RLE: MIDTERM NOTES
CHEST TUBE THORACOTOMY
• TUBE THORACOSTOMY
▪ The insertion of a tube (chest tube) into the pleural cavity to
drain air, blood, bile, pus, or other fluids
▪ Whether the accumulation of air or fluid is the result of rapid
traumatic filling with air or blood or an insidious malignant
exudative fluid, placement of a chest tube allows for
continuous, large volume drainage until the underlying
pathology can be formally addressed. The list of specific
treatable etiologies is extensive, be more formally addressed.
The list of specific treatable etiologies is extensive, but without
intervention, patients are at great risk for major morbidity or
mortality.
• THORACOSTOMY
▪ Inserts a thin plastic tube into the pleural space between the
lungs and the chest wall.
▪ The tube may be attached to a suction device to allow excess
fluid or air to be removed. Or it may be used in a procedure
called pleurodesis in which medication is delivered into the
pleural space to decrease the likelihood of fluid accumulation
▪ Thoracostomy may be performed to treat pneumothorax, also
known as collapsed lung.
INDICATION:
• PNEUMOTHORAX
˗ Spontaneous Pneumothorax
˗ Traumatic Pneumothorax
˗ Iatrogenic Pneumothorax, most commonly due to central line
placement
˗ Tension Pneumothorax
˗ Bronchopleural Fistula, postoperative or due to mechanical
ventilation
USES:
• HEMOTHORAX
˗ Chest trauma (blunt or penetrating); postoperative following
thoracic or upper abdominal surgery.
˗ Pleural effusion, sterile effusion, infected effusion (example:
empyema, para pneumonic effusion), chylothorax malignant
effusion, other effusion.
• Physicians perform a thoracostomy to treat conditions including:
- Pneumothorax
• The condition may develop as a result of lung diseases, such as:
- Trauma/chest injury
- Cystic fibrosis
- Chronic Obstructive Pulmonary Disease (COPD)
- Lung cancer
- Asthma
- Ventilator-related air leak, which occurs when a mechanical
ventilator pushes air into the lungs and part of the lung
collapses
- Empyema, an infection within the pleural space
- Hemothorax, excess blood in the pleural space caused by
chest injury, tumor or other bleeding problems
- Pleural effusion, excess fluid in the pleural space caused by:
→ Heart failure
→ Infection: pneumonia, tuberculosis or viral infection such as
HIV
→ Lung tumor
→ Lymphatic fluid (chylothorax)
→ Pleurodesis is performed to prevent the collection of pleural
fluid following thoracentesis
CONTRAINDICATIONS:
▪ Certain conditions and diseases may cause excess air, blood
or extra fluid to collect in the pleural space.
→ This may compress or collapse the lung, making it difficult
to breathe.
▪ A chest tube helps remove the excess fluid or air and allows
the lung to expand, making breathing better.
• Imaging techniques such as computed tomography (CT),
fluoroscopy and ultrasound (US) may be used to help guide the
interventional radiologist’s instruments while placing the chest
tube.
• Two thin membranes line the pleural space – one wraps
around the lungs and other lines the inner wall of the chest
▪ The space between these two membranes is usually filled with
a small amount of lubricating fluid that helps the lungs move
within the chest cavity during breathing.
PURPOSE:
• Chest tube insertion is basically for the purpose of draining fluid,
blood or air from the lung cavity to regain negative pressure.
• HEMOPNEUMOTHORAX
˗ Considered for those about to undergo air transport who are at
risk for pneumothorax
˗ Patients with penetrating chest wall injury who are intubated or
about to be intubated.
• The need for emergent thoracotomy is an absolute
contraindication to tube thoracostomy
• Relative contraindications include the following:
- Coagulopathy
- Pulmonary bullae
- Pulmonary, pleural, or thoracic adhesions
- Loculated pleural effusion or empyema
- Skin infection over the chest tube insertion site
• Blind insertion of a chest tube is dangerous in a patient with
pleural adhesions from infection, previous pleurodesis, or
pulmonary surgery; so, guidance by ultrasound or CT scan without
contrast is preferred.
BENEFITS AND RISKS:
• PLEURODESIS
- Chest tube insertion to facilitate the installation of sclerosing
agents into the pleural space is indicated for the treatment of
refractory effusion.
BENEFITS
No surgical incision is needed –
only a small nick in the skin that
does not have to be stitched
closed
RISKS
Any procedure where the skin is
penetrated carries a risk for
infection. The chance of infection
requiring antibiotic treatment
appears to be less than one in
1,000
No radiation remains in a patient’s There is always a slight chance of
body after an x-ray examination
cancer from excessive exposure
X-rays usually have no side
effects in the typical diagnostic
range for this exam
X-ray equipment is relatively
inexpensive and widely available
in emergency rooms, physician
offices, ambulatory care centers,
nursing
homes
and
other
locations, making it convenient for
both patients and physicians
to radiation. However, the benefits
of an accurate diagnosis far
outweigh the risk
Women should always inform
their
physician
on
x-ray
technologist if there is any
possibility that they are pregnant.
See the safety page for more
information about pregnancy and
x-rays.
Complications that may result
from a thoracostomy include:
✓ Pneumothorax
✓ Accidental injury to the
chest wall, arteries, veins or
lung parenchyma
✓ Blood clots
✓ Dislodging of the tube
Because x-ray imaging is fast and
easy, it is particularly used in
emergency
diagnosis
and
treatment.
PRELIMINARY ASSESSMENT:
• Check:
- Ensure a signed informed consent for chest tube insertion. This
is an invasive procedure.
- Provide additional information as indicated. Explain that local
anesthesia will be used but the pressure may be felt.
- Reassure that breathing will be easier once the chest tube is in
place and the lung re-expands. The client may be extremely
dyspneic and anxious and may need reassurance that this
invasive procedure will provide relief.
- Gather all needed supplies, including thoracostomy tray,
injectable lidocaine, sterile gloves, chest tube drainage
system, sterile water, and a large sterile catheter-tipped
syringe to use as a funnel or filling, water-seal and suction
chamber.
