Fundamentals of Nursing Final — Free DOH Study Notes

FUNDAMENTALS OF NURSING

The Basic Human Needs

• Each individual has unique characteristics, but certain needs are common to all people.
• A need is something that is desirable, useful or necessary.
• Human needs are physiologic and psychologic conditions that an individual must meet to achieve a state of health or well-being.

Maslow's Hierarchy of Basic Human Needs

Physiologic

1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex

Safety and Security

1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger

Love and belonging

1. The need to love and be loved
2. The need to care and to be cared for.
3. The need for affection: to associate or to belong
4. The need to establish fruitful and meaningful relationships with people, institution, or organization

Self-Esteem Needs

1. Self-worth
2. Self-identity
3. Self-respect
4. Body image

Self-Actualization Needs

1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty or aesthetics
4. The need for spiritual fulfillment

Characteristics of Basic Human Needs

1. Needs are universal.
2. Needs may be met in different ways

3. Needs may be stimulated by external and internal factor
4. Priorities may be deferred
5. Needs are interrelated

Leavell and Clark's Three Levels of Prevention

a. Primary Prevention – seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening. * Health Promotion - health education - marriage counseling - genetic screening - good standard of nutrition adjusted to developmental phase of life * Specific Protection - use of specific immunization - attention to personal hygiene - use of environmental sanitation - protection against occupational hazards - protection from accidents - use of specific nutrients - protections from carcinogens - avoidance to allergens b. Secondary Prevention – also known as “Health Maintenance". Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability; to prevent catastrophic effects that could occur if proper attention and treatment are not provided * Early Diagnosis and Prompt Treatment - case finding measures - individual and mass screening survey - prevent spread of communicable disease - prevent complication and sequelae - shorten period of disability * Disability Limitations - Adequate treatment to arrest disease process and prevent further complication and sequelae. - provision of facilities to limit disability and prevent death. c. Tertiary Prevention – occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status. To establish a high-level wellness.

"To maximize use of remaining capacities”s Restoration and Rehabilitation

• work therapy in hospital
• use of shelter colony

ROLES AND FUNCTIONS OF THE NURSE

• Care giver
• Decision-maker
• Protector
• Client Advocate
• Manager
• Rehabilitator
• Comforter
• Communicator
• Teacher
• Counselor
• Coordinator
• Leader
• Role Model
• Administrator

COMMUNICATION IN NURSING

COMMUNICATION

1. Is the means to establish a helping-healing relationships. All behavior communication influences behavior.
2. Communication is essential to the nurse-patient relationship for the following reasons:
3. Is the vehicle for establishing a therapeutic relationship.
4. It the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.

Basic Elements of the Communication Process

1. SENDER – is the person who encodes and delivers the message
2. MESSAGES – is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
3. RECEIVER – is the person who receives the decodes the message.
4. FEEDBACK – is the message returned by the receiver. It indicates whether the meaning of the sender's message was understood.

Modes of Communication

1. Verbal Communication – use of spoken or written words.
2. Nonverbal Communication – use of gestures, facial expressions, posture/gait, body movements, physical appearance and body language

Characteristics of Good Communication

1. Simplicity – includes uses of commonly understood, brevity, and completeness.
2. Clarity – involves saying what is meant. The nurse should also need to speak slowly and enunciate words well.
3. Timing and Relevance – requires choice of appropriate time and consideration of the client's interest and concerns. Ask one question at a time and wait for an answer before making another comment.
4. Characteristics of Good Communication
5. Adaptability – Involves adjustments on what the nurse says and how it is said depending on the moods and behavior of the client.
6. Credibility – Means worthiness of belief. To become credible, the nurse requires adequate knowledge about the topic being discussed. The nurse should be able to provide accurate information, to convey confidence and certainly in what she says.

Communicating With Clients Who Have Special Needs

1.Clients who cannot speak clearly (aphasia, dysarthria, muteness)

1. Listen attentively, be patient, and do not interrupt.
2. Ask simple question that require "yes" and "no" answers.
3. Allow time for understanding and response.
4. Use visual cues (e.g., words, pictures, and objects)
5. Allow only one person to speak at a time.
6. Do not shout or speak too loudly.
7. Use communication aid:
   • pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm.

2. Clients who are cognitively impaired

1. Reduce environmental distractions while conversing.
2. Get client's attention prior to speaking
3. Use simple sentences and avoid long explanation.
4. Ask one question at a time
5. Allow time for client to respond
6. Be an attentive listener
7. Include family and friends in conversations, especially in subjects known to client.

3. Client who are unresponsive

1. Call client by name during interactions
2. Communicate both verbally and by touch
3. Speak to client as though he or she could hear
4. Explain all procedures and sensations
5. Provide orientation to person, place, and time
6. Avoid talking about client to others in his or her presence
7. Avoid saying things client should not hear

4. Communicating with hearing impaired client

1. Establish a method of communication (pen/pencil and paper, sign-language)
2. Pay attention to client's non-verbal cues
3. Decrease background noise such as television
4. Always face the client when speaking
5. It is also important to check the family as to how to communicate with the client
6. It may be necessary to contact the appropriate department resource person for this type of disability

4. Client who do not speak English

1. Speak to client in normal tone of voice (shouting may be interpreted as anger)
2. Establish method for client o signal desire to communicate (call light or bell)
3. Provide an interpreter (translator) as needed
4. Avoid using family members, especially children, as interpreters.
5. Develop communication board, pictures or cards.
6. Have dictionary (English/Spanish) available if client can read.

Reports

• Are oral, written, or audiotaped exchanges of information between caregivers.

Common reports:

1. Change-in-shift report
2. Telephone report
3. Telephone or verbal order – only RN's are allowed to accept telephone orders.
4. Transfer report
5. Incident report

Documentation

1. Is anything written or printed that is relied on as record or proof for authorized person.
2. Nursing documentation must be:
   1. accurate
   2. comprehensive
   3. flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflects current standards of nursing practice

4. Effective documentation ensures continuity of care, saves time and minimizes the risk of error.
5. As members of the health care team, nurses need to communicate information about clients accurately and in timely manner
6. If the care plan is not communicated to all members of the health care team, care can become fragmented, repetition of tasks occurs, and therapies may be delayed or omitted.
7. Data recorded, reported, or communicated to other health care professionals are CONFIDENTIAL and must be protected.

CONFIDENTIALITY

1. nurses are legally and ethically obligated to keep information about clients confidential.
2. Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care.
3. Only staff directly involved in a specific client's care have legitimate access to the record.
4. CONFIDENTIALITY
5. Clients frequently request copies of their medical record, and they have the right to read those records.
6. Nurses are responsible for protecting records from all unauthorized readers.
7. when nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, appropriate authorization must be obtained according to agency policy.
8. Confidentiality
9. Maintaining confidentiality is an important aspect of profession behavior. 10.It is essential that the nurse safe-guard the client' right to privacy by carefully protecting information of a sensitive, private nature. 11.Sharing personal information or gossiping about others violates nursing ethical codes and practice standards. 12.It sends the message that the nurse cannot be trusted and damages the interpersonal relationships.

Guidelines of Quality Documentation and Reporting

1.Factual

1. a record must contain descriptive, objective information about what a nurse sees, hears, feels, and smells.
2. The use of vague terms, such as appears, seems, and apparently, is not acceptable because these words suggests that the nurse is stating an opinion.

   Example: " the client seems anxious" (the phrase seems anxious is a conclusion without supported facts.)

2. Accurate

1. The use of exact measurements establishes accuracy. (example: "Intake of 350 ml of water" is more accurate than " the client drank an adequate amount of fluid"
2. Documentation of concise data is clear and easy to understand.
3. It is essential to avoid the use of unnecessary words and irrelevant details

3. Complete

1. The information within a recorded entry or a report needs to be complete, containing appropriate and essential information.

Example:

The client verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 15 minutes ago after twisting his foot on the stair. Client rates pain as 8 on a scale of 0-10.

