiliative. Security seeking behavior. 4. Aggressive. Self protective behavior. 5. Dependence. Nurturance seeking behavior. 6. Achievement. Master of oneself and ones environment according to internalized standards of exc 7. Sexual role identity behavior In addition, she viewed that each person strives to achieve balance and stability both internally and extern environmental forces through learned pattern of response. Furthermore, She believed that the patient striv with social demands; who is able to modify his behavior in ways that support biologic imperatives; who i health care professionals knowledge and skills; and whose behavior does not give evidence of unnecessa

Metaparadigm Person

A system of interdependent parts with patterned, repetitive, and purposeful ways of behaving.

Environment

All forces that affect the person and that influence the behavioral system

Health

Focus on person, not illness. Health is a dynamic state influenced by biologic, psychological, and social f

Nursing

Promotion of behavioral system, balance and stability. An art and a science providing external assistance

Ernestine Wiedenbach (1964) The Helping Art of Clinical Nursing

The Helping Art of Clinical Nursing

Developed the Clinical Nursing A Helping Art Model. She advocated that the nurses individual philosophy or central purpose lends credence to nursing care. She believed that nurses meet the individuals need for help through the identification of the needs, admin Components of clinical practice: Philosophy, purpose, practice and an art.

Metaparadigm Person

Any individual who is receiving help from a member of the health profession or from a worker in the fiel

Environment

Not specifically addressed

Health

Concepts of nursing, client, and need for help and their relationships imply health-related concerns in the

Nursing

The nurse is a functional human being who acts, thinks, and feels. All actions, thoughts, and feelings und

Faye Glenn Abdellah (1960) Twenty One Nursing Problems

Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgemen Introduced Patient Centered Approaches to Nursing Model She defined nursing as service to individ conceptualized nursing as an art and a science that molds the attitudes, intellectual competencies and tech to help people, sick or well, and cope with their health needs.

21 Nursing Problems 1. To maintain good hygiene. 2. To promote optimal activity; exercise, rest and sleep. 3. To promote safety. 4. To maintain good body mechanics 5. To facilitate the maintenance of a supply of oxygen 6. To facilitate maintenance of nutrition 7. To facilitate maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic response of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory functions 12. To identify and accept positive and negative expressions, feelings and reactions 13. To identify and accept the interrelatedness of emotions and illness. 14. To facilitate the maintenance of effective verbal and non-verbal communication 15. To promote the development of productive interpersonal relationship 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying needs. 19. To accept the optimum possible goals 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the role of social problems as influencing factors Metaparadigm

Person

The recipients of nursing care having physical, emotional, and sociologic needs that may be overt or cove

Environment

Not clearly defined. Some discussion indicates that clients interact with their environment, of which nurse

Health

A state when the individual has no unmet needs and no anticipated or actual impairment.

Nursing

Broadly grouped in 21 nursing problems, which center around needs for hygiene, comfort, activity, rest and emotional health promotion, interpersonal relationships, and development of self-awareness. Nursing

Florence Nightingale (1860) Environmental Theory

Environmental Theory

Defined Nursing: The act of utilizing the environment of the patient to assist him in his recovery. Focuses on changing and manipulating the environment in order to put the patient in the best possible con Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and ligh Considered a clean, well-ventilated, quiet environment essential for recovery. Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the bod Developed the described the first theory of nursing. Notes on Nursing: What It Is What It Is Not. She f order to put the patient in the best possible conditions for nature to act.

Metaparadigm Person

An individual with vital reparative processes to deal with disease.

Environment

External conditions that affect life and individuals development.

Health

Focus is on the reparative process of getting well

Nursing

Goal is to place the individual in the best condition for good healthcare

Evelyn Tomlin, Helen Erickson, and Mary Ann Swa (1983) Modeling and Role Modeling Theory

Modeling and Role Modeling Theory

Developed Modeling and Role Modeling Theory. The focus of this theory is on the person. The nurse m interpersonal and interactive theory. They asserted that each individual unique, has some self-care knowledge, needs simultaneously to be atta Nurses in this theory, facilitate, nurture and accept the person unconditionally.