PREPARATION OF CLIENT:
✓ Position as indicated for the procedure. Either an upright
position (as for thoracentesis) or side-lying position may be
used, depending on the site of the pneumothorax
✓ Assist with chest tube insertion as needed. The procedure may be
performed in a procedure room, in the surgical suite, or at the
bedside.
✓ Although chest tube insertion is a relatively simple procedure,
nursing assistance is necessary to support the client and rapidly
establish a closed drainage system.
✓ Identify the fifth intercostal and the midaxillary line. The skin
incision is made in between the midaxillary and anterior axillary
lines over a rib that is below the intercostal level selected for
chest tube insertion. A surgical marker can be used to better
delineate the anatomy.
✓ Prepare the skin around the area of insertion, preferably with
chlorhexidine or alternatively with 10 percent povidone-iodine
solution. Wear sterile gloves, gown, hair cover, and goggles
or face shield, and apply sterile drapes to the area.
POST-PROCEDURE CARE:
✓ Assess respiratory status at least every 4 hours. Frequent
assessment is necessary to monitor respiratory status and the
effect of test tube.
✓ Maintain a closed system. Tape all connections, and secure the
chest tube to the chest wall. These measures are important to
prevent inadvertent tube removal or disruption of the system
integrity.
✓ Keep the collection apparatus below the level of the chest.
✓ Pleural fluid drains into the collection apparatus by gravity flow.
✓ Check tubes frequently for kinks or loops. These could interfere
with drainage
✓ Check the water seal frequently. The water level should
fluctuate with respiratory effort. If it does not, the system may
not be patent or intact. Periodic air bubbles in the water-seal
chamber are normal and indicate that trapped air is being
removed from the chest. Frequent assessment of the system is
important to ensure appropriate functioning.
✓ Measure drainage every 8 hours, marking the level on the
drainage chamber. Report drainage that is cloudy, in excess of
70ml per hour, or red, warm, and free flowing. Red, free
flowing drainage indicates hemorrhage; cloudiness may
indicate an infection. Emptying the drainage would disrupt integrity
of the closed system.
✓ Periodically assess water level in the suction control chamber,
adding water as necessary. Adequate water in the suction control
chamber prevents excess suction from being placed on a delicate
pleural tissue.
✓ Assist with frequent position changes and sitting and
ambulation as allowed. Chest tubes should not prevent
performance of allowed activities. Care is needed to prevent
inadvertent disconnection or removal of the tubes
✓ When the chest tube is removed, immediately apply a sterile
occlusive petroleum jelly dressing. An occlusive dressing
prevents air from re-entering the pleural space through the chest
wound.
POINTS TO REMEMBERS (SAFETY MEASURES):
• Pain and burning sensation in the chest after the procedure
• Monitor heart rate, blood pressure, breathing, and oxygen levels.
• It may be hard to breathe at first. Ease back into normal activities
only when ready.
• Avoid intense activities like heavy lifting for six to eight weeks after
surgery.
• ANY
SURGERY
CAN
HAVE
RISKS.
POSSIBLE
COMPLICATIONS INCLUDE:
- Improper placement
- Horizontal layer (over the diaphragm) – acceptable for
hemothorax; should be repositioned for pneumothorax
- Subcutaneous – must be repositioned
- Placed too far into the chest (against the apical pleura) should
be retracted
- Placed into the abdominal space – should be removed
• Bleeding locally – usually responds to direct pressure
• Hemothorax (lung vs. intercostal artery injury) – requires
emergent laparotomy.
• Organ penetration (usually requires surgical repair)
- Stomach, colon, or diaphragm – occurs as a result of
unrecognized diaphragmatic hernia
- Lung – occurs as a result of pleural adhesions or use of a
thoracostomy tube trocar
- Liver or spleen
• Tube dislodgement
• Empyema – chest tube (foreign object) could introduce bacteria
into the pleural space
• Retained pneumothorax or hemothorax – might require
insertion of a second chest tube.
DIABETIC FOOT CARE
1. You may think of diabetes as a blood sugar problem, and it is.
→ But the nerve and blood vessel damage caused by diabetes
can also become a problem for your feet if you develop
neuropathy (which occurs in about 70 percent of people with
diabetes) and lose feeling in your feet or hands or get an
infection. To ensure the best possible foot health, follow these
11 easy tips to avoid injury, and your feet will be healthy longer.
2. Inspect your feet every day.
→ Nerve damage is a complication of diabetes that makes it hard
to feel when you have sores or cracks in your feet. "Patients
with diabetes are looking for any changes in color, sores, or dry,
cracked skin, says podiatrist Steven Tillet, DPM, of Portland,
Ore. Place a mirror on the floor to see under your feet or ask a
friend or relative for help if you can't see all parts of your feet
clearly.
3. Skip "hot" tubs.
→ When people with diabetes develop nerve damage or
neuropathy, it's hard to tell if the bath water is too hot. "They
won't realize they are actually scalding their skin," explains Dr.
Tillet. Stepping into a bath before checking the temperature can
cause serious damage to your feet, and burns and blisters are
open doors to injection. Use your elbow to check the water
temperature before getting into the tub or shower.
4. Invest in proper footwear and socks.
→ Shoe shopping for people with diabetes requires a little more
attention to detail than you may be used to. Tillet advises
looking for shoes with more depth in the toe box, good
coverage of both top and bottom, and without seams inside the
shoe that can rub on your foot. Likewise, seek socks without
seams, preferably socks that are padded and made from cotton
or another material that controls moisture.
5. Don't go barefoot.
→ Wearing shoes with good coverage outside to protect your feet
makes sense to most people, but even inside your house,
puttering around without shoes puts your feet at risk for small
cuts, scrapes, and penetration by splinters, glass shards, and
the misplaced sewing needle or thumbtack. If you have
neuropathy, you might not notice these dangerous damages
until they become infected. It's best to wear shoes at all times,
even in the house.
6. Keep your skin dry.
→ Make sure that drying your feet is part of your hygiene routine.
"The space between the toes is very airtight," says Tillet. "Skin
gets moist and breaks down, leading to infection." Prevent this
by toweling off thoroughly after washing your feet and by
removing wet or sweaty socks or shoes immediately. You can
still use moisturizer to prevent dry, cracked skin - just avoid
putting it between your toes.
