Fundamentals in NURSINGFundamentals in NURSING

NURSINGNURSING

I. DEFINITION OF NURSING NURSING - is a profession focused on assisting individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. Modern definitions of nursing describes it as a science and an art that focuses on promoting quality of life as determined by persons and families, throughout their life experiences from birth until the end of life. NURSING - Assisting the individual (sick or well) in the performance of those activities contributing to health, or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge- and in doing so, promote independence as much as possible. (Henderson) NURSING – is providing the most favorable environment to an individual for nature to act in order to promote “reparativeness” and maintenance of health and well being. (Nightingale) NURSING – is an art, (ability to perform nursing acts skillfully), and a science (body of knowledge which governs the profession) NURSING - is caring (Watson) 

II. GOALS OF NURSING· Promotion of Health – promoting a healthy lifestyle· Prevention of illness – early detection and treatment· Restoration of health – curing and healing, rehabilitationCare of the dying – maintaining dignity and peaceful death 

III. SCOPE OF NURSING CARE· Individual· FamiliesCommunities 

IV. THEORETICAL FOUNDATIONS OF NURSING & HISTORICAL PERSPECTIVE  Metaparadigm of nursing – identifies the core

content of a discipline. Persons – recipient of nursing care. Represents

an individual, a family, or a community. Health – represents a state of well-being mutually

decided and agreed upon by the client and the nurse.

Environment – may be internal or external to the person

Nursing – is the science and art of the discipline. 

THEORISTS THEORY KEYWORD Florence Nightingale

Focused on organizing and manipulating the physical, social and psychological environment in order to put the person in the best possible conditions for nature to act

Environmental Theory of Nursing

Hildegard Peplau

Presents nursing as an interpersonal process of therapeutic interactions between the nurse and the patient

four phases of the nurse - patient relationship: orientation, identification, exploitation, and resolution

Interpersonal RelationshipNurse – Patient relationship

Virginia Henderson

Views nursing as doing for patients what they cannot do for themselves, and she identifies 14 components of nursing care that need to be considered.

14 fundamental needsDefinition of Nursing

Lydia Hall Focus around the three components of care, core, and cure. Care -represents nurturance and is exclusive to nursing. Core -involves the therapeutic use of self and emphasizes the use of reflection. Cure -focuses on nursing related to the physician’s orders.

Care, core, curePrimary NursingHolistic Nursing

Dorothea Orem

Nursing consists of the three theories of self care, self care deficit and nursing systems. Self-care -includes the human’s ability to care for him- or herself (self-care agency), basic

conditioning factors, a totality of self-care actions needed (therapeutic self-care demand), and three categories of self-care requisites: universal, developmental, and health deviation.

Self-care deficit theory - identifies when nursing is needed because the person is incapable of or provide continuous effective self -care

Nursing systems theory- identifies three nursing systems as wholly compensatory, partly compensatory, and supportive-educative

Theory of self - care

Dorothy E. Johnson

Behavioral system model for nursing has seven subsystems: Attachment or affiliation Dependence Ingestive Eliminative Sexual Aggressive Achievement

Behavioral System model

Faye G. Abdellah

focuses on problem-solving to move the patient toward health21 common nursing problems relative to caring for patients

21 nursing problems

Ida Jean Orlando

Orlando believes that nurses provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. She emphasizes the importance of validating the need and evaluating care based on observable outcomes.

Nursing Process Discipline 

Ernestine Wiedenbach

Strongly believes that the nurse’s individual philosophy or central purpose lends credence to nursing care. She believes that nurses help to meet the individual’s need for help through the identification of the needs, ministration of help, and validation that the actions were helpful.

PhilosophyPurposePractice

ArtPerspective Theory

Myra Levine Views nursing as human interaction: the dependency of individuals on one another. Levine identifies four principles of conservation: conservation of energy, conservation of structural integrity, conservation of personal integrity, and conservation of social integrity

Conservation theory

Imogene King Presents a theory of goal attainment from an open system conceptual framework that integrates personal systems, interpersonal systems, and social systems.

Goal – attainment theory

Martha Rogers Rogers developed the principles of homeodynamics, which focus on the wholeness of human beings, the unitary nature of human beings and their environment, and the nature and direction of human and environment change.

Science of unitary man

Josephine Paterson and Loretta Zderad

Nursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to be nursed. The essential characteristic of nursing is nurturance. Humanistic nursing cannot take place without the authentic commitment of the nurse to being with and doing with the client.

Humanistic Nursing theory

Jean Watson Science of caring is built on a framework of seven assumptions and ten carative factors. She emphasizes the interpersonal nature of caring, describes the nurse as a co- participant with the client, and includes the soul as an important consideration.

Science of caringCarative factors

Rosemarie Rizzo Parse

Emphasizes free choice of personal meaning in relating value priorities, concreting of rhythmical pattern in exchange with the environment, and cotranscending in many dimensions as possibilities unfold.

Human becoming theory

Helen Erickson, Evelyn Tomlin, and Mary Ann Swain

The focus of this theory is on the person. The nurse models (assesses), role models (plans), and intervenes in this interpersonal and interactive theory

Modeling and Role-Modeling

Madeleine Leininger

focuses on the importance of understanding the similarities (universalities) and differences (diversities) of peoples across cultures

Transcultural nursing

Margaret Newman

Health as expanding consciousness. Humans are unitary being in whom disease is a manifestation of the pattern of health. Consciousness is the information capability of the system which is influenced by time, space, and movement and is ever-expanding.

Expanding consciousness

HEALTH, WELLNESS and HEALTH, WELLNESS and ILLNESSILLNESS

I.DEFINITION

HEALTH Ability of the person to maintain a state of

wellness, and using every power an individual possess to the fullest extent (Nightingale, 1969)

Is a state of being that people define in

relation to their own value systemIs a state of complete physical, mental and

social well-being and not merely the absence of disease or infirmity. (WHO 1948)

Is a "resource for everyday life, not the objective of living", and "health is a positive concept emphasizing social and personal resources, as well as physical capacities."( WHO "Ottawa Charter for Health Promotion” 1986)

 WELLNESS

Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall feeling of well-bein

It is the physical state of good health as well as the mental ability to enjoy and appreciate being healthy and fit

Wellness is first and foremost a choice to assume responsibility for the quality of your life. It begins with a conscious decision to shape a healthy lifestyle. Wellness is a mind set, a predisposition to adopt a series of key principles in varied life areas that lead to high levels of well-being and life satisfaction.

 

II. COMPONENTS OF HEALTH AND WELLNESS

Physical – body’s ability to function efficiently and effectively in work and leisure activities, to be healthy, to resist hypokinetic diseases, and to meet emergency situations.

Social - means being aware of, participating in, and feeling connected to the community

Emotional -is demonstrated by the overall comfort with and acceptance of one’s full range of feelings

Intellectual - involves lifelong learning through formal education and informal life experiences

Spiritual-refers to integrating beliefs and values with actions.

Occupational - measures the satisfaction gained from a career and the degree to which you are enriched by that work.

Environmental - trying to live in harmony with the earth by understanding the impact of interaction with nature and personal environment, and taking action to protect the world around an individual.

 III. MODELS OF HEALTH AND WELLNES

CLINICAL MODEL – health is viewed as absence of signs and symptoms

ADAPTIVE MODEL – a person is healthy if he/she can adapt to the different stressors of life.

ROLE PERFORMANCE MODEL – an individual is healthy if he can satisfy societal roles, or ability to fulfill his/her duty or work

EUDEMONISTIC MODEL – refers to the actualization of ones potentials

 

D A E GS 

S

DISEASE / PREMATURE DEATH

HIGH LEVEL OF WELLNESS

HEALTH - ILLNESS CONTINUUM – a predictive grid that displays the likelihood of a person to participate in preventive health care

 

Figure 1.2 Health-Illness Continuum, as shown here, represents the process of achieving high levels of wellness or the consequences of unhealthy lifestyle. In this figure, there are three parameters on how to achieve high levels of wellness. These are: (A) – Awareness, (E) – Education, and (G) Growth. Otherwise, an individual who continuously live an unhealthy lifestyle, will be on the other side of the grid, and would develop the following: (S) – signs and symptoms (S) –syndromes, and (D) – Disorder or disability which may lead disease or premature death.

 AGENT - HOST - ENVIRONMENT MODEL

– primarily used to predict an illness. Agent - Any environmental factor or

stressor, chemical, mechanical, physical, psychosocial that by its presence or absence can lead to illness or disease

Host -Persons who may or may not be at risk of acquiring the disease

Environment -All factors external to the host that may or may not predispose the person to the development of the disease

  

HEALTH BELIEF MODEL - Helps determine whether an individual is likely to participate in disease prevention and health promotion activities.

Useful tools in developing programs for helping people change to healthier lifestyles and develop a more positive attitude toward preventive health measures.

ComponentsIndividual perceptions –

includes perceived susceptibility, seriousness, and threat

modifying factors – includes demographic variables, sociophysiologic variables, structural variables, and cues to action

Likelihood to action – depends on the perceived benefit versus the perceived barriers.

  

HEALTH CARE ADHERENCE – the extent to which behavior is congruent with medical or health advice, which is affected by various factors such as client’s motivation, lifestyle change necessary, severity of the disease, cultural factors,drug side effects, duration of treatment and overall cost.

 

IV. ILLNESS and DISEASEILLNESS – subjective state in which the

person’s functional faculties are thought to be diminished

DISEASE – alteration in body’s physiology which reduces one’s capacities and shortens the normal life span.

ETIOLOGY – the cause of the disease CLASSIFICATIONS OF ILLNESS AND DISEASE:

Acute illness – severe symptoms but short duration which may or may not require medical interventions.

Chronic illness – longer duration with periods of remission and exacerbation.

 STAGES OF ILLNESS:

STAGE 1 (Symptom experience)STAGE 2 (Assumption of the sick role)STAGE 3 (Medical Care contact)STAGE 4 ( Dependent Client Role)STAGE 5 ( Recovery or Rehabilitation)

 V. PREVENTIVE HEALTH CARE LEVELS OF PREVENTION  PRIMARY PREVENTION - deals with promotion of healthy lifestyle and maintenance of current health. Examples: immunization, adequate rest and sleep, avoidance of stress, eating a well balanced diet, and many more. SECONDARY PREVENTION – early detection and prompt treatment Examples: diagnosis and prompt interventions to reduce the effect of disease to achieve the possible level of health for the client (e.g. chest x – ray, pap smear, complete blood count, CT scan) TERTIARY PREVENTION – Directed towards rehabilitation and prevention of complications

Examples: frequent turning of an immobilized client, ROM exercises, administration of medications directed towards recovery or prevention of complications.

 

NURSING INFORMATICSNURSING INFORMATICS

Nursing Informatics – is the integration of computer, information, and nursing science. Nursing informatics - assists the management and processing of nursing data, information, and knowledge to support nursing practice, education, research, and administration.Nursing Informatics - is the science of using computer information systems in the practice of nursing. (Kozier et.al) Nursing Informatics is a growing specialty and will be of greater aid for nurses in the coming years. The advent of technological breakthrough creates a sudden shift of paradigm in practice disciplines such as nursing. The human – machine tandem have proven a lot of change in terms of efficiency, accuracy and precision, cost effectiveness, time value, and many more in various fields of science and commerce. If this process is carried on through nursing, then we can assure of quality client care even in the most unlikely environment. "Computers are incredibly fast, accurate and stupid. Human beings are incredibly slow, inaccurate and brilliant. Together they are powerful beyond imagination." - Albert Einstein CARING AND INFORMATICS Technological proficiency in nurses is a desirable attribute to function optimally in our changing health care system: not as a substitute for nurses' care, but as an actual enhancement of care. The competent use of machine technology is becoming integral to nurses' work, in acute and community settings. Nurses need to develop technological know-how to keep pace with the rapid development of new health technologies.Technological competence requires intentionality, along with compassion, Confidence, commitment,

and conscience.  The relationship between computer literacy, technological competence and a nurse's ability to care is congruent for quality care. Computer literacy represents a proactive response to technology which enhances Caring in nursing TELE-NURSING Tele-nursing is the branch of telehealth that involves actual nursing and client interaction through the medium of information technology. Benefits of Tele-nursing· Nurses can actually view healing wounds, can access physiological monitoring equipment to measure physical indicators such as vital signs and provide routine assessment and follow-up care without the client having to travel to the health care agency for an appointment.New technologies have added a visual component to the interactions that augments the historic audio exchange.  E-HEALTH E-health is a client-centered World Wide Web-based network where clients and health care providers collaborate through ICT mediums to research, seek, manage, deliver, refer, arrange, and consult with others about health related information and concerns Nurses can be primary actors in the virtual arena of E-health, serving as health advisors, Internet guides to help clients select reliable information resources, support group liaisons, web information providers, and so on TERMS

active program or window - The application or window at the front (foreground) on the monitor.

alert (alert box) - a message that appears on screen, usually to tell you something went wrong.

application - a program in which you do your work.

application menu - on the right side of the screen header. Lists running applications.

ASCII (pronounced ask-key ) - American Standard Code for Information Interchange. a commonly used data format for exchanging information between computers or programs.

background - part of the multitasking capability. A program can run and perform tasks in the background while another program is being used in the foreground.

bit - the smallest piece of information used by the computer. Derived from "binary digit". In computer language, either a one (1) or a zero (0).

backup - a copy of a file or disk you make for archiving purposes.

boot - to start up a computer.  bug - a programming error that causes a

program to behave in an unexpected way.

bus - an electronic pathway through which data is transmitted between components in a computer.

byte - a piece of computer information made up of eight bits.

card - a printed circuit board that adds some feature to a computer.

cartridge drive - a storage device, like a hard drive, in which the medium is a cartridge that can be removed.

CD-ROM - an acronym for Compact Disc Read-Only Memory.

Clipboard - A portion of memory where the Mac temporarily stores information. Called a Copy Buffer in many PC applications because it is used to hold information which is to be moved, as in word processing where text is "cut" and then "pasted".

command - the act of giving an instruction to your Mac either by menu choice or keystroke.

compiler - a program the converts programming code into a form that can be used by a computer.

compression - a technique that reduces the size of a saved file by elimination or encoding redundancies (i.e., JPEG, MPEG, LZW, etc.)

control key - seldom used modifier key on the Mac.

control panel - a program that allows you to change settings in a program or change the way a Mac looks and/or behaves.

CPU - the Central Processing Unit. The processing chip that is the "brains" of a computer.

crash - a system malfunction in which the computer stops working and has to be restarted.

cursor - The pointer, usually arrow or cross shaped, which is controlled by the mouse.

database - an electronic list of information that can be sorted and/or searched.

data - (the plural of datum) information processed by a computer.

defragment - (also - optimize) to concatenate fragments of data into contiguous blocks in memory or on a hard drive.

desktop - 1. the finder. 2. the shaded or colored backdrop of the screen.

desktop file - an invisible file in which the Finder stores a database of information about files and icons.  

dialog box - an on-screen message box that appears when the Mac requires additional information before completing a command.

disk drive - the machinery that writes the data from a disk and/or writes data to a disk.

disk window - the window that displays the contents or directory of a disk.

document - a file you create, as opposed to the application which created it.

DOS - acronym for Disk Operating System - used in IBM PCs.

download - to transfer data from one computer to another. (If you are on the receiving end, you are downloading. If

you are on the sending end, you are uploading).

drag - to move the mouse while its button is being depressed.

drag and drop - a feature on the Mac which allows one to drag the icon for a document on top of the icon for an application, thereby launching the application and opening the document.

driver - a file on a computer which tells it how to communicate with an add-on piece of equipment (like a printer).

expansion slot - a connector inside the computer which allows one to plug in a printed circuit board that provides new or enhanced features.

extension - a startup program that runs when you start the Mac and then enhances its function.

file - the generic word for an application, document, control panel or other computer data.

finder - The cornerstone or home-base application in the Mac environment. The finder regulates the file management functions of the Mac (copying, renaming, deleting...)

floppy - a 3.5 inch square rigid disk which holds data. (so named for the earlier 5.25 and 8 inch disks that were flexible).

folder - an electronic subdirectory which contains files.

font - a typeface that contains the characters of an alphabet or some other letterforms.

fragmentation - The breaking up of a file into many separate locations in memory or on a disk.

freeze - a system error which causes the cursor to lock in place.

gig - a gigabyte = 1024 megabytes. hard drive - a large capacity storage

device made of multiple disks housed in a rigid case.

 hardware – physical parts of the computer. Includes central processing unit, input and output devices.

high density disk - a 1.4 MB floppy disk. highlight - to select by clicking once on an

icon or by highlighting text in a document.

icon - a graphic symbol for an application, file or folder.

initialize - to format a disk for use in the computer; creates a new directory and arranges the tracks for the recording of data.

insertion point - in word processing, the short flashing marker which indicates where your next typing will begin.

installer - software used to install a program on your hard drive.

kilobyte - 1024 bytes. landscape - in printing from a computer, to

print sideways on the page. launch - start an application. Measurements (summary) -

*a bit = one binary digit (1 or 0) *"bit" is derived from the contraction b'it (binary digit) -> 8 bits = one byte*1024 bytes = one kilobyte

*K = kilobyte*Kb = kilobit*MB = megabyte*Mb = megabit*MB/s = megabytes per second*Mb/s = megabits per second*bps = bits per secondi.e., 155 Mb/s = 19.38 MB/s

MB - short for megabyte. megabyte - 1024 kilobytes. memory - the temporary holding menu - a list of program commands listed

by topic. menu bar - the horizontal bar across the

top of the Mac¹s screen that lists the menus.

multi tasking - running more than one application in memory at the same time.

operating system - the system software that controls the computer.

optical disk - a high-capacity storage medium that is read by a laser light.

palette - a small floating window that contains tools used in a given application.

partition - a subdivision of a hard drives surface that is defined and used as a separate drive.

paste - to insert text, or other material, from the clipboard or copy buffer.

PC - acronym for personal computer, commonly used to refer to an IBM or IBM clone computer which uses DOS.

peripheral - an add-on component to your computer.

point - (1/72") 12 points = one pica in printing.

pop-up menu - any menu that does not appear at the top of the screen in the menu bar. (may pop up or down)

port - a connection socket, or jack on the Mac.

RAM - acronym for Random-Access Memory.

ROM - acronym for Read Only Memory; memory that can only be read from and not written to.

root directory - the main hard drive window.

save - to write a file onto a disk. save as - (a File menu item) to save a

previously saved file in a new location and/or with a new name.

scroll box - the box in a scroll bar that is used to navigate through a window.

serial port - a port that allows data to be transmitted in a series (one after the other), such as the printer and modem ports on a Mac.

server - a central computer dedicated to sending and receiving data from other computers (on a network).

shut down - the command from the Special menu that shuts down the Mac safely.

software - files on disk that contain instructions for a computer.

spreadsheet - a program designed to look like an electronic ledger.

start up disk - the disk containing system software and is designated to be used to start the computer.

System file - a file in the System folder that allows your Mac to start and run.

System folder - an all-important folder that contains at least the System file and the Finder.

title bar - the horizontal bar at the top of a window which has the name of the file or folder it represents.

Uninterruptible Power Source (UPS)- a constantly charging battery pack which powers the computer. A UPS should have enough charge to power your computer for several minutes in the event of a total power failure, giving you time to save your work and safely shut down.

WORM - acronym for Write Once-Read Many; an optical disk that can only be written to once (like a CD-ROM).

zoom box - a small square in the upper right corner of a window which, when clicked, will expand the window to fill the whole screen.

 

LEVEL OF EXPERTISE AND COMPETENCIES IN NURSING INFORMATICS

 Levels of Expertise: 

Beginner, entry or user level - indicates nurses who demonstrate core nursing informatics competencies.

Intermediate or modifier level - indicates nurses who demonstrate intermediate nursing informatics competencies.

Advanced or innovator level of competency - indicates nurses who demonstrate advanced and specialized nursing informatics competencies

 Competencies: 

Technical - are related to the actual psychomotor use of computers and other technological equipment.

Utility - related to the process of using computers and other technological equipment within nursing practice, education, research and administration

Leadership - are related to the ethical and management issues related to using computers and other technological equipment within nursing practice, education, research and administration

 Each of the three competency levels includes both knowledge and skills required to:" use information and communication technologies to enter, retrieve and manipulate data; interpret and organize data into information to affect nursing practice; and Combine information to contribute to knowledge development in nursing" (Hebert, 1999, p.6). "The need to adopt a culture in nursing that promotes acceptance and use of information technology has been identified as an important parallel initiative to establishing Nursing Informatics competencies and educational strategies" (Hebert, 1999, p. 6).

 GENERAL CONCEPTS IN NURSING INFORMATICS

(Adopted from Fundamentals of Nursing by Kozier et.al)

 Computer in Nursing EducationJust as computers have become standard instructional tools in the primary and secondary school systems, they are used extensively in all aspects of nursing education. Nursing programs require computerized libraries, faculty members use technological teaching strategies in the classroom and for outside assignments, and academic record keeping is facilitated by database programs. Teaching and LearningComputers enhance academics for both students and faculty in at least four ways. These include access to literature, CAI, classroom technologies, and strategies for learning at a distance. 

ASSESSMENT Purpose: To establish database

Activities: Collection of Data Organizing Data Validating Data

Documenting Data 

DIAGNOSINGPurpose: To identify and develop a list of nursing and collaborative problems

Activities:Analysis of Data

Identify strengths, risks, and health problems

Formulate diagnostic statements duly approved by NANDA

EVALUATIONPurpose: to determine the effectiveness of the care

plan and its corresponding actions whether to continue, terminate, or modify the care plan.

Activities Collects and compare data with the outcome

 Relate nursing actions to client’s goals

 Conclude problem status

 Continue, modify or terminate the nursing care

PLANNINGPurpose: To develop an

individualized, goal oriented and therapeutic care plan

Activities:Prioritizing needs

Formulation of GoalsSelection of Nursing Interventions

Writing Nursing Orders

IMPLEMENTATIONPurpose: To assist client meet desired

goals/outcomes and promote maximum level of functioningActivities:

Reassessment of Clients and their response to careDetermination of any need for assistanceImplementation of nursing interventions

Supervising delegated careDocumenting Nursing actions

NURSING PROCESSNURSING PROCESS

DEFINITIONS is a systematic, rational and cyclical method of

planning and providing nursing care PURPOSE

Solve nursing problems Understand a nursing conditions

Systematic → ADPIEIndividualized → UniqueRationale → ScienceCircular/Cycle → sequence

STEPS OF THE NURSING PROCESS 

ASSESSMENT The vital first phase in the nursing process,

assessment consists of the patient history, consultations, lab findings, pharmacological requisites, and the nurse’s physical examination 

Nursing assessment is the systematic process of gathering, verifying and communicating data about a patient. It includes 2 steps (1) collection of data from a primary source (patient), and (2) collection of data from a secondary source (family, health professionals).

 The purpose of assessment is to establish a data

base about the client’s perceived needs, health problems and risks, related experiences, health practices, goals, values, and lifestyle. 

The information contained in the DATA BASE is the basis for an individualized plan of nursing care, developed and refined throughout the time the nurse cares for the client.

InterviewPurpose: To gather information, identify health concerns and provide health teaching.Goal: To develop rapport and trust with the client and to collect data. 

Stages:1. Opening: The purpose is to establish rapport that is achieved through self-introduction, non-verbal gestures (e.g. handshake) etc. The purpose of the interview is explained at this stage.2. Body: The nurse tries to ask the client using open and close-ended questions.3. Closing: After the needed information has been gathered either parties may close the interview. 

Types of data: 

SubjectiveCovert data or symptomsClient’s perceptions about his health

problems. Subjective data usually include feelings of

anxiety, physical discomfort, or mental stress.

 Objective

Overt data or signsObservations or measurements made by the

data collector. The measurement of objective data is based on an accepted standard, such as the Fahrenheit or Celsius measure on a thermometer.

In the physical examination of a patient – involving inspection, palpation, percussion and auscultation – objective data is collected about client’s condition and underlying pathology.

  

NURSING DIAGNOSIS Nursing diagnosis is a “clinical judgment about

individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”- North American Nursing Diagnosis Association (NANDA)

 A nursing diagnosis is a statement that describes the

patient’s actual or potential response to a health problem that the nurse is licensed and competent to intervene.

 Components of a nursing diagnosis: Problem +

Etiology + signs and symptoms / risk factors 

The client’s actual and potential responses are obtained from the assessment data base, a review of pertinent literature, the client’s past medical records, and consultation with other professional, all of which are collected during assessment.

The purpose is to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.

 Types of Nursing Diagnoses: Actual: the client shows manifestations of a health problem or condition.

e.g. ineffective airway clearanceHigh-Risk: A health problem or condition is likely to develop as a result of risk factors being assessed unless the nurse intervenes.

e.g. Risk for injuryWellness: The client is healthy as assessed but he wishes to achieve a higher level of functioning.

e.g. Readiness for enhanced social well being

Possible – a nursing diagnosis is which evidence is unclear unless further provided, but existing condition may predict a possible health problem

e.g. Possible for alteration in nutrition r/t unknown etiology

Syndrome – a clustered nursing diagnosis.e.g. –Disuse Syndrome

  

PLANNING The nursing plan of care refers to a WRITTEN PLAN

of action designed to help nurses deliver quality patient care. It usually becomes part of the permanent part of the patient’s health record and will be used by other members of the nursing team.

The purpose is to develop individualized care plan that specifies client goals and expected

outcomes. 

PLANNING STAGESAssign priorities to the nursing diagnosis

Establish client goals / outcomeSelect appropriate nursing interventionsDocument the nursing diagnosis, expected

outcomes and interventions.Evaluate the effectiveness of the plan of care

 BENEFITS OF A WRITTEN CARE PLANA care plan that is well conceived & properly written

helps decrease the risk of incomplete or incorrect patient care by:giving direction for individualized careproviding continuity of careestablishing professional communicationserving as a key for patient assignments

 GOALS/EXPECTED OUTCOMES

An expected outcome is the specific, step-by-step measurable criterion that leads to attainment of the goal & the resolution of the etiology for the nursing diagnosis.

Outcomes are the desired responses of a client’s condition in the physiological, social, emotional, developmental, or spiritual dimensions. This change in condition is documented through observable or measurable client responses.

Patient goals may be either short term or long term.

 

SPECIFIC How the nurse will know the client’s response has changed.

MEASURABLE What the client will do, when it will be done, and to what extent.

APPROPRIATE Relate with the client in formulating expected outcomes.

REALISTIC Includes client’s health capabilities.TIMELY Time estimate for outcome attainment.

IMPLEMENTATION 

A nursing intervention is any action taken by the nurse to help the client move from a present health state to the health state described in the expected outcomes. The client may require intervention in the form of support, medication, treatment for the current condition, client-family education, or treatment to prevent future health problems.

· The purpose is to assist the client meet desired goals or expected outcomes; promote wellness; prevent illness and disease; restore health and rehabilitation.Consists of carrying out the interventions or delegating nursing interventions, which involves assigning care for a client to another professional or individual while retaining accountability for certain care.

Types: 1. Independent: nurses are licensed to act related to their knowledge and skills.2. Interdependent/ Collaborative: carried out by a nurse with collaboration of other healthcare team.3. Dependent: carried out by a nurse in collaboration with the physician.

EVALUATION Measures the client’s response to nursing actions

and the client’s progress toward achieving goals.The purpose is to determine whether to continue,

modify, or terminate the nursing interventionsThe nurse evaluates whether the client’s behaviors

or responses reflect a reversal or improvement in a nursing diagnosis or maintenance of a health state.

Evaluation may be:Ongoing: done while or immediately after

implementing the nursing intervention.Intermittent: performed at specified

intervals, such as thrice a week.Terminal: performed to indicate the client’s

condition at the time of discharge. Evaluative statements compare the data with the

expected outcomes supported by evidences.Goal met – client’s response is the same

with goalsGoal partially met – only part of the desired

outcome is metGoal unmet – failure to achieve desired

outcome in expected time. 

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

Physical assessment - is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. It provides the foundation for the nursing care plan in which observations play an integral part in the assessment, intervention, and evaluation phases. It is performed in an organized, systematic manner, instead of a random manner.  

CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT

Establish a Positive Nurse/Patient Rapport. This relationship will decrease the stress the patient may have in anticipation of what is about to be done to him.

Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health in order to plan for individualized care.

Obtain an Informed, Verbal Consent for the Assessment. The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly.

Ensure Confidentiality of All Data. If possible, choose a private place where others cannot overhear or see the patient. Explain what information is needed and how it will be used.

Provide Privacy From Unnecessary Exposure. Assure as much privacy as possible by using drapes appropriately and closing doors.

Communicate Special Instructions to the Patient.

 

PURPOSES FOR PERFORMING A PHYSICAL EXAMINATION

To determine the patient's physiological function.

To arrive at a tentative diagnosis when there is a health problem or disease. Provides data for planning intervention

To confirm a diagnosis of disease or dysfunction.

To evaluate the effectiveness of prescribed medical treatment and therapy.

