FUNDAMENTALS OF
NURSING
Fundamentals of Nursing Practice
SRG Integrals 2nd Ed.
Fundamentals of Nursing
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FUNDAMENTALS OF NURSING
I. NURSING
DEFINITION OF NURSING
Henderson
- 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.
Nightingale
- 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.
Watson
- is caring
Modern definition
- 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.
Table 1.0 Definition of Nursing
GOALS OF NURSING
• Promotion of Health – promoting a healthy
SCOPE OF NURSING CARE
lifestyle
• Individual
• Prevention of illness – early detection and
• Families
treatment
• Communities
• Restoration of health – curing and healing,
rehabilitation
• Care of the dying – maintaining dignity and
peaceful death
THEORETICAL FOUNDATIONS OF NURSING
THEORISTS
THEORY
KEYWORD
Florence Nightingale
Focused on organizing and manipulating the
Environmental Theory
physical, social and psychological
of Nursing
environment in order to put the person in
the best possible conditions for nature
to act
Hildegard Peplau
Virginia Henderson
SRG Integrals 2nd Ed.
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
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.
Fundamentals of Nursing
Interpersonal Relationship
Nurse – Patient relationship
14 fundamental needs
Definition of Nursing
2
THEORISTS
Lydia Hall
THEORY
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
Nursing consists of the three theories of self
care, self care deficit and nursing systems
Behavioral system model for nursing has seven
subsystems:
1. attachment or affiliation
2. dependence
3. ingestive
4. eliminative
5. sexual
6. aggressive
7. achievement
KEYWORD
Care, core, cure
Primary Nursing
Holistic Nursing
Faye G. Abdellah
- focuses on problem-solving to move the patient
toward health
- 21 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
Myra Levine
Views nursing as human interaction: the dependency of
individuals on one another.
Levine identifies four principles of conservation:
(1) conservation of energy,
(2) conservation of structural integrity,
(3) conservation of personal integrity, and
(4) conservationof social integrity
Presents a theory of goal attainment from an
open system conceptual framework that
integrates personal systems, interpersonal
systems, and social systems.
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.
Conservation theory
Dorothea Orem
Dorothy E. Johnson
Imogene King
Martha Rogers
SRG Integrals 2nd Ed.
Fundamentals of Nursing
Theory of self - care
Behavioral System
Model
Goal – attainment
theory
Science of unitary man
3
THEORISTS
Callista Roy
THEORY
Major emphasis is on the person as an adaptive
system. To further describe the client of nursing, the
four adaptive modes are identified as physiological, selfconcept, role function, and interdependence
Focuses on the whole person and that person’s
reaction to stress. Her model can be used in illness or
wellness. Nursing’s major concern is to help the client
system attain, maintain, or regain stability
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.
KEYWORD
Adaptation model
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
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
Betty Neuman
Jean Watson
Client Systems model
Prevention as
Intervention
Science of caring
Carative factors
Table 1.1 Theoretical Foundations in Nursing
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II. HEALTH, WELLNESS and ILLNESS
HEALTH
Nightingale, 1969
WHO 1948
WHO Ottawa Charter for
Health Promotion” 1986
Ability of the person to maintain a state of wellness, and using every power an
individual possess to the fullest extent
Is a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity.
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."
Table 2.0 Definitions of Health
WELLNESS
• Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall
feeling of well-being
• It is the physical state of good health as well as the mental ability to enjoy and appreciate being healthy and fit.
MODELS OF HEALTH AND WELLNESS
•
•
•
•
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
EUDAEMONISTIC MODEL – refers to the actualization of ones potentials
SELF-ACTUALIZATION
SELF-ESTEEM
LOVE AND BELONGINGNESS
SAFETY AND SECURITY
PHYSIOLOGIC NEEDS
Figure 2.0 Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs - describes the lifelong needs one must satisfy in a hierarchical manner in order to achieve
fulfillment and complete development, which is a goal of the eudemonistic model.
•
HEALTH - ILLNESS CONTINUUM – a predictive grid that displays the likelihood of
a person to participate in preventive health care
Figure 2.1 Health-Illness Continuum
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.
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•
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
o Helps determine whether an individual is likely to participate in disease prevention and health
promotion activities.
o Useful tools in developing programs for helping people change to healthier lifestyles and develop a
more positive attitude toward preventive health measures.
Components:
Individual 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.
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)
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III. NURSING INFORMATICS
Nursing Informatics
– is the integration of computer, information, and nursing science.
• Assists the management and processing of nursing data, information, and knowledge to support nursing
practice, education, research, and administration.
• is the science of using computer information systems in the practice of nursing. (Kozier et.al)
TELE-NURSING - 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
• provide routine assessment and follow-up carewithout the client having to travel to the health care agency
for an appointment.
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
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
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IV. NURSING PROCESS
NURSING PROCESS – is a systematic, rational and cyclical method of planning and providing nursing care
STEPS OF THE NURSING PROCESS:
ASSESSMENT
• Purpose: to establish a data base about the client’s perceived needs,
health problems and risks, related experiences, health practices,goals,
values, and lifestyle.
• Activites: Collection and organization of data
•
Stages of Interview:
o
Opening (establish rapport – self introduction, non verbal
gestures)
o
Body (open and close-ended questions)
o
Closing
DIAGNOSING
• Purpose: To identify and develop a list of nursing and collaborative problems
• Components: Problem + Etiology + signs and symptoms/ risk factors
• Types of Nursing Diagnoses:
o Actual: the client shows manifestations of a health problem or condition.
▪ e.g. ineffective airway clearance
o High-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 injury
o Wellness: The client is healthy as assessed but he wishes to achieve a higher level of functioning.
▪ e.g. Readiness for enhanced social well being
o 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
o Syndrome – a clustered nursing diagnosis.
▪ e.g. –Disuse Syndrome
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PLANNING
• Purpose: To develop an individualized, goal oriented and therapeutic care plan
• Stages of planning:
1. Assign priorities to the nursing diagnosis
2. Establish client goals / outcome
3. Select appropriate nursing interventions
4. Document the nursing diagnosis, expected outcomes and interventions.
5. Evaluate the effectiveness of the plan of care
How the nurse will know the client’s responsehas changed.
SPECIFIC
What the client will do, when it will be done,and to what
MEASURABLE
ATTAINABLE
REALISTIC
TIMELY
extent.
Relate with the client in formulating expected
outcomes
Includes client’s health capabilities
Time estimate for outcome attainment.
IMPLEMENTATION
• Purpose: To assist client meet desired goals/outcomes and promote maximum
level of functioning
• Activities:
• Reassessment of Clients and their response to care
• Determination of any need for assistance
• Implementation of nursing interventions
• 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
• Purpose: to determine the effectiveness of the care plan and its corresponding
actions whether to continue, terminate, or modify the care plan.
• Activities:
o Collects and compare data with the outcome
o Relate nursing actions to client’s goals
o Conclude problem status
• Evaluation may be:
1. Ongoing: done while or immediately after implementing the nursing
intervention.
2. Intermittent: performed at specified intervals, such as thrice a week.
3. Terminal: performed to indicate the client’s condition at the time of discharge.
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V. PHYSICAL ASSESSMENT
-
is an organized systemic process of collecting objective data based upon a health history and head-totoe or general systems examination.
It provides the foundation for the nursing care plan in which observations play anintegral part in the
assessment, intervention, and evaluation phases.
CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT:
• Establish a Positive Nurse/Patient Rapport.
• Explain the Purpose for the Physical Assessment.
• Obtain an Informed, Verbal Consent.
• Ensure Confidentiality of All Data.
• Provide Privacy From Unnecessary Exposure.
• 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 touch
3.Gloves — reduce risk for transmission of microorganism
4. Laryngeal mirror - Metal instrument with mirror to inspect pharynx and oral cavity
5. Ophthalmoscope - Lighted instrument attached to a battery tube to visualize the eye’s interior
6. 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 reflexes
9. Safety pin - Disposable sharp object to assess pain, sensory system
10. Tape measure - Calibrated in cm to measure circumference
11. Tongue 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 nerve
13. Lubricant - Facilitates insertion of instruments into body cavities
14. Drape - Covers exposed body parts
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ASSESSMENT TECHNIQUES:
“IPPA” – Inspection, Palpation, Percussion, Auscultation
1. Inspection
• use of sense of sight
• visual inspection/examination
• WHAT TO INSPECT: color, tone, and texture, as well as scars, lesions, abrasions, and rashes (skin); movement,
motor dexterity, contour and symmetry of the body, and deformities.
2. Palpation
• use of sense of touch
• WHAT TO PALPATE: size, position, and consistency of various body parts, such as lymph nodes and breast
tissue
NURSING ALERT: Finger pads and the back of the hand are the most sensitive body parts used for palpation!!!
• Types of palpation:
(a) Light palpation – detects superficial mass ( 1 “ depth )
(b) Deep palpation – palpates organ enlargement like liver, mass and pulsations ( 3 – 4” in depth)
3. Percussion
• assess for vibration with the use of fingers
• The finger of one hand taps the finger of the other hand to generate vibration which can be used to determine
a diagnostic sound.
TONE
QUALITY
PITCH
Resonance
Hyperresonance
Tympany
Hollow
Booming
Drum – like
Low
Very Loud
High
Dullness
Thud – like
High
Flatness
Very Dull
Soft - moderate
EXAMPLE
Healthy Lungs
Emphysema
GI Bubbling, empty stomach
or large intestine
Kidney, full bladder, feces,
filled intestine
Bones and muscles
(very dense tissues), heart,
spleen, liver
Table 5.0 Percussion Sounds and Tones
4.Auscultation
• use of sense of hearing with the use of the unaided ear or a stethoscope
• frequently assessed organs: heart, lungs, abdomen, and blood vessels
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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 illness
• Date of onset
• Characteristics at onset
• Severity of symptoms
• Course since onset
• Associated signs and symptoms
• Aggravating or relieving factors
• Effect on activities
• Treatments tried and results
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.
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VITAL SIGNS
• Also called Cardinal signs
PURPOSE
• To obtain baseline measurement of the patient’s vital signs
• To assess patient’s response to treatment or medication
• To monitor patient’s condition after invasive procedures
REFERS TO THE MEASUREMENT OF “TPR – BP ”
• Temperature
• Pulse Rate
• Respiratory Rate
• Blood Pressure
GENERAL EQUIPMENT NEEDED:
• oral thermometer (Slim tip)
• rectal thermometer (stubby, 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
• Alcohol swab
• Stethoscope
• Watch with second hand
• Sphygmomanometer with proper cuff size
Age
Temperature( ° 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
Table 5.1 Variations in Vital Signs by Age
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Factor
Exercise and
metabolism
Temperature
Increases
Pulse
Short Term:
increases
Long – term :
lowers the resting
rate and
return time to
the resting rate
post exercise
Respiration
Rate and depth
increases
Blood Pressure
Increases
Anxiety and stress
Postural
changes
Increases
No change
Increases
Increases with
sitting or
standing ;
Decrease when
lying down
Increases
Decreases with
stooped or
slumped positions
due to
decreased
chest expansion
None
Increases
Decrease with
sitting or standing
Diurnal variations / Lowest level:
Decreases during
circadian
4:00 AM –6:00AM
sleep
rhythm
Highest level:
8:00 PM – 12:00
AM
Table 5.2 Factors influencing Vital Signs
Lowest level: early
morning
Highest level: late
afternoon or early
evening
TEMPERATURE
• Reflects the balance between heat produced and heat lost from the body.
TYPE
A. Radiation
B. Evaporation
C. Convection
D. Conduction
E. Insensible heat loss
SRG Integrals 2nd Ed.
DEFINITION
EXAMPLE
The transfer of heat from the surface - Warming through a drop light
of one object to another
without contact between objects
Continuous insensible loss from the - Natural drying after excessive
skin and lungs when water is sweating
converted from liquid to gas.
It accounts for the greatest heat loss
when body
heat increases.
Dispersion of heat by air currents. The - Facing a fan for cooling
body usually has a small amount of
warm air adjacent to it. The air rises
and is replaced by cooler air
The transfer of heat from one - Tepid Sponge Bath
molecule to a molecule of
lower temperature (with contact)
The heat that is lost through the
continuous, unnoticed water loss that
occurs with vaporization, accounting
for 10% of basal heat production.
Table 5.3 Heat Loss
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TYPES of TEMPERATURE
A. Core Temperature
• Measured thru tympanic and rectal routes
B. Surface Temperature
• Measured thru oral and axillary routes, skin patch or
temperature – sensitive tape
Conversion:
• Fahrenheit to Celsius
°C= (°F-32) x 5/9
• Celsius to Fahrenheit
°F= (°C x 9/5) + 32
ALTERATIONS IN BODY TEMPERATURE:
1.Pyrexia- temperature above the usual range. (hyperthermia)
• Above 40°C – hyperpyrexia
2.Fever
• Intermittent - 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
3. Hypothermia – a body temperature of 35 degrees Celsius or lower resulting from cold weather
exposure or artificial induction
4. Frostbite – freezing of the body’s surface areas (earlobes, fingers, and toes) in extremely low
temperatures
5. Heat Stroke - a critical increase in body temperature ( 41 degree Celsius to 44 degree Celsius)
resulting from exposure to high environmental temperature
ROUTES FOR ASSESSING BODY TEMPERATURE:
1. Oral – accessible and convenient
• Contraindications:
• Infants and very young children
• Patients with oral surgery
• Unconscious or irrational patients
• Seizure-prone patients
• Mouth breathers and pts. with oxygen
2. Axilla - safest and non invasive
• Least accurate
3. Rectal – most reliable measurement
• Contraindications:
• Rectal abnormalities
• Diarrhea
• Certain heart conditions
• Immunosuppressed
4. Tympanic – accessible, less invasive
• Contraindications:
• Presence of ear ache
• Significant ear drainage
• Scarred tympanic membrane
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PULSE
• Wave of blood created by contraction of the left ventricle of the heart.
SITES
1. Temporal – accessible; used routinely for infants and when
radial pulse is not accessible
2. 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
3. Apical – used to auscultate heart sounds and assess apical - radial pulse
o (Pulse deficit = Apical pulse – radial pulse; taken simultaneously)
4. Femoral – assess circulation to the legs and during cardiac arrest
5. Brachial – used in cardiac arrest of infants and used to asses for lower arm
circulation and to auscultate for BP
6. Radial – used routinely to assess for character of peripheral pulses in adults
7. Popliteal – used to assess circulation to the legs and to auscultate leg blood pressure
8. Posterior Tibial – used to assess circulation to the feet
9. Dorsalis Pedis - used to assess circulation to the feet
CHARACTERISTICS OF PULSE:
• Rate – 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 athlete may have lower
• Bradycardia: a pulse that is below normal rate.
• Tachycardia: a pulse that is above normal rate.
• 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.
• Factors affecting pulse volume:
o the volume of blood in the arteries,
o the strength of the heart contractions
o the elasticity of the blood vessels
NURSING ALERT: 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
• Measuring 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:
• For a regular rhythm, count number of beats for 30 seconds and multiply by 2.
• For an irregular rhythm, count number of beats for a full minute, noting number of irregular
beats.
• When counting for the first time, count for a full minute
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• Measuring Apical Pulse:
1. Raise client’s gown to expose sternum and left side of chest.
2. Locate Apex of heart:
a. With client lying on left side, locate suprasternal notch.
b. Palpate second intercostal space to left of sternum.
c. Place index finger in intercostal space,counting downward until fifth intercostal space is located.
d. 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)
3. Keep index finger of nondominant hand on the PMI.
4. 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.
5. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound
6. Start to count while looking at second hand of watch. Count lub-dub sound as one beat:
a. For a regular rhythm, count rate for 60 seconds.
b. For an irregular rhythm, count rate for a full minute, noting number of irregular beats.
7. 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
Types of Respiration:
o External Respiration
▪ Refers to the interchange of oxygen and CO2 in the alveolo-capillary membrane
o Internal Respiration
▪ Exchange of gasses between the Blood and the cells
o Inhalation/inspiration –active process
o Exhalation/Expiration – passive process due to elastic recoil
o Normal respiratory rate: 12-20 breaths per minute in adult (eupnea).
Respiratory Controls:
o Medulla Oblongata: Central Chemoreceptor
o Carotid and Aortic bodies: Peripheral Chemoreceptor
Characteristics of Respiratory Wave Pattern (R.A.R)
o Rate
o Amplitude/depth
o Rhythm / Pattern
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Breathing Pattern/ Sounds
A. Kussmaul’s
B. Apneustic
C. Dyspnea
D. Orthopnea
E. Cheyne-Stokes
F. Wheezing
G. Stridor
H. Crackles/ Rales
I. Gurgles/ Rhonchi
Characteristics
- Faster and deeper respiration without pauses in
between panting
- Prolonged grasping breathing followed by extremely short inefficient exhalation
- difficulty of breathing
-DOB unless patient is sitting; can breathe only when in an upright position.
- 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.
- narrowing of airways, causing whistling or sighing sounds
- high-pitched sounds heard on inspiration with laryngeal
obstruction
- sound caused by air passing thru fluid or mucus in the airways usually heard on
inhalation
- sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm
usually heard during exhalation ; course , dry, wheezy or whistling sound
Table 5.4 Breathing Pattern and Sounds
BLOOD PRESSURE
• Pressure exerted by blood to the blood vessel wall
• SYSTOLIC - ventricular contraction
• DIASTOLIC - Ventricular relaxation
• AVERAGE: 120/80 mmHg
DETERMINANTS:
• Pumping action of the heart
• Peripheral vascular resistance
• Blood volume
• Blood viscosity
TECHNIQUES
• The direct method (CVP)
• The indirect method (sphygmomanometer and stethoscope)
• Common site : brachial artery
• Contraindications for brachial artery:
o Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis
o Surgery involving the breast, axilla, shoulder, arm, or hand
o Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or
bandage
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18
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
• Body Built- Obese
• Exercise- Muscular exertion temporary
• Pain- Physical discomfort
• Emotional Status- Fear, worry, or excitement
• Disease States and Medication -Some disease conditions and/or the medications influence the blood pressure.
POINTS TO REMEMBER WHEN ASSESSING BLOOD PRESSURE
• Select an appropriate cuff size.
• Wrap the blood pressure cuff on the arm 1 inch above client’s brachial pulsation.
• Position arm at heart level, extend elbow with palm turned upward.
• 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.
• Place bell piece over brachial artery below the level of the chest
• With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30
mm Hg above diminished pulse point identified
• 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:
1. A faint, clear tapping sound appears and increases in intensity (phase I). – Systolic pressure
2. Swishing sound (phase II).
3. Intense sound (phase III).
4. Abrupt, distinctive muffled sounds (phase IV).
5. Sound disappears (phase V) – Diastolic Pressure
• Deflate cuff and wait for 2 minutes if reassessment is needed
CONDITIONS RELATED TO BLOOD PRESSURE
A. Hypotension refers to a systolic blood pressure less than 90 mmHg or 20 to 30 mm Hg below the client’s
normal systolic pressure.
CAUSES:
• 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.
B. 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.
SRG Integrals 2nd Ed.
Fundamentals of Nursing
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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 ASSESSMENT
• Levels of Consciousness - Can be measured by RLS (Reactive Level Score) and Glasgow Coma Scale
• REACTIVE LEVEL SCORE (RLS)
o Alert
o Drowsy
o Very Drowsy
o Unconscious Localizing
o Unconscious Withdrawing
o Decorticating
o Decerebrating
• 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 (EVerMoRe)
o The score in each category is added in order to get the overall scale.
o The highest possible score is 15. If a score falls below 7, the patient is considered is comatose status.
GLASGOW COMA SCALE (GCS) TABLE:
Eye Opening Response
Spontaneous ( open with blinking at baseline)
Opens to verbal command, speech, or shout
Opens to pain, not applied to face
None
Best Verbal Response
Oriented
Confused conversation, but able to answer
questions
Inappropriate responses, words discernible
Incomprehensible speech
None
Motor Response
Obeys commands for movement
Purposeful movement to painful stimulus
Withdraws from pain
Abnormal (spastic) flexion, decorticate posture
Extensor (rigid) response, decerebrate posture
None
Score
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Total
15
Table 5.5 Glasgow Coma Scale
• Appearance: Neat, clean; clothes appropriate to occasion, season, and sex
• Affect: Attentive, cooperative, pleasant
• Speech : Articulate, fluent, readily answers questions
• Memory: Responds appropriately to questions:
o Immediate: “Why are you here?”
o Recent: “What did you eat for breakfast?”
o Remote: “Where were you born?”
SRG Integrals 2nd Ed.
Fundamentals of Nursing
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• Orientation :
o Person (self, others)
o Place
o Time
• General knowledge/intellectual level:
o Responds appropriately to general questions like “Who is the president of the Philippines?”
MNEMONICS
MNEMONICS
CN 1 OLFACTORY
OH
SENSORY
SOME
CN 2 OPTIC
OH
SENSORY
SAYS
CN3 OCULOMOTOR
OH
MOTOR
MARRY
CN4 TROCHLEAR
TO
MOTOR
MONEY
CN5 TRIGEMINAL
TOUCH
BOTH
BUT
CN6 ABDUCENS
AND
MOTOR
MY
CN7 FACIAL
FEEL
BOTH
BROTHER
CN8 ACOUSTIC
A
SENSORY
SAYS
CN9 GLOSSOPHARYNGEAL
GIRLS
BOTH
BIG
CN10 VAGUS
VAGINA
BOTH
BOOBS
CN11 SPINAL ACCESORY
SO
MOTOR
MATTER
CN12 HYPOGLOSSAL
HEAVEN
MOTOR
MOST
Table 5.6 Cranial Nerves Assessment Tool
SRG Integrals 2nd Ed.
Fundamentals of Nursing
21
I
Olfactory
Cribiform Plate
Special Sensory: Smell
II
Optic
Optic Canal
Special Sensory: Sight Vision
III
Oculomotor
Superior Orbital
Fissure
Somatic 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
Sup Orbital
Fissure
V1:
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
VIII
Acoustic
Internal Auditory
Canal
Special Sensory: Auditory/Balance Maintain equilibrium;
hearing
IX
Glossopharyngeal
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
XII
Hypoglossal
Hypoglossal
Canal
Somatic Motor: Tongue Tongue movement
Table 5.7 Cranial Nerve Locations and Functions
nd
SRG Integrals 2 Ed.
Fundamentals of Nursing
22
Neurologic Assessment
Motor Function
assessment of the
motor system
involves testing for
muscle size, tone,
and strength
under voluntary
movements
Assessment Tool
Muscle strength.
Flexion and extension.
Muscle tone
Normal Findings
• Equal size on both sides of
body
• Usually firm
• Equal strength on both
sides of
the body
• Smooth , coordinated
movements
Significant Findings
NOTE: Tics, tremors,
fasciculations
may suggest neurologic
involvement.
Reflexes
Scale Response
0 Absent
+ Present but diminished
++ Normal
+++ Mildly increased but
not pathologic
++++ Markedly hyperactive;
clonus may be
present
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?”
Perform Romberg’s test:
o 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
Blink reflex
Gag and swallow reflex
Plantar response (Babinski
reflex)
Deep tendon reflex
Biceps
Triceps
Brachioradialis
Patellar – NORMAL:
extension of
leg below the knee
Achilles – Normal: plantar
flexion
of feet
Plantar (babinski) –
Normal: bending of toes
downward
Normal sensations
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
Cerebellar Function
NOTE: Inappropriate
response
indicates neurologic
disorder.
Table 5.8 Neurologic Assessment Tool and Finding
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Fundamentals of Nursing
23
Assessment
Assessment
Tool
Inspection :
Size or contour
Normal
Findings
Normocephalic
Scalp
Inspection
Smooth, nontender
Head circumference
Measuring Tape :
(measured at largest
point above eyebrow
and behind occiput)
Between 5th and
95th percentile on
standardized growth chart.
Head
Anterior fontanel
3–4 cm in length and2–3 cm
in width until
9–12 mo of age.
Soft, flat; bulges while
crying. Closes between
9 and 18 mo.
Posterior fontanel
0.5–1 cm across. May
be closed at birth or
by 3 months of age.
Significant
Findings
Hydrocephalic
Microcephalic
Asymmetric
NOTE: Scaling,
masses, tenderness
Exceeds chest
circumferenceby 1–2
until 18 mo.
cm
NOTE: Unusually
large fontanel may indicate
hydrocephaly
(faulty circulation or
absorption of
CSF).
Unusually small fontanel
may indicate
craniosynostosis
(premature closure of
sutures).
Delayed
closure
may
indicate hydrocephaly.
Table 5.9 Head Assessment
Assessment
Face
Sinuses
Cranial nerve:
(CN)VII:facial,
motor
CN V: trigeminal:
Motor
CN V: trigeminal:
sensory
SRG Integrals 2nd Ed.
Assessment
Tool
Inspection
Normal
Findings
Symmetric,
with relaxed
facial expressions
Frontal and
maxillary
sinuses nontender
Able to smile, puff cheeks,
frown, raise eyebrows,
with symmetry noted
Bilateral contractions of
temporal and masseter
muscles when teeth are
clenched
Significant
Findings
Asymmetric, weak; involuntary movements;
tense or expressionless facies
Tenderness
Unable to purposely and symmetrically
use facial muscles
Weak or asymmetric contraction of
muscles
Able to distinguish
Unable to distinguish
touch on
type and location of
both sides of
touch
face
Table 5.10 Face Assessment
Fundamentals of Nursing
24
EYE ASSESSMENT
•
• Visual acuity
o Snellen Chart (a chart that contains various-sized letters with standardized numbers at the end of
each line of letters)
o standardized numbers or denominators indicates the degree of visual acuity from a distance of 20
feet
• Note for external lesions.
• Equality of eyelid movement
o 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).
o Presence of discharge.
o Internal lesions.
o 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.
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, lip-reading, and speaking in a loud voice.
• Auditory acuity
• Whispered voice test:
• Weber test:
• Rinne test:
• Note Presence of external lesions.
• Note Presence of discharge.
•
•
•
•
•
NOSE ASSESSMENT
Inspect the nose for symmetry, deformity, flaring, or inflammation
and discharge from the nares. Located symmetrically, midline of the face
and is without swelling, bleeding, lesions, or masses.
Test patency of each nostril by instructing the client to close the mouth
and apply pressure on one naris and breathe.
SRG Integrals 2nd Ed.
Fundamentals of Nursing
25
•
•
•
Assess nasal cavity with penlight:
Assess each nostril.
Palpate the nasal sinuses by applying gentle, upward pressure on frontal and maxillary areas, avoiding
pressure on the eyes, percuss with middle or index finger and note the sound. Nontender, airfilled
cavities, resonant to percussion.
*Pain or tenderness may be caused by viral, bacterial, or allergic processes - inflammation and obstruction, eliciting a
dull sound.
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 hygiene
• Acetone 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.
LIPS
• Lip lesion:
o Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that rupture and crust over.
o Chancre (primary lesion of syphilis) is a reddish round, painless lesion with a depressed center and
raised edges that appears on the lower lip.
o 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 lesions
o Pale or cyanotic lips may indicate systemic hypoxemia. Dry, cracked lips occur with dehydration or
exposure to weather.
o Swollen lips (angioneurotic edema) result from allergic reactions
GUMS
•
•
•
•
TONGUE
•
are pink, smooth, moist and firm
Pale gums that bleed easily may indicate periodontal disease or vitamin C deficiency.
Inspect teeth: note tartar, cavities, extraction and color.
Note position and alignment
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.
o Palates are concave and pink. Hard palate has ridges; soft palate is smooth
• Inspect pharynx using a tongue depressor and penlight
o Instruct client to say “ah.” Note the position, size, and appearance of tonsils and uvula
o 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.
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Fundamentals of Nursing
26
NECK ASSESSMENT
Inspect Neck
• Test sternocleidomastoid muscle
o Muscles 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 Nodes
• Palpate 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 GLAND ASSESSMENT
• Position: Stand behind patient and gently push trachea to one side. Palpate extended side as patient swallows
o 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 gland
* NOTE: Enlargement (goiter), nodules, tenderness
SKIN ASSESSMENT
• Part of Integumentary system which includes: skin, scalp, nails
• Color- inspect under natural sunlight for accuracy
*NOTE color, size, and anatomic location and distribution ,mobility, contour and consistency presence of lesion:
• Primary lesion:
o macule - localized changes in skin color < 1 cm in diameter like freckles
o papule – solid elevated lesion < 0.5cm in diameter like elevated nevi
o vesicle – elevated mass containing serous fluid accumulation between the upper layers of the skin example: 2nd
degree burns, chicken pox
o patch – localized changes in skin pigmentation of <1cm in diameter; ex. Vitiligo, pressure ulcer stage 1
o plaque – solid elevated lesion > 0.5cm in diameter; ex psoriasis
o bullae – like vesicle but > 0.5cm in diameter
o nodule – solid and elevated;extends deeper than the papule into the dermis or subcutaneous tissues;0.5 to 2 cm
▪ ex.lipoma, erythema
o pustule – pus filled vesicles or bullae, <0.5 cm in diameter.
▪ Ex. Impetigo, acne
o cyst – subcutaneous or dermis mass ex: sebaceous cyst
• Secondary lesion:
o scales – flaking of the skin’s surface ex. dandruff , psoriasis
o erosion – loss of epidermis ex.ruptured chicken pox
o scar – fibrous tissue that replaces dermal tissue after injury
▪ ex. Surgical incision
o crust – dried serum, blood or pus on skin surface
o fissure – linear crack in the epidermis that can extend to the dermis ex. Chapped hands or lips
o keloid – enlarging of a scar past wound edges due to excess collagen formation ( more prevalent in dark skinned
person
o atrophy – thinning of the skin surface and loss of markings
▪ ex. Striae
o ulcer – depressed lesion of the epidermis and upper papillar layer of the dermis ex. Stage 2 pressure ulcer
SRG Integrals 2nd Ed.
Fundamentals of Nursing
27
o
o
o
o
o
o
o
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 ;
> Pitting edema scale:
▪ Ex varicose veins
1+ indentation of 1 cm or less
petechia – reddish purple, flat round lesion , 1 – 3mm in size
2+ indentation of 2cm
ecchymosis ( bruise ) purplish blue, fading to green, yellow and brown
3+ indentation of 3cm
▪ usually results from blood vessel trauma
4+ indentation of 4cm
▪ may indicate vit C deficiency, blood clotting
5+ indentation of 5cm
▪ disorders,liver disease or drug interactions
• Turgor and mobility
o Measures the elasticity of skin -determines degree of hydration
o For mobility, palpate dependent areas such as sacrum, feet, ankles by applying pressure with fingers, noting
the degree of indention.