7. Treat foot woes promptly.
→ Attend to bunions, calluses Corns, hammertoes, and other
aggravations promptly, so they don't lead to infection due to
pressure sores and uneven rubbing. Even seemingly harmless
calluses may become problems if you ignore them, notes Tillet.
See a podiatrist, a doctor who specializes in foot care, instead
of heading to the pharmacy for an over-the-counter product for
feet - some products are irritating to your skin and can actually
increase the risk of infection even while they treat the bunion,
callus, or corn on your foot.
8. Consider Orthotics.
→ Because wearing the correct shoes is so important, orthotic
footwear is a great investment in protection and comfort. Shoes
made especially for people with diabetes are available at
specialty stores and through catalogs, or you can visit your
podiatrist for advice. Medicare Part B will cover one pair of
depth-inlay or custommolded diabetic shoes a year, plus
additional inserts to reduce pressure on your feet. Your doctor
may recommend this type of diabetic shoe if you have an ulcer
or sore that is not healing.
9. Opt for Non-impact Aerobics.
→ People with diabetes benefit from exercise, but you still must
go easy on your feet. Many fitness classes and aerobics
programs include bouncing, jumping, and leaping, which may
not be the best activities for your feet, especially if you have
neuropathy. Instead, look into programs, such as walking, that
don't put too much pressure on your feet. Just make sure you
have the right shoe for whatever activity you choose.
10.
Quit smoking now.
→ The dangers of smoking run from your head to your feet. "The
nicotine in a cigarette can decrease the circulation in the skin
by 70 percent," says Tillet. So, if you smoke, you are depriving
your feet of the nutrient-and oxygen-rich blood that helps keep
them healthy and fights infection. "Diabetic patients already
have risk factors that compromise their blood vessels. It's never
too late to stop smoking." says Tillet.
11.
Control blood sugar.
→ "There's a direct relationship between blood sugar level and
damage to the nerve cells," says Tillet. Out-of-control blood
sugar leads to neuropathy, which will make it hard to know
when your feet are at risk or being damaged. The better you
are at controlling your blood sugar, the healthier your feet will
be over the long term. Finally, if you already have an infection,
high blood sugar levels can make it hard for your body to fight
it
consolidation, blocking, erasure and destruction of personal
data; and
3. Ensures that the Philippines complies with international
standards set for data protection through National Privacy
Commission (NCP)
DATA PRIVACY ACT OF 22012 PRIMER AND ISSUES:
Confidentiality, Privacy, and Security of Patient’s Data
• Confidentiality in health care refers to the obligation of
professionals who have access to patient records or
communication to hold that information in confidence.
• Rooted in confidentiality of the patient-provider relationship that
can be traced back to the fourth century BC and the Oath of
Hippocrates, this concept is foundational to medical
professionals’ guidelines for confidentiality.
OVERVIEW OF THE DATA PRIVACY ACT. OF 2012:
• Privacy – is viewed as the right of the individual client or patient
to be let alone and to make decisions about how personal
information is shared.
• Security – refers directly to protection, and specifically to the
means used to protect the privacy of health information and
support professionals in holding that information in confidence.
The concept of security has long applied to health records in
paper form; locked file cabinets are a simple example. As use of
electronic health record systems grew, and transmission of
health data to support billing became the norm, the need for
regulatory guidelines specific to electronic health information
became more apparent.
PRIVACY
Refers to freedom from intrusion
into one’s personal matters, and
personal information; the Right to
be Let Alone
Applies to the
PERSON/INDIVIDUAL
Right of Individual to keep his or
her individual information from
being disclosed
Limits the access of the public
Not obligatory; it is personal
choice of an individual
CONFIDENTIALITY
Refers to personal information
shared with an attorney,
physician, therapist, or other
individual that generally cannot
be divulged to 3rd parties
Applies to the
DATA/INFORMATION an
extension to privacy
Data required for a particular
purpose whose use is limited to
that purpose
Prevents information documents
from unauthorized access
Obligatory, when the information
is professional and legal
HELLO RA 10173:
• A 21st century law to address 21st century crimes and concerns
1. Protects the privacy of individuals while ensuring free flow of
information to promote innovation and growth
2. Regulates the collection, recording, organization, storage,
updating or modification, retrieval, consultation, use,
CONSENT OF THE DATA SUBJECT:
• Consent of Data Subject - refers to any freely given, specific,
informed indication of will, whereby the data subject agrees to
collection and processing of personal information about and/or
relating to him or her.
• Consent shall be evidenced by a written, electronic or recorded
means. It may also be given on behalf of the data subject by an
agent specifically authorized by the data subject by an agent
specifically authorized by the data subject to do so.
SENSITIVE PERSONAL INFORMATION:
• Individual's race, ethnic origin, marital status, age, color, and
religious, philosophical or political affiliations; individual's health
education, genetic or sexual life of a person, or to any proceeding
for any offense committed or alleged to have been committed by
such individual, the disposal of such proceeding, or the sentence
of any court in such proceedings;
• Issued by government agencies peculiar to an individual which
includes, but is not limited to, social security numbers, previous or
current health records, licenses or its denials, suspension or
revocation, and tax returns; and
• Specifically established by an executive order or an act of
Congress to be kept classified.
PREVILEGED INFORMATION:
• refers to any and all forms of data which under the Rules of
Court and other pertinent laws of constitute privileged
communication
PROCESSING:
•
•
•
•
•
Create and Collect
Store and Transmit
Use and Distribute
Retain
Dispose and Destroy
PROCESSING OF SENSITIVE PERSONAL INFORMATION:
• The processing of sensitive personal information and privileged
information is prohibited.
ALLOWABLE PROCESSING (EXCEPTIONS):
PERSONAL INFOMRATION
SENSITIVE PERSONAL
INFORMATION
Sec. 21, Rule V, DPA (IRR)
Sec. 22 Rule V, DPA (IRR)
CONSENT
CONSENT
CONTRACT
LAWS AND REGULATIONS
LEGAL OBLIGATION
PROTECT LIFE AND HEALTH
PROTECT INTEREST OF DATA PUBLIC ORGANIZATION
SUBJECT
NATIONAL EMERGENCY
MEDICAL TREATMENT
FULFILLMENT OF MANDATE: COURT, LEGAL CLAIMS
LEGITIMATE INTEREST
KNOW YOUR DATA PRIVACY RIGHTS:
• Organizations who deal with your personal details, whereabouts,
and preferences are duty bound to observe and respect your data
privacy rights
• If you feel that your personal data has been misused, maliciously
disclosed, or improperly disposed, or if any of the rights discussed
here have been violated, the data subject has a right to file a
complaint with NCP.
