Health Promotion • Loss – situation in which something is

Health - a state of complete physical, mental gone, no longer available,

and social well-being and not merely the • Grief- reaction to loss, happens to
absence of disease or Infirmity (WHO) someone or something who has made
a bond to the certain loss
Levels of Prevention • Death – fundamental loss
Primary – Health promotion and protection
from diseases, awareness Views of loss
Secondary- Early detection, treatment • Situational- Loss of child, job, theft
Tertiary- Curative • Developmental- retirement, death of
Quaternary- Palliative aged parents
Grief responses
Illness behaviors • Normal
• Symptom experience -abbreviated (replaced by another)
• Assumption of the “sick” role -anticipatory (responding to a coming
• Medical care contact loss)
• Dependent care contact • Abnormal grief (dysfunctional)
• Recovery or rehabilitation -unresolved (too long grieving)
- inhibited (normal symptoms of
Nursing Process grieving is absent)
*ADPIE PROCESS*
Assessment Stages of grieving
 Collecting data *DABDA*
o Client Denial
o Family Anger
o Records Bargaining
o Observing, interview, physical Depression
examination Acceptance
Diagnosing- judgment about the client’s
response to actual or potential health Vital signs
conditions or needs. Temperature
Types of nursing diagnoses • Core temperature – deep tissues
1. Problem focused- “Ineffective (abdominal and pelvic cavity),
breathing pattern” constant
2. Risk- “Risk for infection” • Surface temperature – skin,
3. Health promotion- “Readiness for subcutaneous fat, rises and falls
enhanced family coping”
4. Syndrome- “Chronic pain syndrome” Types of fever
- Intermittent
Planning - Remittent
 Specific - Relapsing
 Measurable - Spiking
 Attainable - Constant
 Realistic - Lysis
 Time bounded - Crisis

Implementing Assessing temperature

Evaluation 1. Oral
2. Rectal
Stress and coping 3. Axilla
Physical- dilated pupils, sweat, increase VS 4. Tympanic
Psychological- anxiety, fear, anger,
depression Pulse sites
• Temporal
Developmental stressor • Carotid
• Child – beginning school • Apical
• Adolescent – relationships, career • Brachial
• Young adult – marrying, leaving house, • Radial
managing a home, getting started at a • Femoral
job • Popliteal
• Middle adult- accepting aging, • Posterior tibial
maintaing standard of living • Dorsalis pedis
• Older adult – accepting decreasing
health, retirement, accepting death of Pulse normal values
friends, spouse Adult- 60- 100
Children- 80- 120
Loss, grieving, death Infants- 120- 160
*it varies depending on the book and author Abdomen assessment- using the 4 quadrant
method or the 9 region method
Respiration normal values
Adult- 12- 21 Positions per assessment
Children- 20- 30 Sitting- Head, neck, back, posterior thorax
Infants- 30- 60 and lungs, extremities
Supine- Head, neck, anterior thorax and
Blood pressure lungs, breast, axillae, heart, abdomen,
Category Systolic Diastolic extremities
Hypotension Less 90 Less 60 Dorsal- Head, neck, anterior thorax and
Desired 90- 119 60- 79 lungs, breast, axillae, heart
Prehypertensi 120- 139 80- 89 Sim’s- Rectum and vagina
on Prone- Posterior thorax and lungs, hips
Stage 1 HPN 140- 159 90- 99 Knee chest- Rectum
Stage 2 HPN 160- 179 100- 109 Lithotomy- Female genitalia

Korotkoff sounds Asepsis- Process of inhibiting the growth

Phase I— faint, repetitive, clear tapping and multiplication of microorganisms. The
sounds which gradually increase state of being free of pathogenic organisms.
Phase II—A swishing quality.
Phase III—The return of sharper sounds, Infection modes:
which become crisper Bacterial
Phase IV—muffling sounds, which become Viral
soft and blowing in quality. Fungal
Phase V—sounds finally disappear Nosocomial

