BECOMING A STUDENT NURSE CHANNEL: visual (sight, observation, perception); auditory (hearing, listening)

kinesthetic (procedural touch, caring touch)

- make a work plan; be willing to accept changes in work load & assignment
- report to nurse/CI: patient’s request/complaint calling for prof nurse’s decision RECEIVER/DECODER- listen, observe, attend, interpret sender’s message
changes in patient’s condition/unusual for you - Decode: sort meaning; depends on similarity of knowledge, experience,
problem/question about your work sociocultural background
- be dependable: being on the job/being there on time; keep promises : decoded message = sender’s intent (effective/ineffective)
Doing assigned task & finish on time RESPONSE/FEEDBACK - message receiver returns to sender; verbal/non
- trustworthy: report accidents/errors; keep shared personal experiences Therapeutic Commun- promote understanding; establish constructive relationship
Avoid careless waste of materials/senseless abuse of equipment - goal-directed; nurse needs to respond to verbal message & feelings
PERSONAL HEALTH & HYGIENE- Attentive Listening- w/mindfulness, all senses; attention to details & total message
Visibly Tuning in- nonverbal behavior; convey empathy
Health- (WHO, 1948): complete physical, mental, social wellbeing; not merely absence
of disease/infirmity
Hygiene- self-care for skin, hair, nail, teeth, oral/nasal, eye, ears, perineal/genital
- accept responsibility to keep oneself/others healthy; 6-8 glasses of H2O
- obtain enough sleep/rest daily (6-8 hrs); eat balanced (protein, carb, fat, fiber)
- if over/underweight, consult to expert; bathe daily for health & social reasons
- use mild soap & skin cleanser; 3x daily mouth care; shampoo frequently
- attend hands for personal health & appearance; use lotion; keep fingernails trimmed
- wash feet, trim toenails straight across; hose must be larger & longer than foot
- check posture; keep even & keen emotion; do hobbies; be openminded

MODES OF COMMUNICATION
Communication- to collect assessment data, provide educ, interact by therapeutic
communication to promote personal growth & attain health goals
- (WHO) intimate connection for quality of care & meaning for patient & nurse
- (Kozier & Erbs) exchange info/feelings; basic comp of human relationship
Purpose: influence others & obtain info
Modes: VERBAL- spoken/written
Pace & Intonation- manner; rate/rhythm & tone; modify feeling & impact
- tone: enthusiasm, anger, amusement, sadness
- rate: interest, anxiety, boredom, fear
Simplicity- use common words, brevity, completeness Patient’s Call
Clarity & Brevity- direct & simple Timing & Relevance Humor - keep alert for patient’s call/bell; go immediately to patient’s bedside
Adaptability- alter acc to client’s behavioral cues - do what patient’s asks if you’re SURE it’s right & safe
Credibility- worthiness of belief, trustworthy, reliable - go at once to CI/Headnurse if you cant do request; place signal cord within reach
Personal Appearance- clothing, adornment; show financial status, culture Answering Phone
Posture & Gait- how we carry ourself; show self-concept, mood, health - when receiving, state: HOSPITAL, WARD, NAME, POSITION, “May I help you”
NONVERBAL/BODY LANGUAGE- gesture, touch - when someone’s looking for person: “Who’s calling pls? Just a minute”
Facial Expression Gesture- emphasize/clarify spoken words - when person concerned is out: “Sorry he’s not in, would you like to leave a message?”
- when terminating: “Thank you & goodbye”
ELECTRONIC- email, computer
Using Hospital Phone
Factors Influencing Communication Process
- length of call; don’t use for personal use; answer ward phone promptly; modulated voice
- Development - Personal space - Environment - Boundaries
- Gender - Territoriality - Congruence Bringing Cellphones
- Values & Perception - Roles & Relationship - Interpersonal Attitude - turn off to not disturb patients; don’t send text while on duty; answer only emergency
calls for 3 min max
Communication among Health Professionals
Think of patient as individual who:
- promote therapeutic communication in nurse & client
- needs help; have fears & worries on illness; allowed to maintain healthy; given privacy,
DISRUPTIVE BEHAVIOR: dignity, & maintain self-esteem; can continue to practice own customs; allowed to
Incivility- rude; cause psycho/physiological distress; cause threatening situat continue habits; know what you’re going to do
Lateral/Horizontal Violence/Horizontal Hostility- abuse to RN coworkers
To give care to patient means to
Bullying- repeated, unreasonable action to employee to intimidate, degrade
- help patient maintain physical fitness
RESPONSE TO DISRUPTIVE BEHAVIOR - provide comfy atmosphere; help prevent injuries & contracting new disease
Individual- be respectful, raise awareness; increase communication to intervene
Administrative- develop position statement that support 0 tolerance; define NURSING- act of utilizing patient’s env to assist in recovery
disruptive behavior not allowed; “ emotionally safe env; intervene - assist sick/well; perform unaided if one has strength, will, knowledge
during disrupting behavior; assess culture; model prof ethical behavior - common themes: caring, helping, client-centered, holistic, adaptive, art, sci
Nursing Academic Program & Nursing Continuing Education as art: require proficiency & dexterity
- develop/implement curricula to educate on & stop DB incidence as science: needs systematic application of scientific knowledge
- provide training in conflict management
- develop educ programs on strategies to recognize/address DP Characteristics of Nursing
- caring; involves close, personal contact w/care recipient
Nurse & Physician Communication - services that considers man as multifacet being
- Communication Styles - Assertive Commu - Submissive - committed to promote person & nat’l health goals in best manner
- Emotional Intelligence - Nonassertive “ - Aggressive - involved in ethical, legal, political issues in health care delivery
- utilize research to improve life quality
Components
SOURCE/SENDER- convey message; source-encoder Nursing Roles
- encoding: use symbols (language, tone, gesture, arrangement) THERAPEUTIC/HEALING/CURATIVE- use techniques for natural process of healing
- 2 language levels: layman’s & health professionals CARING/COMFORTING- provide support while preserving client’s dignity
- message: actually said/written COMMUNICATING- identify client’s needs & communicate to other healthcare team
TEACHING- impart info & reinforce change in client’s behavior TRANSFER- discharge patient from 1 unit & admit them to another unit
- assess learning need/readiness; set learning goals; enact learning strat; - informs patient/family, complete transfer summary, speaks w/ nurse on transfer
measure learning unit, transports patient/belongings & chart, checks orders/makes new
PLANNING- used during entire phases of nursing care; nurse plan addressograph card w/new room #
COORDINATION- to achieve high quality care; prevents unnecessary duplication/gaps Who/What involved in Planned Discharge
PROTECTING- “safety of patients” (falls, precautions, adverse reaction) Physician’s Order- unit secretary calls for transport; copy chart/order
REHABILITING- maximize patient’s remaining potential/capability (teach use of device) Care Provider- RN/social worker Safekeeping- extended care facility
SOCIALIZING- engagement of enjoyable, carefree convo; offers distraction from illness Patient- nurse explain discharge instructions to family/caregiver
COUNSELOR- help client recognize & cope w/problems Setting Standards
LEADERSHIP- influence others to work & accomplish goal - American Nurse’s Association sets standard for pt care; documentation for RN’s
- levels: clientele, colleague, community - IPN’s are governed by JCAH
ADMINISTRATIVE- nursing service is organized, coordinated, dispensed appropriately - don’t use “seems” /“appears” in documentation (implies doubt & lack of knowledge)
- determine if patient referred to community service
- interview patient to know perceptions about discharge & recovery
ADMITTING IN HEALTH CARE AGENCY - explore patient’s/family’s attitude & belief affecting health & illness
Involves: A. Authorization from Physician
B. Collection of Billing Info from Admitting Department DISCHARGING CLIENT FROM HEALTH CARE AGENCY
C. Completion of The Admission Process by Nursing
Purpose: to return person to state of independence
D. Documenting Pt’s Med Hx & Physical Exam
to provide continued care by home-health nurse/family assistance
E. Initial Med Orders for Treatment
Assessment:
Responsibilities of Admitting Department - Review discharge planning form; Discuss option after discharge
- Gather info for billing - Initiate medical record - obtain initial orders - Know if patient/fam has knowledge/skill to maintain current health. Explore dietary
- Prepare id bracelet (most effective way of identifying patient) change, medication administration, use & care of equipment
- May bypass in emergency situation - make addressograph card - identify if assistive devices (walker/commode) have been obtained
- Consent forms are signed (living will, directives, waivers) - check if home env’s been modified to avoid structural barriers
- Verbal report given to floor RN - Patient is escorted - assess if patient can obtain transportation for subsequent heathcare
- check if patient had contact w/social worker for finance, insurance assistance
Nursing Responsibilities
- know if patient’s been referred to community services
PREPARE ROOM- provide personal care items, suction, O2, IV pole - interview patient to know perceptions on discharge & discovery
- bed in high pos if arrived by guerney, low if arriving by w/c, blue pads if nec. - explore his & family’s attitude/beliefs that affect health/illness
IDENTIFY SELF- makes PT feel secure & welcome; alleviates anxiety/fear
Procedure: Check that patient has written discharge order
ORIENT PATIENT- location of nurse’s station, clothes storage, call light, bed controls
Patient/support person must have discharge instruction (diet, medication)
light switch, telephone policy, tv controls, mealtimes, safety measures (bedrail),
Return unused medicine & inform watcher that returning medicine after 72 hrs
visiting hours, scheduled tests, diet, room boundary, scheduled surgery time,
are not acceptable
times for dr visits
Scan computer for unrendered services before tagging “may go home”
GATHER INFO- medical order, TXs, lab, tests, diet, activity, physical assessment in 24hrs.
Send summary of discharge to accounting office; instruct watcher to go to
Types of Admission office for financial assessment & payment
INPATIENT- longer than 24 hrs Review chart for completeness
Planned: no immediate threat, planned elective surgery, tests, PT is prepared After bill settlement, watcher give discharge slip to headnurse for signature &
Emergency: unplanned, stabilize in emergency room (chest pain, trauma) return medications bought by patient outside hospital. Write exact discharge time
Direct: unplanned, bypass emergency (vomiting, diarrhea) Transport by wheelchair & assist into car, give discharge slip to guard
OUTPATIENT- < 24 hrs Strip linen & clean patient’s unit
Observational: head injury, premature labor, unstable vital signs Record patient chart & complete discharge summary
*log time of discharge in 24 hrs floor census & discharge notebook
Valuable- documents: use words: white/yellow metal not gold; clear stone not diamond
- have a witness, have nurse & PT sign valuables list, include dentures, glasses, DISCHARGE PATIENT AMA - send home patient per patient/relative on their will
- when transferring PT, sign-off w/ nurse, know facility’s valuables policy Reference: patient’s chart
Patient Comfort- provide privacy, assist if needed, collect info for database, performObjective: ensure proper communic to patient going home hot returned to normal health
initial admission assessment (some require RN to do initial assessments),Procedure: Patient- request discharge; sign form on discharge against advice present duly
obtain physician orders for TX’s, labs, tests, meds, activity, within 24hrs accomplished clearance to ward nurse
Staff nurse- refer request to physician; fill AMA form; request patient to sign
Components of Medical History prepare & send clearance slip to billing section
- identify data - personal hx - present illness hx - body systems review discharge him after duly paid & sign clearance slip w/date & time
- chief complaint - past health hx - family hx - conclusion discharge patient per wheelchair/stretcher
Attending physician- advise patient/watcher on implication & consequence of
What to observe in newly admitted:
discharge against advice; indicate AMA on patient’s chart
Anxiety- appearance: separation anxiety, worried, reduced appetite, insomnia, restless
- help: acknowledge feelings, explain & instruct before procedure, inquire on ABSCONDED- no medical order of MGH; went home, not able to settle hospital bill
stress due to children/pets/spouse at home, reassure Procedure: nurse must do rounds frequently
Loneliness- frequent contact w/patient, orient client, allow liberal visitation when nurse discovers that patient isn’t in bed/left unit, take note of date/time
Decreased Privacy- knock, pull curtains, identify room boundary, careful on exposing inform attending physician; document findings
patient, announce visitors after 24 hrs, patient hasn’t return, nurse may discharge him
Loss of Identity- use preferred name, allow using own gown, display pics, give choices OUT ON PASS/OOP
Procedure: patient inform nurse that they wish to go out on pass
DISCHARGE- end care from health care agency Nurse inform physician on patient’s request
- Meds Env Treatment Health Teaching Outpatient Referral Diet (METHOD) Physician explains consequence to patient & let patient sign on medical order
- AMA (against medical advice): PT leaves prior to obtaining written order. nurse sheet stating they go OOP & promise to comeback at what time
requests PT to sign form. if refuses, nurse let PT leave Nurse takes note of exact time patient left unit
& note refusal to sign AMA in chart. Upon patient’s return, nurse takes note of exact time & document
Nurse Responsibility for Discharging Patient OUT OF BED/OOB- has medical order of MGH; patient left unit w/o discharge slip
- gather belongings/check inventory - arrange transportation Procedure: nurse notes exact time patient left unit
- inform PT of checkout time - escort until PT safely inside vehicle check w/accounting department if patient paid hospital bill
- write discharge summary - terminal cleaning patient can be officially discharged after 24 hrs
 BODY MECHANICS WAXING- apply protective coating to area later polished by friction; wax, dust cloth
- efficient, coordinated, safe use of body to move objects and carry out ADLs - rub dust cloth to wax
- start: corner to center, top to bottom
Purpose: help safe/efficient use of appropriate muscle groups to maintain balance,
- may be followed: apply friction w/cloth & scrub floor for smooth/shiny finish
reduce energy, fatigue, risk of injury for nurse & client during transferring,
lifting, repositioning WASHING- depending on article to be washed
Avoid: work-related musculoskeletal disorder (MSD) (back/shoulder injury) DUSTING
Consider: assess weight, determine assistance needed, evaluate available resources acc to materials used: dry dusting- use dry cloth to remove dust (varnished furniture)
damp “ - use damp cloth to remove dust not destroyed by moisture
Principle of Balance acc to height:
- balance is maintained when object’s line of gravity passes through base of support low- all places easily reached by standing on floor; done daily
- center of gravity is constant: when object is tilted, line of gravity shifts away from - tray w/basin half-filled w/water, laundry soap, whisk broom/stick w/cloth on 1 end,
center of its base metal polish, dusting cloth, newspaper for lining
- lower center of gravity = more stable object - chair/stool: line w/newspaper & place tray on it (never on floor)
- start: from highest point towards floor
- between bars/crevice: use small brush, chicken feathers, stick w/cloth
- dusting bars: palm cloth & grasp bar as you wipe along surface
- if soap-water is used: rub cloth w/soap to area w/friction. Rinse & dry
- clean/oil furniture wheels; polish door knobs w/metal polish
Anatomical Position- balanced upright position high- easily reached by standing on chair; done periodically (general cleaning)
- feet apart w/toes pointed ahead, straight head, knees slightly flexed, - broom/brush w/long handle, newspaper to cover cabinet tops
torso straight, chin tucked in, arms hang loosely at sides, palms slightly - move all furniture to 1 side/cover w/newspaper; remove cobwebs from top to bottom
forward, elbow/fingers slightly flexed - window screen/bar: use dry cloth/soap & water
- body has ≈ same weight when divided to upper/lower (as you lean - sweep floor; dust inside cabinet
forward from hips, you throw half of total body weight out of alignment CARE OF LINEN- inspect if it needs mending; sorted; folded uniformly
Pivoting- body is turned that avoid spine twisting CARE OF MEDICINE CONTAINER
- place 1 foot ahead of other, raise heels very slightly, put weight on balls of feet.- Medicine: remove from shelf; bottles wiped w/damp cloth, don’t remove cap, label not
- when weight is off heels, frictional surface is decreased & knees aren’t twisted discolored
when turning - cabinet: cleaned w/damp newspaper; wiped w/dry cloth; lock after
- keeping body aligned, turn/pivot 90o to direction (foot forward now behind)
Daily Care of Unit
Remember: Work as close to center of gravity; Bend from hips & knees, never on back
Hold objects to be lifted as close to center of gravity Unit- area furnishings & equipment; needed for patient care
Flex hips & knees slightly in preparation for lifting/moving Suite- includes living room bedroom, bathroom
Always stand so as to face work Single room- furnishings, supplies for comfort & care for 1 person
Stabilize body against stationary object to prepare to move/lift Ward- many patients
Tighten abdominal & gluteal muscles for advanced lifting - maintain lighting/ventilation; dust all articles & arrange in good condition
Use body weight to assist moving/lifting towards direction of movement - check if trashcan are emptied & toilet/bathroom are cleaned
Roll, slide, pull, push object than lift - take flowers to utility room; buzzer: functioning properly, within easy reach
Pull than push if there’s option; use arms as levers in lifting
Elimination of Unpleasant Odor
Use verbal cues to synchronize move/lift
- patient cleaned daily; bed linen changed acc to hospi policy
- soiled linen & garbage disposed properly
HOUSEKEEPING - water in flower vase changed daily; receptacles of patient excrete cleaned
- provide patient w/safe, pleasant, suitable env - bathroom cleaned daily, clean mop free from odor
Responsibility: daily car of patient’s unit; care of departmental facility Cleaning Toilet & Bathroom
Clean room after discharge of patient for next patient - scrub tiled walls; flush toilet, clean w/soap/brush on outside portion
Control insect/pest - scrub floor; wipe walls, outside toilet bowl; replenish tissue supply
Factors: furniture must be clean & in good working condition Lavatory & Sink
Equipment for personal care must be cleaned/ready to use at all times - wash w/soap-water using mop/brush; use cleanser for stains; rinse/dry w/damp cloth
Solid waste must not be thrown in toilet; Report damage to carpentry shop
Immediately clean spillage on furniture Care of Bed
Bed cranks: pull completely out to elevate/lower head/foot of bed - comfort + rest & sleep = health & recovery from disease
Daily clean room: don’t marred/scratch furniture - meal, recreation, occupation, exercise may be done in bed
- mattress brush, basin half-filled water, detergent, dust cloth, chicken feathers, lubricant
Cleaning Operation
WASTE SEGREGATION
Purpose: to maintain safe, clean, healthful surrounding for patient, visitor, staff
Black- dry waste, nonbio Yellow- infectious Orange- radioactive
SWEEPING- equipment: broom/brush, dust pan, trashcan Green- wet, bio Red- sharps
- trashcan: out of traffic but near place of work
- start: entrance w/proper strokes toward center; accumulate dirt in dustpan into trash MICROORGANISM
- if dust is heavy: tap brush/broom on floor at end of each stroke to free dirt
- mostly harmless, some beneficial, some resident flora
- after sweeping: examine floor/dust streaks
- characteristics: virulence, severity of disease, degree of communicability
- straighten furniture; clean equipment used & return to proper place
RESIDENT FLORA: Staphylococcus epidermis, Propionibacterium acnes, staphylococcus
MOPPING- floor mop, pail w/soap solution, pail w/rinsing water, mop wringer
aureus, streptococcus pneumoniae, lactobacillus, fusobacterium,
- dip mop in soap solu, place into wringer & wring
clostridium, candida albicans
- starting from corner, mop floor by firm & heavy strokes to loosen dirt
- rinse & dry until whole area is mopped; clean all tools & return to proper place Infection- invasion by microorg/infectious agent
a. asymptomatic/subclinical stage b. disease/detectable alteration
SCRUBBING- rub hard using brush w/w/o soap & water i

