Professional Documents
Culture Documents
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6 6
> the act of utilizing the environment of the patient to assist him in
his
recovery.
-- Florence Nightingale
Ô Nursing is Caring.
Ô Nursing is an Art.
Ô Nursing is Science.
Ô Nursing is Client-Centered.
Ô Nursing is Holistic.
Ô Nursing is Adaptive.
Ô Nursing is concerned with health Promotion,
Health Maintenance and Health Restoration.
Ô Nursing is a Helping Profession.
6
- calling that requires special knowledge, skill and
preparation.
Primary Characterisitics:
1. Education
2. Theory
3. Service
4. Autonomy
5. Code of Ethics
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1. Intuitive Nursing
ºprimitive times to 6th century)
f. The last two decades of the 19th century is also called the
³awakening of nursing´
g. In the early decades of the 00th century, hospitals started to
segregate patients according to their disease process thus the
concept of clinical nurse specialist arose
a. Began at the end of World War II; associated with scientific and
technological developments and social changes since 19^
c. Professionalization of Nursing
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- wife of Jose Rizal. Installed a field hospital in an estate
house of Tejeros. Provided nursing care to the wounded
night and day.
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- converted their house into quarters for the Filipino soldier
during the Philippine-American war that broke out in 1899.
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-wife of Amelio Aguinaldo; organized the Filipino Red
Cross under the inspiration of Apolinario Mabini.
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- second wife of Emilio Aguinaldo. Provided nursing care
for the Filipino soldiers during the Revolution. President of
the Filipino Red Cross branch in Batangas.
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- nurse the wounded Filipino soldiers and gave them
shelter and food.
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- ³Ina ng Biac na Bato´, stayed in the hospital at Biac na
Bato to care for the wounded soldiers.
6
+
$ -.
(Iloilo City, 1906)
It was run by the Baptist Foreign Mission Society of
America.
Miss Rose Nicolet ± first superintendent
Miss Flora Ernst ± an American nurse, took charge of
the school in 1942
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$ -.
(Manila, 1907)
The hospital was established by the Archbishop of
Manila, Õ e Most Reverend Jeremia Harty, under the
supervision of the Sisters of St. Paul de Chartres.
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$ -.
(Manila, 1907)
In 1907, with the support of the Gov. Gen. Forbes and
the Director of Health and among others, opened classes
in nursing under the auspices of the Bureau of Education.
ënastacia Giron-Õupas, was the first Filipino to occupy
the position of Chief Nurse and Superintendent in the
Philippines.
^ %/
$ -.
(Quezon City, 1907)
The Hospital is an Episcopalian Institution. It began as a
small dispensary in 1903. In 1907, the school opened with
3 Filipino girls admitted.
Mrs. Vitiliana Beltran was the first Filipino Director of
the school.
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$ -.
(Manila, 1907)
It started as a small dispensary on Calle Cervantes.
It was called Bethany Dispensary and was founded by
the Methodist Mission.
Miss Librada Javelera was the first Filipino Director of
the school.
Õ 2 -. "
1948
Consuelo Gimeno ± First Principal
Ô 3( 1- " 4-.
1948
Ms. Julita Sotejo ± First Dean
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- process by which a person learns the ways of a group or society
in order to become a functioning participant
Stage ^: Proficient
- perceives a situation as a whole rather than just its
individual aspects; nurse focuses on long-term goals and
is oriented toward managing the nursing care of the client
rather than performing specific tasks
Stage : Expert
- no longer relies on rule, guidelines or maxims to
connect an understanding of the situation to an
appropriate action; have highly developed perceptual
acuity or recognitional ability, and their performance is
fluid, flexible and highly proficient
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- primarily concerned with the clients needs.
*** Recognize the patient¶s most immediate needs.
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- communicates with the client, support persons and
colleagues.
***Establish trust.
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- provides health teaching to effect behavior change
which focuses on acquiring new knowledge or
technical skills.
*** Assess client¶s learning needs/ Assess client¶s
readiness to learn.
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- process of helping a client to recognize and cope
with stressful psychological or social problems, to
develop improved interpersonal relationships and to
promote personal growth.
*** Render active listening/ Do not give advice.
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- advocates for client rights.
