Gapuz Fundamentals of Nursing

FUNDAMENTALS OF NURSING Man  Forms the Nursing

foundation

Vital Reparative Process  By Florence Nightingale  Man is passive in influencing the nurse or the environment

of

Four Components or Attributes of Man  Capacity to think on an Abstract Level  Establish a family  Establish a territory  Ability to use verbal symbols as language

Man is a whole. Man is complete  By Virginia Henderson  Man has fourteen (14) fundamental needs Human Needs  Needs are physiologic and psychologic  Both these needs must be met in order to maintain wellbeing.

Concept:  Animals form a family by instinct  Via hormonal scents

Key Concept:  Basic Human Needs are equivalent to COMMON NEEDS

Nursing Concepts of Man Biopsychosocial Spiritual Being  By Sister Calista Roy  Man interacts with the environment

Characteristics of Human Needs  Universal  Interrelated  One need is related to another need  May be stimulated by internal or external factors  May be deferred (but not indefinitely)

Open System  By Martha Rogers  Man interacts with the environment  Exchanges matter with energy  Exchanges energy with environment

Maslow’s Hierarchy of Needs

Unified Whole  By Martha Rogers  Man is composed of certain parts  Total of those parts is more than the sum of all parts  This is because man has attributes

Why do we study this?  In order to prioritize nursing actions 1. Physiologic needs  Food, maintenance homeostasis 2. Safety and security 3. Love and belongingness 4. Self-Esteem

1

of

 Feeling good about one’s self  Two factors affecting Selfesteem o Yourself  Sense of adequacy  Accomplishment o Others  Appreciation  Recognition  Admiration  Belongingness 5. Self-Actualization  Able to fulfill needs and ambitions  Maximizing one’s full potential 6. Aesthetics  Beauty

 Open to new ideas o Not adopts new ideas o Not one track mind  Highly creative and flexible  Does not need fame  Problem-centered rather than self-centered Concept:  Self-Actualization is very difficult to attain  It is impossible to attain  New needs come after getting one need Illness  Highly subjective feeling of being sick or ill Two types of Illness: Acute Illness  Sudden in onset (most of the time, but not always)  Less than six (6) months

Two Additional Needs by Maslow  Need to know  Need to understand Richard Kalish  Man needs stimulation  Needs to explore o Sex o Activity o Novelty  Stimulator  Desire to come up with something of your own

Chronic Illness  Gradual in onset (most of the time, but not always)  Types of Chronic Illness o Exacerbation  Period characterized by active signs and symptoms of the illness o Remission  Periods where no signs and symptoms are present

Characteristics of Self-Actualized Persons  Judges people correctly  Superior perception  Decisive o Capable of making decisions  Clear notion as to what is right and wrong

Disease  Objective pathologic process Concepts: 2

 Illness without disease is possible  Disease without illness is possible  Illness may or may not be related to a disease  One can have a disease without necessarily feeling ill

Walter Cannon  Ability to maintain homeostasis  A dynamic equilibrium  A state of balance of the internal environment while external environment is changing

Deviance  Any behavior that goes against social norms  Shortens life span  Results to disrupted family and community Concept:  Deviant behavior can considered a disease

Florence Nightingale  Health is using one’s power to the fullest  Being well  Can be maintained by manipulating the environment Virginia Henderson  Viewed in terms of ability to perform the fourteen (14) fundamental needs or components of nursing care UNAIDED

be

Rationale:  Because it also shortens the life span like a disease

Martha Rogers  Positive health symbolizes wellness  Health is a value term defined by a certain culture

Example:  Alcoholism o A disease rather than a social problem Wellness  Feeling of being well

Sister Calista Roy  A state and process of being and becoming an INTEGRATED PERSON

Definitions of Health World Health Organization  Health is the complete physical, mental, social (totality) well-being and not merely the absence of disease or infirmity  A high-level wellness!

Dorothea Orem  Characterized by soundness and wholeness of DEVELOPED HUMAN STRUCTURES and FUNCTIONS

Claude Barnard  Ability to maintain internal milieu

Imogene King  A dynamic state in the life cycle (contrasted with illness)

3

o Perceived seriousness o Perceived threat  Likelihood of Action influenced by: o Perceived benefit out of the action o Perceived barriers

 Illness is interference in the life cycle Betty Neuman  Wellness is that all parts and subparts are in harmony with each other and the whole system Dorothy Johnson  Elusive dynamic state influenced by biologic, psychologic and social factors

Smith’s Four Levels of Health 1. Clinical Model  Man is viewed as a Physiologic Being  If there are no signs and symptoms of a disease, then you are healthy  Against WHO definition of health  This is the NARROWEST concept of health 2. Role Performance Model  As long as you are able to perform SOCIETAL functions and ROLES you are healthy 3. Adaptive Model  Health is viewed in terms of capacity to ADAPT.  Therefore, goal of treatment is to restore capacity to adapt.  Failure to adapt is disease 4. Eudaemonistic Model  This is the BROADEST concept of health  Because health is viewed in terms of Actualization

Models of Health and Illness Health-Illness Continuum Dunn’s High Level Wellness and Grid Model  X-axis is HEALTH  Y-axis is environment Quadrant 1  High-level wellness in favorable environment Quadrant 2  Protected poor health in favorable environment Quadrant 3  Poor health in unfavorable environment Quadrant 4  Emergent high-level wellness in unfavorable environment Health Belief Model  By Rosentock  Based on a motivational theory  It assumed that good health is an objective common to all people  Consider perceptions (influences individuals motivation toward results) o Perceived susceptibility

Leavell and Clark’s Agent, Host, Environment Model  Also known as the Ecologic Model  Expands to the MULTICAUSATION of a DISEASE  Definitions of a disease as to its cause is expanded to a

4

multi-causation of a disease (i.e. cancer is a multi-factorial disease)  Triad is composed of the agent, host and susceptible host  Based on the interplay of three components of the model

Effects of Adrenalins  Increases Cardiac Rate  Response to increased metabolic rate and oxygen demand  Increases Respiratory Rate  Response to increased metabolic rate and oxygen demand  Bronchodilation  Vasoconstriction  Increased Peripheral Resistance  Increased Cardiac Workload  Increased Blood Pressure  Decreased Renal Perfusion  Decreased Renal Output  Pale, Cool, Clammy Skin

Concept of Health and Illness Stress  By Hans Selye  Is a non-specific response of the body to any demand placed upon it.  General Adaptation Syndrome (GAS)  Local Adaptation Syndrome (LAS)

Adrenal Gland is composed of: 1. Adrenal Medulla  Releases adrenalins 2. Adrenal Cortex  Releases the following:  Mineralocorticoids o Aldosterone  Glucocorticoids  Cortisol o A potent vasoconstrictor

General Adaptation Syndrome Involves two (2) body systems:  Nervous System  Endocrine System Nervous System involves:  Sympathetic Nervous System  Parasympathetic Nervous system Endocrine System involves:  Adrenal Glands

Mineralocorticoids  Increased Aldosterone levels  Increases sodium retention and water retention  Increases circulating blood volume  Increases cardiac workload (due to vasoconstriction)

The Adrenal Gland is composed of:  Adrenal Medulla  Adrenal Cortex Adrenal Medulla Adrenalins or Fight Hormones:  Epinephrine  Norepinephrine

releases or Flight

Glucocorticoids  Increased (transient)

5

hyperglycemia

Increased glycogenolysis Increased neogenesis Increases blood sugar Increases osmotic pressure Increases fluid retention (glucose is a colloid which attracts water and adheres to it)  Increases cardiac workload

 Stress resulted from interaction of man with his environment and fellowman  Therefore, Lazarus describes the SOCIAL ASPECT OF STRESS  Also an adopted PHYSIOLOGIC RESPONSE

    

Key Concept!  The most comprehensive concept of stress is the stress concept of LAZARUS as it combines Physiologic and Social aspects of stress.

Concept: Complications of Stress:  Cerebrovascular Attack  Increased Diabetic Ketoacidosis (if patient is diabetic)  Hypertension leading to cardiac arrest

Statements about Stress  Stress is NOT a nervous energy  Man, whenever he encounters stress, tends to adopt  Are you going around all stress? ANSWER IS NO!!! because stress is not always to be avoided and stress is not always undesirable  Stress may lead to another stress  A single stress does not lead to a disease

Local Adaptation Syndrome  Also known as non-specific inflammatory response  Bradykinin o Activates inflammatory response o Activates histamine  Histamine o Activates the following:  Prostaglandin  Serotonin

Concepts:  Adaptation to stress comprises of adjustments made in order to cope with a stressor

Concept:  Bradykinin, Histamine, Prostaglandin, and Serotonin all increase swelling Key Concept!  Hans Selye o Author of Physiologic Response to Stress

 Man is holistic in his adaptation to stress  It involves the totality of man: o Physiologic o Psychologic o Social

Lazarus  Stress is a transaction

6

Illness Behavior and Stages of Illness

Factors Affecting Compliance  Client motivation  Degree of required change in lifestyle  Perceived severity of health problem  Difficulty of understanding instructions  Belief about the effectiveness of the therapy  Nature of the therapy itself o Adverse effects o Cost  Cultural influences  Degree of satisfaction with the relationship with health care providers

Illness Behavior  Pertains to any activity undertaken by a person who feels ill in order to  Define his state of health  Discover a suitable remedy IGUN – Eleven stages of Illness and Health-seeking Behaviors 1. Symptom Experience  Client realizes there is a problem  Client responds emotionally 2. Self-medication / Self-treatment (if not effective) 3. Communication to others 4. Assessment of symptoms  Purpose is to verify the veracity of the complaint 5. Sick-Role Assumption 6. Concern Stage 7. Efficacy of treatment  Assess sources of treatment  Assess potential effectiveness of treatment 8. Selection of Treatment Stage  Availability  Cost of Treatment 9. Treatment Proper 10. Assessment of Effectiveness of Treatment  May go back to stage 7 (Efficacy of Treatment) if treatment is not effective  May go to next stage if treatment is effective 11. Recovery and Rehabilitation

Suggested Nursing Actions in case of Non-compliance  Assess the reasons  Correct the misconception  Demonstrate a caring attitude  Encourage and provide positive reinforcement o Focusing on the positive rather than on the negative o Focus on things patient can still do and not on what the patient can no longer do  Establish a therapeutic relationship of freedom and mutual responsibility o Make patient realize he is also responsible for his recovery o He is a partner with the health care team o He is an active participant

Compliance  Adherence to professional’s advice

Guidelines Compliance 7

to

Enhance

 Be sure patient understand procedure by giving information  Make sure patient is capable of performing activity o Set realistic goals  Ensure that he is a WILLING participant o Look for buying signals  Looking at wound  Looking at materials needed

Martha Rogers  Nursing is a HUMANISTIC SCIENCE dedicated to compassionate concern for the promotion of health, prevention of illness and rehabilitation of the sick Sister Calista Roy  Nursing is a THEORETICAL SYSTEM OF KNOWLEDGE that prescribes analysis and action related to the care of the sick or ill  It is a set of knowledge

Definitions of Nursing: American Nurses Association  Nursing is the diagnosis and treatment of human responses to illness (to actual and potential health problems)

Dorothea Orem  Nursing is a helping service to any individual who is sick  It comprises of wholly dependent or partly dependent care when the person is unable to do so.  Defines nursing in terms of a NEED!