- coconut husk/electric polisher, brush, pail w/soap solu, pail w/rinsing water,Pathogenicity- ability to produce disease by pathogen
mop, dust cloth a. true pathogen (healthy person) b. opportunistic pathogen (only in susceptible)
- dip brush in soap solu, rub against surface; use long strokes & follow grain of wood Nosocomial Infection- associated w/delivery of healthcare service
- wipe dry using same strokes; after care of tools - develop during client’s stay in facility/after discharge
- develop in urinary tract, respiratory tract, bloodstream, wound
ASEPSIS- absence of microorg; Aseptic technique- prevent pathogen transmission d. When stripping & making bed, make up 1 side as completely as possible before other side
a. Medical- to confine microorg; limit number, growth, transmission (to conserve time & energy)
clean: absence of almost all morg; dirty: soiled, contaminated e. Gather all needed linen before starting to strip a bed (avoid trips; conserve time & energy)
b. Surgical- free of all morg; destroy morg including spores f. Do medical handwashing in making bed (prevent transfer of microorg to hands)
- In procedures involved in sterile areas of body; sterile vs unsterile g. Observe proper body mechanics (avoid muscle strain)
h. Linen must be smooth & wrinkle-free to avoid decubitus ulcer/ bed sores
Chain of Infection
Ulcer- deeper loss of epidermis & dermis; may bleed & scar
- ex: stasis ulcer of venous insufficiency, syphilitic chancre