 EQUIPMENT AND SUPPLIES USED FOR PHYSICAL EXAMINATION:

1. Aromatic substances - Test functioning of first cranial nerve (olfactory) (ex. vanilla, coffee)2. Cotton balls - Assess sensory system for light touch3. Gloves reduce risk for transmission of microorganism4. Laryngeal mirror - Metal instrument with mirror to inspect pharynx and oral cavity5. Ophthalmoscope - Lighted instrument attached to a battery tube to visualize the eye’s interior6. Otoscope - Special ear speculum that attaches to an ophthalmoscope to visualize external and middle ear (eardrum)7. Penlight / Flashlight to test pupillary reaction to light and third, fourth, and sixth cranial nerves (oculomotor, trochlear, and abducens)8. Percussion hammer- Instrument with rubber head to test reflexes9. Safety pin - Disposable sharp object to assess pain, sensory system10. Tape measure - Calibrated in cm to measure circumferenceTongue depressor - Wooden tongue blade to inspect oral cavity and stimulate gag reflex to assess ninth and tenth (glossopharyngeal and vagus) cranial nerves

12. Tuning fork - Metal fork that vibrates when tapped and is used to perform Rinne test to assess eighth (acoustic) cranial nerve13. Lubricant - Facilitates insertion of instruments into body cavitiesDrape - Covers exposed body parts ASSESSMENT TECHNIQUES:

 “IPPA” – Inspection, Palpation,

Percussion, Auscultationinspection

use of sense of sight visual inspection/examinationExample, the skin is inspected for color,

tone, and texture, as well as scars, lesions, abrasions, and rashes. Throughout the examination the nurse should visually observe the client’s general body appearances such as movement, motor dexterity, contour and symmetry of the body, and deformities.

palpationuse of sense of touchThe back of the hand can be used to assess

skin temperature over an inflamed joint or a leg with impaired circulation because the skin at the back of the hand is thinner and sensitive to temperature changes

The finger pads are also sensitive and are used to palpate the size, position, and consistency of various body parts, such as lymph nodes and breast tissue

Types of palpation:Light palpation – detects superficial

mass ( 1 “ depth )Deep palpation – palpates organ

enlargement like liver, mass and pulsations ( 3 – 4” in depth)

percussionassess for vibration with the use of fingersThe finger of one hand taps the finger of the other hand to generate vibration which can be used to determine a diagnostic sound.

auscultation use of sense of hearing with the use of

the unaided ear or a stethoscopefrequently assessed organs: heart,

lungs, abdomen, and blood vessels 

HEALTH HISTORY: Biographic information Chief complaint Present health status Health history Family history Psychosocial factors Nutrition 

History of Present illness includes:Statement of general health before

illnessDate of onsetCharacteristics at onsetSeverity of symptomsCourse since onset

TONE QUALITY PITCH EXAMPLEResonance Hollow Low Healthy LungsHyperresonance Booming Very Loud EmpysemaTymphany Drum – like High GI Bubbling,Empty

stomach or Large intestine

Dullness Thud – like high kidney, full bladder, feces filled intestine

Flatness Very Dull Soft - moderate

Bones and muscles ( very dense tissue ) , heart, spleen, liver

Associated signs and symptomsAggravating or relieving factorsEffect on activitiesTreatments tried and resultsAdditional assessment question:

What do you think caused this problem?

Is anyone else in the household sick?

 Past Health History – any diseases and illness

experienced in the past which includes childhood illnesses and immunization status, any recent surgeries, admission, or recurrent illnesses.

Family Health History – any hereditary condition which makes the client susceptible of developing a disease.

 

Vital SIGNSVital SIGNS

Also called Cardinal signs

PURPOSE:To obtain baseline measurement of

the patient’s vital signsTo assess patient’s response to

treatment or medicationTo monitor patient’s condition after

invasive proceduresRefers to the measurement of “ TPR – BP ”

TemperaturePulse RateRespiratory RateBlood Pressure

 Variations in Vital Signs By Age

FACTORS INFLUENCING VITAL SIGNS

Factor Temperature Pulse Respiration Blood Pressure

Exercise and metabolism

Increases Short Term: increasesLong – term : lowers the resting rate and return time to the resting rate post exercise

Rate and depth increases

Increases

Anxiety and stress

Increases Increases Increases Increases

Postural changes

No change Increases with sitting or standing ;Decrease when lying down

Decreases with stooped or slumped positions due to decreased chest expansion

Decrease with sitting or standing

Diurnal variations / circadian rhythm

Lowest level: 4:00 AM – 6:00AMHighest level:8:00 PM – 12:00 AM

Decreases during sleep

None Lowest level: early morningHighest level: late afternoon or early evening

Age Temp. ( ° C)

Pulse Respiratory Cycles/min

BP( mmHg)

Newborn 36 . 8 80 – 180 30 – 80 73 / 55

1 Year 36 . 8 80 – 140 20 – 40 90 / 55

5 – 8 years old

37 75 – 120 15 – 25 95 / 57

10 years old

37 50 – 90 15 – 25 102 / 62

Teen 37 50 – 90 15 – 20 120/80

Adult 37 60 - 100 12 - 20 120/80

Elderly 37 60 - 100 15 – 20 130 / 90

TEMPERATUREReflects the balance between heat produced

and heat lost from the body.  HEAT PRODUCTION

Heat is produced in the body’s cells through food metabolism that results in the release of energy

ENERGY – measured in terms of heat

1 kilocalorie equals 1000 calories (the amount of heat required to raise the temperature of 1 kilogram of water 1°C).

Body continually produces heat as a by product of metabolism

Factors that affect metabolism :Food metabolism Muscle ActivityIncreased thyroxine

productionFever

basal metabolic rate, or BMR - the rate of energy use in the body needed to maintain essential activities

age and exerciseThyroxine output - Increases rate of

cellular metabolism throughout the body(Chemical Thermogenesis)

Epinephrine, Norepinephrine, & symphatetic Nervous System Stimulation - Increase cellular metabolism

 HEAT LOSS

Radiationtransfer of heat from the

surface of one object to another without contact between objects

ex. Warming through a drop light

EvaporationContinuous insensible loss

from the skin and lungs when water is converted from liquid to gas

ex. Natural drying after excessive sweating

 Convection

Dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. The air rises and is replaced by cooler air

ex. Facing a fan for coolingConduction

transfer of heat from one molecule to a molecule of lower temperature

-( with contact)ex.Tepid Sponge Bath

Insensible heat loss - is the heat that is lost through the continuous, unnoticed water loss that occurs with vaporization, accounting for 10% of basal heat production.

Evaporation accounts for the greatest heat loss when body heat increases.

Conversion:Fahrenheit to Celsius°C= (°F-32) x 5/9

Celsius to Fahrenheit°F= (°C x 9/5) + 32

TYPES of TEMPERATURE

1. Core Temperature Measured thru tympanic and rectal routes2. Surface TemperatureMeasured thru oral and axillary routes, skin patch or temperature – sensitive tape

 Alterations in Body Temperature:

Pyrexia- temperature above the usual range. (hyperthermia)- Above 40°C – hyperpyrexia

FeverIntermittent - fluctuation of body

temp. at regular intervals between periods of fever and periods of Normal or subnormal Temperature

Remittent- fluctuations above Normal of more than 2 °C

Relapsing – a fever that subsides and after few days returns.

Constant – a fever with minimal temperature fluctuations

Hypothermia – a body temperature of 35 degrees Celsius or lower resulting from cold weather exposure or artificial induction

Frostbite – freezing of the body’s surface areas (earlobes, fingers,and toes) in extremely low temperatures

Heat Stroke - a critical increase In body temperature ( 41 degree Celsius to 44 degree Celsius) resulting from exposure to high environmental temperatures

  

ROUTES FOR ASSESSING BODY TEMPERATURE:

Oral – accessible and convenient

Contraindications: 1. Infants and very young children2. Patients with oral surgery3. Unconscious or irrational patients4. Seizure-prone patients5. Mouth breathers and pts. with oxygen

Equipment : oral thermometer Slim tip

Axilla - safest and non invasive - Least accurate

Rectal – most reliable measurement

Contraindications:1. Rectal abnormalities2. Diarrhea3. Certain heart conditions4. Immunosuppressed

Equipment: rectal thermomterStubby, pear-shaped tip

electronic thermometer : Battery-powered display unit with a sensitive probe(blue for oral and red for rectal) covered with a disposable plastic sheath for individual use

Tympanic – accessible, less invasiveContraindications:1. Presence of ear ache2. Significant ear drainage3. Scarred tympanic membrane

 

PULSEWave of blood created by contraction of the

left ventricle of the heart. 

Sites Temporal – accessible; used

routinely for infants and when radial pulse is not accessible

Carotid - used routinely for infants and during shock or cardiac arrest when other peripheral pulses are too weak to palpate ; used to assess for cranial circulation

Apical – used to auscultate heart sounds and assess apical - radial pulse =pulse deficit

Femoral – assess circulation to the legs and during cardiac arrest

Brachial – used in cardiac arrest of infants and used to asses for lower arm circulation and to auscultate for BP

Radial – used routinely to assess for character of peripheral pulses in adults

Popliteal – used to assess circulation to the legs and to auscultate leg blood pressure

Posterior tibial – used to assess circulation to the feet

Dorsalis Pedis - used to assess circulation to the feet

 

CHARACTERISTICS OF PULSERate – number of beats per minute; assess

this by compressing an artery with the pads of three fingers.

*A client in pain will have elevated pulse; an athletic may be lower.

*Bradycardia: a pulse that is below normal *Tachycardia: a pulse that is above normal

Rhythm – pattern or regularity of beats and interval between each beat. Pulse rhythm is the spacing of the heartbeats. When the intervals between the beats are the same, the pulse is described as normal or regular. When the pulse skips a beat occasionally, it is described as intermittent or irregular

 Volume/amplitude – amount of blood pumped

with each heartbeat. Pulse volume describes the force with which the heart beats. The volume of the pulse varies with the volume of blood in the arteries, the strength of the heart contractions, and the elasticity of the blood vessels.

Pulse Force/ Pulse Volume Grading:+3: bounding pulse+2: normal+1: thready pulse, weak or

difficult to feel 0: absent pulse

Cardiac Output – 5-6 Liters of blood is forced out of the left ventricle per minute

Pulse Deficit – difference between the apical and radial counts taken simultaneously

Equipment used to assess pulse rate:Alcohol swabStethoscopeWatch with second

handMeasuring Radial Pulse:

1. Inform client of the site at which you will measure the pulse rate

2. Flex client’s elbow and place lower part of arm across chest.

3. Place your index and middle finger on inner aspect of client’s wrist over the radial artery and apply light but firm pressure until pulse is palpated

4. Count pulse rate by using second hand on a watch:

a. For a regular rhythm, count number

of beats for 30 seconds and multiply by 2.

b. For an irregular rhythm, count number of beats for a full minute, noting number of irregular beats.

5. When counting for the first time, count for a full minute

Measuring Apical Pulse1. Raise client’s gown to expose sternum and

left side of chest.2. Locate Apex of heart:3. With client lying on left side, locate

suprasternal notch.4. Palpate second intercostal space to left of

sternum.5. Place index finger in intercostal

space,counting downward until fifth intercostal space is located.

6. Move index finger along fourth intercostal space left of the sternal border and to the fifth intercostal space, left of the midclavicular line to palpate the point of maximal impulse (PMI)

7. Keep index finger of nondominant hand on the PMI.

8. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 seconds to warm.

9. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound

10. Start to count while looking at second hand of watch. Count lub-dub sound as one beat:

11. For a regular rhythm, count rate for 60 seconds.

12. For an irregular rhythm, count rate for a full minute, noting number of irregular beats.

13. Document 

RESPIRATORY RATE 

Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides clinical data regarding the pH of arterial blood.

Normal breathing is slightly observable, effortless, quiet, automatic, and regular.

 Method of Assessment:

Observing chest wall expansion and bilateral symmetrical movement of the thorax.

Place the back of the hand next to the client’s nose and mouth to feel the expired air.

Should assess by counting the number of breaths per minute

Equipment for Assessment: watch with second hand

External Respiration- refers to the interchange of oxygen and CO2 in the alveolo-capillary membrane

Internal Respiration - exchange of gasses between the Blood and the cells

Inhalation/inspiration –active processExhalation/Expiration – passive process due to

elastic recoilNormal respiratory rate: 12-20 breaths per minute

in adult (eupnea).

Respiratory Controls:Medulla Oblongata: Central ChemoreceptorCarotid and Aortic bodies: Peripheral Chemoreceptor

Characteristics of Respiratory Wave Pattern “RAR”

RateAmplitude/depthRhythm / Pattern  

Breathing Pattern and SoundsKussmaul’s - Faster and deeper respiration

without pauses in between pantingApneustic - Prolonged grasping breathing

followed by extremely short inefficient exhalation

Dyspnea - difficulty of breathingOrthopnea -DOB unless patient is sitting; can

breathe only when in an upright position.

Cheyne-Stokes is the term for cycles of breathing characterized by deep, rapid breaths for about 30 seconds, followed by absence of respirations for 10 to

30 seconds. It usually precedes death in cerebral hemorrhage, uremia, or heart disease.

Wheezing - narrowing of airways, causing whistling or sighing sounds

Stridor - high-pitched sounds heard on inspiration with laryngeal obstruction

Crackles/ Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on

inhalationGurgles/ Rhonchi- sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually heard during exhalation ; course , dry, wheezy or whistling sou

BLOOD PRESSURE 

Pressure exerted by blood to the blood vessel wall

SYSTOLIC - ventricular contractionDIASTOLIC - Ventricular relaxationAVERAGE: 120/80 mmHg DETERMINANTS;

Pumping action of the heartPeripheral vascular resistanceBlood volumeBlood viscosity 

Techniques :The direct method requires an invasive

procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. -CVP

The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation are needed.

Common site : brachial arteryContraindications for brachial artery:

Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis

Surgery involving the breast, axilla, shoulder, arm, or hand

Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or bandage

 

Factors affecting Blood Pressure:Age -Children normally have lower

blood pressure at birth (80/60), which gradually increases until the age of 18 when it becomes equal to the normal adult pressure. Older adults frequently have higher blood pressure due to a decrease in blood vessel elasticity.

Sex - Men have higher blood pressure than women of the same age.

Body Built-Blood pressure is usually elevated in an obese person.

Exercise- Muscular exertion will temporarily elevate the blood pressure. A regular exercise program can eventually decrease the resting blood pressure.

Pain- Physical discomfort will usually elevate the blood pressure.

Emotional Status- Fear, worry, or excitement can elevate the blood pressure.

Disease States and Medication -Some disease conditions and/or the medications influence the blood pressure.

  Points to remember when Assessing

Blood Pressure:Equipment:Sphygmomanometer with proper size

cuffStethoscopeAlcohol swabs 

1. Select a cuff size that completely encircles upper arm without overlapping

2. Wrap the blood pressure cuff on the arm 1 inch above client’s brachial pulsation, with bladder centered over brachial artery

3. Position arm at heart level, extend elbow with palm turned upward.

4. Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears, then slowly release valve (deflating cuff), noting reading when pulse is felt again.

5. Place bell piece over brachial artery below the level of the chest

6. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified 

7. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per second. Listen for five phases of Korotkoff’s sounds while noting manometer reading:

8. A faint, clear tapping sound appears and increases in intensity (phase I). – systolic pressure

9. Swishing sound (phase II).10. Intense sound (phase III).11. Abrupt, distinctive muffled sounds (phase

IV).

12. Sound disappears (phase V) – Diastolic Pressure

a. Deflate cuff and wait for 2 mins if reasessement is needed

13. Document

Conditions related to Blood Pressure: Hypotension refers to a systolic blood

pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Hypotension is caused by a disruption in hemodynamic regulation, such as:

Decreased blood volume (e.g., hemorrhage)

Decreased cardiac output (e.g., myocardial infarction [heart attack])

Decreased peripheral vascular resistance (vascular dilation) (e.g., shock)

Orthostatic hypotension (postural hypotension) refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position. Orthostatic hypotension usually occurs with aging and is a common antiadrenergic side effect of several medications, such as chlorpromazine hydrochloride.

 Hypertension refers to a persistent systolic

pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. Diagnosis of hypertension is based on the average of two or more readings taken at each of two or more visits after an initial screening.

 Faulty techniques that constrict

blood flow will produce a false high pressure reading:

A cuff too narrow for the extremity

A cuff that does not fit snugly around the extremity

A cuff that is deflated too slowly 

NEUROLOGICAL NEUROLOGICAL ASSESSMENTASSESSMENT

NEUROLOGICAL ASSESSMENTLevels of Consciousness - Can be

measured by RLS (Reactive Level Score)

and Glasgow Coma ScaleREACTIVE LEVEL SCORE (RLS)

AlertDrowsyVery DrowsyUnconscious LocalizingUnconscious WithdrawingDecorticatingDecerebrating

 Glasgow Coma scale is a tool used to

measure the levels of consciousness and the degree of impairment. Included in the GCS are: assessment of eye opening, best verbal response, and best motor response.( Refer to table below)The score in each category is added in order to get the overall scale. The highest possible score is 15. If a score falls below 7, the patient is considered I comatose status.

 

GLASGOW COMA SCALE (GCS) TABLE: Score

Eye Opening Response

Spontaneous ( open with blinking at baseline) 4Opens to verbal command, speech, or shout 3Opens to pain, not applied to face 2None 1

Best Verbal Response

Oriented 5Confused conversation, but able to answer questions

4

Inappropriate responses, words discernible 3Incomprehensible speech 2None 1

Motor Response

Obeys commands for movement 6Purposeful movement to painful stimulus 5Withdraws from pain 4Abnormal (spastic) flexion, decorticate posture 3Extensor (rigid) response, decerebrate posture 2None 1

Total   15

Appearance: Neat, clean; clothes appropriate to occasion, season, and sexAffect: Attentive, cooperative, pleasant

Speech : Articulate, fluent, readily answers questionsMemory: Responds appropriately to questions:

Immediate: “Why are you here?”Recent: “What did you eat for breakfast?”Remote: “Where were you born?”

 Orientation :

Person (self, others)PlaceTime 

 

CRANIAL NERVES ASSESSMENT TOOL 

I Olfactory Cribiform Plate Special Sensory: Smell Smell

II Optic Optic Canal Special Sensory: Sight VisionIII Oculomotor Superior Orbital

FissureSomatic Motor: Superior, Medial, Inferior Rectus, Inferior Oblique  ; Visceral Motor: Sphincter Pupillae  Pupil Constriction, elevation of upper lid

IV Trochlear Superior Orbital Fissure

Somatic Motor: Superior Oblique Eye movement,

V Trigeminal V1: Sup Orb Fissure V2: Foramen Rotundum V3: Foramen Ovale

Somatic Sensory: Face  Somatic Motor: Mastication, Tensor Tympani, Tensor Palati Controls muscle of chewing

VI Abducens Superior Orbital Fissure

Somatic Motor: Lateral Rectus Eye movement,

VII Facial Internal Auditory Canal

Somatic sensory: Posterior External Ear Canal  Special Sensory: Taste (Anterior 2/3 of Tongue)  Somatic Motor: Muscles Of Facial Expression Visceral Motor: Salivary Glands, Lacrimal Glands Controls muscle for facial expression

VIIIAcoustic

Internal Auditory Canal

Special Sensory: Auditory/Balance Maintain equilibrium; hearing

IX Glossophar-yngeal

Jugular Foramen Somatic Sensory: Posterior 1/3 Tongue, Middle Ear  Visceral Sensory: Carotid Body/Sinus  Special Sensory: Taste Somatic Motor: Stylopharyngeus  Visceral Motor: Parotid Controls muscle of throat

X Vagus Jugular Foramen Somatic Sensory: External Ear  ; Visceral Sensory: Aortic Arch/Body  ; Special sensory: Taste Over Epiglottis  Somatic Motor: Soft Palate, Pharynx, Larynx (Vocalization and Swallowing)  Visceral Motor: Bronchoconstriction, Peristalsis, Bradycardia, Vomitting Controls muscle of throat, thoracic and abdominal organs

XI Spinal Accessory

Jugular Foramen Somatic Motor: Trapezius, Sternocleidomastoid Controls neckmuscles

XI Hypoglossal Hypoglossal Canal Somatic Motor: Tongue Tongue movement

Neurologic Assessment

Assessment Tool

Normal Findings Significant Findings

Motor Functionassessment of themotor systeminvolves testing formuscle size, tone,and strengthunder voluntarymovements

Muscle strength.Flexion and extension.Muscle tone

  

 

· Equal ize on both ides of body· Usually firm· Equal strength on both sides of the body· Smooth , coordinated movements

NOTE: Tics, tremors, fasciculations may suggest neurologic involvement.

 

Reflexes 

Scale Response0 Absent+ Present but

diminished++ Normal+++ Mildly increased

but not pathologic++++ Markedly

hyperactive; clonus may be present

 

Blink reflexGag and swallow reflexPlantar response (Babinski reflex)Deep tendon reflexBiceps - Triceps – BrachioradialisPatellar – NORMAL: extension of

leg below the kneeAchilles – Normal: plantar flexion

of feetPlantar (babinski) – Normal:

bending of toes downward 

NOTE: Diminished or absent reflexes may suggest upper or lower motor neuron disease; however, this may also be found in normal people. (Reinforcement by isometric contraction such as asking patient to push his or her hands together while knee reflex is checked may increase reflex activity.)

A positive Babinski’s reflex may be seen in pyramidal tract disease or in the unconscious patient  

Sensory Function 

Asses for: (done after symmetric testing of the arms, legs, and trunk)

Pain: “Sharp or dull?”Temperature: “Hot or

cold?”Light touch: “Feel

touch?”Vibration: “Feel tuning

fork vibrating against joint?”

Position sense (proprioception): “Am I moving your toe up or down?”

 

NOTE: Inappropriate response indicates neurologic disorder. 

Cerebellar Function 

Perform Romberg’s test: ask the client to stand erect, feet together and arms at side, first with eyes open, then closed. The nurse should stand close to the client to catch the client in the event of a fall

 

. Note the client’s ability to maintain balance with eyes open and closed for 20 seconds with minimum swaying 

 

NOTE: Loss of balance is termed “positive Romberg test” (indicates sensory ataxia).

Uncoordinated gait may suggest cerebral palsy, parkinsonism, or drug side effect. Inappropriate movements suggest cerebellar disease

 

HEAD ASSESSMENT 

Assessment Assessment Tool

Normal Findings

Significant Findings

Head Inspection :Size or contour

Normocephalic HydrocephalicMicrpcephalicAsymmetric

Scalp inspection Smooth,nontender

NOTE: Scaling, masses, tenderness

Head circumference

Measuring Tape : (measured at largest point above eyebrow and behind occiput)

Between 5th and 95th percentile on standardized growth chart.

Exceeds chest circumference by 1–2 cm until 18 mo.

 

Anterior fontanel 

  3–4 cm in length and 2–3 cm in width until 9–12 mo of age. Soft, flat; bulges while crying. Closes between 9 and 18 mo.

 

NOTE: Unusually large fontanel may indicate hydrocephaly (faulty circulation or absorption of CSF). Unusually small fontanel may indicate craniosynostosis(premature closure of sutures).  

Posterior fontanel 

  0.5–1 cm across. May be closed at birth or by 3 mo of age.

Delayed closure may indicate hydrocephaly.

 

FACE ASSESSMENT 

Assessment Assessment Tool

Normal Findings

Significant Findings

Face:    

Inspection Symmetric, with relaxed facial expressions

 

Asymmetric, weak; involuntary movements;tense or expressionless facies

Sinuses   Frontal and maxillary sinuses nontender

Tenderness

Cranial nerve: (CN)VII: facial, motor

 

  Able to smile, puff cheeks, frown, raise eyebrows, with symmetry noted

Unable to purposely and symmetricallyuse facial muscles

CN V: trigeminal:Motor  

  Bilateral contractions of temporal and massetermuscles when teeth are clenched

Weak or asymmetric contraction ofmuscles

CN V: trigeminal:sensory

  Able to distinguish touch on both sides of face

Unable to distinguish type and location oftouch

Eye Assessment

Visual acuityassessment of visual acuity is a

simple, noninvasive procedure that is performed with the use of a Snellen chart(a chart that contains various-sized letters with standardized numbers at the end of each line of letters)

standardized numbers or denominators indicates the degree of visual acuity from a distance of 20 feet

External lesions. Equality of eyelid movement

Test extraocular muscle function:Record results. Eye

movements should be symmetrical as both eyes follow the direction of the gaze. The upper eyelids cover only the uppermost part of the iris and are free from nystagmus (involuntary, rhythmical oscillation of the eyes).

Presence of discharge. Internal lesions. Differences between pupil size

and reaction.Record results PERRLA (pupils equal, round, reactive to light and accommodation). Pupil should constrict quickly in direct response to light and the opposite pupil should also constrict.Pupils should be equal in size.  Pupillary accommodation causes constriction in response to objects that are near, and dilation occurs to accommodate distant vision, with symmetrical convergence of eyes.

Pupil Size: 

Common Refractory Error:Myopia (nearsightedness) elongation of the

eyeball or an error of refraction that causes the parallel rays to focus in front of the retina

Hyperopia ( farsightedness) rays of light entering the eye are brought into focus behind the retina

Presbyopia ( far sightedness) results from loss of elasticity of the lens of the eye

Astigmatism – unequal spherical curve of the cornea that prevents the light from being focused directly in a point on the retina

 

Ear Assessment

The nurse should observe the client for signs of hearing difficulty during the physical examination, such as turning the head, lipreading, and speaking in a loud voice.

Auditory acuityWhispered voice test:Nurse stands 1–2 feet away from client, out

of view to avoid client lipreading, and softly whispers numbers on side of open ear. Increase voice volume until client identifies words correctly.

Inability to hear words may indicate a high-frequency hearing loss (e.g., resulting from excessive exposure to loud noises).

 Weber test: Hold the base of the vibrating fork with your

thumb and index finger and place the base of the fork on center of top of client’s head

Sound perceived equally in both ears; results indicate a “negative” Weber test.

Positive : conductive hearing loss ( impacted cerumen, perforated tympanic membrane, cerum or pus in the middle ear, fusion of the ossicles

Sensorinueral hearing loss : auditory nerve damage , prolonged loud noise, effect of ototoxic agent

 

Rinne test:Vibrate prongs of tuning fork and place base of

fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears sound

Sound heard longer in front of the right auditory meatus than on the mastoid process because air conduction is twice as long as bone.

Bone conduction is equal to or greater than air conduction. Occurs with conductive hearing loss resulting from diseases, obstruction, or damage to outer or middle ear.

 Note Presence of external

lesions.Note Presence of discharge.

 

Mouth and Lip Assessment Mouth:

Stand 12–18 inches in front of client and smell the breath. Breath should smell fresh.Halitosis (foul-smelling breath) occurs with tooth decay or disease of gums, tonsils, or sinuses or with poor oral hygieneAcetone breath (“fruity” smell) is common in malnourished or diabetic clients with ketoacidosis.

Musty smell is caused by the breakdown of nitrogen and presence of liver disease.Ammonia smell occurs during the end stage of renal failure from a buildup of urea.

LipLip lesion:

Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that rupture and crust over.Chancre (primary lesion of syphilis) is a reddish round, painless lesion with a depressed center and raised edges that appears on the lower lip.Squamous cell carcinoma (most common form of oral cancer) usually involves the lower lip and may appear as a thickened plaque, ulcer, or warty growth.Lips and mucosa should be pink, firm, and moist without inflammation or lesionsPale or cyanotic lips may indicate systemic hypoxemia. Dry, cracked lips occur with dehydration or exposure to weather. Swollen lips (angioneurotic edema) result from allergic reactionsGums are pink, smooth,moist and firmPale gums that bleed easily may indicate periodontal disease or vitamin C deficiency.Inspect teeth: note tarter, cavities, extraction and color.Note position and alignment

 

Tongue:tongue lies midline,medium red or

pink in color, moist and

smooth along lateral margins, with free mobility. Ventral surface is slightly rough (taste buds), and dorsum is highly vascular.

NOTE:Enlarged tongue may indicate glossitis or stomatitis or may occur with myxedema, acromegaly, or amyloidosis.

Inspect the hard and soft palate with penlight.

Palates are concave and pink. Hard palate has ridges; soft palate is smooth

pharynx using a tongue depressor and penlight

 

Instruct client to say “ah.” Note the position, size, and appearance of tonsils and uvula

With phonation, the soft palate and uvula rise symmetrically.The pharynx is pink, vascular, lesion-free.

NOTE: Reddened, edematous uvula and tonsillar pillars with yellow exudate indicate pharyngitis.

 

Neck Assessment

Inspect Neck:Test sternocleidomastoid muscleMuscles are symmetrical with head in

central position. Movement through full range of motion without complaint of discomfort or limitation.

NOTE: Prominent lateral deviation of sternocleidomastoid muscles (torticollis) is commonly associated with inflammation of viral myositis or trauma

Lymph NodesPalpate anterior and cervical lymph

nodes (with gentle pressure)Note size, shape, mobility,

consistency, and tenderness. Lymph nodes should not be palpable. Small, movable nodes are insignificant.

NOTE: palpable lymph nodes indicates infectious process or malignancy

THYROID GlandPosition: Stand behind patient and

gently push trachea to one side. Palpate extended side as patient swallows

There should be no enlargement, masses, or tenderness. (Gland is normally slightly enlarged during pregnancy and puberty. Right lobe may be slightly larger.)