THE RIGHT TO OBJECT:
• Your CONSENT is necessary before any organization can
LAWFULLY collect and process your personal data. If without your
consent, any such collection and processing can be contested as
unlawful or ILLEGAL, and would therefore be answerable to the
Data Privacy Act of 2012
• In case you already gave your consent by agreeing to an
organization’s privacy notice, you can withdraw consent if the
personal information processor decided to amend said notice
THE RIGHT TO BE INFORMED:
• The data subject has a right to be informed whether personal data
pertaining to him or her shall be, are being, or have been
processed, including the existence of automated decision-making
and profiling.
• The right to be informed is the most basic right as it empowers the
data subject to consider other actions to protect his or her data
privacy and assert other privacy rights.
• The data subject shall be notified and furnished with relevant
information before the entry of his or her personal data into the
processing system or at the next practical opportunity.
• This right also requires personal information controllers3 to notify
the data subject in a timely manner if his or her personal data has
been compromised.
THE RIGHT TO ACCESS:
• This is your right to find out whether an organization hold any
personal data about you and if so, gain “reasonable access” to
them. Through this right, you may also ask them to provide you
with a written description of the kind of information they have about
you as well as their purpose/s for holding them.
• Under the Data Privacy Act of 2012, you have a right to obtain
from an organization a copy of any information relating to you that
they have on their computer database and/or manual filling
system. It should be provided in an easy-to-access format,
accompanied with a full explanation executed in plain language.
THE RIGHT TO DAMAGES:
• You may claim compensation if you suffered damages due to
inaccurate, incomplete, outdated, false, unlawfully obtained or
unauthorized use or disclosure of his or her personal data, taking
into account any violation of his or her rights and freedoms as data
subject.
THE RIGHT TO DATA PROTABILITY:
• This right assures the data subject that he or she remains in full
control of his or her personal data. Data portability allows the data
subject to obtain and electronically move, copy or transfer his or
her personal data in a secure manner for further use. It enables
the free flow of personal information across the internet and
organizations, according to the data subject’s preference. This is
important especially now that several organizations and services
can reuse the same data.
THE RIGHT TO RECTIFICATION:
• To preserve the integrity of his or her personal data, the data
subject has the right to dispute the inaccuracy or error in his or her
personal data and have the personal information controller correct
it immediately and accordingly, unless the request is vexatious or
otherwise unreasonable.
• If the personal data has been corrected, the personal information
controller shall ensure the accessibility of both the new and the
retracted information and the simultaneous receipt of the new and
the retracted information by the intended recipients thereof.
THE RIGHT TO ERASURE OR BLOCKING:
• The data subject has the right to suspend, withdraw or order the
blocking, removal or destruction of his or her personal data. This
right may be exercised upon discovery and substantial proof of
any of the following:
1. The personal data is incomplete, outdated, false, or unlawfully
obtained;
2. The personal data is being used for a purpose not authorized
by the data subject;
3. The personal data is no longer necessary for the purposes for
which they were collected;
4. The data subject withdraws consent or objects to the
processing of his or her information, and there is no other legal
ground or overriding legitimate interest for the processing;
5. The personal data concerns private information that is
prejudicial to data subject, unless justified by freedom of
speech, of expression, or of the press or otherwise authorized;
6. The processing is unlawful; or
7. The personal information controller or personal information
processor violated the rights of the data subject.
THE RIGHT TO FILE A COMPLAINT:
• The data subject whose personal information has been misused,
maliciously disclosed, or improperly disposed, or whose data
privacy rights have been violated, has the right to file a complaint
with the National Privacy Commission.
GENERAL OBLIGATIONS UNDER DPA:
1. ADHERE TO DATA PRINCIPLES
2. IMPLEMENT SECURITY MEASURES
3. UPHOLD RIGHTS OF DATA SUBJECTS
DATA PRIVACY PRINCIPLES:
1. Transparency
- The data subject must be aware of the nature, purpose, and
extent of the processing of his or her personal data, including
the risks and safeguards involved, the identity of PIC, his or her
rights as data subject, and how these can be exercised.
2. Legitimate Purpose
- The processing of information shall be compatible with a
declared and specified purpose which must not be contrary to
law, morals, or public policy. This should have individuals’
consent, or must be authorized or allowed by the Constitution
or law.
3. Proportionality
- The processing of information shall be adequate, relevant,
suitable, necessary, and not excessive in relation to a declared
and specified purpose. Personal data shall be processed only
if the purpose of the processing could not reasonably be
fulfilled by other means.
HEALTH PRIVACY CODE: ON COLLECTION AND PROCESSING
OF HEALTH INFORMATION
1. The CONSENT shall conform to the requirements or
characteristics of a valid informed consent which consist of the
following:
a. Competence – of sound mind, at least 18 years old, and not
under the influence of drugs or liquor
b. Amount and Accuracy of Information – relevant factual data
about a procedure and/or treatments, its benefits, risks, and
possible complications or outcomes
c. Patient Understanding – education, language or dialect
d. Voluntariness – make an autonomous decision without force
or intimidation, and understands that he/she can withdraw
consent anytime without consequences.
1.1. For Persons with Disabilities (PWDs) – use of appropriate
means of communication such as verbal or sign language
1.2. Persons to Obtain Consent – consent shall be obtained by a
duly authorized staff who shall be responsible for informing the
patients regarding the implementation of the PHIE, and the
validation of patient information.
1.3. Persons to Give Consent – consent shall be given by a
patient of legal age and sound mind, or otherwise incapacitated
to give consent, any of the following in the order stated
hereunder, can give consent:
a. Immediate relatives within the 3rd degree of consanguinity
based on hierarchy; provided, that in the case of minors,
either parent may give consent, unless the married, in which
case, preference shall be given to the mother
b. Cohabitant partner for a minimum of one (1) year or actual
and identified guardian of the patient
c. Social worker
d. Attending physician
• Provided, that if a patient has a duly executed advance directive
or power of attorney for healthcare, the same shall be given effect.