Canadian Nurses Association  The same definition plus…  … includes the supervision of functions and services in collaboration with others to promote health

Imogene King  Nursing is a helping profession that assists a person (same with Henderson) towards a DIGNIFIED DEATH

Florence Nightingale  Nursing is the act of utilizing the ENVIRONMENT for the following purposes: o Recovery o Reparative process

Betty Neuman  Nursing is a profession that is concerned with INTRAPERSONAL, INTERPERSONAL, and EXTRAPERSONAL VARIABLES affecting a person’s response to stressors

Virginia Henderson  The unique function of the nurse is to assist individuals, sick or well, with the activities towards health that he would do unaided, if with strength and knowledge. If that is not possible, towards a PEACEFUL DEATH

8

Dorothy Johnson  Nursing is an EXTERNAL REGULATORY FORCE that regulates the ACTION or BEHAVIOR of a person when such behavior constitutes a threat, in order to preserve his organization

2. Dorothy Johnson  Behavioral Systems Model  Seven Subsystems o Attachment and Affiliative o Dependency o Ingestive o Eliminative o Sexual Achievement o Aggressive

 Example: o In a COPD patient who remains a smoker, the nurse who encourages the patient not to smoke, serves as an external regulatory force

3. Virginia Henderson  Fourteen (14) Fundamental Needs focusing on PHYSIOLOGIC SOCIAL RECREATION 4. Faye Abdella  Problem Solving Approach to Twenty-One (21) Nursing Problems  Focus is on PROPER IDENTIFICATION of the problem  Particularly about the proper nursing diagnosis

Faye Abdella  Nursing is a service to individuals, families… and therefore, to society  Conceptualized nursing as an ART and SCIENCE of MOLDING THE INTELLECT, ATTITUDE and SKILLS of the nurse  Nursing in terms of providing education

5. Marjorie Gordon  Proposed the Human Functional Health Patterns used as a systematic framework for data collection  Focus is on Eleven (11) Health Patterns  Advantage to the nurse: o It enables the nurse to determine the client’s response as functional or dysfunctional  Eleven Functional Health Patterns o Health perception o Nutritional / Metabolic o Elimination

Hildegard Peplau  Nursing is the INTERPERSONAL process of THERAPEUTIC INTERACTION between the nurse and the patient. NURSING THEORIES Concept:  First Nursing School Florence Nightingale

–

1. Florence Nightingale  Environmental Nursing Theory

9

o Activity and Exercise Pattern o Cognitive Perceptual Pattern o Role Relationship Pattern o Sexuality / Reproductive o Coping-StressTolerance o Value Belief Patterns

 3. Conservation of Personal Integrity o Example: maintain patient’s privacy  4. Conservation of Social Integrity o Example: maintenance of patient’s relationships 9. Betty Neuman  Health Care Systems Model  The concern of nursing is to PREVENT STRESS INVASION

6. Imogene King  Goal Attainment Theory  Patient has three (3) interacting systems: o Individuals / Personal systems o Group systems / Interpersonal systems fraternity o Social systems

10. Dorothea Orem  Self-care and Self-care Deficit Theory  Three (3) Nursing Systems based on Art of Care of Patient Needs  1. Partial Compensatory o Patient performs some of nursing care needs  2. Wholly Compensatory or Total Compensatory o For paralyzed patients, for ICU patients  3. Supportive-Educative o For up and about patient

7. Madeleine Lehninger  Transcultural Nursing Theory / Model  Nursing is a HUMANISTIC and SCIENTIFIC mode of helping through CULTURESPECIFIC PROCESS 8. Myra Levine  Four (4) Conservation Principles of Nursing  1. Conservation of Energy o Example: complete bed rest without bathroom privileges  2. Conservation of Structural Integrity o Example: turn patient from side to side every two hours to avoid bed sores

11. Hildegard Peplau  Interpersonal Model  Four (4) Phases of NursePatient Interaction  1. Orientation o Nurse and patient test the role each one assumes o Prepares patient for termination o Patient identifies areas of difficulty 10

 2. Identification Phase o Patient identifies with the personnel who can satisfy his needs  3. Exploitation Phase o Nurse maximizes all the resources to benefit the patient  4. Resolution Phase or Termination Phase o Occurs when patient’s needs have been met

 Man is a BIOPSYCHOSOCIAL BEING  Four (4) modes of Adaptation o Physiologic Mode  Compatible with Hans Selye o Self Consent o Role Function o Interdependence 14. Lydia Hall  CARE, CORE, CURE  Care o Comfort measures given by the nurse to a patient o Nurturance aspect of Nursing  Core o Therapeutic use of self  Cure o Activities in relation to doctors’ orders o Dependent orders

Concepts:  Various settings for application of: o Pre-Interaction Phase  In psychiatric setting, this consists of gathering data o Pre-Entry Phase  In community health nursing, this consists of a courtesy call 12. Martha Rogers  Science of Unitary Human Beings  Man is composed of energy fields, which are in constant interaction with the environment

15. Jean Watson  Human Caring Model  Nursing involves the application of ART and HUMAN SCIENCE through TRANSPERSONAL TRANSACTIONS in order to help the person achieve mind, body and soul harmony

Concept:  The most reliable method of identification is the Energy Field. This is better than the fingerprints as a person’s energy field is absolutely unique!

16. Rosemarie Rizzo Parse  Theory of Human Becoming  Emphasis is a FREE CHOICE (with personal meaning)  Actions of patients may either be: o Revealing or concealing o Enabling or limiting

13. Sister Calista Roy  Adaptation Model

11

20. Margaret Newman  Health as Expanding Consciousness  Humans are Unitary Human Beings  The nurse is a NOT A GOALSETTER or an OUTCOME PREDICTOR, rather is a PARTNER OF THE PATIENT

 Therefore, there is a consequence o This pertains to behavior and action 17. Josephine Patterson and Loretta Zderad  Humanistic Nursing Practice Theory  Nursing is an EXISTENTIAL EXPERIENCE between the nurse and the patient (nagkataon-nagkatagpo!)  Nursing is a LIVE DIALOGUE between the patient who wants to be nursed and the nurse who has the skill to nurse

21. Joyce Travelbee  Interpersonal Process Theory  Nurse needs to go beyond nursing roles to establish therapeutic relationship  TRANSPERSONAL COMMUNICATION as the means to establish therapeutic relationship  This implies that the nurse should not be rigid in the nursing role

18. Helen Tomlin, Evelyn Tomlyn and Mary Ann Swain  Modeling and Remodeling Theory  Focus is on the PERSON  Emphasis is on the UNCONDITIONAL ACCEPTANCE of the PATIENT

22. Ida Jean Orlando  Dynamic Nurse-Patient Relationship Model  There is movement, the relationship is not static  If the patient’s condition improved, then the intervention is effective and the patient moves on to new problems

19. Ann Boykin and Savina Schoenhofer  Grand Theory of Nursing as Caring Theory  Nursing is NOT BASED on a DEFICIT but rather it is an EGALITARIAN MODE of helping  This theory is against the theory of OREM  Nursing is an obligation towards humanity, whether there is a need or NOT!

23. Nola Pender  Health Promotion Model  Motivation to participate in health care activities is influenced by COGNITIVE and PERCEPTUAL FACTORS, which are: o Importance of health to the person o Perceived control of health

12

o o o o

Self-efficiency Perceived health status Definition of health Perceived barriers to action

o Patient’s illness is controlled o Patient may still be in the hospital  6. Unstable Phase o Patient is on a critical period o Signs and symptoms are present o Patient is NOT in the hospital o Patient is NOT under control o Patient is OUT of the hospital  7. Downward Phase o Patient is in a deteriorating phase  8. Death

24. Poppy Buchanan, Barker and Phil Barker  Tidal Model (Psychiatric Nursing)  Helping patients recall their own personal stories of DISTRESS is the FIRST STEP in helping them regain control of their lives again! 25. Corbin and Strauss  Trajectory Model  The patient moves in a TRAJECTION of Eight (8) Phases  Nurse needs to follow the patient along the eight phases of trajection:  1. Pre-Trajectory Phase o Patient shows no signs and symptoms of illness o No sickness

26. Bonnie Weaver and Duldt Battey  Humanistic Nursing Communication Theory  Emphasis is on the interpersonal relationship between the nurse, the patient, the peers and colleagues 27. McGill Model of Nursing  Emphasis is to encourage and engage the patient and the family to actively participate in learning about health

 2. Trajectory Onset Phase o Patient now has signs and symptoms of illness  3. Crisis Phase o Patient is unstable o Patient is in a lifethreatening situation o Patient is critical  4. Acute Phase o Patient is in a state of active illness  5. Stable Phase

28. Kathryn Barnard  Parent-Child Interaction Model (Pediatric Nursing)  In order to produce a healthy person, the baby’s need should be ADDRESSED AT ONCE!  Application: Bonding

13

29. Alfred Adler  The personality of an individual is affected by the BIRTH ORDER

o Environmental Sanitation o Recreation Housing

30. Gladys Husted and James Husted  Symphonological Bioethical Theory  Symphono- means harmony and agreement  Governed by ethical standards, which influence nursing actions.