Auscultate over glandNOTE: Enlargement (goiter), nodules,

tenderness 

Assessment of the Skin

Part of Integumentary system which includes: skin scalp,nails)

Color- inspect under natural sunlight for accuracynote color, size, and

anatomic location and distribution ,mobility, contour and consistency

presence of lesion:

 primary lesion

macule - localized changes in skin color < 1 cm in diameter like freckles

papule – solid elevated lesion < 0.5cm in diameter like elevated nevi

vesicle – elevated mass containing serous fluid accumulation between the upper layers of the skin example: 2nd degree burns, chicken pox

patch – localized changes in skin pigmentation of <1cm in diameter ; ex. Vitiligo, pressure ulcer stage 1

plaque – solid elevated lesion > 0.5cm in diameter; ex psoriasis

bullae – like vesicle but > 0.5cm in diameternodule – solid and elevated; extends deeper

than the papule into the dermis or subcutaneous tissues; 0.5 to 2 cm ex.lipoma, erythema

pustule – pus filled vesicles or bullae, <0.5 cm in diameter. Ex. Impetigo, acne

cyst – subcutaneous or dermis mass ex: sebaceous cyst

 

secondary lesion scales – flaking of the skin’s surface

ex. Dandruff , psoriasis erosion – loss of epidermis ex.ruptured

chicken pox scar – fibrous tissue that replaces dermal

tissue after injury ex. Surgical incision crust – dried serum, blood or pus on skin

surface fissure – linear crack in the epidermis that

can extend to the dermis ex. Chapped hands or lips

keloid – enlarging of a scar past wound edges due to excess collagen formation ( more prevalent in dark skinned person

atrophy – thinning of the skin surface and loss of markings ex. Striae

ulcer – depressed lesion of the epidermis and upper papillary layer of the dermis ex. Stage 2 pressure ulcer 2

excoriation – loss of epidermal layers exposing the dermis ex. Abrasion

vascular and purpuric lesion cherry angioma - ruby red – 1-3 mm, round

lesion spider angioma – fiery red lesion up to 2 cm

with central body surrounded by erythema and radiating legs ( in liver disease, pregnancy)

venous star – bluish , varying in size from small to 1 – 2inches, may resemble a spider or be linear. Indicates an increased pressure in superficial veins ; Ex varicose veins

petechia – reddish purple, flat round lesion , 1 – 3mm in size

ecchymosis ( bruise ) purplish blue, fading to green, yellow and brown usually results from blood vessel trauma may indicate vit C deficiency, blood clotting disorders,liver disease or drug interactions

  

Turgor and mobilityMeasures the elasticity of skin -determines degree of hydration

For Mobility, palpate dependent areas such as sacrum,feet,ankles by applying pressure with fingers, noting the degree of indention.Pitting edema scale:1+ indentation of 1 cm or less2+ indentation of 2cm3+ indentation of 3cm4+ indentation of 4cm5+ indentation of 5cm

Moistness and temperature.Moisture: wetness and oiliness

Excessive moisture or perspiration (hyperhidrosis) caused by hyperthermia, infection, hyperthyroidism, strong emotion

Dryness usually occurs in dehydrationBromhidrosis ( body odor) caused by

perspiration or bacterial decomposition

Temperature: Sensation/ texture

quality, thickness, supplenessgeneralized roughness is seen in

hypothyroidism 

Common skin alterations:

Melanin – naturally occurring brown pigment ( ex decreased in albinism)

Cyanosis - bluish discoloration in the lips, mucous membranes, and nails results from an increased amount of reduced hemoglobin in the blood caused by a cold environment or heart or lung disease.

Jaundice (yellowish discoloration) results from increased bilirubin levels caused by red blood cell hemolysis in liver disease as observed first in the sclera and mucous membranes and then generalized.

Carotenemia (yellowish discoloration) is described as normal as a result of increased levels of carotenoid pigments in the palms, soles, and face from a diet high in carotene.

 Hair

Hair is distributed over the body except for the palmar and plantar surfaces, lips, nipples, and the glans penis.Vellus – fine, unpigmented

hair that covers most of he body parts

Terminal Hair - coarser, darker hair of scalp, eyebrows and eyelashes; axillary and pubic hair becomes terminal with the onset of puberty

Nails The nail plate (translucent tissue

that covers the distal portion of the digits and provides protection) changes with many disease processes

Normal nail : angle of approximately 160 degrees between the fingernail and the nail base ; feels firm when palpated

Clubbing : indicates hypoxia; angle greater than 180 degrees ; feels springy when palpated

Koilonychia (spoon nail) concave curves associated with iron deficiency anemia

Beau’s line : transverse depression in the nails often associated with injury and severe systemic infections

Paronychia: inflammation in the nail base associated with trauma and local infection

 

Thorax Assessment 

Inspect for Thoracic contour : shape, symmetry , and

developmental:▪ Pigeon chest▪ Funnel chest▪ Spinal Deformities▪ Kyphosis▪ AP to Lateral diameter▪ till age 6 - 1:1 (equal)▪ 1:2 in normal adult▪ barrel chest - 1:1 in adult▪ presence of chronic pulmonary disease▪ Ribs and interspaces▪ retraction of interspaces indicative of obstructionbulging during exhalation result of air outflow obstruction: tumor, aneurysm, cardiac enlargement slope of ribs, costal angle 

Thoracic Expansion:▪ Posteriorly- level of 10th rib▪ Thumbs should separate 3 - 5 cm▪ Feel during quiet I & E▪ Palpate during deep inspiration▪ Should be symmetrical▪ Tactile Fremitus▪ palpable vibrations of chest wall over lung fields from speech or sounds- Use palmar or ulnar surface

Tactile Fremitus Increased- conditions

that increase density of thoracic tissue

consolidation of pneumonia

some lung tumorTactile Fremitus

Decreased - obstruction of transmission of vibrations-

pleural effusion pleural thickening

(fibrosis) pnemothorax bronchial

obstruction COPD/emphysema

 Lung AssessmentRespiratory Pattern Rate

adult NL: 12 - 20 resting tachypnea = > 20 bradypnea= <10 Rhythm

Depth : shallow, deep Hyperventilation :Hypoventilation

Effort/Quality unlabored labored- dyspnea, orthopnea shallow grunting

Respiratory movement thoracic or abdominal

Men & children - abdominal breathers

Women- thoracic Normal rate, rhythm, quality termed 

eupnea rhythmic 

effortless quiet symmetrical 

Respiratory Auscultation: During

auscultation, the client should be instructed to breathe only through the mouth because mouth breathing decreases air turbulence that could interfere with an accurate assessment Note quality and location of lung sounds

Vesicular breath sounds soft, breezy, and low-pitched sounds heard longer on inspiration than expiration that result from air moving through the smaller airways over the lung’s periphery,

Bronchovesicular breath sounds medium-pitched and blowing sounds heard

equally on inspiration and expiration from air moving through the large airways, posteriorly between the scapula and anteriorly over bronchioles lateral to the sternum at the first and second intercostal spaces

Bronchial breath sounds loud and high-pitched sounds with a hollow quality heard longer on expiration than inspiration from air moving through the trachea

Adventiitous Breath Sounds Abnormal breath sounds are characterized

by decreased or absent sounds. Crackles: heard predominantly on inspiration

over the base of the lungs as an interrupted fine crackle (dry, high-pitched crackling, popping sound of short duration) that sounds like a piece of hair being rolled between the fingers in front of the ear or a coarse crackle (moist, low-pitched crackling, gurgling sound of long duration) that sounds like water going down the drain after the plug has been pulled on a full tub of water

Rhonchi: heard predominantly on expiration over the trachea and bronchi as a continuous, low pitched musical sound. Also called gurgle

Wheezes: heard predominantly on expiration all over the lungs as a continuous sonorous wheeze (low-pitched snoring) or sibilant wheeze (high pitched musical sound)

Pleural friction rub: heard on either inspiration or expiration over the anterior lateral lungs as a continuous creaking, grating sound

Stridor: heard predominantly on inspiration as a continuous crowing sound

 

Breast and Axillae Assessment

Position: sitting position on the edge of examining table or bed facing you

For Female Breasts: Symmetric (Normal for dominant side to be slightly larger.)Significant differences in size or symmetry of breasts, axillae, areolar areas, or nipples may be indicative of a tumor

Skin: intact, no edema, color consistent with rest of body, smooth, convex contour

Consistency: varies widely (Firm, transverse inframammary ridge along lower breast edge should not be mistaken as abnormal mass

NOTE: Reddened areas of breasts, areolar areas, nipples, or axillae may be an indication of inflammation, infection, or inflammatory carcinoma

Thickening or edema of breast tissue or nipple causes enlarged skin pores that give the appearance of an orange rind (peau d’orange), which may be indicative of obstructed lymphatic drainage

Signs of breast cancer: peau d’orange skin (edema/thickened skin with enlarged pores), retractions, dimpling. Hard, irregular, fixed, noncircumscribed masses

AreolaSmall elevations around the nipple (Montgomery’s glands) are normal.NOTE: Rashes or ulcerations may suggest cancer of mammary ducts (Paget’s disease).

 

NipplesNipples should point upward and laterally or outward and downward. Nipples may be inverted from puberty, making breastfeeding difficult. Usually elastic, everted ( in geriatric patients: Nipples become smaller and flatter) Intact skin, no dischargeOccasional hair around nipple

NOTE: Asymmetrical nipple direction or recent nipple inversion, flattening, or depression is indicative of nipple retraction. Thickening of a previously inverted nipple may indicate a tumorNipple discharge in nonpregnant or nonlactating woman may be caused by tranquilizers, oral contraceptives, manual stimulation, infection, or malignant or benign breast disease.

For Male breasts:Flat or muscular appearance without masses

NOTE for Gynecomastia: a firm disk-shaped glandular enlargement on one or both sides resulting from imbalance in estrogen/androgen ratio, sometimes drug-related (spironolactone, cimetidine, digitalis preparations, estrogens, phenothiazines, methyldopa, reserpine, marijuana, or tricyclic antidepressants)

Axillae:Rash (may be caused by deodorant). Velvety, smooth deeply pigmented skin should be further evaluated.

Palpate Lymph Nodes:Position: place arms at side. Place client’s head in a flexed position (relaxes sternocleidomastoid muscle)

NOTE: Enlarged, tender, hard nodes may be due to hand or arm infection but may also be a sign of breast cancer. 

Heart Assessment

Cardiac Landmarks1. Aortic area is the second intercostal

space (ICS) to the right of the sternum.2. Pulmonic area is the second ICS to the

left of the sternum.3. Erb’s point is located in the third ICS to

the left of the sternum.4. Tricuspid area (right ventricular area or

septal area) is the fifth ICS to the left of the sternum.

5. Mitral area (left ventricular or apical area) is the fifth ICS at the left midcavicular line.

S1 heart sounds - Atrioventricular heart sounds

S2 heart sounds - Semilunar heart sounds

S3 heart sounds – (Ventricular gallop)sound resembles the pronunciation of the word “Kentucky” (lub-dub-by )

S3 can be a normal physiological sound in children and young adults; in adults it may be indicative of cardiac dysfunction

S4 heart sounds (atrial gallop)sound resembles the pronunciation of the word “Tennessee” (le-lub-dub).

 

Heart murmurs:Grades and Characteristics of Murmurs:Grade I: Barely audible

Grade II: Audible immediatelyGrade III: Moderate intensityGrade IV: Loud, may be associated with a thrillGrade V: Loud, with palpable thrill, audible with stethoscope in contact with chest wallGrade VI: Louder, heard without stethoscope, palpable thrill

Distinct abnormal findings on palpation and auscultation

thrills (vibrations that feel similar to what one feels when a hand is placed on a purring cat)

heaves (lifting of the cardiac area secondary to an increased workload and force of left ventricular contraction).

stenosis or regurgitation sounds:1. click (a high-pitched systolic sound

created by the opening of the valve) or2. a murmur (swishing or blowing sounds of

long duration heard during the systolic and diastolic phases created by turbulent blood flow through a valve

3. bruits (blowing sounds that are heard when the blood flow becomes turbulent as it rushes past an obstruction

 ASSESSMENT OF THE ABDOMENPlace client in a supine position with knees flexed over a pillow, hands at sides or across chest.

Order of assessment: Inspection, Auscultation, Percussion and Palpation ( “ IAPP” )

Assessment should always begin in the right lower quadrant (RLQ).

Inspect: Inspect abdomen from rib margin to pubic area

Contour is flat or rounded and bilaterally symmetrical

A convex symmetrical profile reveals either a protuberant abdomen (results of poor muscle tone from inadequate exercise or obesity) or distension (taut stretching of skin across abdominal wall

Asymmetry may indicate a mass, bowel obstruction, enlargement of abdominal organs, or scoliosis

Umbilicus is depressed and beneath the abdominal surface.

Umbilicus bulging may indicate a herniaEngorged or dilated veins around the umbilicus

are associated with circulatory obstruction of superior or inferior vena cava

Abdomen rises with inspirations and falls with expirations, free from respiratory retractions.

Uneven respiratory movement with retractions may indicate appendicitis.

Visible peristalsis slowly traverses the abdomen in a slanting downward movement as observed in thin clients. Pulsations of the abdominal aorta are visible in the epigastric area in thin clients

Strong peristaltic movement may indicate intestinal obstruction. Marked pulsations in epigastric area may indicate an aortic aneurysm

Auscultation:Order: RLQ, RUQ, LLQ, LUQ  High-pitched sounds, heard every 5 to 15

seconds as intermittent gurgling sounds in all four quadrants as a result of air and fluid movement in the gastrointestinal tract

Hypoactive sounds may indicate decreased motility of the bowel, such as occurs with peritoneal irritation or paralytic ileus

Absent bowels sounds (none heard for 3–5 minutes) may signal paralytic ileus, peritonitis, or an obstruction

Hyperactive (loud, audible, gurgling sounds similar to stomach growling; sounds also called borborygmi) may occur with diarrhea or hunger

A bruit over an abdominal vessel reveals turbulent blood flow suggestive of an aortic aneurysm or partial obstruction (e.g.,renal or femoral stenosis).

Percussion: (deleted landmarks)

Note when tympany changes to dullness. Tympany is heard because of air in the stomach and intestines.Dullness is heard over organs (e.g., the liver).Dullness over the stomach or intestines may indicate a mass or tumor; ascites (excessive fluid accumulation in the abdominal cavity) or full intestines

Palpation:Never palpate over areas where bruits are auscultated.Order of palpation: RLQ, RUQ, LLQ, LUQShould feel smooth with consistent softness.Tenderness and increased skin temperature may indicate inflammation. Large masses may be due to tumors, feces, or enlarged organs. 

Genitourinary AssessmentThe male genitalia may be examined with the patient either standing or supine. However, the patient should stand as you check for hernias or varicoceles. Examine the female genitalia with the patient in a dorsal recumbent position. Check for urine frequency and urgency; dysuria; nocturia; polyuria or oliguria; hematuria; incontinence. 1. When assessing the urinary system, check for and evaluate edema. 2. Palpate the bladder for distention and tenderness. Press deeply in the midline about 1 to 2 inches above the symphysis pubis. During deep palpation, the patient may feel the need to urinate; this is a normal response. 3. Ask the patient about urinary patterns such as retention, urgency and frequency. Ask the patient if he has noticed blood in his urine or if he has pain when urinating. Ask the patient to urinate into a

specimen cup. Assess the sample for color, odor, and clarity.4. Provide the patient with a gown. and drape appropriately. Be sure to wear gloves. 5. Inspect the inguinal and femoral areas carefully for bulges. A bulge that appears on straining suggests a hernia.6. Look for nits or lice at the bases of the pubic hairs.7. Have the male patient assume a supine position. Begin assessment of the male genital system by inspecting the penis. Look for ulcers, scars, nodules, or signs of inflammation. Compress the glans gently between your index finger and thumb to open the urethral meatus and inspect it for discharge.8. Inspect the scrotum. Note any swelling, lumps, or veins. Palpate each testis and epididymis. Note their size, shape, consistency, and tenderness. 9. Ask. Explain in advance what you are about to do.10. Assess the perineal area for character of skin and abnormal masses or discharge. Spread her labia with a gloved hand and inspect the urethral meatus; it should appear pink and free of swelling or discharge. In any patient, inflammation and discharge may signal urethral infection. Ulceration usually indicates a sexually transmitted disease.

Musculoskeletal AssessmentGait

PostureMuscular palpation

Joint palpationRange of motionMuscle strength

 Procedure and Technique

1. Inspect spinal curvature. 2. Have the patient stand with his feet together. Note the relation of one knee to the other. The knees should be symmetrical and located at the same height in a forward-facing position.3. Ask the patient to walk away, turn around, and walk back. If the patient is elderly or infirmed, remain

close and ready to help if he should stumble or start to fall. Observe and evaluate his posture, pace and length of stride, foot position, coordination, and balance. Normal findings include smooth, coordinated movements, erect posture, and 2 to 4 inches between the feet. Abnormal findings include a wide support base, arms held out to the side or in front, jerky or shuffling motions, toeing in or out, and the ball of the foot, rather than the heel, striking the floor first.4. To assess gross motor skills, have the patient perform range-of-motion (ROM) exercises (see Nursing Fundamentals I, To assess fine motor coordination, have the patient pick up a small object from a flat surface.5. Assess muscle tone.

Assess muscle mass. decreased muscle size (atrophy), excessive muscle size (hypertrophy) without a history of muscle building exercises, flaccidity (atony), weakness (hypotonicity), spasticity (hypertonicity), and involuntary twitching of muscle fibers (fasciculations).

Assess muscle strength and joint ROM.  

MUSCLE TONE AND STRENGTH0=COMPLETE PARALYSIS1=10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE2=25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT3=50% - NORMAL MOVEMENT AGAINST GRAVITY4= 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL RESISTANCE5=100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE

DIAGNOSTIC EXAMINATIONS

  

Diagnostic tests are either noninvasive or invasive. Diagnostic testing is a critical element of assessment. Ongoing client assessment and evaluation of the client’s expected outcomes requires the incorporation of diagnostic findings  Invasive - means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure Non – invasive - means the body is not entered with any type of instrument  3 phases of Diagnostic Testing: PretestFocus: Client PreparationConsent is secured for every invasive procedure or diagnostic testFor radiologic studies: special precautions for pregnant clientsKnow the supplies and equipment needed for a specific testKnow if the client needs to be on NPO prior to the test and if a dye is needed; if so, assess client for allergy

 IntratestFocus: specimen collection and assisting or performing the testUse or practice standard precaution and sterile techniquesProvide emotional and physical support to the client

 Post – TestFocus: providing nursing care and follow – up 

I. GIT- Direct visualizations ( invasive) Lower GI Endoscopy: Anoscopy Visualization of the anal canal

Proctoscopy Visualization of the rectum

Proctosigmoidoscopy Visualization of the rectum and sigmoid colon Position: knee chest or lateralCleansing enema is neededPre Test: laxativePost test: position in a supine manner for a few minutesMonitor for bleeding and perforation

Colonoscopy Needs to be sedated Position: sims/ left side, knees flexed Post test: assess for bradycardia and hypotension Assess also for perforation Endoscopy ( UGI)Pre test: NPO Needs sedation Local spray anesthetic is administeredPost Test:NPO until gag reflex returns

 Gastric Analysis▪ Measures gastric pH and pepsin▪ Pre Test: NPO for 12 hours▪ Requires NGT insertion that is connected to a suctionSpecimen is taken every 15 min to one hour

 I. GIT- Indirect:

 Barium Swalllow ( upper GIT )▪ To visulalize esophagus down to the jejunum▪ Needs to be on NPO for 6 – 8 hours▪ Barium Sulfate is taken by mouth prior to the procedurePost test: Laxative is given to wash off barium White stool is observed for about 72 hours Barium Enema ( Lower GIT )▪ Visualize colonPretest: low residue/clear liquid diet for 2 days laxative cleansing enema is administered in the morning before the test barium sulfate via rectal routepost test: laxative increase OFI  FecalysisGuaic Stool Exam Used to assess Gastro intestinal BleedingPre Test: increase fiber diet 48 -72 hours prior▪ No red meat, iron and steroids, indomethacin and colchicine these can alter results▪ Taken in 3 consecutive days▪ Stool for Ova and Parasites Specimen should be sent immediately ( warm and fresh ) Stool Culture Stool for Lipids To assess stool for steatorrhea Ultrasonography▪ Needs to be on NPO for 8 to 12 hours▪ Laxative prior to test 

Magnetic Resonance Imaging▪ Views cross sectional images of an organ using magnetic field▪ CI: with pacemakers, Aneurysym clips, orthopedic screwsPre Test: NPO for 6 – 8 hoursInstruct client to remain still throughout the procedure

 II. Respiratory System

Invasive

Mantoux Test▪ Purified protein Derivative▪ Intradermal injection which will be read after 48 hours and 72 hours▪ 10 mm induration is positive for Mycobacterium tuberculosis▪ 5 mm induration for an HIV positive patient is already positive montoux test BronchographyPre test: A radioopaque medium is injected into the trachea and bronchial tree Check for allergies to seafoods, iodine and lidocaine Requires to be on NPO for 6 – 8 hours Meds prior to test: Atropine sulfate ValiumPost: Remain on NPO until gag reflex returns Position on side lying 

Bronchoscopy

▪ visual examination of the larynx, trachea & bronchi with a fiber-optic bronchoscope

Pre test: NPO 6 – 8 hours Needs to be sedated

Post Test: Remain on NPO until gag reflex returns Monitor for complications: bronchospasm, bronchial perforation, crepitus, dysrhythmia, fever, hemorrhage, hypoxemia, and pneumothorax Notify the MD if complications occur

 Lung Scan▪ Used to detect pulmonary embolismPre test: radio isotope is injected▪ Scans are taken with scintillation camera Thoracentesis▪ Aspiration of fluid / air from pleural space▪ Position : upright leaning on over bed table or Side lyingPost Test: Position on the unaffected side to prevent leakage Lung Biopsy▪ To detect malignancyPre Test: NPO prior  Local anesthetic  Pressure during insertion and aspiration  Administer analgesics & sedativesPost Test: Pressure dressing  Monitor for bleeding  Monitor for respiratory distress  Monitor for complications: pneumothorax and air emboli  Prepare for Chest – X - ray for re evaluation 

Pulmonary Angiography

▪ insertion of a flouroscopy via the antecubital or femoral vein into the pulmonary artery▪ it involves iodine or radiopaque or contrast materialPre Test: Assess for allergies to iodine, seafood & dyes  NPO prior to procedurePost Test: No BP for 24 hrs in the affected extremity  Monitor peripheral neurovascular status  Assess for bleeding  Monitor dye reaction Ventilation Perfusion Scan▪ determines the patency of the pulmonary airways▪ a radionuclide may be injectedPre Test: Assess for allergies to dye, iodine, or seafood  Remove jewelry  Review breathing methods  Administer sedation  Emergency resuscitation equipment For 24 hrs following the procedure, handle body secretions carefully,Instruct the client to wash hands carefully with soap and H2O for 24 hrs following the procedure

 Non – invasive

Chest X – ray / fluoroscopy▪ Metal objects and other jewelries should be removed prior to the test Sputum Examination▪ obtained by expectoration or tracheal suctioning▪ identify organisms or abnormal cells▪ ideally taken early morning upon awakening▪ sterile specimen is needed▪ only 15 ml of sputum▪  Rinse the mouth with water prior to collection▪  Take several deep breaths and then cough forcefully Collect the specimen before antibiotics III. Cardio Vascular System

Invasive Hemodynamic MonitoringCentral Venous Pressure

Obtained by inserting a catheter into the external jugular, antecubital, or femoral vein and threading it into the vena cava. The catheter is attached to an IV infusion and H2O manometer by a three way stopcockAssess pressure of the right atrium, blood volume, pumping function of the right side of the heartNormal range is SV : 0 -12 cm H20

RA : 4-10 cmH20; elevation indicates hypervolemia, decreased level indicates hypovolemiaMaintain zero point of manometer always at level of right atrium (midaxillary line)Stop ventilatory assistance during measurement of CVPPractice Strict Aseptic Technique

 Pulmonary Artery Pressure and Pulmonary Capillary Wedge PressureUses Swanz – Ganz Catheter

A multi lumen catheter with a balloon tip that is advanced through the superior vena cava into the RA, RV, and PA. When it is wedged it is in the distal arterial branch of the pulmonary artery.

Purpose:Proximal port: measures RA pressure Distal port: measures Pulmonary Artery pressure and Pulmonary Capillary Wedge PressureNormal Range: PAP : 4 – 12mmHg

PCWP : 4 – 12 mmHEnsure that balloon is deflated with a syringe attached except when PCWP is readIrrigate line before each reading of PCWPMaintain client in same position for each readingRecord PA systolic and diastolic readings at least every hour and PCWP as ordered. 

Cardiac catheterization

- catheter is inserted into the right or left side of the heart to measure intracardiac pressures and oxygen levels in various parts of the heart with injection of a dye, it allows visualization of the heart chambers, blood vessels and blood flow (angiography

Pre Test:any allergies esp. to iodine keep client on NPO for 8-12 hrs 

Non Invasive:

Electrocardiogram (ECG)Monitors the electrical activity of the heartstrip: small square: 0.04secs. and large square: 0.2secs

P wave: produced by atrial depolarization; indicates SA node functionP-R interval (N˚= 0.12 - 0.20 secs.)

a. indicates AV conduction time or the time it takes an impulse to travel from the atria down and through the AV node

b. measured from beginning of P wave to beginning of QRS complex

QRS complex (N˚= 0.06-0.10 secs.)a. indicates ventricular depolarizationb. measured from onset of Q wave to end of S

wave 

ST segmenta. indicates time interval between complete

depolarization of ventricles and repolarization of ventricles

b. measured after QRS complex to beginning of T wave

T wavea. represents ventricular repolarizationb. follows ST segment 

ECG in MI:

Elevated ST segmentInverted T waveQ wave

 

Echocardiographynoninvasive recording of the cardiac structures using ultrasound

Portable recorder (Holter monitor) provides continuous recording of ECG for up to 24 hrsassess activities of the heart which precipitate dysrythmias and time it occurred

Exercise ECG (stress test)the ECG is recorded during prescribed exercise; may show heart disease when resting ECG does not

Cardiac enzymes: in MIa. Troponin T: detected 3-12 hours after chest pain

b. Troponin I: detected 3-12 hrsc. creatine phosphokinase (CPK – MB): 6-12Hrsd. Aspartate aminotransferase (AST) (SGOT): 24 Hrs after chest pain

e. Lactic dehydrogenase (LDH): 36 Hrs 

IV. Endocrine System Radioactive iodine reuptake A thyroid function test that measures the absorption of the iodine isotope to determine how the thyroid gland is functioning. Administration of I123 or I131 orally followed in 24 hrs. by a scan of the thyroid for the amount of radioactivity emitted. Normal value is 5-35% in 24 hours Increased: hyperthyroidism , thyrotoxicosis Decreased: hypothyroidism, thyroiditis T3 and T4 resin

 Blood test for diagnosis of thyroid disordersNormal Value : T3: 80-230 ng/dL

T4: 5-12 ng/dL increase in hyperthyroidism & decreased in hypothyroidism Thyroid Stimulating Hormone Test: Blood test used to differentiate the diagnosis of primary hypothyroidism from secondary hypothyroidism  Normal value is 0.2 to 5.4 uU/ml Elevated in primary hypothyroidism & decreased in hyperthyroidism or secondary hypothyroidism Thyroid ScanPerformed to identify nodules or growths in the thyroid glands Discontinue medications containing iodine 14 days prior to test and discontinue thyroid meds 4-6 weeks prior to test.NPO post MN; if iodine is used client will fast an additional 45 minutes after ingestion of radioactive isotope & scan is done after 24 hours. A radio isotope of iodine or technetium is administered prior to the scanning of the thyroid gland. NEEDLE ASPIRATION OF THYROID TISSUE  Aspiration of thyroid tissue for cytological exam, No preparation needed Light pressure applied to aspiration site after the procedure Eight-hour intravenous ACTH Test Used to determine function of adrenal cortex Administration of 25 units of ACTH in 500 ml of saline over an 8-hr period 24-hr urine specimens are collected, before & after administration, for measurement of 17-ketosteroids and 17-hydrocorticosteroids▪ In Addison’s disease, urinary output of steroids does not increase following administration of ACTH; normally steroid excretion increases threefold to fivefold ff. ACTH administration

▪ In Cushing’s syndrome, hyperactivity of the adrenal cortex increases the urine output of steroids in the second urine specimen tenfold Glucose Tolerance Test: Pre test:▪ eat a high-carbohydrate (200 to 300 g) diet for 3 days before the test▪ avoid alcohol, coffee & smoking 36 hours before testing▪ fast midnight before test fasting blood glucose & urine glucose specimens obtained.

1. avoid strenuous exercise 8 hours before & after test

2. client ingests 100g glucose; blood sugar drawn at 30 & 60 mins, then hourly for 3-5 hrs

3. urine specimens may also be collected

Glycosylated Hemoglobin : Is a reflection of how well blood glucose levels have been controlled for up to the prior 4 months  Fasting is not neededValues:Diabetics with good control: 7.5% or lessDiabetics with fair control: 7.6% to 8.9%Diabetics with poor control: 9% or greater  V. Peripheral Vascular Disorders

Non – invasive

Doppler UltrasonographyNon-invasive diagnostic procedure that changes sound waves into an image that can be viewed on a monitor.It is frequently used to detect problems with heart valves or to measure blood flow through the arteries.There is no special preparation needed for this test. The ultrasound technician may apply a clear gel to

the skin in order to help the transducer more freely over the body.

NOTE: Disrupted or obstructed blood flow through the neck arteries may indicate the person is a risk of having a stroke

 Computed Tomography ( CT – SCAN )CT imaging uses special x-ray equipment to produce multiple images and a computer to join them together in cross-sectional views.