1.4. When to Get Consent – upon order of discharge/prior to
discharge from the health facility.
1.5. The Consent Form. The standard “Consent for Participation
to PHIE” shall be used by participating health care providers.
1.6. Valid formats of consent. Consent can either be in written,
recorded, and/or in electronic form. It must be signed by the
patient, guardian, or authorized representative, in accordance
with this code. If a patient is incapable of affixing his or her
signature, a finger print, thumb mark, electronic signature, or
other biometrics may be considered, provided that a witness of
legal age and sound mind is present.
1.7. Revocation and Reinstating Consent. Where consent was
previously given by an authorized representative on behalf of
an unconscious or otherwise incapacitated patient, such
consent may be subsequently revoked by the latter once he or
she recovers consciousness or regains the capacity to give
consent.
1.8. Exemptions for Consent. Consent shall not be required for
the processing of personal data in the PHIE under the following
conditions:
a. For purpose of medical treatment, carried out by a medical
practitioner or a medical treatment institution;
b. When necessary to protect the life and health of the patient
or another person, and the patient is not legally or physically
able to express his or her consent prior to the processing;
c. When processing is requires by existing law and regulation,
such as, but not limited to:
1. Act 3573: law of reporting of communicable diseases;
2. Administrative Order No. 2008-0009: Adopting the
2008 revised list of notifiable diseases, syndromes,
health-related events and conditions
PRIVACY: the individual’s desire for privacy is never absolute, since
participation in society is an equally powerful desire. Thus, each
individual is continually engaged in a personal adjustment process in
which he balances the desire for privacy with the desire for disclosure
and communication of himself to others, in light of the environmental
conditions and social norms set by the society in which he lives.
VIVARES vs. STC:
• For instance, a Facebook user can regulate the visibility and
accessibility of digital images (photos), posted on his or her
personal bulletin or “wall”, except for the user’s profile picture and
ID, by selecting his or her desired privacy setting:
▪ Public – the default setting; every Facebook user can view the
photo
▪ Friends of Friends – only the user’s Facebook friends and
their friends can view the photo
▪ Friends – only the user’s Facebook friends can view the photo
▪ Custom – the photo is made visible only to particular friends
and/or networks of the Facebook user; and
▪ Only me – the digital image can be viewed only by the user
• Facebook extends its users an avenue to make the availability of
their Facebook activities reflect their choice as to “when and to
what extent to disclose facts about themselves – and to put others
in the position of receiving such confidences.
USE OF SOCIAL MEDIA:
1. Definition of Social media. This refers to electronic
communication, websites or applications through which users
connect, interact or share information or other content with other
individuals, collectively form part of an online community. This
includes such online platforms as Facebook, Twitter, Google+,
Instagram, LinkedIn, Pinterest, Blogs, Social Networking Sites.
2. Unauthorized posting of personal data of patients in social media,
including pictures, shall be penalized in accordance with the
provisions of the DPA.
3. Administrative Responsibilities. Health facilities shall provide
for guidelines regarding the use of social media. In line with this,
the social media activity of all facility personnel, whether
temporary or permanent, shall be monitored for any privacy
breaches. For this purpose, “facility personnel” shall include: (a)
physicians; (b) employees; (c) other healthcare providers; (d)
students; (e) and residents in training, practicing their
profession, working, or fulfilling academic and clinical
requirements within the health facility. Unprofessional
behavior or misinformation witnessed in social media that violates
patient privacy or privacy of other individuals shall be reported to
appropriate authorities.
4. Responsible Social Media Use of Health Care Professionals.
Health care professionals shall always be mindful of their duties
to their patients, community, their profession and their colleagues
thus they must take into account that any content, once posted
online, may be easily disseminated to others and is essentially
irreversible.
5. Health Education and Promotion. Caution must be observed
when sharing health-related information, education, and
promotion for advocacy purposes. Only general opinions may be
shared in social media. Specific medical diagnosis, advice,
treatment or projection shall not be dispensed with therein.
Accordingly, social media use, whenever appropriate, shall always
include statements reminding the public that they should not rely
on advice given online, and that medical concerns are best
addressed in the appropriate settings. For social media use to
crowd source support, identity of the patient can only be revealed
to the support group upon patient’s consent. Confidentiality of data
shall still be upheld by removing any information or features that
are easily identifiable to the patient.
6. Professional Guidelines for Social media Use for Persons
Involved in the PHIE. A health care professional shall:
6.1. strive to develop, support and maintain a privacy culture in
the health facility. He or she shall abide by the social media
use policy of the facility.
6.2. advise the patients of their privacy rights and encourage
them not to post in social media any activity or confidential
information that may put them at risk, such as, but not limited
to medical diagnosis and laboratory results.
6.3. conduct himself or herself in social media or online the same
way that he or she would in person for this purpose, he or
she shall act in a manner befitting his or her profession,
thereby inspiring trust in the service he or she provides. This
is particularly the case if said professional maintains the
same social media account for both his professional and
personal lives.
6.4. refrain from using the name, log, or any other symbol of the
health facility in his or her social media activity, without
proper authorization. An individual shall also not identify
himself or herself in social media as a representative of the
facility absent any authority to do so.
6.5. refrain from posting, sharing, or using photos or videos
taken within the facility that will violate their right to privacy.
• US v. Gines-Perez: a person who places a photograph on the
internet precisely intends to forsake and renounce all privacy
rights to such imagery, particularly under circumstance such as
here, where the Defendant did not employ protective measures or
devices that would have controlled access to the Web page or the
photograph itself.
• United States v. Maxwell: the more open the method of
transmission is, the less privacy one can reasonably expect.
Messages sent to the public at large in the chat room or e-mail
that is forwarded from correspondent to correspondent loses any
semblance of privacy.
PENAL PROVISIONS:
SPECIAL NOTES:
• For HOSPITALS, it is important to take note of existing laws and
regulations that specifically mandate the CONFIDENTIALITY OF
RECORDS.