2. Secondary Prevention  Emphasis placed on: o Early detection / diagnosis o Prompt treatment o Health maintenance of persons already having health problems o Prevention of complications  When given: o During illness  Examples: o Screening survey o Encouraging regular check-ups o Complying with regular check-ups o Teaching Breast-selfexamination o Teaching Testicularself-examination

LEVELS OF PREVENTION: 1. Primary Prevention  Emphasis on: o Generalized health promotion and specific protection o Recipients are GENERALLY HEALTHY PEOPLE  When given: o Before onset of illness or before onset of disease  Examples: o Generalized health education  Prevention of accidents  Standards of nutrition o Immunizations  Specific preventions o Risk Assessment for specific disease o Family Planning Services and Marriage Counseling

and

 Concept: o Most effective method of teaching is DEMONSTRATION  Additional Examples of Secondary Prevention o Assessment of growth and development o General nursing assessment and care at the hospital, community and the home 3. Tertiary Prevention  Emphasis placed on: 14

o Support of the client to achieve the following:  Successful readaptation  Optimal reconstitution  Regain highlevel wellness  Therefore, the purpose is more of REHABILITATION  When given: o Begins after the illness or when a defect or disability is fixed or irreversible  Examples: o Referring a client to support groups o Teaching a diabetic client how to inject insulin

o Helping develop skills

the new

patient coping

Concept:  Do not give advice! o This is meant to facilitate decisionmaking on the part of the client o This is observed so that the client would not develop DEPENDENCY 3. Client Advocate  Protects rights of patients  Activity: o Speaking on behalf of the patient 4. Change Agent  Brings change or adjustments  Nurse only influences a patient  Nurse does not change the patient

ROLES OF A NURSE 1. Caregiver / Care Provider  To convey understanding and support  Activities: o Support and comfort measures (mothering aspect of nursing / nurturance aspect of nursing)

5. Teacher  Teaching  Imparting of knowledge 6. Leader  Application of interpersonal influence to bring out desired behavior (leadership)

2. Counselor  Involves helping patient identify and avoid stressful and psychological problems  Focuses on: o Helping client establish capacity for successful interpersonal relations

7. Manager  Decision-making  Planning  Giving directions  Monitoring operations  Facilitating staff development

15

 Therefore, this is done on the supervisory level of organization

 Addresses affective cognitive learning 3. Answering Questions  Cognitive

8. Researcher  After graduation, nurse cannot yet be a researcher  He can only be a researcher after he receives his Master of Arts in Nursing (M.A.N) degree TEACHING AND STRATEGIES

and

4. Demonstration  Motor 5. Discovery  Cognitive and Affective

LEARNING

Concept:  Learning is more effective if the learner discovers the content for himself. (That is, through experience!)

Basic Guidelines  Develop a well-defined objective  Assess client’s readiness to learn  Start with what the client is concerned about  Assess and start with what the client already knows; proceed from the known to the unknown  Start with the simple proceeding to the complex  Schedule a review of the content

6. Group Discussion  Affective and Cognitive  Sharing feelings during group dynamics 7. Practice  Motor 8.Printed and Audiovisual Material 9. Role-playing  For pediatric and psychiatric nursing settings

Concept:  Areas of Learning Domain o Knowledge – cognitive o Skills – motor o Attitude – emotional

10. Modeling  What you say is what you do 11. Computer Assisted Learning Programs  Online review

TEACHING STRATEGIES

THE NURSING PROCESS

1. Explanation and Description  Address cognitive aspect of learning

Concept:  The Nursing Process was introduced by LYDIA HALL!

2. One-to-one Discussion

Definition: 16

BENEFITS DERIVED FROM THE NURSING PROCESS

 The Nursing Process is a systematic, organized, rational method of planning and providing individualized, humanistic nursing care

Concepts:  Both the nurse and the patient benefit from the nursing process  Patient obtains greater benefit  Remember:  Nursing process is CLIENTCENTERED or PATIENTCENTERED and NOT NURSE-CENTERED

Purposes of the Nursing Process:  To identify health status o Actual health problems o Potential health problems  To establish plans  To deliver specific nursing care

Benefits from Nursing Process:  Improves quality of care  Ensures continuity and appropriate level of care  Facilitates client participation through planning with patient  Enables nurse to maximize resources  Feedback allows nurse to evaluate care  Serves as a framework for accountability through documentation  Promotes a positive working atmosphere through collaboration  Helps the nurse define roles to those outside the profession  For job satisfaction  Facilitates professional growth  Avoidance of legal action  Meeting standards of accredited hospitals

Characteristics of Nursing Process (MEMORIZE THIS!!!) 1. Goal-oriented and clientcentered 2. Cyclical (no absolute beginning and end), dynamic (moving) rather than static 3. Plan of care organized according to client problems rather than nursing goals 4. Basis of prioritizing nursing activities would be the problems and not the goals 5. Follows a logical sequence 6. Universally applicable (to any type of patient) 7. Interpersonal and collaborative  Work with patients and relatives  Work with colleagues and other members of the health team 8. Adaptation of problem-solving techniques and principles 9. Problem-oriented, flexible, open to new information 10. Allows creativity of nurse and patient

PARTS OR COMPONENTS THE NURSING PROCESS

17

OF

 When performed: o Integrated throughout the nursing process  Purpose of On-going Assessment: o To identify problems overlooked earlier o To determine the status of a health problem (i.e. hydration status every fifteen minutes)

ASSESSMENT PHASE OF THE NURSING PROCESS Nursing Activities Assessment Phase  Data collection  Data Organization  Data Validation  Data Recording

in

the

IMPORTANT CONCEPT!  No conclusion is developed in the assessment phase

3. Emergency Assessment  When done: o During acute physiologic and psychologic crisis  Where done: o Emergency Room o Comfort Room o Anywhere!!! o On site!!!  Purpose of Emergency Assessment o To identify lifethreatening condition  Framework or Principle in Emergency Assessment o A – Airway o B – Breathing o C – Circulation o Utilize either Maslow’s Hierarchy of Needs or ABC principle

Purposes of the Assessment Phase  To create a data base of the client’s response to health and illness  To determine the nursing care needs of the patient Four (4) types of Assessment: 1. Initial Assessment  When performed: o At specified time after admission  Where done: o Done at the ward  Where Admitted: o At the ward  Purpose of Initial Assessment: o To create a data base for problem identification o For reference and future comparison

4. Time-Lapsed Assessment  When done: o Several months after initial assessment  Purpose of Time-Lapsed Assessment o To compare current status of patient with base line data (initial assessment)

2. Focus Assessment or On-going Assessment

18

 The person who brought the patient to the hospital

ASSESSMENT PROCESS Concepts:  Data is information

equivalent

3. Environment of the Patient  Example: o Patient with diabetes mellitus exhibits acetone breath  Assess for diabetic ketoacidosis

to

What is the initial output of the Assessment Phase?  Data or Recorded Data  Never validated data!!! Types of Data:

Methods of Data Collection  Observing  Interviewing  Examining

1. Subjective or Covert Data  Felt by the patient  During the recording of data, this should be stated using the patient’s own words  These are the symptoms felt by the patient

1. Observing  It should be deliberate  Exert effort Two (2) aspects of observation process:  Noticing the stimuli  Do an interpretation of the stimuli

2. Objective or Overt Data  Capable of being observed by use of senses – sight, touch, smell, taste, hearing  These are the signs which are observable

2. Interviewing Two (2) types of Interview:

Sources of Data:

Directive Type of Interview  Structured  Uses closed-ended questions calling for specific data  When used: o When you need to elicit specific data o When there is little time available

1. Primary Source  Patient himself except when: o He is unconscious o Patient is a baby o Patient is insane 2. Secondary Source  Patient’s record  Health care members  Related literature or journals  Significant others (they become primary source when patient is unconscious  Family or relatives

Concept: Characteristics of Closed-ended questions:  Yes or No questions

19

you already know or what information is available  An interview is a planned conversation with a purpose

 Asks when or asks for the time when event happened  Asks how many  Point with finger when asking to provide clarity  Therefore, they call for highly specific answers

 An interview is a two-way process  When is it done? o When patient available o When patient comfortable

Non-Directive Type or RapportBuilding Interview  Uses more open-ended questions  Advantage is that it allows the patient to volunteer information

is

 Recommended distance from the patient is three (3) to four (4) feet.

Types of Interview Questions: 1. Open-Ended Questions  Questions not answerable by “yes” or “no”  Questions that elicit information or explanation

Stages of the Interview 1. Opening Stage Key Concept!!!  This is the most important part of the interview Rationale  What was said and done during the opening stage sets the tone all throughout the interview

2. Closed-Ended Questions  Questions answerable by “yes” or “no”  Leading Questions  Phrasing of question suggests what answer the interviewer is expecting

2. Body of the Interview  Occurs when patient responds to questioning

3. Neutral Questions  Phrasing allows patient to answer with least pressure  Usually NOT addressed to patient personally (i.e. what is your opinion about…)  Raised as a general topic

3. Closing Stage  How to close the interview: o Summarizing Technique Validation of Data  Act of double-checking the data  Purposes of Data Validation o To ensure the:  Correctness  Completeness

Planning the Interview Setting Concepts:  Before the determine what

is

interview, information

20



Accuracy of the data

 Problem present at the time the statement was made

Guidelines in Validating Data  Compare subjective and objective data  Be familiar with word usage (particularly if the patient is a child)  Reassess / double-check data which are extremely abnormal  Be sure that your data contains CUES and not INFERENCES  Be sure that your data is FREE OF BIASES  Avoid jumping to conclusions

2. High-Risk Nursing Diagnosis  A diagnosis that a patient is more vulnerable or susceptible compared with others in the same situation 3. Possible Nursing Diagnosis  There is an evidence of a health problem but the causes are NOT fully understood 4. Wellness Nursing Diagnosis  A positive statement  Indicates a healthy response  Examples: o Potential for increased compliance related to increased level of knowledge o Potential for enhanced body image related to regular exercise o Potential for effective coping related to adequate support systems

Data Recording Concepts:  Data Recording COMPLETES the Assessment Phase  Initial Output of the Assessment Phase is DATA  Final Output of the Assessment Phase is RECORDED DATA DIAGNOSING PHASE NURSING PROCESS

OF

THE

Domains of Nursing Diagnosis Key Concept!  It only includes health problems that a nurse is capable and licensed to treat

Activities during the Diagnosing Phase:  This involves sorting, clustering, analyzing and interpreting data

Parts of a Nursing Diagnosis 1. Problem Statement  Example: o Fluid Volume Deficit 2. Presumed Etiology  Example: o …related to frequent loss of bowel movement

Concept:  The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!! Different Types of Nursing Diagnoses: 1. Actual Nursing Diagnosis

21

3. Defining Characteristics  Example: o …as manifested by decreased skin turgor

o At specified time upon or after admission of the patient 2. On-going Planning  Who are involved: o Done by all nurses who worked with the patient o The patient himself o The family o But primarily, the NURSE  Purposes of On-going Planning o To determine if the client’s health status has changed o To decide which problems to focus on during the shift o To set priorities for client care during the shift o To coordinate the patient care and activities so that more than one problem can be addressed at the same time

Advantages of Using Standardized Diagnostic Terminology  Provides professional accountability and autonomy by defining and describing the independent areas of practice  Provides effective vehicle of communication  Provides an organizing principle for meaningful research  Facilitates continuity and individualized care PLANNING PHASE NURSING PROCESS