Physical assessment Chain of infection

*IPPA* Agent  Reservoir  Portal of exit  Mode
Inspection of transmission  Portal of entry 
Palpation susceptible host
Percussion
Auscultation Modes of transmission
• Direct
Percussion sounds • Indirect
Flat – head on muscle, bone – Vehicle borne/fomite
Dull- heard on liver, heart – Vector borne
Resonance- heard on normal lungs – Air borne/ droplet
Hyper resonance- heard on abnormal lungs
Tympany- heard on a gas- filled stomach Body’s defense against infection
• Intact skin
General Survey • Nasal passages
Weight- weigh the same weighing scale, • Saliva
same time, same clothing • Phagocytes
Hair- check for white specks • Eyes
Skin- check for macule, papule, plaque, • Stomach
nodule, vesicle, bulla, pustule, cyst, wheal • Vagina
Nails- look for trauma, clubbing, abnormal • Inflammatory response
shape, infection
Eyes- assess for the 6 cardinal gazes, Preventing infection
newsprint test, Snellen test, Ishihara test,  Hand hygiene (washing, alcoholizing,
presbyopia, hyperopia, myopia nail cutting/ filing)
Hearing- check for hearing losses
Isolation precautions
Chest physiotherapy- For patients in a. Isolation
whom cough is insufficient to clear thick, b. Revers isolation
tenacious, or localized secretions. c. Quarantine
Contraindications- Increased ICP, neck injury,
bleeding, empyema, rib fracture, Universal precautions
uncontrolled HPN Tier 1
Directions- Using vibration on chest wall or -Used in all patients
back, 2-3 times a day, before meals and -wash hands
bedtime. #-15 minutes per position. -gloves
-wear mask
Breast assessment -prevent scalpel injuries
Assess for size, nipple color, areola,
discharge, hair, retraction, asymmetry Tier 2 Airborne
-Include tier 1
-Private room with negative pressure • Ointment (semisolid)
-2 patients- 1 room • Pill (pellet)
-Use N95 mask • Powder
-Surgical mask on patient during transport • Suppository
• Syrup (sugar)
Tier 2 Droplet • tablet
-Include tier 1
-Private room Routes of administration
-Wear mask 3 ft when working with patient Oral
-Surgical mask on client during transport Sublingual/ buccal
Rectal
Tier2 Contact Topical
-Include tier 1 Transdermal
-Private room Intramuscular
-Gloves Intradermal
-Gown Intravenous
-Use equipment exclusively Intraosseus