Pretest Reminders:1. Metal objects including jewelry, eyeglasses,

dentures and hairpins may affect the CT images and should be left at home or removed. You may also be asked to remove hearing aids and removable dental work.

2. If contrast medium will be used, patient needs to be on NPO. And assess for seafood and iodine allergy.

3. Pregnant women may not be allowed to undergo this test.

4. if an intravenous contrast material is used, you will feel a slight pin prick when the needle is inserted into your vein. You may have a warm, flushed sensation during the injection of the contrast materials and a metallic taste in your mouth that lasts for a few minutes

5. You will be alone in the exam room during the CT scan, however, the technologist will be able to see, hear and speak with you at all times.

6. After a CT scan, you can return to your normal activities. If you received a contrast material, you may be given special instructions.

 

Magnetic Resonance Imaging ( MRI )noninvasive, usually painless medical test

Useful in detecting Abdominal Aortic Anuersyms and deep vein thrombosisSome MRI examinations may require the patient to swallow contrast material or receive an injection of contrast into the bloodstream.the contrast material used for an MRI exam, called gadolinium, does not contain iodine and is less likely to cause an allergic reaction.metal and electronic objects are not allowed in the exam room. These items include: ( because this will interfere with the magnetic field)

1.Jewelry, watches, credit cards and hearing aids, all of which can be damaged.

2.Pins, hairpins, metal zippers and similar metallic items, which can distort MRI images.

3.Removable dental work. 4.Pens, pocketknives and eyeglasses. 5.internal (implanted) defibrillator6.cochlear (ear) implant7.clips used on brain aneurysms

You may request earplugs to reduce the noise of the MRI scanner, which produces loud thumping and humming noises during imaging.

 Invasive

PlethysmographyPlethysmography is a test used to measure changes in blood flow or air volume in different parts of the body. Limb plethysmography is a test that compares blood pressure in the legs and arms. It is usually done to check for blood flow blockages in the legs.Position: supine with the involved extremity elevated above the level of the heartThree blood pressure cuffs are wrapped snugly around your arm and leg. The cuff will be inflated and a machine called a plethysmograph measures the pulses from each cuff. The test records the maximum pressure produced when the heart contracts (systolic blood pressure) If there is a decrease in the pulse between the arm and leg, it may indicate a blockage.

Pre test preparation:Do not smoke for at least 30 minutes before the test. clothing from the arm and leg being tested should be removed.

VenographyPhlebogram - leg; Venography - leg test used to see the veins in the leg.Veins are not normally seen in an x-ray, so a special dye (called contrast) is used to highlight themX-rays are taken as the dye flows through the leg.Assess for iodine allergies and for any history of allergic reactions

AngiographyArteriography or angiography is test that uses x-rays and a special dye to see inside the arteries.a dye, called contrast material, is injected into the blood stream. X-rays will be taken to see how the dye flows through the arteries. The test can be used to determine if there are any blocked or damaged arteries.

Pre Test:Assess for allergies ( esp. to seafoods and iodine)NPO for 2 to 6 hours

Post Test:Monitor peripheral pulses on punctured extremityPressure dressing and ice packs at the puncture site

 

VI. Hepato – Biliary System 

Liver Function Test:

Serum blood test:

AlbuminThe normal range is 3.4 - 5.4 g/dL.Because albumin is made by the liver,:decreased serum albumin may result from liver disease(for example hepatitis, cirrhosis, or hepatocellular necrosis). It can also result from kidney disease, which allows albumin to escape into the urine.Decreased albumin may also be explained by malnutrition or a low protein diet.Pre TesT: Drugs that can increase albumin measurements include anabolic steroids, androgens, growth hormone, and insulin. They are asked to withheld prior to testing.

A1AT (Alpha-1 antitrypsin )Alpha-1 antitrypsin is ordered to help diagnose the cause of persistent jaundice and other signs of liver dysfunction

ALP (Alkaline phosphatase ) a protein found in all body tissues. Tissues with particularly high amounts of ALP include the liver, bile ducts, and bones

increased: hepatocellular damagedecreased: Hypothyroidism, malnutrition, pernicious anemia, placental insufficiency

Normal range: Adult: 20–90 U/L ; Child: 60–270 U/L

ALT

SGPT; Serum glutamate pyruvate transaminase; Alanine transaminaseMost accurate indicator of liver function4–36 U/L (varies by method)0.07–0.6 _kat/LIncreased: Liver disorders, muscular dystrophy, muscular trauma, MI, CHF, renal failure, mono, burns, shock, alcohol, numerous medsDecreased: Exercise, salicylates

 

AST/SGOTMale: 8–46 U/LFemale : 7–34 U/LNB: 16–72 U/LIncreased: Liver or biliary disorder, MI (between 6 hr and 3–4 days), shock, infectious mono, CHF, CVA, infection or inflammation of muscle tissueDecreased: Pregnancy, DKA, salicylates

 GGT ( Gamma-glutamyltranspeptidase) Male: 6–37 U/LFemale: < 45 yr old 5–27 U/L ; > 45 yrs old 6–37 U/L

Child : 3–30 U/LIncreased: Liver disease, biliary obstruction, CHF, MI, epilepsy, cancer, mono, diabetes mellitus, alcohol, numerous medsDecreased: Late pregnancy, oral contraceptives

 Partial thromboplastin time activated (PTT)28–40 sec or within 5 sec of controlIncreased: Heparin, vit K deficiency, hemophilia, liver disease, DIC, polycythemia, leukemiaDecreased: Extensive cancer

 Serum bilirubin : indirect: up to 0.8mg/dLincreased: Sickle cell anemia, pernicious anemia, hemolytic anemia, septicemia, Rh or ABO incompatibility in newborn, numerous medsDirect: up to 0.4mg/dLIncreased: Liver disorders, obstructive jaundiceDecreased: Barbiturates, salicylates, penicillin, caffeine (These can affect all types of bilirubin.) Total up up 1.0mg/dLUrine urobilinogenBilirubin, a physiological product of RBC, is metabolized in the liver and excreted into bile ducts, therefore an appearance of jaundice means that there is a breakdown of balance of bilirubin

metabolism and the patient may have a problem of liver or RBC production and destructionNV : 0.2 – 1.2 Units or 0 - 8 mg/dl / less than 17 umol/l (< 1mg/dl)

Increased values: overburdening of the liver excessive RBC breakdown increased urobilinogen production re-absorption - a large hematoma restricted liver function hepatic infection poisoning liver cirrhosis

Low values: failure of bile production and obstruction of bile passage

 Ultrasound of the LiverPre Test:Needs to be on NPO 8 – 23 hoursIncrease fluid intakeLaxative is administered a night prior the test

 Liver biopsyexamines a small piece of tissue from the liver for signs of damage or disease. A special needle is used to remove the tissue from the liverpre test:the physician will take blood samples to make sure blood clots properly.One week before the procedure, the patient will have to stop taking aspirin, ibuprofen, and anticoagulantNPO 2 – 4 hoursVit K is injectedInstruct to hold breath for 5 – 10 seconds during the insertion of needle to prevent trauma to the diaphragm

Intratest : position: left side or supine position with pillow under the right

Post test:Lie down on the right side for 4 hours with pressure dressing or apply pressure on the incision site to prevent bleedingBed rest for 24 hours

Paracentesis:a procedure to aspirate fluid that has collected in the peritoneumThe fluid is taken out using a long, thin needle put through the belly. The fluid is sent to a lab and studied to find the cause of the fluid buildup. Paracentesis also may be done to take the fluid out to relieve abdominal pressure or pain in people with cancer or cirrhosis.

Pre Test:Empty bladder prior to test to prevent puncturing the bladderCheck serum protein studies

Intra Test: Position client: sitting or upright position

Post Test:Monitor client’s vital signs and rigidity of abdomen/ signs of peritonitis

VII. Neurologic System CT SCANA cranial CT scan is computed tomography of the head, including the skull, brain, orbits (eye sockets), and sinuses.A type of brain scanning that may or may not require an injection of a dyeUsed to detect intracranial bleeding, space- occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain structures

Pre Test:

1.Assess allergies if dye is used2.Instruct the client to lie still and flat during test3.Remove objects from the head4.Inform the client of possible mechanical noises

during the test5.When dye is injected – there may be a hot,

flushed sensation and metallic taste

Post Test:1.Provide replacement fluids because diuresis is

expected if dye is used2.Monitor allergic reaction from the dye3.Assess dye injection site for bleeding and

monitor extremity for color, warmth, and the presence of distal pulses

 MRI ( magnetic resonance imaging )Non-invasive procedure that identifies types of tissues, tumors, and vascular abnormalitiesProvides more details than CT scanmetal and electronic objects are not allowed in the exam room. These items include: ( because this will interfere with the magnetic field)

- jewelry, watches, credit cards and hearing aids, all of which can be damaged.

- pins, hairpins, metal zippers and similar metallic items, which can distort MRI images.

- removable dental work. - pens, pocketknives and eyeglasses. - internal (implanted) defibrillator- cochlear (ear) implant- clips used on brain aneurysms

Remove IV pumps during testIf patient have pulse oximeter – extra precaution is doneAssess for claustrophobiaEEG (electroencephalogram )a test that measures and records the electrical activity of the brain.Special sensors / electrodes are attached to the head and hooked by wires to a computer.

Any conditions, such as seizures, can be seen by the changes in the normal pattern of the brain's electrical activity.

Pretest:certain medicines (such as sedatives and tranquilizers, muscle relaxants, sleeping aids, or medicines used to treat seizures) should be WITH HELD before the test.Do not eat or drink foods that have caffeine (such as coffee, tea, cola, and chocolate) for 8 hours before the test.it is important that the hair be clean and free of sprays, oils, creams, and lotions. Shampoo the hair and rinse with clear water the evening before or the morning of the test. Do not put any hair conditioner or oil on after shampooing.The client may be asked not to sleep at all the night before the test or to sleep less (about 4 or 5 hours) by going to bed later and getting up earlier than usualIf a child is going to be tested, try to keep him or her from taking naps just before the test

Intra test:The client may be asked to go to sleep. If he cannot fall asleep, he may be given a sedative to help fall asleep. If an EEG is being done to check a sleep problem, an all-night recording of the brain's electrical activity may be done.

 

InvasiveLumbar PunctureInsertion of a spinal needle through L3-L4 interspace into the lumbar subarachnoid space to obtain CSF,

measure CSF pressure, or instill air, dye or medicationsContraindicated in clients with increased ICP

Pre Test: Have the client empty the bladder

Intra Test:1. Position the client in lateral recumbent

position and have the client draw knees up to abdomen and chin unto the chest

2. Maintain strict asepsis

Post Test:1. Flat on bed for 8 hours2. Observe for bleeding at puncture site’3. Observe for changes in vital signs

 MyelogramInjection of dye or air into the subarachnoid space to detect abnormalities of the spinal cord and vertebrae

Pre Test:1. Provide hydration for at least 12 hours

before the test2. Assess for allergies3. If taking Phenothiazine – hold the

medication4. Needs sedation

Post Test:1. Assess vital signs and neurologic condition2. Elevate head 15 – 30 degrees for 6-8 hours

if water –based dye is used3. Place flat on bed for 6-8 hours if oil-based

dye is used 

Cerebral AngiographyInjection of contrast through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions

 a contrast dye is injected into one or more arteries to make them visible.the contrast dye is injected into one or both of the carotid arteries in the neck.The test is most frequently used to confirm cases of stroke , tumor , bulging of the artery walls, a clot , or a narrowing of the arteries

Pre Test: 1. Assess for allergies2. Hydration 2 days before3. NPO 4-6 hrs prior the test4. Remove metals

 PET SCAN (positron emission tomography )A PET scan can measure such vital functions as blood flow, oxygen use, and glucose metabolism, which helps doctors identify abnormal from normal functioning of organs and tissues.The test involves injecting a very small dose of a radioactive chemical, called a radiotracer, into the vein of the arm. The tracer travels through the body and is absorbed by the organs and tissues being studied.

Pretest:1. Generally, most patients are told not to eat

anything for a minimum of 6 hours before the scan.

2. Heart patients are also told to not take any product with caffeine for at least 24 hours

intratest:1. The client will be asked to lie down on a flat

examination table that is moved into the center of a PET scanner—a doughnut-like shaped machine.

 

VIII. Musculoskeletal System

Invasive: 

Blood Test:ESR (Erythrocyte sedimentation rate) Male : Up to 15 mm/h Female: Up to 20 mm/h Child: Up to 10 mm/hIncreased: Inflammation, infection, pregnancy, acute MI, cancerDecreased: Polycythemia vera, CHF, sickle cell anemia

Rheumatoid Factor ( RF )<1 : 20 or negativeIncreased: Rheumatoid arthritis, SLE, scleroderma, dermatomyositis

Antinuclear antibodies (ANA)Neg at 1 : 10 dilution ; SI units NegativePresent / positive:SLE, Sjögren’s syndrome, scleroderma, hepatitis, rheumatoid arthritis, cirrhosis, ulcerative colitis, leukemia, infectious mononucleosis

Anti – DNAAnti-DNA or Anti-DNPNormal: Negative ; SI Units <2.0 kU/LPositive: SLE or lupus nephritis

 C – reactive Protein C-reactive protein measures general levels of inflammation in your body.High levels of CRP are caused by infections and many long-term diseasesNormal range: 0–1.0 mg/dL or less than 10 mg/L (SI units)X – rays ( Bones )Used to asses fractures of the bones

 Bone Scan A bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown A bone scan can often detect a problem days to months earlier than a regular X-ray test.

For a bone scan, a radioactive tracer substance is injected into a vein in the arm. The tracer then travels through the bloodstream and into the bones

Pretest:1. limit fluids for up to 4 hours before the test

because you will be asked to drink extra fluids after the radioactive tracer is injected.

2. The client should empty your bladder right before the scan.

3. He usually has to wait 1 to 3 hours after the radioactive tracer is injected before the bone scan is done.

4. Remove any jewelry that might interfere with the scan

5. Take off all or most of the clothes, depending on which area is being examined (the client may be allowed to keep on his underwear if it does not interfere with the test).

Intra test:1. The client will lie on his back on a table and

a large scanning camera will be positioned closely above him

2. The client may be asked to move into different positions so the area of interest can be viewed from other angles. He needs to lie very still during each scan to avoid blurring the pictures.

Post Test:1. Increase fluid intake to wash off radioactive

tracer 

Arthroscopy Arthroscopy is a type of joint surgery in which a thin tube with a light source (called an arthroscope) is inserted into the joint through a small incision (cut) in the skin, allowing the doctor to see the inside of the joint

Surgery will not cure rheumatoid arthritis or stop the disease's progress, but it may improve function and provide some pain relief.

Post Test:1. the joint should be used as infrequently as

possible for several days. 2. Crutches may be needed if the foot or knee

joint was examined, depending on the extent of the procedure and the doctor's preference.

 Arthrocentesisa joint fluid aspiration

 MyelogramA myelogram uses a special dye (contrast material) and X-rays (fluoroscopy) to make pictures of the bones and the fluid-filled space (subarachnoid space) between the bones in the spine (spinal canal).A myelogram may be done to find a tumor, an infection, problems with the spine such as a herniated disc, or narrowing of the spinal canal caused by arthritis.

Pretest:1. NPO 8 hours prior to the test2. The client may need to take a laxative or

have an enema before the test to empty the bowels.

3. Assess if the client:- Has epilepsy or a seizure problem.- Is or might be pregnant.- Is allergic to any medicines, contrast

material, or iodine dye.- Has bleeding problems or take blood-

thinning medicines, such as aspirin, heparin, or warfarin (Coumadin).

- Has asthma.- Has ever had a severe allergic reaction

(anaphylaxis).- Has had kidney problems.

- Has diabetes, especially if you take metformin (Glucophage).

- take off jewelry that might be in the way of the X-ray picture.

Post test:1. Elevate head 15 – 30 degrees for 6-8 hours

if water –based dye is used2. Place flat on bed for 6-8 hours if oil-based

dye is used 

EMG ( electromyogram)An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction and electrical activity in response to stressMeasuring the electrical activity in muscles and nerves can help find diseases that damage muscle tissue (such as muscular dystrophy) or nerves (such as amyotrophic lateral sclerosis or peripheral neuropathies)

 

IX. Eyes and Ears

EyesSnellen’s ChartNon invasive procedure to test visual acuitystandardized numbers or denominators indicates the degree of visual acuity from a distance of 20 feet  TonometryA tonometry test measures the pressure inside your eye, which is called intraocular pressure (IOP)This test is used to check for glaucoma, an eye disease that can cause blindness by damaging the nerve in the back of the eye (optic nerve)Tonometry measures IOP by recording the resistance of the cornea to pressure (indentation Pre test instruction:

1. Do not drink more than 2cups of fluid 4 hours before the test.

2. Do not drink alcohol for 12 hours before the test.

3. Do not smoke marijuana for 24 hours before the test.

Intratest: Numbing eyedrops are used. 

GonioscopyGonioscopy is an eye examination to look at the front part of the eye (anterior chamber) between the cornea and the iris.Gonioscopy is a painless examination to see whether the area where fluid drains out of the eye (called the drainage angle) is open or closed.

Pretest:1. remove contact lenses before this test and

do not put them back in for one hour after the test or until the medicine used to numb the eye wears off.

2. Gonioscopy does not usually cause any discomfort. The eyedrops used to numb your eye may burn a little.

EarsTuning ForkRinne testVibrate prongs of tuning fork and place base of fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears soundSound heard longer in front of the right auditory meatus than on the mastoid process because air conduction is twice as long as bone.If bone conduction, time is equal to or greater than air conduction. This indicates conductive hearing loss resulting from diseases, obstruction, or damage to outer or middle ear. 

Weber Test

Hold the base of the vibrating fork with your thumb and index finger and place the base of the fork on center of top of client’s headIf sound is perceived equally in both ears,indicate a “negative” Weber test.Positive : conductive hearing loss ( impacted cerumen, perforated tympanic membrane, cerum or pus in the middle ear, fusion of the ossiclesSensorinueral hearing loss : auditory nerve damage , prolonged loud noise, effect of ototoxic agent

 Whisper Voice Test▪ Nurse stands 1–2 feet away from client, out of view to avoid client lipreading, and softly whispers numbers on side of open ear. Increase voice volume until client identifies words correctly.▪ Inability to hear words may indicate a high-frequency hearing loss (e.g., resulting from excessive exposure to loud noises).

Audiometryevaluates a person's ability to hear by measuring the ability of sound to reach the brain.helps determine what kind of hearing loss the client has by measuring your ability to hear sounds that reach the inner ear through the ear canal (air-conducted sounds) and sounds transmitted through bones (bone-conducted sounds).

X. Genito – Urinary System

Non invasiveU/A– see opposite page KUBX – ray of the kidneys, bladder and bladder

Pretest:1. Enema/ clean colon preparation prior to test

  Description Normal Value Clinical SignificancepH Evaluate the client’s acid – base status

 Urine ph is normally acidic with an average of 6

4.6 – 8.0 (adults) 5.0 – 7.0 (newborns)

Increased: alkaline Decreased : acidosis

Specific Gravity Indicator of urine concentration or the amount of solutes (wastes) present in the urine Method:Urinometer/hydrometer in a cylinder of urineSpectrometer / refractometer

1.010 – 1.025 Increased: fluid deficit , dehydration, excess solutes such as glucose / ketones Decreased:Excess fluid intake, disease in the kidney

Glucose This is an inadequate measure of blood glucose Used to screen clients for DM and assess abnormal glucose tolerance during pregnancy

None Positive ; DM

Ketones Product of breakdown of fatty acids 

None Positive in poorly controlled or uncontrolled DM

Blood   0 – 2 RBCs Positive: bleedingProtein   Qualitative: none

Quantitative:10 – 100 mg / 24 h

Presnt if glomerular membrane has been damaged

Osmolality Measures the solute concentration of urine Monitors Fluid and Electrolyte imbalances

500 – 800 OsM/Kg Increased:Fluid volume deficit Decreased:Fluid volume excess

Invasive :

Blood Studies:

BUN 5–25 mg/dL ( SI UNIT: 1.8–7.1 mmol/L)Child: 5–20 mg/dL /2.5–6.4 mmol/LInfant: 4–18 mg/dL / 1.4–6.4 mmol/LIncreased: Dehydration, renal disorders (cause usually not renal if serum creatinine normal), tissue necrosis, CHF, shock, MIDecreased: Inadequate protein intake, liver disease, water overload, nephrotic syndrome

Serum Creatinine0.6–1.5 mg/dL/ 53–133 µmol/LChild: 0.3–0.7 mg/dLNewborn: 0.3–1.0 mg/dLIncreased: Impaired renal function, massive muscle damageDecreased: Muscular dystrophy, pregnancy, eclampsia

Uric AcidMale: 4.0–8.5 mg/dL / 0.24–0.51mmol/LFemale: 2.7–7.3 mg/dL / 0.16–0.43 mmol/LChild: 2.5–5.5 mg/dL / 0.15–0.33 mmol/LIncreased: Gout, excessive purine intake, psoriasis, sickle cell anemia, chemotherapy, tissue destruction, eclampsia, alcohol, numerous medsDecreased: Fanconi’s syndrome, numerous meds

Albumin3.5–5.0 g/dL or 52–68% of total proteinChild: 4.0–5.8 g/dLIncreased: Dehydration, exercise, meds, prolonged application of tourniquet prior to venipunctureDecreased: Malnutrition, chronic diseases, liver disorders, SLE, scleroderma, ascites, burns, nephritic syndrome, chronic renal failure, Hodgkin’s disease, meds

 

Cystoscopy Cystoscopy, also called a cystourethroscopy or, more simply, a bladder scope, is a test to measure the health of the urethra and bladder.Direct visualization of the urinary tractPosition: lithotomy

Post – test:1. Pink tinged urine (24 – 48 hours) , dysuria,

hematuria will be observed2. Observe for signs of infection3. Increase fluid intake4. Hot sitz bath to relieve pain

 IVPAn intravenous pyelogram (IVP) is an X-ray test that provides pictures of the kidneys, the bladder, the ureters, and the urethraDuring IVP, a dye called contrast material is injected into a vein in the arm. A series of X-ray pictures is then taken at timed intervals.

Pretest:1. Needs to be on NPO for 6 – 8 hours2. Assess for allergy to seafoods and iodine or

any history of allergic reaction

Post test:1. Increase fluid intake to excrete dye 2. Bed rest3. Asses for any delayed allergic reaction

 Renal BiopsyRenal tissue sample is taken and sent to a lab to detect any malignancy

pre test:1. sedation is done2. done with local anesthesia 3. needs to be on NPO for 6 – 8 hours

intra test:1. position client to PRONE2. hold breath and remain still during needle

insertion3. post test: bed rest for 24 hours4. increase fluids up to 3000ml per day5. observe for bleeding tendencies and

infections

LABORATORY DATA 

Laboratory studies are usually simple measurements to determine how much or how many analytes, (a substance dissolved in a

solution, also called a solute) are present in a specimen.

Laboratory tests are ordered to: Detect and quantify the risk of future disease Establish and exclude diagnoses Assess the severity of the disease process and determine the prognosis Guide the selection of interventions Monitor the progress of the disorder Monitor the effectiveness of the treatment Laboratory Values:Hematologic System: types of blood Cells

Cell Origin Range ( in SI Units)

Major Function

Erythrocytes Bone Marrow F: 4.0 – 5.2 x 10 12 / LM: 4.5 – 5.9 x 1012 /L

Transport hemoglobinTransporting carbon

dioxide in the form of sodium

bicarbonateBeing an acid-base buffer

for whole blood

Leukocytes Granulocytes 4.5 – 11.0 x 10 9 /L

The protective system

Monocytes  Bone MarrowLymphocytesPlasma CellsLymph Tissue

Platelets Bone Marrow from megakaryocytes

150 – 300 x 10 9 / L Vascular Repair

Analyte SI Range Increased Decreased

Red Blood Cell Count

F: 4.0 – 5.2 x 10 12 /LM: 4.5 – 5.9 x 1012 / L

DehydrationInduced hypoxiaPolycythemia

AnemiasHypothyroidismleukemias

Hemoglobin F: 120 – 150 g/LM: 139 – 163 g/L

Obstructive lung diseasePolycythemiaHigh altitude burnsShock

AnemiaSevere hemorrhage

Hematocrit F: 0.36 – 0.46M: 0.41 – 0.53

DehydrationPolycythemia

LuekemiaHemorrhage

Mean Red Cell 26 – 34 pg/RBC Macrocytosis Microcytic hypochromic anemia

Mean Red Cell Concentration

310 – 370 g/L Spherocytosis Chronic IDA

Mean Red Cell Volume

80 -100 fl Aplastic anemiaFolic and Vit B12

IDA, Thalassemias, Chron. Anemia

White Blood Cells 4.5–11.0 109/L Acute leukemia, infections, surgery,trauma

Acute chronic leukemias, aplasticanemia, agranulocytosis

WBC Differential % of total WBC      Band Neutrophils 0–0.06% Severe bacterial disease  - INC.

Segmented neutrophils

0.31–0.76% Diabetic acidosis, infarctions,inflammatory diseases,malignancies  - INC.

Lymphocytes 0.14–0.44% Chronic lymphocytic leukemia

Lupus erythematosus,Hodgkin’s disease

Monocytes 0.02–0.11% Chronic inflammatory diseases –INC.

Eosinophils 0–0.04% Allergies, parasites  - INC.

Basophils 0–0.02% Myelofibrosis  - INC.

Blood Type and Cross Matchinga laboratory test that identifies the client’s blood type and determines the compatibility of blood between a potential donor and

recipienttype O negative blood are often called universal donorstype AB positive blood are called universal recipients

Cell Type A B AB O

Antibodies Anti – B Anti – A None Anti – A and Anti – BAntigens A antigen B Antigen A and B antigen None

Hematologic Function Studies 

Test Normal Range SignificanceErythrocyte sedimentation rate(ESR or sed rate)  

Westergren:F: < 50 yr 0–25 mm/h> 50 yr 0–30 mm/hM: < 50 yr 0–15 mm/h> 50 yr 0–20 mm/h

Alterations in the plasma proteins cause aggregation of the RBCs with an elevated ESRmoderately, with inflammatory diseaseshigh, with multiple myeloma, macroglobulinemias, hyperfibrinogenemias.

Haptoglobin 0.10–0.30 g/L12–35 ìmol/L

The test measuresenzyme deficiencies that are hereditary, sex-linked conditions carried on thefemale X chromosome, which causes hemolytic anemia. Clinical disease traitsare found in males

Glucose-6-phosphate dehydrogenase (G6PD)(red blood cell)

F: 7.4–9.4 IU/g hemoglobin Whites6.5–9.3 IU/g hemoglobin African-AmericansM: 7.4–9.4 IU/g hemoglobin Whites6.6–10.8IU/g hemoglobin African-Americans

Increased in hereditary spherocytosis, spherocytosis resulting from autoimmunehemolytic anemia, severe burns, chemical poisoning, erythroblastosisfetalis, transfusion reactions, prosthetic heart valve transplantation.  Decreased insickle cell and iron deficiency anemia, polycythemia vera, hemoglobin C disease,thalassemia major, liver disease, obstructive jaundice, or splenectomy

Test Normal Range SignificanceOsmotic fragilityTest measures the fragility of RBCs to aid in the diagnosis of hereditary spherocytosis.

0.30%–0.45% saline< 0.30% saline> 0.50% saline

Increased inhemolytic and sickle cell anemia; hereditary spherocytosis; treatment of anemiasfrom iron, vitamin B12 , and folic acid deficiencies. Decreased in aplastic,iron deficiency and untreated pernicious anemias; chronic infection; radiationTherapy

Reticulocyte countUsed to differentiate between hypoproliferative and hyperproliferative anemias;to assess blood loss and bone marrowresponse to therapy.

Adults 0.5–2.0%Children 0.5–2.0%Infants 0.5–3.5%Newborns 2.5–6.0%

 

Blood Chemistry

Blood Glucose▪ Glucose measurement is performed by either : Skin puncture or venipuncture fasting blood sugar (FBS) normal fasting value is 70 to 115 mg/dl nonfasting (usually 2-hours postprandial) less than 120 mg/dl 2-hour postprandial - This test is used to screen for diabetes mellitus; if the results are abnormal, the practitioner may order a glucose tolerance test A glucose tolerance test is the most accurate test for diagnosing hypoglycemia and hyperglycemia (diabetes mellitus). Requires fastingThe test is conducted as follows:Initial blood and urine specimens are obtained. An oral loading dose of glucose is administered.Blood and urine specimens are obtained at 30 minutes, 1 hour, 2 hours, 3 hours, and sometimes 4 hours after loading dose.