4. TRANSMISSION:
a. Direct
b. Indirect: vehicle & vector
c. Air: large droplet, small droplet, droplet nuclei (settle longer)
6. SUSCEPTIBLE HOST: susceptible- can be affected but can resist
Compromised- immune system compromised, def catch disease
Disinfectant- chemical preparation; phenol/ionic compounds used on inanimate object
Antiseptic- on skin
Sterilization: moist heat, gas, boiling water, radiation
Handwashing- atleast 10-30 sec vigorous washing w/plain soap/disinfectant & water areas susceptible to ulcerations: over bony prominence (spine/scapula) & buttocks
- equipment: liquid/bar soap, towel, sink w/running water, trashcan, tissue
Types of Faucet: Knee-lever, Foot-pedal, hand-operated, long-lever
VITAL SIGNS
Times to assess: on admission, institution policy, before/after invasive
HOSPITAL BED-MAKING procedure/medication, change in client’s condition,
- apply/change bed linens; process: series of actions, sequence, step by step Cardinal Signs- reflect body’s physiologic status to regulate temp, maintain local &
Hygienic Env: Env – assess age, severity of illness, level of activity systemic blood flow, oxygenate tissues
Room temp–20-23 C (very young/old, acutely ill need higher)
Ventilation- remove pleasant odors (urine, draining wounds, vomitus)
a. BODY TEMP- reflect balance in heat produced/loss; measured by degrees
types: Core-deep tissues (abdominal/pelvic cavity) Surface- skin, subcutaneous tissue, fats
Prerequisites
Factors: Age- young: ↑ BMR = ↑temp
1. Principle of Medical Handwashing (basic in all nursing procedures)
Diurnal Variation/Circadian Rhythm- highest: 8 pm-midnight; lowest: sleep 4-6 am
2. Principles & Rules of Body Mechanics (observed all throughout)
Exercise Hormones- epi/norepinephrine; progesterone : ↑ BMR = ↑temp
3. Turning a client on his side (occupied bed)
Stress- SNS stimulation Environment
4. Moving a client toward head of bed
5. Knowing type of hospital bed Alteration:
PYREXIA/HYPERTHERMIA/FEVER - abnormal ↑ temp
HOSPITAL BED- 66 cm (26 in) high; 0.9 meters (3 ft) wide; 1.9 m (6.6 ft) length
Hyperpyrexia- very high fever Febrile- client w/fever
Reason: so nurse can reach client from other side & prevent muscle fatigue to nurse
Fever types: Intermittent- alternating temp at reg intervals between fever & normal temp
Standard Equipment: Remittent- wide fluctuations (>2 C) over 24 hrs (above normal)
Mattress- inner springs (even support to body); covered w/H2O repellent material Relapsing- short febrile for few days interspersed of ½ days of normal temp
that resists soiling & can be easily cleaned Constant- fluctuate minimally but remain above normal
- relieve pressure on bony prominences; helpful for those confined for long
Siderail/Safety side- standard to all beds; used in hospital beds & stretchers
Hand crank- 1. Raise head, knee, feet
2. Assist in positioning patients safely & comfortably
3. Height is adjustable for convenience of staff
Wheel lock- engaged by foot; to prevent bed from moving
Client Signal- within easy reach; instruct client how & when to use Fever Spike- temp rise to fever rapidly after normal temp & returns to normal in few hrs
Bed Positions Fever resolution: Resolution-by-crisis Resolution-by-lysis
Flat- common; mattress completely horizontal
Fowler’s- sitting pos; semi-fowler (head raised 15-45o), fowler (head & trunk at 90o)
- relief from lying, for eating & reading; position of choice to patient w/
difficulty of breathing & with cardiac problems HYPOTHERMIA- abnormal ↓ temp
- gravity pulls downward, allowing greater lung expansion Types: Accidental- expose to cold env, cold H2O immersion, lack clothing, house, heat
Trendelenburg- bedhead lowered, bed foot elevated; for postural drainage Induced
- contraindicated for those w/ head injuries, chest injury, resp distress. Thermometer- inaccurate if client ingested hot/cold food/fluid; thermo break if bitten
Reverse Trendelenburg- straight tilt on opposite direction; head elevated, foot lower Rectal
- for those w/problems in arterial circulation to leg - reliable; C/I for w/MI, clotting d/o, rectal surgery, hemorrhoid, least desirable for baby
Hyperextension- head & foot lowered 15o; for clients w/ fracture Axillary- for newborns; not accurate to detect fever in infants
- only w/specific orders & continuous nursing assessment of client Tympanic- readily accessible core temp; risk of injuring tympanic membrane
Other bed types: (ppt) Types: Mercury In-glass, Electronic, Chemical disposable, Temp-sensitive, Infrared,
Concepts in Bedmaking Temporal artery
a. Linen soiled w/secretions & excretions have microorg that can be transmitted directly Scale: Degrees (Celsius centigrade/Fahrenheit)
(nurse wash hands thoroughly after handling, hold soiled linen away from uniform)
b. Soiled linen is never shaken in air (disseminates microorg)
c. Soiled linen is placed directly in portable linen hamper/soiled pillowcase
Thermal Balance Indicators to heart fxn: Stroke Volume- blood # ejected from heart w/each beat
Cardiac Output- “ “ “ each minute
Heart Rate- # of beats/minute; directly proportional to CO
Preload-left ventricular & diastolic volume stretch of myocardium
Afterload- resistance where heart pump to eject blood into circ
Contractility-myocardium inotropic state; contraction strength
Rate factors: Fever, Medication, Hypovolemia, Stressor, Position change, Pathology
Actual assessment site: 4th, 5th, 6th intercostal space, left midclavicular line
Heat Production
Normal result: Normal- S1 heard all sites, louder at apex; S2 all sites, louder than base
Factors: BMR- rate of energy utilization Stress Fever Heat Loss
- S3 in children & young adult; S4 in older adults
Muscle activity Thyroxine- effect: chem thermogenesis
Factors: Radiation- heat transfer w/o contact between object (infrared, sunlight) d. BLOOD PRESSURE- measure pressure exerted by blood as it flows through arteries
Conduction- “ between objects in contact - systolic & diastolic pressures; 120 (SBP)/ 80 (DBP) mmHg
Convection- heat disperse air current; warm air rise & replaced by cooler air Determinants: Cardiac Contractility, Periph Vascular Resistance, Blood Vol, B Viscosity
Vaporization- moisture evap from body surface (insensible water/heat loss)
Sites (Alternatives) BP can’t be measured on either arm; BP comparison
Bulky Cast presence; Limb surgery; IVF Infusion; AV fistula/shunt
b. PULSE- blood wave by contraction of left ventricle; expressed in bpm
- represent stroke volume output & blood # enter artery w/each ventricle contract Factors: Obesity, Medication, Race, Disease Process, Diurnal Variation, Stress
Method: Direct- insert catheter into brachial, radial, femoral artery
Compliance- contract & expand Peripheral Pulse- located away from heart
Indirect- auscultatory & palpatory
Cardiac Output- blood volume into arteries by heart (CO = SV x HR)
Apical Pulse- central pulse on heart apex Errors in Checking: BP cuff too narrow/wide; unsupported arm; insufficient rest; failure to use
same arm consistently, arm above/below heart level
Sites: Radial- readily accessible Temporal- when radial inaccessible
Pulse Pressure- difference in DBP & SBP; normal: 40-100 mmHg
Carotid cardiac arrest/shock; determine brain circulation
Korotkoff’s Sounds- during auscultatory checking of BP
Apical- < 3 y/o Brachial- measure BP; infant cardiac arrest
Phase: Sharp tapping, Swish/Whoosh, Thumb, Muffled Blowing, Silence
Femoral- cardiac arrest/shock; leg circulation Popliteal- LL circulation
P. Tibialis & D. Pedis- foot circulation
e. PAIN- unpleasant sensation; assessed in multidimensional approach; sign, symptom
Assess: Palpation, Auscultation, Doppler Ultrasound Stethoscope
Pulse Rhythm- beat pattern & its intervals assessment show: onset, duration, quality, aggravate/alleviating factor; severity, barriers
Dysrhythmia/Arrhythmia- irregular; random/predictable beats; need ECG/EKG Scale: Single-Dimensional- only by self-reporting
Multidimensional- intensity, nature, impact on mood, location
Rate: Tachycardia- excessive fast heart rate Bradycardia- decrease rate
Pulse Volume/Pulse Strength/Amplitude - blood force w/each beat Elderly- hard bc: underreporting, medical comorbidity overshadow pain; ↓ sensory
Infant- use behavioral & physiologic measurements
Normal- felt w/moderate pressure of fingers Young Children- limited cognitive/language; >3 y can use self-report
Full/Bounding- forceful/full blood volume, difficult to obliterate
Weak, Feeble, Thready- readily obliterated w/finger pressure
Elasticity of Arterial Wall- expansibility/deformity; normal: straight, smooth, soft, pliable
Apical Assess- irreg/no peripheral pulse;, w/cardiov, pulmonary, renal disease
- commonly assess prior cardiotonics; newborn, infant, children (2-3 y/o)
Apical-Radial Pulse: Normal- apical-radial rates identical
Abnormal- apical > radial; pulse deficit- discrepancy in 2 pulse rate
 apical pulse will never be lower than radial pulse

c. RESPIRATIONS
types: Costal/Thoracic- external intercostal muscles & accessory muscles (sternocleido)
Diaphragmatic/Abdominal- contraction & relaxation of diaphragm
Inspiration (active)- chest cavity size; intrathoracic pressure = negative; air into lungs
Expiration (passive)- recoil of stretched chest wall & lung; chest cavity size decrease
- intrathoracic pressure ↑; air away from lungs
Mechanism:
Lung Pressure: Inhale = (-) pressure (lung expansion) Exhale = + press (lung recoil)
Rate- bpm Depth- watching chest movement Rhythm Quality & Effectiveness VS RECORDING
Abnormal pattern: Rate: Tachypnea, Bradypnea, Apnea Ease/Effort- dys/orthopnea Where to record:
Volume- hyper/hypoventilation VITAL SIGNS MASTERLIST
Quality & Character- Stridor, Stertor, Wheeze TPR SHEET
PATIENT’S CHART: Graphic Chart, Vital Signs Sheet, Nurses Notes
Considerations:
- reassessment of abnormal results before recording
- follow protocol on use of appropriate pen colors
- ask permission before using patient’s chart
- mistaken entry in chart isn’t allowed
- no tampering of entries

Top to bottom:
Bath blanket
Bottom sheet
Top sheet
Pillowcase
Cardiovascular system- O2 transport, nutrition, waste removal
- hollow, cone-shaped in mediastinum between lungs underlying sternum Morning care- AFTER breakfast
Cardiac Cycle/Heartbeat: Systole/Contract- heart eject blood into pulmo & systemic circ
Diastole/Relax- ventricles fill w/blood
 PROVIDING HYGIENE Requisites: Bath blanket/large towel 3 Bath towels 1 towelette
3 wash cloth patient clothing linen
Hygiene- science of health & maintenance
Tray w/: wash basin half filled w/water temp preferred by patient
- personal hygiene: attend to functions as bathing, toileting, grooming
Soap in soap dish; patient comb/hair brush
SKIN Talcum powder/lotion/oil; pair of nail cutter
Function: protection, thermoregulation, sensation transmission, sebum, vit D 2 pitchers (1 w/cold, 1 w/hot water); paper for lining; bath thermo
Sudoriferous/Sweat Glands Pail for used H2O Bedpan/urinal Laundry bag 2 pairs working gloves
Apocrine- axillae & anogenital areas; odorless turn to musky odor w/bacteria
Eccrine- palms, feet, forehead Tubular Secretion- absorption- convoluted tubule
Skin Problem: Abrasion Excessive Dryness Ammonia Acne
Erythema Hirsutism Hyperhidrosis Bromhidrosis URINE ELIMINATION
General Guidelines on Skincare URINARY SYSTEM - produce & excrete urine (liquid waste)
- component: kidneys, ureters, bladder, urethra
1. Intact, healthy skin is body’s 1st line of defense
Function
2. Degree where skin protect underlying tissue depend on cell, subcutaneous tissue #,
Ureter- transport urine from kidneys to urinary bladder
skin dryness
Bladder- store urine
3. Moisture in skin in long time increase bacterial growth & irritation Urethra- discharge urine from body
4. Body odors are caused by resident skin bacteria acting on secretion Kidneys- excrete waste in urine; regulate blood volume & composition & BP; make glucose,
5. Skin sensitivity to irritation varies acc to health release erythropoietin; participate in vit D synthesis
6. Skin agents have selective action/purpose
Types of Hygienic Care NEPHRON
1. Early Morning 3. Afternoon 5. As-needed/prn care - kidney’s functional unit; actually produce urine when removing waste from blood
2. Morning (after breakfast) 4. Hour of Sleep 6 parts: glomerulus, Bowman’s capsule, proximal tubule, Loop of Henle, distal tubule,
collecting duct
BATHING- remove accumulated oil, perspiration, skin cell, bacteria
- stimulate circulation; sense of wellbeing; allow nurse to assess
2 bath types:
Cleaning- complete bed bath: nurse wash entire body of dependent patient
- self-help “ “ : bathe oneself w/help of nurse to wash back & feet
- partial: only parts that cause discomfort/odor (face, hands, axillae)
- towel: in-bed bath using quick-dry solution w/disinfectant & softening
agent in H2O
- Bag: use solution & wash cloths warmed in microwave
- Tub: immerse body in tub of water
` - Shower: w/shower chair
Therapeutic- to soothe irritated skin/treat area medications in water
SHAMPOO IN BED- wash hair w/shampoo/bath soap
Purpose: cleanse hair/scalp; maintain/improve self-esteem
Treat scalp conditions w/topical medical application
Remove blood, secretion, electrode jelly (electroencephalogram)
Assessment:
- examine hair’s distribution, cleanliness, texture, parasitic infection
- inspect scalp for laceration, dry scaly patches, scratch, lesions, swelling
- observe signs of itchiness of scalp & dandruff on shoulders/back clothing
- know if patient has toxic chemo/radiation that cause hairloss
- read medical record for pathology (hypothyroidism, steroid therapy)
- know if there’s sensory, cognitive, endurance, mobility, motivational deficits
- ask usual routine of shampooing (frequency, hair products)
- ask if there’s itching, burning, scalp tenderness; history of scalp/hair problem

