fundamentals of nursing - by darius candelario

7/27/2019 Fundamentals of Nursing - By Darius Candelario

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Fundamentals of Nursing

Professor Darius J. CandelarioRM,RN, MAN, MSN,

US-RN #026-0031609 Vermont &Florida


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NURSING

Nursing is an art & a science. It is the

diagnosis and treatment of human responses toactual and potential health problems. Earlieremphasis was on care of the sick; now promotion ofhealth is being stressed

-ANA, Alfaro,R.

The unique function of the nurse is to assistthe individual, sick or well, in the performance ofthose activities contributing to health, its recovery,or to a peaceful death. The client will perform theseactivities unaided if he had the necessary strength,

will or knowledge. Nurses help the client gainindependence as rapidly as possible-Virginia Henderson,ICN


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THEORETICAL MODELS OF NURSING

PRACTICE

A. NIGHTANGLES THEORY (mid-1800) : Focuseson the patient and his environment.

Developed and described the first theory ofnursing. She focused on changing and

manipulating the environment in or

der to putthe patient in the best possible conditions fornature to act. She believed that in thenurturing environment, the body could repairitself. Clients environment is manipulated toinclude appropriate noise, nutrition, hygiene,

socialization and hope.


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B. PEPLAU, HILDEGARD (1951) : Introduced the

Interpersonal ModelDefined nursing as a therapeutic, interpersonal

process which strives to develop a nurse- patientrelationship in which the nurse serves as a resource

person, counselor and surrogate.

Four Phases of the Nurse-Client Relationship:

1. Orientation: the nurse and the client initially do not

know each others goals and testing the role eachwill assume. The client attempts to identifydifficulties and the amount of nursing help that isneeded.


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2.Identification: the client responds to help

professionals or the significant others who canmeet the identified needs. Both the client andthe nurse plan together an appropriateprogram to foster health.

3. Exploitation: the clients utilize all available

resources to move toward a goal of maximumhealth functionality.4.Resolution: refers to the termination phase of

the nurse-client relationship. It occurs whenthe clients needs are met and he/she can

move toward a new goal. Peplau furtherassumed that nurse-client relationship fostersgrowth in both the client and the nurse.


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C. ABDELLAH, FAYE G. : Introduced Patient Centered

Approaches to Nursing ModelD. ORLANDO, IDA : Three elementsclient behavior,nurse reaction & nurse actions compose thenursing situation

E. LEVINE, MYRA : Believes nursing intervention is a

conservation activity, with conservation of energy asa primary concern, four conservation principles ofnursing includes: conservation of client energy,conservation of structured integrity, conservation ofpersonal integrity, conservation of social integrity.

F. JOHNSON, DOROTHY : Focuses on how the clientadapts to illness; the goal of nursing is to reducestress so that the client can move more easilythrough recovery.


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G. ROGERS, MARTHA : Considers man as a unitary humanbeing co-existing with in the universe, views nursingprimarily as a science and is committed to nursingresearch.

H. OREM, DOROTHEA : Developed the Self-Care DeficitTheory. She defined self-care as the practice ofactivities that individuals initiate to perform on their

own behalf in maintaining life, health well-being.I. IMOGENE KING : Nursing process is defined as dynamicinterpersonal process between nurse, client and healthcare system. Postulated the Goal AttainmentTheory. Described nursing as a helping profession thatassists individuals and groups in society to attain,

maintain, and restore health. If is this not possible,nurses help individuals die with dignity.


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J. BETTY NEUMAN: Stress reduction is a goal of system model

of nursing practice. Nursing actions are in primary,secondary or tertiary level of prevention.

K. SIS CALLISTA ROY (Adaptation Theory): Views the client asan adaptive system. The goal of nursing is to help the

person adapt to changes in physiological needs, self-

concept, role function and interdependent relations duringhealth and illness.

L. LYDIA HALL: Introduced the model of Nursing: What Is it? Itfocuses on the notion that centers around three

components of CARE, CORE and CURE. Care representsnurturance and is exclusive to nursing. Core involves thetherapeutic use of self and emphasizes the use ofreflection. Cure focuses on nursing related to thephysicians orders. Core and cure are sharedwith the other

health care providers.


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M. Virginia Henderson : Introduced The Nature of

Nursing Model. She identified fourteen basic needs.She postulated that the unique function of the nurse isto assist the clients, sick or well, in the performance ofthose activities contributing to health or its recovery,the clients would perform unaided if they had the

necessary strength, will or knowledge.N. Madaleine Leininger(1978, 1984): Developed the

Trans-cultural Nursing Model.

O. Ida Jean Orlando (1961) : Conceptualized the Dynamic

Nurse Patient Relationship Model.P. Ernestine Weidanbach (1964) : Developed the Clinical

Nursing A Helping Art Model.

Q. Jean Watson (1979-1992): Introduced the theory of

Human Becoming


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S. Josephine Peterson and Loretta Zderad (1976):Provided the Humanistic Nursing PracticeTheory.

T. Helen Erickson, Evelyn Tomlin, and Mary AnnSwain (1983) :Developed Modeling and RoleModeling Theory.

U. Margaret Newman : Focused on health asexpanding consciousness. She believed thathuman are unitary in whom disease is amanifestation of the pattern of health. Shedefined consciousness as the informationcapability of the system, which is influenced bytime, space movement and is ever expanding.


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Moral TheoriesFreud (1961)

Believed that the mechanism for right and wrongwithin the individual is the superego, or conscience. Hehypnotized that a child internalizes and adopts themoral standards and character or character traits of themodel parent through the process of identification. Thestrength of the superego depends on the intensity of thechilds feeling of aggression or attachment toward the

model parent rather than on the actual standards of theparent.

Erikson (1964)Eriksons theory on the development of virtues or

unifying strengths of the good man suggests thatmoral development continuous throughout life. Hebelieved that if the conflicts of each psychosocialdevelopmental stages favorably resolved, then an ego-strength or virtue emerges.


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Kohlberg

Suggested three levels of moral development. Hefocused on the reason for the making of a decision, not onthe morality of the decision itself. At first level called thepremolar or the pre-conventional level, children areresponsive to cultural rules and labels of good and bad,right and wrong. However, children interpret these in

terms of the physical consequences of the actions, i.e.,punishment or reward. At the second level, theconventional level, the individual is concerned aboutmaintaining the expectations of the family, groups ornation and sees this as right. At the third level, peoplemake post-conventional, autonomous, or principal level.At this level, people make an effort to define valid valuesand principles without regard to outside authority or tothe expectations of others. These involve respect for otherhumans and belief that relationships are based on mutualtrust.


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Spiritual Theories

Fowler (1979) :Described the development of faith. He

believed that faith, or the spiritual dimensionis a force that gives meaning to a persons life.

He used the term faith as a form of knowinga way of being in relation to an ultimateenvironment. To Fowler, faith is a relationalphenomenon: it is an active made-of-being-

in-relation to others in which we investcommitment, belief, love, risk and hope.