• Moisture and temperature.
o Excessive moisture or perspiration (hyperhidrosis) caused byhyperthermia, infection, hyperthyroidism,
strong emotion
o Bromhidrosis ( body odor) caused by perspiration or bacterial decomposition
• Sensation/ texture
o quality, thickness, suppleness
o generalized roughness is seen in hypothyroidism
• Common skin alterations:
o Melanin – naturally occurring brown pigment
▪ (ex decreased in albinism)
o 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.
o 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.
o 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
SRG Integrals 2nd Ed.
Fundamentals of Nursing
28
o
o
o
o
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 and symmetry
o Pigeon chest
o Funnel chest
o Spinal Deformities
o Kyphosis
• AP to Lateral diameter
o till age 6 - 1:1 (equal)
o 1:2 in normal adult
o barrel chest - 1:1 in adult
* presence of chronic pulmonary disease
• Ribs and interspaces
o retraction of interspaces indicative of obstruction
o bulging during exhalation result of air outflow obstruction: tumor, aneurysm, cardiac
enlargement slope of ribs, costal angle
• Thoracic Expansion:
o Posteriorly- level of 10th rib
o Thumbs should separate 3 - 5 cm
o Feel during quiet I & E
o Palpate during deep inspiration
o Should be symmetrical
• Tactile fremitus
o palpable vibrations of chest wall over lung fields from speech or sounds
o Use palmar or ulnar surface
o Tactile Fremitus Increased- conditions that increase density of thoracic tissue
▪ consolidation of pneumonia
▪ some lung tumor
o Tactile Fremitus Decreased - obstruction of transmission of vibrations
▪ pleural effusion
▪ pleural thickening (fibrosis)
▪ pneumothorax
▪ bronchial obstruction
▪ COPD/emphysema
LUNG ASSESSMENT
• Respiratory Pattern
• Rate
o adult NL: 12 - 20 resting
o tachypnea = > 20
o bradypnea= <10
o Rhythm
• Depth : shallow, deep
o Hyperventilation :Hypoventilation
• Effort/Quality
SRG Integrals 2nd Ed.
Fundamentals of Nursing
29
o unlabored
o labored- dyspnea, orthopnea
o shallow
o grunting
• Normal rate, rhythm, quality termed eupnea
o rhythmic
o effortless
o quiet
o 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.
o Vesicular breath sounds
▪ soft, breezy, and low-pitched sounds heard longer on inspiration than expiration that result
from air moving through the smaller airways
▪ Location: lungs’ periphery
o Bronchovesicular breath sounds
▪ medium-pitched and blowing sounds heard equally on inspiration and expiration from air
moving through the large airways
▪ Location: Posteriorly between the scapula and anteriorly over bronchioles lateral to the sternum
at the first and second intercostal spaces
o Bronchial breath sounds
▪ loud and high-pitched sounds with a hollow quality heard longer on expiration than inspiration
from air moving
▪ Location: trachea
• Adventitious Breath Sounds - abnormal breath sounds are characterized by decreased or absent sounds.
o
o
o
o
o
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 (lowpitched 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 AXILLA ASSESSMENT
• Position: sitting position on the edge of examining table or bed facing you
• For Female Breasts:
o 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
o Skin: intact, no edema, color consistent with rest of body, smooth, convex contour
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o
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
• Areola
o Small elevations around the nipple (Montgomery’s glands) are normal.
*NOTE: Rashes or ulcerations may suggest cancer of mammary ducts (Paget’s disease).
• Nipples
o Nipples should point upward and laterally or outward and downward. Nipples may be inverted from
puberty, making breastfeeding difficult.
*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 tumor
o Nipple 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:
o 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
o
Rash (may be caused by deodorant). Velvety, smooth deeply pigmented skin should be further
evaluated.
▪ Palpate Lymph Nodes:
o In sequential manner
o 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.
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HEART ASSESSMENT
• Cardiac Landmarks
1. 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.
• Heart Sounds
o S1 heart sounds - Atrioventricular heart sounds
o S2 heart sounds - Semilunar heart sounds
o 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
o S4 heart sounds (atrial gallop) sound resembles the pronunciation of the word “Tennessee” (le-lub-dub).
• Heart murmurs:
o Grades and Characteristics of Murmurs:
▪
Grade I: Barely audible
▪
Grade II: Audible immediately
▪
Grade III: Moderate intensity
▪
Grade IV: Loud, may be associated with a thrill
▪
Grade V: Loud, with palpable thrill, audible with stethoscope in contact with chest wall
▪
Grade 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:
o click (a high-pitched systolic sound created by the opening of the valve)
o murmur (swishing or blowing sounds of long duration heard during the systolic and diastolic
phases created by turbulent blood flow through a valve
o bruits (blowing sounds that are heard when the blood flow becomes turbulent as it rushes past
an obstruction
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ABDOMINAL ASSESSMENT
• Position: Place 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 ( I.A.P.P )
• Assessment should always begin in the right lower quadrant (RLQ).
• Inspect: Inspect abdomen from rib margin to pubic area
o 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
o Umbilicus is depressed and beneath the abdominal surface.
▪ Umbilicus bulging may indicate a hernia
▪ Engorged or dilated veins around the umbilicus are associated with circulatory obstruction of
superior or inferior vena cava
▪ Uneven respiratory movement with retractions may indicate appendicitis
o 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, LUQ, LLQ
• 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
* NOTE: 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:
o Order of percussion:
* 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).
o Dullness over the stomach or intestines may indicate a mass or tumor; ascites (excessive fluid
accumulation in the abdominal cavity) or full intestines
•
Palpation
o
o
o
o
Never palpate over areas where bruits are auscultated.
Order of palpation: RLQ, RUQ, LUQ, LLQ
Should feel smooth with consistent softness
Tenderness and increased skin temperature may indicate inflammation. Large masses may be due to
tumors, feces, or enlarged organs.
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MUSCULOSKELETAL ASSESSMENT
(Great Maids Readily Make Pineapple Juice)
• Gait
• Muscular palpation
• Range of motion
• Muscle strength
• Posture
• Joint palpation
Procedure and Technique
Procedure
Normal/Significant Findings
Have the patient stand with his feet together.
The knees should be symmetrical and located at the same
height in a forward-facing position.
Observe and evaluate his posture, pace and
length of stride, foot position, coordination,
and balance.
Assess muscle mass.
Normal findings include smooth, coordinated movements,
erect posture, and 2 to 4 inches between the feet.
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).
Table 5.11 Musculoskeletal Assessment Procedure and Findings
MUSCLE TONE AND STRENGTH
0 = COMPLETE PARALYSIS
1 = 10%-NO MOVEMENT CONTRACTION OF MUSCLE PALPABLE/VISIBLE
2 = 25% - FULL MOVEMENT AGAINST GRAVITY WITH SUPPORT
3 = 50% - NORMAL MOVEMENT AGAINST GRAVITY
4 = 75%- NORMAL MOVEMENT AGAINST GRAVITY WITH MINIMAL
RESISTANCE
5 = 100%-NORMAL FULL MOVEMENT WITH FULL RESISTANCE
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VI. DIAGNOSTIC EXAMINATIONS
• 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:
A. Pretest
• Focus: Client Preparation
• Consent is secured for every invasive procedure or diagnostic test
• For radiologic studies: special precautions for pregnant clients
• Know the supplies and equipment needed for a specific test
• Know if the client needs to be on NPO prior to the test and if a dye is needed; if so, assess client for
allergy
B. Intratest
• Focus: specimen collection and assisting or performing the test
• Use or practice standard precaution and sterile techniques
• Provide emotional and physical support to the client
C. Post – Test
• Focus: providing nursing care and follow – up
A. GIT
DIRECT VISUALIZATIONS (INVASIVE)
(a) Lower GI Endoscopy:
A. Anoscopy — Visualization of the anal canal
B. Proctoscopy —Visualization of the rectum
C. Proctosigmoidoscopy
o Visualization of the rectum and sigmoid colon
Position: knee chest or lateral
o Cleansing enema is needed
o Pre Test: laxative
o Post test: position in a supine manner for a few minutes
▪ Monitor for bleeding and perforation
D. Colonoscopy
o Needs to be sedated
Position: sims/ left side, knees flexed
o Post test: assess for bradycardia and hypotension
▪ Assess also for perforation
▪ Endoscopy ( UGI)
o Pre test:
▪ NPO
▪ Needs sedation
▪ Local spray anesthetic is administered
o Post Test:
▪ NPO until gag reflex returns
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(b) Gastric Analysis
• Measures gastric pH and pepsin
• Pre Test: NPO for 12 hours
• Requires NGT insertion that is connected to a suction
• Specimen is taken every 15 min to one hour
INDIRECT VISULAIZATION
(a) Barium Swalllow ( upper GIT )
o To visulalize esophagus down to the jejunum
o Needs to be on NPO for 6 – 8 hours
o Barium Sulfate is taken by mouth prior to the procedure
o Post test:
▪ Laxative is given to wash off barium
▪ White stool is observed for about 72 hours
(b) Barium Enema ( Lower GIT )
o Visualize colon
o Pretest:
▪ low residue/clear liquid diet for 2 days
▪ laxative
▪ cleansing enema is administered in the morning before the test
▪ barium sulfate via rectal route
o Post test:
▪ laxative
▪ increase OFI
(c) Fecalysis
A. Guaiac Stool Exam
o Used to assess Gastro intestinal Bleeding
o Pre Test: increase fiber diet 48 -72 hours prior
▪ No red meat, iron and steroids, indomethacin and colchicine these can alter results
o Taken in 3 consecutive days
B. Stool for Ova and Parasites
o Specimen should be sent immediately (warm and fresh)
C. Stool Culture
D. Stool for Lipids
o To assess stool for steatorrhea
B. RESPIRATORY SYSTEM
INVASIVE
(a) Mantoux Test
o Purified protein Derivative
o Intradermal injection which will be read after 48 hours and 72 hours
o 10 mm induration is positive for Mycobacterium tuberculosis
o 5 mm induration for an HIV positive patient is already positive mantoux test
(b) Bronchography
o Pre test:
▪ A radioopaque medium is injected into the trachea and bronchial tree
▪ Check for allergies to seafoods, iodine and lidocaine
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o
o
Requires to be on NPO for 6 – 8 hours
Meds prior to test:
▪ Atropine sulfate
▪ Valium
o Post-test:
▪ Remain on NPO until gag reflex returns
▪ Position on side lying
(c) Bronchoscopy
o visual examination of the larynx, trachea & bronchi with a fiber-optic bronchoscope
o Pre test:
▪ NPO 6 – 8 hours
▪ Needs to be sedated
o Post Test:
▪ Remain on NPO until gag reflex return
▪ Monitor for complications: bronchospasm, bronchial perforation, crepitus, dysrhythmia, fever,
hemorrhage, hypoxemia, and pneumothorax
▪ Notify the MD if complications occur
(d) Lung Scan
o Used to detect pulmonary embolism
o Pre test: radio isotope is injected
o Scans are taken with scintillation camera
(e) Thoracentesis
o Aspiration of fluid / air from pleural space
o Position : upright leaning on over bed table or
▪ Side lying
o Post Test:
▪ Position on the unaffected side to prevent leakage
(f) Lung Biopsy
o To detect malignancy
o Pre Test:
▪ NPO prior
▪ Local anesthetic
▪ Pressure during insertion and aspiration
▪ Administer analgesics & sedatives
o Post 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
(g) Pulmonary Angiography
o insertion of a flouroscopy via the antecubital or femoral vein into the pulmonary artery
o it involves iodine or radiopaque or contrast material
o Pre Test:
▪ Assess for allergies to iodine, seafood & dyes
▪ NPO prior to procedure
o Post Test:
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▪
▪
▪
▪
No BP for 24 hrs in the affected extremity
Monitor peripheral neurovascular status
Assess for bleeding
Monitor dye reaction
(h) Ventilation Perfusion Scan
o determines the patency of the pulmonary airways
o a radionuclide may be injected
o Pre Test:
▪ Assess for allergies to dye, iodine, or seafood
▪ Remove jewelry
▪ Review breathing methods
▪ Administer sedation
▪ Emergency resuscitation equipment
o For 24 hrs following the procedure, handle body secretions carefully,
o Instruct the client to wash hands carefully with soap and H2O for 24 hrs following the procedure
C. CARDIOVASCULAR SYSTEM
INVASIVE HEMODYNAMIC MONITORING
(a) Central 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 stopcock
• Purpose: Assess pressure of the right atrium, blood volume, pumping function of the right side of the heart
• Normal range is SV : 0 -12 cm H20
RA : 4-10 cmH20;
o elevation indicates hypervolemia,
o decreased level indicates hypovolemia
• Maintain zero point of manometer always at level of right atrium (midaxillary line)
• Stop ventilatory assistance during measurement of CVP
• Practice Strict Aseptic Technique
(b) Pulmonary Artery Pressure and Pulmonary Capillary Wedge Pressure
• Uses 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:
o Proximal port: measures RA pressure
o Distal port: measures Pulmonary Artery pressure and Pulmonary Capillary Wedge Pressure
o Normal Range: PAP : 4 – 12mmHg
o PCWP : 4 – 12 mmH
o Ensure that balloon is deflated with a syringe attached except when PCWP is read
o Irrigate line before each reading of PCWP
o Maintain client in same position for each reading
o Record PA systolic and diastolic readings at least every hour and PCWP as ordered.
(c) 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
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• with injection of a dye, it allows visualization of the heart chambers, blood vessels and blood flow
(angiography)
• Pre Test:
o any allergies esp. to iodine
o keep client on NPO for 8-12 hrs
NON INVASIVE
(a) Electrocardiogram (ECG)
ECG in MI:
• Monitors the electrical activity of the heart
> Elevated ST segment
• Strip: small square: 0.04secs. and large square: 0.2secs
> Inverted T wave
o P wave: produced by atrial depolarization; indicates SA node function
> Q wave
o P-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
o QRS complex (N°= 0.06-0.10 secs.)
a. indicates ventricular depolarization
b. measured from onset of Q wave to end of S wave
o ST segment
a. indicates time interval between complete depolarization of ventricles and repolarization of
ventricles
b. measured after QRS complex to beginning of T wave
o T wave
a. represents ventricular repolarization
b. follows ST segment
(b) Echocardiography
o noninvasive recording of the cardiac structures using ultrasound
(c) Portable recorder (Holter monitor)
o provides continuous recording of ECG for up to 24 hrs
o assess activities of the heart which precipitate dysrhythmias and time it occurred
(d) Exercise ECG (stress test)
o the ECG is recorded during prescribed exercise; may show heart disease when resting ECG does not
Cardiac enzymes: in MI
a. Troponin T: detected 3-12 hours after
chest pain
b. Troponin I: detected 3-12 hrs
c. creatine phosphokinase (CPK – MB):
6-12Hrs
d. Aspartate aminotransferase (AST)
(SGOT): 24 Hrs after chest pain
e. Lactic dehydrogenase (LDH): 36 Hrs
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D. ENDOCRINE SYSTEM
(a) 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
•
hyperthyroidism , thyrotoxicosis
•
hypothyroidism, thyroiditis
(b) T3 and T4 resin
• Blood test for diagnosis of thyroid disorders
• Normal Value : T3: 80-230 ng/dL
T4: 5-12 ng/dL
• increase in hyperthyroidism & decreased in hypothyroidism
(c) 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
(d) Thyroid Scan
• Performed 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.