 Glycosylated Hemoglobin Reflects serum glucose for the past 2 – 4 monthsMost accurate Serum Electrolytes▪ These tests measure the serum concentration of sodium, potassium, calcium, chloride, magnesium, and phosphate.▪ An electrolyte is an element or compound that, when dissolved in water or another solvent, separates into ions and provides for cellular reactions Sodium - 135–148 mEq/L, adult 138–144 mEq/L, children 133–144 mEq/L, newborns▪ Clinical Significance : Increased: excessive intake of sodium without water; salt water drowning; high solute concentration (tube feeding, IV, hyperalimentation) without fluid correction; diarrhea; diabetes insipidus; primary aldosteronism; renal failure

Decreased: excessive intake of water without sodium (oral, IV therapy, tap water enemas); heart failure, cirrhosis; nephrosis and massive diuretic therapy Potassium (serum) - 3.5–5.0 mEq/L, adult, 3.4–4.7 mEq/L, children, 3.7–5.9 mEq/L, newbornsClinical Significance :Increased: high potassium intake (oral, IV therapy, rapid infusion of aged blood); renal disease; drugs (adrenal steroids, potassium-conserving diuretics, potassium penicillin, chemotherapeutic agents); Addison’s disease; burns and other massive tissue trauma; metabolic and respiratory acidosis.Decreased: drugs (diuretics, digitalis); metabolic alkalosis; primary aldosteronism; Cushing’s disease;vomiting and gastric suction Calcium - Total 8.4–10.5 mg/dl Ionized 1.13–1.32 mmol/LClinical Significance :Increased: hyperparathyroidism; bone catabolism (multiple myeloma, leukemia, bone tumors); immobility.Decreased: renal failure; sprue; pancreatitis; Crohn’s disease; hyperphosphatemia; drugs (aminoglycosides, antacids containing aluminum, caffeine, cisplatin, corticosteriods, loop diuretics Chloride - 1.3–2.0 mEq/L, adult 1.6–2.6 mEq/L, children 1.4–2.9 mEq/L, newbornClinical Significance:Increased : hyperparathyroidism; drugs (ammonium chloride, ion exchange resin, phenylbutazone); metabolic acidosis; respiratory acidosis; dehydration.Decreased: prolonged vomiting and gastric suction; diarrhea; diuretics(ethacrynic acid and furosemide). Magnesium - 1.3–2.0 mEq/L, adult 1.6–2.6 mEq/L, children 1.4–2.9 mEq/L, newborn▪ Clinical Significance : 

Increased: chronic renal failure, drugs (magnesium sulfate, antacids, enemas containing magnesium, sedatives); acute adrenalcortical insufficiency.Decreased: chronic diarrhea and alcoholism, nontropical sprue, steatorrhea, hereditary alabsorption, starvation, bowel resection, diuretics (mannitol,urea, glucose); hypoparathyroidism

 Phosphate - 2.7–4.5 mg/dl, adult 4.5–5.5 mg/dl, children 4.5–6.7 mg/dl, newborn▪ Clinical Significance :increased: renal insufficiency; intake, IV solutions and enemas; blood transfusion; muscle necrosis; hypoparathyroidism.Decreased: alcohol withdrawal;hyperventilation; diabetic ketoacidosis; phosphate-binding antacids

Blood Enzymes

CPK Isoenzymes 

Enzymes are globular proteins produced in the body that catalyze chemical reactions within the cells by promoting the oxidative reactions and synthesis of various chemicals, such as lipids, glycogen, and adenosine triphosphate (ATP).

Isoenzyme Normal Range

Clinical Significance

CPK1 (BB) 0 IU/I Primarily inbrain/indicative of cerebrovascularaccident

CPK2 (MB) 0–7 IU/I Exclusively inmyocardium/indicativeof myocardial infarction

CPK3 5–70 IU/I

Found in skeleton andmyocardium/skeletalmuscle disorders

LDH Isoenzymes

Isoenzyme Normal Range

Clinical significance

LDH1 17–33 Primarily in heart,kidneys, RBCs

LDH2 27–37 Primarily in heart,kidneys, RBCs

LDH3 18–25 Primarily in lungs, to a lesser extent in pancreas, thyroid, adrenal glands,lymph nodes

LDH4 3–8 Liver and skeletal TissueLDH5 0–5 Liver and skeletal tissue

Digestive Enzymes Enzyme Normal

RangeClinical Significance

Alanineaminotransferase

0–30 IU/L HepatocellularDamage

Aldolase 0–8 IU/L Anemia (hemolyticand megaloblastic);granulocyticleukemia; metastaticcarcinoma; skeletalmuscle tissuedamage

Amylase Total: 40–220 IU/L

Pancreatitis

Aspartate aminotransferase

0–35 IU/L Hepatitis; infectiousmononucleosis;cirrhosis

Lipase 0–1 Cherry-Crandell U/L

Acute pancreatitis

5'-Nucleotidase

0–17 U/L Biliary cirrhosis;extrahepaticobstruction; hepaticcarcinoma

Blood Lipids

Cholesterol and other fats cannot dissolve in the blood; they have to be transported to and from the cells by special carries called lipoproteins (blood lipids bound to protein).The types of lipoproteins:

1. Chylomicrons—mainly ingested triglycerides2. Very low-density lipoproteins (VLDLs)—

mainly endogenous triglycerides3. Low-density lipoproteins (LDLs)—moderate

amounts of phospholipids with 50% cholesterol

4. High-density lipoproteins (HDLs)—50% protein

5. LDL is the major cholesterol carrier in the blood. When too much LDL circulates in the blood, it can slowly build up in the walls of the arteries feeding the heart and brain which will form atherosclerotic plaque, then will thrombus which will then cause CVA or MI

Lipid Normal Range/Border Line

Risk for CHD

Cholesterol < 200 mg / dl 200 – 239

> 250 mg/dl

LDL Cholesterol

< 130 mg/dl 130 – 159 mg/dl

> 160 mg /dl

HDL Cholesterol

> 40 mg /dl 35 -40 mg/dl

< 35 mg/dl

Triglyceride < 250 mg/dl 250 – 500 mg/dl

> 500 mg /dl

Arterial Blood Gas Measures the acidity and the levels of oxygen and carbon dioxide in the blood.Normal Blood Gas Values

Ph 7.35 – 7.45Pco2 35 – 45 mmHgPO2 80 – 100 mmHgHCO3 22 – 26 mmHg

Interpretation

▪ Key Points: In acidosis, Ph is low: in alkalosis, Ph is high The respiratory function indicator is PCO2 and the metabolic function indicator is HCO3 Steps:1.assess Ph – low acidic; high alkalosis2. assess PCO2 – if opposite to the response of Ph then it is respiratory imbalance if not look at HCO3 concentration;3. assess HCO3 – if HCO3 concentration is proportionate with the Ph then it is a metabolic imbalance4. A COMPENSATION has occurred if the Ph is in normal range (7.35 - 7.45). if not assess the respiratory and metabolic function indicator If respiratory imbalance: assess HCO3 concentration:▪ If normal it is uncompensated▪ If abnormal, then it is partial compensation▪ If metabolic imbalance: assess PCO2▪ If normal it is uncompensated▪ If abnormal, then it is partial compensation  Coagulation Studies: aPTT ( activated partial Thromboplstin)▪ normal value: 20 to 36 seconds▪ measures the time it takes for a citrated plasma to clot,after a partial thromboplastin to clot▪ antidote: warfarin sodium/coumadin▪ Prothrombin time and International Normalized Ration (INR) ▪ M: 9.6 to 11.8 seconds▪ F: 9.5 – 11. 3 seconds▪ INR : 2 – 3 seconds for warfarin therapy▪ INR : 3 – 4.5 seconds for high dose of warfarin therapy▪ Measures the amount of time it takes for a clot formation ; used to evaluate warfarin sodium therapy.▪ INR evaluates the effects of oral anticoagulants▪ Antidote: Vit KThyroid Lab data:

Used to evaluate thyroid disorders 

  Normal RangeTSH (thyroid stimulating Hormone) / thyrotropin

0.2 – 5.4 microunits/mL

Thyroxine 5.0 – 12.- mcg/dlTriiodothyronine 80 – 230 ng/dl

Hepatitis Test: Serological tests ( detects specific virus ) HIV/AIDS The following tests detects presence of antibodies▪ Enzyme Linked immunosorbent assay ( ELISA)▪ Western Blot - CONFIRMATORY TEST▪ Immunofluorescence assay ( IFA)▪ CD4+ T cell counts:▪ Monitors / evaluates the progress of the virusNormal : 500 – 1600 cellµ/ 

Acetaminophen ( Tylenol) 10 – 20 mcg/mL

Amikacin ( Amikin) 25 – 30 mcg/mL

Amitriptyline ( Elavil ) 120 – 150 ng/mL

Carbamazepine (tegretol) 5 – 12 mcg/ mL

Chloramphenicol 10 – 20 mcg/mL

Digoxin ( Lanoxin ) 0.5 – 2.0 ng/mL

Imipramine(Tofranil) 150 – 300 ng/mL

Lidocaine 1.5 – 5.0 mcg/mL

Lithium 0.5 -1.3 mEq/L

Phenobarbital 50 – 150 ng/mL

Phenytoin (dilantin) 10- 20 mcg/mL

SPECIMEN COLLECTION 

Sputum Specimen:Purpose:For Culture and sensitivity test. To test for specific microorganismCytology ( identify origin, structure, function and pathology of cells)For AFB to detect TBDone in 3 consecutive daysEvaluate effectiveness of therapy

NOTE:1. Best collected in the morning upon

awakening2. If client cannot cough, do pharngeal

suctioning\3. Mouth care should be done prior to

obtaining specimen ( water only)4. 1 – 2 tablespoon or 15 – 30 ml (4 – 8 fluid

dram) of sputum is needed 

Throat Culture:Collected from the mucosa of the oropharynx and tonsillar region with the use of culture swabPurpose: detect specific microorganismThis is an invasive procedurePosition of patient: sitting position ( if tolerated ) Extension of tongue ( to expose the pharynx)Let the patient say “ah” to relax the throat muscles

 Blood collectionLaboratories employ a phlebotomist (an individual who performs venipuncture) to collect blood specimens; however, it is  the responsibility of a nurse to know how to perform a venipuncture Point of care testing (POCT) is a common practice in critical care settings and is proving to be a cost-effective. With advances in POCT technology over the past two decades, critical care nurses can perform a blood analysis and within seconds to minutes have a measurement upon which to change or implement an intervention 

Venipuncture▪ To assses Venous Blood▪ Test tubes ( vacuum Tubes ) are used to collect blood specimens. Vacuum Tube Color Coding: Red—no additive  Lavender—EDTA (ethylenediaminotetraacetic acid) Light blue—sodium citrate Green—sodium heparin Gray—potassium oxalate Black—sodium oxalate

 Arterial Puncture▪ To assess Arterial Blood Gas ( ABG )Blood gases are ordered to evaluate:

Oxygenation Ventilation and the effectiveness of

respiratory therapy Acid-base level of the blood

▪ Arterial blood samples are drawn from a peripheral artery (e.g., radial or femoral) or from an arterial line.▪ Allen’s test is performed prior to drawing of arterial blood. ( performed to measure the collateral circulation to the radial artery)▪  The arterial blood sample is collected in a 5-ml heparinized syringe. The syringe is then rotated to mix the blood with the heparin to prevent clotting▪ Direct pressure must be applied to the puncture site until all bleeding has stopped, a minimum of 5 minutes.

Arterial punctures should not be performed:1. If the client is hyperthermic2. Immediately after breathing and suctioning

treatments3. If there have been changes on ventilator

settings4. Anticoagulant therapy5. Clotting disorders6. Symptomatic peripheral vascular disease7. Negative Allen test

 Capillary Puncture▪ Skin punctures are performed when small quantities of capillary blood are needed for analysis or when the client has poor veins.▪ Ex. Drawing blood for Hgt monitoring▪ The common sites for capillary punctures are the: Heel—most common site for neonates and infants Fingertip—the inner aspect of palmar fingertip used most commonly in children and adults  Earlobe—when the client is in shock or the extremities are edematous Central Lines▪ A central line refers to a venous catheter inserted into the superior vena cava through the subclavian, internal, or external jugular vein▪ A central line is inserted when a peripheral route cannot be obtained, for treatment, and to withdraw blood for analysis▪ It is standard practice to mark each lumen of a multilumen catheter with the name of the infusion (e.g., fluid or medication)▪ Implanted Port▪ port-a-cath (a port that has been implanted under the skin) over the third or fourth rib▪ The port has a catheter that is inserted into the superior vena cava or right atrium through the subclavian or internal jugular vein.Blood can be withdrawn for sampling by accessing the port using strict sterile technique 

Urine Collection▪ The different methods of urine collection are:  Random collection (routine analysis)  It can be collected at any time using a clean cup The urine does not have to be collected in a sterile container. Timed collection done over a 24-hour period. The urine is collected in a plastic gallon container that contains preservatives. discard the specimen at the beginning of the collection and save all other voided specimens until 1000 hours the following day The collection container should be refrigerated or kept on ice throughout the 24 hours. This retards bacterial growth and stabilizes the analytes The last urine collection, 1000 hours, should be a complete, forced voiding at the exact timed period. Collection from a closed urinary drainage system Urine collection from a client with an indwelling Foley catheter with a closed drainage system The urine specimen should not be obtained from the drainage bag. The analytes in the urine drainage bag change; this will cause inaccurate results. Collect urine from the aspiration port that is used for sterile urine collection Clean-voided specimen / Clean Catch Urine Clean-voided (clean-catch, or midstream) specimen collection is done to secure a specimen uncontaminated by skin flora. Obtained on first voiding in the morning Stool Collection Stools can be collected for either a one-time defecation or over 24, 48, or 72 hoursIf a specimen is needed over a prolonged period of time, all stools must be placed into a container and refrigerated, otherwise, a clean container is enough. 

Nutrition

NUTRITION Vitamins and Minerals 

Vitamin / Mineral

Recommended Daily Allowance 

Uses Food Source

Men WomenFAT SOLUBLE VITAMINS

A 1000 RE 800 RE Proper vision, growth Liver, milk, eggs, beta-carotenefound in dark-orange and darkgreenfruits and vegetables (carrots,pumpkins, broccoli, spinach)

D 5 µg 5 µg Proper bone formation, cell Function Fortified milk, liver, fish

E 10 mg 8 mg Immune system functioning, destruction of free radicals (by-products of metabolism that can cause vascular damage)

Vegetable oils, green leafy vegetables, whole grains

K 80 µg 65 µg Blood clotting, bone formation Green leafy vegetables, dairy products

WATER SOLUBLE VITAMINSC 60 µg 60 µg Collagen synthesis, destruction of free

radicals, assistance n iron absorption, nfection fighting, healing

Fruits and vegetables (especially citrus fruits)

Thiamine (B1)

1.5 mg 1.4 mg Converting carbohydrates and fats to energy Fortified and whole grains, lean cuts of pork, legumes (beans and peas), seeds, nuts

Riboflavin (B2)

1.7 mg 1.3 mg Converting bodily fuels toEnergy

Dairy products, meat, poultry,fish, whole-wheat and fortified grain products, green leafy vegetables

Niacin (B3)

19 mg 15 mg Converting carbohydrates,fats, and amino acids toenergy

Meat, milk, eggs, poultry, fish, enriched breads and cereals

B6 2 mg 1.6 mg Assistance in at least 50enzyme reactions—the mostimportant regulate nervoussystem activity

Chicken, fish, liver, pork, eggs, whole-wheat products, peanuts, walnuts

Folate 200 µg 180 µg Manufacturing of DNA andnew body cells

Liver, leafy vegetables, legumes, fruits

B12 2 µg 2 µg Manufacturing of new bodycells and mature new redblood cells, maintenance ofnerve growth, protection ofnerve cells

Meat, poultry, fish, dairy products

MINERALSCalcium 800 mg 800 mg Building bone, transmitting

nerve impulses, and aidingmuscle contractions

Dairy foods, canned sardines and salmon with the bones, fortified orange juice; smaller amounts in some fruits and vegetables (broccoli, tangerines, pumpkins)

Phosphorus

800 mg 800 mg Building bone, helping thebody utilize energy andreproduce cells

In nearly all foods

Magnesium

350 mg 280 mg Holding calcium in toothenamel, assistance in relaxingmuscles after contractions

Nuts, legumes, cereal grains,green vegetables, seafood

Iron 10 mg 15 mg Transporting oxygen in redblood cells and musclecells, DNA synthesis, formationof major enzymes

Meat, poultry, fish, dried beansand peas, fortified grain products

Zinc 15 mg 12 mg Promotion of healing andgrowth, maintainingimmune function, DNA synthesis,and a normal senseof taste

Meats, oysters, milk, egg yolks

Iodine 150 µg 150 µg Helping the thyroid regulateMetabolism

Seafood, iodized table salt

Selenium 70 µg 55µ g Destruction of free radicals,formation of enzymes

Fish, meat, breads, cereals

Tips Fats, oils and Sweet Treats. Go easy. Milk, Yogurt and Cheese▪ 2 to 3 servings a day. One serving (one and one-half ounces) of cheese is about the size of six dice or three dominoes. A serving of milk or yogurt is one cup (or one small container of yogurt).▪  Vegetables▪ 3 to 5 servings a day. If you're talking leafy-green veggies like spinach, kale or collard greens, put a baseball-sized portion (one cup) on your plate. Half a baseball will do it for veggies like green beans, carrots and Brussels sprouts. Since that equals about eight green beans, 10 carrot slices or three Brussels sprouts, it should be easy to get a few servings at a time. A small (6-ounce) glass of tomato or other vegetable juice works too. Meat, Poultry, Fish, Eggs and Nuts▪ 2 to 3 servings a day. A deck of cards or a small fist describes what one serving (three ounces) of meat, fish or poultry looks like. A 1 1/2 cup portion of cooked beans make a great stand-in for three ounces of meat. Two tablespoons of peanut butter—about the size of a golf ball—are a third of a serving. Fruit▪ 2 to 4 servings a day. Picture filling half a baseball with fruit. That's all it takes to get one half-cup serving. Whole fruits only need to be about the size of a tennis ball, and a small (6-ounce) glass of juice counts as a serving too. Bread, Cereals, Rice and Pasta6 to 11 servings a day. It's easier to eat your share than it sounds. Your bagel would only have to be the size of a hockey puck to equal one serving (one ounce) of bread.

THERAPEUTIC DIETS 

 Acid-ash diet Retards the formation of alkalinic renal stonesIndicated to patients with renal calculi (Alkaline stones)E.g. cheese, cranberries, eggs, meat, plums, prunes, whole grains

Alkaline ash diet Retards the formation of acid renal stones.Indicated to patients with renal stones (Acidic stones)E.g. fruits (except cranberries, plums, prunes), milk, vegetables

Bland dietLow fiber, mechanical irritants, chemical stimulantsIndicated for patients with gastritis, diarrhea, biliary indigestion, and hiatal hernia

BRAT DietBanana, Rice, Apple. Toast Indicated for patients with diarrhea

Butterball dietSpare protein but high in carbohydratesIndicated for patients with liver disorders

Clear liquid DietTo relieve thirst and help maintain fluid balanceIndicated for post-operative patients and following vomiting and gastroenteritis

Diabetic Diet/Well balance dietThe purpose is to maintain near to normal blood glucose levelIndicated to patients with diabetes mellitus

Full liquid diet It serves to provide nutrition to patients who cannot chew or tolerate solid foodsIndicated to patients with stomach upsets, post-surgical patients, after progression from clear liquid diet

Giordano DietSpare proteinIndicated to patients who suffers from Chronic renal Failure

Gluten free DietNo to B R O W – Barley. Rye. Oat, WheatThis is the diet of a patient who suffers from celiac’s Disease

Halal DietNo pork dietDiet of the Muslims

High Fiber DietFruits and vegetableIt speeds up the passage of food to the digestive tract, it softens the stool,Indicated to patients who are constipated, with diverticolosis, with hyperlipedemia High Protein DietLean-meat, cheese, eggs, Indicated to patients with nephrotic syndrome

Kosher DietMeat ad milk cannot be served simultaneouslyDiet of the Orthodox Jews

Low carbohydrate dietIndicated to patients with dumping syndrome

Yin DietCold deserts after a surgery. It is a Chinese belief.

Low fat/cholesterol DietIt serve the purpose of reducing hyperlipedemia, and to patients with intolerance to fatsIndicated to patients with cardiovascular diseases, patients who underwent resection of the small intestines, hypertension cholecystitis and cholelithiasis

Low Residue dietReduces the bulk of stoolsIndicated to patients with ulcerative colitis, diverticulitis, patients who will undergo surgery of the GI tract

Low Sodium DietIndicated to patients with cardiovascular and renal disorders

Purine restricted dietTo reduce uric acidIndicated to patients with gouty arthritis, renal calculi, and hyperuricemia

Sodium-restricted dietIndicated to patients with heart failure, hypertension, renal diseases, PIH, and steroid therapy

Soft diet Used to provide nutrition for those patients who have problems in chewingFor patients with ill-fitting dentures; transition from full-liquid to general diet, patients with gastrointestinal disturbances such as gastric ulcers and cholelithiasis

Tyramine-free DietUse to prevent hypertensive crisis for patients who are taking-in MAOI antidepressant.No to ABC’s- Avocado, Banana, Canned and Processed Foods, and also, no to fermented foods

Vegan DietDiet of the Seventh Day Adventists

THERAPEUTIC NURSING PROCEDURES

POSITIONING CLIENTS

BASIC PRINCIPLES IN POSITIONING OF PATIENTS

1. Maintain good patient body alignment. Think of the patient in bed as though he were standing.

2. Maintain the patient's safety.3. Reassure the patient to promote comfort

and cooperation.4. Properly handle the patient's body to

prevent pain or injury.5. Keep in mind proper body mechanics for the

practical nurse.6. Obtain assistance, if needed, to move heavy

or helpless patients.7. Follow specific physician's orders.

Position Description Therapeutic Use

DORSAL RECUMBENT

Flat on back with legs flexed at hips and knees

Feet flat on mattress

For perineal and rectal examination

FOWLER’S Head of bed up 30 to 90 degrees1. High Fowler’s: sitting upright at

Promote maximum lung expansionRelieve DOB/ SOB  

90 degreesSemi-Fowler’s: head and torso elevated 45 to 60 degrees

2. Low Fowler’s: head and torso elevated to 30 degrees Knees slightly flexed

KNEE-CHEST

prone with weight of upper body supported on flat surface by chest

• Hips and knees flexed to elevate buttocks

To prevent further cord prolapse. , Promotes Maximum exposure of Rectum

LITHOTOMY

Flat on back with legs flexed 90 degrees at hips andknees• Feet up in

stirrups

For vaginal/ perieneal procedures and assesment

PRONE • Flat on abdomen with knees slightly flexed• Head turned to side• Arms flexed at side

SIMS • Halfway between side lying and prone with bottomknee slightly flexed• Lower arm behind back• Upper arm flexed, hand near head

TRENDELEN-BURG’s

• Head is low with body and legs elevated on aninclined plane

LATERAL RECUMBENT

• Side lying with upper leg flexed at hip and knee• Lower arm flexed with shoulder positioned to avoid

weight of body on shoulder

SUPINE Flat on back with body in anatomic alignment

Common Positions after surgery / after a procedure:  Autograft:

site is immobilized for 3 to 7 daysBurns of face and Head:

elevate head of bedCircumferentiated burns of Extremities:

elevate extremities above the level of the heart

Skin graft: elevate and immobilize

Mastectomy:Semi fowler’s with affected arm elevated on a pillow

Perineal and Vaginal Procedures:Lithothomy Positions

Hypiphysectomy:Elevate head of bead ( prevent ICP )

Thyroidectomy:Semi – fowlers position May use sand bags or pillows for the

head and neckHemorrhoidectomy:

Lateral Side Lying PositionGERD:

Reverse Trendelenburg’sLiver Biopsy:

During:Supine with right side of upper

abdomen exposed

Right arm is raised and extended over the left shoulder behind the head

After:Right Lateral side lying positionSmall pillow or folded towel under

the puncture site for 3 hours NGT

Insertion:High fowler’s position with head tilted forward

Irrigations and tube feedingsSemi fowlers ( 30 ° ) 

Rectal Enemas/ Irrigations:Sim’s Position

Sengstaken – Blakemore and Minnesota tubes:Maintain elevation of head of the bed

COPD:Sitting position, leaning forward

Laryngectomy:Semi fowler’s or fowler’s position

Bronchoscopy:Semi – fowler’s

Postural Drainage:Lung segment to be drained should be

in the uppermost positionThoracentesis:

During:Sitting on the edge of the bed and

leaning over the bedside table or

Lying in bed on the affected side with head of bed elevated ( 45°)

After:Position on the unaffected side

Abdominal Anuerysm Resection:After:

Fowler’s PositionAmputation of the Lower Extremities:

1st 24 hours:Elevate foot of the bed; stump

supported with pillows but not elevated

Prone Position for 10 – 30 mins twice a day

Arterial Vascular Grafting of an ExtremityBed rest for 24 hours; affected extremity

is kept straight Cardiac Catheterization:

Affected extremity is kept straight and head is elevated to no greater than 30 °

Congestive Heart Failure and Pulmonary Edema:Upright Preferably legs dangling to the side of

the bed to decrease venous returnVaricose Vein:

Leg elevation above heart levelCataract Surgery:

After:Semi to fowler’s position and position

patient on the back or non operative side

Retinal Detachment:If gas bubble is injected:Face down or toward the unoperative

sideAutonomic Dysreflexia:

High Fowler’s PositionCerebral Anuerysm:

Semi – fowler’s to fowler’s positionCVA:

Hemorrhagic Strokes:HOB is elevated to 30°

Ischemic Strokes:Flat

Craniotomy:Should NOT be positioned on the

operative siteSemi to fowler’s position

Laminectomy:Back is kept straightLogroll client

ICP:Semi – Fowler’s to Fowler’s Position

LP:During:

Lateral (side lying ) position; knees flexed upto the abdomen and head is bent so that chin is resting on the chest

Fetal positionAfter:

Supine ( 4 to 12 hours )

SCI:Immobilze on a spinal backboard

Myelogram:After:

Water Soluble dye: HOB elevated 30 to 60 degrees

If Oil based : supineTotal Hip Replacement:

Avoid internal and external RotationAvoid adduction and side lying on the

operative sideMaintain abduction if on supine position

( pillows between legs)Do not cross legs

To promote relaxation :Obtain comfortable bedding. Allow some of

patient's own possessions (such as a pillow or afghan) when possible.

Change the bed position (head and knee). Reduce the noise and light in the patient's

room. Check for mechanical reasons for

discomfort: Bed linens which are gathered and

wrinkled under the patient. Plastic mattress covers that wrinkle and

cause pressure. Top covers which may be pulled too

tightly over the feet and legs. The patient lying on tubes, drains,

syringe caps, or other equipment.

Soiled dressings, urine, and feces causing the bed to be wet.

Nonfunctioning equipment, to include alarms sounding without cause

 Log rolling   Logrolling is a technique used to turn a patient whose body must at all times be kept in a straight alignment (like a log). This technique is used for the patient who has a spinal injury. The bed should be in the flat position at a comfortable working height. Lower the side rail on the side of the body at which you are working. Position yourself with your feet apart and your knees flexed close to the side of the bed Place your arms under the patient so that a major portion of the patient's weight is centered between your arms. The arm of one nurse should support the patient's head and neck.On the count of three, move the patient to the side of the bed, rocking backward on your heels and keeping the patient's body in correct alignment. Place pillows in front of and behind the patient's trunk to support his alignment in the lateral position.

  

PRINCIPLES OF ASSISTING PATIENTSOUT OF BED

1. Reassure the patient of his personal safety against injury and over-exertion.2. If necessary, get additional help to assist you in ambulating the patient.3. Support the affected side or extremities of the patient when ambulating or moving.4. Do not overtire the patient; increase time up in the chair and ambulation gradually.5. Lock all wheelchair or litter wheels before transferring the patient from the bed.6. Stabilize the footstool, when it is utilized.

7. Place a signal cord or call-light button within easy reach of the patient while he is up.8. Check on the patient frequently. 

ACTIVE AND PASSIVE RANGE OF MOTION EXERCISE

PURPOSES OF EXERCISE FOR THE IMMOBILE PATIENT

To maintain joint mobility is done by putting each of the patient's joints through all possible movements to increase and/or maintain movement in each joint.

To prevent contracture, atony (insufficient muscular tone), and atrophy of muscles.

To stimulate circulation, preventing thrombus and embolus formation.

To improve coordination. To increase tolerance for more activity. To maintain and build muscle strength.

 TYPES OF EXERCISES

PassiveThese exercises are carried out by the

nurse, without assistance from the patient. Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones.

Active Assistive.These exercises are performed by the

patient with assistance from the nurse. Active assistive exercises encourage normal muscle function while the nurse supports the distal joint.

Active.Active exercises are performed by the

patient, without assistance, to increase muscle strength.

Resistive. These are active exercises performed

by the patient by pulling or pushing against an opposing force.

Isometric These exercises are performed by the

patient by contracting and relaxing muscles while keeping the part in a fixed position. Isometric exercises are done to maintain muscle strength when a joint is immobilized. Full patient cooperation is required.

BODY MOVEMENT 

Flexion -The state of being bent. The cervical spine is flexed when the chin is moved toward the chest.

Extension -The state of being in a straight line. The cervical spine is extended when the head is held straight.

Hyperextension - The state of exaggerated extension. The cervical spine is hyperextended when the person looks overhead, toward the ceiling.

Abduction -Lateral movement of a body part away from the midline of the body. The arm is abducted when it is held away from the body.

Adduction - Lateral movement of a body part toward the midline of the body. The arm is adducted when it is moved from an outstretched position toward the body.

Rotation -Turning of a body part around an axis. The head is rotated when moved from side to side to indicate "no."

Circumduction -Rotating an extremity in a complete circle. Circumduction is a combination of abduction, adduction, extension, and flexion.