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ROLES AND FUNCTIONS OF THE NURSE

1. Caregiver 2. Teacher

3. Counselor 4. Coordinator 5. Leader 6. Role Model7. Administrator 8. Decision-maker9. Protector 10. Client Advocate11. Manager12. Rehabilitator13. Comforter14. Communicator


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CONCEPTS OF HEALTH AND ILLNESS

HEALTHA state of complete physical, mental andsocial well-being, not merely the absenceof disease or infirmity.A dynamic state inwhich the individual adapts to changes ininternal and external environment tomaintain a state of well-being

- World Health Organization(WHO)


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VARIABLES INFLUENCING HEALTH BELIEFS

AND PRACTICES

I NTERNAL VARIABLES1. Developmental Stage

2. Intellectual Background

3. Perception of functioning

4. Emotional and Spiritual Factors

EXTERNAL VARIABLES

1. Family practices

2. Socioeconomic Factors

3. Cultural Background


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MODELS OF HEALTH AND ILLNESS

1. HEALTH-ILLNESS CONTINUUM (NEUMAN)

- Degree of client wellness that exist at anypoint in time--ranging from an optimalwellness condition, with available energy atits maximum--to death, which representstotal energy depletion.

- Dynamic state that continuously alters as aperson adapts to changes in the internal &external environment to maintain a state ofphysical, emotional, intellectual, social,developmental & spiritual well- being.


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2. HIGH-LEVEL WELLNESS MODEL (HALBERT DUNN)

- The high-level wellness model is orientedtoward maximizing the health potential of anindividual. This model requires the individualto maintain a continuum of balance and

purposely direction within the environment. Itinvolves progress toward a higher level offunctioning, an open-ended and ever-expanding challenge to live at the fullest

potential. Last, there is continued integrationof health practices by the individual atincreasingly, higher levels throughout life.


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3. AGENT-HOST-ENVIRONMENT MODEL (LEAVELL)

The level of health of an individual or group

depends on the dynamic relationship of the

agent, host and environment.

a. AGENT is any internal or external factor that by itspresence or absence can lead to disease or illness.

b. HOST is the person or persons who may be

susceptible to a particular illness or disease. Host

factors are physical or psychosocial situations orconditions putting an individual or group at risk for

becoming ill.


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c. ENVIRONMENT consists of all factors

outside of the host, physical

environment includes economic level,

climate, living conditions, and elements

such as light and sound levels. Socialenvironment consists of factors involving

a persons or groups interaction with

others, including stress conflicts withothers, economic hardships and life

crises such as the death of a spouse.


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4. HEALTH-BELIEF MODEL (HBM)- Addresses the relationships between apersons belief and behaviors. It provides away of understanding and predicting howclients will behave in relation to their healthand how they will comply with health caretherapies.

FOUR COMPONENTS:a. The individuals perception of susceptibility to an

illness.For example, a clients needs torecognize the familial link for coronary arterydisease. After this link is recognize, particularlywhen one parent and two siblings have died intheir fourth decade from myocardial infarction,the client may perceive the personal risk ofheart disease.


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b. The individuals perception of the seriousness of the

illness.- this perception is influenced and modified bydemographic and sociophysiological variables,perceived threats of the illness and cues to action

(for example, mass media campaigns and advicefrom family, friends, and medial professionals)

c. The perceived threat of a disease.

- this perception refers to beliefs a person holds

about whether or not a disease poses a real threatto him. Perceived threat is influenced by certaincues to action in relation to health (e.g. mass-mediacampaigns, advice from others or a reminder apostcard from a dentist or physician).


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d. The perceived benefits of taking preventive action.

- This perception refers to beliefs a person holdsabout the effectiveness of preventive action hemight take to prevent illness. Perceived barriers totaking preventive action may relate, for example, towhatever the person believes stands in his way. For

example, a barrier to seeing a dentist regularly toprevent tooth decay may be a persons intense fearthat the procedure is very painful.

5. EVOLUTIONARY-BASED MODEL

- illness and death serves as an evolutionaryfunction.

- Evolutionary viability reflects the extent to whichindividuals function to promote survival and well-being.


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6. HEALTH PROMOTION MODEL

- A complimentary counterpart to models of healthprotection

- Directed at increasing a clients level of well-being.

- Explains the reasons for clients participation inhealth-promotion behaviors.

The model focuses on three functions:

It identifies factors (demographic and social) thatenhance or decrease the participation in healthpromotion.

It organizes cues into a pattern to explain thelikelihood of a clients participation in health-promotion behaviors.

It explains the reasons that individuals engage inhealth activities.


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THE THREE LEVELS OF

PREVENTION

PRIMARY PREVENTION

-Generalized health promotion

specific protection against disease.

It precedes disease or dysfunction

and is applied to generally healthy

individuals or groups.


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Health Promotion

Health Education Good standard of nutrition adjusted

to developmental phases of life Provision of adequate housing &

recreation Marriage counseling and sex

education Genetic screening Periodic selective exams


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Health education about accident andpoisoning prevention, standards of nutritionand of growth and development for eachstage or life, exercises requirements, stressmanagement protection against occupationalhazards, and so on

Immunizations

Risk assessment for specific disease Family planning services and marriage

counseling Environmental sanitation and provision of

adequate housing recreation, and workconditions


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Specific Protection

Use of specific immunizations Attention to personal hygiene

Use of environmental sanitation

Protection against occupational hazards

Protection from accidents

Use of specific nutrients

Protection from carcinogens Avoidance of allergens


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SECONDARY PREVENTIONEmphasizes early detection

disease, prompt intervention, and

health maintenance for individualsexperiencing health problems.

Includes prevention of complications

and disabilities.

E l Di i d P t
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Early Diagnosis and Prompt

Treatment

Case finding measures; individual and mass;

selective examinations Cure and prevention of disease process to prevent

spread of communicable disease, preventcomplications and shorten period of disability

Screening surveys and procedures any type (e.g.,Denver Developmental Screening Test, hypertension

screening) Encouraging regular medical and dental checkup

Teaching self-examination for breast and testicularcancer

Assessing the growth and development of children

Nursing assessments and care provided in home,hospital, or other agency to prevent complications.
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Disability Limitations

Adequate treatment to arrest

disease process and prevent further

complications

Provision of facilities to limit

disability and prevent death


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TERTIARY PREVENTION

Restoration and Rehabilitation

- Begins after an illness, when a defect

or disability is fixed, stabilized, ordetermined to be irreversible. Its focus is

to help rehabilitate individuals & restore

them to an optimum level of functioningwithin the constraints of the disability


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Provision of hospital and community facilities forretraining and education to maximize use of remainingcapacities

Education of the public and industries to userehabilitated persons to the fullest possible extent

Selective placement

Work therapy in hospitals

Use of sheltered colony

Referring a client who has had a colostomy to a supportgroup

Teaching a client who has diabetes to identify andprevent complications

Referring a client with a spinal cord injury to arehabilitation center to receive training that willmaximize use for remaining abilities


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Difference between Health Promotion

and Health ProtectionHealth Promotion

Not disease oriented

Motivated by personal, positive approach towellness

Seeks to expand positive potential for health

Health Protection

Illness or injury specific

Motivated by avoidance of illness

Seeks to thwart the occurrence of insults tohealth and well-being


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Factors Affecting the Nursing Shortage

Aging Nurse Workforce Number of Nurses under 30 decreasing

Number of nurses age 40-49 increasing with 40%older than 50 by 2010

New graduates entering workforce at an older ageand will have fewer years to work

Aging of Nurses Faculty

As nursing faculty retire, nursing programs may havefewer faculty to educate future nurses

Aging Population

- Individuals 65 and older to double between 2000 and2030

- Increasing health care needs of aging population


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Increased Demand for Nurses

- Increased acuity of hospital clients requiringskilled and specialized nurses.

- Shorter hospital stays resulting in transfer ofclients to long term care and communitysettings, creating increased demand for

nurses in the community Workplace Issue

- Inadequate staffing

- Heavy workloads

- Increased use of overtime- Lack of sufficient support staff

- Inadequate recruiting and retaining nurses


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STRESS- Stress refers to tension resulting from changes in theinternal and external environment either: physiologic,

psychologic or social factors.- Stress is the nonspecific response of the body to any

demand made upon it- Modern Stress Theory, Selye,H.