FOOT & TOENAIL CARE

Purpose: cleanse & promote feet comfort; maintain integument integrity
stimulate circulation to lower extremity; prevent injury; treat inf; prevent odor
equipment: warm water in pitcher, wash basin, soap in dish, 2 hand towels, nail GLOMERULAR FILTRATION- water & solutes in blood filter across glomerular capillaries’
cutter/scissor, nail file, lotion/power (optional), waterproof underpad, wall into Bowman’s capsule then into renal tubule
working gloves, nail brush Daily filtrate: 150 L (female) 180 L (males)
TUBULAR REABSORPTION- tubule cells reabsorb 99% of filtered water & useful solutes
CLEANSING BED BATH
Purpose: cleanse body, refresh patient, stimulate circulation, exercise muscle/joint,
tactile stimulation, comfort/relaxation, self-concept, head-to-toe assessment
Instruction:
1. privacy; bed is screened if in ward; windows is adjusted in PR
2. Bed bath given 1 hr before/after meals
3. Have everything ready; if patient is weak; assist to prevent exertion from px
4. Children never alone while bath is ongoing; avoid exposure of chilling
5. Focus on behind ears, axillae, umbilicus, pubis, groins, between fingers/toes, areas
where 2 skin surfaces contact
6. Observe objective signs as rash, swell, discoloration, pressure sore, discharge,
abrasion, lice, burn (recorded in nurse notes)
7. Enema, douches, field preparation must be before bath so patient is clean
8. Nurse may work quickly but must be quiet soothing & unhurried fashion; strokes are
smooth & firm, ends of washcloth must not dangle
 Problems in Urinary Elimination
ALTERED URINE COMPOSTION: Hematuria (RBC) Pyuria (pus/WBC) Bacteria
Albuminuria (albumin) Proteinuria (protein)
Glucosuria (glucose) Ketonuria (ketones)
ALTERED URINARY PRODUCTION
Normal urine output: 30-60 cc/hr (Polyuria: > 30 cc/hr) (Oliguria: < 30 cc/hr)
(Anuria: < 10 cc/hr or none)
Oliguria & Anuria- describe decreased urinary output
Oliguria- low urine output (< 500 ml/day)
ALTERED URINARY FREQUENCY
U. Frequency- voiding at frequent intervals (> 4-6x/day); ↑ fluid intake = ↑ voiding freq
Nocturia- ↑ urinary freq at night (2 or more x/night); expressed in # times one gets out of
bed to void (ex: “nocturia x 4”)
Urgency- sudden, strong urge to void immediately; not/may great deal of urine in bladder
- accompanies psychological stress & urethra irritation
Enuresis- involuntary urination in children beyond age of voluntary bladder control (4-5 y/o)
Urinary Incontinence/Involuntary/Loss of Bladder Control
- health symptom, not disease; only normal in infants
Retention- can’t empty all urine from bladder
URINARY TRACT OBSTRUCTION
Clinical sign: a. discomfort in pubic area b. bladder distention
- blockage inhibiting urine flow through its normal path (urinary tract) & kidneys,
c. Inability to void/frequent voiding small #
ureter, bladder, urethra
d. disproportionately small # output in relation to fluid intake
e. ↑ restlessness & feeling of need to void
Dysuria- painful urination
Hesitancy- difficulty in initiating voiding of atleast 5 secs

Nursing Interv to Induce Voiding

1. Provide privacy (most effective)
2. Encourage ↑ OFI (unless contraindicated), CHF, CRF
3. Assist in anatomical position of voiding 4. Serve clean, warm, dry bedpan/urinal
5. Allow patient to listen to sound of running water
6. Dangle patient fingers in warm water 7. Pour warm water over perineum
8. Provide adequate time to void
9. Do Crede’s maneuver: if bladder is distended C/I crede’s
Only if w/difficulty in voiding & w/o distention
10. Administer cholinergic as ordered 8. Last resort: urinary catheterization
Purpose of Catheterization
URINARY TRACT INFECTION
- relieve discomfort bc of bladder distention/give gradual decompression of distended blad
- inflammation of urinary epithelium in response to pathogen colonization
- assess # residual urine if bladder empties incompletely
- caused by E.coli, Staphylococcus, Proteus, Klebsiella
- obtain sterile urine specimen; empty bladder completely prior surgery
NORMAL URINE Types of Catheter
1. STRAIGHT- for urine specimen; 1-time removal of urine from bladder
2. 2 WAY/RETENTION/FOLEY CATH

EXTERNAL DOUCHING
Mons veneris- rounded, soft, fatty, loose connective tissue over symphysis pubis
- where dark and curly pubic hair grows
Labia majora- lengthwise fatty folds of skin from mons to perineum
- protects labia minora, urinary meatus, & vaginal introitus-
Labia minora- thinner, lengthwise w/hairless skin; Fxn: Glands lubricates vulva
Clitoris- small erectile organ beneath pubic arch; more nerve endings than glans penis
- sensitive to temp & touch; secretes a fatty substance smegma
Vaginal Orifice- elastic, partial fold of tissue surrounding opening to vagina
Urethral “ - external opening to urinary bladder
Perineum- muscular, skin-covered area between vaginal opening & anus
External Douche
- Washing of genitals & anal area w/plain water & medicated solution.
PERINEAL-GENITAL CARE/PERINEAL CARE/PERI CARE (kozier)
Indications: Patients who underwent perineal, rectal or genital surgery.
 POSTPARTUM HEMORRHAGE
- blood loss of: 500 ml or more= after vaginal birth; 1000 ml or more= after cesarean birth
HYPOVOLEMIC SHOCK- emergency situation; 30-40% blood loss

Purpose
1. To cleanse area of secretion & excretion 2. To reduce unpleasant odor CLEANING THE PENIS
3. To prevent skin irritation & excoriation 4. To control the potential for infection FIRST: Glans
5. To promote comfort 2ND: Glans penis
Equipment 3RD: Shaft (all, going down)
- Bedpan w/cover - Waterproof underpad - Bath blanket 4TH: BASE TO OUTWARDS (TOWARDS SCROTUM)
- tray containing: a. sterile covered flushing can w/sterile water/solution to be used 6TH: UNDER BALLS
b. sterile pick up forceps in a disinfectant sol’n 7TH: FROM UNDER TOWARDS
- jar of dry sterile CB: d. a jar of sterile CB soaked in soap sud solution WET, SOAK, RINSE, DRY
e. A jar of sterile CB soaked in antiseptic sol’n
f. Kidney basin lined in paper for waste
g. Toilet paper (patient’s supply)
h. A piece of paper to wrap vaginal pads
i. working forceps in a sterile pack
` j. working gloves
- Adult diaper/sanitary pad (patient’s supply)
Circumcised Penis
PENIS –spongy tissue cavernous bodies-sound fill w/ blood.
- Main vehicle for semen from male into vagina for reproductive purposes.
Scrotum- small walnut- shaped wrinkled bag of skin that holds testicles.
Testicles- contains seminiferous tubules; manufactures > 250 mil sperm cells per day.
Prostate Gland- control mechanism to stop urine & semen from mixing together
- urine & semen are discharged through urethra

WATER: farther thigh (outer) towards center (perineum), nearer thigh (outer) towards
center, then center
SWABBING: 1. Tip of clitoris up to mons pubis to lower hypogastrium
2. farther thigh (inner part of groin to outer thigh)
3. Near thigh (inner part of groin to outer thigh)
What to assess (EPISIORRHAPHY) 4. farther labia majora to perineum
- assess vulva (presence of hematoma), vaginal discharges, episiotomy (surgical cut) 5. Nearer labia majora to perineum
R – redness 6. Clitoris to urinary meatus to vaginal orifice to perineum
E – edema 7. Clitoris, urinary meatus, vagina, perineum, anus
E – ecchymosis (bluish discoloration) WATER: farther thigh (inner to outer), nearer thigh (inner to outer), then center
D – discharge
A – approximation (check if stitch is open)
Secretions post-delivery
LOCHIA RUBRA (1-3 days)- dark-red in moderate amount
LOCHIA SEROSA (4th – 7th day)- pinkish to brownish in decreased amount
LOCHIA ALBA (8th day – 2 weeks)- whitish scanty discharges
Characteristics of Bleeding
birth of fetus until placenta separation- excessive bleeding
Hypothalamus (assisted by
Dark blood – venous (superficial laceration) Bright blood – arterial (deep) medulla oblongata

Spurts of blood with clots – partial placenta separation

What ELSE to assess
- if discharge is dark red (indicate retained placental fragments)
- smell: must never have foul, musty smell (indicate infection)
- # of discharge (if exceeds 250-300 cc of blood = post-partum hemorrhage)
DRY HEAT- to sterilize sharp instruments
BOILING WATER- least expensive but less efficient
 sterile field is maintained by: instruments on sterile towel on top of table until it’s used
 if sterile barrier is breached, PLACE ANOTHER STERILE DRAPE ONTOP OF OLD DRAPE

Heat = ↓ BP Cold = ↑ BP
USE HEAT FOR: non-inflammatory pain/chronic (↑ inflammation, delaying healing)
USE COLD FOR: acute injury/inflammation (minimize swelling)
Inner thigh

Gout - Cold
Nosebleed - Cold
Sprain - Cold
Strain - Hot/Cold
Back Spasm - Hot
Amputated Finger - Cold
5-degree burn - Cold
Stiff Neck - Hot
Sty - Hot
Insect Bite - Cold
Fever - Cold
Menstrual Cramps – Hot

MEDICATION- given w/purpose; given by NURSE

DRUG- the thing you give

Polypharmacy- 4-9 medications

Excessive: 10+

Digoxin- antidote for digibind

Marijuana- natural

Over-the-counter- paracetamol (bc it doesn’t harm)

Prescription-only- antibiotic (multi-drug resistance)
- dangerous drugs (addictive)
- given by DOCTORS, NURSES IN RURAL UNITS
Behind the counter- vitamins, supplements

Superscription/heading/patient info
Prescriber’s signature- doctors signature w/PTR & license
PTR- if patient is a senior who needs a discount

Generic name- chemical

Brand name- by manufacturer
Trade name-

Adverse effect- STOP MEDICATION!