OF

THE

Concept: Planning means:  Determining ahead of time  Forecasting a course of action Key Concept!!!  For your plans to be effective, involve the patient and the family

3. Discharge Planning  Purpose of Discharge Planning o To ensure continuity of care

IMPORTANT CONCEPT!!!  Final output of the Planning Phase is a NURSING CARE PLAN or a WRITTEN CARE PLAN

Characteristics or the Planning Process  S – Specific  M – Measurable  A – Attainable  R – Realistic  T – Time bound

Types of Planning 1. Initial Planning  Done by the nurse  When done:

Activities during Planning Process

22

 Set priorities  Set goals  Identify alternatives of nursing care  Select nursing measures  Write nursing orders (supervisors do this)  Write the nursing care plan

Requirements for Implementation  Adequate knowledge  Technical Skills  Communication skills  Therapeutic use of self  Right attitude as a requirement Nursing Activities during the Implementation Phase  Reassess the patient o Rationale  To determine if the procedure is still needed  Determine the need for nursing assistance  Implement the nursing strategies  Communicate the procedure performed by documenting the procedure  Understand orders o Clarify / verify doctors’ orders  Encourage patient to participate actively

Purposes of Goal-setting  To set direction  To provide a time span  To have a criteria for evaluation  To enable the nurse and the patient to determine whether the problem has been resolved or not  To help motivate the client and the patient by providing a sense of accomplishment Key Concept!!!  For your goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS IMPLEMENTING PHASE OF THE NURSING PROCESS

Guidelines for Implementation of the Nursing Strategies

Implementation  Putting the care plan into action

Key Concept!!!  It should be based on scientific knowledge, research, professional standards of practice (care) o Rationale:  This is done to ensure safe nursing care  It should be adapted to the individual patient  It should always be safe. Do not compromise

Purpose of Implementation  To carry out planned activities  To help the client Concept!!!  The implementation phase ends upon recording of the care given and the response of the patient to that procedure

23

o Allows the nurse to decide and make onthe-spot modification/s in an intervention

 It should be holistic  It should be accompanied by support, comfort and teaching

EVALUATION PHASE NURSING PROCESS

OF

THE 2. Intermittent Evaluation  When done: o At a specified time  Purpose: o It shows the extent of progress of the patient  Importance: o Enables the nurse to correct deficiencies and modify the nursing care plan

Purpose of the Evaluation Phase  To determine client’s progress  To determine the effectiveness of the care plan  To determine as to what extent the nursing goals have been met Importance of doing an Evaluation  It determines if the care plan will be: o Continued o Modified o Discontinued

3.Terminal Evaluation  When done: o At or immediately before discharge  Importance:  States the status of a health problem at the time of discharge  It determines whether the goals are: o Met o Partially met o Unmet

Activities during the Evaluation Phase  Identify the OUTCOME CRITERIA to be used as measurement  Gather information (data) relevant to the outcome criteria  Compare outcome (data) with the criteria  Assess the reasons for the outcome  Revise the nursing care plan as needed

DOCUMENTATION  It is a written, formal document  A record of client’s progress

Types of Evaluation 1. On-going Evaluation  When done: o During or immediately after the intervention  Importance:

Purposes of Documentation  Planning Care  Communication  For legal documentation purposes  For research 24

assembled into an orderly or scientific manner  Classification of information is based on SOURCE  Each person or department maintains a different section on chart

 For education  Reimbursements  For statistics, reporting, epidemiology  Accreditation, licensing Guidelines on Documentation  Timing o Document patient care as soon as possible  Observe confidentiality  Observe permanence o Use non-erasable ink o Do not use sign pen  Signature o Sign full name and append R.N.  Accuracy o Ensure that data is correct o Avoid biases o Avoid ambiguous terms  Appropriateness o Write only appropriate information  Completeness  Use standard terminology  Brevity o Make it concise yet meaningful  Legal Awareness o Cross out erroneous entry o Write “Error” o Countersign

Components of a Source Oriented Clinical Record  Admission Sheet  Face Sheet  Medical History and Physical Examination Sheet  Diagnostic Findings Sheet  TPR Graphic Sheet  Doctor’s Treatment and Order Sheet  Therapeutic Sheet Problem Oriented Clinical Record  Same as Problem Oriented Medical Record  Entry of data is based on CLIENT’S PROBLEM  Example: o Problem No. 1: constipation  Increase fluid intake: doctor  Diatabs: pharmacist  NPO:  Includes observations about the patient  Example: o Radiologist’s notes are with doctor’s notes under one problem

TYPES OF RECORDS Source Oriented Clinical Record  Accumulation of chronological, variative notations that are difficult to follow because they are not

Problem List  Contains problems information problem) 25

only ACTIVE (and relevant about the

 No potential problems (these are contained only in the progress notes)

 Is the Kardex a part of the patient’s record?  No, it is not!!!  It is just a bulletin board

Four (4) Basic Components of Problem Oriented Clinical Record

Purpose of the Kardex  To make valuable information readily available  Allergies are written in red ink  It is a reminder  It is not a record

1. Baseline Data  All information gathered from a patient when he first entered the agency 2. Problem List

Concept:  A Nursing Care Plan is not a record

3. Initial list of orders or Care Plans

COMMUNICATION IN NURSING

4. Progress Notes  Includes: o Nurses’ narrative notes (SOAPIE) o Flow sheets o Discharge Notes and Referral Summaries

Communication  Exchange of ideas, information, feelings, data between two communicators Concept:  Communication is the basic component of Human Relationships

Formats:  SOAPIE – for revisions COMMON METHODS OF COMMUNICATION AMONG NURSES

Elements of Communication 1. Message  Data 2. Sender  Encoder 3. Receiver  Decoder 4. Feedback 5. Context  Setting  Overall environment where the communication takes place

1. Referring  To endorse patient’s special concern to a higher authority or a specialized department or personnel 2. Confer  Verifying information 3. Reporting  Giving information concerned person

to

TECHNIQUES

a

Modes of Communication 1. Verbal

KARDEX 26

      

o One person believes that the space and all the things in that space belongs to him o Do not enter abruptly; this may result in breach of privacy  Roles and relationships

Oral Spoken Written communication Texted communication Cable communication Telex communication Facsimile communication

2. Non-verbal communication  Facial expression  Grimacing  Posture  Gait  Adornment  Make-up  Gestures

Therapeutic Communication in Nursing  Using Silence o Supplement with nonverbal communication  Provide General Leads o Examples:  “…go on”  “…tell me more”  Open-ended questions  Use Touch o But assess the culture of the patient o If the patient is a child, touch the patient on the top of the head o If the patient is an elderly, touch the patient on the hand o If the patient is of the same age level, touch the patient on the shoulder  Offering yourself o For autistic child  Stay nearby or stay beside the patient  Presenting Reality o Example:  “You are in the hospital”  Reflecting o Example:

Factors Affecting Communication  Ability of the communicator  Perceptions  Proxemics o Distances between communicators  Intimate Distance • Actual physical contact to 1.5 feet  Personal Distance • 1.5 feet to 4 feet • 3 feet to 4 feet for interview  Social Distance • 4 feet to 12 feet  Public Distance • 12 feet and beyond  Territoriality

27

“What do you think will make you happy” o Never agree nor disagree o Reflect it back or throw it back

 REM sleep is NOT AS RESTFUL as NON-REM sleep  However, REM sleep is NEEDED  Dreaming is a psychological outlet of pent up emotions

Non-therapeutic Communication  Stumbling blocks to effective communication  Stereotyping  Generalizing  Agreeing and Disagreeing  No confrontation  No argument  Being defensive  Moralizing or Passing Judgment  Giving Common Advise  Examples:  “If I were you…”  “You should have done it…”

Nursing Alert!  Deprivation of REM sleep results to: o Irritability o Restlessness o Poor concentration



2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)  Deep restful sleep  Benefit is that it restores the body physically and psychologically (especially for post-operative patients) Concept!  Deprivation of Non-REM sleep causes: o Physical exhaustion o Decreased resistance against infection

PROMOTING REST AND SLEEP Circadian Rhythm  A biological rhythm  A biological clock  Regulated from outside the person’s body

Wellness Teachings to Enhance or Promote Sleep  Establish a regular routine  Have adequate exercise at daytime o Avoid stimulating activity by bedtime  Avoid all types of stimulants o Caffeine-containing foods  Coffee  Cocoa  Chocolate  Tea  Cola

Types of Sleep 1. Rapid Eye Movement Sleep (REM sleep)  Increased brain metabolism and activity  Also called PARADOXICAL SLEEP  Characterized by: o Vivid dreams o Easily recalled upon awakening Concepts! 28

   



  

o Nicotine o Alcohol  Prolongs the REM stage of sleep  It excites the patient like an anesthetic  Not a stimulant Avoid shabu Use the bed mainly for sleep If unable to sleep, get up and pursue satisfying activity Drink something warm or hot (except stimulants) o Milk contains Ltryptophan o L-tryptophan is an amino acid with a natural sedative effect that induces one to sleep Do something HOT! o Twice-a-week masturbation is ideal o Facilitates release of tension of the day Side-to-side turning every two hours with back tapping Support bedtime rituals Remove all music in order to sleep

 Fats Concepts:  Glucose is a ready source of energy for metabolic processes Carbohydrates  When eaten are metabolized to glucose for energy  Excess carbohydrates are converted to glycogen and stored in the liver  Other excess carbohydrates go to the fat cells Key Concept!  During starvation, stored glycogen is converted to glucose via a process called glycogenolysis  If glycogen is used up, fat resources are converted to glucose via a process called gluconeogenesis Nursing Alert!  Fat conversion to glucose produces waste products called KETONE BODIES  These give rise to metabolic acidosis as in Diabetic Ketoacidosis

PROMOTING NUTRITION

Additional concepts!  During starvation protein reserves are converted to glucose via process called gluconeogenesis

Proteins  Macromolecules composed of o Carbon o Hydrogen o Oxygen o Nitrogen

Gluconeogenesis  Production of glucose out of non-carbohydrate products

Basic Body Needs:  Carbohydrates  Proteins

Lipoproteins 29

2. Non-essential Proteins  Proteins that can be produced by the body

 Substances composed of fats and proteins Types of Lipoproteins 1. High Density Lipoproteins (HDL)  High-grade lipoprotein  Good grade lipoprotein  Good cholesterol  Function of HDLs o Transports the bad cholesterol from systemic circulation to the liver for metabolism and eventual elimination

