NURSING PROCESS

it was first used by Lydia Hall in 1985 it is a systematic method that directs the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result it is a G O S H approach (goal-oriented, organize, systematic, and humanistic care) for efficient and effective provision of nursing care. Steps: Assessing It is the systematic and continuous collection, validation, and communication of client data. Activities: Collection of data Validation of data- data confirmation Organization data Data analysis Recording/ documentation of data Types of data: Subjective data (symptoms)- described by person experiencing it (e.g. pain, dizziness, vertigo etc.) Objective data (signs)- can be observed (by the use of senses) and measured (e.g. BP 130/90, abdominal rigidity upon palpation, exopthalmus, pallor, redness etc.) Sources of data Primary Data- data directly gathered from the client Secondary data- data gathered from clients significant others, clients medical records, patients chart, other members of the health team, and related health care literature

 Assessing is primarily focused on the clients response to health problem Methods of Collecting data Interview- a planned communication with the client Observation- the use of five senses and instruments Physical Assessment- assessment for objective data and is focused primarily on the clients functional abilities Diagnosing It is a process which results to Nursing Diagnosis Purpose: to identify health care needs and prepare a Nursing Diagnosis Nursing Diagnosis is a statement of a clients potential or actual health problem resulting from analysis of data Nursing Diagnosis uses PES format: Problem, Etiology, and Signs and Symptoms Activities: Data Clustering Comparing data against standards Data analysis Identify gaps and inconsistencies Determine health problems Formulation of Nursing Diagnosis Types of Nursing Diagnosis Actual Nursing Diagnosis- problem is present Potential Nursing Diagnosis- problem may arise Possible Nursing Diagnosis- problem may be present

Wellness Nursing diagnosis- transition from a specific level of wellness to a higher level of wellness. Prioritizing nursing diagnosis is based on what problem endangers life. Planning Identifying beforehand the specific actions to be done before implementation of nursing interventions Purpose: to determine the goals of care and the course of actions to be undertaken during the implementation phase. Activities: Priority setting Setting goals and objectives: Goals may be short-term or long term; the characteristics of a well-stated behavioral objectives are as follows: o S specific o M measurable o A attainable o R realistic o T time-framed Identify alternative nursing care Select nursing measure Formulation of Nursing Care Plan (NCP) The Nursing Care Plan is made mainly as a guide to individualize care. Implementing Putting the Nursing Care Plan into action Purpose: carrying out NCP and meeting clients health goals Requirements for implementation

 Therapeutic use of self (TUOS) Knowledge Technical skills Communication skills Nurses implement independent (nurseprescribed), interdependent (collaborative), and dependent (physician-prescribed) nursing actions On-going data collection directs revision of plan of care and interventions Evaluating Measuring the clients health achievements based on the goals specified Purpose: to determine the extent of which goals of nursing care have been achieved Activities: Data collection about the clients response Compare to data to outcome criteria Analyze the result Modify the nursing Care Plan as necessary To encourage further goal achievement, it is important for the nurse to evaluate clients goal achievement as early as possible

HEALTH ASSESSMENT Nursing Health History A structured interview designed to collect specific data and to obtained a detailed health record of the patient Components of nursing health history Biographic data- consist of name, address, age, sex, race, marital status, occupation, religion Reason for visit/ chief complaint- it is the answer given to the question, What is troubling you, or What brought you to the hospital or clinic. It is the primary reason by the client why he/she sought consultation or hospitalization. History of Present Illness (HPI)- it includes the, 1. Usual health status, 2. Chronological story, 3. Family history, 4. Disability assessment. Past Health History- includes all previous immunizations and experiences with illness. Family History- reveals the risks factors for certain diseases (e.g. DM, Hypertension, Cancer etc). Review of Systems- review of all health problems by body systems Lifestyle- it provides basis for planning health promotion, maintenance and restoration. It includes personal habits,

diets, sleep or rest patterns, activities of daily living, and recreations or hobbies. Social Data- include family relationships, ethnic affiliations, educational background, economic status, and home and neighborhood conditions Psychological data- reveals much information about the clients emotional state Patterns of health care- includes all health care resources

Physical Examination It provides objective information about the person which is essential in nursing process. Conducted cephalocaudally Prepare all the necessary articles to conserve time, energy and effort Provide privacy to the client when performing physical exam Determine the level of consciousness of the client before performing the procedure Directional Terms: Superior- upper part (cephalad) Inferior- lower part (caudad) Anterior- front (ventral) Posterior- back (dorsal) Medial- near midline Lateral- far from midline Intermediate- between two structures Ipsilateral- on same side Contralateral- on opposite side Proximal- nearer attachment Distal- farther assessment Superficial- on surface