- initiates changes and assists the client makes
modifications in the lifestyle to promote health.
- helps the client to speak up for themselves.
*** Patient must develop self awareness.
- mutual process of interpersonal influence through
which the nurse helps a client make decisions in
establishing and achieving goals to improve client¶s
well-being.
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- plans, gives direction, develops staff, monitors
operations, gives reward fairly and represents both
staff members and administration as needed.
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- participates in scientific investigation and uses
research findings in practice.
6
- initiates nursing actions within the health team.
§ §§§ §
§
1. Nurse Practitioner
0. Clinical Nurse Specialist
3. Nurse Anesthetist
^. Nurse Midwife
. Nurse Researcher
6. Nurse Administrator
7. Nurse Educator
8. Nurse Enterpreneur
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1. Health and Wellness Promotion
- helping people develop resources to maintain or
enhance their well-being.
0. Illness Prevention
- maintain optimal health by preventing disease.
3. Health Restoration
- helping people to improve health following health
problems or illness.
^. Care of the Dying
- comforting and caring for people of all ages while they
are dying.
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- recipient of the nursing care.
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- the degree of wellness and well being that a person
experiences.
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- pertains to the internal and external surroundings
that affects a person.
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- pertains to attributes, characteristics and actions of
the nurse providing care in behalf of the client or in
conjunction with the client.
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WHOLLY COMPENSATORY
- nurse acts for the patient; patient has no active
role.
PARTIALLY COMPENSATORY
- both nurse and patient perform care measures.
SUPPORTIVE -EDUCATIVE
- patient is able to perform.
- patient only needs health teaching.
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RECONSTITUTION
- process by which a person progresses from his normal
line of defense to a higher or lower state of wellness.
WELLNESS
- occurs after adaptation to stressors.
D. NURSING
NURSING INTERVENTION MODALITIES OF PREVENTION:
1. Primary Prevention
- promotion of client wellness and protection of normal line
of defense by strengthening flexible line of defense
through the reduction of risk factors and stress
prevention.
0. Secondary Prevention
- protection of basic structure by strengthening internal line
of resistance.
3. Tertiary prevention
- promotion of existing reconstitution by supporting existing
strengths and resource.
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focuses on how the client adapts to illness; the goal of
nursing is to reduce stress so that the client can move
more easily through recovery.
Viewed the patient¶s behavior as a system, which is a
whole with interacting parts.
7 Subsystems of Behavior:
1. Ingestive
- taking in nourishment in socially and culturally
acceptable ways.
2. Eliminative
- ridding the body of waste in socially and culturally
acceptable ways.
3. Affiliative
- security seeking behavior.
4. Aggressive
- self-protective behavior.
5. Dependence
- nurturance-seeking behavior.
6. Achievement
- master of oneself and one¶s environment according
to internalized standards of excellence.
7. Sexual and Role Identity behavior
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> defined nursing as a therapeutic, interpersonal process which
strives to develop a nurse-patient relationship in which the
nurse serves as a resource person, counselor and surrogate.
Transcultural Nursing
m is culturally competent nursing care focused on
differences and similarities among cultures, with respect
to caring, health and illness, based on the client¶s cultural
values, beliefs, and practices.
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1. Formation of a humanistic-altruistic value system.
2. Faith-hope.
3. Cultivation of sensitivity to self and others.
4. Establishing a helping-trust relationship.
5. Expression of feelings, both positive and negative.
6. Research and systematic problem-solving.
7. Promotion of interpersonal teaching-learning.
8. Provisions for a supportive, protective and corrective
mental, physical, socio-cultural and spiritual environment
9. Assistance with the gratification of human needs.
10. Allowance for existential-phenomenological factors.
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- directed towards increasing the level of well-being and
self-actualization of a given individual or group.
ex. maintaining 6 to 8 hours of daily sleep
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- activities directed towards decreasing the probability of
experiencing illness by active protection of the body
against pathological stressors.
ex. BCG vaccination
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- is something that is essential to the survival of humans.
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1. Absence may lead to illness
2. Presence may signal health or prevent illness
3. If unmet needs are met or fulfilled, health may be
restored
FIRSÕ LEVEL: " 1$.
a. Oxygen e. Elimination
b. Fluids f. Shelter
c. Nutrition g. Rest
d. Temperature H. Sex
SECOND LEVEL: - 1$ 1.