Functions of Protein  Main element of our cells. o Building blocks of the cells are proteins  Resistance against infection o Formation of Immunoglobulins (globular proteins)  Maintenance of normal intravascular fluid volume o Works with glucose and sodium o Albumin  Main protein of blood  Acts as a colloid  Attracts water around it

2. Low Density Lipoproteins (LDL)  Low-grade lipoprotein  Bad cholesterol  Function of LDLs  They clog the blood vessels 3. Very Low Density Lipoproteins (VLDL)  Very bad cholesterol

Concepts!!!  If protein levels are decreased, sodium and glucose will not be enough to hold plasma inside blood vessel resulting into edema

Functions of Fats  Insulation  Heat Conservation  Source of Energy

 In liver cirrhosis, hypoalbuminemia results to edema

Proteins Two (2) types in terms of needs of the body: 1. Essential Proteins  Proteins that cannot be produced by the body itself  To be sourced out from food eaten  Animal protein is complete protein  Plant protein is considered as incomplete protein

VITAMINS Two (2) types of Vitamins  Fat Soluble Vitamins  Water Soluble Vitamins Fat Soluble Vitamins 1. Vitamin A  Essential for normal vision  For transmission of light stimulus via the optic nerve

30

 Forms: o Tablet o Liquid o Injectable  Oral (tablet and liquid forms) o Take on an empty stomach o If there is GI distress (i.e. diarrhea), take with food o If GI distress subsides, take on an empty stomach  Toxic effects: o Constipation (first option)  Oral Liquid Iron o Use dropper and apply at the back of the tongue or use a straw

2. Vitamin D  Source is food  Precursor is in the skin  Sunlight is needed for Vitamin D to be converted to its active form  Function: o Influences calcium metabolism o To metabolize calcium Concept!  Without Vitamin D, there would be decreased calcium levels  Increased levels of Vitamin D leads to increased calcium levels Vitamin E  Anti-oxidant  Promotes cell membrane integrity (like Vitamin C)  Vitamin for the heart and skin  Sources are meats and in vegetables  Deficiency results to Vitamin E deficiency hemolytic anemia

o Rationale:  To avoid staining the teeth  Health Teaching!!! o To enhance iron absorption, advice taking orange juice o Vitamin C in orange juice enhances iron absorption o Do not take milk o Milk inhibits absorption of iron o Too much fiber prevents absorption of iron o Thus, do not take oats when taking iron.  Injectable Iron o Route is deep I.M. o Use Z-track technique

Vitamin K  Synthesis of clotting factors  Synthesis of prothrombin Concept!  Decreased levels of Vitamin K leads to prothrombin deficiency  Deficiency in prothrombin leads to bleeding MICRONUTRIENTS Ferrous sulfate (FeSO4)

31

o Gauge of Needle is at least 18 o Length of Needle is 1.5” to 2.0” o Site of administration is the GLUTEAL MUSCLE ONLY!!! o Rationale:  To avoid staining the skin  Concept: o Use an airlock o Place 0.5 ml of air in syringe so that medication would not leak into the subcutaneous tissues  Nursing Alert! o Apply firm pressure for at least five (5) minutes after injection  Do NOT massage



Whole grains and cereals

3. Pureed Diet  Osteorized diet 4. Full Liquid Diet  Foods that melt or liquefy at body temperature 5. Clear Liquid Diet  Given to surgical patients  Limited to: o Water o Coffee o Tea o Cola o Clear stained broth o Gelatin o Hard candies  Nursing Alert! o Dairy products are avoided

SPECIAL DIETS 1. Light Diet  Given for post-operative patients  Plainly cooked  No spices  Large amounts of FAT omitted  Avoid bran and high fiber

6. High Fiber Diet  For patients constipation

at

risk

for

7. Candidiasis Diet  Free of the following: o Fruits o Sugar o Yeast o Fermented foods

2. Soft Diet  For people with difficulty with swallowing and chewing  Generally low residue diet  Nursing Alert! o Avoid the following:  Nuts  Seeds (tomato, guava, berry)  Raw fruits and vegetables  Fried Foods

8. Low Residue Diet  Reduced fiber  To decrease GI irritation  For patients with bowel inflammatory diseases: o Chron’s disease o Ulcerative colitis Acid-Ash Diet

32

1. NASOGASTRIC TUBE FEEDING (NGT)  Purpose of NGT insertion o For gastric gavage and lavage o For administration of food and medication o To keep the stomach empty o To prevent aspiration from regurgitation of gastric contents o For gastric decompression  How to Insert NGT o Depth of Insertion  Measure length from the tip of the nose to the ears to the tip of the xiphoid process  Insertion: o Position the patient in semi-Fowler’s or Fowler’s position o While inserting to NASOPHARYNX  Position the head in a hyperextended manner o When glottis, epiglottis are approached  Flex the head o Rationale:  To prevent entry of the tube into the trachea  Nursing Alert! o Watch for signs and symptoms of RESPIRATORY DIFFICULTY

 To alkalinize urine  To soothe an irritated bladder and urethra  Give citrus fruits  Give vegetables  Exceptions are: o Prune Juice o Cranberry Juice o Both produce ACIDIC URINE Ash-Acid Diet  Given to acidify urine  To minimize or help control Urinary Tract Infections  Give the following: o Protein o Meat o Poultry ASSESSMENT OF NUTRITIONAL STATUS Anthropometric Measurements Skin Fold Test  Derived from reserved fat of the body Mid-upper arm Circumference Measurement  Obtains the muscle mass of the body  This reflects the protein reserves of the body  Laboratory diagnostic procedure for albumin SUPPORTING NUTRITION OF PATIENT: ENTERAL AND PARENTERAL FEEDING ENTERAL FEEDING

33









o If there are signs, WITHDRAW TUBE o While inserting tube, observe for coughing or difficulty of breathing After inserting, ascertain proper placement on the stomach Concept! o Most accurate method to test for proper placement of the NGT is via X-RAY Other ways to test proper placement: o 1. Let patient hum  If positive for humming, tube is in the esophagus and stomach  If negative for humming, tube is in the trachea Nursing Alert! o Small-bore tube allows patient to hum o Therefore, this method is NOT RELIABLE o 2. Determine the pH of the aspirate  Use litmus paper  Change of color from BLUE to RED indicates that the aspirate is acidic and, therefore, from stomach contents  Change of color from RED to BLUE indicates that the aspirate is basic and,

therefore, from lung contents  IMPORTANT CONCEPTS!!! o To insure safety of the patient prior to feeding, CHECK THE FOLLOWING:  Placement of the tube • For patient safety • To prevent LUNG aspiration of food  Patency of the tube • To insure successful introduction or administration of food o 3. By auscultating the epigastric region while insufflating 50 ml of air  Hear gurgling sound TUBE FEEDING  Never try to submerge the free end of the NGT to water o This is potentially dangerous o If in trachea and submerging of free end to water coincides with inspiration, it will suck the water and lead to pulmonary aspiration  Position during feeding: o Fowler’s Position  Measure gastric residual volume

34

 

 



o Subtract this from total feeding to introduce o If aspirate is greater than 50 ml for adult or 10 ml for infant, then WITHHOLD FEEDING for 2 – 3 hours. o Rationale:  Patient is not yet ready for next feeding. o If same occurs after 2 – 3 hours, NOTIFY DOCTOR.  There is a problem with gastric emptying Watch out for COUGHING o Leakage to trachea If with DIFFICULTY OF BREATHING o Stop the procedure Flush with water after feeding to avoid clogging of the tube After the procedure o Do not place the patient on bed before 30 minutes have lapsed o Rationale:  To prevent aspiration and regurgitation Average volume of feeding: o 300 ml to 400 ml

 Important Concept!!! o Tube must reach two (2) centimeters before or above the RIGHT ATRIUM  Nursing Responsibilities: o Watch out for signs and symptoms of embolism  Care of Insertion Site o Application of sterile dressing with antibacterial ointment as ordered by doctor (prn) GASTROSTOMY TUBE FEEDING (Enteral)  No auscultation needed  Assess for the patency of the tube  Use water to do this PROMOTING OXYGENATION DEEP BREATHING Two (2) types of Deep Breathing: 1. APICAL DEEP BREATHING  Done to expand the upper portion of the lungs  Let the patient place palms on the upper chest  Concentrate on that area  Take a slow deep breath at a count of 1,2,3  Release it slowly through the nose or a pursed lip at a count of 4,5,6,7  Therefore, expiration is longer than inspiration  Rationale: o To prevent respiratory alkalosis  Taught to patients who will undergo: o Upper abdominal surgery

TOTAL PARENTERAL NUTRITION  Introduced directly to the bloodstream  Tube is inserted via the: o Subclavian vein o Internal jugular vein of the neck o External jugular vein of the neck 35

o Cholecystectomy  Incision site on diaphragm  Patient does not want to breathe  Predisposed to hypostatic pneumonia

o Coughing is contraindicated in the following patients:  With increased intracranial pressure (ICP)  With increased intraoptical pressure (IOP)  With cardiac arrhythmias (but are allowed to do deep breathing)

2. BASAL DEEP BREATHING  Same procedure  Area of concentration is the lower ribcage  When to teach patient: o Before surgery o Before pain is present  Rationale: o If pain is already present, it would be difficult for patient to follow  When done: o Done q2 hours together with turning

Concepts!!!  Deep Breathing and Coughing o Purpose is to stimulate surfactant production  Yawning and sneezing also stimulate surfactant production OXYGEN INHALATION ADMINISTRATION

AND

Practical Application Concept!  When administering oxygen, be sure to open the valve of the oxygen tank first.  Be certain that the valve on the regulator is closed so that the flow meter would not break!

COUGHING EXERCISES  Purpose o To expand the lungs o To facilitate expectoration of secretions  How often done: o At least every two (2) hours  Procedure o Teach the patient to inhale and exhale o Tell the patient to inhale and exhale a second time o Tell the patient to inhale and cough out  NURSING ALERT!!!