Deep- away from the surface Parietal- outer wall of cavity Visceral- covering of organs Methods of examination Inspection- assessing by using the sense of sight Palpation- assessing by the use of touch Percussion- tapping body parts to produce sounds Auscultation- listening to body sounds by the use of a stethoscope When assessing the abdomen, the following sequence is used: Inspection Palpation Percussion Auscultation No to abdominal palpation in patients with abdominal aortic aneurysm and wilhms tumor Sequence of examining the abdomen: 1. Start from the Right lower quadrant (RLQ) 2. Then going up to Right upper quadrant (RUQ) 3. Left upper quadrant (LUQ) is the next area to be examined 4. And the last quadrant to be examined is the left lower quadrant (LLQ) In examining the abdomen, let the patient assume dorsal recumbent position to relax the abdominal muscles for better palpation. During chest examination, let the client assume a sitting position In examining the back of the patient, he/she is advised to assume standing position- that is, to enable the client to assess for posture and gait

 If a female client is to be examined by a male doctor, a female nurse must be present General Survey This is used to assess the general appearance and behavior of an individual It includes: Age, sex, race Body built, height, weight, lifestyle and health Posture and gait Hygiene and grooming Body and breath odor Signs of distress Obvious signs Attitude, effect, speech and thought processes Level of consciouness

Vital Signs The persons body temperature, pulse, respiration, and blood pressure Body Temperature The balance between heat produce by the body and heat loss from the body Types of body temperature Core temperature- deep tissue temperature of the body Surface temperature- temperature of the skin, subcutaneous tissue, and fats The normal core body temperature is between 36.7C (98.7F)- 37C (98.6F). The thermoregulation center of the body is the hypothalamus Types of fever: Constant- temperature is constantly high Intermittent- the temperature fluctuates between periods of fever and periods of normal temperature Relapsing- increase in temperature alternated with 1 or 2 days normal temperature Remittent fever- the temperature fluctuates with in a wide range over 24 hours period but remains above normal temperature. Routes of Temperature Taking

Oral o Most accessible and most convenient o Temperature is taken in 2-3 minutes time o 15 minutes before taking the oral temperature, dont allow the client to take hot or cold foods and fluids Rectal o Most accurate measurement o Thermometer is inserted 0.5-1.5 inches o Temperature is taken in 2 two minutes time. Axillary o The most non-invasive and the most safest o Temperature is taken in 5-9 minutes time If the body temperature declines suddenly, it is termed as crisis and this indicates hypothalamic disturbances; while if there is a gradual decline of fever, we term that as lysis that indicates normal functioning of the hypothalamus Antipyretic is the drug of choice for patients with fever Pulse It is the wave of blood created by the contraction of the left ventricle Pulse rate is regulated by the autonomic nervous system (ANS) The normal pulse rate of an adult ranges from 60-100 beats per minute Pulse amplitute describes the quality of the pulse in terms of its fullness

Number 0 1 2 3 4

Definition absent thready weak

Description

no pulsation not easily felt stronger than thready normal easily felt bounding stronger pulsation Pulse deficit is the difference between the apical pulse and radial puls Pulse rate vary in different age levels: 1 year old- 80-180 beats per min (BPM) 2 years old- 80-140 BPM 6 years old- 75-120 BPM 10 years old 50-90 BPM Adult - 60-100 When palpating for the pulse, use two to three finger tips. Dont use the thumb Pulse sites and reasons for use: Temporal- used when radical pulse is not accessible Carotid- used for infants, in cases of cardiac arrest, to determine the circulation of the brain Apical- routinely used for infants and children up to three years old; to determine discrepancies with radial pulse; used in conjunction with some medications. Brachial- used to measure blood pressure; during cardiac arrests of infants Radial- readily accessible and routinely used Femoral- used in cases of cardiac arrest, infants children, determine the circulation of the legs

Popliteal- to determine circulation of the lower leg and the site for the measurement of BP in the lower extremities Posterior Tibial- to assess for the circulation of the foot Pedal- to assess for the circulation of the foot

Respiration It is the act of breathing: breathing in (Inhalation), breathing out (Exhalation) Types of Respiration: External Respiration- exchanges of gasses (oxygen and Carbon Dioxide) that happens in the alveoli of the lungs Internal Respiration- exchange of gasses that happens in the cell Types of breathing: Costal (thoracic) breathing-involves the movement of the chest Diaphragmatic (abdominal)- involves the movement of the abdomen The medulla oblongata is the primary respiratory center of the body There are three(3) processes involved in respiration Ventilation- the movement of gasses in and out of the lungs Diffusion- exchange of gasses from an area of greater pressure to an area of lower pressure. It occurs at the alveolocapillary membrane.

