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RLE8

Self Breast Exam /Gynecologic Exam

Mammography women withfamily hx of bc, dx disease, earlydetection of bc

Ultrasound sound waves,visualization of heart, spleen, liver,kidney

Pelvic Examination preventivehealth care, 18 y.o above women,CI: mens heavily, physicalimmaturity, mental/ physical d/o

Papinocolaou smear / PAP smear obtain cells from cervix, sexuallyactiveCI: mens heavily, vaginal douche

Steps of self breast examPositions4 positions:

Arms relaxed at

sides Hands on hips

Arms raised abovethe head

Bending forwardPalpation: Side-lying and FlatPerimeterPressurePattern of SearchVertical Strip, Wedge, Circle

Importance of breast exam

Early detection of breast cancer

Detects changes in breast

Check for discharges of nipples

to promote peace of mindknowing that we are assured ofthe safety of our breast

Indications of self breast exam

Premenopausal women

Teenagers

Men

Nursing responsibilities ofself breast examBefore1. provide safety2. talk to the patient to establishrapport

During1. warm hands2. keep talking to the patient3. still provide privacy

After1. give health teaching2.after care

TESTICULAR SELF EXAMINATION

Importance:1. To look for any swelling,tenderness, excess fluids and

unusual lumps2. To detect testicular cancerearly.

Purpose :

To detect testicular cancerat an early stage.

To detect lumps orabnormalities of the testicles.

To notice swelling that canbe a sign of injury or infection.

detect the causes of pain,inflammation, swelling, congenitalabnormalities (such as an absentor undescended testicle), andlumps or masses that mayindicate testicular cancer.

Indications:1. All adult males 15 yearsold and above2. Males with family history oftesticular cancer3. Testicular cancer

Contraindications:

Men who have trauma orinjury to the reproductive tissue

Men who have burns to thereproductive tissue

Guidelines:1. Wear personal protectiveequipment and apply theprinciples of standard precautionsif contact with body fluids, blood,mucous membranes or nonintactskin.2. The testicular self

examination should be performedonce a month after a warm bathor shower.3. Test should be done onone testicle at a time.4. Refer any unusual findingto a physician.

Nursing Responsibilities:

Before:1. Instruct patient on thesteps in doing the procedure2. Provide a comfortableenvironment3. Provide privacy

4. Allow patient to do medicalhandwashing5. Assist patient in removinghis clothing6. Nurse must haveprotective wear such as gloves,etc

During1. Ensure clients privacy2. Be alert to any needs orconcerns that the client wouldhave3. Guide the client on what todo, step by step.

4. inform client that heshouldnt feel any pain whendoing the exam5. inform client not to bealarmed if one testicle seemsslightly larger than the other,thats normal

After1. Allow client to change afterexamination2. Inquire for any unusualfindings in his self examination3. Ask patient for hisevaluation of the examination4. Instruct patient to domedical handwashing5. Do after care anddocument

RLE9

Post Mortem Care andDischarge Process

PURPOSES OF POST MORTEMCARE

to aid in preserving the

physical appearance of thedeceased

to prevent discolorationand damage of the corpse skin

to safeguard all thebelongings of the deceased

to support family membersduring the initial hours of theirbereavement to show respect forthe deceased

CLINICAL SIGNS OF IMPENDINGDEATH

Loss of Muscle Tone

Slowing of the Circulation

Changes in Respirations

Sensory Impairment

PHYSIOLOGIC CHANGES AFTERDEATH

Rigor Mortis (Post MortemRigidity)

due to the disappearance ofadenosine triphosphate (ATP)from the muscle

usually begins 2-4 hours afterdeath, and fully develops in 6-12hours

Algor Mortis (Post Mortem

Cooling)internal body temperature beginsto fall at approximately 1C perhour

Livor Mortis (Post Mortem Lividity)reddish purple discoloration independent areas of the body dueto accumulation of blood in thesmall vessels of the dependentareas secondary to gravity. It isfirst evident about 30 minutesafter death and fully develops in6-10 hours.ortem Lividity)

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PutrefactionThe body decomposes as a result

of bacterial and microorganismaction. In general, decompositionbegins within 24 to 30 hours ofdeath, and its start can be seen inthe greenish discoloration of theright lower abdominal area.