4. Current

1. Timely entries are essential in the clients ongoing care. To increase accuracy and decrease unnecessary duplication, many healthcare agencies use records kept near the client's bedside, which facilitate immediate documentation of information as it is collected from a client

5. Organized

1. The nurse communicates information in a logical order.

   For example, an organized note describes the client's pain, nurse's assessment, nurse's interventions, and the client's response

Legal Guidelines for recording

1. Draw single line through error, write word error above it and sign your name or initials. Then record note correctly.
2. Do not write retaliatory or critical comments about the client or care by other health care professionals.

   Enter only objective descriptions of client's behavior; client's comments should be quoted.

3. Correct all errors promptly
   • errors in recording can lead to errors in treatment
   • Avoid rushing to complete charting, be sure information is accurate.
4. Do not leave blank spaces in nurse's notes.

   Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.

5. Record all entries legibly and in blank ink
   • Never use pencil, felt pen.
   • Blank ink is more legible when records are photocopied or transferred to microfilm.

Legal Guidelines for Recording

6. If order is questioned, record that clarification was sought.
   • If you perform orders known to be incorrect, you are just as liable for prosecution as the physician is.
7. Chart only for yourself
   • Never chart for someone else.
   • You are accountable for information you enter into chart.
8. Avoid using generalized, empty phrases such as "status unchanged" or "had good day".
   • Begin each entry with time, and end with your signature and title.
   • Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure to sign each entry.
9. For computer documentation keep your password to yourself.
   • maintain security and confidentiality.
   • Once logged into the computer do not leave the computer screen unattended.

Assessing Vital Signs

Vital Signs or Cardinal Signs are:

• Body temperature
• Pulse
• Respiration
• Blood pressure
• Pain

I. Body Temperature

• The balance between the heat produced by the body and the heat loss from the body.

Types of Body Temperature

• Core temperature - temperature of the deep tissues of the body.
• Surface body temperature

Alteration in body Temperature

• Pyrexia – Body temperature above normal range (hyperthermia)
• Hyperpyrexia – Very high fever, 41°C (105.8 F) and above
• Hypothermia – Subnormal temperature.

Normal Adult Temperature Ranges

Methods of Temperature-Taking

1. Oral – most accessible and convenient method.

a. Put on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far back as possible. It promotes contact to the superficial blood vessels and ensure a more accurate reading. b. Wash thermometer before use. c. Take oral temp 2-3 minutes. d. Allow 15 min to elapse between client's food intake of hot or cold food, smoking. e. Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the thermometer in his mouth.

Contraindications

• Young children and infants
• Patients who are unconscious or disoriented
• Who must breath through the mouth
• Seizure prone
• Patient with N/V
• Patients with oral lesions/surgeries

2. Rectal- most accurate measurement of temperature

a. Position- lateral position with his top legs flexed and drape him to provide privacy. b. Squeeze the lubricant onto a facial tissue to avoid contaminating the lubricant supply. c. Insert thermometer by 0.5 – 1.5 inches d. Hold in place in 2minutes e. Do not force to insert the thermometer

Contraindications

• Patient with diarrhea
• Recent rectal or prostatic surgery or injury because it may injure inflamed tissue
• Recent myocardial infarction
• Patient post head injury

3. Axillary – safest and non-invasive

a. Pat the axilla dry b. Ask the patient to reach across his chest and grasp his opposite shoulder. This promote skin contact with the thermometer c. Hold it in place for 9 minutes because the thermometer isn't close in a body cavity

Note:

• Use the same thermometer for repeat temperature taking to ensure more consistent result
• Store chemical-dot thermometer in a cool area because exposure to heat activates the dye dots.

4. Tympanic thermometer

a. Make sure the lens under the probe is clean and shiny b. Stabilized the patient's head; gently pull the ear straight back (for children up to age 1) or up and back (for children 1 and older to adults) c. Insert the thermometer until the entire ear canal is sealed d. Place the activation button, and hold it in place for 1 second

5. Chemical-dot thermometer

a. Leave the chemical-dot thermometer in place for 45 seconds b. Read the temperature as the last dye dot that has change color, or fired.

Nursing Interventions in Clients with Fever

a. Monitor V.S b. Assess skin color and temperature c. Monitor WBC, Hct and other pertinent lab records d. Provide adequate foods and fluids. e. Promote rest f. Monitor I & O g. Provide TSB h. Provide dry clothing and linens i. Give antipyretic as ordered by MD

II. Pulse – It's the wave of blood created by contractions of the left ventricles of the heart.

Normal Pulse rate

Tachycardia – pulse rate of above 100 beats/min Bradycardia- pulse rate below 60 beats/min Irregular – uneven time interval between beats.

What you need: a. Watch with second hand

b. Stethoscope (for apical pulse) c. Doppler ultrasound blood flow detector if necessary Radial Pulse a. Wash your hand and tell your client that you are going to take his pulse b. Place the client in sitting or supine position with his arm on his side or across his chest c. Gently press your index, middle, and ring fingers on the radial artery, inside the patient's wrist. d. Excessive pressure may obstruct blood flow distal to the pulse site e. Counting for a full minute provides a more accurate picture of irregularities Doppler device a. Apply small amount of transmission gel to the ultrasound probe b. Position the probe on the skin directly over a selected artery c. Set the volume to the lowest setting d. To obtain best signals, put gel between the skin and the probe and tilt the probe 45 degrees from the artery. e. After you have measure the pulse rate, clean the probe with soft cloth soaked in antiseptic. Do not immerse the probe

III. Respiration - is the exchange of oxygen and carbon dioxide between the

atmosphere and the body Assessing Respiration

• Rate - Normal 14-20/ min in adult
• The best time to assess respiration is immediately after taking client's pulse
• Count respiration for 60 second
• As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.
• Respiratory rates of less than 10 or more than 40 are usually considered abnormal and should be reported immediately to the physician.

IV. Blood Pressure

Adult - 90-132 systolic 60-85 diastolic Elderly 140-160 systolic 70-90 diastolic a. Ensure that the client is rested b. Use appropriate size of BP cuff. c. If too tight and narrow- false high BP d. If too lose and wide-false low BP e. Position the patient on sitting or supine position

f. Position the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading g. Use the bell of the stethoscope since the blood pressure is a low frequency sound. h. If the client is crying or anxious, delay measuring his blood pressure to avoid false-high BP Electronic Vital Sign Monitor a. An electronic vital signs monitor allows you to continually tract a patient's vital sign without having to reapply a blood pressure cuff each time. b. Example: Dinamap VS monitor 8100 c. Lightweight, battery operated and can be attached to an IV pole d. Before using the device, check the client7s pulse and BP manually using the same arm you'll using for the monitor cuff. e. Compare the result with the initial reading from the monitor. If the results differ call the supply department or the manufacturer's representative.

V. Pain

How to assess Pain a. You must consider both the patient's description and your observations on his behavioral responses. b. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack of pain and 10 denoting the worst pain imaginable. c. Ask: d. Where is the pain located? e. How long does the pain last? f. How often does it occur? g. Can you describe the pain? h. What makes the pain worse i. Observe the patient's behavioral response to pain (body language, moaning, grimacing, withdrawal, crying, restlessness muscle twitching and immobility) j. Also note physiological response, which may be sympathetic or parasympathetic Managing Pain

1. Giving medication as per MD's order
2. Giving emotional support
3. Performing comfort measures
4. Use cognitive therapy Height and weight a. Height and weight are routinely measured when a patient is admitted to a health care facility. b. It is essential in calculating drug dosage, contrast agents, assessing nutritional status and determining the height-weight ratio.

c. Weight is the best overall indicator of fluid status, daily monitoring is important for clients receiving a diuretics or a medication that causes sodium retention. d. Weight can be measured with a standing scale, chair scale and bed scale. e. Height can be measured with the measuring bar, standing scale or tape measure if the client is confine in a supine position. Pointers: a. Reassure and steady patient who are at risk for losing their balance on a scale. b. Weight the patient at the same time each day. (usually before breakfast), in similar clothing and using the same scale. c. If the patient uses crutches, weigh the client with the crutches or heavy clothing and subtract their weight from the total determined patient' weight.