Perfusion- movement of blood for transport of gasses, nutrients, and metabolic wastes products Normal adult breathes 16-20 times per minute Blood Pressure It is the pressure exerted by the blood in the arteries Normal adults BP is 120/80 Systolic Pressure is the pressure resulting from the contraction of the ventricles Diastolic pressure is the pressure when the ventricles are at rest. (Normal: 60-90 mm Hg) Pulse pressure is the difference between the systolic and diastolic pressure (Normal: 30-40) Hypertension abnormally high blood pressure over 140/90 mm Hg for at least two consecutive readings Hypotension- abnormally low blood pressure, systolic pressure below 100mm Hg Postural/ orthostatic hypotension is a sudden drop in blood pressure caused by a sudden changed in position If the BP cuff is too small for a patient, the BP reading may result to false high measurement; if the BP cuff is too big for a patient, the BP reading may result I false low measurement Women usually have lower BP than men The series of sounds that the nurse listens during BP reading is called Korotkoff sounds In assessing the BP, use the bell-shaped diaphragm of the stetoscope since BP is a low frequency sound Always read the lower meniscus of the mercury of the BP apparatus at eye level to prevent error

Diagnostic Procedures
A Abdominal assessment PURPOSE: To determine the presence of mass, abnormal bowel sounds, lesions and other abnormalities in the abnormal region. NURSING KEYPOINTS: Position: Dorsal Recumbent Sequence of Assessment: Inspection, Auscultation, percussion, and Palpation; start palpating from RLQ to RUQ to LUQ, to LLQ Palpation is done last because it can possibly alter the bowel rhythms and may therefore give rise to abnormal sounds No to palpation to patients with wilhms tumor and abdominal aortic aneurysm

Arterial blood gas analysis

PURPOSE: To monitor the patients response to oxygen therapy and detects the presence of acidbase balance. NURSING KEYPOINTS: No to Suctioning prior to obtaining blood specimen Assess for bleeding and hematoma at the puncture site Apply firm pressure at the puncture site for 5-10 minutes Specimen should be placed in iced-container Assess for metabolic alkalosis for patient with vomiting, and on the other hand, observe for signs and symptoms of metabolic acidosis for patients with diarrhea. B Barium enema PURPOSE: To assess the large intestines NURSING KEYPOINTS: Provide a Liquid diet before the procedure. Ensure that a laxative is given before the procedure to promote better visualization, and after the procedure to prevent constipation Report to the doctor if bowel movement does not occur in 2 days Instruct the patient to increase fluids and eat foods rich in fiber The patient should also increase intake of fluids Barium swallow PURPOSE: To assess for the esophagus, stomach, and some portion of the small intestines. NURSING ALERT:

 NPO for 6-8 hours before the procedure Laxative is administered after the procedure to counteract the constipating effects of the barium Withhold anticholinergics and narcotics for 24 hours before the test Instruct patient to increase fluids and intake of fiber-rich foods Cardiac catheterization PURPOSES: To measure oxygen concentration, saturation, tension and pressure in various chambers of the heart. To determine a need for cardiac surgery. NURSING KEYPOINTS: Check for informed consent Assess allergy to iodine NPO for 6-8 hours before the procedure Check for distal pulses after the procedure Check for bleeding at the arterial puncture site and apply pressure Keep a 20 lbs sandbag at the bedside as a pressure instrument if bleeding occurs Keep the patient flat on bed with the lower extremities hyperextended for 4-6 hours Neurovascular assessment must be performed distal to the catheter insertion site and report any abnormal findings Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter. NURSING ALERT: Know the necessary facts:

Principles Position Length of tube French number or Circumference Length of tube to be inserted Balloon size

Male Supine 40 cm./ 15.75 in. #14- 16 2-3 in. 5-10 ml. (30 ml Can be used to achieve hemostasis of the prostatic area following prostatectomy lower abdomen

Female Dorsal recumbent 22cm./ 8.66 in. #18 6-9 in. 5-10 ml

Place to secure

Inner thigh

The procedure is sterile Maintain a close system The draining bag must always be below the bladder The catheter bag should not be allowed to lie on the floor Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it Chest X-RAY PURPOSE: To detect abnormalities of the organs in the thoracic area NURSING KEYPOINTS: Remove any metallic object before the procedure Lead shield for women of childbearing age

CT Scan

PURPOSE: Provides photograph of tissue densities with the use of radiation. NURSING ALERT: If contrast medium will be used, assess for any allergy to iodine and instruct the patient to be on NPO for 4 hours prior to the procedure Assess for any fear of close spaces (claustrophobia) This procedure is contraindicated to patients who are pregnant and obese (>300 lbs) Let the patient lye still during the whole course of the procedure CVP (Central Venous Pressure) monitoring PURPOSE: It measures the pressure of the Right Atrium NURSING KEYPOINTS: The nurse should place the zero level of the manometer at the level of the Right atrium at the 4th intercostals space to get an accurate reading Instruct the client to avoid coughing and straining as it alters the readings Normal CVP reading is 2-12 mm Hg ( when the tube is at the superior vena cava) Cystoscopy PURPOSE: To assess the bladder and urethra NURSING KEYPOINTS: Check for the informed consent. If general anesthesia will be used have the client on NPO; liquid diet if local anesthesia will be used. Monitor intake and output. After: Force fluids as prescribed.