1. Records pertaining to cases of violence against women
and their children (RA 9262)
2. Medical Confidentiality of HIV cases (RA 8504)
3. Records of cases of child sexual abuse (PD 603) and
Childe Abuse (RA 7610)
4. Records of drug dependents under Voluntary and
Compulsory Submission program (RA 9165)
BASIC LIFE SUPPORT: Hands-Only CPR
NURSING PROCESS APPLIED TO PSYCHIATRIC NURSING
PRACTICE AND THE STANDARDS OF CARE
ASSESSMENT:
ASSESSMENT:
➢ Critical Elements of HANDS-ONLY COPR (Adult & Teens)
➢ Heart Attack – obstruction (blockage) – NO NEED FOR BLS!
➢ Cardiac Arrest – heart stops pumping blood – NEED
IMMEDIATE BLS!
RESPONSIVENESS
ASK FOR HELP
CAROTID PULSE – feel for 5 to 10 seconds.
BREATHING – rise and fall of chest.
CALL ERS (Emergency Response Service)
• ADULT
→ Mask is on; Gloves is on; Face Shield is on; The scene is
safe; I am safe.
→ Hey, are you okay! 2x
→ No response, I need help
→ Check for pulse and breathing simultaneously
- 1,001 to 1,006
→ No pulse, no breathing
→ Activate EMS. Get me and AED.
→ Compression
✓ Push hard at the center of the chest (2”/5cm) mid nipple
✓ Push fast (100 – 120 per/min)
✓ Allow complete chest recoil (do not lean; do not stab)
✓ 30 compressions; 2 ventilations
• BABY
→ Mask is on; Gloves is on; Face Shield is on; The scene is
safe; I am safe.
→ Baby, are you okay! 2x
- Flick the sole of the baby (Baby, are you okay! 2x)
- Rub the back of the baby (Baby, are you okay! 2x)
→ No response, I need help
→ Check for pulse and breathing simultaneously
- Check for brachial pulse
- 1,001 to 1,006
→ No pulse, no breathing
→ Activate EMS. Get me and AED.
→ Compression:
✓ Push hard at the center of the chest (1 ½ “/4cm)
✓ Push fast
✓ 30 compressions; 2 ventilations
CHOKING:
• ADULT
→ Stand behind the person and put your arms around their belly
(abdomen)
→ Make a fist with one hand and clasp your other hand tightly
around it
→ Place the thumb side of your fist just below their ribcage and
about two inches above their belly button (navel)
→ Sharply and quickly thrust your hands inward and upward five
times (J MOVE)
→ Repeat this process until you free (dislodge) the object stuck
in their windpipe, or the person becomes unconscious
• CHILD
→ Get a chair that is comfortable for you to sit in while relieving
baby that is choking
→ Turn the infant face down with their chest resting on your
forearm or thigh. Make sure their head is lower than their
body
→ Using the heel of your hand, strike the infant between their
shoulder blades five times. The strikes should be firm but not
so hard that you cause injury
→ Check the infant’s mouth and remove any visible objects
• Principles and Techniques of Psychiatric Nursing Interview
▪ Establishing boundaries
▪ How?
→ Greet the patient
→ State the name of the PATIENT
→ State YOUR name
→ Your background info
→ Your ROLE
→ Patient’s ROLE
→ Schedule of interaction
→ End of interaction
• Presenting problem
• Present illness
• Medical history
• Recent stressors/losses
• Psychosocial/Psychiatric History
• Coping skills and Relationship
• Education
• Legal
• Marital History
• Social History
• Support System
• Insight
• Value-belief system
▪ Spiritual Values
• Special Needs
• Discharge Goals
• Client participation
• Elements of Psychiatric History
• Mental Status Exam
WHY ASSESSMENT IS CRUCIAL?
HOW TO USE AN AED?
• Assessment Rating Scale that can be applied to patients done
by Psychiatrists
▪ Hamilton Anxiety Scale – anxiety
▪ Beck Inventory/Geriatric Depression Scale
(GDS)/Hamilton Depression Scale – depression
▪ Mania Rating Scale – mania
▪ Brief Psychiatric Scale/Overall Psyche Scale –
schizophrenia
▪ Abnormal Involuntary Movement Scale/Mini-Mental – EPS
effects
▪ Alzheimer’s Disease Rating Scale – cognitive disorder
▪ Eating Dso. Inventory/Body Attitude Test – eating disorder
▪ Global Assessment of Functioning – level of overall
function
NURSING DIAGNOSIS:
*NOTE: Always prioritize specific nursing diagnosis
• Actual
▪ Post trauma syndrome r/t overwhelming anxiety sec. to rape
or assault/ illness/ war or disaster as evidenced by
reexperience (flashbacks), repetitive nightmares, intrusive
thoughts about traumatic events, excessive verbalization of
the event
• Potential or Risk Diagnosis
▪ Risk for suicide r/t history of suicide or through verbal remarks
of harming self
• Imbalanced Nutrition; Less than the body requirements
• Ineffective Coping
OUTCOME IDENTIFICATION AND PLANNING:
OUTCOME IDENTIFICATION:
• Identification of expected client behaviors resulting from nursing
interventions individualized to the client
• Should be SMART
▪ Specific
▪ Measurable
▪ Attainable
▪ Realistic
▪ Time-bounded
Nursing
Diagnosis
Anxiety
Ineffective
Coping
Hopelessness
Incorrect
Outcome
Exhibits
decreases
anxiety
Demonstrates
Coping abilities
Expresses
increased
feelings of hope
Correct Outcome
Verbalizes feeling calm, relaxed,
absence of muscle tension &
diaphoresis, practices deep
breathing
Makes own decision, interacts to
staff and personnels
Makes plans for the future, states
“my kids need me to be well”
PLANNING:
• Developing plan of care that is negotiated among the pt., nurse,
family and interdisciplinary team and prescribes evidencedbased intervention to attain expected outcomes
• The Process:
→ Meeting and working w/ client, family, treatment team
→ Identifying priorities of care
→ Coordinating and delegating responsibilities
→ Making clinical decisions about the use of psychotherapeutic,
scientific principles using evidence-based practice