*Stress is always a part of the fabric of life*Stress is not always something to be avoided*Stress does not always lead to distress*Stress may lead to another stress*A stress, whenever prolonged or intense may lead to

exhaustion

*Man, whenever he encounter stress, he tends to adaptto it


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ADAPTATION

- The adjustments that a person makes indifferent situations; individuals reaction to andattempt to deal with stress

Types of AdaptationA. General Adaptation Syndrome (GAS)

- Man, whenever he responds to stress, theentire body is involved- There are many similar manifestations thatcharacterize different disease conditions; andthere are very few specific manifestations thatcharacterize a particular disease. Fever,

weakness fatigue, headache, anorexia, pain areexamples of manifestations that characterizevarious disease conditions.


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Stages of GAS

1. Stage of Alarm (SA)

The person becomes aware of the presence ofthreat or danger.

Levels of resistance are decreased.

Adaptive mechanisms are mobilized (fight-or-flight reaction).

If the stress is intense enough, even at the

stage of alarm, death may ensure. Example:profuse bleeding in amputated limb due tovehicular accident.


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2. Stage of Resistance (SR)

- Characterized by adaptation &parasympathetic nervous system activity.

- Levels of resistance are increased &hormonal levels return to normal.

- The person moves back to homeostasis &stabilization.

3. Stage of Exhaustion

- Results from prolonged exposure to stress

and adaptive mechanisms can no longerpersist.

- Unless other adaptive mechanism will bemobilized, death may ensue.


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Local Adaptation Syndrome (LAS)

- Man may respond to stress through aparticular body part or body organ (e.g.inflammation, backache, headache, diarrhea).

Modes of AdaptationPhysiologic/Biologic Adaptive Mode

- e.g. enlargement of arm and chest musclesamong men whose jobs include heavy lifting;

people who live in countries with veryhot/warm climate develop dark skin. This is dueto overproduction of melanin to protect innerlayers of the skin.


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Psychologic Adaptive Mode

- e.g. use of ego defense mechanismlike denial, rationalization.

Sociocultural Adaptive Mode

- e.g. talking, acting, dressing like topeople in a particular place

Technologic Adaptive Mode

-e.g. nurses learn how to useelectronic devices and computers.


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Homeostasis

- A state of dynamic equilibrium; stability;

balance; constancy; uniformity. It is now

more commonly referred to ashomeodynamics, because it is

characterized by constant change.

It is regulated by negative feedbackmechanism.


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Concepts of Homeostasis(homeodynamics)

(Systemic Physiologic Response to

Stress)

A. Symatho-Adreno-Medullary

Responses (Walter Cannon)

(SAMR or Fight-or Flight Response)


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Stressors:

a. Physical injury

b. Elevated body temp.

c. Dehydration

SNS

(norepinephrine)

Adrenal Medulla

(Epinephrine & norepinephrine)

hypothalamus


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Brain: alertness; restlessnessEyes: dilated pupils; visual perceptionMouth: salivary secretion, thirst & drynessHeart: tachycardia; coronary vasodilation; force of cardiac

contractility; cardiac outputLungs: hyperventilation, bronchodilation

Blood vessels: peripheral vasoconstriction; BPSkin: pallor; diaphoresis; cold, clammy skinLiver: glycogenolysis, & gluconeogenesis; blood glucose

level

Muscles: glycogenolysis; muscle tensionG.I. Tract:gastric motility;HCl secretion; peristalsis;

constipation; flatulence

Spleen: contraction; hemolysisPancreas: secretion. of insulin and pancreatic enzymesUrinary Bladder: relaxation of the detrusor muscles

B Adreno Cortical Response


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B. Adreno

Cortical Response

Stressor: Hypoglycemia

(Blood glucose level = 60 mg/dl. And below)

Hypothalamus

Anterior Pituitary

ACTH

Adrenal Cortex

Glucocorticoid: Increases gluconeogenesis;Increases blood glucose levels

Mineralocorticoid: Retention of sodium and water;

Increase ECF volume Increase BP.

Androgen/Estrogen:

(sex hormones)

h h l


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C. Neurohypophyseal ResponseStressors: Blood loss (hemorrhage, excess loss of body

Hypothalamus

Posterior Pituitary

ADH (antidiuretic)

Kidneys (renal) tubules

Retention of water in the renal

Oliguria

Conservation of

Circulating Volume

Prevention of

Hypovolemic Shock


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Local PhysiologicResponses to StressInflammation involves mobilization of

specific and nonspecific defensemechanism in response to tissue injury

or infection.


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Inflammants: Prevention of Hypovolemic Shock

Mechanical

ChemicalMicrobial

Electrical

1. Vascular Response

-Transitory vasoconstriction followed immediately by vasodilation(due to the release of histamine, bradykinin, prostaglandin E)

Increased Capillary Permeability

Hyperemia:

Redness (rubor)

Heat (calor)

Fluid / Cellular

Cont d


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Exudates

SerousSerosanguinous

Sanguinous

Purulent

Mucoid/catarrhal

Edema

Pain (dolor)

Compression of nerve endings

by edema fluids

Injury to nerve endingsRelease of bradykinin

Impaired function


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Purposes of Inflammation

1. To localize tissue injury

2. To protect tissue from injury

3. To prepare tissue for repair

Cellular Response

Neutrophils. First to be launched at thesite of tissue injury.

Monocytes. Perform phagocytosis inchronic tissue injury.

Lymphocytes. Responsible for immuneresponse.


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Processes Involved:

Marginal/pavementation. Phagocytes line up atthe peripheral walls of the blood vessels.

Emigration/diapedesis. Phagocytes line up at theperipheral walls of the blood vessels.

Chemotaxis. Injured tissues release substances,which exert magnet like force to the phagocytesto bring them to the area of injury.

Phagocytosis. Phagocytes ingest or engulf the

antigens.Healing Process (Reparative Phase)

Regeneration. Involves replacement ofdamaged tissue cells by new cells which areidentical in structure or function.


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Scar Formation. Involves replacement ofdamaged tissue cells by fibrous tissueformation. In the early stage, granulationtissue (pink or red, fragile gelatinous tissue)forms; later in the process, a cicatrix or scarforms because the tissue shrinks and the

collagen fibers contract.

Healing May also be classified as follows:

First Intention: Occurs in clean-cut wound (e.g.

surgical wound). The wound edges areapproximated, there is minimal or no scar tissueformation (also primary intention healing orprimary union)


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Second Intention: Occurs when the

wound is extensive and there is agreat amount of tissue loss (e.g.decubitus ulcer). The repair time is

longer; the scarring is greater (also,secondary intention healing).