 Administer sitz bath for abdominal pain. Pink-tinged or tea-colored urine is expected. Notify the doctor if bright red urine or clots occur. D Doppler ultrasound PURPOSE: Evaluates patency of veins and arteries in the lower extremities. NURSING KEYPOINT: Inform the patient that it is painless. E ECG (Electrocardiogram) PURPOSE: Records electrical waves of the heart. NURSING KEYPOINTS: Instruct the patient to lie still, breathe normally during the procedure Let the patient refrain from talking during the test. ST segment elevation or T wave inversion, indicates MI EEG (Electroencephalogram) PURPOSES: Records the electrical activity of the brain, detects intracranial hemorrhage and tumors NURSING KEYPOINTS: Advise the client to shampoo hair before anj after the procedure

 If the electrode gel is non removed by shampooing, the patient may use acetone Withhold stimulants,m antidepressants, tranquilizers, and anticonvulsants for 24-48 hours prior to the test F Fasting Blood Sugar level PURPOSE: Detects diabetes mellitus NURSING KEYPOINTS: Normal blood sugar level is 80-120 mg/dl A blood sugar level of more than 140 mg./dl confirms diabetes. G Gastric analysis PURPOSES: This test is used to detect ulcers, and to rule-out pernicious anemia. It may also be done to analyze acidity, appearance and volume of gastric secretions NURSING KEYPOINTS: In gastric ulcer, HCL is normal, In duodenal ulcer, HCL is elevated. Refrigerate gastric samples if NOT tested within 4 hours.

IVP (Intravenous pyelography) PURPOSE: Visualization of the urinary tract NURSING KEYPOINTS: Check for the consent. NPO for 8-10 hours before the procedure Administer laxative to clear bowels before the procedure. Check for allergy to iodine, seafoods or shellfish before the procedure since the procedure requires the use of iodine based dye. Keep epinephrine at the bedside to counteract possible allergic reaction. IVP requires the use of a contrast medium while KUB does not. Inform the patient about the possible salty taste that may be experienced during the test. Increase fluid intake after the procedure to facilitate excretion of the dye. K KUB PURPOSE: Determines the size, shape and position of kidneys, ureters and bladder. NURSING KEYPOINT: No special preparation needed. L Liver biopsy PURPOSE: To determine liver disorders. NURSING KEYPOINTS: Check for the consent.

 Obtain the result of blood tests before biopsy since bleeding may occur Let the patient assume left side or supine during biopsy Instruct the patient to inhale, exhale and hold breath during the insertion of to stabilize position of the liver and prevent accidental puncture of the diaphragm Position the patient on the Right side after liver biopsy with pillows underneath to prevent bleeding Bedrest for 24 hours after the procedure

Lumbar Puncture PURPOSE: To withdraw CSF to determine abnormalities. NURSING KEYPOINTS: Before the procedure: empty bladder and bowel. Position: C-position. (fetal posistion) During the procedure: needle is inserted between L3 -L4 or L4-L5 to prevent accidental puncture to the spinal cord since the spinal cord ends at L2. After: Position the patient flat for 6-12 hours to prevent spinal headache. Increase fluid intake.

Mammography PURPOSE: Detects the presence of breast tumor. NURSING KEYPOINTS: Instruct the patient not to use deodorant, talcum powder, lotion, perfume or any ointment on the day of exam as these may give false-positive result Let the patient know that her breasts will be compressed between 2 x-ray plates Provide teachings related to Self-breast examination Done 7 days after menstruation Position: lying down with pillow under the shoulder of the breast being examined or sitting in front of a mirror while raising the hands of the side of the breast being examined. Mantoux test PURPOSE: A test to determine exposure to TB NURSING KEYPOINTS: A positive test yields an induration of 10 mm. or more for foreign born children below 4 years old An induration of 5 mm or more is considered positive in patients with HIV, with treated TB, and if he has had a direct exposure TB Patients. BCG may cause false positive reaction. Assess for previous history of PTB and report immediately to the doctor Result is read after 48-72 hours MRI (Magnetic Resonance Imaging)

PURPOSE: Provides cross-sectional images of brain tissues, more detailed than a CT scan. NURSING KEYPOINTS: Contraindications: pregnant women, obesity (more than 300 lbs.), claustrophobic patients, patients with unstable vital signs patients with metal implants like pacemaker, hip replacements and jewelries. P Paracentesis PURPOSES: To assess the contents of the peritoneal fluid NURSING KEYPOINTS: Check for consent. Instruct the patient to void prior to the procedure to prevent accidental puncture of the bladder During the procedure, instruct the patient to sit up with feet resting on footstool. Patient is weighed before and after the procedure. Evaluate the effect of the procedure by assessing: Weight Abdominal girth Respiratory rate Pulse Rate Notify the physician if the urine becomes bloody, pink or red. Rinnes test