Metaparadigm

Person

A differentiation is made between patients and clients in this theory. A patient is given treatment and inst goal is for nurses to work with clients. A client is one who is considered to be a legitimate member of t the planned regimen, and who is incorporated into the planning and implementation of his or her own car

Environment

Environment is not identified in the theory as an entity of its own. The theorist see environment in the so both cultural and individual. Biophysical stressors are seen as part of the environment.

Health

Health is a state of physical, mental and social well-being, not merely the absence of disease or infirmit various subsystems [of a holistic person].

Nursing

The nurse is a facilitator, not an effector. Our nurse-client relationship is an interactive, interpersonal pr develop his or her own strengths.

Hildegard Peplau (1951) Interpersonal Relations Theory

Interpersonal Relations Theory

Defined Nursing: An interpersonal process of therapeutic interactions between an Individual who is sick educated to recognize, respond to the need for help. Nursing is a maturing force and an educative instrument Identified 4 phases of the Nurse - Patient relationship:

1. Orientation - individual/family has a felt need and seeks professional assistance from a nurse (who is a

2. Identification - where the patient begins to have feelings of belongingness and a capacity for dealing with inner strength ensues. Here happens the selection of appropriate professional assistance. 3. Exploitation - the nurse uses communication tools to offer services to the patient, who is expected to take 4. Resolution - where patients needs have already been met by the collaborative efforts between the patient links are dissolved, as patient drifts away from identifying with the nurse as the helping person. Metaparadigm Person

An organism striving to reduce tension generated by needs

Environment

The interpersonal process is always included, and psychodynamic milieu receives attention, with emphas

Health

Ongoing human process that implies forward movement of personality and other ongoing human process personal, and community living.

Nursing

Interpersonal therapeutic process that functions cooperatively with others human processes that make he educative instrument, a maturing force that aims to promote forward movement of personality.

Ida Jean Orlando (1961) The Dynamic Nurse-Patient Relationship

The Dynamic Nurse-Patient Relationship

Conceptualized The Dynamic Nurse Patient Relationship Model. She believed that the nurse helps patients meet a perceived need that the patient cannot meet for themselv assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness.

She emphasized the importance of validating the need and evaluating care based on observable outcomes To interact with clients to meet immediate needs by identifying client behaviors, nurses reactions, and nu

Metaparadigm Person

Unique individual behaving verbally nonverbally. Assumption is that individuals are at times able to mee

Environment

Not defined

Health

Not defined. Assumption is that being without emotional or physical discomfort and having a sense of we

Nursing

Professional nursing is conceptualized as finding out and meeting the clients immediate need for help.

Imogene King (1971, 1981) Goal Attainment Theory

Goal Attainment Theory

Nursing process is defined as dynamic interpersonal process between nurse, client and health care system Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists indi health. If is this not possible, nurses help individuals die with dignity. In addition, King viewed nursing as an interaction process between client and nurse whereby during perce occurred and goals are achieved.

Metaparadigm Person

Biopsychosocial being

Environment

Internal and external environment continually interacts to assist in adjustments to change.

Health

A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing

Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situations

Jean Watson (1979) The Philosophy and Science of Caring

The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health. Nursing is a human science of persons and human health-illness experiences that are mediated by profess transactions She defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a pe demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the pe Carative Factors: 1. The formation of a humanistic-altruistic system of values 2. Instillation of faith-hope 3. The cultivation of sensitivity to ones self and others 4. The development of a helping- trust relationship

5. The promotion and acceptance of the expression of positive and negative feelings. 6. The systemic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning 8. The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritu 9. Assistance with the gratification of human needs 10. The allowance for existential phenomenological forces Metaparadigm Person

A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated

Environment

Social environment, caring and the culture of caring affect health

Health

Physical, mental, and social wellness

Nursing

A human science of people and human health; illness experiences that are mediated by professional, perso transactions.