STAGES OF GRIEVING

Denial Stage Anger Stage

Bargaining Stage

Depression Stage

Acceptance Stage

PROCEDURES OCCURRINGAFTER DEATH

Pronouncement of Deathand Death Certificate

Autopsy

Inquest

Organ Donation

GUIDELINES OF POST MORTEMCARE

Observe standard precautionwhile performing post mortemcare.

Bathe and dress over leakingwounds.

Clean up body thoroughly.

Allow the family to say goodbyethrough touching and talking.

NURSING RESPONSIBILITIESBEFORE, DURING, AND AFTERPOST MORTEM CARE

Before

o Check for the certification of

death of the patient signed bythe physician.

o Introduce yourself and explain

to the significant others thatyou will perform post mortemcare.

o Gather and prepare thenecessary materials.

o Provide privacy.

o Do medical handwashing andput on clean gloves.

During

o Maintain the body in a supine

position with head of bed raised

at 30 degrees.o Remove all supplies, dirty

linens, and medical equipmentor devices such as IV lines,tubes, drains, and monitorsaccording to the hospitalprotocol.

o Remove any jewelry and collect

all other personal belongings tobe sent to the family. List eachpiece of jewelry as it is beingremoved.

o Bathe the body thoroughly.

o Give the family option to viewor not to view the patient andaccompany them as they do so.

o Ensure that the identification

tags are properly placed.o Wrap the body with a shroud

before it is taken to themorgue.

After

o Do after care.

o Transfer the body from the bedto a stretcher for transport tothe morgue.

o Document the procedure.

PHASES OF THE DISCHARGEPROCESS

1. Acute Phase medicalattention dominatesdischarge-planning efforts

2. Transitional Phase theneed for acute care is stillpresent, but its urgencydeclines and clients beginto address and plan fortheir future health careneeds

3. Continuing Care theclients are able toparticipate in planning andimplementing continuingcare activities needed fordischarge

ELEMENTS ON WRITTENDISCHARGE

Mode of Discharge

Instructions for self-careactivities

Clients signature showing

understanding of instructions

PURPOSES OF DISCHARGINGTHE PATIENT

to ensure that the clienthas the proper knowledgeand skill to perform self-care after discharge

to return patient to a stateof independent living

to ensure adequate homehealth care support

to minimize clients anxietyafter discharge

to prepare a client to movefrom one level of care toanother within or outsidethe current healthcarefacility

to maintain a safe level ofself-care

REASONS FOR DISCHARGE

The patient has completedtreatment and no longerneeds the medical careprovided in that particularservice

The patient does notcomply with the plan ofcare despite the efforts tohelp him/her understandthe steps in the treatmentplan and the importance ofthe treatment

The patient has recovered

The patients condition hasstabilized

Death

NURSING RESPONSIBILITIES OFDISCHARGING A PATIENT

Assess needs of client onthe day of admission andcontinue assessmentduring hospitalization.

Involve the client / familyin the discharge process.

Provide written and verbalinstructions at the client /familys level ofunderstanding.

Verbally explaininstructions to client /

family prior to dischargeand provide client / familya written copy.

Ascertain that client hasfollow-up care arranged atdischarge.

Provide verbal and writteninformation on what signsand symptoms to observeand when to contact thephysician.

Assess if any communityresources should be usedand contact appropriatepersonnel.

Document all discharge

teaching on DischargeInstruction Sheet andNursing notes.

If the client is determinedto leave against medicaladvice (AMA), ask him orher to sign a special formwhich releases thephysician and agency fromfuture responsibility of anycomplication.

Ensure that all dischargeinstructions have beenprovided.

Provide a written summaryof discharge instructions.

NURSING RESPONSIBILITIES OFDISCHARGING A DEAD PATIENT

Evaluate the nursingcare for the grievingand dying clientthroughcommunication andassessment.

Evaluate the situationin clear and preciseterms as stated by thechoice of a applicablenursing diagnosisbased on accurate

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database that isevolving and realistic

Document the ff:o time of death andactions taken toprevent the death, ifapplicableo who pronounced

the death of the cliento who was called

and who came to thehospitalo personal articles

left on the body andtaped to skin or tubesleft ino personal items

given to the familyo time of discharge

and destination of thebodyo location of nametags on the bodyo special requests

by the familyo any other

statements that mightbe needed to clarifythe situation

Medical forms must besigned by a doctor orregistered nurse.