Steps on PPE Needles

Donning ID- 3/8 to 5/8 length, 26 to 27 gauge
-Gown SQ- ½ to 1inch length. 25 to 26 gauge
-Mask IM- 1 to 1 ½ inch length 24 to 25 (adult) and
-Goggles 23 to 24 (child) gauge
-Gloves
Wound types
Doffing Open – Puncture, abrasion, laceration,
-Gloves avulsion, incision
-Gown Closed- strain, sprain, internal bleeding
-Goggles
-Mask Wound drainage
• Serous exudate – fluid exudate
Hygiene • Purulent drainage – pus exudate
Mouth- brush 3 times a day • Sanguenous – bloody drainage
Hair- treat dandruff and lice
Hair grooming- comb at the tip of the hair Bleeding
going up the scalp, brush the hair starting at Arterial – spurting blood
the scalp going to the tip, shampoo every Venous- even flow
other day, shave with the hair direction Capillary- bleeding on distal parts like finger
Eyes- wear glasses and contact lenses 14 tips, ears, toes
hours a day
Ears- swab every other day Measures for wound healing
• Irrigation
Specimen collection • Heat and cold applications
-Clean catch- collect the mid stream • Debridement
-Timed urine- discard the first urine
Measures to secure wound
Catheters • Gauze
-Straight- used for short term interventions • Arm sling
(NSD, surgery) • Binder
-Foley catheters- used for long term • Bandage
interventions (ICU, stroke patient, elderly
patients) Pressure ulcers
Areas susceptible to ulcers
Sputum collection- collect upon waking up, • Back of head
instruct patient to take 3 deep breaths • Scapula
Stool collection- 1 inch for solid stool, 30 ml • Elbows
for liquid stool • Side of palms
• Buttocks
Drugs • Ankles
• Capsule
• Cream (greasy) Stage 1 ulcer- Nonblanchable erythema of
• Elixir (w/alcohol) the skin
• Extract Stage 2 ulcer- skin loss involving epidermis,
• Jelly dermis, abrasion
• Liniment(liquid) Stage 3 ulcer- full thickness loss involving
• Lotion (non greasy) SQ tissue
• Lozenge Stage 4 ulcer- damage to muscle and bone
 R- REGION/RADIATION
Assistive devices S- SEVERITY
Cane- used when one side of the body is T- TIMING
weak, cane is on the strong side of the body
Steps- cane  weak leg  strong leg *1 to 10 pain scale
Wong baker scale
Walker- used when both legs are weak
Steps- Walker  one leg  other leg Therapeutic massage
• Manipulation of layers of muscle
Crutch- used when a leg or both legs are • Using pressure, tension, vibration
injured • For joints, long bones, and big muscles
Steps Types
2 point gait- right crutch and opposite leg - Reflexology
forward  left crutch and opposite leg to - Pregnancy massage
follow - Sports massage
3 point gait- crutches forward  weak leg  - Stone massage
strong leg - Shiatsu
4 point gait- right crutch  left leg  left - Thai
crutch  right leg - Deep tissue
- Swedish
Going up the stairs- Strong leg  crutches  - Aroma therapy
weak leg - Back massage
Going down the stairs- Crutches  weak leg
 strong leg Body mass index
Formula: Weight in kg divided by height in
Sleep meters squared
NON- REM • BMI of 20 to 25 -optimal
• Stage 1 – light sleep • BMI below 20 -underweight
• Stage 2 – sleep that can be disturbed • BMI below 20 due to disease
• Stage 3 – snoring occurrences • BMI above 25 -overweight
• Stage 4 –deep sleep, can’t be awakened • BMI 30 - obese
REM • BMI over 40 - morbidly obese
• Dreaming & can be awakened suddenly
Nasogastric feeding tube tips
Sleeping and development • Insertion – n.e.x (nose, ears, xyphoid
Newborns – 16 – 18 hours process)
Infants – 22 hours • Feeding bag must be 12 to 18 inches
Toddlers – 12 hours above insertion site (nose)
Preschool – 12 hours • Ask patient to swallow while inserting tube
Adolescent – 8 – 10 hours
Young adult – 7 – 8 hours NGT placement
Middle age – 6 – 8 hours • Check the aspirate by measuring the pH
Elder – 6 hours less than 4
• Present bowel sounds
Sleeping alterations • XRAY – Confirmatory
• Insomnia
• Hypersomnia Fecal Elimination
• Narcolepsy • Esophagus – passageway of food
• Sleep apnea • Stomach – digestion area
• Somnumbolism • Small intestines – absorption area
• Somniloquy • Large intestines- further absorption
• Bruxism
Colostomy- solid stool, needs irrigation of
Pain 750 ml of fluid
A feeling of unpleasantness, it is subjective Ileostomy- liquid stool, does not need
and individual irrigation
Pain Assessment
O- ONSET CLOSED CHEST TUBE DRAINAGE
L- LOCATION (THORACOSTOMY TUBE)
D- DURATION CHEST TUBE/ WATER SEAL DRAINAGE
C- CHARACTERISTIC DEFINITION: catheter into intrapleural space
A- AGGRAVATING FACTORS to maintain NEGATIVE PRESSURE
R- RADIATION
T- TREATMENT PURPOSES:
• To remove air and/ or fluid
P- PROVOKED • To reestablish negative pressure
Q- QUALITY
PRINCIPLES
GRAVITY
SUCTION
• Speeds up removal of air from pleural
space
WATER
• WATER acts as a seal; provides barrier
between atmospheric air and
intrapleural pressure

DRAINAGE BOTTLE NORMALS

• bloody drainage/24 hours
• 500 – 1000 ml/24 hours
If there is NO DRAINAGE
• Resolution
• Obstruction - pinch

WATER SEAL MUST KNOWS

• Immerse tube in 2- 3 cm of sterile h2o
NORMAL:
• INTERMITTENT BUBBLING
NO FLUCTUATIONS
• Obstruction – check and pinch the
tubing
• Low suction
• Expanded lungs – do chest X- ray for
confirmation
CONTINUOUS BUBBLING
• Air leakage
SUCTION CHAMBER NORMALS
• Immerse the tube in 10 to 20 cm of
sterile H20
COMMON OBSERVATIONS
• Continuous bubbling

Urinary alterations
• Polyuria (2 liters and more per day)
• Oliguria (low urine, 300-500ml/day)
• Anuria ( less than 50 ml/day
• Urinary frequency (urinating too often)
• Nocturia (urinating at night)
• Urgency (sudden urge)
• Dysuria (painful urination)
• Enuresis (bed wetting)
• Urinary incontinence (cannot control
urine)
• Urinary retention (lack of ability)

Oxygen modalities
Device LPM 02
Nasal canula 1- 6 24- 45 %
Face mask 5- 8 40- 60 %
Partial 6- 10 60- 90 %
rebreather
mask
Non rebreather 10- 15 95- 100 %
mask
Venture mask 4- 10 Based on
color
Face tent 4- 8 30- 50 %