Supination. - The palm or sole is rotated in an upward

GUIDELINES FOR RANGE OF MOTION EXERCISES

2. Plan when range of motion exercises should be done

3. Plan whether exercises will be passive, active-assistive, or active. Involve the patient in planning the program of exercises and other activities because he/she will be more apt to do the exercises voluntarily.

4. Expect the patient's heart rate and respiratory rate to increase during exercise.

5. Range-of-motion exercises should be done at least twice a day. During the bath is one appropriate time. The warm bath water relaxes the muscles and decreases spasticity of the joints. Also, during the bath, areas are exposed so that the joints can be both moved and observed. Another appropriate time might be before bedtime. The joints of helpless or immobile patients should be exercised once every eight hours to prevent contracture from occurring.

6. Joints are exercised sequentially, starting with the neck and moving down. Put each joint needing exercise through the range of motion procedure a minimum of three times, and preferably five times. Avoid overexerting the patient; do not continue the exercises to the point that the patient develops fatigue. Some exercises may need to be delayed until the patient's condition improves.

7. Start gradually and move slowly using smooth and rhythmic movements appropriate for the patient's condition.

8. Support the extremity when giving passive exercise to the joints of the arm or leg.

9. Stretch the muscles and keep the joint flexible.

10. Move each joint until there is resistance, but never force a joint to the point of pain.

11. Keep friction at a minimum to avoid injuring the skin.

12. Return the joint to its neutral position.

13. Use passive exercises as required, however, encourage active exercises when the patient is able to do so.

Gastric tube InsertionPurpose:

Administer tube feedings and medications to clients who cannot take in food per orem ( Gavage )

Prevent gastric distention, nausea and vomotting

To remove stomach contents for laboratory analysis

To lavage / wash stomach in case of poisoning or over dose of medication

Procedure:1. Gather the necessary equipment.2. Explain procedure to the patient3. Wash hands.4. Position the patient in a sitting position5. Check nostrils for patency by asking the

patient to breathe through one naris while occluding the other.

6. Measure length of NG tubing to be inserted by measuring the distance from tip of nose to ear-lobe and from ear-lobe to about 1 inch beyond base of xiphoid process. Use a small strip of adhesive tape to mark the measured distance on the tube.

7. Don gloves and lubricate tube in water or a water soluble lubricant. (Never use mineral oil or petroleum jelly.)

8. Ask the patient to tilt his or her head backward, and gently advance the NG tube into an unobstructed nostril; direct tube

toward back of throat and down.9. As the tube approaches the nasopharynx,

ask the patient to flex head toward chest (to close the trachea) and allow him or her to swallow sips of water or ice chips as the tube is advanced into the esophagus (about 3 to 5 inches each time the patient swallows).

NOTE: If the patient coughs or gags, check the mouth and oropharynx. If the tube is curled in the mouth or throat, withdraw the tube to the pharynx and repeat attempt to insert the tube.

10. Ask the patient to continue swallowing until the tube reaches the premeasured mark.

11. Check for proper tube placement in the stomach by aspirating with a syringe for gastric drainage or by instilling about 20 mL of air into the NG tube while listening with a stethoscope for a gurgling sound over the stomach.

12. Secure the tube after checking for proper placement by cutting a 3-inch strip of 1-inch tape and then splitting the tape lengthwise at one

13. end, leaving 1 inch intact at the opposite end 14. Place the intact end of the tape on top of the

patient’s nose, and wrap one side of the split tape end around the tube and secure on a nostril. Repeat with the other split tape end.

15. Connect the NG tube to suction if ordered, or clamp.

16. Wrap adhesive tape around the distal end of the tubing and attach a safety pin through the tape tab to the patient’s gown.

17. Document the size and type of tube inserted. Note the nostril used and the patient’s tolerance of the procedure. Document how placement was validated and whether tubing was left clamped or attached to other equipment.

INTERMITTENT (BOLUS) TUBE FEEDING 

1. Explain procedure to the patient.2. Assist the patient to a normal position for eating; if patient cannot tolerate this position or it is contraindicated, raise head of bed at least 30 degrees.3. Wash hands, don gloves, and organize supplies.4. Verify gastric tube placement by aspirating gastric contents and checking its pH level (this may be difficult with small-bore duodenal tubes); or quickly instill 20 ml air into the tube while auscultating for gurgling sound over the gastric area.5. Aspirate and measure gastric residual and re- instill contents through tube; check physician’s orders or follow unit policy regarding residual as the determinant of whether to administer or avoid feeding (commonly held if residual greater than 100 mL ); if feeding held due to excess gastric residual, turn patient on right side and recheck residual in 30 to 60 minutes.6. Prepare dietary formula; formula should be at room temperature to prevent gastrointestinal muscle cramping.7. Place syringe barrel (with plunger removed) into the end of the tube and slowly pour formula into the barrel until it is almost full; regulate formula administration rate by adjusting the height of the syringe (typically held 6 to 8 inches above tube insertion site). Allow formula to flow slowly by gravity. Continue to add formula to the syringe barrel until feeding is complete; to prevent entrance of air into the stomach, do not allow the syringe to completely empty.8. Follow the feeding with water as ordered or 30 to 50 ml to flush the tube.9. Clamp the tube and maintain elevation of the head of the bed at least 30 degrees for 30 to 60 minutes following feeding to prevent aspiration.10. Clean or dispose of equipment appropriately.11. Wash hands.

12. After checking residual between bolus feedings, follow by using water to clear the tubing unless contraindicated 13. Monitor bowel sounds, bowel regularity, and hydration on any patient receiving tube feedings.14.Document tube placement, gastric residual check, type and amount of feeding, and patient tolerance

CONTINUOUS TUBE FEEDING The feeding bag is hung on an IV pole about 12 inches above the patient’s head if dietary formula is delivered by gravity; the drop factor is regulated to deliver the ordered rate of flow. If using a pump designed for tube feedings, simply hang the bag above the pump.1. For bolus feeding, follow steps 1 to 6 above.2. Pour no more than 1 can (240 mL) or approximately 4 hours’ volume into the bag (bacterial growth is promoted when formula hangs for prolonged periods at room temperature).3. Prime the tubing by allowing the formula to run through and expel air; clamp the tube and attach it to the patient’s feeding tube.4. Insert the bag’s tubing into the pump mechanism and set pump to deliver appropriate volume; unclamp the tubing and start the pump.If using gravity delivery method, calculate the drip rate and regulate manually with the tubing clamp.5. Maintain elevation of head of bed at least 30 degrees while dietary formula infuses and for 30 to 60 minutes thereafter, if feedings are stopped.6. Related care:

• Monitor bowel sounds, bowel regularity, andhydration on any patient receiving tube feedings.• Check tube placement at least once per shift.• Check gastric residuals every four hours duringcontinuous tube feedings; flush tube with waterafter checking residuals.• Replace bag and tubing every 24 hours or

according to agency policy to decrease

chance of organism growth and contamination of feeding.

Colostomy Care 

OSTOMIES – divert and drain fecal material/ bowel resection

temporary ( trauma / inflammatory condition)permanent ( Cancer / congenital or Birth

defects )Stoma – red, initial slight bleeding - normal, no

redness or irritation 2 to 5 inches surrounding the area, no burning sensation

Colostomy Ileostomy

– can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation

Ascending colon colostomy: liquid stool

Transverse Colon Colostomy: loose to semi formed

Descending Colon Colostomy: close to normal Stool

 

– no irrigation , wet fecal material , appliance all the time , meticulous skin care, prevent skin breakdown, constant flow not regulated, bag emptied half full

 

Monitor color changes in the stoma:

Normal color : pink or redPale pink : low hgb / hctPurple black: compromised circulation

If pouch is not in place: Place petroleum jelly gauze over the stoma to keep it moist followed by a dry sterile dressing .

Healthy stoma is red: a color change ( dark black to blue is notifeable)

Stool is liquidPost op drainage is dark green then yellow as the client begins to eat

Precautions avoid gas forming foods and nuts , but can

have any food at tolerated after 6 weeks… yogurt recommended

dry skin before applying appliance karaya – barrier to prevent contamination

with excreta appliance can be up to 2 weeks ; 24-48

hours if eroded or ulceratedwith deodorant ( Charcoal filter Disk, Bismuth )

refer to enterostomal therapy nurse for complications

Enema Administration: 

Enema is a solution introduced into the rectum and large intestines.Its aim is to distend the intestine and irritate the intestinal mucosa;stimulates peristalsis and excretion of feces

Non – retention Enema:

Retention Enema:

Fluids: tap watersoap sudsNSSHypertonic Fluids

Fluids:Carminative enemaOil (mineral , olive,

cottonsee) 

Height of solution: 18 inches above the rectum

Height of solution: 12 inches above the rectum

Position: Left Lateral ( adult) dorsal recumbent ( child)After administering the solutions, press buttocks together to prevent feces from expelling

For abdominal cramps: stop temporarily 

Types:Cleansing EnemaIt irritates the colon producing peristalsis by distending the colon with volume fluid

High enemaTarget: colon1L of solution is introduced

Low enemaTarget: rectum and sigmoid process½ L is administered

 Carminative EnemaAims to expel flatusAbout 60mL to 180 mL of solution is administered

 Retention enemaUses oil based solution( which acts as stool softeners and facilitates passage of feces)Administer oil into the rectum and sigmoid colon, then the oil is retained for 1 – 3 hours

 Return flow / colonic Irrigation

Aims to expel flatusUses an inflow – outflow process

that is repeated 5 – 6 timesSolution container is lowered so that

the fluid backs out through the rectal tube into the container

Intravenous Therapy 

IV therapy is administering fluids / medications through a vein

 Purpose: sustain clients who are unable to take foods/fluids via oral routeused to replace fluids and electrolytes provides vascular access for immediate or rapid delivery of substances or medications especially in emergency situation

 Scope of PracticeRole Definition- the I.V nurses are registered nurse committed to ensure the safety of all patients receiving I.V Therapy

Ethico-legal Implications

The I.V nurse in compliance with PRC, Board of Nursing Resolution No. 08 series of 1994 shall

uphold the Philippine Nursing Act of 1991, the Nurse’s Code of Ethics and the established Nursing Standards of Safe Nursing Practice

Basis of PracticeLegal therapeutic prescription of a licensed physician. Thorough knowledge of the vascular system, interrelatedness of the body system with proficiency in the skill of the IV nurse.

Key points prior to initiation of I.V therapy

Physician’s prescribed treatment. The initiation of intravenous therapy is upon the written prescription of a licensed physician which is checked for the following:

type and amount of solutionflow ratetype, dose and frequency of medication to be

incorporated/push & others affecting the procedure (x-ray,Tx of the extremities.

Patient assessmentFactors to consider for IV Therapy duration of therapy cannula sizecondition of the vein / skintype of solutionpatient’s level of consciousness patient’s activity patient agedominant armclinical status of patient

I.V set and equipment preparationcheck for expiration datecheck for clarity; any presence of holes on plaster cover (packaging); plastic container (bag) or presence of sediments or insect.check labels against the physician’ orderlabel for any medication(s) that are added: date, time, medication and amount; compatibility of drug with the solution.function ability of Infusion Pump,(Patient controlled analgesia )

▪ For Blood products, anesthetics : G 14,16,18 or 19▪ For Standard IV fluid and clear liquid IV : G 22 or 24▪ For clients with small veins: G 24 - 25 Filters▪ Used to prevent particles from entering the client’s vein▪ Needleless System

Drip ChambersMicrodrip chambers Used if solution contains potent medication that needs to be titrated Used if fluid will be infused at slow rate ( about 50 mL per hour)Macrodrip ChambersDrop factors varies from 10 – 20 drops/mL

  

Administration of Medications and IV solutions

Types of IV solutions

IsotonicIsotonic fluids have an osmolality the same as that of blood; that is, about 310 mEq/L of total electrolytes.

HypotonicHypotonic fluids have an electrolyte content below 250 mEq/L. Lower osmalality than the body thus causing movement of solutes into the cells by osmosis Used to prevent cellular edema

HypertonicHypertonic fluids have an electrolyte content above 375 mEq/L. Higher osmolality than the bodyMovement is from cell to extracellular compartment

CrytalloidsUsed for fluid volume replacementContains mostly of electrolytes

ColloidsOr plasma expander Used in cases such as severe hemorrhage and hypovolemia

 Flow rate: amount of fluid _ drop factor on tubing box ÷ running time stated in total number of minutes

Type of Solution Fluid Uses

Isotonic Solutions  0.9% saline ( NS ) 5% dextrose in water ( D5W) 5% dextrose in 0.255% saline (5% D ¼ NS) Lactated Ringers solution ( LR)

  Supplies calories as carbohydrates; prevents dehydration; maintains water balance; promotes sodium diuresis

Hypotonic  0.45 Saline ( ½ NS) 0.25% Saline ( ¼ NS) 0.33 % Saline (1/3 NS)

 Replaces fluid and electrolyte loss

Hypertonic  3% Saline ( 3% NS) 5% Saline ( 5% NS) 10% Dextrose in water ( D10 W) 5% dextrose in 0.9% saline ( 5% D/NS) 5% Dextrose in 0.45% saline ( 5% D/1/2 Solution

 Replaces fluid and electrolyte loss

Colloid  Dextran Albumin

 Maintains colloid osmotic pressure

Infusion Sets / infusion pumps

INFUSION TECHNIQUES

CONTINUOUS;- Administration of a drug over a period of

several hours.

INTERMITTENT:- Administration of medication in a relatively

short span.

BOLUS:- Medication given all at one time Through an

existing port or lock. 

SECONDARY INFUSION:- Administration of a drug that has been

diluted in a small volume of IV solution, usually over 30-60minutes. (Piggyback) Hang higher than Primary.

 VOLUME CONTROL SET:

- Chamber in IV tubing that holds a portion of the solution from a larger container. Avoids overloading Circulatory System. (Volutrol, Buretrol, Soluset.)

Selection of IV Site Veins in the hands , forearm, antecubital ( most suitable access) Veins in the lower extremities ( not suitable because of high risk for embolism, pooling of medication )Veins in the scalps ( for infants)

 Complications of IV TherapyLocal /Phlebitis- involves only the insertion site and manifest aspericatheter inflammation  ;  Warm erythematous skin over an indurated or tender vein an often precedes or is associated with more severe infections. 

Bacteremic catheter related infection—is defined as a positive blood culture with clinical or microbiologic evidence that strongly implicates the catheter as source of infection. Cellulitis- Warm erythematous and often tender skin surrounding the site of cannula insertion, pus is rarely detectable. Purulent thrombophlebitis- warm, erythematous skin over an indurated or tender vein with purrulent drainage from the cannula wound.Pus may drain spontaneously or express by pressure. Infiltration – Edema, pain, and coolness at the site ( may not have back flow) Catheter Embolism – decrease in BP, pain along the vein, weak and rapid pulse, cyanosis Circulatory Overload – distented jugular vein, high Blood Pressure, dyspnea, moist cough and crackles Hematoma – ecchymosis, immediate swelling and leakage of blood at the site of insertion and painful lumps Air embolism – tachycardia, dyspnea, hypotension, cyanosis, decreased LOC

Administration of Blood and Blood Products

Guidelines in Administering Blood and Blood Products:

 1. Verify physician’s order.2. Check expiration date on product.3. Verify accuracy of component with another licensed nurse or physician.

4. Check patient’s ID band for proper identification.5. Explain procedure to patient and tell him or her to report any unusual symptoms or sensations that may occur during infusion.

6. Check baseline vital signs (VS) and report any abnormal findings to the physician before beginning infusion of component.7. Warm blood in approved blood warmer for use in rapid transfusions or for neonatal exchange transfusions.8. Ascertain that the IV line is present and not infiltrated before beginning infusion.9. Flush any solution from present IV line with 0.9% normal saline. (Flush again with saline after completion of product.)

Contraindications :- Do not store blood products in nursing unit

refrigerators. (Blood must be stored at a temperature between 1° and 6°C.)

- Do not use a blood filter for more than 6 hours nor administer more units than recommended by the manufacturer.

- Do not heat blood products in a microwave oven. (Doing so could result in cellular damage.)

- Do not discontinue IV access if an undesirable reaction occurs.

- Do not save blood administration tubing for future use.

10. Check manufacturer’s information before using any pump to administer product. (Some pumps may cause hemolysis of red cells.)11. Initiate infusion within 30 minutes from the time the product is released from the blood bank.12. Remain with the patient for at least 5 minutes after transfusion has begun.13. Check VS 15 minutes after product infusion has begun, then 15 minutes later, and at least every 30 minutes until the infusion is completed.14. Administer a maximum of 50 mL of product over the first 15 minutes of transfusion.15. Complete the infusion within a 4 hours..16. Validate teaching, assessment (including VS), product ID check, procedure (including time infusion begun and completed), and reaction in the patient’s record.

Types of Blood Products:

Fresh Whole Blood—complete componentsRed Blood Cells

Used to replace erythrocytes1 unit increases hgb by 1g/dl and hct by 2 – 3 % after transfusion

White Blood Cells / Granulocyte ConcentrateRarely used

PlateletsUsed to treat thrombocytopeniaAdministered rapidly over 15 to 30 minutes

Fresh Frozen PlasmaUsed to provide clotting factors or for volume

expandersAlbumin

To maintain colloid osmotic pressure

Stop infusion of blood product, maintain IV access with 0.9% normal saline, and notify the physician , send blood and blood set to the lab and reasseintensive monitoring if any of the following occurs:

- Burning at injection site- Pain in any area- Flushing or rash- Itching- Fever

TPNTotal parenteral nutrition (TPN) is delivered via a

central venous catheter to reverse starvation and promote tissue synthesis, wound healing, and normal metabolic function.

ACCESS:peripheral< 2 weeks – phlebitisPIC – Basilic / cephalicPCC – subclavianTriple Lumen- infuse and draw

blood;TPN;MedicationsAtrial- Hickman/Biovac and Groshong; Huber

needle port Guidelines:

1. Monitor the patient for infection.2. Maintain patency by flushing catheter

according to agency policy. Usually he catheter is flushed with twice the catheter volume of heparinized

saline at specified intervals, and all medication dosages and blood sample withdrawals are followed by saline and heparin flushes.

3. The Groshong catheter is not flushed with heparin because it has a valve that restricts blood backflow. Clamps should not be used on the Groshong as they may damage the catheter. This catheter is flushed, according to agency policy, with 0.9% normal saline after medication administration and after withdrawal of blood samples.

4. Central Venous Tunneled Catheters ( CVT) are catheters with single, double, or triple lumens and can be used for administering drugs, blood products, and total parenteral nutrition as well as for obtaining blood samples for lab tests.

5. CVTCs can be used for months or years if infection does not occur

6. Dressing changes are made on all catheters using sterile technique. (Both nurse and patient should wear a mask during the procedure.)

TPN solutions are nutritionally complete, based onthe patient’s weight and caloric/nutrient needs.Content - mixture of:

dextrose (20 to 70 percent) amino acids multivitamins electrolytes, and trace elements. Insulin is often added to the content as

needed to control blood glucose. Five hundred milliliters of 10 or 20 percent fat emulsion (lipids) is also administered to meet the patient’s remaining nutritional needs.

DIRECT COMPLICATIONS:hyperglycemia- hyperosmolar(HA, Nausea and

Vomiting, fever, chills, malaise)Infection ( IV tubing and filter Q24 changed,

solutions refrigerated and warmed just prior to administration )

Pneumothorax ( dyspnea , ecchymosis, diminished / absent lung sound )

 

TPN-AMINO ACID-DEXTROSE- 2-3 L /24H – FINE BACTERIAL FILTER USED

TNA-TOTAL NUTRIENT ADMIXTURE AMINO ACID, DEXTROSE AND LIPIDS-1 LITER /24 HOURS – NO FILTER

INDIRECT COMPLICATIONHypoglycemia Guidelines:

1. Verify central line placement after initial insertion via chest (radiograph) prior to beginning ( pneumothorax or hemothorax is a risk with central line placement.)

2. Check vital signs (including blood pressure) at least every 6 hours after initiating infusion.

3. Check central line insertion site frequently for signs of infection ( which may lead to sepsis)

4. Follow agency policy regarding frequency of dressing changes and procedure.

5. Change IV line setup every 24 hours. (TPN fluidsare an excellent medium for bacterial growth.)

6. Do not administer IV piggyback or direct IV push medications through or draw blood samples from the TPN line. Only lipids may be “piggybacked” carefully through the TPN line beyond the in-line filter.

7. Monitor blood glucose every 6 hours; administer sliding scale insulin as ordered.

8. Weigh patient daily. (High glucose content of TPN can cause an osmotic diuresis and lead to dehydration.)

9. Order TPN solutions from the pharmacy in a timely manner; remove the next container from the refrigerator an hour before needed to prevent central infusion of cold solutions.

 Oxygen TherapyIndicated to clients who need additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.

Pulmonary Volumes and Capacities:

O2 Therapy safety precautions:1. NO Smoking2. Avoid use of volatile and flammable

materials such as alcohol, oils, greases, ether and acetone

  Description Normal Value

Tidal Volume (VT) Volume inhaled and exhaled during normal quiet breathing

 

500

Inspiratory Reserve Volume ( IRV )

Maximum amount of air that can be inhaled over and above a normal breath

3100

Expiratory Reserve Volume (ERV)

Maximum amount of air that can be exhaled following a normal breathing

1200

Total Lung Capacity ( TLC )

Total volume of the lungs at maximum inflationTLC = (VT) + ( IRV ) + (ERV) + ( RV )

6000

Residual Volume (RV )

The amount of air remaining in the lungs after maximal inhalation

1200

Vital Capacity Total amount of air that can be inhaled after a maximal inspiration;

VC = (VT) + ( IRV ) + (ERV)

4800

Inspiratory Capacity ( IC )

The volume left in the lungs after normal quiet exhalation

IC = (VT) +( IRV )

3600

Functional RESIDUAL Capacity ( FRC )

The volume left in the lungs after a normal exhalation

FRC = ( ERV ) + ( RV)

2400

Postural DrainageDrainage by gravityPre therapy:Administer bronchodilator or nebulization therapyFrequency: 2 – 3 times a dayBest time:

Before breakfast Before lunch Before bedtime

CI: spinal cord injurySequence: Positioning, Percussion, Vibration, cough / suctioningTo drain the middle and lower portions of your lungs:

Positions: 1. If a hospital bed is available, put in

Trendelenburg position (head lower than feet)

2. Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip

3. Stack 18-20 inches of pillow under hips. 4. Place on a tilt table, with head lower than

feet. 5. Lower head and chest over the side of the

bed. 6. To drain the upper portions of your lungs,

you should be in a sitting position at about a 45 degree angle.

7. Remain in each position approximately five to ten minutes. Use suction or assisted cough before changing position to insure removal of any secretions drained while in that position.

Incentive Spirometry:

Sustained maximal inspiration deviceMeasures the flow of air inhaled through the mouthpieceUsed to expand collapsed alveoli loosen secretions and improved pulmonary ventilation

Artificial Airway

Orophharyngeal and Nasopharyngeal Airway

Devices that keeps the airway open / patent Oropharynheal airways stimulates gag reflex

and SHOULD only be used with altered LOC When inserting, hold it by the outer flange,

with distal end pointing up Should be inserted along the top of the

tongue with the distal end pointing up When the distal end reached the back of the

mouth, rotate airway 180 degress downward, and slip it to the uvula into the oral pharynx

Suction and mouth care as needed Never tape the airway in place

 Nasopharyngeal Airway

From the nose to the oropharynxFrequents oral and nasal care

  Endotracheal Tube

Suction as needed to prevent pooling of secretions and keep the airway patent

Monitor cuff pressure ( should be 20 – 25 mm Hg or as recommended) to prevent tracheal tissue necrosis

Mouth care as needed Provide humidified oxygen Communicate frequently using pad and pen. ▪ If with mechanical vent ensure alarms are

functioning Tracheostomy

Surgical incision of the trachea which is used as a long term airway support

Tracheostomy tube components: Outer cannula with flange Inner cannula Obturator Inflatable cuff( secures the placement of the tube) Tracheostomy tubes have an outer cannula with a flange ( which rests on the neck) this allows the tube to be secured in place with a tie / tape

 The obturator is used to insert the outer cannula and then removed. This should remain at the bedside incase the tube will be dislodged and needs reinsertion

 NOTE: children donot require cuffed tubes because their tracheas are resilient enough to seal the air space around the tube  Tracheostomy care:▪ Air is not filtered and humidified therefore, a mist collar or a 4 ix 4 guaze may be held in place with a cotton tie over the stoma to filter the air as it enters.▪ tie new tie before removing the old tie to prevent accidental dislodgement▪ use precut gauze and perform care once a day at least.▪ soak inner cannula in antiseptic soak with hydrogen peroxide, rinse well▪ suction as needed and do oral care frequently 

Suctioning

Aspiration of secretions through a catheter that is connected to a suction machine or wall suction outlet Catheters:1. Open tipped

- Most effective in aspirating secretions2. Whistle tipped

- Less irritating

Oral suctioning: Yankauer device / oral suction tubeCatheter have a thumb port which serves as a controller when suctioning Notes:▪ NEVER suction more 10 – 15 seconds▪ Use aseptic technique when suctioning▪ HYPEROXYGENATE prior to suctioning▪ Do oral care after suctioning▪ DO NOT suction while inserting the catheter▪  When u close the thumb port with your finger the suctioning is done▪  Open thumb port ( no suction is done)▪  Suction in a circular manner/ by rotating catheter ( ensures all surfaces are reached and prevents trauma)▪  Apply intermittent suction on withdrawal of the catheter

Urinary Catheterization

Procedure1. Explain procedure to the patient.2. Provide privacy.3. Prepare trash receptacle.4. Wash hands.5. Position the female patient supine with knees flexed; male patient supine with legs slightly spread.6. Place waterproof pad under buttocks.7. Drape patient, diamond fashion, with sheet.8. Arrange for adequate lighting.9. Wash perineum with soap and water if soiled.10. Open kit using sterile technique.

11. Don sterile gloves.12. Set up sterile field (off bed if the patient may contaminate).13. Test balloon if catheter will be indwelling.14. With nondominant hand, spread labia (female) or retract foreskin (male).This hand is no longer sterile. Using provided antiseptic solution and cotton balls or swabs, cleanse perineum (female) from clitoris toward anus with top-to-bottom motion or retract foreskin (male) and use circular motion from meatus outward.Repeat this step at least three times.

 NOTE: Each swab is used only once and discarded into the trash receptacle, away from the sterile field.

 15. Lubricate catheter.16. Slowly insert catheter until urine is noted (2 to 3 inches for female or 7to 8 inches for male)For male patient, hold penis perpendicular to body and pull up gently during insertion.17. Collect specimen if needed. 18. Remove catheter if it is not indwelling.

IF INDWELLING19. Inflate balloon. If patient has sudden pain, deflate balloon, then advance catheter slightly and reinflate.20. Pull catheter gently to check adequacy of balloon.21. Attach catheter to collection tubing if not already connected by manufacturer.22. Tape catheter to patient’s inner thigh. Allow slack for patient movement.23. Discard gloves and equipment.24. Wash hands.25. Document size and type of catheter inserted, amount and appearance of urine, and patient’s tolerance of procedure.

Catheter Irrigation:1. Gather equipment.

2. Explain procedure to the patient.3. Wash hands and don gloves.4. Place waterproof pad beneath the patient’s hips.5. Pour sterile normal saline into a sterile basin and draw into sterile irrigation syringe.6. Using aseptic technique, disconnect drainage tubing. (Avoid contaminating end of catheter tube or drainage system.)7. Instill 30 mL of solution into bladder.8. Allow irrigation solution to return by gravity.

Chest Tube:

Types of Chest Tube Drainage System: Simple drainage systema simple drainage system that can be connected to suction or to a Heimlich valve. The fluid-collection bottle would have measurement markings on it to help clinicians track the amount of fluid collected.

Water Seal Drainage System addition of a water-sealed bottle to the simple drainage system. This helps to stop the problem of air moving back into the chest, and it also provides greater capacity for the collection of blood or body fluids without any clogging of the suction outlet/connection.

Three-bottle drainage system.the system has a fluid-collection bottle and a water-sealed bottle, along with a pressure-regulating bottle. This bottle helps the system maintain a measured, constant negative pressure and negative flow.

Chest Tube care1. Gather equipment and unwrap Pleur-Evac or other closed-chest drainage apparatus.2. Fill the water-seal chamber to the 2-cm level according to manufacturer’s instructions regardless of whether suction is to be used.3. If suction is ordered, fill chamber to the ordered level; typically 20 cm H2O.4. Hang drainage unit from the bed frame5. After chest tube insertion (by the physician) and before tube clamp removal, attach drainage unit to the tube.6. Attach long (drainage unit) tube to suction source, if ordered, and advance suction until gentle bubbling occurs in suction-control chamber. Amount of suction applied to the pleural space is determined by the height of fluid in the suction-control chamber and not the wall suction source.

 MAINTENANCE1. Note accumulated drainage in the collection chamber at the start of each shift or more frequently if warranted by patient condition, and mark the date and time of observation on the collection chamber.2. Check the water-seal and suction-control fluid levels at the start of each shift and replace water as necessary;water will evaporate from the suction-control chamber, especially with vigorous bubbling.To check fluid levels,temporarily turn off the wall suction.3. Observe the water-seal chamber for fluctuations (tidaling) that occur with the patient’s ventilations; unless the patient is on a ventilator, the column of fluid rises with inhalation and falls with exhalation.4. Observe the water-seal chamber for bubbling. Bubbling is normal on exhalation when the patient has a pneumothorax; continuous bubbling indicates an (abnormal) air leak in the system.5. Maintain extra lengths of tubing by coiling it on the bed in order to prevent dependent loops that may slow/stop drainage.6. If drainage slows or stops, gently “milk” the chest

tube from proximity to the patient toward the collection chamber: to milk the tube, grasp and squeeze it between the fingers and palm of one hand; release and repeat with the other hand on the next lower portion of the tube; continue toward the Collection chamber, squeezing the tube with only one hand at a time.