CATHETER
Sizes:
10-12 (children)
6-8 (newborn)
12, 14, 16 (adult)

16- orange
10- white
18- gray
25-
HOT APPLICATION:
- place bag with opening AWAY from patient. Stay w/patient for first 15 min to ensure
safety & observe their response
- therapeutic effect last for 20-30 min, beyond 40 min, tissues congest & vasoconstrict
= REBOUND EFFECT)
COLD APPLICATION: topical anesthesia

DRUG ADMINISTRATION
- med is administered determining whether patient gains clinical benefit/suffer adverse  Curative- cures disease (antibiotics)
effect  Restorative- return body to health; agent promoting renewal of health/strength

Drug/Medication- affect living process; diagnose, cure, mitigate, treat, prevent (FDA) - Total Parent Nutrition, IV fluids
 Supportive- support body function until other treatment/body response can take over
Pharmacology- study of drugs & interactions w/living systems
- bronchodilator
Pharmacopoeia- book w/list of products in medicine w/descriptions, chemical tests to
 Substitutive- replace body fluid (insulin, thyroid hormone)
determine identity & purity, formulas/prescription
Pharmacy- art of preparing, compounding, dispensing drugs d. Secondary Effect- unintended; occur w/usual therapeutic doses
Polypharmacy- use of multiple meds by patient esp when too many meds are e. Adverse “ – abnormal, harmful, undesirable; cause anatomical/functional damage,
used/prescribed than clinically warranted irreversible physical change, increase susceptibility to stress

Drug Sources Stevens-Johnson Syndrome- fatal form of erythema multiforme present w/flulike prodrome
- severe mucocutaneous lesion w/pulmonary, cardiac, gastrointestinal, renal
NATURAL–from plants (digitalis), animals (insulin), inorganic comp (aluminum, gold)
Ex: opium, digitalis, iron, NaCl, Insulin, Vaccines
TOXICITY/TOXIC EFFECT- degree to which something is poisonous
SYNTHETICS/NON-NATURAL – from starting materials not found in nature - result from exposure to toxin/toxic # of substance that doesn’t cause
Ex: Sulfonamides (antibiotic), Propoxyphene HCl adverse effect in smaller #
Drug Classifications IDIOSYNCRASY/TYPE B REACTION
OTC (Over-the-Counter)– available w/o special restrictions/don’t need prescription; - rarely, unexpected/unexplainable effect; peculiar/indiv reaction
legally safe for the lay person to use when taken acc to directions - uncommon response to drug bc of genetic predisposition. Manifests as abnormally
Ex: Paracetamol, Acetaminophen, Aspirin short/large/long response to drug but possible for response to be qualitatively different
POM (Prescription Only Medicine)- prescribed by licensed medical practitioner HYPERSENSITIVITY- state of altered reactivity; exaggerated immune response to foreign
Ex: Antibiotics DRUG ALLERGY- hypersensitive state from exposure to drug
BTC (Behind-the-Counter) – don’t need prescription, but kept in dispensary not visible ANAPHYLAXIS- rapidly progressing, life-threating allergic reaction where immune sys respond
to the public, & only sold by a pharmacist to harmless substance within minutes/seconds
- allow a patient to access drugs after assessment & decision by a pharmacist. - airway constriction, skin & intestinal irritation, altered heart rhythm
Ex: Birth Control Pills - severe: complete airway obstruction, shock, death
Other drug effects: Drug Tolerance, Cumulative Effect
Parts of Prescription
SUPERSCRIPTION- descriptive pt info (name, age, address), date prescribed, Rx symbol TERATOGENIC- cause malformations of embryo/fetus (alcohol, tetracycline)
INSCRIPTION- name & dosage strength of prescribed med CARCINOGENIC- ability to cause cancer (alcohol, acetaldehyde)
SUBSCRIPTION- dispensing instructions for pharmacist HEPATOTOXIC- destructive to liver (acetaminophen, isoniazid)
SIGNATURA- directions for client
NEPHROTOXIC- “ to kidneys (aminoglycosides, amphotericin B)
PRESCRIBER’S SIGNATURE
OTOTOXIC- “ to 8th nerve/organs of hearing & balance (aminoglycoside, furosemide, aspirin)
NUEROTOXIC- “ to nervous sys, lead to ↑ excitability, numbness, muscle cramp, paresthesia,
systemic failure, cardiac arrest (aminoglycosides, ciprofloxacin)
CONTRAINDICATION- preclude use of ordered drug; when drug shouldn’t be taken
PRECAUTION / WARNING- safeguard; protect from danger, failure, injury
- lists harmful side effects & give recommendation (pt monitor)
DRUG INTERACTION- list drug shouldn’t be taken at same time as this drug to prevent
unwanted effect
- pharmacological result of drug interacting w/themselves/w/other drug,
endogenous chem agent, diet, chemicals
DOSE- # given at one time
DOSAGE- frequency, size, # doses; major determinant of drug action/response (therapeutic
& adverse)
HALF-LIFE- time required for half quantity of drug to be metabolized/eliminated in body

Types of Medication Order

Drug Names 1. STAT- meds given immediately & only once
CHEMICAL - describes drugs molecular structure & identifies its chemical structure - nalbuphine HCl (nubain) 5mg IV STAT; paracetamol (biogesic) 500mg po STAT
Ex: 2-acetoxybenzoic acid; N-(4-hydroxyphenyl)acetamide, N-(4-hydroxyphenyl) 2. SINGLE/ONE-TIME- given once at specified time
ethanamide - bisacodyl (Dulcolax) I supp hs (hour of sleep) preoperatively
GENERIC- official name; nonpropriety/common; complete copy branded drugs 3. STANDING- may/not have termination date; carried out indefinitely
Ex: acetyl salicylic acid; acetaminophen/paracetamol0 - mefenamic acid (dolfenal) 500mg I tab q 8 hrs
i

TRADE (BRAND NAME)- patented propriety for drug sold by specific manufacturer 4. PRN (AS NEEDED)- when, in nurse’s judgment, client requires it
Ex: aspirin, Tylenol - paracetamol (alvedon) 500mg I tab q 4 hrs prn for temp >37.6C

Pharmacology Medication Tickets

MECHANISM OF ACTION (MOA) a. WHITE (ORAL MED)
- specific biochemical interaction where drug produces it pharmacological effect
- include mention of specific molecular targets where drug binds (enzyme, receptor)
INDICATION- necessary/expedient; reason to prescribe/perform treatment
- ex: bacterial infection is indication for prescription of antibiotic
PHARMACOTHERAPEUTICS
- study on drug use in treating disease
- 2 concerns: drug’s effects on body & body’s response to drugs
a. Systemic Effect- reach widespread areas; affect body systems
b. Local “- limited to area where drug is administered
c. Therapeutic “ - intended/desired/primary effect; desired response to drug
BLUE (PARENTERAL MED/NSG (TREATMENT) PROCEDURE)
 Palliative- relieve symptoms but doesn’t affect disease itself (analgesics, antipyretics)
 - gather info (subj/obj data); confirm client diagnosis & appropriateness of med
- Identify all concurrent medications
g. Right Documentation
- important; reflect client's name, ordered med name, time, dose, route, frequency
- sign medication sheet immediately after administration

c. RED/PINK (STAT MED GIVEN IMMEDIATELY/NO DELAY)

GENERAL RULES IN ADMINISTRATION OF MEDICINE

I. OBSERVE RIGHTS OF DRUG ADMINISTRATION
a. Right Client- important step in administering safely
- check med administration form (ticket) against client identification
bracelet & ask to state their name to ensure bracelet has correct info
b. Right Drug / Medication
- receive labeled drugs safely w/o discomfort acc w/rights of drug administration
- when administering, nurse compares drug label container w/medic form
- nurse checks label 3 times: before removing container from shelf
As # of medication ordered is removed from container
Before returning container to storage h. Client's Right to Education
- patient confused: check their reaction to drug as you administer it - be informed of med's name, purpose, action, potential undesired effects.
Stop what you’re doing & recheck order - be advised of med therapy’s experimental nature & give written consent to be used
c. Right Dose- in doing med calculation/conversion; nurse must have another qualified i. Right Evaluation- on client’s status in relation to goals & expressed outcomes
nurse check dose - on client’s response to drug
Computation: A = D/H (V or Q) Where: A = # of drug to be given j. Client’s Right to Refuse- refuse med regardless of consequence; not receive unnecess med
D = desired dose of drug
H = tock of drug on hand II. PRACTICE ASEPSIS- handwash before & after preparing med to reduce microorg transfer
V/Q = volume/quantity of available drug III. NURSE WHO ADMINISTERS MED IS RESPONSIBLE FOR OWN ACTION
d. Right Time- nurse know why med is ordered for certain times day & if time schedule - question any order that’s incorrect (unclear/inappropriate)
can be altered; med that act at certain times is priority (insulin before meal) IV. BE KNOWLEDGEABLE ON MED ADMINISTERED
- each institution has recommended time sched for meds ordered at - fundamental rule: Never administer unfamiliar medication
frequent interval V. KEEP NARCOTICS IN LOCKED PLACE
VI. USE ONLY MED CLEARLY LABELED CONTAINERS. RELABELING IS BY PHARMACIST.
VII. RETURN LIQUID CLOUDY IN COLOR TO PHARMACY
VIII. BEFORE ADMINISTERING, IDENTIFY CLIENT
IX. DON’T LEAVE MED AT BEDSIDE. STAY W/CLIENT UNTIL THEY ACTUALLY TAKE MEDS
X. NURSE WHO PREPARES DRUG ADMINISTERS IT. ONLY NURSE WHO PREPARES DRUG
KNOWS WHAT DRUG IS. DON’T ACCEPT MED ENDORSEMENT.
XI. IF CLIENT VOMITS AFTER MED, REPORT TO NURSE-IN-CHARGE/PHYSICIAN
XII. PREOPERATIVE MEDS ARE DISCONTINUED DURING PREOP UNLESS CONTINUED
XIII. WHEN MED IS OMITTED, RECORD THE FACT & REASON
XIV. WHEN MED ERROR IS MADE, REPORT TO NURSE-IN-CHARGE/PHYSICIAN
- To implement measures immediately; prevent any adverse effects of the drug.
Major Administration
Routes & Drug Forms