Laboratory and Diagnostic examination

I. Urine Specimen

1.Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test a. Best time to collect is in the morning, first voided urine b. Provide sterile container c. Do perineal care before collection of the urine d. Discard the first flow of urine e. Label the specimen properly f. Send the specimen immediately to the laboratory g. Document the time of specimen collection and transport to the lab. h. Document the appearance, odor, and usual characteristics of the specimen. 2. 24-hour urine specimen a. Discard the first voided urine. b. Collect all specimen thereafter until the following day c. Soak the specimen in a container with ice d. Add preservative as ordered according to hospital policy 3. Second-Voided urine – required to assess glucose level and for the presence of albumen in the urine. a. Discard the first urine b. Give the patient a glass of water to drink c. After few minutes, ask the patient to void 4. Catheterized urine specimen a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected. b. Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary surgery.

II. Stool Specimen

1. Fecalysis – to assess gross appearance of stool and presence of ova or parasite a. Secure a sterile specimen container b. Ask the pt. to defecate into a clean, dry bed pan or a portable commode. c. Instruct client not to contaminate the specimen with urine or toilet paper( urine inhibits bacterial growth and paper towel contain bismuth which interfere with the test result.
2. Stool culture and sensitivity test

• To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.

3. Fecal Occult blood test

• are valuable test for detecting occult blood (hidden) which may be present in colo- rectal cancer, detecting melena stool a. Hematest- (an Orthotolidin reagent tablet) b. Hemoccult slide- (filter paper impregnated with guaiac) Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours. c. Colocare a newer test, requires no smear Instructions: a. Advise client to avoid ingestion of red meat for 3 days b. Patient is advise on a high residue diet c. Avoid dark food and bismuth compound d. If client is on iron therapy, inform the MD e. Make sure the stool in not contaminated with urine, soap solution or toilet paper f. Test sample from several portion of the stool. Venipuncture Pointers a. Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or blood administration because it mat affect the result. b. Never collect venous sample from an infectious site because it may introduce pathogens into the vascular system c. Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury. d. Don't wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine. e. If the patient has a clotting disorder or is receiving anticoagulant therapy, maintain pressure on the site for at least 5 min after withdrawing the needle. Arterial puncture for ABG test a. Before arterial puncture, perform Allen's test first.

b. If the patient is receiving oxygen, make sure that the patient's therapy has been underway for at least 15 min before collecting arterial sample c. Be sure to indicate on the laboratory request slip the amount and type pf oxygen therapy the patient is having. d. If the patient has just receive a nebulizer treatment, wait about 20 minutes before collecting the sample.

IV. Blood specimen

a. No fasting for the following tests:

• CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes b. Fasting is required:
• FBS, BUN, Creatinine, serum lipid ( cholesterol, triglyceride)

V. Sputum Specimen

1. Gross appearance of the sputum a. Collect early in the morning b. Use sterile container c. Rinse the mount with plain water before collection of the specimen d. Instruct the patient to hack-up sputum
2. Sputum culture and sensitivity test a. Use sterile container b. Collect specimen before the first dose of antibiotic
3. Acid-Fast Bacilli a. To assess presence of active pulmonary tuberculosis b. Collect sputum in three consecutive morning
4. Cytologic sputum exam- -to assess for presence of abnormal or cancer cells.

Diagnostic Test

1. PPD test a. read result 48 – 72 hours after injection. b. For HIV positive clients, induration of 5 mm is considered positive
2. Bronchography a. Secure consent b. Check for allergies to seafood or iodine or anesthesia c. NPO 6-8 hours before the test d. NPO until gag reflex return to prevent aspiration
3. Thoracentesis – aspiration of fluid in the pleural space. a. Secure consent, take V/S b. Position upright leaning on over bed table c. Avoid cough during insertion to prevent pleural perforation

d. Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity e. Check for expectoration of blood. This indicate trauma and should be reported to MD immediately. 4. Holter Monitor a. it is continuous ECG monitoring, over 24 hours period b. The portable monitoring is called telemetry unit 5. Echocardiogram – a. ultrasound to assess cardiac structure and mobility b. Client should remain still, in supine position slightly turned to the left side, with HOB elevated 15-20 degrees 6. Electrocardiography- a. If the patient's skin is oily, scaly, or diaphoretic, rub the electrode with a dry 4x4 gauze to enhance electrode contact. b. If the area is excessively hairy, clip it c. Remove client's jewelry, coins, belt or any metal d. Tell client to remain still during the procedure 7. Cardiac Catheterization a. Secure consent b. Assess allergy to iodine, shelfish c. V/S, weight for baseline information d. Have client void before the procedure e. Monitor PT, PTT, ECG prior to test f. NPO for 4-6 hours before the test g. Shave the groin or brachial area h. After the procedure: bed rest to prevent bleeding on the site, do not flex extremity i. Elevate the affected extremities on extended position to promote blood supply back to the heart and prevent thrombplebities j. Monitor V/S especially peripheral pulses k. Apply pressure dressing over the puncture site l. Monitor extremity for color, temperature, tingling to assess for impaired circulation. 8. MRI m. secure consent, n. the procedure will last 45-60 minute o. Assess client for claustrophobia p. Remove all metal items q. Client should remain still

r. Tell client that he will feel nothing but may hear noises s. Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI. t. Client with cardiac and respiratory complication may be excluded u. Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedure 9. UGIS – Barium Swallow a. instruct client on low-residue diet 1-3 days before the procedure b. administer laxative evening before the procedure c. NPO after midnight d. instruct client to drink a cup of flavored barium e. x-rays are taken every 30 minutes until barium advances through the small bowel f. film can be taken as long as 24 hours later g. force fluid after the test to prevent constipation/barium impaction 10. LGIS – Barium Enema a. instruct client on low-residue diet 1-3 days before the procedure b. administer laxative evening before the procedure c. NPO after midnight d. administer suppository in AM e. Enema until clear f. force fluid after the test to prevent constipation/barium impaction 11. Liver Biopsy a. Secure consent, b. NPO 2-4 hrs before the test c. Monitor PT, Vit K at bedside d. Place the client in supine at the right side of the bed e. Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD insert the needle f. Right lateral post procedure for 4 hours to apply pressure and prevent bleeding g. Bed rest for 24 hours h. Observe for S/S of peritonitis 12. Paracentesis a. Secure consent, check V/S b. Let the patient void before the procedure to prevent puncture of the bladder c. Check for serum protein. excessive loss of plasma protein may lead to hypovolemic shock. 13. Lumbar Puncture a. obtain consent b. instruct client to empty the bladder and bowel

c. position the client in lateral recumbemt with back at the edge of the examining table d. instruct client to remain still e. obtain specimen per MDs order

NURSING PROCEDURES

1. Steam Inhalation a. It is dependent nursing function. b. Heat application requires physician's order. c. Place the spout 12-18 inches away from the client's nose or adjust the distance as necessary.