• Tools used in Planning:
→ Interdisciplinary standardized care plans (NANDA) diagnosis
→ Clinical pathways
IMPLEMENTATION:
•
•
•
•
Counseling – speak less, listen more
Milieu Therapy
Promotion of Self-care Activities
Others:
▪ Psychologic Interventions – art, dance, music therapies
▪ Health teachings
▪ Case management
▪ Health promotion and Health maintenance
GENERAL NURSING CONSIDERATIONS:
•
•
•
•
•
•
•
•
•
•
e. Incoherence – disorderly progression of thinking, ideas run
into one another without logical sequence, disorganization of
syntactical structure
Promoting health and safety
Monitoring medications schedule and effects
Providing adequate nutrition/hydration
Creating a nurturing, therapeutic environment
Continuing to build trust, self-esteem and dignity
Participating in therapeutic groups and activities
Developing client strengths and coping methods
Improving communications and social skills
Connecting family and community support systems
Preventing relapse through effective discharge planning
f. Blocking – thought of obstruction, progression and expression
of thought suddenly cease
3. DISORDERS OF CONTENT OF THOUGHT
▪ Delusion – false belief; a strong belief opposed to reality which
the individual steadfastly maintains in spite of logical
persuasion and evidence to the contrary
3.1. Delusion of grandeur – psychotic belief that one is an
exalted personage
EVALUATION:
• Evaluation of the client’s progress in attaining expected
outcomes
• Compare the client’s current mental health state/condition w/ the
outcome statement
• Consider all possible reasons why the client did not achieve
outcomes
DOCUMENTATION:
✓ Evaluation of the clients changing condition
✓ Informed consent
✓ Response to medication
✓ Ability to engage in treatment programs
✓ Signs and symptoms (most critical suicidal/homicidal tendencies)
✓ Client concerns
✓ Other critical incidents that occur
SYMPTOMATOLOGY
• Symptom of actual mental illness
DISORDERS OF PERCEPTION
• Perception organization & Interpretation of stimuli; awareness of
events & sensations & ability to make distinctions between them
1. Illusion – false perception, misinterpretation (create an
oversensitivity to colors, shapes, & background activities which
occur when the person exaggerates stimuli)
2. Hallucination – sensory impression of external objects in the
absence of any appropriate stimulus in the environment
DISORDERS OF THINKING
1. DISORDERS IN THE PRODUCTION OF THOUGHT
2. DISORDERS IN PROGRESSION OF THOUGHT
a. Flight of Ideas – characterized by increases associative
activity, rapid digression from one ideas to another
3.4. Delusion of Self-Accusation – ideas of remorse and selfaccusation are used to assuage feeling of guilt
3.5. Depressive Delusions – ideas concerning guilt, disease or
poverty
3.6. Religious Delusions – often center around the second
coming of Christ or another significant religious figure or
prophet
3.7. Somatic Delusions – generally vague and unrealistic
beliefs about the client's health or bodily functions, factual
information or diagnostic testing does not change these
beliefs
▪ Hypochondria – patient's attention is abnormally concentrated
on his own body; he is depressed and his thought are
obsessively preoccupied with some bodily organ which he is
convinced is incurably diseased although pathological process
can be demonstrated
▪ Obsessions – thoughts that persistently thrust themselves into
consciousness against the conscious desire of the patient
▪ Phobias – fears, doubts, indecisiveness, irrational fear
resulting from the displacement of fear unto some
environmental object or situation other than the original cause
of fear
1. Agoraphobia – fear of being outside (Greek: fear of the
marketplace)
2. Social Phobia – anxiety provoked by certain social or
performance situations
3. Specific Phobias – irrational fear of an object or situation
3.1. Natural Environmental
3.2. Blood-injection
b. Retardation – initiation & movement of thought are slow
repetitions
3.3. Delusion of Reference (Ideas of Reference) – psychotic
belief that chance happenings and conversations are aimed
at oneself
3 Categories:
a. Autistic Thinking (Dereistic thinking) - determined primarily by
the individual needs or desires; tends to be Indulged in for selfgratification without necessary regard to reality, as in
daydreaming
c. Perseveration – abnormally persistent
continuance in expression of an idea
3.2. Delusion of Persecution – psychotic belief that one is
being plotted against and is in danger; characteristics of
paranoid patients
or
d. Circumstantiality – the patient finally reaches its ideational
objective after many unnecessary and trivial details have led
him into tiresome digression
3.3. Situational
3.4. Animal
3.5. Other types of specific phobias
DISTURBANCE OF CONSCIOUSNESS
• Consciousness – clear mindedness or awareness
1. Confusion – impairment of the sensorium, difficulty of grasp,
bewilderment, perplexity, disorientation disturbance of
associative functions and poverty of Ideas
2. Clouding of Consciousness – clear mindedness is not
complete, threshold of consciousness in high perceptions are
not produced by ordinary stimuli
3. Stupor – sense or feeling is greatly diminished, marked
unresponsiveness to stimuli
4. Dream State – also known as twilight state, consciousness
disturbed, visual and auditory hallucinations present
5. Delirium – condition marked by clouding of consciousness,
bewilderment,
restlessness,
confusion.