1. Physical Safety:
- involves reducing or eliminating threats to the body
such as illness, accident and environmental exposure.
2. Psychological Safety:
- understanding and the appropriateness of what to
expect from others, from new experiences and from
encounters with the environment.
ÕHIRD LEVEL: ( Ô .
- need to establish social relationships and to
experience emotional nurturance and care to and from
others.
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± alteration in the body functioning which results in
the reduction of capacities and shortening of life span.
± a personal state in which the person feels
unhealthy.
In other words:
Misease is an illness with objective facts while Illness is a
subjective perception of not being well.
Stages of Illness:
"#1"(
- applied on healthy individual.
!ocus: health promotion, disease prevention
& $1"(
- applied on patient¶s with signs and symptoms.
!ocus: screening, diagnosing, case-finding, early
detection, prompt treatment
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- applied on patients with chronic and debilitative
disease.
!ocus: rehabilitation
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- use of spoken or written words.
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- use of gestures, facial expressions, posture/gait,
body movements, physical appearance and body
language.
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1. Simplicity
- the use of commonly understood words.
0. Clarity
- saying what is actually meant.
- speak slowly and enunciate words.
3. Õiming and Relevance
- appropriate time.
- consider client¶s concerns and interests.
4. ëdaptability
- ability to adjust.
- consider circumstances and behavior
5. Credibility
- pertains to worthiness of words and reliability
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- a formal and legal document that provides evidence
of the client¶s care.
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1. Communication
2. Planning client care
3. Audit and quality assurance
4. Research
5. Education
6. Reimbursement
7. Legal documentation
8. Statistics
Responsible for the disposal of medical records in
government hospital:
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Where to get the chart of a pt who has been discharged:
- Medical Records Section
Ôasic omponents:
A. Admission Sheet
B. Physician¶s Order
C. Medical History
D. Nurse¶s Notes
E. Special Records and Reports
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rINDS:
I. hange of Shift Reports
- exchange of information from the nurse of the
previous shift to the next shift.
A. Oral
B. Audiotape recording
C. Nursing Rounds
II. Telephone Orders & Reports
- reports and orders via telephone.
Important:
1. It must be countersigned by the physician within 24 hrs.
2. If it was not signed within 24 hours, notify the Head
Nurse.
3. Ideally, 2 nurses must receive the telephone order.
III. Incidence Reports
- record of accidents or unusual events that occurs in
the agency.
Purpose: To prevent future harm/accidents.
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1. Client¶s name and ID number
2. Date, time and place of the incidence
3. Facts of the incidence
4. Client¶s account of the incident
5. Witnesses of the incident
6. Equipments and medications involved
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1. It must be filed within 24 hours.
2. It should be submitted to the Risk Manager.
3. It should not be included in the patient¶s chart.
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DOCUMENTATION
- is anything written or printed that is relied on as record or
proof for authorized person.
Nursing documentation must be:
Ë Accurate.
Ë Comprehensive.
Ë Flexible enough to retrieve critical data, maintain continuity of
care,
track client outcomes, and reflects current standards of
nursing
practice.
Ë As members of the health care team, nurses need to
communicate
information about clients accurately and in timely manner.
Ë Effective documentation ensures continuity of care, saves
time and
minimizes the risk of error.
Ë Data recorded, reported, or communicated to other health
care
Different Sheets:
R ± Readily accessible.
E ± Ensure continuity of care.
S ± Series of flips cards kept at a portable index file at the nurse¶s
station.
T ± Tool for communication.
0 Parts:
1. Activity and Treatment Section
0. Nursing Care Plan
. Discharge Summary
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The use of exact measurements establish accuracy .
Documentation of concise data is clear and easy to
understand.
It is essential to avoid the use of unnecessary words
and irrelevant details.
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The information within a recorded entry or a report
needs to be complete, containing appropriate and
essential information.
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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.
9
The nurse communicates information in a logical order.
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â Draw single line through error, write word error above it
and sign your name or initials. Then record note correctly.
â Do not write retaliatory or critical comments about the
client care by other health care professionals.