2. Suctioning a. Assess the lungs before the procedure for baseline information. b. Position: conscious – semi-Fowler's c. Unconscious – lateral position d. Size of suction catheter- adult- fr 12-18 e. Hyper oxygenate before and after procedure f. Observe sterile technique g. Apply suction during withdrawal of the catheter h. Maximum time per suctioning –15 sec

3. Nasogastric Feeding (gastric gavage) Insertion: a. Fowler's position b. Tip of the nose to tip of the earlobe to the xyphoid Tube Feeding a. Semi-Fowler's position b. Assess tube placement c. Assess residual feeding d. Height of feeding is 12 inches above the tube's point of insertion e. Ask client to remain upright position for at least 30 min. f. Most common problem of tube feeding is Diarrhea due to lactose intolerance

4. Enema a. Check MD's order b. Provide privacy c. Position left lateral d. Size of tube Fr. 22-32 e. Insert 3-4 inches of rectal tube f. If abdominal cramps occur, temporarily stop the flow until cramps are gone. g. Height of enema can – 18 inches

5. Urinary Catheterization a. Verify MD's order b. Practice strict asepsis c. Perineal care before the procedure d. Catheter size: male-14-16 , female – 12 – 14 e. Length of catheter insertion male – 6-9 inches ,female – 3-4 inches For retention catheter: Male -anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure Female- inner aspect of the thigh
6. Bed Bath a. Provide privacy b. Expose, wash and dry one body part a time c. Use warm water (110-115 F) d. Wash from cleanest to dirtiest e. Wash, rinse, and dry the arms and leg using Long, firm strokes from distal to proximal area – to increase venous return.
7. Foot Care a. Soaking the feet of diabetic client is no longer recommended b. Cut nail straight across
8. Mouth Care a. Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables b. Dental check every 6 mounts
9. Oral care for unconscious client a. Place in side lying position b. Have the suction apparatus readily available
10. Hair Shampoo c. Place client diagonally in bed d. Cover the eyes with wash cloth e. Plug the ears with cotton balls f. Massage the scalp with the fatpads of the fingers to promote circulation in the scalp.
11. Restraints g. Secure MD's order for each episode of restraints application. h. Check circulation every 15 min i. Remove restraints at least every 2 hours for 30 minutes

Normal Values

Alkaline phospokinase 32-92 U/L Albumin 3.2-5.5 mg/dl

COMMON THERAPEUTIC DIETS

1. CLEAR-LIQUID DIET

Purpose:

relieve thirst and help maintain fluid balance.

Use:

• post-surgically and following acute vomiting or diarrhea.

Foods Allowed:

• carbonated beverages; coffee (caffeinated and decaff.); tea; fruit-flavored drinks; strained fruit juices; clear, flavored gelatins; broth, consomme; sugar; popsicles; commercially prepared clear liquids; and hard candy.

Foods Avoided:

• milk and milk products, fruit juices with pulp, and fruit.

2. FULL-LIQUID DIET

Purpose:

• provide an adequately nutritious diet for patients who cannot chew or who are too ill to do so.

Use:

• acute infection with fever, GI upsets, after surgery as a progression from clear liquids.

Foods Allowed:

• clear liquids, milk drinks, cooked cereals, custards, ice cream, sherbets, eggnog, all strained fruit juices, creamed vegetable soups, puddings, mashed potatoes, instant breakfast drinks, yogurt, mild cheese sauce or pureed meat, and seasoning.

Foods Avoided:

• nuts, seeds, coconut, fruit, jam, and marmalade

SOFT DIET

Purpose:

➤provide adequate nutrition for those who have troubled chewing.

Use:

➤patient with no teeth or ill-fitting dentures; transition from full-liquid to general diet; and for those who cannot tolerate highly seasoned, fried or raw foods following acute infections or gastrointestinal disturbances such as gastric ulcer or cholelithiasis.

Foods Allowed:

➤very tender minced, ground, baked broiled, roasted, stewed, or creamed beef, lamb, veal, poultry, or fish; crisp bacon or sweet bread; cooked vegetables; pasta; all fruit juices; soft raw fruits; soft bread and cereals; all desserts that are soft; and cheeses.

Foods Avoided:

➤coarse whole-grain cereals and bread; nuts; raisins; coconut; fruits with small seeds; fried foods; high fat gravies or sauces; spicy salad dressings; pickled meat, fish, or poultry; strong cheeses; brown or wild rice; raw vegetables, as well as lima beans and corn; spices such as horseradish, mustard, and catsup; and popcorn.

SODIUM-RESTRICTED DIET

Purpose:

➤reduce sodium content in the tissue and promote excretion of water.

Use:

• heart failure, hypertension, renal disease, cirrhosis, toxemia of pregnancy, and cortisone therapy.

Modifications:

• mildly restrictive 2 g sodium diet to extremely restricted 200 mg sodium diet.

Foods Avoided:

• table salt; all commercial soups, including bouillon; gravy, catsup, mustard, meat sauces, and soy sauce; buttermilk, ice cream, and sherbet; sodas; beet greens, carrots, celery, chard, sauerkraut, and spinach; all canned vegetables; frozen peas;

➤all baked products containing salt, baking powder, or baking soda; potato chips and popcorn; fresh or canned shellfish; all cheeses; smoked or commercially prepared meats; salted butter or margarine; bacon, olives; and commercialy prepared salad dressings.

RENAL DIET

Purpose:

➤ control protein, potassium, sodium, and fluid levels in the body.

Use:

• acute and chronic renal failure, hemodialysis.

Foods Allowed:

• high-biological proteins such as meat, fowl, fish, cheese, and dairy products- range between 20 and

60 mg/day.

• Potassium is usually limited to 1500 mg/day.
• Vegetables such as cabbage, cucumber, and peas are lowest in potassium.
• Sodium is restricted to 500 mg/day.
• Fluid intake is restricted to the daily volume plus 500 mL, which represents insensible water loss.

➤Fluid intake measures water in fruit, vegetables, milk and meat.

Foods Avoided:

➤Cereals, bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips, raw fruit, yams, soybeans, nuts, gingerbread, apricots, bananas, figs, grapefruit, oranges, percolated coffee, Coca-Cola, orange crush, sport drinks, and breakfast drinks such as Tang or Awake

HIGH-PROTEIN, HIGH CARBOHYDRATE DIET

Purpose:

to correct large protein losses and raises the level of blood albumin. May be modified to include low- fat, low-sodium, and low-cholesterol diets.

Use:

➤burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis, protein deficiency due to poor eating habits, geriatric patient with poor intake; nephritis, nephrosis, and liver and gall bladder disorder.

Foods Allowed:

• general diet with added protein.

Foods Avoided:

• restrictions depend on modifications added to the diet. The modifications are determined by the patient's condition.

PURINE-RESTRICTED DIET

Purpose:

• designed to reduce intake of uric acid-producing foods.

Use:

• high uric acid retention, uric acid renal stones, and gout.

Foods Allowed:

• general diet plus 2-3 quarts of liquid daily.

Foods Avoided:

• cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils, dried peas and beans, broth, bouillon, gravies, oatmeal and whole wheat, pasta, noodles, and alcoholic beverages. Limited

quantities of meat, fish, and seafood allowed.

BLAND DIET

Purpose:

• provision of a diet low in fiber, roughage, mechanical irritants, and chemical stimulants.

Use:

➤Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI disorders, gastric atony, diarhhea, spastic constipation, biliary indigestion, and hiatus hernia.

Foods Allowed:

• varied to meet individual needs and food tolerances.

Foods Avoided:

• fried foods, including eggs, meat, fish, and sea food; cheese with added nuts or spices; commercially prepared luncheon meats; cured meats such as ham; gravies and sauces; raw vegetables;

➤potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheats; rye bread; bran cereals; rich pastries; pies; chocolate; jams with seeds; nuts; seasoned dressings; caffeinated coffee; strong tea; cocoa; alcoholic and carbonated beverages; and pepper.

LOW-FAT, CHOLESTEROL-RESTRICTED DIET

Purpose:

• reduce hyperlipedimia, provide dietary treatment for malabsorption syndromes and patients having acute intolerance for fats.

Use:

• hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease of intestinal tract characterized by malabsorption), gastrectomy, massive resection of small intestine, and cholecystitis.

Foods Allowed:

• nonfat milk; low-carbohydrate, low-fat vegetables; most fruits; breads; pastas; cornmeal; lean meats; nsaturated fats

Foods Avoided:

• remember to avoid the five C's of cholesterol- cookies, cream, cake, coconut, chocolate; whole milk and whole-milk or cream products, avocados, olives, commercially prepared baked goods such as donuts and muffins, poultry skin, highly marbled meats

➤butter, ordinary margarines, olive oil, lard, pudding made with whole milk, ice cream, candies with chocolate, cream, sauces, gravies and commercially fried foods.