Third Intention: Occurs when there is

delayed surgical closure of infectedwound (also, tertiary intentionhealing)

The Systemic Manifestations of
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Sy f f

Inflammation:A. Fever

endogenous pyrogens(prostaglandins, leukotrienes, bacterial endotoxins, interleukin 1)

Hypothalamus

Resetting of the body temperature set-point at a higher level

Increasing heat production/decreasing heat loss

(shivering; sweating is inhibited; vasoconstriction)

Increased production of interferon

(protects the cell from viral invasion)

Increased phagocytic activity


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b. Leukocytosis (elevated WBC)

c. Elevated ESR (erythrocyte sedimentation

rate)

d. Lymphadenopathy

e. Anorexia

f. Headache

g. Body Weakness/Fatigueh. Body Malaise

STRESS MANAGEMENT


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STRESS MANAGEMENT

a. Eat a well balanced diet

b. Get sufficient amount of restc. Exercise regularly

d. Use relaxation methods & techniques

1. Deep breathing2. Guided imagery

3. Progressive relaxation: various musclesgroups in the body are progressively &

systematically tensed & relaxed, from head totoe


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Suggested Steps:1.Focus attention on a particular muscle group

2. Tense the muscle group upon which attention isfocused

3. Maintain muscle tension for 5-7 secs.4. Slowly relax the muscle group while continuingthe focus

5. Repeat these steps for each muscle group in thebody, from head to toe


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4. Meditation: contemplative reflection &thought, & communication w/ self

5. Yoga: system of meditation & mental toattain a balance in the continuum of mend &

body6. Biofeedback: providing information to a

subject about current status of some bodyfunction; goal-gain & maintain control in

real-life circumstancesE. Engage in social support system


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Nursing Responsibilities in

Stress Management

I. To assist client & his family to adapt to stress &

manage it wisely

II. Recommended four guideposts when the nurse

helps the client to manage stress

A. Eliminate as many stressors as possible

B. Teach about both the beneficial anddetrimental effects of stress

C. Teach how to cope & adjust with stress


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NURSING PROCESS

-A deliberate, problem-solving approach tomeeting the health care & nursing needs ofpatients -Sandra Nettina

- The most efficient way to accomplishpersonalized care in a time of explodingknowledge and rapid social change. It assists insolving or alleviating both simple and complexnursing problems. Changing, expanding, more

responsible role demands knowledgeablyplanned, purposeful, and accountable action bynurses

Reasons for documentation of


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Reasons for documentation of

nursing care:

1. Provide evidence of comprehensive andsystematic nursing care

2. Satisfy requirements of regulatoryagencies

3. Provide a legal document that reflectsthe care given to and the progress of thepatient

4. Provide a data base for continuousquality improvement programs


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Steps in the Nursing Process (ADPIE)

1. Assessment : Collection of personal, social, medical,and general data

a. Sources: Primary (client and diagnostic testresults) and secondary (family, colleagues, Kardex,literature)

b. Methodsb.1 Interviewing formally (nursing health

history) and informally during various nurse-client interactions

b.2 Observationb.3 Review of records

b.4 Performing a physical assessment


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Types of Assessment1. Initial Assessment

- Performed within specified time after

admission to health care agency- To establish a complete database forproblem identification, reference, and

future comparison- example: Nursing admissionassessment


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2. Problem-focused assessment- Ongoing process integrated with care

- To determine the status of a specific problem

identified in an earlier assessment

- To identify new or overlooked problems

- example: Hourly assessment of clients fluid

intake and urinary in an ICU.

Assessment of clients ability to perform self-care while assisting a client to bathe


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3. Emergency assessment- During a physiologic or psychologiccrises of the client

- To identify life-threatening problems

- example: Rapid assessment of a personairway, breathing status, and circulationduring a cardiac arrest

Assessment of suicidal for violence


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4. Time-lapsed reassessment- Several month after initial assessment

- To compare the clients current status to

baselines data previously obtained- example: Reassessment of a clients

functionally health patterns in a home

care or outpatient setting or, in a hospital,at shift change


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Example of subjective data:

I feel weak all over when I exert myself.

Client states he has a cramping pain in hisabdomen. States I feel sick to my stomach.

Im short or breath.

Wife states: He doesnt seem so sad todayI would like to see the chaplain before

surgery.


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Examples of objective data:

Blood pressure 90/50

Apical pulse 104

Skin pale and diaphoretic

Vomited 100 mL green-tinged fluid

Abdomen firm and slightly distended

Active bowel sounds auscultated in all fourquadrants

Lung sounds clear bilaterally; diminished in right

lobe Client cried during interview

Holding open Bible

Has small silver cross on bedside table.


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2. Nursing Diagnosis : Definition of client's

problem: making a nursing diagnosisA nursing diagnosis is a definitive statementof the client's actual or potential difficulties,concerns, or deficits that are amenable tonursing interventions .This step is to organize,

analyze and summarize the collected data.There are two components to the statement ofa nursing diagnosis joined together by thephrase "related to"

Part I: a determination of the problem(unhealthful response of client)

Part II: identification of the etiology(contributing factors)


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3. Planning: the nursing care plan, ablueprint for action remembering client

is the center of the health team; client,

family, and nurse collaborate withappropriate health team members to

formulate the plan


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Guidelines:a. Planned intervention may include independent,

interdependent,and dependent functions of thenurse; prescriptions made by physician or alliedhealth professionals may be included

b. New diagnoses should be noted on the nursingcare plan and progress notes as they are

identifiedc. Client outcomes (goals of nursing intervention)

are reflected in expected changes in the clientc.1 Expected client outcome is written next toeach nursing diagnosis on nursing care plan

c.2 These outcomes must be objective, realistic,measurable alterations in the client's behavior,activity, or physical state; a time period should beset for achievement of the outcome


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c.3 The outcome provides a standard of measurethat can be used to determine if the goaltoward which the client and nurse areworking has been achieved

d. Nursing interventions (nursing orders) arewritten for each nursing diagnosis and shouldbe specific to the stated outcome or goal;each goal may have one or more applicableinterventions

4. Implementation: the actual administration ofthe planned nursing care


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5. Evaluation: Outcome and revision of

nursing care plana. Process is ongoing throughout client'streatment/hospitalization

b. If outcome/goal is not reached inspecified time, the client is reassessed todiscover the reason

c. Reordering of priorities and new goalsetting may be necessary

d. When diagnosis/problem is resolved,the date should be noted on care plan

Examples of Critical Thinking in the Nursing Process


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Examples of Critical Thinking in the Nursing Process

Nursing Process

Phase

Critical Thinking Activities

Assessing Making reliable observations

Distinguishing relevant from

irrelevant dataDistinguishing important from

unimportant data

Validating & Organizing data

Categorizing data according to

a framework

Recognizing assumptions


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Diagnosing Findings patterns and relationships

among cuesIdentifying gaps in the data & Making

Inferences

Suspending judgment when lacking

data

Making interdisciplinary connections

Stating the problems

Examining assumptions

Comparing patterns with norms

Identifying factors contributing to the

problem


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Planning Forming valid generalizations

Transferring knowledge from onesituation to another

Developing evaluative criteria

Hypothesizing & Makinginterdisciplinary connections

Prioritizing client problems

Generalizing principles from other

sciences


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Implementing

Evaluating

Applying knowledge to

perform interventionsTesting hypothesis

Deciding whether hypotheses

are correctMaking criterion-based

evaluation

Ad f i


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Advantages of nursing process

1. Encourages thorough individual clientassessment by nurse

2. Determines priority of care

3. Provides comprehensive and systematic nursingcare planning and delivery4. Permits independent, creative, and flexible

nursing intervention5. Facilitates team cooperation by promoting:

a. Contributions from all team membersb. Communication among team membersc. Coordination & Continuity of care


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6. Provides for continuous involvement andinput from client

7. Facilitates the "costing-out" of nursing

services and care

8. Facilitates nursing research

9. Provides accurate legal document of client

care

COMMUNICATION


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COMMUNICATION

Refers to reciprocal exchange of information,

ideas, beliefs, feelings and attitudes between 2

persons or among a group. The need to

communicate is universal. People

communicate to satisfy needs. Clear and

accurate communication among members of

the health team, including the client, is vital tosupport the client's welfare

-Dolores Saxton

Si f L k f C i i


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Signs of Lack of Communication

a. Efforts to change the subject-the client

may not understand what the nurse is

sayingb. Lack of questions

c. Non-Verbal Clues : Blank expression,

lack of eye contact, etc.