e. Right Route- where drug administered/enter body

- if prescriber’s order don’t do/designate route, nurse must consult prescriber
- if specified route isn’t recommended, nurse alert prescriber immediately
- check specified in med order & product label
- make sure ordered form of drug is appropriate for intended route

f. Right Assessment- to have qualified nurse/physician assess med history/allergy1. ORAL (Solid)
a. TABLET Tuberculin- originally for tuberculin (TB exposure)
- solid dosage form w/medicinal substances w/w/o suitable diluents; vary in - narrow, calibrated in tenths & hundredths of a mL
shape, size, weight; classed acc to method of manufacture (compressed tablet) - for drugs that needs precise measurements/small doses
Chewable- w/base of flavored/sugar alcohol for children Other Sizes- 5, 10, 20, 50 mL; to add meds to intravenous solu/irrigate wounds
Enteric Coated- coated to prevent/minimize dissolution in stomach but allow Prefilled
dissolution in small intestine.
Variations on Tip
- protect stomach from irritating drug (aspirin)/protect drug (erythromycin)
1. Luer-Lok- tip requires needle to be twisted onto it to avoid accidental needle removal
from partial degradation in acidic stomach
2. Non-Luer-Lok- smooth graduated tip onto which needles are slipped
Prolonged action/Sustained Release- released & absorbed in stages/gradually
Scored- surfaces were grooved/scored
b. NEEDLES- made of stainless steel & mostly disposable
b. CAPSULE- drug is enclosed in hard/soft soluble container/shell of gelatin - parts: Hub: fits into syringe Cannula/shaft: attached to hub
c. CAPLET- capsule + tablet; smooth, coated, oval tablet to be temper-resistant Bevel: slanted part at needle tip
d. TROCHE/LOZENGE- small, disc/rhombic w/solidifying paste w/astringent, antiseptic, 3 Variable Characteristics of Needle
or demulcent drug for local treatment of mouth/throat 1. Bevel Slant/ length: Long = sharpest & causes less discomfort; for IM & SC
- troche held in mouth until dissolved Short = for ID & IV injections (prevent: occlusion inside)
e. EFFERVESCENT TABLET- granular effervescent salts that release gas 2. Needle Length: ½ - 2 inches; depends on client’s muscle dev’t., wt, type of injection
f. PILL- one/more drugs mixed w/cohesive material; oval, round, flat shapes 3. Gauge/Shaft Diameter: gauge #18 - #28
g. PELLETS- dry meds like powder but larger particles Nursing alert: LARGER the gauge #, smaller the diameter.
h. POWDER- dry mass of small separate particles of any substance SC= g.24-26 ; IM= g. 20- 22
- homogeneous dispersion of finely divided particles w/one/more substance
Preventing Needle Stick Injuries
i. GRANULES
- Use puncture-proof disposal containers for sharps (needle, blades, lancets, broken wires)
j, LIQUID EMULSIONS- dispersions of fine droplets of oil in water/water in oil
- When recapping: Do “SCOOP METHOD” or “Fish hook Technique”
k. SUSPENSION- w/solid drug particles suspended in suitable liquid medium
l. SOLUTION Preparing Injectable Medications
Syrup- sucrose solu to disguise unpleasant meds & preservatives AMPULES- glass container to hold single dose of a drug; clear glass; w/constricted neck
Elixir- aromatic, sweetened, alcoholic preparation used as flavor vehicle - some have colored marks/dots indicating where they are pre-scored
Tincture- alcohol/hydroalcoholic from vegetable/chemicals - If not pre-scored, it should be filed w/small file, then broken off at neck
Extract- concentrated preparation of vegetable/animal drug VIALS- small glass bottle w/ sealed rubber cap; single dose/multi-dose
- Reconstitution (technique of adding solvent to powdered drug for administration)
2. PARENTERAL - Before withdrawing meds from vial, swab rubber cap w/ disinfectant.
a. SOLUTION- powder diluted in water; measured doses of solid med in powdered
form usually dissolved in water before ingestion. Preparing Medication from Ampule
a. Break neck of ampule b. Withdraw medication from ampule
3. RECTAL
a. SUPPOSITORY- cylinder/cone which melts gradually in body temperature
b. SOLUTION- aqueous solu of nonvolatile substance
c. SOAD SUD SOLUTION
d. ENEMA- rectal injection to clear out bowel/administer drugs

4. VAGINAL
a. SUPPOSITORY b. TABLET
c. FOAM- liquid powder/foam deposited in thin layer on skin by air pressure
d. GEL- jelly, solid/semisolid phase of colloidal solution
c. Inject air into vial d. Withdraw med from vial held w/base down
5. TOPICAL
a. AEROSOL- liquid/particle dispersed in air, gas, vapor in form of fine mist for
therapeutic/ insecticidal purpose
b. CREAM- semisolid emulsion of oil-in-water/water-in-oil type
c. LOTION- liquid suspensions/dispersions intended for external application
- some w/finely powdered, insoluble solids held in permanent suspension by
suspending agents or surface-active agents
- others are oil-in-water emulsions stabilized by surface-active agents.
d. OINTMENT- semi-solid; application on skin/mucous membrane; oil-based e. Withdraw med from inverted vial
e. PASTE- stiff mixture of powder + ointment
f. PATCH- deliver constant, controlled med # through skin & bloodstream, achieving a
steady, prolonged systemic effect
g. POWDER- inert chemical w/medication; dry the skin & reduces maceration/ friction
h. LINIMENT- for external use to gums; clear dispersions, suspensions, emulsions
- frequently applied by friction to skin
- mixed w/ alcohol, oil, soapy emollient & applied to the skin

PARENTERAL MEDICATIONS Aspirating Meds from Vials

Parenteral Administration
- Meds is absorbed quickly & irretrievable once injected, nurse prepare & administer
them ACCURATELY & CAREFULLY.
- ASEPTIC TECHNIQUE MUST BE USED since injections are highly invasive procedures.
Equipment
a. SYRINGES- 3 parts: Tip, Barrel, Plunger
- parts kept sterile: tip, inside of barrel, plunger shaft
Kinds: Hypodermic- 2ml, 2.5mL, 3mL sizes; 2 scales: minim & mL INTRADERMAL INJECTION (ID)
Insulin- 100-unit calibrated scale (common) - into dermal layer just beneath epidermis; for skin test, TB screening, BCG vaccinations
- common sites: inner lower arm, upper chest, back beneath the scapulae
Reassessment after Injection

5. Rectus Femoris- anterior aspect of thigh

- advantage: for patients who administer own injections as it’s easy to reach
SUBCUTANEOUS INJECTION (SC or SQ)
Z-TRACK TECHNIQUE
- into subcutaneous layer
Common sites: upper arm outer aspect, Thighs anterior aspect, Abdomen - for Parenteral iron preparation (seal drug deep into muscle & prevent staining of skin)
Upper back Scapular area; Upper ventrogluteal site & dorsogluteal site - Retract skin laterally (use ulnar side of nondominant hand to pull skin appx. 1 inch to side)
- Don’t massage injection site.
Indication: Vaccines, Pre-operative medications, Narcotics, Insulin, Heparin
Advantage: Drug almost completely absorbed from tissue, so # absorbed is predictable
` Drug generally acts in 30 minutes
Needle size & length: Pinch tissue-length of needle is half the width of skin fold
45° angle-1 inch of tissue can be grasped
90° angle-2 inches of tissue can be grasped
Site: rotate injection sites

INTRAMUSCULAR INJECTION (IM)]

- into muscle tissue; angle: 90o
IV Medications
- needle size depend on: muscle, solu type, # adipose covering muscle, client age
Indication: rapid absorption of drugs because it is rich w/ blood supply - Injecting medications into vein - has a rapid effect on the patient’s body
administer greater volume of fluid (up to 3 mL) - lessens discomfort
medications that are irritating Using IV Push:
common sites
a. Ventrogluteal- gluteus medius muscle which lies over gluteus minimus
- position: supine/ side lying; knee & hip flexed to relax gluteal muscles
Advantage: area has no large nerves & blood vessels; w/ less fat than buttocks
sealed off by bone

b. Vastus Lateralis- thick, well-developed muscle in adult & children

- on anterior lateral aspect of infant’s thigh (middle third)
- Site: infants < 7 mos. Old; Position: supine or sitting
rationale: absence of major blood vessels/ nerves on area

c. Dorsogluteal- thick gluteal muscles of buttocks; not for children below 3 y/o unless
they’re walking for at least 1 year
- Locate site carefully to not strike sciatic nerve, major blood vessel, bone
- Position: prone or side-lying w/ upper knee flexed & front of lower leg.

4. Deltoid- lateral aspect of upper arm, 2-3 fingerbreadths below acromion process
- not for IM injections bc its close proximity to radial nerve & artery
OTHER ROUTES FOR DRUG ADMINISTRATION
- for adults because of rapid absorption; accommodate up to 1mL - path by where drug/fluid/substance is brought into contact w/body
Divisions 3. Assess area, note odor/discharge, ask on itching/discomfort
1. TOPICAL- applied topically to skin/mucous membranes for local action 4. if px can’t do perineal care, place them on bedpan & do externa, douche. Dry buttocks
- applied to circumscribed area w/tissue. Don gloves.
5. If using suppository, remove it from foil wrapper. Lubricate its rounded edge
a. DERMATOLOGIC- lotion, liniment, ointment, powder
6. Use gloved nondominant hand to gently retract labial folds
 Dermal- (local action) cream, ointment, lotion, liniment, powder
7. Insert rounded end 3-4 in/length of index finger along posterior vaginal wall
 Transdermal- (systemic action) through skin
8. Withdraw finger & wipe w/tissue remaining lubricant around orifice & labia
1. Before applying, clean skin thoroughly by washing gently w/soap & 9. Px to remain on back for 15 min. Hips can be elevated on pillow.
water, soaking, locally debriding tissue 10. Remove gloves. Wash hands. Record observations & patient response
2. Use surgical asepsis when open wound is present 11. Check patient in 15 min to ensure suppository didn’t slip out & allow px for concern
3. Remove previous application before next
4. Use gloves in applying med on large surface (large burns)
5. Apply 1 thin layer to prevent systemic absorption
b. OPHTHALMIC- drops/ointment
 Instillation- provide meds that client requires
 Irrigation- clear eye of noxious/foreign materials