DIABETIC DIET

Purpose:

➤ maintain blood glucose as near as normal as possible; prevent or delay onset of diabetic complications.

Use:

• diabetes mellitus

Foods Allowed:

• choose foods with low glycemic index compose of: a. 45-55% carbohydrates b. 30-35% fats c. 10-25% protein

➤coffee, tea, broth, spices and flavoring can be used as desired. ➤exchange groups include: milk, vegetable, fruits, starch/bread, meat (divided in lean, medium fat, and high fat), and fat exchanges. ➤the number of exchanges allowed from each group is dependent on the total number of calories allowed. ➤non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics.

Foods Avoided:

• concentrated sweets or regular soft drinks.

ACID AND ALKALINE DIET

Purpose:

➤Furnish a well balance diet in which the total acid ash is greater than the total alkaline ash each day.

Use:

• Retard the formation of renal calculi. The type of diet chosen depends on laboratory analysis of the stone.

Acid and alkaline ash food groups: a. Acid ash: meat, whole grains, eggs, cheese, cranberries, prunes, plums b. Alkaline ash: milk, vegetables, fruits (except cranberries, prunes and plums.) c. Neutral: sugar, fats, beverages (coffee, tea)

Foods allowed:

• Breads: any, preferably whole grain; crackers; rolls
• Cereals: any, preferable whole grains

quantities of meat, fish, and seafood allowed.

BLAND DIET

Purpose: ➤provision of a diet low in fiber, roughage, mechanical irritants, and chemical stimulants.

Use: ➤Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI disorders, gastric atony, diarrhea, spastic constipation, biliary indigestion, and hiatus hernia.

Foods Allowed:

varied to meet individual needs and food tolerances.

Foods Avoided:

fried foods, including eggs, meat, fish, and sea food; cheese with added nuts or spices; commercially prepared luncheon meats; cured meats such as ham; gravies and sauces; raw vegetables; ➤potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheats; rye bread; bran cereals; rich pastries; pies; chocolate; jams with seeds; nuts; seasoned dressings; caffeinated coffee; strong tea; cocoa; alcoholic and carbonated beverages; and pepper.

➤butter, ordinary margarines, olive oil, lard, pudding made with whole milk, ice cream, candies with chocolate, cream, sauces, gravies and commercially fried foods.

DIABETIC DIET

Purpose:

➤ maintain blood glucose as near as normal as possible; prevent or delay onset of diabetic complications.

Use:

diabetes mellitus

Foods Allowed:

choose foods with low glycemic index compose of: a. 45-55% carbohydrates b. 30-35% fats с. 10-25% protein

➤coffee, tea, broth, spices and flavoring can be used as desired. ➤exchange groups include: milk, vegetable, fruits, starch/bread, meat (divided in lean, medium fat, and high fat), and fat exchanges. ➤the number of exchanges allowed from each group is dependent on the total number of calories allowed. ➤non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics.

Foods Avoided:

concentrated sweets or regular soft drinks.

ACID AND ALKALINE DIET

Purpose:

➤Furnish a well balance diet in which the total acid ash is greater than the total alkaline ash each day.

Use:

Retard the formation of renal calculi. The type of diet chosen depends on laboratory analysis of the stone.

Acid and alkaline ash food groups:

a. Acid ash: meat, whole grains, eggs, cheese, cranberries, prunes, plums b. Alkaline ash: milk, vegetables, fruits (except cranberries, prunes and plums.) c. Neutral: sugar, fats, beverages (coffee, tea)

Foods allowed:

Breads: any, preferably whole grain; crackers; rolls Cereals: any, preferable whole grains

Desserts: angel food or sunshine cake; cookies made without baking powder or soda; cornstarch, pudding, cranberry desserts, ice cream, sherbet, plum or prune desserts; rice or tapioca pudding.

➤Fats: any, such as butter, margarine, salad dressings, Crisco, Spry, lard, salad oil, olive oil, ect.

Fruits: cranberry, plums, prunes

Meat, eggs, cheese: any meat, fish or fowl, two serving daily; at least one egg daily

Potato substitutes: corn, hominy, lentils, macaroni, noodles, rice, spaghetti, vermicelli.

Soup: broth as desired; other soups from food allowed

Sweets: cranberry and plum jelly; plain sugar candy

Miscellaneous: cream sauce, gravy, peanut butter, peanuts, popcorn, salt, spices, vinegar, walnuts.

Restricted foods:

no more than the amount allowed each day

1. Milk: 1 pint daily (may be used in other ways than as beverage)
2. Cream: 1/3 cup or less daily
3. Fruits: one serving of fruits daily( in addition to the prunes, plums and cranberries)
4. Vegetable: including potatoes: two servings daily
5. Sweets: Chocolate or candies, syrups.
6. Miscellaneous: other nuts, olives, pickles.

HIGH-FIBER DIET

Purpose:

Soften the stool exercise digestive tract muscles speed passage of food through digestive tract to prevent exposure to cancer-causing agents in food

➤lower blood lipids

➤prevent sharp rise in glucose after eating.

Use: diabetes, hyperlipedemia, constipation, diverticulitis, anticarcinogenics (colon)

Foods Allowed:

recommended intake about 6 g crude fiber daily All bran cereal Watermelon, prunes, dried peaches, apple with skin; parsnip, peas, brussels sprout, sunflower seeds.

LOW RESIDUE DIET

Purpose:

➤Reduce stool bulk and slow transit time

c. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal )

6. RIGHT DOCUMENTATION –Documentation is an important part of safe medication administration a. The documentation for the medication should clearly reflect the client's name, the name of the ordered medication, the time, dose, route and frequency b. Sign medication sheet immediately after administration of the drug

CLIENT'S RIGHT RELATED TO MEDICATION ADMINISTRATION

A client has the following rights: a. To be informed of the medication's name, purpose, action, and potential undesired effects. b. To refuse a medication regardless of the consequences c. To have a qualified nurses or physicians assess medication history, including allergies d. To be properly advised of the experimental nature of medication therapy and to give written consent for its use e. To received labeled medications safely without discomfort in accordance with the six rights of medication administration f. To receive appropriate supportive therapy in relation to medication therapy g. To not receive unnecessary medications

II – Practice Asepsis – wash hand before and after preparing the medication to reduce transfer of microorganisms.

III – Nurse who administer the medications are responsible for their own action. Question any order that you considered incorrect (may be unclear or appropriate)

IV – Be knowledgeable about the medication that you administer

“A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS: “NEVER ADMINISTER AN UNFAMILIAR MEDICATION”

V - Keep the Narcotics in locked place.

VI- Use only medications in clearly labeled containers. Relabeling of drugs are the responsibility of the pharmacist.

VII - Return liquid that are cloudy in color to the pharmacy.

VIII – Before administering medication, identify the client correctly

IX – Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.

X – The nurse who prepares the drug administers it.. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication.

XI – If the client vomits after taking the medication, report this to the nurse in-charge or physician.

XII – Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued.

XIII- When a medication is omitted for any reason, record the fact together with the reason.

XIV – When the medication error is made, report it immediately to the nurse in-charge or physician. To implement necessary measures immediately. This may prevent any adverse effects of the drug.

Medication Administration

1. Oral administration

Advantages a. The easiest and most desirable way to administer medication b. Most convenient c. Safe, does nor break skin barrier d. Usually less expensive

Disadvantages a. Inappropriate if client cannot swallow and if GIT has reduced motility b. Inappropriate for client with nausea and vomiting c. Drug may have unpleasant taste d. Drug may discolor the teeth e. Drug may irritate the gastric mucosa f. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration a. Solid: tablet, capsule, pill, powder b. Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline substances. c. Syrup: sugar-based liquid medication d. Suspension: water-based liquid medication. Shake bottle before use of medication to properly mix it. e. Emulsion: oil-based liquid medication f. Elixir: alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.