PURPOSE: Used to differentiate between conductive and sensorineural hearing losses. NURSING KEYPOINTS: The vibrating tuning fork is shifted between two positions: against the mastoid bone (bone conduction) and two inches from the opening of the ear canal (air conduction). In conductive hearing loss, bone conduction lasts longer than air conduction. S Schillings test PURPOSE: Used to detect Vitamin B12 absorption. NURSING KEYPOINTS: Excretion of 8%-40% of ingested radioactive vitamin B12 within 24 hours is normal; excreting more than 40% indicates pernicious anemia. Requires 24-hour urine specimen. Keep the patient NPO except for water, 8-12 hours before the test. Sputum exam PURPOSE: Determines the presence of microorganisms in the sputum. NURSING KEYPOINTS: Instruct patient to rinse mouth with water ( no to mouth wash or tooth paste) Specimen is collected upon rising Amount required: 15 ml Instruct the patient to take several deep breaths and then cough deeply.

Stool analysis PURPOSE: Assessment of bacteria, virus, malabsorption and blood. NURSING KEYPOINT: Avoid aspirin, red meat and vitamin C three days before the test as these may give a false positive result. Swan-ganz catheterization PURPOSE: Used to monitor pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP) NURSING KEYPOINTS: The catheter has four lumens (one for CVP, one for fluid infusion and venous access for blood samples, one for monitoring PAP and PCWP and the last lumen is used for inflation and deflation of the balloon. If a fifth lumen exists, it is used for measuring oxygen saturation of the blood. The normal adult PAP systotic and diastolic pressure is 20 to 30 mm Hg. The normal PCWP is 8-13 mm Hg. The only time the balloon should be inflated after it is in place is when obtaining further PCWP readings. Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: Hyperoxygenate the patient before and after the procedure.

 Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during the procedure. After the procedure: Position the patient on the unaffected side/puncture site up. Check for bleeding at the puncture site and monitor the respiratory function. Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur. Tonometry PURPOSE: Measures intraocular pressure. NURSING KEYPOPINTS: Normal reading is 12-21 mm. Hg. A reading of 25 mm./Hg. indicates glaucoma. U Urinalysis

PURPOSE: To assess characteristics of urine. NURSING KEYPOINTS: First voided morning sample preferred: 15 ml. Use clean container Decreased specific gravity: diabetes insipidus Increased specific gravity: diabetes mellitus, dehydration, SIADH (+) Protein: PIH, nephrotic syndrome. (+) Glucose: Diabetes mellitus, Infection Urine collection, 24 hour PURPOSE: Determines the excretion of substances from the kidneys, adrenal glands and the stomach. NURSING KEYPOINT: Required for ACTH test and schillings test. Discard the first voided urine W Weber test PURPOSE: Used to detect the presence of unilateral hearing loss. NURSING KEYPOINTS: The tuning fork is set into vibration and placed on the patients forehead or teeth. Placement on the teeth is generally more reliable, even when the patient has false teeth. X X-ray

PURPOSE: Provides radiological data for assessment of certain organs and bones. NURSING KEYPOINTS: Assess the patients exposure level to radiation Let the patient removed all jewelries and other metallic objects before the procudure

COMMON INTERVENTIONS
Anti-embolism Stocking Helps prevents thrombophlebitis by promoting venous return from the legs It usually requires a doctors order The clients extremeties must be properly measured to assure therapeutic effect Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburgs position for 15-20 minutes The stockings must be removed every 8 hours for 20-30 minutes Asses the skin integrity\

Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery. This procedure is done before meal or 90 minutes after a meal Enemas They act by distending the intestines that increases peristalsis and expulsion of feces and flatus. Enemas serve the following purpose: Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and childrendorsal recumbent Administration- administer the enema in a minimum of 15 minutes duration. Conatainers Height- 12 inches above the rectum Temperature- 42C or less Types of Enemas

Cleansing enemas- used to cleanse the bowel Carminative Enema- use to remove flatus Oil retention Enema- lubricates the sigmoid colon and softens the feces If cramping occurs, clamp the tube for 30 seconds then proceed. Do perineal care afterwards. Gastroenteral Feedings This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall. Remember these principles: Position: fowlers or sitting position Prior to feeding, assess the bowel sounds and residual content Assess for tube placement and patency: o Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated. o Aspirate gastric content o Immerse the tip of the tube in water, no bubbles must be produced. Height of feeding: 12 inches above the patients point of insertion Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube Nasogastric Tube Insertion Purposes: Gastric Gavage- gastric feeding Gastric Lavage- stomach irrigation For decompression Medication and supplemental fluid administration Principles:

Position: High-Fowlers position Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm. Lubricate the tip of the tube by a water soluble lubricant before insertion Secure the NGT by taping to the bridge of the nose