(e) Needle Aspiration of Thyroid Tissue
• Aspiration of thyroid tissue for cytological exam,
• No preparation needed
• Light pressure applied to aspiration site after the procedure
(f) 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
o 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
o In Cushing’s syndrome, hyperactivity of the adrenal cortex increases the urine output of
steroids in the second urine specimen tenfold
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(g) Glucose Tolerance Test:
• Pre test:
o eat a high-carbohydrate (200 to 300 g) diet for 3 days before the test
o avoid alcohol, coffee & smoking 36 hours before testing
o fast midnight before test
o fasting blood glucose & urine glucose specimens obtained.
o avoid strenuous exercise 8 hours before & after test
o client ingests 100g glucose; blood sugar drawn at 30 & 60 mins, then hourly for 3-5 hrs
o urine specimens may also be collected
(h) Glycosylated Hemoglobin :
• Is a reflection of how well blood glucose levels have been controlled for up to the prior 4 months
• Fasting is not needed
• Values:
o Diabetics with good control: 7.5% or less
o Diabetics with fair control: 7.6% to 8.9%
o Diabetics with poor control: 9% or greater
E. PERIPHERAL VASCULAR SYSTEM
NON – INVASIVE
(a) Doppler Ultrasonography
• Non-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
(b) 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:
o Metal objects including jewelry, eyeglasses, dentures and hairpins may affect the CT images and
should be left at home or removed.
o If contrast medium will be used, patient needs to be on NPO. And assess for seafood and iodine
allergy.
o Pregnant women may not be allowed to undergo this test.
o 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
o 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.
o After a CT scan, you can return to your normal activities. If you received a contrast material, you
may be given special instructions.
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(c) Magnetic Resonance Imaging ( MRI )
• noninvasive, usually painless medical test
• Useful in detecting Abdominal Aortic Aneurysms and deep vein thrombosis
• Some 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 because this will interfere with the
magnetic field. These items include:
o Jewelry, watches, credit cards and hearing aids, all of which can be damaged.
o Pins, hairpins, metal zippers and similar metallic items, which can distort MRI images.
o Removable dental work.
o Pens, pocketknives and eyeglasses.
o internal (implanted) defibrillator
o cochlear (ear) implant
o 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
(a) Plethysmography
• 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 heart
• Three 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:
o Do not smoke for at least 30 minutes before the test.
o clothing from the arm and leg being tested should be removed.
(b) Venography
• Phlebogram - 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 them
• X-rays are taken as the dye flows through the leg.
• Assess for iodine allergies and for any history of allergic reactions
(c) Angiography
• Arteriography 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. Xrays will be taken to see how the
dye flows through the arteries.
• Pre Test:
o Assess for allergies ( esp. to seafoods and iodine)
o NPO for 2 to 6 hours
• Post Test:
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o Monitor peripheral pulses on punctured extremity
o Pressure dressing and ice packs at the puncture site
F. HEPATO-BILIARY SYSTEM
(a) LIVER FUNCTION TEST
Albumin
• The normal range is 3.4 - 5.4 g/dL.
• 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 damage
• decreased: Hypothyroidism, malnutrition, pernicious anemia, placental insufficiency
• Normal range: Adult: 20–90 U/L ; Child: 60–270 U/L
ALT ( Alanine transaminase)
• SGPT;Serum glutamate pyruvate transaminase; Alanine transaminase
• Most accurate indicator of liver function
• 4–36 U/L (varies by method)
• 0.07–0.6 _kat/L
• Increased: Liver disorders, muscular dystrophy, muscular trauma, MI, CHF, renal failure, mono, burns,
shock, alcohol, numerous meds
• Decreased: Exercise, salicylates
AST/SGOT
• Male: 8–46 U/L
• Female : 7–34 U/L
• NB: 16–72 U/L
• Increased: Liver or biliary disorder, MI (between 6 hr and 3–4 days), shock, infectious mono, CHF, CVA,
infection or inflammation of muscle tissue
• Decreased: Pregnancy, DKA, salicylates
GGT ( Gamma-glutamyltranspeptidase)
• Male: 6–37 U/L
• Female: < 45 yr old 5–27 U/L ; > 45 yrs old 6–37 U/L
• Child : 3–30 U/L
• Increased: Liver disease, biliary obstruction, CHF, MI, epilepsy, cancer, mononucleosis, diabetes
mellitus, alcohol, numerous meds
• Decreased: Late pregnancy, oral contraceptives
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Partial thromboplastin time activated (PTT)
• 28–40 sec or within 5 sec of control
• Increased: Heparin, vit K deficiency, hemophilia, liver disease, DIC, polycythemia, leukemia
• Decreased: Extensive cancer
Serum Bilirubin :
• indirect: up to 0.8mg/dL
• increased: Sickle cell anemia, pernicious anemia, hemolytic anemia, septicemia, Rh or ABO
incompatibility in newborn, numerous meds
• Direct: up to 0.4mg/dL
> Increased: Liver disorders, obstructive jaundice
> Decreased: Barbiturates, salicylates, penicillin, caffeine (These can affect all types of bilirubin.)
• Total up up 1.0mg/dL
Urine Urobilinogen
• Bilirubin, 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 destruction
• NV : 0.2 – 1.2 Units or 0 - 8 mg/dl / less than 17 umol/l (< 1mg/dl)
• Increased values:
o 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 Liver
• Pre Test:
o Needs to be on NPO 8 – 23 hours
o Increase fluid intake
o Laxative is administered a night prior the test
Liver biopsy
• examines 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 liver
• Pre test:
o the physician will take blood samples to make sure blood clots properly.
o One week before the procedure, the patient will have to stop taking aspirin, ibuprofen, and
anticoagulant
o NPO 2 – 4 hours
o Vit K is injected
o Instruct 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:
o Lie down on the right side for 4 hours with pressure dressing or apply pressure on the
incision site to prevent bleeding
o Bed rest for 24 hours
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Paracentesis:
• a procedure to aspirate fluid that has collected in the peritoneum
• The 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:
o Empty bladder prior to test to prevent puncturing the bladder
o Check serum protein studies
• Intra Test:
o Position client: sitting or upright position
• Post Test:
o Monitor client’s vital signs and rigidity of abdomen / signs of peritonitis
G. NEUROLOGIC SYSTEM
(a) CT SCAN
• A cranial CT scan is computed tomography of the head, including the skull, brain, orbits (eye sockets),
and sinuses.
• Used to detect intracranial bleeding, space- occupying lesions, cerebral edema, infarctions,
hydrocephalus, cerebral atrophy, and shifts of brain structures
• Pre Test:
o Assess allergies if dye is used
o Instruct the client to lie still and flat during test
o Remove objects from the head
o Inform the client of possible mechanical noises during the test
o When dye is injected – there may be a hot, flushed sensation and metallic taste
• Post Test:
o Provide replacement fluids because diuresis is expected if dye is used
o Monitor allergic reaction from the dye
o Assess dye injection site for bleeding and monitor extremity for color, warmth, and the
presence of distal pulses
(b) EEG ( 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:
o certain medicines (such as sedatives and tranquilizers, muscle relaxants, sleeping aids, or
medicines used to treat seizures) should be WITH HELD before the test.
o Do not eat or drink foods that have caffeine (such as coffee, tea, cola, and chocolate) for 8
hours before the test.
o it is important that the hair be clean and free of sprays, oils, creams, and lotions.
o 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.
o 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 usual
o If a child is going to be tested, try to keep him or her from taking naps just before the test
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• Intra test:
o 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.
INVASIVE
(a) Lumbar Puncture
• Insertion of a spinal needle through L3-L4 interspace into the lumbar subarachnoid space to obtain
CSF, measure CSF pressure, or instill air, dye or medications
• Contraindicated in clients with increased ICP
• Pre Test: Have the client empty the bladder
• Intra Test:
o Position the client in lateral recumbent position and have the client draw knees up to
abdomen and chin unto the chest
o Maintain strict asepsis
• Post Test:
o Flat on bed for 8 hours
o Observe for bleeding at puncture site’
o Observe for changes in vital signs
(b) Myelogram
• Injection of dye or air into the subarachnoid space to detect
abnormalities of the spinal cord and vertebrae
• Pre Test:
o Provide hydration for at least 12 hours before the test
o Assess for allergies
o If taking Phenothiazine – hold the medication
o Needs sedation
• Post Test:
o Assess vital signs and neurologic condition
o Elevate head 15 – 30 degrees for 6-8 hours if water –based dye is used
o Place flat on bed for 6-8 hours if oil-based dye is used
(c) Cerebral Angiography
• Injection 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:
o Assess for allergies
o Hydration 2 days before
o NPO 4-6 hrs prior the test
o Remove metals
(d) 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.
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• Pretest:
o Generally, most patients are told not to eat anything for a minimum of 6 hours before the scan.
o Heart patients are also told to not take any product with caffeine for at least 24 hours
• Intratest:
o 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.
H. MUSCULOSKELETAL SYSTEM
(a) BLOOD TESTS:
ESR (Erythrocyte sedimentation rate)
• Male : Up to 15 mm/h Female: Up to 20 mm/h Child: Up to 10 mm/h
• Increased: Inflammation, infection, pregnancy, acute MI, cancer
• Decreased: Polycythemia vera, CHF, sickle cell anemia
Rheumatoid Factor ( RF )
• <1 : 20 or negative
• Increased: Rheumatoid arthritis, SLE, scleroderma, dermatomyositis
Antinuclear antibodies (ANA)
• Neg at 1 : 10 dilution ; SI units Negative
• Present / positive:
o SLE, Sjögren’s syndrome, scleroderma, hepatitis, rheumatoid arthritis, cirrhosis, ulcerative
colitis, leukemia, infectious mononucleosis
Anti – DNA
• Anti-DNA or Anti-DNP
• Normal: Negative ; SI Units <2.0 kU/L
• Positive: 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 diseases
• Normal range: 0–1.0 mg/dL or less than 10 mg/L (SI units)
(b) BONE SCAN
• A bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown
• 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:
o 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.
o The client should empty your bladder right before the scan.
o He usually has to wait 1 to 3 hours after the radioactive tracer is injected before the bone scan is
done.
o Remove any jewelry that might interfere with the scan
o 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:
o The client will lie on his back on a table and a large scanning camera will be positioned closely
above him
o 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:
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47
o
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:
o the joint should be used as infrequently as possible for several days.
o Crutches may be needed if the foot or knee joint was examined, depending on the extent of
the procedure and the doctor's preference.
Arthrocentesis
• a joint fluid aspiration
Myelogram
• A 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:
o NPO 8 hours prior to the test
o The client may need to take a laxative or have an enema before the test to empty the
bowels.
o 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).
o take off jewelry that might be in the way of the X-ray picture.
• Post test:
o Elevate head 15 – 30 degrees for 6-8 hours if water –based dye is used
o 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 stress
• Measuring 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)
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I.
EYES AND EARS
Tonometry
• A 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:
o Do not drink more than 2cups of fluid 4 hours before the test.
o Do not drink alcohol for 12 hours before the test.
o Do not smoke marijuana for 24 hours before the test.
• Intratest: Numbing eyedrops are used.
Gonioscopy
• Gonioscopy 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:
o 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.
• Gonioscopy does not usually cause any discomfort. The eyedrops used to numb your eye may burn a little.
EARS
Rinne test: Equipment: Tuning Fork
• 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.
• 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: Equipment: Tuning Fork
• 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
• If 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 ossicles
• Sensorinueral 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 lip-reading, 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).
Audiometry
• evaluates 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)
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J.
GENITOURINARY SYSTEM
NON INVASIVE
(a) KUB
•
X – ray of the kidneys, bladder and bladder
•
Pretest: Enema/ clean colon preparation prior to test
(b) URINALYSIS
Description
Normal Value
Clinical
Significance
Increased: alkaline
Decreased :
acidosis
pH
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)
Specific Gravity
Indicator of urine
concentration
or the amount
of solutes (wastes)
present in the urine
Method:
Urinometer/hydrometer
in a cylinder of urine
Spectrometer /
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
Product of breakdown of
fatty acids
None
Positive ; DM
None
Positive in poorly
controlled or
uncontrolled
DM
Positive: bleeding
Present if
glomerular
membrane has
been damaged
Increased:
Fluid volume
deficit
Decreased:
Fluid volume
excess
Ketones
Blood
Protein
Osmolality
SRG Integrals 2nd Ed.
0 – 2 RBCs
Qualitative: none
Quantitative:
10 – 100 mg / 24 h
Measures the solute
500 – 800 OsM/Kg
concentration
of urine
Monitors Fluid and
Electrolyte
imbalances
Table 5.12 Urinalysis
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50
INVASIVE
Blood Studies:
(a) BUN
• 5–25 mg/dL ( SI UNIT: 1.8–7.1 mmol/L)
• Child: 5–20 mg/dL /2.5–6.4 mmol/L
• Infant: 4–18 mg/dL / 1.4–6.4 mmol/L
• Increased: Dehydration, renal disorders (cause usually not renal if serum creatinine normal), tissue
necrosis, CHF, shock, MI
• Decreased: Inadequate protein intake, liver disease, water overload, nephrotic syndrome
(b) Serum Creatinine
• 0.6–1.5 mg/dL/ 53–133 μmol/L
• Child: 0.3–0.7 mg/dL
• Newborn: 0.3–1.0 mg/dL
• Increased: Impaired renal function, massive muscle damage
• Decreased: Muscular dystrophy, pregnancy, eclampsia
(c) Uric Acid
• Male: 4.0–8.5 mg/dL / 0.24–0.51mmol/L
• Female: 2.7–7.3 mg/dL / 0.16–0.43 mmol/L
• Child: 2.5–5.5 mg/dL / 0.15–0.33 mmol/L
• Increased: Gout, excessive purine intake, psoriasis, sickle cell anemia, chemotherapy, tissue destruction,
eclampsia, alcohol, numerous medications
• Decreased: Fanconi’s syndrome, numerous medications
(d) Albumin
• 3.5–5.0 g/dL or 52–68% of total protein
• Child: 4.0–5.8 g/dL
• Increased: Dehydration, exercise, meds, prolonged application of tourniquet prior to venipuncture
• Decreased: Malnutrition, chronic diseases, liver disorders, SLE, scleroderma, ascites, burns, nephritic
syndrome, chronic renal failure, Hodgkin’s disease, meds
(e) 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 tract
• Position: lithotomy
• Post – test:
o Pink tinged urine (24 – 48 hours) , dysuria, hematuria will be observed
o Observe for signs of infection
o Increase fluid intake
o Hot sitz bath to relieve pain
(f) IVP
• An intravenous pyelogram (IVP) is an X-ray test that provides pictures of the kidneys, the bladder, the
ureters, and the urethra
• During 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:
o Needs to be on NPO for 6 – 8 hours
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51
o
• Post test:
o
o
o
Assess for allergy to seafoods and iodine or any history of allergic reaction
Increase fluid intake to excrete dye
Bed rest
Asses for any delayed allergic reaction
(g) Renal Biopsy
• Renal tissue sample is taken and sent to a lab to detect any malignancy
• Pre test:
o sedation is done
o done with local anesthesia
o needs to be on NPO for 6 – 8 hours
• Intra test:
o position client to PRONE
o hold breath and remain still during needle insertion
• Post test:
o bed rest for 24 hours
o increase fluids up to 3000ml per day
o observe for bleeding tendencies and infections
LABORATORY DATA
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 prognosi
• Guide the selection of interventions
• Monitor the progress of the disorder
• Monitor the effectiveness of the treatment
Laboratory Values:
HEMATOLOGIC SYSTEM
Cell
Origin
Range ( in SI Units)
Erythrocytes
Bone Marrow
F: 4.0 – 5.2 x 10 12 / L
M: 4.5 – 5.9 x 1012 /L
Leukocytes
Bone Marrow
(Granulocytes, monocytes)
Major Function
Transport hemoglobin
Transporting carbon
dioxide in the form of
sodium bicarbonate
Being an acid-base
buffer for
whole blood
4.5 – 11.0 x 10 9 /L
The protective
system
150 – 300 x 10 9 / L
Vascular Repair
Plasma cells, lymph tissues
(lymphocytes)
Platelets
Bone Marrow
from
megakaryocytes
Table 5.13 Types of Blood Cells
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52
COMPLETE BLOOD COUNT
SI Range
Increased
Analyte
Decreased
Red Blood Cell
Count
F: 4.0 – 5.2 x 10 12 /L
M: 4.5 – 5.9 x 1012 /L
Hemoglobin
F: 120 – 150 g/L
M: 139 – 163 g/L
Hematocrit
F: 0.36 – 0.46
M: 0.41 – 0.53
26 – 34 pg/RBC
Dehydration
Induced hypoxia
Polycythemia
Obstructive lungdisease
Polycythemia
High altitude burns
Shock
Dehydration
Polycythemia
Macrocytosis
310 – 370 g/L
Spherocytosis
Luekemia
Hemorrhage
Microcytic
hypochromic
anemia
Chronic IDA
80 -100 fl
Aplastic anemia
Folic and Vit B12
Acute leukemia,
infections, surgery,
trauma
IDA, Thalassemias,
Chronic Anemia
Acute chronic
leukemias,aplastic
anemia, agranulocytosis
Mean Red Cell
Mean Red Cell
Concentration
Mean Red Cell
Volume
White Blood Cells
4.5–11.0 × 109/L
WBC Differential % of total WBC
Band Neutrophils
0–0.06%
Segmented
0.31–0.76%
neutrophils
Lymphocytes
0.14–0.44%
Monocytes
Eosinophils
Basophils
0.02–0.11%
0–0.04%
0–0.02%
Anemias
Hypothyroidism
Leukemias
Anemia
Severe hemorrhage
Severe bacterial disease - INC.