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MAINTENANCE OF EFFECTIVE

COMMUNICATION:THE NURSE'S ROLE

A. Be aware that effective communication

requires skill in both sending and receivingmessages

1. Verbal: for example, words and tone of

voice

2. Written

3. Nonverbal: for example, facial expression,

eye contact, and body language


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B. Recognize the high stress-anxiety potential of

most health settings created in part by:

1. Health problem itself, treatments and

procedures

2. Exclusive behavior of personnel3. Foreign environment

4. Change in lifestyle, body image, and self

concept5. Inability to use normal coping skills such as

exercise or talking with friends


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C. Recognize the intrinsic worth of each person

1. Listen, consider wishes when possible, and explain

when necessary2. Avoid stereotyping, snap judgments, and unjustified

comparisons

3. Be nonjudgmental and non-punitive in response andbehavior

D. Be aware that each individual must be treated as awhole person

E. Recognize that all behavior has meaning and usuallyresults from the attempt to cope with stress

1. Be aware of importance of value systems &significance of cultural differences

2. Be sensitive to personal meaning of experiences toclients


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3. Recognize that giving information may not

alter the client's behavior4. Recognize the defense mechanisms that theindividual is using

5. Recognize own anxiety and cope with it

F. Maintain an accepting, open environment

1. Accept the client but set limits on inappropriatebehavior

2. Identify and face problems honestly

3. Value the expression of feelings & benonjudgmental


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G. Recognize the client as a unique person

1. Use names rather than labels such as room

numbers or diagnoses & maintain the client's

dignity

2. Be courteous toward the client, family, andvisitors

3. Permit personal possessions where practical

(e.g., own nightclothes, pictures, and toys)

4. Explain at the client's level of understanding

and tolerance & encourage expression of

feelings


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H. Support a social environment that

focuses on client needs

1. Use problem-solving techniques thatfocus on the client

2. Be flexible in carrying out routines and

policies


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Special Considerations in Communication

Clients with Hearing Loss

Signs of hearing Loss

a. speech deterioration

b. indifference

c. social withdrawal

d. suspicion

e. tendency to dominate conversation


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Nursing Interventions:a. Face client directly, make sure your face is clearlyvisible

b. Before discussion, tell the client the topic you aregoing to discuss

c. Ensure that the client has access to hearing aid and

that it is functionald. Speak slowly and distinctly; do not shout ; keepsentences short and simple

e. Use written information to enhance spoken word ;resort to writing if unable to understand

f. Pay attention when the person speaks;facial & physicalgestures helps understand what the person is saying


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Clients with Aphasia

Aphasia Syndromesa. Wernickes Aphasia : patient speaks readily butspeech lacks clear content, information and direction

b. Anomic or Amnesic Aphasia : speech is almostnormal but marred by word-finding difficulty

c. Conduction Aphasia : comprehension of language isgood but has difficulty repeating spoken material

d. Non-fluent Aphasia : speech is sparse and producedslowly and with effort and poor articulation

e. Global Aphasia: severe disruption of all aspects ofcommunication (verbal, written, reading,understanding)

Nursing Interventions:


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Nursing Interventions:

a. Face client & establish eye contact

b. Use gestures, pictures and communication boards

c. Limit conversations to practical matters

d. Keep background noise to a minimum; keepenvironment simple and relaxed

e. Do not shout or speak loudly; speak at normal rateand volume (patient not hearing impaired!)

f. Give client time to understand and respond; allowplenty of time to answer

g. If clients has problems speaking, ask yes or noquestions


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Client with Stroke

Refers to onset and persistence of neurologicdysfunction lasting for longer than 24 hours andresulting from disruption of blood supply to thebrain

Nursing Interventions

a. Approach the client from the side of intactvision

b. Remind the client to turn head in the directionof visual loss to compensate for loss of visual

fieldc. Explain location of object when placing it nearthe client

d. Always put client care items in same places


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e. Put objects within clients reach and on

unaffected side

f. Encourage client to repeat sounds of the

alphabet

g. Speak slowly and clearlyh. Use simple sentences with questions or pictures

i. Reorient client to time, place and situation

j. Provide familiar objects & minimize distractionsk. Repeat & reinforce instructions


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Clients with Dementia

Dementia is a disturbance involving multiple cognitivedeficits including memory impairment.Primarydementias are degenerative disorders that areprogressive, irreversible and not due to any otherconditions.

Nursing Interventionsa. Be calm & unhurried; identify yourself & address the

person by name each meeting

b. Keep conversations short & focused ; use simple wordsand phrases

c. Do not ask the client to make decisions

d. Be consistent

e. Avoid distractions

f. Use reality oriented techniques


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ELIMINATIONA. Promotion of normal elimination

1. Urination

a. Adequate fluid intake

b. Normal adult urinary output=80ml/hr

2. Bowel eliminationa. Adequate fluid intake

b. Regular exercise

c. Regular fruit juices, raw fruits & vegetables as

neededd. Normal bowel evacuation: varies in healthyindividuals; no more than 3 movts. /day--3X/wk.


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B. Urinary Incontinence: Involuntary release ofurine

Diagnosis of urinary incontinence

a. History & physical examination

b. Urinalysis-tells whether blood or infection

presentc. Cystoscopy- tells whether abnormalities arepresent

d. Post-void residual-measures amount of urine

remaining in bladder after voiding

e. Stress test-determines if urine leaks afterbladder is stressed due to coughing, lifting, etc.


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Treatment

a. Drug therapy Antispasmodic & anticholinergic-relax &increase

capacity of bladder

Alpha-adrenergic agonists-increase urethralresistance

b. Kegel exercises-strengthen weak muscles aroundthe bladder,

*also very effective in preventing Perineallacerations.

c. Behavioral training-client learns different way tocontrol urge to urinate

d. Bladder retraining

e. Surgery-repair of weakened or damaged pelvicmuscles or urethra


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a. Provide skin care, protective undergarmentsb. Establish toileting schedule-provide easy access

to bathroom & privacy

c. Teach client Kegel exercises:

Stop & start urinary stream while voiding

Hold contraction for 10 secs. & relax fro 10 secs.

Work up to 25 repetitions 3X a day

d. Prevent infection

Cleanse urethral meatus after each void

Acidify urine

Increase daily intake of fluids

C. Catheterization


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Purposes Relieve acute urinary retention

Relieve chronic urinary retention

Drain urine preoperatively & postoperatively Determine amount of post-void residual

Accurately measure output in the critically ill

Obtain sterile urine specimen

Continuous or intermittent bladder irrigation


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Types of Catheter & General Guidelinesa. Indwelling Catheter

Use a closed drainage system Advance catheter almost to bifurcation of catheter, esp.in male patients

Inflate balloon w/in guidelines of manufacturer onlyafter urine is draining properly, then slightly w/drawcatheter

Secure catheter to patients thigh, allowing for someslack to accommodate movement & to lessen drag onpatient

Ensure tubing is over patients legCare of indwelling catheter

Cleanse around area where catheter enters urethralmeatus Do this w/ soap & water during the daily bathing routine

& after defecation


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Dont pull on catheter while cleansing

Dont use powder or spray around perineal area Dont open the drainage system

Avoid raising the drainage bag above the level of thebladder

Avoid clamping the drainage tubing

Catheter is only irrigated when an obstruction, usu.Following prostate or bladder surgery (e.g., potentialblood clots) is anticipated

b. Suprapubic Catheter

Placed to drain the bladder Achieved via a percutaneous catheter or by way

of an incision through the abdominal wall


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c. Intermittent Self-catheterization Purpose: to drain the bladder

Employed by the client w/ Spina Bifida & otherneuromuscular diseases; can be taught to children 7-8 yrs.