disorientation,
coherence of dreamlike thinking, illusions and hallucinations,
apprehensions
Most Common Causes:
Physiologic or Metabolic
Infection (systemic and cerebral)
Drug related
DISTURBANCE OF APPERCEPTION
• disturbances of the function by which one through active,
attentive, through analyzes, synthesizes, integrates, evaluates
and absorbs experience
DISORDERS OF ORIENTATION
• Orientation – process by which one apprehends his environment
and locates himself mentally in relation to it - an individual may be
disoriented as to time, place, and person
DISORDERS OF AFFECTIVITY
• Affectivity – refers to the feeling-like or emotional feeling-tone of
a person
• Affect – strong, temporary variations, modulations
expression of the self-feeling Assessing Affect:
and
1. Blunted – showing little facial expression
2. Broad – displaying full range of emotional expression
3. Flat – showing no facial expression
4. Inappropriate – displaying facial expression incongruent with
mood or situation
5. Restricted – displaying one type of expression usually serious
or somber
A. Pleasurable affects
C. Tension – patient has continuing feeling of tautness both
emotionally and in his muscles; sees restlessness, dissatisfaction,
dread and discomforting expectancy
D. Anxiety – a condition of heightened and often disruptive inner
tension, accompanied by a vague but often most disquieting
feelings of uneasiness and apprehension
a. Mild – sensation that something is different and warrants
special attention; sensory stimulation increases and helps the
person focus attention
b. Moderate – disturbing feeling that something is definitely
wrong; becomes nervous or agitated; person can still process
information
c. Severe – more primitive survival skills take over defensive
responses ensue, and cognitive skills decrease significantly
d. Panic – person's safety is the primary concern; he or she
cannot perceive potential harm and may have no capacity for
rational thought
▪ Echolalia – repeating words or phrases uttered in the
presence of the patient
▪ Echopraxia – imitation of movements noted in others;
imitation of the movements or gestures of someone an
individual is observing
e. Negativism – behavior which is the opposite of what would
ordinarily be called for in a given situation; frequently
expressed in such forms as mutism, refusal of food,
noncompliance with request and resistiveness to efforts to care
for the patient
f. Aversion – unbending and uncompromising refusal to accept
a situation characterized by resentment, hatred, sullen
uncooperativeness and rejection
g. Compulsion – morbid and often irresistible urge to perform an
apparently unreasonable act repetitiously
Common Compulsions:
▪ Checking rituals
E. Panic – a high degree of fear based on prolonged tension, with a
sudden climax is characterized by fear, extreme insecurity,
suspiciousness, and as a tendency to projection and
disorganization
▪ Counting rituals
F. Inadequate affect – emotional dulling or detachment in the form
of indifferences, insensitiveness to those experience that normally
give emotional pleasure or pain
▪ Touching, rubbing, or tapping
G. Inappropriateness of affect – disharmony of affect
▪ Exhibiting rigid performance
H. Ambivalence – contradictory feeling and attitude towards the
same object
▪ Having aggressive urges
I. Depersonalization – pervasive and distressing feeling of
estrangement; feeling of unreality, a loss of conviction of one's
own identity
DISORDERS OF MOTOR ASPECTS OF BEHAVIOR
1. Disturbance of activity
a. Increase activity (hyperactivity) – patient is very busy but his
activities are not productive
b. Decreased activity (hypoactivity) – prolonged delay before
initiating the intended activity and once begin executed slowly
and as if with painful effort; in extreme cases, patient is mute
and motionless
c. Repetitious activities
▪ Stereotype – persistent and constant repetition of certain
activities
▪ Catalepsy – constantly maintained immobility of position;
lasts only in seconds
a. Euphoria – patient is an optimistic mental set, is imbued with
a subjectively pleasant feeling of well-being and confident and
assured in attitude
▪ Cerea flexibilities (waxy flexibility) – joints of the patient's
extremities may be flexed or extended with a wax-like
rigidity; maintenance of posture or position over time
b. Elation – an air of employment and of self-confidence radiance
from the patient even if circumstances should produce
unhappiness
▪ Mannerisms – stereotyped movements in the form of
grimace, repeated gestures, peculiarities of gait
c. Ecstasy – the model is one of a peculiar, entrancing, peaceful
rupture and tranquil sense of power
▪ Verbigeration – repetition of a meaningless word, phrase,
or sentence; stereotyped repetition of words or phrases, that
may or may not have meaning to the listener
B. Depression – an affective feeling-tone of sadness, may vary from
a mild down-heartedness to despair of hope
d. Automatic Obedience – command automatism, suggestions
or requests are compulsively or automatically followed
▪ Washing and scrubbing until the skin is raw
▪ Praying or chanting
▪ Hoarding items
▪ Ordering
DISORDERS OF ATTENTION
• Attention – conscious, selective reaction by which the organism
examines the external work for useful data Distractibility - inability
to hold the attention in a sufficient length of time
• Tenacity – no stimulus or experience can divert the attention to
an idea or object not related to the patient's mental content
DISORDER OF MEMORY
• Memory – the function by which data are stored later to be
summoned again presented to consciousness
3 Process:
▪ reception and registration of a mental impression;
▪ retention or preservation of the previously acquired
impression
▪ reproduction or recalling of the impression
a. Hyper amnesia – abnormally pronounced memory
b. Amnesia – loss of memory
▪ Organic amnesia – disturbance of neurons through chemical
alterations, trauma or degenerative changes
▪ Psychogenic amnesia – recall is inhibited
▪ Anterograde amnesia – progressive with the passage of time
and the stream of experience; extends forward from the time of
injury
▪ Retrograde amnesia – loss of memory extending back over a
period prior to the time when the onset occurred
c. Paramnesia – falsification of memory as well as distortion of
memory
▪ Retrospective falsification – illusions of memory created in
response to affective needs; embroidering the truth to meet
these needs or unconsciously selecting agencies that suits
one's Interest
▪ Déjà vu – illusions of memory, feeling of familiarity or
observation of something of which there has been no previous
observation
▪ Jamais vu – false feeling of unfamiliarity with situations that
have actually been experience
DEMENTIA
• Dementia – reduction of mental state; a permanent irreversible
loss of intellectual efficiency; found in structural disturbances or
degeneration of the higher cortical neurons
• Aphasia – deterioration of language function
• Apraxia – impaired ability to execute motor functions despite
intact motor abilities
• Agnosia – inability to recognize or name objects despite intact
sensory abilities
• Disturbance in executive functioning – ability to think abstractly
and to plan, initiate, sequence, monitor and stop complex behavior
Stages of Dementia:
• Mild – forgetfulness is the hallmark sign
• Moderate – confusion is apparent along with progressive memory
loss
• Severe – personality and emotional changes occur.
Etiology:
• Alzheimer's disease
• Vascular dementia
• Picks' disease
• Creutzfeldt-Jakob disease
• HIV infection
• Parkinson's disease
• Huntington's disease
NOTE: PLS STUDY ALSO THE FF:
•
•
•
•
MS WARD
THERACOM/NON-THERACOM
SELF-AWARENESS
MEDCATION (MOSTLY RELATED TO PSYCHIA –
PSYCHOPHARMACOLOGY)