Diabetic acidosis, infarctions,
inflammatory diseases,malignancies - INC.
Chronic lymphocytic
Lupus erythematosus,
leukemia
Hodgkin’s disease
Chronic inflammatory diseases –INC.
Allergies, parasites - INC.
Myelofibrosis - INC.
Table 5.14 CBC with Significance
(a) Blood Type and Cross Matching
• a laboratory test that identifies the client’s blood type and determines the compatibility of blood between
a potential donor and recipient
• type O negative blood are often called universal donors
• type AB positive blood are called universal recipients
Cell Type
A
B
AB
O
Antibodies
Anti – B
Anti – A
None
Antigens
A antigen
B Antigen
A and B antigen
Anti – A and
Anti – B
None
Table 5.15 Blood Types
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53
Test
Normal Range
Erythrocyte sedimentation
rate
(ESR or sed rate)
Westergren:
F: < 50 yr 0–25 mm/h
> 50 yr 0–30 mm/h
M: < 50 yr 0–15 mm/h
> 50 yr 0–20 mm/h
Haptoglobin
0.10–0.30 g/L
12–35 _mol/L
Glucose-6-phosphate
dehydrogenase (G6PD)
(red blood cell)
F: 7.4–9.4 IU/g
hemoglobin Whites
6.5–9.3 IU/g hemoglobin
African-Americans
M: 7.4–9.4 IU/g
hemoglobin Whites
6.6–10.8IU/g hemoglobin
African-Americans
Osmotic fragility Test measures the
fragility
of RBCs to aid in
the diagnosis of hereditary
spherocytosis.
0.30%–0.45% saline
< 0.30% saline
> 0.50% saline
Significance
Alterations in the plasma
proteins cause aggregation of the RBCs with
an elevated ESR
moderately, with inflammatory diseases
high,
with
multiple
myeloma,
macroglobulinemias, hyperfibrinogenemias.
The test measures enzyme deficiencies that
are hereditary, sex-linked conditions carried
on the female X chromosome, which causes
hemolytic
anemia. Clinical disease traits
are found in males
Increased in hereditary
spherocytosis, spherocytosis
resulting from autoimmune
hemolytic anemia, severe
burns, chemical poisoning,
erythroblastosis
fetalis, transfusion reactions,
prosthetic heart
valve transplantation.
Decreased in
sickle cell and iron deficiency
anemia, polycythemia
vera, hemoglobin C disease,
thalassemia major, liver
disease, obstructive jaundice,
or splenectomy
Increased in hemolytic and sickle cell
anemia; hereditary spherocytosis; treatment
of anemias
from iron, vitamin B12 , and folic acid
deficiencies.
Decreased in aplastic,
iron deficiency and untreated
pernicious anemias;
chronic infection;
radiation therapy
Reticulocyte count
Used to differentiate
between hypoproliferative
and hyperproliferative
anemias;
to assess blood loss and
bone marrow
response to therapy
Adults 0.5–2.0%
Children 0.5–2.0%
Infants 0.5–3.5%
Newborns 2.5–6.0%
Table 5.16 Hematologic Function Studies
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54
BLOOD CHEMISTRY
(a) Blood Glucose
Glucose measurement is performed by either :
• Skin puncture or venipuncture
(b) Fasting Blood Sugar (FBS)
• normal fasting value is 70 to 115 mg/dl
• nonfasting (usually 2-hours postprandial)
• less than 120 mg/dl
(c) 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 fasting
• The test is conducted as follows:
o Initial blood and urine specimens are obtained.
o An oral loading dose of glucose is administered.
o Blood and urine specimens are obtained at 30 minutes, 1 hour, 2 hours, 3 hours, and sometimes
4 hours after loading dose.
(d) Glycosylated Hemoglobin
• Reflects serum glucose for the past 2 – 4 months
• Most accurate
(e) 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 :
o 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
o 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, newborns
Clinical Significance :
o Increased: high potassium intake (oral, IV therapy, rapid infusion of aged blood); renal
disease; drugs (adrenal steroids, potassiumconserving diuretics, potassium penicillin,
chemotherapeutic agents); Addison’s disease; burns and other massive tissue trauma;
metabolic and respiratory acidosis.
o Decreased: drugs (diuretics, digitalis); metabolic alkalosis; primary aldosteronism;
Cushing’s disease;vomiting and gastric suction
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55
• Calcium - Total 8.4–10.5 mg/dl Ionized 1.13–1.32 mmol/L
Clinical Significance :
o Increased: hyperparathyroidism; bone catabolism (multiple myeloma, leukemia, bone
tumors); immobility.
o 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 for adult, 1.6–2.6 mEq/L for children, 1.4–2.9 mEq/L for newborn
Clinical Significance:
o Increased : hyperparathyroidism; drugs (ammonium chloride, ion exchange resin,
phenylbutazone); metabolic acidosis; respiratory acidosis; dehydration.
o Decreased: prolonged vomiting and gastric suction; diarrhea; diuretics(ethacrynic acid
and furosemide).
• Magnesium - 1.3–2.0 mEq/L for adult, 1.6–2.6 mEq/L for children, 1.4–2.9 mEq/L for newborn
Clinical Significance :
o Increased: chronic renal failure, drugs (magnesium sulfate, antacids, enemas containing
magnesium, sedatives); acute adrenalcortical insufficiency.
o Decreased: chronic diarrhea and alcoholism, nontropical sprue, steatorrhea, hereditary
malabsorption, starvation, bowel resection, diuretics (mannitol,urea, glucose);
hypoparathyroidism
• Phosphate - 2.7–4.5 mg/dl for adult, 4.5–5.5 mg/dl for children, 4.5–6.7 mg/dl for newborn
Clinical Significance :
o Increased: renal insufficiency; intake, IV solutions and enemas; blood transfusion;
muscle necrosis; hypoparathyroidism
o Decreased: alcohol withdrawal;hyperventilation; diabetic ketoacidosis; phosphatebinding antacids
(f) Blood Enzymes:
•
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
CPK1 (BB)
0 IU/I
CPK2 (MB)
0–7 IU/I
Clinical Significance
Primarily in brain/indicative of cerebrovascular
accident
Exclusively in myocardium/indicative
of myocardial infarction
5–70 IU/I
Found in skeleton and myocardium/skeletal
muscle disorders
Table 5. 17 CPK Isoenzymes
CPK3
Isoenzyme
LDH1
LDH2
SRG Integrals 2nd Ed.
Normal Range
17–33
27–37
Fundamentals of Nursing
Clinical significance
Primarily in heart, kidneys, RBCs
Primarily in heart, kidneys, RBCs
56
LDH3
18–25
Primarily in lungs, to a lesser extent in
pancreas, thyroid, adrenal glands,
lymph nodes
3–8
Liver and skeletal
Tissue
0–5
Liver and skeletal tissue
Table 5.18 LDH Isoenzymes
LDH4
LDH5
Enzyme
Normal Range
Alanine aminotransferase
Aldolase
0–30 IU/L
0–8 IU/L
Amylase
Aspartate aminotransferase
Lipase
Total: 40–220 IU/L
0–35 IU/L
0–1 CherryCrandell U/L
0–17 U/L
5'-Nucleotidase
Clinical Significance
Hepatocellular Damage
Anemia (hemolytic and megaloblastic);
Granulocytic leukemia; metastatic
carcinoma; skeletal muscle tissue damage
Pancreatitis
Hepatitis; infectious mononucleosis; cirrhosis
Acute pancreatitis
Biliary cirrhosis; extrahepatic obstruction; hepatic
carcinoma
Table 5.19 Digestive Enzymes
(g) 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:
o Chylomicrons—mainly ingested triglycerides
o Very low-density lipoproteins (VLDLs)—mainly endogenous triglycerides
o Low-density lipoproteins (LDLs)—moderate amounts of phospholipids with 50% cholesterol
o 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
o High-density lipoproteins (HDLs)—50% protein
Lipid
Normal Range/Border Line
Risk for CHD
Cholesterol
< 200 mg / dl
200 – 239
> 250 mg/dl
LDL Cholesterol
HDL Cholesterol
Triglyceride
SRG Integrals 2nd Ed.
< 130 mg/dl
130 – 159 mg/dl
> 40 mg /dl
35 -40 mg/dl
< 250 mg/dl
250 – 500 mg/dl
Table 5.20 Types of Lipoproteins
Fundamentals of Nursing
> 160 mg /dl
< 35 mg/dl
> 500 mg /dl
57
(h) Coagulation Studies
• aPTT ( activated partial Thromboplastin)
o
normal value: 20 to 36 seconds
o
measures the time it takes for a citrated plasma to clot,after a partial thromboplastin to clot
o
antidote: warfarin sodium/coumadin
• Prothrombin time and International Normalized Ration (INR)
o M: 9.6 to 11.8 seconds
o F: 9.5 – 11. 3 seconds
o INR : 2 – 3 seconds for warfarin therapy
o 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 K
(i) Thyroid Lab data:
• Used to evaluate thyroid disorders
• Normal Values
TSH (thyroid stimulating Hormone)
Normal Range
TSH (thyroid stimulating Hormone) /
thyrotropin
0.2 – 5.4 microunits/mL
Thyroxine
5.0 – 12.- mcg/dl
Triiodothyronine
80 – 230 ng/dl
Table 5.21 Thyroid Hormones
(j) Hepatitis Test:
• Serological tests ( detects specific virus )
• HIV/AIDS
• The following tests detects presence of antibodies
o Enzyme Linked immunosorbent assay ( ELISA)
o Western Blot - CONFIRMATORY TEST
o Immunofluorescence assay ( IFA)
• CD4+ T cell counts:
o Monitors / evaluates the progress of the virus
o Normal : 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
Digoxin ( Lanoxin )
Imipramine(Tofranil)
Lidocaine
10 – 20 mcg/mL
0.5 – 2.0 ng/mL
150 – 300 ng/mL
1.5 – 5.0 mcg/mL
Lithium
Phenobarbital
SRG Integrals 2nd Ed.
0.5 -1.3 mEq/L
50 – 150 ng/mL
Fundamentals of Nursing
58
Phenytoin (dilantin)
10- 20 mcg/mL
Table 5.22 Therapeutic Range of Medications
SPECIMEN COLLECTION
(a) Sputum Specimen:
Purpose:
• For Culture and sensitivity test. To test for specific microorganism
• Cytology ( identify origin, structure, function and pathology of cells)
• For AFB to detect TB
o Done in 3 consecutive days
o Evaluate effectiveness of therapy
* NOTE:
• Best collected in the morning upon awakening
• If client cannot cough, do pharyngeal suctioning
• Mouth care should be done prior to obtaining specimen (water only)
• 1 – 2 tablespoon or 15 – 30 ml (4 – 8 fluid dram) of sputum is needed
(b) Throat Culture:
• Collected from the mucosa of the oropharynx and tonsillar region with the use of culture swab
• Purpose: detect specific microorganism
• This is an invasive procedure
o Position: sitting position ( if tolerated )
o Extension of tongue ( to expose the pharynx)
o Let the patient say “ah” to relax the throat muscles
(c) Blood collection
• Laboratories 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 costeffective. 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:
o Red—no additive
o Lavender—EDTA (ethylenediaminotetraacetic acid)
o Light blue—sodium citrate
o Green—sodium heparin
o Gray—potassium oxalate
o Black—sodium oxalate
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59
Arterial Puncture
• To assess Arterial Blood Gas ( ABG )
• Blood gases are ordered to evaluate:
o Oxygenation
o Ventilation and the effectiveness of respiratory therapy
o Acid-base level of the blood
o 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:
o
If the client is hyperthermic
o
Immediately after breathing and suctioning treatments
o
If there have been changes on ventilator settings
o
Anticoagulant therapy
o
Clotting disorders
o
Symptomatic peripheral vascular disease
o
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:
o
Heel—most common site for neonates and infants
o
Fingertip—the inner aspect of palmar fingertip used
o
most commonly in children and adults
o
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
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Fundamentals of Nursing
60
(d) 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 24 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, 24 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
(e) Stool Collection
• Stools can be collected for either a one-time defecation or over 24, 48, or 72 hours
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VI. THERAPEUTIC NURSING PROCEDURES
POSITIONING CLIENTS
BASIC PRINCIPLES IN POSITIONING OF PATIENTS:
• Maintain good patient body alignment. Think of the patient in bed as though
he were standing.
• Maintain the patient's safety.
• Reassure the patient to promote comfort and cooperation.
• Properly handle the patient's body to prevent pain or injury.
• Keep in mind proper body mechanics for the practical nurse.
• Obtain assistance, if needed, to move heavy or helpless patients.
• Follow specific physician's orders.