 Do NOT strip the tube; stripping involves both hands with one holding the tube while the other squeezes and pulls toward the drainage chamber. (Stripping greatly increases the negative pressure applied to the pleural space and can cause tissue damage, bleeding, and pain.)7. Document system function, including time initiated/ discontinued, type and amount of drainage, patient respiratory status, details related to chest dressing, and appearance of the tube insertion site.8. Notes for safety:

• Maintain all connections in the system to prevent inadvertent entrance of air into the patient’s pleural space.• Keep drainage unit below chest level.• If drainage system is turned over or water seal disrupted: re-establish water seal, assess the patient’s condition, and encourage coughing and deep breathing. If secretions were present in the disrupted system, obtain a new system.• If the drainage system is broken and no new drainage system is immediately available, place the end of the chest tube in a bottle of saline or water and place the bottle below chest level, encourage the patient to cough and deep breathe, obtain a new drainage system, and attach it to the patient’s chest tube.

ASEPSIS AND PERIOPERATIVE NURSING

“Universal Precautions takes us back to the area where presence of mind matters most, the Operating Room. One of the highlights of the licensure examination is perioperative nursing. In this chapter, let us take a closer look on the standards of perioperative nursing from admission until discharge.”

 ASEPSIS -Is the freedom from disease – causing microorganism

Types :

Medical AsepsisAll practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmissionClean and dirty technique

Surgical AsepsisSterile techniqueAll practices intended to keep an area or objects free of all microorganism, and destroy all microorganism PRINCIPLES OF ASEPTIC TECHNIQUE

1. Only sterile objects should be on the sterile field

2. Things below the waist, above the head, and out of vision are considered unsterile

3. There is a 1 by 1 inch border that is considered unsterile in every sterile pack

4. If in doubt, consider it unsterile5. Overexposed pack is already unsterile6. Gravity may contaminate the sterile field

therefore AVOID overreaching7. Moisture is a good medium for

contamination8. Do not pour fluids on the sterile field

9. Sterile instruments should be stored well, and checked regularly

10. When opening a pack, the outer flap should be opened away from you first

11. The outer pack of a double – wrapped instrument is considered unsterile

12. Honesty and presence of mind should be of greater value when maintaining sterility.

Standard PrecautionPromote hand washing , use of gloves, masks, eye protection, and gowns when in contact with clients APPLIES TO: blood, all body fluids, secretions, non intact skin , mucous membrane 

HEAT AND COLD THERAPYAn intervention that reduces inflammation

Principles:1. Cold application is generally safer than heat

application.2. Heat application usually requires a doctor’s

order3. Cold application is done within 72 hours

after an injury, while heat application is done after 72 hours.

4. The application of heat and cold is done at a maximum of 30 minutes (an average of 15-20 minutes)

5. Check the area of applications are done every 15 minutes.

 Wound DressingsPurpose:

Protect from injury and bacterial contamination

Maintain humidity For thermal insulation Absorb drainage and at the same time

debride the wound Prevent hemorrhage To splint and immobilize wound Provide comfort

 Wound Healing

Inflammation PhaseHEMOSTASIS---FIBRIN----PHAGOCYTOSIS----(3-

4DAYS)

Proliferative PhaseFIBROBLAST—COLLAGEN---CAPILLARIES----

GRANULATION TISSUE---ESCHAR---(3 – 21 DAYS)

Maturation Phase (21 DAYS – 2 YEARS)

 Standard plus + + +

Disease Ways of Protection

Airborne Precaution

MeaslesChicken PoxVaricella Zoster VirusTuberculosis

- Room: negative Pressure- Negative Airflow Pressure- Door must be kept closed- Use of high – efficiency particulate air filter In the room- Use of mask- Must be in a single room- Mask client when in contact with others and when leaving the room

Droplet Precaution

AdenovirusDiphtheriaEpiglottitisInfluenzaMeningitisMumpsPertusisPnuemoniaSepsisRubella

Use of mask ( also by the patient especially when leaving the room )

Room: private room or can be cohorted or grouped

 

Contact Precaution

MDR (multi drug resistant )Enteric Infections (e.g. clostridium difficile)Respiratory Syncytial virusWound InfectionsSkin infestations:

ImpetigoPediculosisScabies

Eye infectionsconjunctivitis

room: private room or can be cohorted or grouped together

use of GLOVES and GOWNS

Types of dressing:

Dry to DryTrap necrotic debris and exudate

Wet to DryUses saline and anti microbial solution this softens debris as it dries and dilute exudate

Wet to dampWound debrided if gauze is removedVariation at dryingWOUND DEBRIDED IF GAUZE REMOVED ( VARIATION at DRYING)

Wet to WetKeeps wound moist ( wound is bathed )Moisture dilutes viscous exudate

Notes:- Use sterile gloves or clean gloves- Use gauze pads (which may be lifted with

sterile forceps) to cleanse the wound with prescribed antiseptic solution.

- Cleanse the wound from the center outward, using a new gauze pad for each outward motion.

- NOTE: Iodine solutions may cause skin irritation if they are left on the skin between dressing changes

- NOTE: “Wet-to-dry dressing change” describes the technique of applying several layers (the number of layers depends on the size of the wound area and the patient) of saline-soaked dressings next to the wound and covering these with dry dressings.

 

PERIOPERATIVE NURSING

Perioperative - refers to the total span of surgical intervention. Surgical intervention is a common treatment for injury, disease, or disorder and has three phases: preoperative, intraoperative, and postoperative

PERIOPERATIVE NURSE - is a nurse who provides patient care, manages, teaches, and studies the care of patients undergoing operative or other invasive procedures.- Provides specialized nursing care to patients

before, during, and after their surgical and invasive procedures

- Helps plan, implement, and evaluate treatment of the patient

- Acts as a patient advocate for patients undergoing surgical and invasive procedures

- Works closely with all members of the surgical team

CLASSIFICATIONS OF SURGERY

Reason/PurposeDiagnostic- removal and examination of tissue (e.g., biopsy).Curative/Ablative-removal of a diseased organ or structure (e.g. appendectomy).Restorative - repair a congenitally malformed organ or tissue. (e.g., harelip; cleft palate repair).Palliative- relief of pain (for example, rhizotomy--interruption of the nerve root between the ganglion and the spinal cord). Reconstructive- repair or restoration of an organ or structure (e.g., colostomy; rhinoplasty, cosmetic improvement).

Degree of UrgencyUrgent – needs immediate interventionsElective- surgery that can be delayedOptional – Patient may opt to have or not to have surgery

Degree of RiskMajor- requires hospitalization, is usually prolonged, carries a higher degree of risk, involves major body organs or life-threatening situations, and has the potential of postoperative complications.  Minor- brief, carries a low risk, and results in few complications

COMMON PSYCHOLOGICAL DISTRESS PRIOR TO SURGERY

Anxiety Loss of a body part. Unconsciousness and not knowing or being

able to control what is happening. Pain. Fear of death. Separation from family and friends. The effects of surgery on his lifestyle at

home and at work. Exposure of his body to strangers. Fear of the unknown (Most common fear)

PREOPERATIVE PHASEBegins when a decision for surgery is made until the client is admitted at the operating room.

PREOPERATIVE ASSESSMENT: Risk Factors

Age Nutritional and health status fluid & electrolytes imbalances radiation cardiopulmonary chemotherapy meds family history

prior surgical experiences (positive/negative)

type of surgery location site

Nursing History past & present meds diet allergies (latex) personal habits occupation finances family support knowledge of surgery attitude

Physical Exam

Diagnostic tests CBC Electrolytes Creatinine Urinalysis x-ray exams EKG Blood Type PTT and PT Platelet Blood donations

PREOPERATIVE CHECKLIST History and physical examination Name of procedure on surgical consent Signed surgical consent Laboratory results Client is wearing an identification bracelet Allergies have been identified NPO Skin preparation completed Vital signs assessed Jewelry removed Dentures removed

Client is wearing a hospital gown and hair cover

Client has urinated Location of IV site, type of intravenous

solution, rate of infusion is identified The prescribed preoperative medication

has been given

PREOPERATIVE HEALTH TEACHINGS leg and deep breathing exercises; ROM

exercises Moving patient ; coughing and splinting Preoperative medications : when they

are given & their effects Postoperative pain control Explanation & description of post

anesthesia care recovery room Discussion of the frequency I assessing

V/S & use of monitoring equipments

PREOPERATIVE - ANESTHESIA

Types1. General2. Regional3. Local

General Anesthetics Inhaled General Anesthetics Nitrous oxide, cyclopropane Inhaled liquid halothane, enflurane, isoflurane Intravenous Anesthetic Pentothal (thiopental)

Local/Regional Epidural Infiltration Nerve Block Spinal Topical

Anesthetic agents Xylocaine, Novocain, carbocaine

Topical

Dermoplast (benzocaine)

ADJUNCTIVE ANESTHESIA Opioid analgesic

AlfentaDemerol and Morphine

BenzodiazepineValium, Versed

Anticholinergic Atropine, scopolamine Sedative-hypnotic

Atarax, Vistaril, Seconal, Nembutal

NURSING RESPONSIBILITIES1. Geriatric concerns2. Address safety issues - sensory decline3. Hepatic, cardiac respiratory and renal

decline4. Assess for preexisting problems such as

cardiac, renal, hepatic, or respiratory.

INTRAOPERATIVE PHASE The intraoperative phase is the period during which the patient is undergoing surgery in the operating room. It ends when the patient is transferred to the post-anesthesia recovery room.

THE SURGICAL TEAM

A. The SurgeonThe surgeon is the leader of the surgical team. The surgeon is ultimately responsible for performing the surgery effectively and safely; however, he is dependent upon other members of the team for the patient's emotional well being and physiologic monitoring.

B. Anesthesiologist/Anesthetist.An anesthesiologist is a physician trained in the administration of anesthetics. An anesthetist is a

registered professional nurse trained to administer anesthetics. The responsibilities of the anesthesiologist or anesthetist include:

(1) Providing a smooth induction of the patient's anesthesia in order to prevent pain. (2) Maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. (3) Continuous monitoring of the physiologic status of the patient for the duration of the surgical procedure. (4) Continuous monitoring of the physiologic status of the patient to include oxygen exchange, systemic circulation, neurologic status, and vital signs. (5) Advising the surgeon of impending complications and independently intervening as necessary.

C. Scrub Nurse/Assistant. The scrub nurse or scrub assistant is a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis while draping and handling instruments, and assists the surgeon by passing instruments, sutures, and supplies. The scrub nurse must have extensive knowledge of all instruments and how they are used. The scrub nurse or assistant wears sterile gown, cap, mask, and gloves.

D. Circulating Nurse. The circulating nurse is a professional registered nurse who is liaison between scrubbed personnel and those outside of the operating room. The circulating nurse is free to respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan. The circulating nurse does not scrub or wear sterile gloves or a sterile gown. Other responsibilities include:

(1) Initial assessment of the patient on admission to the operating room, helping monitor the patient’s condition.

(2) Assisting the surgeon and scrub nurse to don sterile gowns and gloves. (3) Anticipating the need for equipment, instruments, medications, and blood components, opening packages so that the scrub nurse can remove the sterile supplies, preparing labels, and arranging for transfer of specimens to the laboratory for analysis. (4) Saving all used and discarded gauze sponges, and at the end of the operation, counting the number of sponges, instruments, and needles used during the operation to prevent the accidental loss of an item in the wound.

MAJOR CLASSIFICATIONS OF ANESTHETIC AGENTS A. There are three major classifications of anesthetic agents: general anesthetic, regional anesthetic, and local anesthetic. A general anesthetic produces loss of consciousness and thus affects the total person. When the patient is given drugs to produce central nervous system depression, it is termed general anesthesia. (A) General anesthesia is used for major head and neck surgery, intracranial surgery, thoracic surgery, upper abdominal surgery, and surgery of the upper and lower extremities.

(1) There are three phases of general anesthesia: induction, maintenance, and emergence.

Induction, (rendering the patient unconscious) begins with administration of the anesthetic agent and continues until the patient is ready for the incision.  Maintenance (surgical anesthesia) begins with the initial incision and continues until near completion of the procedure. Emergence begins when the patient starts to come out from under the effects of the anesthesia and usually ends when the patient

leaves the operating room. The advantage of general anesthesia is that it can be used for patients of any age and for any surgical procedure, and leave the patient unaware of the physical trauma. The disadvantage is that it carries major risks of circulatory and respiratory depression.

(2) Routes of administration of a general anesthetic agent are:

rectal (which is not used much in today's medical practices), intravenous infusion, and inhalation. No single anesthetic meets the criteria for an ideal general anesthetic. To obtain optimal effects and decrease likelihood of toxicity, administration of a general anesthetic requires the use of one or more agents. Often an intravenous drug such as thiopental sodium (Pentothal) is used for induction and then supplemented with other agents to produce surgical anesthesia. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects.

(3) Characteristics of the ideal general anesthetic are:

(a) It produces analgesia. (b) It produces complete loss of consciousness. (c) It provides a degree of muscle relaxation. (d) It dulls reflexes. (e) It is safe and has minimal side effects.

(B) A regional or block anesthetic agent causes loss of sensation in a large region of the body. The patient remains awake but loses sensation in the specific region anesthetized. In some instances,

reflexes are lost also. When an anesthetic agent is injected near a nerve or nerve pathway, it is termed regional anesthesia.

(1) Regional anesthesia may be accomplished by nerve blocks, or subdural or epidural blocks

 (a) Nerve blocks are done by injecting a local anesthetic around a nerve trunk supplying the area of surgery such as the jaw, face, and extremities. (b) Subdural blocks are used to provide spinal anesthesia. The injection of an anesthetic, through a lumbar puncture, into the cerebrospinal fluid in the subarachnoid space causes sensory, motor and autonomic blockage, and is used for surgery of the lower abdomen, perineum, and lower extremities. Side effects of spinal anesthesia include headache, hypotension, and urinary retention. (c) Epidural block, the agent is injected through the lumbar interspace into the epidural space, that is, outside the spinal canal.

 C)Local anesthesia is administration of an anesthetic agent directly into the tissues. It may be applied topically to skin surfaces and the mucous membranes in the nasopharynx, mouth, vagina, or rectum or injected intradermally.. Local infiltration is used in suturing small wounds and in minor surgical procedures such as skin biopsy. Topical anesthesia is used on mucous membranes, open skin surfaces, wounds, and burns. The advantage of local anesthesia is that it acts quickly and has few side-effects. SELECTION OF AN ANESTHETIC AGENT Depending on its classification, anesthesia produces states such as narcosis (loss of consciousness), analgesia (insensibility to pain), loss of reflexes, and

relaxation. General anesthesia produces all of these responses. Regional anesthesia does not cause narcosis, but does result in analgesia and reflex loss. Local anesthesia results in loss of sensation in a small area of tissue. The choice of route and the type of anesthesia is primarily made by the anesthetist or anesthesiologist after discussion with the patient. Whether by intravenous, inhalation, oral, or rectal route, many factors effect the selection of an anesthetic agent:  The type of surgery. The location and type of anesthetic agent required. The anticipated length of the procedure. The patient's condition. The patient's age. The patient's previous experiences with anesthesia. The available equipment. Preferences of the anesthesiologist or anesthetist and the patient. The skill of the anesthesiologist or anesthetist.Factors considered by the anesthetist or anesthesiologist when selecting an agent are the smoking and drinking habits of the patient, any medications the patient is taking, and the presence of disease. Of particular concern are pulmonary function, hepatic function, renal function, and cardiovascular function.  Pulmonary function is adversely affected by upper respiratory tract infections and chronic obstructive lung diseases such as emphysema, especially when intensified by the effects of general anesthesia. These conditions also predispose the patient to postoperative lung infections.  Liver diseases such as cirrhosis impair the ability of the liver to detoxify medications used during surgery, to produce the prothrombin necessary for blood clotting, and to metabolize nutrients essential for healing following surgery. Renal insufficiency may alter the excretion of drugs and influence the patient's response to the

anesthesia. Regulation of fluids and electrolytes, as well as acid-base balance, may be impaired by renal disease. Well-controlled cardiac conditions pose minimal surgical risks. Severe hypertension, congestive heart failure, or recent myocardial infarction drastically increase the risks.Medications, whether prescribed or over-the-counter, can affect the patient's reaction to the anesthetic agent, increase the effects of the anesthesia, and increase the risk from the stress of surgery. Medication is usually withheld when the patient goes to surgery; but some specific medications are given even then. For example, patients with cardiovascular problems or diabetes mellitus may continue to receive their prescribed medications. (1) Because some medications interact adversely with other medications and with anesthetic agents, preoperative assessment should include a thorough medication history. Patients may be taking medication for conditions unrelated to the surgery, and are unaware of the potential for adverse reactions of these medications with anesthetic agents. (2) Drugs in the following categories increase surgical risk.

(a) Adrenal steroids--abrupt withdrawal may cause cardiovascular collapse in long-term users. (b) Antibiotics--may be incompatible with anesthetic agent, resulting in untoward reactions. Those in the mycin group may cause respiratory paralysis when combined with certain muscle relaxants used during surgery. (c) Anticoagulants--may precipitate hemorrhage. (d) Diuretics--may cause electrolyte (especially potassium) imbalances, resulting in respiratory depression from the anesthesia.

(e) Tranquilizers--may increase the hypotensive effect of the anesthetic agent, thus contributing to shock.

REASONS FOR SURGICAL INTERVENTION Descriptors used to classify surgical procedures include ablative, diagnostic, constructive, reconstructive, palliative, and transplant. These descriptors are directly related to the reasons for surgical intervention:  To cure an illness or disease by removing the diseased tissue or organs. To visualize internal structures during diagnosis. To obtain tissue for examination. To prevent disease or injury. To improve appearance. To repair or remove traumatized tissue and structures. To relieve symptoms or pain.Recovery Room CareThe postoperative phase lasts from the patient's admission to the recovery room through the complete recovery from surgery.  THE RECOVERY ROOM a. The recovery room is defined as a specific nursing unit, which accommodates patients who have undergone major or minor surgery. Following the operation, the patient is carefully moved from the operating table to a wheeled stretcher or bed and transferred to the recovery room. The patient usually remains in the recovery room until he begins to respond to stimuli. General nursing goals of care for a patient in the recovery room are: (1) To support the patient through his state of dependence to independence. Surgery traumatizes the body, decreasing its energy and resistance. Anesthesia impairs the patient's ability to respond to environmental stimuli and to help himself. An artificial airway is usually maintained in place until reflexes for gagging and swallowing return. When the reflexes return, the patient usually spits out the airway. Position the unconscious patient with his

head to the side and slightly down. This position keeps the tongue forward, preventing it from blocking the throat and allows mucus or vomitus to drain out of the mouth rather than down the respiratory tree. Do not place a pillow under the head during the immediate postanesthetic stage. Patients who have had spinal anesthetics usually lie flat for 8 to 12 hours. The return of reflexes indicates that anesthesia is ending. Call the patient by name in a normal tone of voice and tell him repeatedly that the surgery is over and that he is in the recovery room. (2) To relieve the patient's discomfort. Pain is usually greatest for 12 to 36 hours after surgery, decreasing on the second and third post-op day. Analgesics are usually administered every 4 hours the first day. Tension increases pain perception and responses, thus analgesics are most effective if given before the patient's pain becomes severe. Analgesics may be administered in patient controlled infusions. (3) Early detection of complications. Most people recover from surgery without incident. Complications or problems are relatively rare, but the recovery room nurse must be aware of the possibility and clinical signs of complications. (4) Prevention of complications. Complications that should be prevented in the recovery room are respiratory distress and hypovolemic shock.

The difference between the recovery room and surgical intensive care are: (1) The recovery room staff supports patients for a few hours until they have recovered from anesthesia. (2) The surgical intensive care staff supports

patients for a prolonged stay, which may last 24 hours or longer.

 

RESPIRATORY DISTRESS Respiratory distress is the most common recovery room emergency. It may be caused by

laryngospasm, aspiration of vomitus, or depressed respirations resulting from medications.(1) A laryngospasm is a sudden, violent contraction of the vocal cords; a complication which may happen after the patient’s endotracheal tube is removed. During the surgical procedure with general anesthesia, an endotracheal tube is inserted to maintain patent air passages. The endotracheal tube may be connected to a mechanical ventilator. Upon completion of the operation, the endotracheal tube is removed by the anesthesiologist or anesthetist and replaced by an oropharyngeal airway (figure 8-4).  Oropharyngeal airway.(2) Swallowing and cough reflexes are diminished by the effects of anesthesia and when secretions are retained. To prevent aspiration, vomitus or secretions should be removed promptly by suction.(3) Ineffective airway clearance may be related to the effects of anesthesia and drugs that were administered before and during surgery. If possible, an unconscious or semiconscious patient should be placed in a position that allows fluids to drain from the mouth.b. After removal of the endotracheal tube by the anesthesiologist or anesthetist, an oropharyngeal airway is inserted to prevent the tongue from obstructing the passage of air during recovery from anesthesia. The airway is left in place until the patient is conscious. 

POSTOPERATIVE PATIENT CARE ACCORDING TO BODY SYSTEM  Respiratory System

The cough reflex is suppressed during surgery and mucous accumulates in the trachea and bronchi. After surgery, respiration is less effective because of the anesthesia and pain medication, and because deep respirations cause pain at the incision site. As a result, the alveoli do not inflate and may collapse, and retained secretions increase the potential for respiratory infection and atelectasis.  Turn the patient as ordered. Ambulate the patient as ordered. If permitted, place the patient in a semi-Fowler's

position, with support for the neck and shoulders, to aid lung expansion.

Reinforce the deep breathing exercises the patient was taught preoperatively. Deep breathing exercises hyperventilate the alveoli and prevent their collapse, improve lung expansion and volume, help to expel anesthetic gases and mucus, and facilitate oxygenation of tissues. Ask the patient to:

(a) Exhale gently and completely. (b) Inhale through the nose gently and completely. (c) Hold his breath and mentally count to three. (d) Exhale as completely as possible through pursed lips as if to whistle. (e) Repeat these steps three times every hour while awake.

Coughing, in conjunction with deep breathing, helps to remove retained mucus from the respiratory tract. Coughing is painful for the postoperative patient. While in a semi-Fowler's position, the patient should support the incision with a pillow or folded bath blanket and follow these guidelines for effective coughing:

(a) Inhale and exhale deeply and slowly through the nose three times. (b) Take a deep breath and hold it for 3 seconds.

(c) Give two or three "hacking" coughs while exhaling with the mouth open and the tongue out. (d) Take a deep breath with the mouth open. (e) Cough deeply once or twice.  (f) Take another deep breath. (g) Repeat these steps every 2 hours while awake.

An incentive spirometer may be ordered to help increase lung volume, inflation of alveoli, and facilitate venous return. Most patients learn to use this device and can carry out the procedure without a nurse in attendance. Monitor the patient from time to time to motivate them to use the spirometer and to be sure that they use it correctly.

(a) While in an upright position, the patient should take two or three normal breaths, then insert the spirometer's mouthpiece into his mouth. (b) Inhale through the mouth and hold the breath for 3 to 5 seconds. (c) Exhale slowly and fully. (d) Repeat this sequence 10 times during each waking hour for the first 5 post-op days. Do not use the spirometer immediately before or after meals.  

Cardiovascular SystemVenous return from the legs slows during surgery and may actually decrease in some surgical positions. With circulatory stasis of the legs, thrombophlebitis and emboli are potential complications of surgery. Venous return is increased by flexion and contraction of the leg muscles. To prevent thrombophlebitis, instruct the patient to exercise the legs while on bedrest. Leg exercises are easier if the patient is in a supine position with the head of the bed slightly raised to relax abdominal muscles. Leg exercises (figure 8-8) should be individualized using the following guidelines.

(a) Flex and extend the knees, pressing the backs of the knees down toward the mattress on extension. (b) Alternately, point the toes toward the chin (dorsiflex) and toward the foot of the bed (plantar flex); then, make a circle with the toes. (c) Raise and lower each leg, keeping the leg straight. (d) Repeat leg exercises every 1 to 2 hours. Ambulate the patient as ordered.(a) Provide physical support for the first attempts. (b) Have the patient dangle the legs at the bedside before ambulation. (c) Monitor the patient's blood pressure while he dangles.  (d) If the patient is hypotensive or experiences dizziness while dangling, do not ambulate. Report this event to the supervisor.  

 Urinary SystemPatients who have had abdominal surgery, particularly in the lower abdominal and pelvic regions, often have difficulty urinating after surgery. The sensation of needing to urinate may temporarily decrease from operative trauma in the region near the bladder. The fear of pain may cause the patient to feel tense and have difficulty urinating. 1. If the patient does not have a catheter, and has not voided within eight hours after return to the nursing unit, report this event to the supervisor.2. Palpate the patient's bladder for distention and assess the patient's response. The area over the bladder may feel rounder and slightly cooler than the rest of the abdomen. The patient may tell you that he feels a sense of fullness and urgency.3. Assist the patient to void.(a) Assist the patient to the bathroom or provide privacy.

(b) Position the patient comfortably on the bedpan or offer the urinal. 4. Measure and record urine output. If the first urine voided following surgery is less than 30 cc, notify the supervisor.5. If there is blood or other abnormal content in the urine, or the patient complains of pain when voiding, report this to the supervisor.6. Follow nursing unit standing operating procedures (SOP) for infection control, when caring for the patient with a Foley catheter.  Gastrointestinal SystemInactivity and altered fluid and food intake during the perioperative period alter gastrointestinal activities. Nausea and vomiting may result from an accumulation of stomach contents before peristalsis returns or from manipulation of organs during the surgical procedure if the patient had abdominal surgery. 1. Report to the supervisor if the patient complains of abdominal distention.2. Ask the patient if he has passed gas since returning from surgery.3. Auscultate for bowel sounds. Report your assessment to the supervisor, and document in nursing notes.4. Assess abdominal distention, especially if bowel sounds are not audible or are high-pitched, indicating an absence of peristalsis.5. Provide privacy so that the patient will feel comfortable expelling gas.6. Encourage food and fluid intake when the patient in no longer NPO.7. Ambulate the patient to assist peristalsis and help relieve gas pain, which is a common postoperative discomfort.8. Instruct the patient to tell you of his first bowel movement following surgery. Record the bowel movement on the intake and output (I&O) sheet.9. If nursing measures are not effective, the doctor may order medication or an enema to facilitate

peristalsis and relieve distention. A last measure may require the insertion of a nasogastric or rectal tube.10. Document nursing measures and the results in the nursing notes. 

Integumentary Systemwound irrigations and cultures. In addition to assessment of the surgical wound, you should evaluate the patient's general condition and laboratory test results.  complains of increased or constant pain from the wound, wound edges are swollen or purulent drainage, . Generalized malaise, increased pain, anorexia, and an elevated body temperature and pulse rate are indicators of infection.  further assessment should be made and your findings reported and documented.Important laboratory data include an elevated white blood cell count and the causative organism if a wound culture is done. Staples or sutures are usually removed by the doctor using sterile technique. After the staples or sutures are removed, the doctor may apply Steri-Strip® to the wound to give support as it continues to heal.  There are two methods of caring for wounds: the open method, in which no dressing is used to cover the wound, and the closed method, in which a dressing is applied. The basic objective of wound care is to promote tissue repair and regeneration, so that skin integrity is restores. (a) Advantages. Dressings absorb drainage, protect the wound from injury and contamination, and provide physical, psychological, and aesthetic comfort for the patient. (b) Disadvantages. Dressings can rub or stick to the wound, causing superficial injury. Dressings create a

warm, damp, and dark environment conducive to the growth of organisms and resultant infection.  First, gather needed supplies. Items may be

packaged individually or all necessary items may be in a sterile dressing tray.

 Next, prepare the patient for the dressing change by explaining what will be done, providing privacy for the procedure, and assisting the patient to a position that is comfortable for him and for you.

 Finally, use appropriate aseptic techniques when changing the dressing and follow precautions for contact with blood and body fluids. .

 It is especially important to wash hands thoroughly before and after changing dressings and to follow the Center for Disease Control (CDC) guidelines.

 

Precautions for Contact with Blood and Body Fluids

1. Wear gloves when touching blood, body fluids containing visible blood, an open wound, or non-intact skin of all clients and when handling items or surfaces soiled with blood or body fluids.

2. Wash hands thoroughly after removing gloves and if contaminated with blood or with body fluids that contain visible blood.

3. Take precautions to prevent injuries by needles, sharp instruments, or sharp devices.

4. Do not give direct client care if you have open or weeping lesions or dermatitis.

5. If procedures commonly cause droplets or splashing of blood or body fluids to which universal precautions apply, wear gloves, a surgical mask, and protective eyewear, as appropriate.

GENERAL POSTOPERATIVE NURSING IMPLICATIONS 1. Monitor vital signs as ordered.

2. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection).3. Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock).4. Administer analgesics as ordered.Apply all nursing implications related to the patient receiving analgesics whether narcotic or nonnarcotic, to include the following.