Heat and Cold Therapy An intervention the reduces inflammation Principles: Cold application is generally safer than heat application. Heat application usually requires a doctors order Cold application is done within 72 hours after an injury, while heat application is done after 72 hours. The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes) Check the area applications are done every 15 minutes. Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: NO smoking: Oxygen is in used

 Instruct the client not to use woolen blankets as this may create static electricity

SPECIMEN COLLECTION
a. Urine 1. Clean-catch urine specimen For routine urinalysis and culture and sensitivity test Perineal care before collection The best time to collect the specimen is early in the morning (first voided-specimen) Amount needed: 30-50 cc for urinalysis; 5-10 ml for culture and sensitivity test 2. 24 Hours urine Specimen discard the first voided urine Soak specimen in a container of ice

 Add preservative as ordered and indicate in the label the type of preservative added. 3. Second voided Urine Specimen Ask the patient to urinate and discard the first urine specimen and offer a glass of water afterwards After few minutes, ask the client to void again and collect the specimen 4. Catheterize Urine Specimen Clamp the catheter for 45 mins Practice aseptic technique Do not collect specimen from the urine bag Obtain 3-5 ml of specimen for culture and sensitivity test and 10-15 ml for urinalysis b. Stool Specimen 1. Routine Fecalysis Use to assess gross appearance, and presence of ova or parasite in the stool Sterile specimen container must be secured Instruct the client to defecate in the bedpan and obtain 1tbsp or 1 inch long stool specimen using a sterile tongue depressor Label the specimen and bring immediately to the laboratory 2. Stool Culture and Sensitivity Test This is done to assess for specific microorganisms and etiologic agents causing gastroenteritis, and bacterial sensitivity to various antibiotics Sterile technique must be employed Label the specimen properly and send immediately to the laboratory 3. Guiac Stool Exam (Occult Blood) It detects bleeding at the GI tract and cancer of the stomach

 Meatless diet for 3 days prior to the procedure No to red or dark colored foods tom prevent false positive result No to iron: discontinue temporarily for 3 days prior to the procedure c. Sputum specimen 1. Gross Appearance Collect early morning specimen Sterile container must be used Mouth care before: gargle only with water (no to mouthwash, or toothpaste) Instruct the client to deep breath and hack-up sputum from the lungs. 2. Sputum Cultrure and Sensitivity test Used to assess the etiologic agent causing Respiratory tract infection and bacterial sensitivity to various antibiotics 3. Acid Fast Bacillus (AFB) staining To determine active PTB Sputum specimen is collected in 3 consecutive mornings 4. Papanicolao or Cytologic Examination of the sputum To assess for cancer cells d. Blood Specimen 1. Blood Tests that does not require fasting: Complete Blood Count Hemoglobin Hematocrit Level test Clotting studies Enzyme studies Serum electrolyte studies 2. Requires Fasting Fasting Blood Sugar

 Blood Urea Nitrogen Serum Creatinine Serum lipids (cholesterol level, glyceride level) e. Body Secretions 1. Culture and sensitivity test To assess causative agent causing infection, and bacterial sensitivity to various antibiotics Practice aseptic technique

MAINTAINING PATIENTS SAFETY Factors the increases threats to Patients Safety Inability to meet basic human needs Developmental age Infants are prone to choking and aspiration Toddlers are high risk for falls and poisoning Preschoolers usually are at risk to motor accidents and drowning

School Children accidents Lifestyle

are

also

prone

vehicular

Protecting the Dependent Client The bed should always be in a low position unless, raised bed is needed for a procedure As much as possible, ride rails must always be raised-up Restraints are used to protect the client, and must be appropriately used Anything that can irritate the client must be removed in bed (e.g. nails, clips, utensils etc). Prevention of fall Call light must be easily reach by the client Instruct the client to rise slowly to prevent dizziness The room and bathroom must be free with clutter and liquid spills Grab bars must be located in the bathroom Nonskid strips should be applied in the bathtubs and shower area When transferring the client, the wheels of the wheelchairs, stretchers and the bed must be in a brake mode. The patient must easily reach canes, walkers and crutches. Use of Restraints Doctors order is required Apply only the minimum restrictions that will accomplish the purpose of restraint Restraints should not be used as punishment to the patient

 Padding should be use between the patients and restraint to prevent tissue damage.

DIET AND NUTRITION

Special Diets: Acid-ash diet Retards the formation of alkalinic renal stones Indicated to patients with renal calculi (Alkaline stones) E.g. cheese, cranberries, eggs, meat, plums, prunes, whole grains Alkaline ash diet Retards the formation of acid renal stones.