Purpose: treat infection; relieve inflammation; hasten healing after surgery

Diagnose foreign bodies & corneal abrasion; anesthetize eye
Dilate pupils for refraction; lubricate socket for artificial eye insertion
Protect neonate in eye infection (Crede’s prophylaxis) 3. RECTAL- through rectum by suppositories (melt at body temp)/enema
Purpose: produce general/systemic effect (reduce temp & nausea) (paracetamol)
Stimulate defecation by mechanical pressure/chem irritation of nerve endings
(bisacodyl)
Destroy microbes in GIT pre & post GI surgery (metronidazole)
1. Px at side lying/Sim’s pos w/upper leg flexed; cover w/topsheet, expose only anus
2. Don gloves. Remove suppository from wrapper, lubricate pointed end/see
manufacturer’s instruction
3. Px to take slow, deep breaths in mouth to relax anal sphincter
4. Retract buttocks w/nondominant hand. W/gloved index finger, insert suppository
1. Identify & explain procedure to patient gently through anus, w/slight twisting motion past internal sphincter, & against
2. Don gloves. Assess eyes for inflammation discharge & vision change rectal wall: 10 cm (4in) adult, 5 cm (2in) children/infant
3. Supine/siting pos w/neck hyperextended & turned slightly to affected eye 5. Withdraw finger & wipe off patient’s anal area w/toilet paper. Hold both buttocks
4. Cleanse affected eye inner to outer canthus w/CB moistened w/NSS tightly together for secs while patient breathes deeply.
5. Uncap med container. Place nondominant thumb/2 fingers near margin 6. Discard gloves. Px to remain flat/on side for 5 min. If suppository is for laxative, it
of lower eyelid immediately below eyelashes & apply gentle pressure must remain in pos for 25-45 min or until px has urge to defecate. Wash hands.
downward over body prominence 7. If suppository has laxative/fecal softener, place call bell within patient’s reach so px
6. Patient look up while focusing on ceiling can obtain assistance to reach bedpan/toile
7. Dropper close to eye, ½ - ¾ in above conjunctival sack but don’t touch 8. Record obj & subj findings, insertion time, px response
eyelid/eyelash (startle patient & blinking)
8. Go to eye from side & instill prescribed # drop into lower conjunctival sac 4. BUCCAL- held in mouth against mucous membranes of cheek until drug dissolves
9. Release lower lid after drop; patient to gently close eyes - meds not to chew, swallow, placed under tongue (sustained release
10. Apply gentle pressure over naso-lacrimal duct for atleast 30 secs nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
c. OTIC- purpose: to treat infection, relieve pain, soften/remove impacted cerumen - px to alternate cheeks w/each subsequent dose to avoid mucosal irritation
1. Warm solu at room/body temp to avoid vertigo, dizziness, nausea, pain
2. Side-lying pos w/affected ear facing up
3. Hand hygiene, don gloves if there’s drainage
4. Straighten ear canal: (0-3 y/o) pull pinna downward & backward
(>3) pull pinna upward & backward
5. Drop on side of auditory canal for drops to flow & adjust to body temp
6. Press gently but firmly few times on tragus to assist flow into ear canal
7. Side-lying pos for 5 min
8. if MD orders cotton puff insertion into outermost canal: don’t press
cotton into canal. Remove after 15 min.
d. NASAL- for astringent effect (shrink swollen mucous membrane), loosen
secretion, help drainage/infection of nasal cavity/sinuses
- decongestant, steroid, calcitonin
1. Px to blow nose & in supine pos w/pillow under shoulder for head to fall
over edge of pillow
2. Elevate nares slightly by pressing thumb against tip of nose
3. Dropper above client’s nostril & direct drops to midline of superior
concha of ethmoid bone as client breathes through mouth
4. Avoid touching nostril mucous membrane
5. Ask px: inhale slowly & deeply through nose
hold breath for secs, exhale slowly, remain in supine pos for 1 min
discard any med remains in dropper back into bottle
6. px comfort; return tool, wash hands, document
e. INHALATION- nebulizer, metered-dose inhaler
- lungs has excellent surface for absorption when drug is delivered in
gaseous, aerosol, ultrafine solid particle form
2. VAGINAL- by suppositories/irrigation/tablet/applicator
1. Bring equipment to bedside; identify patient & explain
2. px to void & do perineal care; provide privacy; px in dorsal recumbent pos & drape
FINAL ANSWER’S UNIT: RATE = gtt/min DURATION = mL/hr

BLOOD TRANSFUSION = INCLUDE LEUKOCYTES!!!

HEPA B- incurable; attacks liver

HEPA C-

IN-LINE FILTER:

BLOOD TRANSFUSION
- whole blood/component (plasma, serum, erythrocytes, platelet, leukocyte) into px
venous circulation (Evans- Smith, pp 656)
- life-saving in massive blood loss due to trauma, replace blood lost in surgery, severe
anemia, thrombocytopenia by blood disease
LEUKOCYTES: Neutrophils-for bacterial
Eosinophils- ↑ = ↑ antihistamine = parasitic infection & allergic reaction
Basophiles
Lymphocyte- increased when viral
Monocyte
MASSIVE BLOOD LOSS - 40% of total blood loss/4 L in 24 hrs/2L in 2 hrs/150ml in 1 min
- prescribe BLOOD TRANSFUSION Transfusion Reaction (adverse event after blood transfusion)
- IF NO BLOOD AVAILABLE, USE BLOOD EXPANDERS
- take form as allergic reaction (infection) hemolysis (incompatible blood type), immune
SEVERE ANEMIA- hemoglobin in RBC is low/diluted in the body (low amount but sys alternation (r/t transfusion)
distributed all over the body); low O2; not measured in BP
signs & symptoms- Anxiety, Flushing, Tachycardia, Hypotension, chest/back pain, Dyspnea,
THROMBOCYTOPENIA- low platelet count Fever, Chills, Jaundice
Cytopenia=low blood cells Cytosis- high blood cells
types: Febrile non-hemolytic- most common; fever & dyspnea 1-6 hrs post transfusion
Risks: HIV, Hepatitis B (incurable, attacks liver), Hepatitis C - clinically benign, no lasting side effect; differentiated from hemolytic TR
Prior to Transfusion: Proper cross-matching of donor blood & px blood (compatibility) Viral Infection- blood supply in developed countries is screened for infectious
Equipment agents & donors; extremely rare
- risk of getting Hepa B by transfusion in US in 1 in 250000 units transfused
- Blood Product: Fresh whole blood- actual blood extracted
- “ “ “ HIV/Hepa C as of 2006 is 1 in 2 mil units
Packed RBC- administered in 2-4hrs
Platelet concentrates- yellowish-white for thrombocytopenia/dengue Bacterial Infection- blood contaminated after collection while being stored
- given 15-30 min per bag; continuous administration - highest risk is platelet transfusion (stored near room temp & can’t be
Fresh Frozen plasma refrigerated). severe BI & sepsis risk as of 2001 at 1 in 50000 platelet TF, 1
Cryoprecipitate- component of fresh frozen plasma in 500000 RBC
Granulocyte concentrate- usually neutrophils (by leukapheresis) Acute Hemolytic Transfusion-
Albumin- yellow; for burn px - medical emergency from rapid destruction of donor RBC by host antibodies;
caused by clerical error (wrong blood unit given to wrong px)
- Blood administration set (w/ in-line filter) - IVF = 0.9 NaCl (Plain NSS)
- IV pole - IV catheter (gauge 19 or larger) - disposable gloves - tape - fever, chills, back pain, hemoglobinuria
- major complication is hemoglobin released by RBC destruction = acute renal failure
Anaphylactic Reaction
- 1 of 30000-50000 transfusions; common in those w/selective IgA deficiency
(though asymptomatic & cant be detected until reaction occurs)
- medical emergency, require prompt treatment, life-threatening
Transfusion-associated of Acute Lung Injury (TRALI)
- syndrome of acute respiratory distress, associated w/fever, non-cardiogenic
pulmonary enema, hypertension
- 1 of 2000 transfusion; most px recover fully in 96 hrs; mortality rate <10%
Volume Overload- px w/impaired cardiac fx (congestive heart failure); lead to
edema, dyspnea, orthopnea
Iron Overload- each transfused unit of RBC has 250 mg iron; since iron elimination
pathway are limited, iron overload damage liver, heart, kidney, pancreas
- threshold is 12-20 units of RBC
Transfusion-associated Graft-VS-Host Disease (GVHD)
- immune attack by transfused cells; common in stem cell transplantation but very
rare in blood transfusion
Pre-assessment: Obtain baseline VS, lung sounds, urinary output
- in severely immunosuppressed px, w/congenital immune deficiencies/hematologic
review recent lab values; ask about previous transfusion reactions
malignancy from intensive chemo; uniformly fatal; prevent by irradiating blood
inspect IV insertion site & check type of solution

Performing Transfusion:
- prime in-line filter w/blood - stay w/px for first 15 min
- start slowly (25-50ml for first 15 min) - check VS (every 15 min for 1 hr)
1. Determine if px knows reasons for transfusion
2. Explain px event; check for signed consent. Advise px to report chills, itching, rash
3. Give premedications if ordered by physician
4. Hang container of 0.9% normal saline w/blood administration set. Initiate infusion
(delay hanging the blood & notify HCP if there’s FEVER)
5. Start IV w/gauge 18/19. Run normal saline at KVO (maintain patent IV access line)
6. Obtain blood product.
7. Complete identification & check: serial #, blood component, blood type, Rh factor, Treatment: stop transfusion immediately (save remaining blood & IV tubing for testing);
expiration date, screening test (VDRL for STD, provide supportive care
HBsAg for heap B, malarial smear for malaria), clots Positive Outcome - fluid balance, improved cardiac output, enhanced peripheral tissue
8. Take baseline VS 9. Start infusion of blood (thaw first) perfusion
10. Consume blood within 4 hrs 11. Assess frequently for transfusion reaction SEPTICEMIA- BP 90/50mmHg from baseline of 125/78mmHg; temp 100.8F orally from
12. If Transfusion reaction is suspected, stop blood transfusion, run 0.9% normal saline. baseline 99.2F.
Notify doctor & blood bank
13. If transfusion complete, clamp off blood & infuse 0.9 normal saline
14. Record administration of blood & px reaction