Procedure: Gather equipment: catheter, water-soluble lubricant,

soap, water, urine collection container Wash hands Cleanse urethral meatus & surrounding area Lubricate tip of catheter Insert catheter until urine flows W/draw catheter when urine flow stops Clean off residual lubricant from meatus Dispose of urine Wash hands

D. Ostomies


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Types of ostomiesa. Ileostomy

Liquid to semi-formed stool, dependent uponamount of bowel removed

May skew fluid & electrolyte balance, especiallypotassium & sodium

Digestive enzymes in stool irritate skinDo NOT givelaxatives

Ileostomy lavage may be done if needed to clear

food blockage May not require appliance set; if continent ileal

reservoir or Koch pouch


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b.Colostomy

Ascending-must wear appliance--semi-liquid stool Transverse-wear appliance--semi-formed stool

Loop stoma

o Proximal end-functioning stoma

o Distal end-drains mucous

o Plastic rod used to keep loop out

o Usually temporary

Double barrel

Two stomas

Similar to loop but bowel is surgically severed


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Sigmoid Formed stool Bowel can be regulated so appliance not

needed May be irrigated

Stoma assessment

a. Color-should be same color as mucous membranes(normal stoma color- Red not dusky or pale: sign ofinfection)

b. Edema-common after surgery. Bleeding-slightbleeding common after surgery


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Prevent complications of mobility1. Skin change-decubitus ulcer

a. Turn client q 2 hrs.b. Use heel/elbow protectorsc. Use alternate pressure mattress or sheepskin

2. Musculoskeletal changesa. Start ROM exercises to affected joints

b. Provide foot board &/or foot cradle (best for gout)c. Position & turn q 2 hrs.

3. Respiratory changes-pneumonia, atelectasisa. Instruct client to cough & deep breathe q 2 hrs.b. Turn q 2 hrs.

c. Suction if needed (tracheostomy suctioning ADULT-maximum 15 seconds; therapeutic 10 seconds, INFANTS 5 to 10 secs.)

d. Chest physiotherapy as needed


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4. Cardiovascular system changesa. Orthostatic / Postural hypotension(sign & symptoms-

dizziness, headache & pallor): Instruct client to changeposition slowly; especially prone to supine or standing.This is commonly seen as a SIDE EFFECT of Vasodilators ,Anti-hypertensives & Anti-cholinergics.

b. Increased cardiac workload: discourage Valsalvamaneuver

c. Thrombus/embolus formation Apply anti-embolic stockings Turn q 2 hrs. Start anti-coagulation therapy if indicated Initiate exercise

5. Urinary changes: renal calculi, UTIa. Increase fluid intake (2000-3000 cc/day)

6. Psychosocial changes: Provide stimuli to maintainorientation


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B. Types of exercise

1. Passive-carried out by the nurse w/out assistance

from client; purpose is to retain joint mobility&circulation

2. Resistive-carried by the client working againstresistance; purpose is to increase muscular strength

3. Isometric-carried out by the client w/ no assistance;purpose is to increase muscular strength

4. Range of Motion (ROM)-joint is moved throughentire range; purpose is to maintain joint mobility

5. Active-performed by the patient; purpose is tomaintain mobility, muscle strength & muscle size


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C. Use of mechanical aids to promote mobility

1. Crutchesa. Support feet and legs during walking

b. Adjust hand bars to allow 15-20 degrees of

elbow flexionc. Use well-fitting shoes with non-slip soles

d. Use rubber suction tips on crutches

e. May be used temporarily or permanently

f. Teach client crutch walking


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2. Cane

a. Provides stability when walking and relieves

pressure on weight-bearing jointsb. Adjust cane w/ handle @ level of greatertrochanter: elbow flexed at 30-degree angle

c. Teach client to hold cane close to body, & holdin hand on stronger side

d. Move cane @ same time as the weaker leg

3. Walker

a. to assist in weight-bearing mobility

b. Teach client how to sit & turn

D. Prosthetic devices-used to replace a missing bodypart

E. Brace-support for weakened muscles


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P A I NA feeling of distress, suffering or agony caused by

stimulation of specialized nerve endings-Patricia Novac

Theories of Paina. Specificity theory proposes that pain can be

initiated only by painful stimuli.

b. Pattern theory-stimulus goes to receptors in thespinal cord, which signals the brain to perceive painand muscles to respond

c. Gate Control Theory-pain impulses can be alteredor regulated by gating mechanisms along nervepathways. This theory explains how past andpresent experiences can influence the perceptionof pain.

Pain Assessment


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Pain Assessment

Influencing factors

Past experience with pain

Age (tolerance generally increases with age) Culture and religious beliefs

Level of anxiety

Physical state (fatigue or chronic illness maydecrease tolerance)

Characteristics of pain


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Characteristics of pain

Location

Quality

Intensity

Timing and duration Precipitating factors

Aggravating factors

Alleviating factors

Interference with Activities of Daily Living Patterns of response

T f P i


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Types of Pain

1. Acute: Self-Limited, has a beginning and an end

lasting up to 6 mos.2. Chronic: Persistent or episodic pain lasting >6 mos.

Medical Treatment

Pharmacologic

Nonpharmacologic Intervention

a. Acupuncture

Oriental method: insert fine needles atspecified body sites

How acupuncture works physiologically:Unknown


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b. Relaxation Techniques-biofeedback, visualization,meditation, hypnosis-to help client control anxiety

c. Electronic Stimulation such as Transcutaneous ElectricNerve Stimulation (TENS)-electrodes applied over thepainful area or along nerve pathway

d. Distraction-focusing clients attention on something

other than paine. Massage-generalized cutaneous stimulation of the body;

makes the client more comfortable due to musclerelaxation

f. Ice and Heat Therapies-effective in some circumstances;ice may decrease the prostaglandins which intensify thesensitivity of pain receptors

g. Guided Imagery-using ones imagination in a guidedmanner to achieve a specific positive effect


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Patient-Controlled Analgesia (PCA)

Type of intravenous pump that allows the client toadminister his own narcotic analgesic (e.g., morphine)on demand within preset dose and frequency limits.

Goal: To achieve more constant level of analgesia ascompared to PRN IM injection. In general, causes less

sedation and lower risk of pulmonary depression.

Used most often for postoperative pain management; alsoused for intractable pain in terminal illness.

PCA pump may be used solely on PCA mode or may becombined with a continuous basal mode where client isreceiving continuous infusion of narcotic in addition toself-administered bolus injections.



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N g v

1. Instruct client in use of PCA pump

a. Demonstrate how to push controlbutton.

b. Explain concept of patient-controlledanalgesia.

2. Frequently assess clients level of

consciousness (LOC), RR, and degree ofpain relief.