Position
Description
DORSAL
RECUMBENT
Flat on back with legs flexed at hips and
knees
Therapeutic Use
• Feet flat on mattress
•
Position
FOWLER’S
Description
For perineal, rectal and vaginal examination
Therapeutic Use
Head of bed up 30 to 90 degrees
· High Fowler’s: sitting upright at 90
degrees
Semi-Fowler’s: head and torso elevated
45 to 60 degrees
• Low Fowler’s: head and torso
elevated to 30 degrees Knees slightly
flexed
•
•
•
•
•
•
•
SRG Integrals 2nd Ed.
Fundamentals of Nursing
Relieve DOB/ SOB,
post thyroidectomy, laryngectomy, bronchoscopy,
post mastectomy (with the hands elevated on a
pillow),
patients with increased ICP
NGT insertion,
patients with COPD,
post abdominal aneurysm resection,
patients with CHF and pulmonary edema
62
KNEE-CHEST • prone with weight of upper body
supported on flat surface by chest
• Hips and knees flexed to elevate
buttocks
•
Position
LITHOTOMY
Description
To prevent further cord prolapse. , Promotes
Maximum exposure of Rectum
Therapeutic Use
Flat on back with legs
flexed 90 degrees at hips
and
knees
• Feet up in stirrups
PRONE
•
For vaginal/ perennial procedures and assessment
•
After amputation of lower extremities: prone position 10-30
minutes twice a day
•
For rectal enemas/irrigations
• Flat on abdomen with
knees slightly flexed
• Head turned to side
• Arms flexed at side
SIMS
• Halfway between side
lying and prone with
bottom
knee slightly flexed
• Lower arm behind back
• Upper arm flexed, hand
near head
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Position
Description
TRENDELENBURG
• Head is low with body and
legs elevated on an inclined
plane
LATERAL RECUMBENT
Therapeutic Use
• Side lying with upper leg
flexed at hip and knee
• Lower arm flexed with
shoulder positioned to avoid
weight of body on shoulder
SUPINE
•
During Lumbar Puncture
•
After liver biopsy (right side lying)
•
After lumbar puncture
•
During liver biopsy
•
After myelogram (if Oil-based); Head of bed
elevated if water-based
Flat on back with body in
anatomic alignment
Table 6.1 Therapeutic Positions, Description and Uses
ACTIVE AND PASSIVE RANGE OF MOTION EXERCISES
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.
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Fundamentals of Nursing
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•
•
To increase tolerance for more activity.
To maintain and build muscle strength.
Definition
These 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.
Persons Involved
Nurse only
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.
Patient and Nurse
Active
Active exercises are performed by
the patient, without assistance, to
increase muscle strength.
Patient only
Resistive
These are active exercises
performed by the patient by pulling
or pushing against an opposing
force.
Patient and 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
Patient only
Passive
Table 6.2 Types of Exercises
Body Movement
Flexion
Extension
SRG Integrals 2nd Ed.
Definition
Pictures Demonstrating Body
Movement
The state of being bent. The cervical
spine is flexed when the chin is moved
toward the chest.
The state of being in a straight line.
The cervical spine is extended when
the head is held straight.
Fundamentals of Nursing
65
Hyperextension
Abduction
Adduction
Rotation
Circumduction
Supination
Pronation
SRG Integrals 2nd Ed.
The state of exaggerated extension.
The cervical spine is hyperextended
when the person looks overhead,
toward the ceiling.
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.
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.
Turning of a body part around an axis.
The head is rotated when moved from
side to side to indicate "no."
Rotating an extremity in a complete
circle. Circumduction is a combination
of abduction, adduction, extension,
and flexion.
The palm or sole is rotated in an
upward position.
The palm or sole is rotated in a
downward position.
Table 6.3 Body Alignment
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66
NUTRITION
Vitamin /
Mineral
Recommended Daily Allowance
Men
Uses
Food Source
Women
FAT SOLUBLE VITAMINS
A
1000 RE
800 RE
Proper vision, growth
Liver, milk, eggs, betacarotene found in darkorange and dark green fruits
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 VITAMINS
C
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 to energy
Dairy products, meat,
poultry, fish, whole-wheat
and fortified grain products,
green leafy vegetables
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Fundamentals of Nursing
67
Niacin (B3)
19 mg
15 mg
Converting carbohydrates, fats,
and amino acids to energy
Meat, milk, eggs, poultry,
fish, enriched breads and
cereals
B6
2 mg
1.6 mg
Assistance in at least 50 enzyme
reactions—the most important
regulate nervous system activity
Chicken, fish, liver, pork,
eggs, whole-wheat products,
peanuts, walnuts
Folate
200 µg
180 µg
Manufacturing of DNA and new
body cells
Liver, leafy vegetables,
legumes, fruits
B12
2 µg
2 µg
Manufacturing of new body cells
and mature new red blood cells,
maintenance of nerve growth,
protection of nerve cells
Meat, poultry, fish, dairy
products
MINERALS
Calcium
800 mg
800 mg
Building bone, transmitting
nerve impulses, and aiding
muscle 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 the body
utilize energy and reproduce
cells
In nearly all foods
Magnesium
350 mg
280 mg
Holding calcium in tooth
enamel, assistance in relaxing
muscles after contractions
Nuts, legumes, cereal grains,
green vegetables, seafood
SRG Integrals 2nd Ed.
Fundamentals of Nursing
68
Iron
10 mg
15 mg
Transporting oxygen in red
blood cells and muscle cells,
DNA synthesis, formation of
major enzymes
Meat, poultry, fish, dried
beans and peas, fortified
grain products
Zinc
15 mg
12 mg
Promotion of healing and
growth, maintaining immune
function, DNA synthesis,and a
normal sense of taste
Meats, oysters, milk, egg
yolks
Iodine
150 µg
150 µg
Helping the thyroid regulate
metabolism
Seafood, iodized table salt
Selenium
70 µg
55µ g
Destruction of free
radicals,formation of enzymes
Fish, meat, breads, cereals
Table 6.4 Vitamins and Minerals
The Food Pyramid:
THERAPEUTIC DIETS
Illustration 6.1 Food Pyramid
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Fundamentals of Nursing
69
DIET
Acid-ash diet
•
•
•
Alkaline ash diet
•
•
•
Bland diet
•
•
BRAT Diet
•
•
Butterball diet
•
Clear liquid Diet
•
•
Diabetic Diet
•
•
Full liquid diet
•
•
Giordano Diet
•
•
Gluten free Diet
•
•
Halal Diet
•
•
•
•
High Fiber Diet
High Protein Diet
Kosher Diet
SRG Integrals 2nd Ed.
•
•
•
•
Fundamentals of Nursing
Description
Retards the formation of alkalinic renal stones
Indicated to patients with renal calculi (Alkaline
stones)
E.g. cheese, cranberries, eggs, meat, plums,
prunes, whole grains
Retards the formation of acid renal stones.
Indicated to patients with renal stones (Acidic
stones)
E.g. fruits (except cranberries, plums, prunes),
milk, vegetables
Low fiber, mechanical irritants, chemical
stimulants
Indicated for patients with gastritis, diarrhea,
biliary indigestion, and hiatal hernia
Banana, Rice, Apple. Toast
Indicated for patients with diarrhea
Spare protein but high in carbohydrates
Indicated for patients with liver disorders
To relieve thirst and help maintain fluid balance
Indicated for post-op. patients and for vomiting
and gastroenteritis
Well balance diet
The purpose is to maintain near to normal blood
glucose level
Indicated to patients with diabetes mellitus
It serves to provide nutrition to patients who
cannot chew or tolerate solid foods. Indicated to
patients with
stomach upsets, postsurgical patients, after progression from clear
liquid diet
Spare protein
Indicated to patients who suffers from Chronic
renal Failure
No to B R O W – Barley. Rye. Oat, Wheat
This is the diet of a patient who suffers from
Celiac’s Disease
No pork diet
Diet of the Moslem
Fruits and vegetable
It speeds up the passage of food to the digestive
tract, it softens the stool, Indicated to patients
who are constipated, with diverticulosis, with
hyperlipidemia
Lean-meat, cheese, eggs
Indicated to patients with nephrotic syndrome
Meat and milk cannot be served simultaneously
Diet of the Orthodox Jews
70
Low carbohydrate diet
Low fat/cholesterol Diet
•
•
•
Low Residue diet
•
•
Low Sodium Diet
•
Purine restricted diet
•
•
Sodium-restricted diet
•
Soft diet
•
•
Tyramine-free Diet
•
•
Vegan Diet
Yin Diet
SRG Integrals 2nd Ed.
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•
Fundamentals of Nursing
Indicated to patients with dumping syndrome
It serve the purpose of reducing hyperlipedemia,
and to patients with intolerance to fats
Indicated to patients with cardiovascular diseases,
patients who underwent resection of the small
intestines, hypertension and cholecystitis
Reduces the bulk of stools
Indicated to patients with ulcerative colitis,
diverticulitis, and patients who will undergo
surgery of the GI tract
Indicated to patients with cardiovascular and renal
disorders
To reduce uric acid
Indicated to patients with gouty arthritis, renal
calculi, and hyperuricemia
Indicated to patients with heart failure,
hypertension, renal diseases, PIH, and steroid
therapy
Used to provide nutrition for those patients who
have problems in chewing
For patients with ill-fitting dentures; transition
from full-liquid to general diet, patients with
gastrointestinal disturbances such as gastric ulcers
and cholelithiasis
Use 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
Diet of the Seventh Day Adventists
Cold deserts after a surgery. It is a Chinese belief.
71
VII.
GENERAL MEDICAL AND NURSING PROCEDURES
A. GASTROINTESTINAL SYSTEM
(a) GASTRIC TUBE INSERTION
▪
▪
▪
▪
Purposes:
Administer tube feedings and medications to clients who cannot take in food per orem ( Gavage )
Prevent gastric distention, nausea and vomiting
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 patient
3. Wash hands.
4. Position the patient in a sitting position
5. Check nostrils for patency by asking the patient to breathe through one nares while occluding the other.
6. Measure length of NG tubing.
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 end, leaving 1 inch intact at the opposite end
13. 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.
14. Connect the NG tube to suction if ordered, or clamp.
15. Wrap adhesive tape around the distal end of the tubing and attach a safety pin through the tape tab to the
patient’s gown.
16. 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.
(b) TOTAL PARENTERAL NUTRITION (TPN)
SRG Integrals 2nd Ed.
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72
▪
is delivered via a central venous catheter to reverse starvation and promote tissue synthesis, wound healing,
and normal metabolic function.
Access:
Peripheral- 2 weeks – phlebitis
PIC – Basilic / cephalic
PCC – subclavian
Triple Lumen- infuse and draw blood;TPN;Medications
Atrial- Hickman/Biovac and Groshong; Huber needle port
Guidelines:
▪ Monitor the patient for infection.
▪ 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.
▪ 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.
(c) 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.
CVTCs can be used for months or years if infection does not occur
Dressing changes are made on all catheters using sterile technique. (Both nurse and patient should wear
a mask during the procedure.)
Complications:
▪ hyperglycemia- hyperosmolar (HA, Nausea and Vomiting, fever, chills, malaise)
▪ Infection (fever, redness and swelling on site )
▪ Pneumothorax ( dyspnea , ecchymosis, diminished / absent lung sound )
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.)
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TPN solutions are nutritionally complete, based on the 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.
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
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.
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.)
B. CARDIOVASCULAR SYSTEM
(a) ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS
Guidelines:
1. Verify physician’s order.
2. Check expiration date on product.
3. Verify accuracy of component with another licensed nurse or physician.
Types of Blood Products:
• Fresh Whole Blood- complete components
• Red Blood Cells- used to replace erythrocytes. 1 unit increases hgb by 1g/dl and hct by 2 – 3 % after
transfusion
• White Blood Cells / Granulocyte Concentrate- Rarely used
• Platelets- used to treat thrombocytopenia. Administered rapidly over 15 to 30 minutes
• Fresh Frozen Plasma- used to provide clotting factors or for volume expanders
• Albumin- to maintain colloid osmotic pressure
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.
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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.)
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 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.
* NOTE: 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 reassess intensive monitoring if any of the following occurs:
• Burning at injection site
• Pain in any area
• Flushing or rash
• Itching and Fever
• Chills
• Marked change in VS
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.
C. RESPIRATORY SYSTEM
(a) OXYGEN THERAPY
▪ Indicated 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.
•
O2 Therapy safety precautions:
▪ “NO SMOKING” sign on the door/head of bed area
▪ Avoid use of volatile and flammable materials such as alcohol, oils, greases, ether and acetone
•
O2 Delivery System:
1. Cannula
▪ Delivers low concentration of oxygen (24% to 45%) at flow rates of 2 - 6 LPM
2. Facemask
▪ Covers mouth and nose
3. Simple Face mask
▪ 40% - 60% at liters flow of 5 -8 LPM
4. Partial Rebreather Mask
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▪
▪
5.
6.
7.
8.
60% - 90% at liters flow of 6 – 10 LPM
The o2 reservoir bag allows the client to re-breathe about third of the exhaled air in
conjunction with oxygen.
▪ It increases FiO2 by recycling expired oxygen
Non – rebreather Mask
▪ Highest oxygen concentration possible
▪ 95% - 100% at 10 – 15 LPM
Venturi Mask
▪ Oxygen concentrations vary from 24% - 40% - 50% at 4 – 10 LPM
▪ Has wide bore tubing and color coded jet adapters that corresponds to the exact oxygen
concentration and flow liters to be delivered
Face Tents:
▪ Used when O2 masks are not tolerated
*Note: check facial skin frequently for dampness and chaffing
Transtracheal Oxygen delivery
▪ Used in oxygen dependent clients
▪ A catheter is surgically inserted into the trachea and oxygen directly into the lungs
▪ 0.5 – 2LPM
Nursing Care:
1. Keep the catheter patent by cleaning the catheter with Normal Saline
(b) CARING FOR CLIENTS WITH CHEST TUBES
Types of Chest Tube Drainage System:
Simple drainage system
a 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.
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Chest Tube Care:
1. 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 frame
5. 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.
Maintenance:
1. 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:
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• 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.
(c) POSTURAL DRAINAGE
- Drainage by gravity
Pre therapy:
Administer bronchodilator or nebulization therapy
Frequency: 2 – 3 times a day
Best time:
Before breakfast
Before lunch
Before bedtime
Contraindication: spinal cord injury
Sequence: Positioning, Percussion, Vibration, cough / suctioning
• To drain the middle and lower portions of your lungs.
Positions:
• If a hospital bed is available, put in Trendelenburg position (head lower than feet)
• 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
• Stack 18-20 inches of pillow under hips.
• Place on a tilt table, with head lower than feet.
• Lower head and chest over the side of the bed.
• To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.
• 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.