 Indicated to patients with renal stones (Acidic stones) E.g. fruits (except cranberries, plums, prunes), milk, vegetables Bland diet Low fiber, mechanical irritants, chemical stimulants Indicated for patients with gastritis, diarrhea, biliary indigestion, and hiatal hernia BRAT Diet Banana, Rice, Apple. Toast Indicated for patients with diarrhea Butterball diet Spare protein but high in carbohydrates Indicated for patients with liver disorders Clear liquid Diet To relieve thirst and help maintain fluid balance Indicated for post-operative patients and following vomiting and gastroenteritis Diabetic Diet Well balance diet The purpose is to maintain near to normal blood glucose level Indicated to patients with diabetes mellitus Full liquid diet It serves to provide nutrition to patients who cannot chew or tolerate solid foods Indicated to patients with stomach upsets, post-surgical patients, after progression from clear liquid diet Giordano Diet Spare protein Indicated to patients who suffers from Chronic renal Failure Gluten free Diet No to B R O W Barley. Rye. Oat, Wheat This is the diet of a patient who suffers from celiacs Disease

Halal Diet No pork diet Diet of the Moslems High Fiber Diet Fruits and vegetable It speeds up the passage of food to the digestive tract, it softens the stool, Indicated to patients who are constipated, with diverticolosis, with hyperlipedemia High Protein Diet Lean-meat, cheese, eggs, Indicated to patients with nephrotic syndrome Kosher Diet Meat ad milk cannot be served simultaneously Diet of the Orthodox Jews Low carbohydrate diet Indicated to patients with dumping syndrome Low fat/cholesterol Diet It serve the purpose of reducing hyperlipedemia, and to patients with intolerance to fats Indicated to patients with cardiovascular diseases, patients who underwent resection of the small intestines, hypertension cholecystitis and cholelithiasis Low Residue diet Reduces the bulk of stools Indicated to patients with ulcerative colitis, diverticulitis, patients who will undergo surgery of the GI tract Low Sodium Diet Indicated to patients with cardiovascular and renal disorders Purine restricted diet To reduce uric acid Indicated to patients with gouty arthritis, renal calculi, and hyperuricemia Sodium-restricted diet

 Indicated to patients with heart failure, hypertension, renal diseases, PIH, and steroid therapy Soft diet Used to provide nutrition for those patients who have problems in chewing For patients with ill-fitting dentures; transition from fullliquid to general diet, patients with gastrointestinal disturbances such as gastric ulcers and cholelithiasis Tyramine-free Diet Use to prevent hypertensive crisis for patients who are taking-in MAOI antidepressant. No to ABCs- Avocado, Banana, Canned and Processed Foods, and also, no to fermented foods Vegan Diet Diet of the Seventh Day Adventists Vegetarian diet Yin Diet Cold deserts after a surgery. It is a Chinese belief. Vitamins Water Soluble Vitamins Vit. C. (Ascorbic Acid) prolonged deficiency- scurvy Vit. B Complex Vit. B1 (Thiamine) Prolonged deficiency- Beri-beri Vit. B2 (Riboflavin) Prolonged deficiency- Skin Lessions Vit. B3 (Niacin) Prolonged deficiciency- Pellagra Vit. B6( Prridoxine) Peripheral Neuritis Vit. B9 (Folic Acid/ Follacin) Prolonged deficiency- Megaloblastic Anemia Vit. B12 (Cobalamine/ Cyanocobalamine) Prolonged deficiency- Pernicious Anemia

Panthotenic Acid Deficiency- fatigue, sleeplessness, nausea, poor coordination Biotin Deficiency- fatigue, depression Fat-Soluble Vitamins Vit. A. (Retinol) Deficiency- Night Blindness and Opacity of the Lens Vit, D( Ergocalciferol) Deficiency to Children: Rickets Deficiency to Adult: Osteomalacia Vit. E(Tocoferol) Defieciency- Anemia Vit. K( Menadione) Deficiency- Bleeding

ASEPSIS AND CONTROL OF INFECTION The Chain of Infectious Process

Infectious Agents

Reservoirs

Portal of Exit

Susceptible host

Mode of transmission

Portal of Entry

Infectious agents- pathogens (bacteria, fungi, virus, protozoa) Reservoirs- sources or places for growth of the pathogens Portal of Exit and Entry- provides the way for the pathogen to leave one host and enter another host Modes of transmission- vehicles of transmission of the pathogens Susceptible Host- a carrier capable of supporting and transmitting microorganism Body Defenses Against Infection Normal Flora Intact Skin Saliva and Mucus Membrane Cilia of the Upper Respiratory Tract Infection Inflammatory process Immune Response