Joyce Travelbee (1966, 1971) Interpersonal Aspects of Nursing

Interpersonal Aspects of Nursing

She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing indivi regaining health finding meaning in illness, or maintaining maximal degree of health. She further viewed that interpersonal process is a human-to-human relationship formed during illness and

She believed that a person is a unique, irreplaceable individual who is in a continuous process of becomin

Metaparadigm Person

A unique, irreplaceable individual who is in a continuous process of becoming, evolving, and changing.

Environment

Not defined

Health

Heath includes the individuals perceptions of health and the absence of disease.

Nursing

An interpersonal process whereby the professional nurse practitioner assists an individual, family, or com suffering, and if necessary, to find meaning in these experiences.

Lydia Hall (1964) Core, Care and Cure Model

Core, Care and Cure Model

The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (cure) an Introduced the model of Nursing: What Is It? Focusing on the notion that centers around three componen Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emph to the physicians orders. Core and cure are shared with the other health care providers. The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitat

Metaparadigm Person

Client is composed of body, pathology, and person. People set their own goals and are capable of learning

Environment

Should facilitate achievement of the clients personal goals.

Health

Development of a mature self-identity that assists in the conscious selection of actions that facilitate grow

Nursing

Caring is the nurses primary function. Professional nursing is most important during the recuperative per

Madeleine Leininger (1978, 1984) Transcultural Care Theory and Ethnonursing

Transcultural Care Theory and Ethnonursing

Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific processes (cultural values, beliefs and practices) to improve or maintain a health condition. Nursing is a learned humanistic and scientific profession and discipline which is focused on human care p facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally m handicaps or death. Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative st health-illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nur values and health-illness context. Focuses on the fact that different cultures have different caring behaviors and different health and illness

Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Martha Rogers (1970) Science of Unitary Man

Science of Unitary Man

Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human development. The goal of nurses is to participate in the process of Nursing interventions seek to promote harmonious interaction between persons and their environment, str and environmental patterns or organization to achieve maximum health. 5 basic assumptions: 1. The human being is a unified whole, possessing individual integrity and manifesting characteristic 2. The individual and the environment are continuously exchanging matter and energy with each oth 3. The life processes of human beings evolve irreversibly and unidirectionally along a space-time co 4. Patterns identify human being and reflect their innovative wholeness 5. The individual is characterized by the capacity for abstraction and imagery, language and thought

Metaparadigm Person

Unitary man, a four-dimensional energy field.

Environment

Encompasses all that is outside any given human field. Person exchanging matter and energy.

Health

Not specifically addressed, but emerges out of interaction between human and environment, moves forwa

Nursing

A learned profession that is both science and art. The professional practice of nursing is creative and imag

Myra Estrin Levine (1973) Conservation Model

Conservation Model

Believes nursing intervention is a conservation activity, with conservation of energy as a primary concer client energy, conservation of structured integrity, conservation of personal integrity, conservation of soc Described the Four Conversation Principles. She advocated that nursing is a human interaction and pro concerned with the unity and integrity of the individual. The four conservation principles are as follows: 1. Conservation of energy. The human body functions by utilizing energy. The human body needs energy utilization output. 2. Conservation of Structural Integrity. The human body has physical boundaries (skin and muco and prevent harmful agents from entering the body. 3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of t sense of identity, self worth and self esteem, which must be preserved and enhanced by nurses. 4. Conservation of Social integrity. The social integrity of the client reflects the family and the com institutions may separate individuals from their family. It is important for nurses to consider the in

Metaparadigm Person

A holistic being

Environment

Broadly, includes all the individuals experiences

Health

The maintenance of the clients unity and integrity

Nursing

A discipline rooted in the organic dependency of the individual human being on his or her relationship wi

Rosemarie Rizzo Parse (1981) Theory of Human Becoming

Theory of Human Becoming

Nursing is a scientific discipline, the practice of which is a performing art Three assumption about Human Becoming 1. Human becoming is freely choosing personal meaning in situation in the intersubjective process o 2. Human becoming is co-creating rhythmic patterns or relating in mutual process in the universe 3. Human becoming is co-transcending multidimensionality with emerging possibilities.

Metaparadigm Person

A major reason for nursing existence

Environment

Man and environment interchange energy to create what is in the world, and man chooses the meaning gi

Health

A lived experience that is a process of being and becoming

Nursing

Nursing Practice is directed toward illuminating and mobilizing family interrelationships in light of the m the co created patterns of relating.