"NEVER CRUSH ENTERIC-COATED OR SUSTAINED RELEASE TABLET"

e. Apply only thin layer of medication to prevent systemic absorption.

2. Opthalmic - includes instillation and irrigation

a. Instillation – to provide an eye medication that the client requires. b. Irrigation – To clear the eye of noxious or other foreign materials. c. Position the client either sitting or lying. d. Use sterile technique e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus f. Instill eye drops into lower conjunctival sac. g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the medication. h. Avoid dropping a solution onto the cornea directly, because it causes discomfort. i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication. j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of the medication.

3. Otic

Instillation – to remove cerumen or pus or to remove foreign body a. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain.

b. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up. c. Perform hand hygiene. Apply gloves if drainage is present. d. Straighten the ear canal: - 0-3 years old: pull the pinna downward and backward - Older than 3 years old: pull the pinna upward and backward e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature f. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal.

g. Ask the client to remain in side lying position for about 5 minutes h. At times the MD will order insertion of cotton puff into outermost part of the canal.Do not press cotton into the canal. Remove cotton after 15 minutes.

4. Nasal – Nasal instillations usually are instilled for their astringent effects (to shrink

swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin. a. Have the client blow the nose prior to nasal instillation b. Assume a back lying position, or sit up and lean head back. c. Elevate the nares slightly by pressing the thumb against the client's tip of the nose. While the client inhales, squeeze the bottle. d. Keep head tilted backward for 5 minutes after instillation of nasal drops. e. When the medication is used on a daily basis, alternate nares to prevent irritations

5. Inhalation – use of nebulizer, metered-dose inhaler

a. Simi or high-fowler's position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication b. Shake the canister several times. To mix the medication and ensure uniform dosage delivery c. Position the mouthpiece 1 to 2 inches from the client's open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed d. Instruct the client to hold breath for 10 seconds. To enhance complete absorption of the medication. e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the medication. f. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI g. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

6. Vaginal – drug forms: tablet liquid (douches). Jelly, foam and suppository.

a. Close room or curtain to provide privacy. b. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository to dissolve without escaping through orifice. c. Use applicator or sterile gloves for vaginal administration of medications.

Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche. a. Empty the bladder before the procedure b. Position the client on her back with the hips higher than the shoulder (use bedpan)

c. Irrigating container should be 30 cm (12 inches) above d. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation.

7. RECTAL – can be use when the drug has objectionable taste or odor.

a. Need to be refrigerated so as not to soften. b. Apply disposable gloves. c. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter. d. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily. e. Discard gloves to proper receptacle and perform hand washing. f. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication.

8. PARENTERAL- administration of medication by needle.

Intradermal – under the epidermis. a. The site are the inner lower arm, upper chest and back, and beneath the scapula. b. Indicated for allergy and tuberculin testing and for vaccinations. c. Use the needle gauge 25, 26, 27: needle length 3/8", 5/8" or ½" d. Needle at 10–15 degree angle; bevel up. e. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb. f. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous.

Subcutaneous – vaccines, heparin, preoperative medication, insulin, narcotics. The site:

• outer aspect of the upper arms
• anterior aspect of the thighs
• Abdomen
• Scapular areas of the upper back
• Ventrogluteal
• Dorsogluteal a. Only small doses of medication should be injected via SC route. b. Rotate site of injection to minimize tissue damage. c. Needle length and gauge are the same as for ID injections d. Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle. e. For thin patients: 45 degree angle of needle f. For obese patient: 90 degree angle of needle g. For heparin injection: do not aspirate.

Do not massage the injection site to prevent hematoma formation h. For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client. i. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.

Intramuscular a. Needle length is 1", 1 ½", 2" to reach the muscle layer b. Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area. c. Inject the medication slowly to allow the tissue to accommodate volume.

Sites:

Ventrogluteal site a. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated. b. Position the client in prone or side-lying. c. When in prone position, curl the toes inward. d. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection. e. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site.

Dorsogluteal site a. Position the client similar to the ventrogluteal site b. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet. c. To locate the site, the nursedraw an imaginary line from the greater trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line. d. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough. e. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

Vastus Lateralis

a. Recommended site of injection for infant b. Located at the middle third of the anterior lateral aspect of the thigh. c. Assume back-lying or sitting position.

Rectus femoris site –located at the middle third, anterior aspect of thigh.

Deltoid site a. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery. b. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.

IM injection – Z tract injection a. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin. b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn c. Do not massage the site of injection to prevent leakage into the subcutaneous.

GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF

MEDICATIONS

1. Check doctor's order.
2. Check the expiration for medication – drug potency may increase or decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful.client may have anxiety, which can increase the pain.
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size. To minimize tissue injury.
6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones.
7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
10. Introduce the needle in quick thrust to lessen discomfort.
11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client.
12. Minimized discomfort by applying cold compress over the injection site before introduction of medication to numb nerve endings.

13. Aspirate before the introduction of medication. To check if blood vessel had been hit.

14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn.

15. Massage the site of injection to haste absorption.

16. Apply pressure at the site for few minutes. To prevent bleeding.

17. Evaluate effectiveness of the procedure and make relevant documentation. Intravenous The nurse administers medication intravenously by the following method:

18. As mixture within large volumes of IV fluids.

19. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock)

20. By "piggyback" infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line. a. Most rapid route of absorption of medications. b. Predictable, therapeutic blood levels of medication can be obtained. c. The route can be used for clients with compromised gastrointestinal function or peripheral circulation. d. Large dose of medications can be administered by this route. e. The nurse must closely observe the client for symptoms of adverse reactions. f. The nurse should double-check the six rights of safe medication. g. If the medication has an antidote, it must be available during administration. h. When administering potent medications, the nurse assesses vital signs before, during and after infusion. Nursing Interventions in IV Infusion a. Verify the doctor's order b. Know the type, amount, and indication of IV therapy. c. Practice strict asepsis. d. Inform the client and explain the purpose of IV therapy to alleviate client's anxiety. e. Prime IV tubing to expel air. This will prevent air embolism. f. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection. g. Shave the area of needle insertion if hairy. h. Change the IV tubing every 72 hours. To prevent contamination. i. Change IV needle insertion site every 72 hours to prevent thrombophlebitis. j. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered. k. Observe for potential complications.

Types of IV Fluids

Isotonic solution – has the same concentration as the body fluid

1. D5 W
2. Na Cl 0.9%
3. plainRinger's lactate
4. Plain Normosol

Hypotonic – has lower concentration than the body fluids.

a. NaCl 0.3%

Hypertonic – has higher concentration than the body fluids.

1. D10W
2. D50W
3. D5LR
4. D5NM

Complication of IV Infusion

1. Infiltration

– the needle is out of vein, and fluids accumulate in the subcutaneous tissues.

Assessment:

Pain, swelling, skin is cold at needle site, pallor of the site, flow rate has decreases or stops.

Nursing Intervention:

• Change the site of needle
• Apply warm compress. This will absorb edema fluids and reduce swelling.

2. Circulatory Overload

-Results from administration of excessive volume of IV fluids.

Assessment:

• Headache
• Flushed skin
• Rapid pulse
• Increase BP
• Weight gain
• Syncope and faintness
• Pulmonary edema
• Increase volume pressure
• SOB
• Coughing
• Tachypnea
• shock

Nursing Interventions:

• Slow infusion to KVO

• Place patient in high fowler's position. To enhance breathing
• Administer diuretic, bronchodilator as ordered

3. Drug Overload

– the patient receives an excessive amount of fluid containing drugs.

Assessment:

• Dizziness
• Shock
• Fainting

Nursing Intervention

• Slow infusion to KVO.
• Take vital signs
• Notify physician

4. Superficial Thrombophlebitis

– it is due to overuse of a vein, irritating solution or drugs, clot formation, large bore catheters.