Medical and Surgical Asepsis

Medical Asepsis/ Clean Technique Principles: Pathogens move through spaces or air current Pathogens are transferred from one surface to another whenever objects touch. Hand washing removes microorganism Pathogens are released into the air on droplet nuclei when person speaks, breaths, and sneeze. Pathogens are transferred by virtue of gravity Pathogens move slowly on dry surface but very quickly through moisture. Surgical Asepsis/ Sterile Technique Areas of the body considered sterile are: o Blood stream o Spinal Fluid o Peritoneal Cavity o Urinary Tract o Muscles o Bones o Chamber of the Eyes Sterile object remains sterile when touched by another sterile object Sterile objects or fields, which falls out of the range of vision or below ones waist, are considered contaminated. Sterile items become contaminated when they come in contact with microorganism transported through the air. When sterile object/ field come in contact with another surface, it becomes contaminated. Fluids flows in the direction of gravity. The edges of the sterile field are considered unsterile. Isolation Practices

 Strict Isolation- prevents transmission of highly communicable disease by contact and airborne transmission Respiratory isolation- prevents transmission by droplet Enteric precaution- prevents transmission through ingestion Wound and skin precaution- prevents cross-infection by direct contact with wounds and contaminated articles Discharge precaution- prevent cross-infection by secretions-contaminated articles Blood precaution- prevent transmission by contact with blood or items contaminated with blood

Body Mechanics It is the efficient, coordinated, and safe use of the body to produce motion and maintain balance during activity. Principles of Body Mechanics 1. When the line of gravity passes through the base support, balance is maintained and stability can be maintained with the least amount of effort. 2. A wider base support increases stability of the body. 3. When then center of gravity is close to the base of support, a person and an object is more stable. 4. Enlarging the base of support in the direction of force to be applied maintains stability with minimal effort. 5. Tightening the abdominal muscles upward and contracting the gluteal muscle downward requires less energy to move something and the less likelihood of musculoskeletal injury. 6. Synchronize use of muscle groups decreases muscle fatigue. 7. Objects can be moved easily on a flat surface rather than on an inclined surface against gravity. 8. It is easier to lift when the larger leg muscles are used, rather than using the smaller back muscles. 9. The lesser friction when moving objects facilitates motion. 10. It is better to pull than to push because pulling creates lesser friction, hence movement. 11. In lifting and moving objects, the bodys weight must be used to assist. 12. Alternate rest periods with periods of muscle exertion may be used to prevent muscle fatigue. 13. Greater force is required to move a heavy object.

COMFORT AND PAIN Pain The noxious stimilation of threatened or actual tissue damage (Geach, 1987) Whatever the experiencing person says it is, existing whenever he or she says it does (McCaferry, 1979) It is highly subjective and individual and that is one of the bodys defense mechanism indicating that there is a problem. It is protective as it gives warning or signal for tissue injury Classifications of Pain Superficial Pain- in the surface of the skin Radiating Pain- pain that extends in the surrounding tissues Somatic Pain- pain that occurs in the muscles, joints, and bones Visceral pain- pain that occurs internally (abdominal cavity and thoracic cavity) Referred pain- pain that is felt on the other part of the body other than the source of injury Intractable pain- pain that is resistant to intervention Psychogenic Pain- emotional pains Intermittent pain- pain that stops and recurs again and again. Phantom pain- pain is felt in the absence of a part of the body causing the pain. Assessment of Pain Precipitating Factors- What triggers the pain or makes it worse? Quality of Pain- Tell me what the pain feels like Alleviating Factors- What measures relieve your pain Meaning of pain- How do you interpret the pain? Pattern

 Location Pain- Where is your pain Periodicity- How long have you felt the pain sensation? REST AND SLEEP Rest is the diminished state of activity Sleep is a state of decreased perception and reaction to the environment There are theories of sleep: Active theory- there are parts of the brain that inhibit other brain parts Passive theory- the reticular activating system of the brain fatigues and becomes depressed, thus sleeps occurs Stages of Sleep: Non-Rapid Eye Movement (NREM)- for body restoration o Very Light Sleep- drowsy, and readily awakened o Light Sleep- Heart and respiratory rate decreases and the body temperature gradually falls. o PNS domination- Difficult to arouse o Deep Sleep- Decrease metabolism and very difficult to arouse Rapid Eye movement (REM)- increase synthetic processes of the brain o Paradoxical Sleep o Dream state of the sleep o Close to wakefulness but difficult to arouse Common Sleep Disorders Insomia- sleeplessness Hypersomia- Excessive sleep at day time Narcolepsy- Sleep attack Parasomias o Somnambolism- sleep walking o Soliloqy- Sleep talking o Bruxism- clenching and grinding of teeth

o Night Terrors- bad dreams o Nocturnal Erections- wet dreams o Nocturnal Enuresis- bed wetting GRIEF AND LOSS Loss is a universal experience that occurs throughout life span Grief is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement Responses to loss are strongly influenced by ones cultural background The grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss. Responses to loss and patterns of coping with loss are developed early in life. Stages of Grieving (Kubler-Ross) Denial- refuses to believe that the loss has occurred Anger- the individual resists the loss and may act out feelings. Bargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss. Depression- overwhelming feeling of loneliness and withdrawal from others Acceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, and the interaction to other people resumed.