Concept!  Humidifier moistens the oxygen administered  Purpose o To avoid drying and irritation of the mucosal lining o Also traps particulates from the tank

36



2. High Flow Administration  Uses a venturi mask

Iron oxide may be present in the tank (iron plus oxygen produces iron oxide or rust)

NEBULIZATION  With sodium chloride and salbutamol  A physiologic solution  Water liquefies secretions  Sodium chloride stimulates coughing  Salbutamol is a bronchodilator  Purpose: o For expectoration of secretions

Concept!  Fire Precaution o Place ‘NO SMOKING’ sign at the door or at the head part of the patient  Tank and oxygen do not explode  They merely support combustion

Nursing Pre-therapy Assessment Prior to Nebulization  Have baseline data of patient’s breath sounds  Assess again after nebulization to assess effectiveness of the procedure

Other Concepts!  Do not use volatile substances  Acetone and alcohol can react with oxygen and lead to toxicity of patient  Do not use oil based or grease on any part of the oxygen set  Do not allow the patient to use an electric razor as sparks may trigger combustion

SPIROMETRY  Purpose is to expand the lungs  Done when inhaling  Instruction to the patient: o Inhale from the spirometer and NOT blow to the spirometer  Procedure: o Inhale – exhale o Inhale – exhale fully o Place mouthpiece between teeth o Hold breath for four (4) seconds o Then inhale, fully rising the ball  Upon inhalation, the ball rises

Nursing Alert!  Retrolental Fibroplasia occurs if there is excess oxygen administration in infants. Excess oxygen leads to destruction of the retina and blindness Modes of Administration 1. Low Flow Administration  Utilizes nasal cannula or nasal prongs or nasal catheters  Given to COPD patients

CHEST PHYSIOTHERAPY  This is a dependent procedure

37

 There are no absolute contraindications to this procedure  Contraindicated for the following patients with: o Pacemakers o Lung abscess o Hemoptysis o Dangerous Arrhythmias o Active PTB (which goes to the other lobe) o Lung CA (malignancy goes to other lung) Three components of Physiotherapy  Vibration  Percussion  Postural Drainage

 Assess breath sounds to know which lung fields have secretions  Then assess again after procedure to check effectiveness of the procedure. Concepts!!!  Vibration and percussion are done to mechanically dislodge secretions  Nebulization is done to liquefy secretions  Suctioning is done to clear secretions  Postural Drainage is done to drain secretions using gravity

Chest

Postural Drainage  When done: o Before meals o Two (2) hours after meals  Before doing the procedure, the following baseline data are needed: o Breath sounds o Vital signs o Continuous ECG monitoring  During the procedure: o Ensure the comfort of the patient o Provide a kidney basin and tissue paper  Nursing Alert! o Watch out for signs of symptoms which may require stopping of the procedure:  Sudden dyspnea  Cyanosis  Extreme diaphoresis

Vibration  Palms of your hand are placed on chest or back of patient giving quivering motions  Palms remain in contact with the chest or back Percussion  Use cupped hands  Hands alternate in rising and coming into contact with chest or back of patient Postural Drainage  Drain secretions by gravity  Change positions  IMPORTANT CONCEPT!!! o Rule out contraindications before performing chest physiotherapy Pre-therapy Assessment Vibration and Percussion

for

38



  

Sudden alteration of blood pressure, respiratory rate, pulse rate Appearance of arrhythmias Hemoptysis General intolerance of the procedure

SUCTIONING  Purpose is secretions

to

seek

out

Concepts!!!  Question: o If you have only one (1) suction catheter, which will you suction first, the nose or the mouth?  Answer: o If the patient is an infant or a newborn:  Start on the mouth then proceed to the nose  Rationale: o If you start on the nose, you will trigger the sneezing reflex and this would result into aspiration  Answer: o If the patient is an adult, suction the mouth first, then proceed to the nose  Rationale: o This is done for aesthetic reasons

Important Concept!  If any of the above occurs, STOP THE PROCEDURE and inform the physician Concepts!  After the procedure assess the following: o Breath sounds o Vital signs o Quantity and quality of sputum o Overall response of the patient to the procedure  Give oral hygiene o Rationale:  To eliminate phlegm from the mouth Important Concept!!!  Patients with cystic fibrosis benefit much from postural drainage TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning

Depth

Oropharyngeal

39

Duration

Interval with each Pass of Suction

Total Time

Suctioning If patient conscious

is Fowler’s (high 10 – 15 or moderate); centimeters Head turned to one side (towards the nurse)

Not more 20 – 30 than 10 – seconds 15 seconds

Not more than 5 minutes

If the patient is Place on one 10 – 15 unconscious side (facing the centimeters nurse); Tilt neck to move head slightly forward towards the basin to avoid aspiration during suctioning Nasopharyngeal Suctioning

Not more 20 – 30 than 10 – seconds 15 seconds

Not more than 5 minutes

If the patient is Neck should be conscious hyperextended; Fowler’s position

From tip of the nose to tip of the earlobe

Not more 20 – 30 than 10 – seconds 15 seconds

Not more than 5 minutes

If the patient is Flat on bed unconscious with head turned to the nurse Lateral position may be assumed

From tip of the nose to the tip of the earlobe

Not more 20 – 30 than 10 – seconds 15 seconds

Not more than 5 minutes

TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning Orotracheal Suctioning

Depth

Duration

40

Interval with each Pass of Suction

Total Time

If patient is Low to Measure Not more 20 – 30 Not more conscious semifrom mouth than 10 seconds than 5 fowler’s to mid- seconds minutes position sternum If the patient Flat on Measure Not more 20 – 30 Not more is bed; from mouth than 10 seconds than 5 unconscious Suction to mid- seconds minutes trachea sternum through the mouth Nasotracheal Suctioning If the patient Low to From tip of Not more 20 – 30 Not more is conscious semithe nose to than 10 seconds than 5 fowler’s earlobe to seconds minutes position dominating side of neck to the thyroid cartilage If the patient Flat on From tip of is bed; the nose to unconscious Suction earlobe to trachea dominating through the side of nose neck to the thyroid cartilage

41

Not more 20 – 30 Not more than 10 – seconds than 5 15 minutes seconds

TYPES OF SUCTIONING Type of Position of Suctioning the Patient while Suctioning Endotracheal Tube Suctioning

Depth

Interval Total with Time each Pass of Suction Semi-Fowler’s 12.5 5 – 10 2 – 3 Not if not centimeters seconds minutes more contraindicated or 6 inches; than 5 Insert as minutes far as it goes until you meet resistance or until patient coughs

42

Duration

Tracheostomy Tube Suctioning

Semi-Fowler’s Insert as 5 – 10 2 – 3 if not far as it seconds minutes contraindicated gets until you meet resistance or until the patient coughs

Important Concepts!!!  For Endotracheal Suctioning o NO TUBE IS USED HERE o This is suctioning of the trachea through the mouth or through the nose  Two (2) types of Endotracheal Suctioning o Orotracheal Suctioning  Oral approach o Nasotracheal Suctioning  Nasal approach

Not more than 5 minutes

 For Endotracheal and Tracheostomy (Naso and Oral and Tube) o Before suctioning, HYPEROXYGENATE the patient o During intervals, HYPEROXYGENATE the patient  For ET, Tracheostomy, ET Tube o Nursing Alert!  During insertion, if you encounter resistance, withdraw the catheter about one centimeter

General Conditions for Suctioning

43

o

o o o

o

(1 cm) before applying suction Rationale:  To avoid trauma on the mucous membrane Do suctioning intermittently Suctioning should not be continuous Rotate the catheter (between the thumb and the index finger) as you withdraw Apply suction only when you are ready to withdraw (i.e. keep finger away from suction port if you are still not ready)

o Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy the mucous plug o Instill 2.0 ml Normal Saline Solution for children to liquefy the mucous plug  Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the mucous plug VITAL SIGNS TEMPERATURE  Oral  Axillary  Rectal Oral Method  Most convenient  Most accessible  Nursing Alert! o Applicability is for children aged six (6) years and above o Not applicable for children below six (6) years old  Contraindicated in patients with: o Oral surgery o Mouth breathers o History of convulsive seizures o Unconscious o Incoherent o Irrational o Mentally disrupted o Insane  Procedure o Nothing Per Orem for about thirty (30) minutes before taking temperature

How to Hyperoxygenate the Patient  Give two (2) to three (3) blows by ambubag  Increase flow rate and concentration of oxygen  Nursing Alert! o If the patient has thick, tenacious secretions, DO NOT USE AN AMBUBAG o Use an OXYGEN INSUFFLATION SUCTION CATHETER instead!!! o This is a two-lumen catheter (one lumen brings oxygen to the patient, the other lumen brings out secretions from the patient)  In the event of encrustations, PERFORM TRACHEAL LAVAGE

44

o No food intake o No drinks o No smoking o No chewing gum o No whistling o No gargling  Rationale: o Any of the above would alter the result  Placement: o Under the tongue, beside the frenulum (right or left)  Total Time: o Two (2) to three (3) minutes

Rectal Method  Most reliable (except for tympanic thermometer)  Most accurate (except for tympanic thermometer)  Concept! o If tympanic method is used using a tympanic thermometer, the rectal method is only second most reliable and second most accurate  Disadvantage: o Placement on a different site yields a different reading o Therefore, ensure that the bulb of the rectal thermometer rests on the mucous membrane  Contraindications: o Hemorrhoids o Rectal Surgery o Certain Cardiac ailments due to stimulation of the vagus nerve; valsalva maneuver leads to arrhythmias  Position of Patient when taking the reading: o Sim’s left position o Sim’s right position o For Newborn, lift up ankles to keep buttocks up o In Toddlers, set on prone position on adult’s lap  Duration: o Two (2) minutes

Axillary Method  Least realiable  Safest method  Nursing Alert! o During application, be sure that axilla is dry o Dry using a patting motion  Nursing Alert! o Do NOT RUB!!!  Rationale: o This increases heat due to friction o Rubbing increases blood supply to the area o Therefore, there will be increase in temperature reading o Rubbing provides a false-positive elevation of temperature reading  Duration: o In adults – nine (9) minutes o In children – five (5) minutes

Conversion Fahrenheit

45

of

Centigrade

to

 Centigrade = (5/9)F – 32  Centigrade = (F/1.8) – 32 Conversion of Fahrenheit Centigrade  Fahrenheit = (9/5)C + 32  Fahrenheit = (1.8)C + 32

to

Concepts!!!  Peak body temperature occurs at 12NN to 3PM or 4PM  Lowest body temperature occurs in the early morning hours of the day





FEVER  Normally, the hypothalamus is able to adjust body temperatures between 37°C to 40°C  But due to the presence of pyrogenic materials like the following: o Pathogenic microorganisms o Toxins o Foreign substances o Any substance capable of increasing body temperature  Creates a deficiency of -3°C, making a person enter the FIRST STAGE OF FEVER

 

 

First Stage of Fever  Typical signs and symptoms indicate the body’s compliance mechanism to increase and conserve heat: o Chills o Shivering o Gooseflesh  Contraction of arectores

 