 observe for flushing, dyspnea, itching, hives, rash

 question before explaining procedure: HAVE YOU EVER HAD TRANSFUSION BEFORE? OXYGEN THERAPY
- prescribed by PHYSICIAN (specifies concentration, method of delivery, liter flow/min)
- O2 is a medication (underdosage & toxicity); O2 equipment can be source of infection Levin Tube/Nasogastric Tube- commonly used NGT
- nurse may initiate administration in EMERGENCY SITUATION Purposes of NGT Insertion: provide feeding (gastric gavage)
- for COPD: low-flow O2 system (Hypoxic Drive = CO2, O2) irrigate stomach (gastric lavage)
- O2 from cylinder/wall-outlet system can DRY mucosa  use humidifier drainage of gastric content (decompression)
Stimulus for breathing in COPD  DECREASED OXYGEN administer prescribed medications & supplemental fluid
“ “ “ in normal px  INCREASED CO2 Principles
1. Elevate bedhead 30-90o before feeding & leave it up for 30-60 min after feeding.
indication: those w/difficulty ventilating in all areas of lungs
2. Keep bed head elevated at least 30o always if px is receiving continuous feeding.
impaired gas exchange; heart failure; RR changes, CNS changes
3. Assess bowel sounds at least once of 8 hours.
Safety Precautions 4. Assess abdomen for distension.
- O2 is odorless, tasteless, colorless 5. Check tube position in GI tract before each feeding is started/atleast once each shift.
- “no smoking” sign when O2 is in use; electrical devices are in good working order 6. Check gastric residual by aspirating via gastric tube before each intermittent feeding/every
- avoid materials which generate static electricity & volatile/flammable substance 4 hours if px is receiving continuous feeding. If gastric residual is greater than ½ of volume
- ground electronic monitoring device given in last feeding or greater than 150cc reinstill residual & delay next feeding for 1-2 hrs
- know fire extinguisher location; ensure devices are clean Materials:  Nasogatric tube  KY jelly  Gloves  asepto syringe
 Stethoscope  adhesive tape
O2 Delivery Systems
NASAL CANNULA/NASAL PRONGS- most common inexpensive device; easy to apply Procedure: improve/ maintain nutritional status & administer prescribed medication.
- permit movement freedom; low con o2 (24-45%) at 2-6l/min 1. Prepare necessary materials.
FACE MASK- cover nose & mouth; exhalation ports on sides allow exhaled CO2 to escape 2. Inform patient & explain procedure to allay anxiety.
Simple- O2 conc 40-60% at 5-8L/min 3. Position: fully sitting if awake; supine w/ neck flexion if comatose.
4. Don non-sterile gloves. Coil NGT around left hand then hold free end w/ right hand.
Partial Rebreather- 60-90% at 6-10L/min; O2 reservoir bag allow to rebreathe 1st
5. Measure NGT length to be inserted (nose tip to ear lobe tip to xiphoid process - 50cm)
third of exhaled air w/O2, increasing FiO2 by recycling expired O2
(NEX technique)
- bag must not totally deflate during inspiration (avoid CO2 buildup)
6. Lubricate free end (2-4 in of tube) w/water-soluble lubricant to reduce friction. Do
Non-Rebreather- highest O2 95-100% at 10-15L/min not use oil (cause lipoid pneumonia)
- 3 one-way valves on mask & between reservoir bag & mask (prevent
7. Pass tube via either nare posteriorly, past pharynx into esophagus & then stomach.
room air & exhaled air from entering bag)
Instruct px to swallow (offer ice chips/water) & slowly advance tube as px swallows. If there’s
Venturi- 24-30%/50% at 4-10L/min; w/wide-bore tubing & color-coded jet adapters resistance, rotate tube slowly w/downward advancement toward closest ear. Do not force.
that correspond to precise 02 conc & liter flow; most precise
8. When specified NGT level is reached, confirm placement by auscultation on stomach,
- orange (50% O2 conc) gastric content aspiration, or by x-ray in comatose patients. Introduce air into tubing using
FACE TENT- replace o2 masks when it’s poorly tolerated by px; 30-50% at 4-5L/min asepto syringe while auscultating to ascertain correct position (stomach).
TRANSTRACHEAL OXYGEN DELIVERY- for O2-dependent client  Note: x-ray to verify placement before feeding/med or concerns on tube placement.
- O2 delivered via small, narrow plastic cannula surgically inserted 9. Secure tubing onto nostril w/adhesive.
through skin directly in trachea; chain around neck to hold catheter 10. Document reason for tube insertion, type, tube size, nature & amount of aspirate, type of
- less O2 since all flow enters lungs; for late-stage COPD suction, pressure setting for suction, drainage nature & amount, effectiveness of
note: keep catheter patent (1.5 ml NSS). Clean rod in & out of it. Inject again 1.5ml NSS intervention.
done 2-3x daily
Common Problems
OXYGEN HOOD- rigid plastic dome enclose baby’s head; gas don’t blow directly into face 1. Vomiting 2. Aspiration 3. Diarrhea (most common due to lactose intolerance)
Procedure: Explain; wash hands; provide privacy 4. Constipation 5. Hyperglycemia 6. Abdominal distension
Set up O2 equipment. Attach flow meter to wall outlet/tank. Ensure it’s OFF.
Attach humidifier bottle. Attach prescribed tubing Administering Tube Feeding (NGT Feeding, Gastric gavage)
Turn on O2 prescribed rate. Apply O2 delivery device 1. Px in semi-Fowler’s pos in bed/sitting pos in chair/slightly elevated right side lying pos
 special ns consideration in OXYGEN TENTS: give warmth to baby using a banket 2. Assess tube placement & patency.
 Enter 5-20 ml air into NGT & auscultate at epigastric area, gurgling sound (XIPHOID PROCESS)
 Aspirate gastric content, which is yellowish or greenish in color (5-10ml).
 Immerse tip of tube in water, no bubbles should be produced.
 Measure pH of aspirated fluid which should be acidic.
 Ask client to speak or hum
 Observe client for coughing & choking.
 most effective method of checking, NGT placement is radiograph verification then,
checking pH of aspirated gastric content, then aspiration of gastric content.
3. Assess residual feeding contents. To assess absorption of last feeding, if 50 ml or more,
verify if feeding will be given.
4. Introduce feeding slowly. To prevent flatulence, crampy pain, reflex vomiting.
5. Height of feeding is 6-12 in above tube’s point of insertion in to px. This allows slow
introduction of feeding.
 Feed patient first before giving his/her medication.
6. Follow medication w/water into NGT after feeding. To cleanse lumen of the tube.
 2-5 ml. for newborns  20-25ml for children  30-50ml for adults
7. Clamp NGT before all of water is instilled. To prevent entry of air into stomach.
 Ask client to remain in Fowler’s pos/slightly elevated right lateral pos for at least 30 min.
to prevent potential aspiration of feeding.
 Do after care of equipment.  Make relevant documentation.

To do Lavage
1. Introduce water into tubing using asepto syringe.
2. Check return flow by directing NGT downward, allowing drainage to flow by gravity.

NASOGASTRIC FEEDING (GASTRIC GAVAGE) DEATH & DYING (POST MORTEM CARE)
- Administration via NGT or OGT for unconscious, too weak, unable to orally takePOST
medsMORTEM CARE- care provided to px immediately after death
Purpose: Prepare px for viewing by family Equipment: basin half-filled w/water towel & wash cloth cotton balls
Ensure proper identification of px prior to transportation to morgue to morgue, 2 identification tags safety pins forceps mortuary gown
funeral home plastic bag for soiled equipment working gloves plaster/shroud kit
Provide appropriate disposition of px belonging Procedure:
Maintaining VS, if donation is planned 1. Let doctor pronounce death. Note exact time.
Death & Dying R: necessary legal procedure
DYING PROCESS- accompanied by myriad of psychological, spiritual, physical needs, 2. Screen bed in ward/close door in private room
nurses are in ideal position to identify & address R: Other px may be upset w/roommate’s death. Fam appreciates privacy
3. Wash hands. Assemble equipment for cleaning, wrapping, identifying body
5 Stages of Grief Kubler-Ross Model R: Body is prepared in clean condition before transferred to mortuary
1. DENIAL- un/conscious decision to refuse to admit something is true; diff forms exist 4. Don gloves, body in supine pos w/arms extended at side/folded over abdomen
(denial of fact, impact, awareness, cycle, denial) R: normal anatomical pos prevent skin discoloration from pooling blood in area visible in a
- “this can’t be true”, “I’ll be just fine after surgery” casket
- isn’t ready to deal w/practical problems; may assume artificial cheerfulness 5. Close eyelids w/gentle pressure. If it doesn’t close, saturate cotton w/water & place over
2. ANGER- recognize denial can’t continue; become frustrated, esp proximate people eyes (remove after)
- “why me?”; client & fam have feelings of resentment, envy, anger to client, R: Create natural sleeping appearance. Eyes hard to close if time between death &
fam, health providers, God preparation is prolonged
3. BARGAINING- hope that one can avoid cause of grief/loss. Usually, negotiation for 6. Replace/retain dentures within mouth
extended life is made in exchange for reformed lifestyle R: Denture maintain natural contour of face; difficult to insert hours after death
- people facing less serious trauma can bargain/seek compromise 7. Place small towel under chin to close open mouth
- “I just want to see my daughter’s, then I’ll be ready”. 8. Remove soiled dressing, venipuncture device, indwelling catheter, dispose contaminated &
- px/fam ask for more time to reach important even & make promise to God soiled items to appropriate container
9. Pack body orifice w/cotton using forceps. If embalmed immediately, packing isn’t needed
4. DEPRESSION- despair at recognizing mortality; silent, refuse visitors, mournful/sullen
` - “I just don’t know how my wife gets along after im gone” 10. Cleanse obviously soiled areas. Provide grooming & hygiene to person’s face & hair:
- grieves over what has happened & what cannot be a. Wash any secretions from face c. Remove hair clips & pins
b. Comb hair in neat style
5. ACCEPTANCE- embrace mortality/inevitable future/loved one/tragic event
11. Remove & make inventory of valuables still attached to body
- people dying precede survivors in this state, comes w/calm, retrospective view &
12. Endorse valuables to family
stable emotions; come to term w/loss
13. Dress w/mortuary gown. Attach identification tag to right great toe/right ankle
- “I have no regrets—I’ve done everything & proud of what’s accomplished”
14. Cover body w/clean mortuary sheet & zip. Attach 2nd tag on top of sheet
- decreased interest in support person; begin to make plans
15. Remove gloves & dispose properly. Wash hands.
16. Complete charting. Prepare room for terminal disinfection
Body System Indicators of Imminent Death
COGNITION/ORIENTATION- agitated/restless; can’t subjectively respond to verbal sample documentation
stimuli
CARDIOVASCULAR- tachycardia, irregular heart rate; low BP/widening on systolic &
diastolic; dehydration
PULMONARY- tachypnea, dyspnea, acetone breath, Cheyne-strokes breathing, pooling
of secretions, noisy respiration
GASTROINTESTINAL- diminished appetite, less feces, incontinence
RENAL- diminished urine output, incontinence, concentrated urine
MOBILITY- limited mobility; bedfound

What is “DEATH”?
Traditional view: “HEART-LUNG DEATH”- cessation of apical pulse, respiration, BP
World Medical Assembly- total lack of response to external stimuli; no reflexes
- no muscular movements, flat encephalogram (most accurate sign)
CEREBRAL DEATH/HIGHER BRAIN DEATH
clinical syndrome: no responsiveness, no cephalic reflexes, apnea, isoelectric
encephalogram

Development of Concept of Death

INFANCY/5 y/o- doesn’t understand concept; irreversible, temporary departure/sleep
- immobility & inactivity as attributes of death
5-9 y/o- death is final; own death is avoided; associates death w/aggression/violence
9-12 y/o- inevitable end of life; idea gathered from parents/older adults
12-18 y/o- fears lingering death; fantasize that death can be defied, acting out defiance
through reckless behavior
- reach adult perception of death but emotionally unable to accept it
18-45- attitude influenced by religious/cultural beliefs
45-65- accept own mortality; face parents”/peers’ death; peak of death anxiety (diminish
w/emotional wellbeing)
> 65- fears prolonged illness; face family/peers; death as having multiple meanings

Physiologic Change
RIGOR MORTIS- body stiffening 2-4 hrs after death; starts in involuntary muscles
ALGOR MORTIS- gradual ↓ of temp after death due to termination of bloodflow to
hypothalamus; drop 1oC/hr; skin losses elasticity
LIVOR MORTIS- tissue discoloration in lowermost, dependent areas of body
POSTMORTEM CARE- given to body after death
purpose: prepare body in a manner that reduces fam’s distress in viewing body
prevent distortions in appearance
)