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Electrical Stimulation Technique for Pain

Control Transcutaneous ElectricalNerve Stimulator (TENS)

Noninvasive alternative to traditional methods of

pain reliefUsed in treating acute pain (e.g., post-op pain) and

chronic pain (e.g., chronic low back pain

chronic)

1. Consists of impulse generator connected by

wires to electrodes on skin ; produces tingling,

buzzing sensation in the area


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2. Mechanism based on gate-control theory: electrical

impulse stimulates large diameter nerve fibers toclose the gate

a. Dont place electrodes over incision site, broken skin,carotid sinus, eyes, laryngeal or pharyngeal muscles.

b. Dont use in client with cardiac pacemaker.

c. Provide skin care.

remove electrodes once a day; wash area with soap& water, & air dry

wipe area with skin prep pad before reapplying

electrode

assess area for signs of redness; repositionelectrodes if redness persists for more than 30mins.

Nursing Assessment &

Interventions for Pain


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Interventions for Pain

1. Evaluate objectively the nature of the patients pain:location, duration, quality, & impact on daily activities.

2. Use a pain intensity scale of 0 (no pain) to 10 (worstpossible pain). Take careful history of prior & present

medications, response, & side effects.3. Assess relief from medications & duration of relief. (Use

the same measuring scale every time).

4. Base the initial analgesic choice on the patients reportof pain.

5. Administer drugs orally whenever possible; avoidintramuscular injection.

6. Administer analgesia around the clock rather thanPRN.


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7. Convey the impression that the patients pain isunderstood & that the pain can be controlled.

8. Take a careful pain history. Explore pain interventionsthat have been used & their effectiveness. Determine ifthe intensity of the pain correlates w/ the prescribedanalgesic.

9. Reevaluate the pain frequently. The requirement foranalgesia should decrease if other treatment is given,including radiation/chemotherapy.

10. Use alternative measures to relieve pain such asimaging, relaxation, & biofeedback.

11. Provide ongoing support & open communication.

12. Consider referral to a pain specialist for intractable pain.


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13. Provide education.

A. Method of administration of medications &

importance of maintaining prescribed scheduleB. Need to call health professionals if pain hasincreased or occurred in another area of the body

C. Side effects of medication

Constipation-best treated prophylactically

Nausea-antiemetic therapy helpful

Tolerance-increasing doses often required achievingthe same effect. This is a normal physiologicresponse to opioids. Patient reports shorterduration of effect. There is no maximum opioiddose as long as side effects are tolerable.

Addiction usually isnt a problem to needednarcotics.

SLEEP


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- A state of consciousness in w/c the individualsperception & reaction to the environment aredecreased

A. Physiology

1. Reticular Activating System (RAS)-maintains a state ofwakefulness & mediates some stages of sleep. Sleep isan active process involving the RAS & a dynamicinteraction of neurotransmitters.

2. Serotonin is a major neurotransmitter associated w/

sleep. It is derived from its precursor Tryptophan, anaturally occurring amino acid. It decreases activity ofRAS, thereby inducing & sustaining sleep. Otherneurotransmitters-acetylcholine & norepinephrineappear to be required for the REM sleep cycle.


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B. Theories

1. Active Theory of Sleep: proposes that there are centersthat cause sleep by inhibiting other brain centers.

2. Passive Theory of Sleep:states that the RAS simplyfatigues & therefore becomes inactive thus, sleep occurs.

C. Stages

1. NREM (Non-Rapid Eye Movt.) StageA. Very light sleep;drowsy, relaxed; readily awakened-

Stage (St.) 1

B. Light sleep; eyes are still; HR & RR decrease slightly;body temperature falls-St. 2

C.Domination of PNS; body process slows further;difficult to arouse-St. 3

D. Deep sleep; difficult to arouse; V/S; metabolism, brain waves, muscles relaxed-St. 4

2 REM (Rapid Eye Movt ) Stages


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2. REM (Rapid Eye Mov t.)Stages

a. Eyes appear to roll

b. Paradoxical Sleepc. Close to wakefulness but difficult to arouse

d. Dream state of sleep

e. Sympathetic Nervous System dominates

f. Flow of gastric acid increases

g. Restores a person mentally-learning, psychologicaladaptation & memory

h. The sleeper reviews the days events & processes &restores information

D. Functions1. NREM-body restoration

2. REM-increases synthetic processes in the brain


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E. Sleep-promoting Nursing Interventions

1. Warm bath- relaxes muscles, which induces sleep.

2. Drink Milk rich in tryptophan, which induces sleep.

3. Attend to individuals bedtime rituals that promote sleep

4. Emphasize adequate exercise.

*Exercise at least 2 hrs. Before sleep to enhance NREM,

not immediately before sleep.5. Give or advisehigh protein food; they containtryptophan, w/c is a CNS depressant.

6. Assess habits of sleep rhythm & wake-up time.

7. Avoid caffeine & alcohol in the evening.

8. Make sure client goes to bed when sleepy.9. Use the bed mainly for sleep.

10. Be judicious in using minor tranquilizers.

F C Sl Di d


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F. Common Sleep Disorders

1. Insomnia: *difficulty in falling asleep *intermittent sleep

*premature awakening2. Hypersomnia: *excessive sleep (daytime or night time)

*r/t psychologic problems, CNS damage, metabolicdisorders

3. Narcolepsy/Sleep Attack: *overwhelming sleepiness

*REM uncontrolled4. Sleep Apnea: periodic cessation of breathing during

asleep; characterized by snoring

5. Parasomnias

a. Somnambolism/Sleep Walking

b. Night Terrors: After having slept for few hrs., the childbolts upright in bed, shakes & screams, appears pale &terrified.

c. Nocturnal Enuresis/Bedwetting

d. Soliloquy/Sleep-talking

e Bruxism: clenching & grinding of teeth during sleep; may


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e. Bruxism: clenching & grinding of teeth during sleep; mayerode & diminish the height of dental crowns & may causethe teeth to become loose

Physical Assessment

Use the following techniques of examination as appropriatefor eliciting findings:

Inspectiona. Begins with first encounter with the patient and is themost important of all the techniques

b. Is an organized scrutiny of the patients behavior andbody

c. With knowledge and experience, the examiner canbecome highly sensitive to visual clues.

d. The examiner begins each phase of the examination byinspecting the particular part with the eyes.


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Palpation

Involves touching the region or body part just observedand noting what the various structures feel like.

With experience comes the ability to distinguishvariations of normal from abnormal.

Is performed in an organized manner from region to

region.Percussion

By setting underlying tissues in motion, percussion helpsin determining whether the underlying tissue is air filled,fluid filled, or solid.

Audible sounds and palpable vibrations are produced,which can be distinguished by the examiner.

There are five basic notes produced by percussion which can be


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There are five basic notes produced by percussion, which can be

distinguished by differences in the qualities of sound, pitch,

duration, and intensity. These are:Relative

Intensity

Relative

Pitch

Relative

Duration

Example

Location

1. Flatness Soft High Short Thigh

2. Dullness Medium Medium Medium Liver

3. Resonance Loud Low Long Normal lung

4. Hyper

resonance

Very loud Lower Longer Emphysemat

ous lung

5. Tympany 5.

Tympany

Gastric air

bubble or

puffed out

cheek


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c. The technique for percussion may be described asfollows:

1 .Hyperextend the middle finger of your left hand,pressing the distal portion and joint firmly against thesurface to be percussed.

Other fingers touching the surface will damp the

sound. Be consistent in the degree of firmness exerted by

the hyper extended finger as you move it from areato area or the sound will vary.

2. Cock the right hand at the wrist, flex the middle

finger upward, and place the forearm close to thesurface to be percussed. The right hand and forearmshould be as relaxed as possible.