(d) INCENTIVE SPIROMETRY
•
•
•
Sustained maximal inspiration device
Measures the flow of air inhaled through the mouthpiece
Used to expand collapsed alveoli loosen secretions and improved pulmonary ventilation
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(e) ARTIFICIAL AIRWAY
•
Oropharyngeal and Nasopharyngeal Airway - Devices that keeps the airway open / patent
Oropharyngeal 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 oropharynx
▪ Frequent oral and nasal care
(f) CARING FOR CLIENTS WITH 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
(g) CARING FOR CLIENTS WITH TRACHEOSTOMY
•
•
•
•
•
Air is not filtered and humidified therefore, a mist collar or a 4 x 4 gauze may be held in place with a
cotton tie over the stoma to filter the air as it enters.
soak inner cannula in antiseptic soak with hydrogen peroxide, rinse well
tie new tie before removing the old tie to prevent accidental dislodgement
use precut gauze and perform care once a day at least.
suction as needed and do oral care frequently
(h) 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 secretions
2. Whistle tipped
• Less irritating
3. Oral suctioning: Yankauer device / oral suction tube
• Catheter has a thumb port which serves as a controller when suctioning
Points to remember:
• NEVER suction more 10 – 15 seconds
• Use aseptic technique when suctioning
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•
•
•
•
•
•
•
HYPEROXYGENATE prior to suctioning
Do oral care after suctioning
DO NOT suction while inserting the catheter
When you 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
D. URINARY AND BOWEL ELIMINATION
(a) URINARY CATHETERIZATION
Procedure:
1. Explain procedure to the patient.
2. Provide privacy.
3. Prepare trash receptacle.
4. Wash hands.
5. Position;
a. female patient supine with knees flexed;
b. 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 indwelling:
19. 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.
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(b) CARING FOR CLIENTS WITH COLOSTOMY
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
– no irrigation , wet fecal material , appliance all the
time , meticulous skin care, prevent skin breakdown,
constant flow not regulated, bag emptied half full
Ascending colon colostomy: liquid stool
Transverse Colon Colostomy: loose to semi formed
Descending Colon Colostomy: close to normal Stool
•
•
•
•
•
Monitor color changes in the stoma:
Normal color : pink or red
Pale pink : low hgb / hct
Purple 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 liquid
Post op drainage is dark green then yellow as the
client begins to eat
Points to Remember in Colostomy Care:
•
•
•
•
•
•
Avoid gas forming foods and nuts, but can have any food at tolerated after 6 weeks… yogurt recommended
Dry skin before applying appliance
Karaya powder – barrier to prevent contamination with excreta
Appliance can be up to 2 weeks; 24-48 hours if eroded or ulcerated
With 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
• Position: Left Lateral ( adult) dorsal recumbent ( child)
• After administering the solutions, press buttocks together to prevent feces from expelling
• For abdominal cramps: stop temporarily
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Non – retention Enema:
Retention Enema:
•
•
•
•
•
Fluids:
tap water
soap suds
NSS
Hypertonic Fluids
•
•
•
Fluids:
Carminative enema
Oil (mineral , olive, cottonseed)
•
Height of solution: 18 inches above the rectum
•
Height of solution: 12 inches above the rectum
Types of Enemas:
1. Cleansing Enema- It irritates the colon producing peristalsis by distending the colon with volume fluid
A. High enema
Target: colon
1L of solution is introduced
B. Low enema
Target: rectum and sigmoid process
½ L is administered
2. Carminative Enema- Aims to expel flatus. About 60mL to 180 mL of solution is administered
3. Retention enema- Uses 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
4. Return flow / colonic Irrigation- Aims to expel flatus. Uses an inflow – outflow process that is repeated 5
– 6 times. Solution container is lowered so that the fluid backs out through the rectal tube into the
container.
E. CIRCULATORY SYSTEM
(a) INTRAVENOUS THERAPY
- IV therapy is administering fluids / medications through a vein
Purposes:
• sustain clients who are unable to take foods/fluids via oral route
• used to replace fluids and electrolytes
• provides vascular access for immediate or rapid delivery of substances or medications especially in
emergency situation
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Physician’s prescribed treatment.
Patient assessment
The initiation of intravenous therapy is upon the written
prescription of a licensed physician which is checked
for the following:
Factors to consider for IV Therapy
•
•
•
•
•
•
•
•
•
•
•
type and amount of solution
flow rate
• type, dose and frequency of medication to be
incorporated/push & others affecting the
procedure (x-ray,Tx of the extremities.
duration of therapy
cannula size
condition of the vein / skin
type of solution
patient’s level of consciousness
patient’s activity
patient age
dominant arm
clinical status of patient
I.V set and equipment preparation
•
•
•
•
•
Check for expiration date
Check for clarity; any presence of holes on plaster cover (packaging); plastic container (bag) or presence of
sediments or insect.
Check labels against the physician’ order
Label 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 Chambers
Microdrip chambers
• Used if solution contains potent medication that
needs to be titrate
• Used if fluid will be infused at slow rate ( about 50
mL per hour)
Macrodrip Chambers
• Drop factors varies from 10 – 20 drops/mL
Scope of Practice
• Role 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
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(b) ADMINISTRATION OF MEDICATIONS AND IV SOLUTIONS
Types of IV solutions
• Isotonic
▪ Isotonic fluids have an osmolality the same as that of blood; that is about 310 mEq/L of total
electrolytes.
• Hypotonic
▪ Hypotonic 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
• Hypertonic
▪ Hypertonic fluids have an electrolyte content above 375 mEq/L.
▪ Higher osmolality than the body
▪ Movement is from cell to extracellular compartment
Crytalloids
▪ Used for fluid volume replacement
▪ Contains mostly of electrolytes
Colloids
▪ Or plasma expander
▪ Used in cases such as severe hemorrhage and hypovolemia
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
Table 7.1 Types of Fluids and Uses
•
Flow rate: amount of fluid drop factor on tubing box ÷ running time stated in total number of minutes.
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•
Infusion Sets / Infusion pumps
Infusion Techniques :
• CONTINUOUSAdministration 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 INFUSIONAdministration 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 Therapy:
1. Local /Phlebitis - involves only the insertion site and manifest as pericatheter inflammation ; Warm
erythematous skin over an indurated or tender vein an often precedes or is associated with more severe
infections.
2. 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.
3. Cellulitis- Warm erythematous and often tender skin surrounding the site of cannula insertion, pus is rarely
detectable.
4. 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.
5. Infiltration – Edema, pain, and coolness at the site ( may not have back flow)
6. Catheter Embolism – decrease in BP, pain along the vein, weak and rapid pulse, cyanosis
7. Circulatory Overload – distented jugular vein, high Blood Pressure, dyspnea, moist cough and crackles
8. Hematoma – ecchymosis, immediate swelling and leakage of blood at the site of insertion and painful lumps
9. Air embolism – tachycardia, dyspnea, hypotension, cyanosis, decreased LOC
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VIII. 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.”
A. ASEPSIS
• Is the freedom from disease – causing microorganism
Types :
Medical Asepsis
• All practices intended to confine a specific microorganism to a specific area, limiting the
number, growth, and transmission
• Clean and dirty technique
Surgical Asepsis
• Sterile technique
• All 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 unsterile
5. Overexposed pack is already unsterile
6. Gravity may contaminate the sterile field therefore AVOID overreaching
7. Moisture is a good medium for contamination
8. 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.
Precautions for Contact with Blood and Body Fluids:
• 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.
•
Wash hands thoroughly after removing gloves and if contaminated with blood or with body fluids that contain
visible blood.
•
Take precautions to prevent injuries by needles, sharp instruments, or sharp devices.
•
Do not give direct client care if you have open or weeping lesions or dermatitis.
•
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.
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Standard plus + + +
Airborne Precaution
Disease
Measles
Chicken Pox
Varicella Zoster Virus
Tuberculosis
Ways of Protection
- 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
Adenovirus
Diphtheria
Epiglottitis
Influenza
Meningitis
Mumps
Pertusis
Pnuemonia
Sepsis
Rubella
- 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 virus
Wound Infections
Skin infestations:
Impetigo
Pediculosis
Scabies
Eye infections
Conjunctivitis
-Room: private room or can be cohorted or
grouped together
-Use of GLOVES and GOWNS
Table 8.1 Standard Precaution
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(b) HEAT AND COLD THERAPY
• An intervention that reduces inflammation
Principles:
• Cold application is generally safer than heat application.
• Heat application usually requires a doctor’s order
• Cold application is done within 72 hours after an injury, while heat application is done after 72 hours.
• The application of heat and cold is done at a maximum of 30 minutes (an average of 15-20 minutes)
• Check the area of applications are done every 15 minutes.
(c) WOUND DRESSINGS
Types of dressing:
1. Dry to Dry
Trap necrotic debris and exudate
2. Wet to Dry
Uses saline and anti microbial solution
this softens debris as it dries and dilute exudate
3. Wet to damp
Wound debrided if gauze is removed
Variation at drying
WOUND DEBRIDED IF GAUZE REMOVED ( VARIATION at DRYING)
4. Wet to Wet
Keeps 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.
Wound Healing
1.Inflammation Phase
HEMOSTASIS
FIBRIN
PHAGOCYTOSIS (3-4DAYS)
2.Proliferative Phase
FIBROBLAST
COLLAGEN
GRANULATION TISSUE
Stages of Inflammation /
Inflammatory Process:
Dolor (pain)
CAPILLARIES
ESCHAR(3 – 21 DAYS)
3.Maturation Phase (21 DAYS – 2 YEARS)
Calor (heat)
Rubor ( redness)
Tumor (swelling)
Loss of Function
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IX. PERIOPERATIVE NURSING
(a) 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
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
Classification of Surgery:
•
According to Reason/Purpose:
1. Diagnostic- removal and examination of tissue (e.g., biopsy).
2. Curative/Ablative-removal of a diseased organ or structure (e.g. appendectomy).
3. Restorative - repair a congenitally malformed organ or tissue. (e.g., harelip; cleft palate repair).
4. Palliative- relief of pain (for example, rhizotomy--interruption of the nerve root between the
ganglion and the spinal cord).
5. Reconstructive- repair or restoration of an organ or structure (e.g., colostomy; rhinoplasty, cosmetic
improvement).
•
According to Degree of Urgency
1. Urgent – needs immediate interventions
2. Elective- surgery that can be delayed
3. Optional – Patient may opt to have or not to have surgery
4.
According to Degree of Risk
1. Major- 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.
2. 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)
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(b) PRE-OPERATIVE PHASE
• begins when a decision for surgery is made until the client is admitted at the operating room.
•
Preoperative Assessment:
▪ Risk Factors
o Age
o Nutritional and health status
o Fluid & electrolytes imbalances
o Radiation
o Cardiopulmonary
o Chemotherapy
▪
Nursing History
o past & present
o meds
o diet
o allergies (latex)
o personal habits
o
o
o
o
o
Medications
Family history
Prior surgical experiences
(positive/negative)
Type of surgery
Location site
o
o
o
o
o
occupation
finances
family support
knowledge of surgery
Attitude
•
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
•
Nursing responsibilities:
▪ Geriatric concerns
▪ Address safety issues - sensory decline
▪ Hepatic, cardiac respiratory and renal decline
▪ Assess for preexisting problems such as cardiac, renal, hepatic, or respiratory.
(c) INTRA - OPERATIVE 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 Surgeon
• the leader of the surgical team.
• 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
• 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.
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(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
• 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
• 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) 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.
•
•
ADVANTAGE of general anesthesia: it can be used for patients of any age and for any surgical procedure, and
leave the patient unaware of the physical trauma.
DISADVANTAGE: 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
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•
Inhalation. 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: 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.
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•
•
Topical anesthesia is used on mucous membranes, open skin surfaces, wounds, and burns.
ADVANTAGE of local anesthesia: 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.
•
Factors that affect the selection of an anesthetic agent:
1. The type of surgery.
2. The location and type of anesthetic agent required.
3. The anticipated length of the procedure.
4. The patient's condition.
5. The patient's age.
6. The patient's previous experiences with anesthesia.
7. The available equipment.
8. Preferences of the anesthesiologist or anesthetist and the patient.
9. 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:
▪ Pulmonary function- Presence of upper respiratory tract infections and chronic obstructive lung
diseases such as emphysema predispose the patient to postoperative lung infections.
▪ Liver function- 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 function- renal insufficiency may alter the excretion of drugs and influence the patient's response
to the anesthesia.
▪ Cardiac function- 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.
(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.
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•
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:
o To cure an illness or disease by removing the diseased tissue or organs.
o To visualize internal structures during diagnosis.
o To obtain tissue for examination.
o To prevent disease or injury.
o To improve appearance.
o To repair or remove traumatized tissue and structures.
o To relieve symptoms or pain.
(d) RECOVERY ROOM CARE
•
•
•
•
•
•
The postoperative phase lasts from the patient's admission to the recovery room through the complete
recovery from surgery.
THE RECOVERY ROOM
• is defined as a specific nursing unit, which accommodates patients who have undergone major
or minor surgery.
• 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.
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.
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.
(2) Early detection of complications.
Complications or problems are relatively rare, but the recovery room nurse must be aware of the possibility and
clinical signs of complications.
(3) 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.
•
Effects of Anesthesia
A. RESPIRATORY DISTRESS-is the most common recovery room emergency.
Causes:
(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.
(2) Swallowing and cough reflexes are diminished by the effects of anesthesia and when secretions are
retained.
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(3) Ineffective airway clearance may be related to the effects of anesthesia and drugs that were
administered before and during surgery.
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.
(e) POSTOPERATIVE PATIENT CARE
1. DEEP BREATHING EXERCISES
• Deep breathing exercises hyperventilate the alveoli and prevent their collapse
• Improve lung expansion and volume
• Help to expel anesthetic gases and mucus
• Facilitate oxygenation of tissues
• Ask the patient to:
1. Exhale gently and completely.
2. Inhale through the nose gently and completely.
3. Hold his breath and mentally count to three.
4. Exhale as completely as possible through pursed lips as if to whistle.
5. Repeat these steps three times every hour while awake.
2. COUGHING EXERCISES 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.
3. INCENTIVE SPIROMETER may be ordered to help increase lung volume, inflation of alveoli, and facilitate
venous return.
(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.
4. LEG EXERCISES
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.
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.
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(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.
5. URINARY CATHETERIZATION
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.
6. POST-OPERATIVE DIET
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.
7. WOUND CARE
There are two methods of caring for wounds:
• open method, in which no dressing is used to cover the wound
• 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.
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STEPS IN WOUND CARE:
1.) Gather needed supplies. Items may be packaged individually or all necessary items may be in a sterile
dressing tray.
2.) 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.
3.) Use appropriate aseptic techniques when changing the dressing and follow precautions for contact with
blood and body fluids. .
•
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.
5. 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.
10. Prepare the patient and the family for disposition (transfer, return to duty, discharge). Supply the patient or
family member with written instructions for:
• Wound care
• Medicatios
• Making outpatient appointments
• An emergency, including the phone numbers for doctors and/or clinics
11. Document the patient's disposition in the nurse's notes in accordance with unit SOP.
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X. PROVISION OF SAFETY
Safety in emergency
“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”
A. 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:
PASS:
P – Pull the pin while holding the extinguisher upright
A – Aim nozzle at the Base of the fire
S – Squeeze the handle firmly
S – Sweep the fire
*REMEMBER:
•
•
•
•
Do not use elevator
Turn of oxygen and appliances
For patients with mechanical ventilation , do ambubagging
Observe proper transfer techniques for non ambulatory patients
B. ELECTRICAL
Safety:
•
•
SRG Integrals 2nd Ed.
Avoid overloading any circuit
Read warning labels on all equipment
Fundamentals of Nursing
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C. RADIATION
Safety:
• Label potentially radioactive material
Principles:
• 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)
D. FALLS
To prevent falls:
• Provide adequate lightning
• Eliminate clutter and obstruction in the room
• Personal items should be within reached
• Lock all beds , wheelchairs and stretchers
• Keep bed in low position with side rails up.