 46

pilorum or pilo arecti muscles o Vasoconstriction  Decreases blood supply to the skin  Pallid Skin o Cyanotic nail beds Key Concept!!! o Patient complains of feeling cold o Sweating will stop because body will minimizes heat loss Also called: o Onset Stage o Chill Stage o Cold Stage This stage is characterized by low febrile temperatures Nursing Management o Key Concept  Aim is to minimize heat loss o Key Concept  Do NOT apply TEPID SPONGE BATH because this would make patient progress to SHOCK Provide additional clothing as necessary Provide additional blankets as necessary Provide something warm to drink These measures would result to a gradual increase in body temperature Question: o When will you start application of TSB? Answer:

o If there is a 1°C to 2°C increase in body temperature

o Loss of appetite o Myalgia or muscle pains due to increased catabolism  Nursing Management o Tepid Sponge Bath o Cooling Bed Bath

Second Stage of Fever  Also called: o Coarse Stage of Fever o Peak Stage of Fever  Key Concept! o Patient does not feel hot or cold o Skin is warm to touch o Skin is flushed o Fever blisters are present  Herpetic lesions o Absence of shivering o Possible dehydration  Important Concept!!! o For every increase of temperature, there is a corresponding increase in pulse rate  Rationale: o Increase in temperature results in an increase in pulse rate due to increased metabolic rate o Increased metabolic rate increases oxygen demand o Due to increased oxygen demand of susceptible brain cells, CONVULSIVE SEIZURES may occur. These may also be due to irritation of nerve cells – FEBRILE CONVULSIONS  Increased oxygen demand also leads to an increase in respiratory rate  Patient complains of:

Tepid Sponge Bath  Temperature of water is 32°C o This temperature is maintained throughout the procedure  How to apply: o Done by patting  Rationale: o To avoid friction, which increases temperature  Important Concept! o Do NOT use ALCOHOL when applying TSB  Rationale: o Alcohol dries the skin and leads to irritation  Key Concept! o TSB should not be done hurriedly  Rationale: o When done hurriedly, TSB will stimulate shivering o Shivering would lead to increased muscle activity o Increased muscle activity would lead to increased temperature Cooling Bed Bath 47

 Water temperature will start at 32°C  Procedure will go on with gradual decrease in water temperature until it is maintained at 18°C  Therefore, to achieve this drop in temperature, utilize ice  Same procedure of application as in Tepid Sponge Bath Types of Fever 1. Intermittent Fever  A fever that is alternated at regular intervals by periods of normal and subnormal temperature

 If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by two (2). This is legal!  If pulse is irregular, count or monitor the pulse for one (1) FULL minute Assessment of the Pulse Deficit  This is the most accurate method  Involves two nurses using one watch  Starts at the same time  Ends at the same time  Comparison of results ensues  Count is done for one (1) full minute

2. Remittent Fever  Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE NORMAL.  Duration is within a 24hour period

Scale in Pulse Assessment  0 - Absent or cannot be felt  1+ - Weak or thready  2+ - Normal  3+ - Grounding BLOOD PRESURE

3. Relapsing Fever  Short periods of febrile episodes alternated by one (1) to two (2) days of normal temperature

Systolic  Produced by ventricular contraction  Pressure on blood vessels during depolarization or ventricular contraction

4. Constant Fever  Minimal fluctuations of temperature, all of which are ABOVE NORMAL

Diastolic  Pressure that remains in the walls of the blood vessels during relaxation or repolarization or resting

5. Staircase or Spiking Fever  Common in patients with TYPHOID FEVER

Broadly two (2) types:  Direct o By insertion catheter

PULSE ASSESSMENT Concepts!

48

of

a

o 160 / no muffling / 110

 Indirect Method o Auscultatory method o Palpatory method o Flush Method

Concepts!!!  Take systolic on loudest sound if patient is an adult  If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or loud  If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then there is a sound at 130 mmHg down to 80 mmHg then…  Use the PALPATORY METHOD in combination with the AUSCULTATORY METHOD because there is an auscultatory gap

Auscultatory Method  Uses Korotkoff sound o A popping sound o NOT the heart beat o It is a phenomenon – an unknown phenomenon! Determining Amount of Inflation  Using auscultatory method o Ask patient what is his last BP reading and then add 30 – 40 mmHg from last systolic reading. o Deflate gradually – rate is approximately 2 – 3 mmHg per second  Alternative auscultatory method o Auscultate for the last sound as you go up. Then add 30 – 40 mmHg o Then deflate

Repeat using:  Auscultatory method  Palpatory method How to do the Palpatory Method  Inflate o Determine up to what point to inflate o Palpate pulse o If pulse is absent, add 30 – 40 mmHg  Deflate o First palpable pulse is true systolic pressure  For diastolic pressure, proceed using the auscultatory method

Tripartite Blood Pressure  Done if patient is an adult.  Example:  140 mmHg systolic – first loudest sound  100 mmHg 1st diastolic – muffling  70 mmHg 2nd diastolic – last sound o Therefore, the tripartite blood pressure is 140 / 100 / 70  If there is no muffling, an example would be:

Flush Method  Represents the mean blood pressure  Represents the average of the systolic and diastolic pressures

49

 When done: o When you have a BP apparatus without a stethoscope o Used for pediatric patients  How done: o Inflate up to the point where extremity becomes pale o Deflate slowly and look for a REBOUND FLUSH – when extremity becomes red again  This is the true reading!!  Note that there is only ONE reading!!!

Stage 1  Involves the epidermis  Manifestation o Non-blanchable erythema of INTACT SKIN o This is the first heralding sign of decubitus ulceration Stage 2  Partial Thickness Skin Loss  Involves epidermis and dermis  Manifestation o Blister formation o Shallow craters o Shallow abrasion and ulceration

SKIN INTEGRITY  Decubitus ulcers are caused by: o Unrelieved, sustained pressure o Localized ischemia o Shearing force o Pressure plus friction  Predisposing Factors: o Unconsciousness o Incontinence o Loss of Sensation o Hypoproteinemia  Decreased lean muscle mass  Increase in fluid shifting leads to edema  Dependent position is the skin attached to or facing the bed o Emaciation Stages of Formation

Decubitus

Stage 3 Full Thickness Skin Loss Ulceration  There is skin loss already  Involves necrosis of the skin and subcutaneous tissues EXTENDING TO but NOT THROUGH the underlying fascia Stage 4  Formations and manifestations of Stage 3 plus… o Involvement of bones, supporting structures (tendons), joint capsules o Massive damage Tools to Assess Risk of Ulceration  Norton’s Pressure Area Risk Assessment Form  Shannon’s Scoring System

Ulcer

50

 Branden Scale of Predicting Ulceration  Waterlow Risk Assessment Cards o Most important tool o Most common tool o Most often used tool

 3+  4+  5+

-

3 cm induration 4 cm induration 5 cm induration

PAIN MANAGEMENT Pain  A noxious stimulation of actual or threatened / potential tissue damage

EDEMA  Caused by shifting of fluid into the interstitial tissues

Categories of Pain according to Origin  Cutaneous o Skin  Deep Somatic o Tendons, ligaments o Bones o Blood Vessels  Visceral Pain o Organs of the body

Management of Edema 1. Elevation of the edematous part Nursing Alert!  If edema is due to Congestive Heart Failure (Right Sided), NEVER ELEVATE THE LOWER EXTREMITIES Rationale:  This increases the workload of the right side of the heart

Categories of Pain based on Cause  Acute o Due to trauma or surgery o Persists for less than six (6) months  Chronic Malignant Pain o Related to cancer o On and off o Persists for more than six (6) months  Chronic Non-malignant Pain o Persists for more than six (6) months

Concept!  If edema is due to prolonged standing, DO THE ELEVATION 2. Wear elastic stockings 3. Use warm compress alternated with cold compress Rationale:  Vasoconstriction and vasodilation causes recirculation of fluid Concept!  This is contraindicated if there is inflammation

Categories of Pain according to Where It Is Experienced  Radiating Pain o Felt on the source and is extending to nearby tissues  Referred Pain

Assessment of Edema Induration  1+ 1 cm induration  2+ 2 cm induration

51

o Felt on other parts detached from the source o Example: o Pain on a lacerated liver may be felt on the right shoulder and not on the right upper quadrant  Intractable Pain o Highly resistant to painrelief methods  Phantom Pain o Pain that is felt on a MISSING BODY PART or a PART THAT IS PARALYZED by SPINAL CORD INJURY.

o Pain signals are carried to the spinal cord by the small diameter nerve fibers  Large diameter nerve fibers also pass through the substancia gelatinosa o Large diameter nerve fibers close the gate – prevents the transmission of impulses through the spinal cord o Therefore, when LARGE DIAMETER NERVE FIBERS ARE STIMULATED, THE GATE IS CLOSED  Pain management operates on the principle of how to stimulate the Large Diameter Nerve Fibers to close the gate.

Pain Threshold  Amount of pain stimulation that is required in order to feel pain

Pain Management Strategies

Pain Tolerance  Maximum amount of pain and duration that a person is willing to endure

Pharmacologic Methods  Narcotics  NSAIDs  Adjuvants or Co-analgesics

Gate Control Theory Concept!  This is the most widely used theory in pain management

Non-Pharmacologic Methods  Physical Interventions  Cognitive / Behavioral Interventions

Concepts!  At the dorsal horn of the spinal cord is a gate.  This gate is called the SUBSTANCIA GELATINOSA  A series of nerves pass through this gate  Small diameter nerve fibers pass through the substancia gelatinosa

Non-Pharmacologic Physical Interventions 1. Cutaneous Stimulation  Massage o Effleurage o Soft massage o Gentle stroking  Petrissage o Hard massage

52









o Large and quick pinches o Also done by striking Application of Counter-Irritant o Bengay o Menthol o Omega Pain Killer o Flax Seeds o Poultices Heat and Cold Application o Nursing Alert! o Rebound Phenomenon  When you apply heat (usually done for 20 minutes), vasodilation is produced  If heat is applied for more than 20 minutes, there is vasoconstriction  This is an inherent defense mechanism from burning of tissues Cold Application o Maximum vasoconstriction is reached when skin reaches 15°C o If there is further drom in temperature, there is vasodilation (skin becomes reddish) o This is the inherent defense mechanism from being frozen Accupressure o Pressure on certain points of the body o Stimulates release of endorphins, which have

natural analgesic effects o This started in Ancient China  Accupuncture o Insertion of long slender needles on certain chemical pathways o Origin is also Ancient china  Contralateral Stimulation o Example: Injury on left side and massage is done on the right side o Useful when patient cannot be accessed:  For patients in a cast  For patients with burns  For patients with phantom pain 2. Immobilization  Application of splints 3.Transcutaneous Electrical Nerve Stimulation  Composed of electrodes  Operated by battery  Electrodes are applied on painful site or over the spinal cord 4.Administration of a Placebo  Relieves pain because of its intent and not because of physical or chemical properties Cognitive or Behavioral NonPharmacologic Interventions  Purpose: o To alter pain perception