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With a quick, sharp, relaxed wrist motion,

strike the extended left middle finger with theflexed right middle finger, using the tip of thefinger, not the pad. (A very short fingernail is amust!) Aim at the end of the extended leftmiddle finger (just behind the nail bed) wherethe greatest pressure is exerted on the surfaceto be percussed.

Lift the right middle finger rapidly to avoid

damping the vibrations. The movement is atthe wrist, not at the finger, elbow, or shoulder;the examiner should use the lightest touchcapable of producing a clear sound.


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EQUIPMENTThermometer Cotton applicator stick

Sphygmomanometer Stethoscope

Oto-ophthalmoscope Reflex Hammer

Flashlight Tuning Fork

Tongue Depressor Safety Pin

Additional items include disposable gloves and lubricantfor rectal examination and a speculum for examination of

female pelvis

VITAL SIGNS


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VITAL SIGNS

ImportanceMany major therapeutic decisionsare based on the vital signs; therefore, accuracyis essential.

Vital Signs or Cardinal Signs are: Body temperature

Pulse

Respiration

Blood pressure

Pain

Body Temperature


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Types of Body Temperature

a. Core temperaturetemperature of the deeptissues of the body.

b. Surface body temperature

Normal Adult Temperature Ranges

1. Oral 36.537.5 C

2. Axillary 35.8 37.0 C

3. Rectal 37.0 38.1 C4. Tympanic 36.8 37.9C


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2. Rectal- most accurate measurement of temperature

Position- lateral position with his top legs flexed anddrape him to provide privacy.

Insert thermometer by 0.5 1.5 inches

Hold in place in 2 minutes

Do not force to insert the thermometer

Contraindications

Patient with diarrhea

Recent rectal or prostatic surgery or injury because it

may injure inflamed tissue

Recent myocardial infarction

ll f d


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3. Axillary safest and non-invasive

Pat the axilla dry

Hold it in place for 9 minutes because the thermometerisnt close in a body cavity

Note:

1. Use the same thermometer for repeat temperature

taking to ensure more consistent result

2. Store chemical-dot thermometer in a cool area becauseexposure to heat activates the dye dots.

T t


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Temperature

Routinely, whereaccuracy is not crucial,

an oral temperature will

suffice.

A rectal temperature isthe most accurate.

Unless contraindicated

(as in a patient with asevere cardiac

arrhythmia), a rectal

temperature is often

preferred

May vary with thetime of day.

oOral: 370C (98.60F) is

considered normal. May

vary from 35.80C to37.30C (96.40-99.10F)

oRectal: Higher than

oral by 0.40C to 0.50C(0.70-0.90F).


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Nursing Interventions in Clients with Fever

Monitor V.S Assess skin color and temperature

Monitor WBC, Hct and other pertinent lab records

Provide adequate foods and fluids.

Promote rest

Monitor I & O

Provide TSB

Provide dry clothing and linens Give antipyretic as ordered by MD

P l I h f bl d d b i f h l f


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PulseIts the wave of blood created by contractions of the left

ventricles of the heart.

Normal Pulse rate

1 year 80-140 beats/min

2 years 80- 130 beats/min

6 years 75- 120 beats/min10 years 60-90 beats/min

Adult 60-100 beats/min

Tachycardia pulse rate of above 100 beats/min

Bradycardia- pulse rate below 60 beats/minIrregular uneven time interval between beats.
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Radial Pulse

Gently press your index, middle, and ring fingers

on the radial artery, inside the patients wrist.

Excessive pressure may obstruct blood flow distalto the pulse site

Counting for a full minute provides a more

accurate picture of irregularities.

Pulse
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Pulse

Palpate the radial

pulse and count for at

least 30 seconds. I f the

pulse is irregular, count

for a full minute andnote the number of

irregular beats/min.

Note: Whether the beat

of the pulse against your

f inger is strong or weak,

bounding or thread.

Normal adult pulse is

60 to 80 beats/min;

regular in rhythm.

Elasticity of the arterial

walls, blood volume,and mechanical action

of the heart muscle are

some of the factors that

affect strength of thepulse wave, which

normally is full and

strong.

Doppler device


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Apply small amount of transmission gel to the

ultrasound probe Position the probe on the skin directly over a

selected artery

Set the volume to the lowest setting

To obtain best signals, put gel between the skinand the probe and tilt the probe 45 degrees fromthe artery.

After you have measure the pulse rate, clean theprobe with soft cloth soaked in antiseptic.Do notimmerse the probe

Respiration is the exchange of oxygen and carbon dioxide


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Respiration - is the exchange of oxygen and carbon dioxide

between the atmosphere and the body

Assessing Respiration

Rate Normal 14-20/ min in adult

The best time to assess respiration is

immediately after taking clients pulse

Count respiration for 60 second

As you count the respiration, assess and recordbreath sound as stridor, wheezing, or stertor.


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Blood Pressure


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Adult 90- 132 systolic

60- 85 diastolic

Elderly 140-160 systolic

70-90 diastolic Ensure that the client is rested

Use appropriate size of BP cuff.

If too tight and narrow- false high BP If too lose and wide-false low BP


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Blood PressureMeasure the blood pressure

in both arms.

Normal range:Systolic95-140 mm Hg

Diastolic60-90 mm Hg


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Palpate the systolic pressure

before using the stethoscopein order to detect an

auscultatory gap.*

Apply cuff firmly; if too

loose, it will give a falselyhigh reading.

Use cuff in appropriate size:

a pediatric cuff for children;

a leg cuff for obese people.The cuff should be

approximately 2.5 cm (1

inch) above the antecubital

fossa

g

A difference of 5 to 10 mm

Hg between arms incommon.

Systolic pressure in lower

extremities is usually 10 mm

Hg higher than reading inupper extremities.

Going from a recumbent to a

standing position can cause

the systol ic pressure to fall 10to 15 mm Hg and the diastolic

pressure to r ise slightly (by 5

mm Hg).

Electronic Vital Sign Monitor


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An electronic vital signs monitor allows you to

continually tract a patients vital sign without having toreapply a blood pressure cuff each time.

Example: Dinamap VS monitor 8100

Lightweight, battery operated and can be attached to an

IV pole Before using the device, check the client7s pulse and BP

manually using the same arm youll using for the

monitor cuff.

Compare the result with the initial reading from themonitor. If the results differ call the supply department

or the manufacturers representative.

SPECIFIC SURGICAL POSITIONS FOR


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SPECIFIC SURGICAL POSITIONS FOR

PATIENT


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Position Placement Use


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Position Placement Use

Trendelenburgs Head of bed

lowered and foot

raised

Percussion,

vibration, and

drainage;

promotes venous

return

Reversetrendelenburgs

Bed frame is titlesup with foot of the

bed

Gastricconditions,

prevent

esophageal reflux

Amputation: lower extremity


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- No pillows under stump after first 24hours

- Turn patient prone several times aday

Rationale:

- Prevents flexion deformity of thelimb


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Burns (extensive)


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- Usually flat for first 24 hours

Rationale:

- Potential problem is hypovolemia,

which will be more symptomatic in a

sitting position

i


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Cast, extremity

- Keep extremity elevated

Rationale:- Prevent edema

Craniotomy


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- Head elevated with supratentorial incision

- flat with cerebellar or brainstem incision

Rationale:- Reduces cerebral edema, which

contributes to increase intracranial

pressure

Flail chest


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- Position on affected side

Rationale:

- Reduces the instability of the chestwall that is causing the paradoxical

respiratory movements

Gastric resection


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- Lie down after meals

Rationale:

- May be useful in preventing

dumping syndrome

fundamentals of nursing - by darius candelario

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