E. 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 equipment
• Chemical – use of medications ( e. g. Nueroleptics, sedatives, anxiolytics )
Legal Implication:
2 standards for applying restraints:
Behavior management standard: if client is a danger to self or others
Medical Surgical Care Standard: if it is related to any procedure
Kinds of Restraints
Adults:
a. Jacket Restraints
b. Belt Restraints
c. Mitt or hand Restraints
d. Limb Restraints
Infants and Children:
a. Mummy restraints and Crib Nets Restraints
b. Elbow Restraints
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XI. CLIENTS IN BIOLOGIC CRISIS AND FIRST AID
A. EMERGENCY TRIAGE
Purpose:
• 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.
Age
Cardiac
Compression Location
Method
Depth
(inches)
Ventilation:
Compression
Ratio
Cycles / minute
Neonate
One finger width below the
imaginary nipple line
2 fingers
1/2–1
Infant <1 yr
One finger width below the
imaginary nipple line
2 fingers
1/2–1
2:30
5
Child 1–8 yr
Simplified approach- center of
the chest
1 hand (heel)
1–1 ½
2:30
5
Adult
Simplified approach- center of
the chest
2 hands
1 1/2–2
2:30
5
Table 11.1 CPR Guidelines
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B. DEFIBRILLATION
• To terminate ventricular fibrillation by electric countershock.
• Synchronous countershock
Indications:
• Ventricular fibrillation
• Pulseless ventricular tachycardia
*NOTE: CPR efforts should be enacted during preparation for defibrillation.
Method:
1. 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. Apply second electrode
just below and lateral to left nipple.
4. Set defibrillator at 200 joules (J)
5. Grasp paddles by insulated handles only.
6. Give “Stand Clear” command, and ascertain that no one is touching patient or bed.
7. Push discharge buttons in both paddles simultaneously, using pressure to ensure firm contact with the
patient’s skin.
8. Remove paddles and assess patient and ECG pattern.
9. 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 Defibrillator - used in pre-hospital setting
Cardioversion:
• Treatment for arrhythmias
• The procedure restores the normal heart rate and rhythm, allowing the heart to pump
more effectively.
• Synchronized counter shock
• The defibrillator is synchronized to the client’s R wave
• Oxygen should be stopped during the procedure
Pacemakers:
• Temporary or permanent device that provides electrical stimulation and maintains heart
rate when the intrinsic pacemaker fails
Types:
a.) Synchronous / demand Pacemaker
• Paces only if the client’s intrinsic rate falls below the set pacemaker rate
b.) Asynchronous or Fixed Rate
• Paces at preset rate regardless of client’s intrinsic rhythm
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C. TRAUMA IN EMERGENCY SETTING
PRIMARY SURVEY
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 SURVEY
- consists of a history and a complete head-to-toe assessment.
PURPOSE: 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 - ray
7. Administer 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
Pedestrian hit by car
•
Injuries
Head, chest, abdominal injuries fractures of femur, tibia, and
fibula on side of impact
•
Pedestrian hit by large vehicle or
dragged under vehicle
•
Pelvic fractures
•
Front seat occupant (lap and
shoulder restraint 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, abdomen, pelvis
•
•
•
Front seat passenger
(unrestrained, head-on collision)
Back seat passenger (without head
restraints, rear-end collision)
Fractures of femurs and/or patellas, posterior dislocation of
acetabulum
Hyperextension of neck with associated high cervical fractures
•
Fall injuries with landing on feet
•
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Compression fractures of lumbosacral spine and fractures of
calcaneus (heel bone)
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XII. MEDICAL EMERGENCIES
A. INCREASED INTRACRANIAL PRESSURE (ICP)
• 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 ICP
*NOTE: Increased 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 neurological check. 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 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 fiber-optic catheter may be used to continuously assess changes in ICP.
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Rigid Postures (with Neurological Conditions): Medical Emergency:
Decorticate 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 rigidity
-Arms are stiffly extended,
adducted, and hyperpronated.
Legs and feet are stiffly
extended with feet plantar
flexed. Teeth may be clenched
(may be seen with
opisthotonos). Indicates brain
stem pathology and poor
prognosis.
Opisthotonos
-Rigid hyperextension of the spine.
The head and heels are forced
backward and the trunk is pushed
forward. Seen in meningitis, seizures,
tetanus, and strychnine poisoning.
B. SEIZURES:
Emergency Care of Patient during Seizure Activity
1. 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:
▪ VS
▪ Presence of aura
▪ Behavior after seizure
▪ Circumstances in which the seizure activity occurred
▪ Injury
▪ Time of the onset of seizure activity
▪ Muscle groups involved (and whether unilateral or bilateral)
▪ Total duration of seizure activity
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Type
Description
Causes
Signs and Symptoms
Treatment
Anaphylactic
shock
Dilation of blood
vessels, fluid shifts,
edema, and spasms
of respiratory tract.
Allergic reaction
Respiratory distress
Hypotension
Edema
Rash
Pale, cool skin
Convulsions possible
O2
Epinephrine
Corticosteroids
Antihistamine
IV fluids
Aminophylline
Cardiogenic
shock
Failure to maintain
blood supply to
circulatory system
and tissues because
of inadequate
cardiac output.
Acute left or right
ventricular failure
Acute mitral
regurgitation
Acute ventricular
septal defect
Acute pericardial
tamponade
Acute pulmonary
embolism
Acute myocardial
Infarction
Increased pulse rate
Weak pulses
Cardiac dysrhythmias
Prolonged capillary fill time
Cool, clammy skin
Cyanosis
Altered mental ability
IV fluids
O2
Dopamine
Norepinephrine
Nitroprusside if BP
adequate
Dobutamine
Hypovolemic
shock
Decrease in
intravascular volume
relative to vascular
capacity. Results
from blood volume
deficit of at least 25%
and larger interstitial
fluid deficit.
Hemorrhage
Vomiting
Diarrhea
Any excess loss of
body fluids
Hypotension
Decreased pulse pressure
Tachycardia
Rapid respiratory rate
Pale, cool skin
Anxiety
Control bleeding
IV fluids
O2
Elevate legs
Volume expanders
Neurogenic
shock
Increase in vascular
capacity and
subsequent decrease
in blood volume:
space ratio resulting
from profound
vasodilation.
Anesthesia
Spinal cord injury
Hypotension
Bradycardia
Bounding pulse
Pale, warm, and dry skin
Supine position
O2
IV fluids
Possibly
Vasopressors
Septic shock
Circulatory failure
and impaired cell
metabolism
associated with
septicemia. Divided
into “early warm”
(increased cardiac
output) and “later
cold” (decreased
cardiac output).
Endotoxins released
most commonly by
gram-negative
organism
Elevated temperature
Flushed, warm skin
Vasodilation (early)
Vasoconstriction (late)
Decreased WBC at first
Normal urinary output
(early)
Decreased urinary output
(late)
O2
IV fluids
Culture, e.g., blood, urine,
sputum, wounds.
Antibiotics
Possibly
Vasopressors
Table 12.1 Kinds of Shock
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D. 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 Management:
• Assess and document: Alignment, warmth, tenderness, sensation, motion, circulatory status distal to
injury and intactness 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.
*NOTE: 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:
Pain
Pulselessnes
Pallor
Paralysis
Paresthesia (e.g., numbness, burning, tingling)
Types of fractures:
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E. BURNS
Classification
Description
1st Degree Burn
> Involves epidermis only
> Erythematous and painful skin
> Looks like sunburn
2nd Degree Burn
a. Superficial partial thickness
>Extends beyond epidermis superficially into dermis
>Red and weepy appearance
>Very painful
>Formation of blisters
b. Deep partial thickness
> Extends deep into dermis
> May appear mottled
> Dry and pale appearance
3rd Degree ( Full Thickness )
>Extends through epidermis, dermis, and into
subcutaneous tissues
• Dry, leathery appearance
• May be charred, mottled, or white
• If red, will not blanch with pressure
• Painless in the center of the burn
Table 12.2 Classifications of Burn
Estimation of Burned Body Surface
• Rule’s of Nine ( adult )
• Body surface Area Proportions (Children)
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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)
Table 12.3 American Burn Association’s Classification of Burns: BSA % Estimation
First Aid Management:
• 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).
• Assess cardiovascular status. (Look for symptoms of shock.)
• Assess percentage and depth of burns, as well as presence of other injuries.
• 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.
• 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).
· Weigh patient to establish baseline and assist in determination of fluid needs
• 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.
• Administer analgesics as indicated.
• 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.
• Cover burn area with sterile dressing.
• Put on Hold NPO until function of GI system is evaluated.
• Insert NG tube for gastric decompression if indicated.
• Insert Foley catheter (to monitor urine output) for severe and some moderate burns.
· Assess need for and administer tetanus prophylaxis
• 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.
• 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
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F. TETANUS PROPHYLAXIS
Td: Tetanus and diphtheria toxoids adsorbed (for adult use).
TIG: Tetanus immune globulin (human).
A.) 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.
B.) For persons 7 years old and older, - Td is preferable to tetanus toxoid alone.
G. 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 directions
4. 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:
A.Ipecac syrup (PO)
Child under 1 year: 5–10 mL followed by 100 to 200 mL water
Child 1 year or older: 15 mL followed by 100 to 200 mL water
Adult: 15 mL followed by 100 to 200 mL water
*Dose 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 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. Destruction and/or swelling of esophageal and airway tissue is likely with corrosive
ingestion. Monitor respiratory status closely.
7. 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.
8. Continue ABCs of life support and monitor fluids, electrolytes, and urine output.
H. CHEMICAL EYE CONTAMINATION
• Flush eye with sterile water for 15 to 20 minutes, allowing water to drain away from uncontaminated
eye.
Respiratory alkalosis
Respiratory acidosis
• Treat underlying cause
• Treat underlying cause
• Breathe into paper bag to >
• IV fluids
PaCO2
• Bronchodilators
• Sedatives and calm
• Mechanical ventilation
environment
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•
O2
Metabolic alkalosis
• Correct cause
• IV normal saline; IV
potassium, as indicated
• Seizure precautions
• Monitor and correct
electrolyte imbalances
Metabolic acidosis
• Correct underlying cause
• IV sodium bicarbonate
• Seizure precautions
• Monitor and correct electrolyte imbalances
H. EMERGENCY MANAGEMENT OF OB PATIENTS
ASK:
• Due date?
• Contractions?
• Frequency?
• Duration?
• Ruptured BOW?
• Bleeding?
• Number of previous
pregnancies (gravida)?
OBSERVE:
• Size of abdomen
• Fundal height
• Presentation (cephalic or breech)
• Fetal heart tones (not assessed if birth is imminent)
•
•
•
•
Number of births
(parity)?
Problems with past
deliveries?
Problems with
pregnancy?
Has the baby moved
today?
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 do
Keep 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.
Wait for the placenta to separate.
Inspect the placenta for completeness
•
•
•
•
•
•
•
•
•
•
SRG Integrals 2nd Ed.
Fundamentals of 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.
Do not put traction on the cord or pull on the cord
Do 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
110
•
•
I.
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:
• Question and examine the patient in privacy.
• Assure confidentiality.
• Examine entire body.
• Ask specific questions related to suspected abuse
• Be aware that the perpetrator may retaliate if exposed by the patient.
• Encourage patient to seek shelter if abuse is suspected.
• Give patient contact information for community resources.
• Call law enforcement immediately if violence is threatened (do not warn the perpetrator of this
action).
J. GRIEF, LOSS, DEATH and DYING
“Even in loss and grief, death and dying, Nursing is still there. In this chapter, Caring continues…”
(a) Loss
• Actual or potential situation where in something valued is changed / lost / gone
• That something can be: significant others, job, sense of well being, security etc
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(b) Grief
•
•
▪
Types of Loss
o Actual
- by others
o Perceived
- Only the “ self ” can experience
- Cannot be verified by others
o 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
Response or reaction to loss
Bereavement
▪ Subjective Response
▪ Mourning
▪ Behavioral Response
Types of Grief Responses:
• Abbreviated Grief
▪ Genuinely felt grief but brief
• Anticipatory Grief
▪ Grieving in advance
• Disenfranchised Grief
▪ Unable to acknowledge the loss to other people
▪ Examples are unacceptable loss that cannot be spoken about like suicide, abortion
• Dysfunctional Grief
▪ Pathologic grieving
• Unresolved Grief
▪ Extended / lengthy and severe grieving
▪ May deny loss or grieve beyond expected time
• Inhibited Grief
▪ Suppressed grieving
KÜbler Ross
Engel
Sander
Denial
“ No! not me”
Shock and Disbelief
(accepts situation but denies
emotionally)
Shock
Anger
“why me?”
Awareness
Awareness of Loss
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Bargaining
“if only I could live a little longer.”
Restitution
( do rituals of mourning)
Conservation/Withdrawal
(social withdrawal/ needs time to be alone)
Depression
silence
Resolving Loss
Healing: The turning point (acceptance)
Acceptance
“I’m ready”
Idealization
Renewal
(new self – awareness; learning to live
independently without loved ones)
Outcome
Table 12.4 Stages of Grieving
(c) Death and Dying
• Concept of Death
Infancy to 5 years - no concept of death
5 -9 years old – begins to understand death; death is final
9-12 ears old – death as inevitable and end of life
a. Heart – lung death
▪ Indications of death :
- Total lack of response to external stimuli, no muscular movement and reflexes, flat brain waves and
ECG (asystole)
b. Cerebral death or higher brain death
- When cerebral cortex( this is the brain center) is irreversibly damaged
•
Legal Aspects Related to Death
▪ Advance Health Care Directives
- Variety 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 Care 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.
Euthanasia
▪ Mercy killing
▪ Act of painlessly putting to death persons suffering from incurable / terminal/ distressing
disease
•
Autopsy
▪ Postmortem examination
▪ Done in certain cases where death is sudden to know the cause of death and in some legal cases
•
Do – Not – Resuscitate Orders
▪ DNR / no Code
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▪
▪
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
• Assisting the Client to a peaceful death
• Maintaining humanity, consistent with the client’s values, beliefs and culture
• Support client’s will and hope because dying clients often strive for self fulfillment more then for self
preservation.
• Meeting Physiologic Needs of the dying client
o Airway clearance
o Hygiene / bathing
o Nutrition
o Urinary and fecal elimination
• Providing spiritual support
• Facilitating expressions of feelings and emotions about death
• Arranging an appointment with a clergy or a spiritual adviser if the client wishes to.
• Use of therapeutic communication for the family to be able to express feelings
(d) Hospice Care
• Current trend in nursing care
• Common setting: home or in a nursing home
• Goal: facilitates peaceful and dignified death
• Eligible for hospice care are those diagnosed / predicted to die within 6 months
(e) Post Mortem Care
Guidelines:
• Do post mortem care according to hospital policy
• Identify religious belief of clients
• All equipment, tubes, supplies must be removed
• A pillow is placed under the head and shoulders to prevent discoloration in the face
• A complete bath is not necessary ( the mortician will do the bathing
• Identification band should be attached before the body is taken to the morgue
• A shroud is used to wrap the body
Intervention
Rigor Mortis
(stiffening of the body; starts in the
involuntary muscles like the heart etc.)
( 2 – 4 hours after death)
Algor Mortis
(gradual decrease of temperature)
•
•
•
Position the body naturally (in natural /
neutral manner)
Place dentures (if there is)
Close eyes and mouth
Livor Mortis
( discoloration of the body)
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
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•
•
•
•
SRG Integrals 2nd Ed.
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.
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