53

o To alter pain behavior o To provide client with a greater sense of control over the pain

URINARY ELIMINATION Oliguria  Renal output of less than 500 ml per day

Specific Interventions 1.Distraction  Purpose is to divert attention from pain  Slow Rhythmic Breathing o Stare at a certain object o Take deep breath slowly o Release or exhale slowly o Concentrate on breathing o Picture a peaceful scene o Establish a rhythmic pattern 2.Massage Breathing

and

Slow

Anuria  Renal output of less than 100 ml per day Retention  Positive for distended bladder  May also occur in the absence of bladder distention Altered Urinary Elimination Enuresis  Common among pediatric patients  Age 4 – 5 years old child has adequate bladder control  Primary Enuresis o Never had a dry period  Secondary Enuresis o Acquired enuresis o At age 7, bladder control is present for at least one year o Then, enuresis comes back o Urinating could NOT be controlled again

Rhythmic

3.Rhythmic Singing and Tapping  Key Concept! o Faster beat music is more preferable 4.Guided Imagery  Imagine that you are walking along a peaceful shore  Eyes are closed and suggestions are given

Incontinence  Involuntary passage of urine

5.Hypnosis  The success of hypnosis depends on the ability of the patient to concentrate and the capacity of the hypnotist to suggest  Based on suggestion  Progressive relaxation

Types of Incontinence 1.Functional Incontinence  Involuntary passage  Unpredictable time

54

2.Reflex Incontinence  Occurs at somewhat predictable times when specific bladder volume is reached  No awareness of bladder filling  No urge to void  It may be related to neurologic impairment

o Advise patient to stand with legs slightly apart o Concentrate on perineum o Draw perineum upward slowly  Alternative way: o When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing o Advantage of Kegel’s Exercises o Increases muscle tone of the pelvis o Increases muscle control

3.Stress Incontinence  Loss of urine is less than 50 ml occurring with increased intra-abdominal pressure o Occurs when laughing o Occurs when sneezing o Occurs when smiling Total Incontinence  Continuous flow of urine  No bladder distention  No bladder spasm  No awareness of bladder filling

2.Clean Intermittent Self Catheterization  Applicable for Reflex Incontinence  How done: o Use a mirror for:  Obese male patients  Female patients  Concept! o Possible Board Question:  Is your Clean Intermittent Self Catheterization procedure a sterile procedure? o Answer:  No, it is just a clean procedure. Therefore, you can just wash the catheter for the next use.

Urge Incontinence  Urine flows as soon as a strong sense of feeling to void occurs  Strong bladder spasm Management of Incontinence 1.Kegel’s Exercises  Also called: o Pubococcygeal Muscle Exercises o Pelvic Floor Muscle Exercises  Applicable for: o Functional Incontinence o Stress Incontinence  How done:

3.Crede’s Maneuver

55

 Application of a steady but gentle pressure on the suprapubic region to force urine out of the bladder  Nursing Alert! o Do not use if there is OBSTRUCTION (i.e. renal obstruction in the form of renal stones) o This is done only for patients who are no longer expected to regain control (Reflex incontinence and retention)



    

o Let patient wash genitals o Dry the genitals o Get to bed Place patient in semi-Fowler’s position when she is ready to void Clean and spread labia with two fingers Remain holding labia Then let patient urinate Let go of first flow Collect next flow

CATHETERIZATION

4.Prompted Voiding or Scheduled Toileting  For Reflex Incontinence

 Coude Catheter o Elbowed catheter for Benign Prostatic Hypertrophy patients  Robinson Catheter o Straight catheter  Multi-Lumen Retention Catheter o Foley catheter  One lumen is for inflation  One lumen is for drainage of urine  One lumen is for irrigation  A three-way catheter  Aspirate using syringe and needle  This is made with a selfsealing rubber

5.Application of Adult Catheter and External Condom Catheter  For elderly with Total Incontinence 6.Catheterization MIDSTREAM CLEAN CATCH URINE SPECIMEN How is this done?  If patient is a Male… o Clean the penis o Do this from the meatus down to the shaft o Let the patient urinate o Discard the first or the initial urine o Collect midstream urine o Purpose is to attain sterile specimen for urine culture and sensitivity testing  If patient is a Female…

Concepts!!!  See to it that penis is perpendicular to body to straighten up the urethra to bladder  While inserting the catheter, ask the patient to breathe through the mouth  Cleanse the penis before insertion 56

 Grasp penis firmly to avoid stimulating erections  Where to tape catheter o Tape it upward on the abdomen  Rationale: o To avoid scrotal excoriation o Tape on the inner thigh (with penis sideways either on left or right and follow the normal contour of the penis  Length of Catheter o 40 centimeters  Depth of Insertion o While inserting, the point at which urine starts to flow, insert further by five (5) centimeters and then inflate the balloon – KOZIER o Insert up to a the Ypoint, retract after inflating (this method is more prone to infection  For females o Insert at female Urethra  Length of Catheter o 22 centimeters  Depth of Insertion o Point at which urine starts to flow, insert further by five (5) centimeter before inflating balloon

 Avoid ignoring the urge to defecate  Do not abuse laxatives Concepts!  For Flatulence o Avoid carbonated drinks o Do not use straw o Avoid chewing gum o Avoid gas-forming foods:  Camote  Cabbage  Cauliflower  Onions For Constipation:  Increase fluid intake  Prune juice  Papaya  Increase fiber in the diet  Use METAMUCIL (natural fiber) instead of laxatives Special Laboratory Procedures 1.Guiac Test  To determine the presence of occult blood  Concepts!!! o Have a meat-less diet three (3) days before examination o Withhold oral iron supplements o Injectible iron is allowed o Avoid any food that discolors the stool.

GIT – FECAL ELIMINATION Wellness Teachings  Fluid intake of at least 2,000 ml per day  Regular exercise  High fiber diet

2.GI SERIES Upper GI Series – Barium Swallow  Nursing Considerations:

57

o Elimination of contrast medium  How: o Increase fluid intake o Increase fiber in the diet  Rationale: o To offset the risk of constipation o Inform patient that the color of the stool will be WHITE

 Rationale: o Can lead to rupture of the appendix 2. Carminative Enema  Used to expel out flatus  Burned sugar  Now commercially available 3. Oil Retention Enema  Purpose: o To lubricate the colon and to soften the feces o Retention time is one (1) to three (3) hours

Lower GI Series – Barium Enema  Done at the radiology department  Nursing Concern: o Elimination of Barium  How: o Cleansing enema may be needed after barium enema

4. Retention Flow Enema  Also called Harish Flush Enema  Solution is continually administered until what comes out of the body is clear. Positions in Enema  Cleansing Enema  High Cleansing Enema o Clean as much of the colon as possible o On introduction, Sim’s Left position facilitates flow of enema to sigmoid colon o Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse colon o Then, Right Side-Lying position to facilitate flow of enema to the descending colon  Low Cleansing Enema o For cleaning of rectum and colon only

Different Types of Enema 1. Cleansing Enema  Soap suds enema  Alkaline solution  Nursing Alert! o Contraindicated in patients with liver cirrhosis and with increased ammonia in the blood  Rationale: o Alkaline solution facilitates transfer of ammonia from the GI tract to the bloodstream  Therefore, use lemon juice or dilute vinegar instead!!!  Nursing Alert! o Also contraindicated in possible appendicitis or appendicitis patients

SEXUALITY

58

o Erection of the penis  Females o Redness near the ear o Nipples, breasts move up o Fourchette retracts o Clitoris becomes visible o Increased vaginal secretion o If female is unaroused, there is backpain as penis hits the cervix  If the female is wellstimulated, the cervix rises

Human Sexual Response Excitement / Physical Stimulation  Erotic stimuli causes sexual stimulation  Lasts for a few minutes to several hours Types of Stimulation Physical Stimulation  Oral stimulation o Fellatio  Oral stimulation of the penis using the mouth o Cunningulus  Oral stimulation of the vagina o Anningulus  Oral stimulation of the anus  In homosexual male, typhoid fever may be obtained from anningulus  Male and Female oral sex is called SOIXANTE NEUF

Plateau Stage  Lasts thirty (30) seconds to three (3) minutes  In males: o Scrotum rises upward o Shaft of penis increases in length and width  In females: o Cervix rises  In both sexes: o There is increased muscle tone o Myotonia Orgasmic Phase or Orgasmic Stage  Climax of sexual tension  Peak of sexual experience  Lasts three (3) to ten (10) seconds

Physiological Sexual Stimulation  Stimulation by: o Smell o Sight o Hearing o Fantasy o Spoken words o Mental imagery

Resolution Stage  Key Concepts! o Females have longer resolution phase o Males have shorter resolution phase

During stimulation or Period of Excitement  Males

PERIOPERATIVE NURSING 59

 If hair needs to be removed, the best method would be through the use of: o Clippers o Depilatory cream  Shaving is NOT ADVISED. This is the last choice  Where is shaving done? o Not at the Operating Room!

Stages of Perioperative Nursing  Pre-operative Phase  Intra-operative Phase  Post-operative Phase Pre-operative Phase  Begins upon decision of patient to undergo the operation  Ends when patient is placed on the operating table

TYPES OF WOUNDS

Intra-operative Phase  Begins when patient is placed on the operating table  Ends when client is admitted to the Post-Anesthesia Care Unit or PACU

1. Clean Wound  Uninfected  No inflammation  Respiratory, Alimentary and Urinary tracts are not entered 2. Clean Contaminated Wound  A surgical wound  No evidence of infection  Respiratory, GI, Urinary tracts are entered

Post-operative Phase  Begins upon admission to the PACU  Ends upon the discharge of the patient Skin Preparation  Purpose: o To reduce postoperative infection by:  Removing soil and transient microbes  Reducing microbial count to subpathological level in a short period of time with minimal skin irritation.  Concepts!  Hair on the skin should not be shaved if it does not interfere with the procedure

3. Contaminated Wound  Involves large spillage of content from the GI, Urinary and Respiratory tracts  Positive for inflammation  Positive for infection  Dirty Infected Wound  Old wounds  Necrotic, gangrenous wound Modes of Dressing

Applying

Gauze

1. Dry to Dry  A wide mesh of cotton applied to the surface of the wound  A second layer is applied over it 60

2. Wet to Dry  Inner layer is saturated with NSS or anti-microbial agent  On top is a moist absorbent material 3. Wet to Damp  A variation of wet to dry  It is removed before it is completely dried 4. Wet to Wet  Inner layer is saturated with NSS or anti-microbial solution  Second layer is a wide mesh  It is kept moist with a wetting agent

61