Sister Callista Roy (1979) Adaptation Model

Adaptation Model

Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who adaptation mechanisms. Presented the Adaptation Model. She viewed each person as a unified biopsychosocial system in const that the person as an adaptive system, functions as a whole through interdependence of its part. The syste Focuses on the ability of Individuals, families, groups, communities, or societies to adapt to change. The degree of internal or external environmental change and the persons ability to cope with that change Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptat To identify the types and demands placed on a client and clients adaptation to the demands.

Metaparadigm Person

Biopsychological being and the recipient of nursing care.

Environment

All conditions, circumstances, and influences surrounding and affecting the development of an organism

Health

The person encounters adaptation problems in changing the environment.

Nursing

A theoretical system of knowledge that prescribes a process of analysis and action related to the care of th

Virginia Henderson (1955) The Nature of Nursing Model

The Nature of Nursing Model

Introduced The Nature of Nursing Model. She identified fourteen basic needs. She postulated that the unique function of the nurse is to assist the clients, sick or well, in the performanc clients would perform unaided if they had the necessary strength, will or knowledge. She further believed that nursing involves assisting the client in gaining independence as rapidly as possib no longer possible. Defined Nursing: Assisting the individual, sick or well, in the performance of those activities contributin individual would perform unaided if he had the necessary strength, will or knowledge. Identified 14 basic needs :

1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range 8. Keeping the body clean and well-groomed 9. Avoiding dangers in the environment 10. Communicating with others

11. Worshipping according to ones faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing/participating in various forms of recreation 14. Learning, discovering or satisfying the curiosity that leads to normal development and health and using ava Metaparadigm Person

Individual requiring assistance to achieve health and independence or a peaceful death. Mind and body ar

Environment

All external conditions and influences that affect life and development

Health

Equated with independence, viewed in terms of the clients ability to perform 14 components of nursing c comfort, sleeping, resting clothing, maintaining body temperature, ensuring safety, communicating, wors

Nursing

Assists and supports the individual in life activities and the attainment of independence.

Physical Examination
Purposes The nurse uses physical assessment for the following reasons:

To gather baseline data about the clients health To supplement, confirm or refute data obtained in the nursing history To confirm and identify nursing diagnoses To make clinical judgments about a clients changing health status and management

Preparation of Examination

Environment A physical examination requires privacy. An examination room that is well equipped for Equipment Hand washing is done before equipment preparation and the examination. Hand washing re Client

1. Psychological Preparation clients are easily embarrassed when forced to answer sensitive ques and examined. The possibility that the examination will find something abnormal also creates anx priority before the examination 2. Physical Preparation the clients physical comfort is vital to the success of the examination. Be toilet. 3. Positioning during the examination, the nurse asks the clients to assume proper positions so tha Clients abilities to assume positions will depend on their physical strength and degree of wellness

Order of Examination

1. General Survey includes observation of general appearance and behavior, vital signs, height and weight 2. Review of systems 3. Head to toe examination

Skills in Physical Examination

1. Inspection to detect normal characteristics or significant physical signs. To inspect body parts accurate o Make sure good lighting is available o Position and expose body parts so that all surface can be viewed o Inspect each areas fro size, shape, color, symmetry, position and abnormalities o If possible, compare each area inspected with the same area of the opposite side of the body o Use additional light (for example, a penlight) to inspect body cavities 2. Palpation the hands can make delicate and sensitive measurements of specific physical signs, so palpat nurse uses different parts of the hand to detect characteristics such as texture, temperature and the percept 3. Percussion examination by striking the bodys surface with a finger, vibration and sound are produced. the character of the sound depends on the density of the underlying tissue 4. Auscultation is listening to sound created in body organs to detect variations from normal. Some sound sounds can be heard only through a stethoscope. o Bowel sounds o Breath sounds: Vesicular Bronchovesicular Bronchial Examples of Adventitious Breath Sounds 1. 2. 3. 4. Crackles (previously called rales) Rhonchi Wheeze Friction rub