Check each medication order against the doctor's order.

Prepare the medications (check labels, accurately calculate dosages, observe proper asepsis techniques with needles and syringes).

Check the patient's identification wristband to ensure positive identification before administering medications.

Administer the medications. Offer each drug separately if administering more than one drug at the same time.

Remain with the patient and see that the medication is taken. Never leave medications at the bedside for the patient to take later.

Document the medications given as soon as possible.

6. Administer IV fluids as ordered. Maintain and monitor all IV sites. Follow SOP for infection control.7. Participate with the health team in the patient's nutrition therapy.8. Apply all nursing implications related to the patient diets (serving, recording intake, and food tolerance).9. Coordinate with team leader for "take-home" wound care supplies and prescriptions for self-administration.Prepare the patient and the family for disposition (transfer, return to duty, discharge). Supply the patient or family member with written instructions for:10. Document the patient's disposition in the nurse's notes in accordance with unit SOP.

PROVISION OF SAFETY Safety in emergency

Fire:RACE: R – Rescue ( remove clients from the utility )A – Alarm ( Activate Fire alarm. Then report fire)C – Confine ( close doors to confine fire )E – Extinguish ( use extinguisher if available ) Extinguisher: PASSP – Pull the pin while holding the extinguisher uprightA – Aim nozzle at the Base of the fireS – Squeeze the handle firmlyS – sweep the fire  

“Nurses are known to work best under pressure. In this Chapter, Provisions of safety, and emergency management of client’s in biologic crisis will be comprehensively reviewed. A system not only applicable in the examination, but also in the actual clinical experience” FIRE  

Do not use elevator Turn of oxygen and appliances For patients with mechanical Ventilation , do

ambubagging Observe proper transfer techniques for non

ambulatory patients

ElectricalSafety:

avoid overloading any circuitRead warning labels on all equipment

RadiationSafety: Label potentially radioactive material

Principle: Distance: keep distance of at least 3 feet

Time: limit time when doing nursing procedures and communicating with patient ( 5 minutes per contact; total of 30 minute per shift)

Shield : use LEAD apron Never touch radiation implants with bare hands ( use forceps and put in a lead container)

FallsTo prevent falls:

1. Provide adequate lightning2. Eliminate clutter and obstruction in the room3. Personal items should be within reached4. Lock all beds , wheelchairs and stretchers5. Keep bed in low position with side rails up.

Restraints A protective device used to limit physical

activity of a client or a body part Used to immobilize an extremity or

extremities

Types:Physical – involves manual or physical or mechanical device, material or equipmentChemical – use of medications ( e. g. Nueroleptics, sedatives, anxiolytics )

Legal Implication:2 standards for applying restraints:

1. Behavior management standard: if client is a danger to self or others

2. Medical Surgical Care Standard: if it is related to any procedure

The nurse will apply the restraints BUT the physician must see the client WITHIN 1 HOUR for evaluation. Or a written order must be obtained within 24 hoursThe written order, after the evaluation is VALID for 4 HOURSMedical surgical Standard allows until 12 hours for the physician to write the written order

Key Points:

Orders must be renewed daily Ensure that the restraints allow some

movement of the body part Nuerovascular and Circulatory assessment

should be checked every 30 minutes and restraints must be removed every 2 hours to 4 hours ( or according to hospital policy)

 Permission of the client or the family Is required

A restraint must never be applied as a punishment for any behavior or merely for the nurse’s convenience

Pad bony prominence before applying restraints

Never tie the ends to the side rails or to the fixed frame of the bed

Never leave the patient unattended when restraints are removed temporarily

Kinds of RestraintsAdults:

Jacket Restraints Belt Restraints Mitt or hand Restraints Limb Restraints

Infants and Children Mummy restraints and Crib Nets Restraints Elbow Restraints

 

CLIENTS IN BIOLOGIC CRISIS AND FIRST AID Emergency TriageThe purpose of triage is to classify severity of illness or injury and determine priority needs for efficient use of health care providers and resources.

Category: 1. Emergent: Conditions that are life threatening and require immediate attention.

Examples: Cardiopulmonary arrest, pulmonary edema, chest pain of cardiac origin, and multisystem trauma. These patients frequently arrive by ambulance.Treatment must be immediate. 2. Urgent: Conditions that are significant medical problems and require treatment as soon as possible. Vital signs are stable. Examples: fever, simple lacerations, uncomplicated extremity fractures, significant pain, and chronic illnesses such as cancer or sickle cell disease.Treatment may be delayed for several hours if necessary. 3. Nonurgent: Minor illnesses or injuries such as rashes, sore throat, or chronic low back pain. Treatment can be delayed indefinitely 

CPR Guidelines

Trauma in Emergency Setting

PRIMARY SURVEY

Age CardiacCompression Location

Method Depth Compression(rate / minute)

Ventilation: Compression Ratio

Cycles / minute

Neonate Center sternum

2 fingers 1/2–1 120    

Infant <1 yr

Center sternum

2 fingers 1/2–1 100 1 : 5 20

Child 1–8 yr

Center sternum

1 hand (heel)

1–1 ½ 100 1 : 5 20

Adult Lower half, sternum

2 hands 1 1/2–2 100 2 : 30 5

1. Airway maintenance with cervical spine immobilization: Use jaw thrust, clear secretions, and insert artificial airway as needed.2. Breathing:Intubate if needed. Administer high-flow oxygen.3. Circulation with hemorrhage control: Use pressure as needed, establish two large-bore IVs, and draw blood for cross-match.4. Neurologic status: Assess and document LOC, assess pupil reaction to light, and assess for head and neck injuries.5. Injuries: Expose patient to completely assess for injuries.

 As life-threatening problems are identified, each must be dealt with immediately.

  

SECONDARY SURVEYThe secondary survey consists of a history and a complete head-to-toe assessment. The purpose of the survey is to identify problems that may not have been identified as life threatening. If, at any time during the secondary survey, the patient’s condition worsens, return to the steps in the primary survey.1. Take history and complete head-to-toe assessment.2. Splint fractures.3. Insert urinary catheter unless there is gross blood at meatus.4. Assess urinary output and check urine for blood. Insert NG tube (OG if facial fractures are involved).6. Obtain Chest X - ray7. Administer tetanus prophylaxis (see Tetanus Prophylaxis) and antibiotics (question regarding allergies first) if indicated.8. Continue to monitor components under primary survey as well as adequacy of urine output, and document findings. 

Predictable Injury in a Trauma Patient:

 

Trauma InjuriesPedestrian hit by car Head, chest, abdominal injuries fractures of

femur, tibia, andfibula on side of impact

Pedestrian hit by large vehicle or dragged under vehicle

Pelvic fractures

Front seat occupant (lap and shoulderrestraint worn)

Head, face, chest, ribs, aorta, pelvis, and lower abdomen

Front seat occupant (lap restraint only)

Cervical or lumbar spine, laryngeal fracture, head, face,chest, ribs, aorta, pelvis, and lower abdomen

Unrestrained driver Head, chest, abd, pelvis

Front seat passenger (unrestrained,head-on collision)

Fractures of femurs and/or patellas, posterior dislocation of acetabulum

Back seat passenger(without head restraints,rear-end collision)

Hyperextension of neck with associated high cervicalfractures

Fall injuries withlanding on feet

Compression fractures of lumbosacral spine andfractures of calcaneus (heel bone)

Medical Emergencies Increased intracranial PressureIncreased intracranial pressure (ICP) is defined as intracranial pressure above 15 mm Hg. It can result from head injury, brain tumor, hydrocephaly, meningitis, encephalitis, or intracerebral hemorrhage.

 MANIFESTATIONS OF INCREASED ICP

• Headache• Change in level of consciousness• Irritability• Increased systolic BP• Decreased HR (early)• Increased HR (late)• Decreased RR• Hemiparesis• Loss of oculomotor control• Photophobia (light sensitivity)• Vomiting (with subsequent decreased

headache)• Diplopia (double vision• Papilledema (optic disk swelling)• Behavior changes• Seizures· Bulging fontanel in infants

 MANAGEMENT OF INCREASED ICPIncreased ICP should be treated as a medical emergency

1. Elevate head of bed 15 to 30 degrees. Keep head in neutral alignment. Do not flex or rotate neck.2. Establish IV access.3. Insert Foley catheter. (Output may be profound if diuretic is given.)4. Meds that may be used include osmotic diuretics, sedatives, neuromuscular blocking agents, corticosteroids, and anticonvulsants.5. Restrict fluids.6. Closely monitor vital signs and perform neuro checks. Monitor fluids and electrolytes (diuretic

administration can predispose the patient to hypovolemic shock).7. Schedule all procedures (including bathing and especially suctioning) to coincide with periods of sedation.8. Discourage patient activities that result in use of Valsalva’s maneuver.9. Keep environment as quiet as possible.10. Ventilator may be used to maintain PaCO2 between 25–35.11. Ventricular tap may be performed if unresponsive to other measures.12. ICP monitoring via a fiberoptic catheter may be used to continuously assess changes in ICP.

 Rigid Postures (with Neurological Conditions): Medical Emergency:  

Decorticate rigidityDecorticate rigidity: Flexion of the arm, wrist, and fingers, with adduction of upper extremities. Extension, internal rotation, and vigorous plantar flexion of lower extremities indicate lesion in cerebral hemisphere, basal ganglia, and/or diencephalon or metabolic depression of brain function.

Decerebrate rigidityDecerebrate rigidity: Arms are stiffly extended, adducted,and hyperpronated. Legs and feet are stiffly extended withfeet plantar flexed. Teeth may be clenched (may be seenwith opisthotonos). Indicates brain stem pathology andpoor prognosis.

OpisthotonosOpisthotonos: Rigid hyperextension of the spine. The head and heels are forced backward and the trunk is pushed forward.Seen in meningitis, seizures, tetanus, and strychninepoisoning.

SEIZURES:EMERGENCY CARE OF PATIENT DURING SEIZURE ACTIVITY1. If the patient is standing or sitting when seizure begins, ease him or her to the floor to prevent fall.2. Move furniture and other objects on which the patient may injure himself or herself during uncontrolled movements.3. Do not put objects (e.g., tongue blades, depressors) into the patient’s mouth.4. After the seizure, turn the patient to the side and ascertain patency of airway.5. Allow the patient to rest or sleep without disturbance

What to document after seizure: Presence of aura Circumstances in which the seizure activity

occurred Time of the onset of seizure activity Muscle groups involved (and whether

unilateral or bilateral) Total duration of seizure activity VS Behavior after seizure Injury

 

SHOCK 

Type Description Causes Signs and Symptoms

treatment

Anaphylactic shock

Dilation of blood vessels, fluid shifts, edema, and spasms of respiratorytract.

Allergic reaction Respiratory distressHypotensionEdemaRashPale, cool skinConvulsions possible

O2EpinephrineCorticosteroidsAntihistamineIV fluidsAminophylline

Cardiogenic shock

Failure to maintainblood supply to circulatory system and tissues because of inadequate cardiac output.

Acute left or rightventricular failureAcute mitralregurgitationAcute ventricularseptal defectAcute pericardialtamponadeAcute pulmonaryembolismAcute myocardialInfarction

Increased pulse rateWeak pulsesCardiac dysrhythmiasProlonged capillary fill timeCool, clammy skinCyanosisAltered mental ability

IV fluidsO2DopamineNorepinephrineNitroprusside if BPadequateDobutamine

Type Description Causes Signs and Symptoms treatment

Hypovolemic shock

Decrease in intravascularvolume relative to vascular capacity. Results from blood volume deficit of at least 25% and larger interstitial fluid deficit.

HemorrhageVomitingDiarrheaAny excess lossof body fluids

HypotensionDecreased pulse pressureTachycardiaRapid respiratory ratePale, cool skinAnxiety

Control bleedingIV fluids (Replacetype F&E lost ifknown.)O2Elevate legsVolume expanders

Neurogenic shock

Increase in vascularcapacity and subsequent decrease in blood volume: space ratio resulting from profound vasodilation.

AnesthesiaSpinal cord injury

HypotensionBradycardiaBounding pulsePale, warm, and dry skin

Supine positionO2IV fluidsPossiblyVasopressors

Septic shock Circulatory failure and impaired cell metabolism associated withsepticemia. Divided into “early warm” (increased cardiac output) and “later cold” (decreasedcardiac output).

Endotoxins released most commonly bygram-negative organism

Elevated temperatureFlushed, warm skinVasodilation (early)Vasoconstriction (late)Decreased WBC at firstNormal urinary output (early)Decreased urinary output(late)

O2IV fluidsCulture, e.g., blood,urine, sputum,wounds.AntibioticsPossiblyvasopressors

FRACTURES 

Signs and Symptoms Obvious deformity (in alignment, contour, or

length) Local and/or point tenderness that increases

in severity until splinting Localized ecchymosis Edema Crepitus (grating sound) on palpation False movement (unnatural movement at

fracture site) Loss of function related to pain

 

First Aid ManagementAssess and document:

AlignmentWarmthTendernessSensationMotionCirculatory status distal to injuryIntactness of skin

Cover open fractures with a sterile dressing.Remove rings from fingers immediately if upper extremity is involved. (Progressive swelling may make it impossible to remove rings without cutting).Splint injured extremity.Never attempt to force bone or tissue back into wound.

Elevate injured extremity and apply ice (do not apply ice directly to skin).

Assess for and document frequently the five Ps:

 PainPulselessnesPallorParalysisParesthesia (e.g., numbness, burning, tingling)

 TYPES OF FRACTURES 

BURNS

 American Burn Asso. Classification of Burns:

Classification Description1st Degree Burn involves epidermis only

Erythematous and painful skinLooks like sunburn

2nd Degree Burn Superficial partial thicknessExtends beyond epidermis superficially into dermisRed and weepy appearanceVery painfulFormation of blistersDeep partial thicknessExtends deep into dermisMay appear mottledDry and pale appearance

3rd Degree ( Full Thickness )

Extends through epidermis, dermis, and into subcutaneoustissues• Dry, leathery appearance• May be charred, mottled, or white• If red, will not blanch with pressure• Painless in the center of the burn

Minor Second-degree burns over _15% BSA (body surface area) for adult or < 10% BSA for child• Third-degree burns of 2%

Moderate Second-degree burns over 15 to 25% BSA for adult or 10 to 20% BSA for child• Third-degree burns of 2% to 5% BSA• Burns not involving eyes, ears, face, hands, feet, or perineum

Major Second-degree burns >25% BSA for adult or > 20% BSA for child• Third-degree burns ≥ 10% BSA• All burns of hands, face, eyes, ears, feet, or perineum• All inhalation injuries• Electric burns• All burns with associated complications of fractures or other trauma• All high-risk patients (with such conditions asdiabetes, COPD, or heart disease)

First Aid Management of Burns1. First, evaluate respiratory system for

distress or smoke inhalation (any abnormal respiratory findings in rate, effort, noise, or observations of smoky odor of breath or soot in nose or mouth).

2. Assess cardiovascular status. (Look for symptoms of shock.)

3. Assess percentage and depth of burns, as well as presence of other injuries.

4. Flush chemical contact areas with sterile water; 20 to 30 minutes of flushing may be needed to remove chemical. Fifteen to 20 minutes of normal saline irrigation is preferable for chemical burns to eyes. Contact lens must be removed prior to eye irrigation.

5. Insert IV line(s) for major and some moderate burns. (Establish more than one large-bore IV site if possible.) Attempt to insert IV(s) in unburned area(s).

6. Weigh patient to establish baseline and assist in determination of fluid needs.

7. Fluid resuscitation with Ringer’s lactate or Hartmann’s solution for the first 24 hours as

follows:4 mL fluid x kilograms of body weight x percent of burned BSA. Administer 1/2 of fluid in first 8 hours.Administer 1/4 of fluid in second 8 hours.Administer 1/4 of fluid in third 8 hours.

NOTE: Time is calculated from time of injury, not time of admission.

8. Administer analgesics as indicated.9. Remove easily separated clothing. Soak any

adherent clothing to facilitate removal.

NOTE: Keep patient warm. Removal of clothing may result in rapid and dangerous drop in temperature.

10. Cover burn area with sterile dressing.

11. Put on Hold NPO until function of GI system is evaluated.

12. Insert NG tube for gastric decompression if indicated.

13. Insert Foley catheter (to monitor urine output) for severe and some moderate burns.

14. Assess need for and administer tetanus prophylaxis

15. Frequently monitor vital signs (be aware that patients who have inhaled smoke are subject to progressive swelling of the airway for several hours following injury), ABGs, and serum electrolytes.

16. Monitor urine output and titrate fluids to maintain: 30 to 50 mL urine/h in the adult;0.5 to 2 mL urine/kg of body weight/h in the child

 Tetanus Prophylaxis

Td: Tetanus and diphtheria toxoids adsorbed (for adult use).

TIG: Tetanus immune globulin (human).For children younger than 7 years old,

diphtheria and tetanus toxoids and pertussis vaccine adsorbed (or diphtheria and tetanus toxoids adsorbed, if pertussis vaccine is contraindicated) is preferable to tetanus toxoid alone.

For persons 7 years old and older, Td is preferable to tetanus toxoid alone.

 

POISONING

Management:1. Focus initially on the ABCs of life support:

A - Establish and maintain airway.B - Assess RR, and provide oxygen and respiratory support PRN.C - Assess HR and BP, establish IV access, and keep warm (shock may occur).

2. Attempt to identify poison.3. Contact poison control center for directions4. Vomiting is to be induced only if the patient is conscious and nonconvulsive and only if the ingested substance is noncorrosive (corrosives will further damage esophagus if vomited and may also be aspirated into the lungs). Vomiting may be induced by tickling the back of the throat or administering ipecac syrup in the following dosages:

Ipecac syrup (PO)Child under 1 year: 5–10 mL followed by 100 to 200 mL waterChild 1 year or older: 15 mL followed by 100 to 200 mL waterAdult: 15 mL followed by 100 to 200 mL waterDose may be repeated after 20 minutes if patient does not vomit.

5. Gastric lavage with NG tube can be used to remove poison but must not be attempted if corrosive has been ingested (corrosives severely damage tissue and NG tube may cause perforation). Corrosives include strong acids and alkalies such as drain cleaners, detergents, and many household cleaners as well as strong antiseptics such as bichloride of mercury, phenol, Lysol, cresol compounds, tincture of iodine, and arsenic compounds.6. Corrosives should be diluted with water and the poison control center contacted immediately. Activated charcoal may be given via NG tube. Destructionand/or swelling of esophageal and airway tissue is likely with corrosive ingestion.7. Monitor respiratory status closely.8. If several hours have passed since poison ingestion, large quantities of IV fluids are given to

promote diuresis. Peritoneal dialysis or hemodialysis may be required.9. Continue ABCs of life support and monitor fluids, electrolytes, and urine output. Chemical Eye Contamination:Flush eye with sterile water for 15 to 20 minutes, allowing water to drain away from uncontaminated eye.

Respiratory acidosisTreat underlying causeIV fluidsBronchodilatorsMechanical ventilationO2

Metabolic acidosisCorrect underlying causeIV sodium bicarbSeizure precautionsMonitor and correct electrolyte imbalances

Respiratory alkalosisTreat underlying causeBreathe into paper bag to > PaCO2Sedatives and calm environment

Metabolic alkalosisCorrect causeIV normal salineIV potassium, as indicatedSeizure precautionsMonitor and correct electrolyte imbalances

 

EMERGENCY MANAGEMENT OF OB PATIENTS ASK

Due date?

Contractions?Frequency?Duration?Ruptured BOW?Bleeding?Number of previous pregnancies (gravida)?Number of births (pararity)?Problems with past deliveries?Problems with pregnancy?Has the baby moved today?

OBSERVESize of abdomenFundal heightPresentation (cephalic or breech)Fetal heart tones (not assessed if birth is imminent)

Signs of Imminent Birth Mother is experiencing tension, anxiety,

diaphoresis, and intense contractions. With a contraction, the mother catches her

breath and grunts with involuntary pushing (with inability to respond to questions).

A blood “show” is caused by a rapid dilatation of the cervix.

The anus is bulging, evidencing descent. Bulging or fullness occurs at the perineum.

“Crowning” of the head at the introitus of a multiparous mother means that the birth is very imminent. In nulliparous birth, it means that the birth may be up to 30 minutes later. (Birth is near when the head stays visible between contractions.)

 What to do What NOT to doKeep calm.Allow the baby to emerge slowly.Clear the airway.Dry the baby off.Hold the baby at or slightly above the level of introitus.Put the baby next to the mother’s skin and allow nursing.

Do not put your fingers into the birth canal.Do not force rotation of the baby’s head after the head emerges.Do not try to pull out the baby’s arm.Do not overstimulate the baby by slapping.

Wait for the placenta to separate.Inspect the placenta for completeness

Do not put traction on the cord or pull on the cordDo not hold the baby up by the ankles.Do not allow the baby to become cold.Do not hold the baby below the mother’s perineum.Do not “strip” or “milk” the umbilical cord.Do not push on the uterus to try to deliver the placenta.Do not cut the cord unless you have sterile equipment.Do not allow the mother’s bladder to become distended.

Domestic Violence

Clues of abuse in patient history:• frequent injuries reported as “accidental”• history of repeated miscarriages• vague or changing description of pain or injury• lack of patient cooperation during collection of subjective and/or objective data

Common sites of injuries caused by physical abuse:

• head and neck (most common)• breasts• chest· abdomen

 Signs of possible abuse:

• multiple injuries• bilateral distribution of injuries• injuries at different stages of healing• fingernail marks• bruises shaped like a handprint or instrument• rope burns• cigarette burns• bites

• spiral fractures• burns

Appropriate nursing actions:1. Question and examine the patient in privacy.2. Assure confidentiality.3. Examine entire body.4. Ask specific questions related to suspected

abuse5. Be aware that the perpetrator may retaliate if

exposed by the patient.6. Encourage patient to seek shelter if abuse is

suspected.7. Give patient contact information for

community resources.8. Call law enforcement immediately if violence

is threatened (do not warn the perpetrator of this action).

 Defibrillation:To terminate ventricular fibrillation by electric countershock. 

Synchronous contershockIndications:

• Ventricular fibrillation• Pulseless ventricular tachycardia

NOTE: CPR efforts should be enacted during preparation for defibrillation.

METHOD1. Place two gel pads on the patient’s bare

chest or apply gel to entire surface of paddles. (To prevent burns and improper conduction, remove gel from your hands and the sides of the paddles, and remove any gel that may have fallen on the patient’s chest.)

2. Temporarily discontinue oxygen (if applicable).

3. Apply one electrode below right clavicle just to the side of the upper sternum.

4. Apply second electrode just below and lateral to left nipple.

5. Set defibrillator at 200 joules (J) 6. Grasp paddles by insulated handles only.7. Give “Stand Clear” command, and ascertain

that no one is touching patient or bed.

8. Push discharge buttons in both paddles simultaneously, using pressure to ensure firm contact with the patient’s skin.

9. Remove paddles and assess patient and ECG pattern.

10. Successive attempts at defibrillation may deliver 200 to 300 J, then 360 J.

Energy levels for biphasic models are 50 J, 100 J, 150 J.

AHA recommends that, if three rapidly administered shocks fail to defibrillate, CPR should be continued, IV access accomplished, epinephrine given, and then shocks repeated.

Automatic External DefibrillatorUsed in prehospital setting

CardioversionTreatment for arrhythmiasThe procedure restores the normal heart rate and rhythm, allowing the heart to pump more effectively.

Synchronized countershockThe defibrillator is synchronized to the client’s R wave Oxygen should be stopped during the procedure

PacemakersTemporary or permanent device that provides electrical stimulation and maintains heart rate when the intrinsic pacemaker fails

Types:

1. Synchronous / demand Pacemaker- Paces only if the client’s intrinsic rate

falls below the set pacemaker rate2. Asynchronous or Fixed Rate

- Paces at preset rate regardless of client’s intrinsic rhythm

 

GRIEF, LOSS, DEATH and DYING 

LossActual or potential situation where in something valued is changed / lost / goneThat something can be: significant others, job, sense of well being, security etc Types of Loss1. Actual- Can be recognized by others

2. Perceived- Only the “ self ” can experience- Cannot be verified by others

3. Anticipatory- Experienced before the actual loss- Loss can be situational or developmental Sources of Loss▪ Aspect of Self ( physiologic function / psychologic , body part)▪ External to oneself▪ Separation from accustomed environment▪ Loss of loved or Valued person 

Grief- Response or reaction to loss- Bereavement- Subjective Response- Mourning- Behavioral Response

 Types of Grief Responses:1. Abbreviated Grief- Genuinely felt grief but brief

2. Anticipatory Grief

- Grieving in advance

3. Disenfranchised Grief- Unable to acknowledge the loss to other people- Examples are unacceptable loss that cannot be spoken about like suicide, abortion

4. Dysfunctional Grief- Pathologic grieving

5. Unresolved Grief- Extended / lengthy and severe grieving- May deny loss or grieve beyond expected time

6. Inhibited Grief- Suppressed grieving Stages of Grieving 

Death and Dying

KÜbler Ross Engel Sander

Denial“ No! not me”

Shock and Disbelief(accepts situation but denies emotionally)

Shock

Anger“why me?”

Awareness 

Awareness of Loss 

Bargaining“if only I could live a little longer.”

Restitution( do rituals of mourning)

Conservation/Withdrawal(social withdrawal/ needs time to be alone)

Depressionsilence

Resolving Loss 

Healing: The turning point (acceptance)

Acceptance“I’m ready”

Idealization Renewal(new self – awareness; learning to live independently without loved ones)

Outcome

Concept of DeathInfancy to 5 years - no concept of death5 -9 years old – begins to understand death; death is final9-12 years old – death as inevitable and end of lifeHeart – lung death

Indications of death:- Total lack of response to external stimuli, no

muscular movement and reflexes, flat brain waves and ECG (asystole)

- Cerebral death or higher brain death- When cerebral cortex( this is the brain

center) is irreversibly damaged  

Legal Aspects Related to DeathAdvance Health Care DirectivesVariety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become incapable of verbalizing their care preference

2 types:Living Will- Provides specific instructions about what

medical treatments the client choose to refuse in the event that the client is incapable of making decisions

Health Car Proxy- Durable Power of Attorney for Health Care- Notarized / witnessed statement appointing

SOMEONE ELSE (relative or friend) to manage health care treatment and decisions when the client is incapable of doing so.

 EuthanasiaMercy killingAct of painlessly putting to death persons suffering from incurable / terminal/ distressing disease

Autopsy

Postmortem examinationDone in certain cases where death is sudden to know the cause of death and in some legal cases

Do – Not – Resuscitate OrdersDNR / no Code

Ordered by physician when the client / health care proxy has verbalized the wish for no resuscitation when the client will have respiratory or cardiac arrest

DNR indicates that the goal of treatment is a comfortable dignified death and further life sustaining interventions will not be done to patients any longer. 

Nursing Responsibility in Dying Patients 

1. Assisting the client to a peaceful death. Done by helping clients die with dignity

2. Maintaining humanity , consistent with the client’s values, beliefs and culture

3. Suggesting/introducing options available like location of care (at home or hospital)

4. Support client’s will and hope because dying clients often strive for self fulfillment more than for self preservation.

5. Meeting Physiologic Needs of the dying client

Airway clearance Hygiene / bathing Nutrition Urinary and fecal elimination

6. Providing spiritual support7. Facilitating expressions of feelings and

emotions about death8. Arranging an appointment with a clergy or a

spiritual adviser if the client wishes to.9. Supporting Family10. Use of therapeutic communication for the

family to be able to express feelingsHospice CareCurrent trend in nursing careCommon setting : home or in a nursing home

Goal: facilitates peaceful and dignified deathEligible for hospice care are those diagnosed / predicted to die within 6 months   InterventionRigor Mortis(stiffening of the body; starts in the involuntary muscles like the heart etc.)( 2 – 4 hours after death)

Position the body naturally (in natural / neutral manner)Place dentures (if there is)Close eyes and mouth

Algor Mortis(gradual decrease of temperature)

Livor Mortis( discoloration of the body)

Post Mortem Care

Stages of PMC 

1. Do post mortem care according to hospital policy

2. Identify religious belief of clients3. All equipment, tubes, supplies must be

removed4. A pillow is placed under the head and

shoulders to prevent discoloration in the face

5. A complete bath is not necessary ( the mortician will do the bathing

6. Identification band should be attached before the body is taken to the morgue

7. A shroud is used to wrap the body 8. Must Know for Nurses in caring for dying

Clients: Identify personal feelings about death

and how they can affect when caring for dying patients

Focus on client’s needs Ask client and family support about the

client’s usual coping with stress Provide caring and genuine concern

Acknowledge the client’s feelings and struggles

Be honest with the client especially on questions about death

Have an available time for the client to be able to listen, support and interact with him / her.

9. Document intake and output measurements; color, appearance, and amount of urinary drainage; and patient’s response to procedure.

10. When a new container of TPN is needed, but is not available, follow agency policy to maintain the ordered fluid delivery rate with D10W until the TPN is available. (High glucose content of fluid stimulates release of insulin, which may cause hypoglycemia if fluids are discontinued abruptly.)

11. Do not attempt to “catch up” on fluids if rate inadvertently slows.

12. Discontinue TPN solution gradually at the end of therapy to prevent hypoglycemia.

13. Monitor lab values. (Liver complications, electrolyte imbalances, and pH changes are possible.)