Assessment:

• Pain along the course of vein
• Vein may feel hard and cordlike
• Edema and redness at needle insertion site.
• Arm feels warmer than the other arm

Nursing Intervention:

• Change IV site every 72 hours
• Use large veins for irritating fluids.
• Stabilize venipuncture at area of flexion.
• Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption.
• “Do not irrigate the IV because this could push clot into the systemic circulation'

5. Air Embolism

– Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.

Assessment:

• Chest, shoulder, or backpain
• Hypotension
• Dyspnea
• Cyanosis
• Tachycardia
• Increase venous pressure
• Loss of consciousness

Nursing Intervention

• Do not allow IV bottle to "run dry"
• "Prime" IV tubing before starting infusion.

• Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.

6. Nerve Damage

– may result from tying the arm too tightly to the splint.

Assessment

• Numbness of fingers and hands

Nursing Interventions

• Massage the are and move shoulder through its ROM
• Instruct the patient to open and close hand several times each hour.
• Physical therapy may be required

Note: apply splint with the fingers free to move.

7. Speed Shock

– may result from administration of IV push medication rapidly.

• To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.

BLOOD TRANSFUSION THERAPY

Objectives:

1. To increase circulating blood volume after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia
3. To provide selected cellular components as replacements therapy (e.g clotting factors, platelets, albumin)

Nursing Interventions:

a. Verify doctor's order. Inform the client and explain the purpose of the procedure. b. Check for cross matching and typing. To ensure compatibility c. Obtain and record baseline vital signs d. Practice strict Asepsis e. At least 2 licensed nurse check the label of the blood transfusion

Check the following:

• ✓ Serial number
• ✓ Blood component
• ✓ Blood type
• ✓ Rh factor
• ✓ Expiration date
• ✓ Screening test (VDRL, HBsAg, malarial smear)
• this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.

f. Warm blood at room temperature before transfusion to prevent chills. g. Identify client properly. Two Nurses check the client's identification. h. Use needle gauge 18 to 19. This allows easy flow of blood.

j. Use BT set with special micron mesh filter. To prevent administration of blood clots and particles. k. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes. l. Monitor vital signs. Altered vital signs indicate adverse reaction.

• Do not mixed medications with blood transfusion. To prevent adverse effects
• Do not incorporate medication into the blood transfusion
• Do not use blood transfusion line for IV push of medication. m. Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis. n. Administer BT for 4 hours (whole blood, packed rbc). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.

Complications of Blood Transfusion/ TRANSFUSION REACTION

1. Allergic Reaction

– it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.

Assessments

• ✓ Flushing
• ✓ Rush, hives
• ✓ Pruritus
• ✓ Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic

– it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion

Assessments:

• ✓ Sudden chills and fever
• ✓ Flushing
• ✓ Headache
• ✓ Anxiety

3. Septic Reaction

– it is caused by the transfusion of blood or components contaminated with bacteria.

Assessment:

• ✓ Rapid onset of chills
• ✓ Vomiting
• ✓ Marked Hypotension
• ✓ High fever

4. Circulatory Overload

– it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.

Assessment

2TYPES OF PAIN v Acute Pain – lasts from seconds to 6 months v Chronic Pain – constant or intermittent pain that lasts for 6 months or longer. o Persistent, non-malignant v Cancer-related Pain

CHARACTERISTICS OF PAIN (PQRST) NURSING HEALTH ASSESSMENT

🖼️ [Diagram: PAIN ASSESSMENT "OPQRSTU"]: This image presents a mnemonic "OPQRSTU" for pain assessment in nursing. It details each letter:

• O (Onset): When did it begin? How long? How often? What were you doing?
• P (Provoking or Palliating Factors): What brings it on? What makes it better or worse?
• Q (Quality): What does it feel like? Description (throbbing, stabbing, dull, etc.)
• R (Region & Radiation): Does it radiate? Where does it spread? Point to where it hurts.
• S (Severity): Intensity (pain scale 1-10)? At worst? Other symptoms?
• T (Time & Treatment): When did it begin? Medications taken? Effectiveness? Side effects?
• U (Understanding & Impact): What is causing it? How does it affect ADLs and family? Other concerns?

The diagram also includes information about pain assessment being crucial for nurses, pain being a subjective experience associated with actual or potential tissue damage, and a call to action to see more mnemonics and tips on nurseslabs.com.

ASSESSMENT OF PAIN Descriptive Pain Intensity Scale No Pain to Worst Possible Pain

Numeric Pain Scale 0 to 10

Visual Analogue Scales No pain to Pain as bad as it could be

🖼️ [Diagram: Pain Intensity Scales]: This image displays four different pain intensity scales:

1. Verbal Pain Intensity Scale: Ranges from "No Pain" to "Worst Possible Pain" with intermediate steps like "Mild Pain," "Moderate Pain," "Severe Pain," and "Very Severe Pain."
2. Visual Analogue Scale: A continuous line with "No Pain" at one end and "Worst Possible Pain" at the other, without numerical indicators.
3. 0-10 Numeric Pain Intensity Scale: A scale from 0 to 10 where 0 is "No Pain," 5 is "Moderate Pain," and 10 is "Worst Possible Pain."
4. Wong-Baker FACES® Pain Rating Scale: Consists of six cartoon faces depicting emotions from happy (no pain) to crying (worst pain imaginable), each with a corresponding number (0, 2, 4, 6, 8, 10) and verbal descriptor (No Hurts, Hurts Little Bit, Hurts Little More, Hurts Even More, Hurts Whole Lot, Hurts Worst).

v The sequence of methods for physical examination is as follows: (IPPA)

• Inspection
• Palpation
• Percussion
• Auscultation v The sequence for examination of the abdomen is as follows: (IAPePa)
• Inspection
• Auscultation
• Percussion
• Palpation ASEPSIS AND INFECTION CONTROL v Nosocomial infection
• Associated with the delivery of health care services in a health care facility
• Can be develop during client's stay in the facility or manifest after discharge
• Endogenous — microorganisms that cause infection originates from the client themselves.
• Exogenous — microorganisms that caused infection originates from the hospital environment and/personnel
• Iatrogenic infection - direct result of diagnostic or therapeutic procedures

DISINFECTING AND STERILIZING v Disinfectant

• Chemical preparation (phenol / iodine compounds) used on inanimate objects
• Frequently caustic and toxic to tissue v Antiseptics are chemical preparation used on skin and tissues
• Bactericidal (destroys bacteria)
• Bacteriostatic (prevents growth & reproduction of some bacteria) Types of Disinfection
• Concurrent Disinfection On going practices that are observed in the care of the client, his supplies, his immediate environment to limit/control the spread of microorganisms
• Terminal Disinfection practices to remove pathogens from the client's belongings and his/her immediate environment after his/her illness is no longer communicable COMMONLY USED ANTISEPTICS AND DISINFECTANTS v Isopropyl and Ethyl alcohol
• Kills bacteria, TB, fungi, virus
• Used on hands & vial stoppers v Chlorine (bleach)
• Kills bacteria, TB bacteria, spores, fungi, virus
• Used to clean blood spills v Hydrogen peroxide
• Kills bacteria, TB, spores, fungi, virus; used on surfaces

Kubler-Ross Stages of Grievings

🖼️ [Diagram: Kübler-Ross Grief Cycle]: This flowchart illustrates the five stages of grief. It shows a cycle starting from:

• DENIAL: AVOIDANCE, CONFUSION, ELATION, SHOCK, FEAR
• ANGER: FRUSTRATION, IRRITATION, ANXIETY
• BARGAINING: OVERWHELMED, HELPLESSNESS, HOSTILITY, FLIGHT
• DEPRESSION: STRUGGLING TO FIND MEANING, REACHING OUT TO OTHERS, TELLING ONE'S STORY
• ACCEPTANCE: EXPLORING OPTIONS, NEW PLAN IN PLACE, MOVING ON

Below the cycle, there are key support areas: INFORMATION & COMMUNICATION, EMOTIONAL SUPPORT, and GUIDANCE AND DIRECTION.

Advanced Directives & Living Wills

• Advanced Directive: a set of instructions someone prepares in advance of ill health that determines his healthcare wishes.
• Living Will: one type of advance directive that becomes effective when a person is terminally ill.
• Legal documents
• Prepared for when the patient is not able to communicate their own wishes
• Can specify DNR, Full code, or specific interventions

Medical Power of Attorney

• Legal document
• Designates a specific person to make medical decision for the patient should they be unable to make their own decisions
• If the patient doesn't have a MPOA laws vary state by state on who the decision goes to

Federal Laws to know

• Health Insurance Portability and Accountability Act
  • HIPAA
  • Will discuss further :)
• American Disabilities Act - ADA
  • A civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public.
• Emergency Medical Treatment and Active Labor Act - EMTALA
  • Requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay

TERMINOLOGY

• Tort: A wrongful act or an infringement of a right
• Negligence: Failure to take proper care in doing something.
• Malpractice: Improper, illegal, or negligent professional activity or

treatment,.

• Assault: An act, criminal or tortious, that threatens physical harm to a person, whether or not actual harm is done.
• Battery: Unconsented physical contact with another person, even where the contact is not violent but merely menacing or offensive.
• False Imprisonment: The state of being imprisoned without legal authority.

Health Insurance Portability and Accountability Act

• Protecting patient health information
• Specific rules about sharing this information
• If someone doesn't NEED the information to do their job, DON'T share itwith them.
  • Can share with other health care providers that need it to take care of the patient
  • Can share with their family WITH the patient's permission.

How you can protect your patient's information

• Turn off your computer screen when not using
• Do not speak about patients in a public place
• Shred personal health information
• NEVER post information for patients on social media
• Don't use computers that are not secure for PHI
• Don't send PHI to your personal email
• Don't open the chart of patients you're not taking care of.

🖼️ Diagram: A graphic illustrating the SBAR communication method.

• S (Situation) is at the top in a blue box.
• B (Background) is in the next blue box.
• A (Assessment) is in the third blue box.
• R (Recommendation) is in the bottom blue box.

Situation

• Identify yourself
• Identify the patient
• Briefly communicate what is going on with the patient

"This is Morgan, the nurse taking care of Johnny in room 2 today. I'm calling because his heart increased from the 90's to the 150's about 5 minutes after starting his blood transfusion. I am concerned he is having a transfusion reaction."

Background

• Why is the patient in the hospital?
• Chief complaint
• Diagnosis
• Pertinent lab values

Johnny is a 5 year old with ALL whose Hgb dropped to 6.1 after his last round of chemotherapy. We started a transfusion of 1 unit of PRBCs on Johnny about 5 minutes and his heart rate and blood pressure are both elevated.

Assessment

• What do you think the problem is
• Nursing diagnosis
• Vital signs
• Pertinent clinical assessment findings

"His vital signs are: T - 37.8 С, Р - 157, BP - 130/94, R - 36, SPO2 - 96%. He appears flushed, diaphoretic, and his having trouble catching his breath”

Recommendations

• What do YOU think is going on
• What do YOU want to happen
  • Labs to be ordered?
  • Imaging?
  • MD to bedside?
  • Stop an infusion/medication?
  • New order? Changed order?

"I suspect Johnny is having a transfusion reaction. I have stopped the transfusion and I would like for you to come to the bedside immediately."

Chest Tubes

What is a chest tube?

• Tube inserted into the pleural spaceof the lungs.

• Helps to remove air or fluid that has caused the lung to collapse Also placed after cardiac surgery to help drain blood and fluid from around the heart

Nursing Considerations - Drainage system

• Always keep the drainage system below the level of the patient's chest
• Ensure the tubing is free of kinks and draining freely
• There should be no dependent loops in the tubing
• Monitor the drainage
  • Color - serous - serosanguinous. Know WHY the patient has a CT!
  • Odor - none
  • Consistency - thin-thick
  • Amount - no more than 100ml/hr. More? Call the doc!!
  • Mark hourly

Nursing Considerations - Water Seal Chamber

• Water will fluctuate as the patient breathes
  • Increase during inspiration
  • Decrease during expiration
• Bubbling..... Okay or not okay?
  • Some bubbling - expected. Air is leaving the pleural space.
  • Excessive bubbling - not okay. There is a leak somewhere.
  • No bubbling - investigate further. Lung could be re-expanded - good news. Or, there could be a kink - you need to fix this.

What to do if the chest tube comes out

• Cover the site with a sterile dressing
• Tape on 3 sides
  • Air can
  • Open edge (fl
  • but prevents a

Isolation Precautions

Standard

• Perform hand hygiene
• Use PPE if you expect to be exposed to bodily fluids
• Disinfect patient equipment
• Follow safe injection practices
  • 1 needle, 1 syringe, 1 time

🖼️ [Image]: On the left, an illustration of a medical syringe with text "ONE NEEDLE, ONE SYRINGE, ONLY ONE TIME." On the right, an image of hands being washed with soap lather, illustrating hand hygiene.

Contact

🖼️ [Diagram]: A poster titled "STOP CONTACT PRECAUTIONS EVERYONE MUST:". It lists instructions: "Clean their hands, including before entering and when leaving the room." with an icon of a hand sanitizer. "PROVIDERS AND STAFF MUST ALSO:" with three bullet points below: "Put on gloves before room entry. Discard gloves before room exit." with glove icon. "Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person." with gown icon. "Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person." with stethoscope icon. CDC logo is at the bottom.

• PPE to wear:
  • Gown
  • Gloves
• Patient dedicated equipment
  • Disposable stethoscope
  • BP cuff
  • Thermometer
• Limit transport of patient
• Appropriate patient placement
  • Single patient room
  • Same infections grouped together
• Infections requiring contact precautions:
  • MRSA (Methicillin-resistant Staphylococcus aureus)
  • VRE (Vancomycin-resistant enterococc)
  • Diarrheal illnesses

Droplet

🖼️ [Diagram]: A poster titled "STOP DROPLET PRECAUTIONS EVERYONE MUST:". It lists instructions: "Clean their hands, including before entering and when leaving the room." with an icon of a hand sanitizer. "Make sure their eyes, nose and mouth are fully covered before room entry." with icons of a person wearing a medical mask and a person wearing a medical mask and eye protection, separated by an 'or'. "Remove face protection before room exit." CDC logo is at the bottom.

• PPE to wear:
  • Mask
  • Eye cover
  • Goggles or face shield
• Limit transport of patient
  • When transporting, place mask on patient.
  • Teach patient to cough into elbow
• Appropriate patient placement
  • Single patient room
  • Same infections grouped together
• Infections requiring droplet precautions:
  • Influenza
  • Pertussis
  • Mumps
  • RSV
  • Rhinovirus

Airborne

🖼️ [Diagram]: A poster titled "STOP AIRBORNE PRECAUTIONS EVERYONE MUST:". It lists instructions: "Clean their hands, including before entering and when leaving the room." with an icon of a hand sanitizer. "Put on a fit-tested N-95 or higher level respirator before room entry." with a respirator icon. "Remove respirator after exiting the room and closing the door." with a respirator icon. "Door to room must remain closed." with a door icon. CDC logo is at the bottom.

• PPE to wear:
  • Respirator
    • N95 or PAPR
  • Gown
  • Gloves
• Airborne isolation room
  • Positive pressure when possible
  • Private room
• Appropriate healthcare personnel
  • Restrict susceptible personnel from entering room.
  • Limit number of people needed to enter room.
• Limit transport of patient
  • Put mask on patient if they must leave the room.
• Infections requiring airborne precautions:
  • Tuberculosis
  • Measles
  • Chickenpox
  • Disseminated herpes zoster

🖼️ [Image]: A light red-orange silhouette of a phoenix, with yellow highlights along its wings and head, on a white background.