Ë Enter only objective descriptions of client¶s behavior;
client¶s comments should be quoted.
â Correct all errors promptly.
"
- To establish a data base.
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- completed upon admission.
- Ex. Nursing History, Assessment Worksheet
0. Problem-Focused/Ongoing ëssessment
- on-going assessment performed during nursing
care.
- Hourly Assessment of Intake and Output
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- rapid assessment of the patient¶s ABC during any
physiologic and psychologic crisis.
- Cardiac Arrest, Suicidal Ideation
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- assessment performed in two periods of time.
- Operation Timbang, Assessment for Hypertension
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- gathering data using the 5 senses.
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- a planned and purposive conversation between the
nurse and the client.
ë. Mirective interview:
- ³highly structured´
- elicits specific information.
Ô. Nondirective interview:
- ³less structured´
- allows the client to verbalize his thoughts and
feelings.
3 Õypes o! Interview Questions:
1. Closed-ended
2. Open-ended
3. Leading questions
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- systematic data collection method using the
techniques of IPPA.
- objective data are collected.
0 Õypes o! Data:
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- data that are apparent only to the person affected.
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- data that can be seen, heard, felt, smelled, or even
tasted.
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± clustering
± analysis
. ± nursing diagnosis formulation
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- judgment about a client¶s response to a health problem
at the time of assessment and signified by the presence
of associated signs of symptoms.
Examples:
Fluid volume deficit
Ineffective airway clearance
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- a clinical judgment that a client is more vulnerable to
develop the problem than others in the same situation.
Examples:
Risk for injury
Risk for infection
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- evidence about a certain health problem is unclear or
the causative factors are unknown; needs collection of
more data either to support or refute it; not a real type or
nursing diagnosis.
Examples:
Possible social isolation
Possible ineffective coping
^ @.M0.9
- is a clinical judgment about an individual, family, or
community in transition from a specific level of wellness to
a higher level of wellness.
Example:
Readiness for enhanced spiritual well-being
9+"9..Õ92.3'.0M0.9
1. Problem
- client¶s response to his/her illness.
- ex. Elimination, Breathing pattern, airway clearance
Quali!iers ± words added to give meaning to the
diagnostic statement.
- ex. Decreased, Ineffective, Impaired
0. Etiology
- related factor/probable cause.
3. Signs and symptoms
- defining characteristics.
- evidences or manifestations.
Guidelines !or Writing Nursing Diagnosis«
1. Word the statement so that is legally advisable.
Example:
Impaired skin integrity related to improper positioning«
2. Make sure that both elements of the statement do not say
the same thing.
Example:
Impaired skin integrity related to skin ulceration.
3. Make sure to use universally accepted abbreviations.
Example:
Ineffective airway clearance related to accu. of secre¶ns«
4. Use nursing terminology rather than medical term to
describe the client¶s response.
Example:
Ineffective airway clearance related to pneumonia.
5. Use non-judgmental statements.
Example:
Ineffective sexuality pattern related to sexual role
confusion.
6. Word the diagnosis specifically and precisely to provide
direction for planning nursing intervention.
Example:
Impaired oral mucous membrane related to noxious
agent.
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â Establishing priorities.
â Writing goals/outcomes and developing an evaluate
strategy.
â Selecting nursing strategies/interventions.
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- the process of establishing the preferential
sequence or rank of interventions in accordance to the
client¶s most immediate needs.
.05:$ 9 $#
- declaration of purposal intention which directs
interventions.
Types of Goals:
1. Short Term
- can be achieved in a short period of time.
2. Long Term
- requires longer period of time to be accomplished.
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1. Reassessing
2. Set priorities
3. Perform nursing intervention
4. Record actions
Composed o! 3 D¶s:
1. Doing
2. Delegating
3. Documenting
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* Cognitive Skills ± ³ intellectual skills´
* Technical Skills ± ³psychomotor skills´
* Interpersonal Skills ± ³communication skills´
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1. Reassessing the client.
2. Prepare the client physically and psychologically.
3. Prepare the equipment and supplies.
4. Implement the interventions.
5. Communicate the nursing actions.
M
- the transfer of responsibility or task to a subordinate with
commensurate authority while retaining accountability for
the outcome.
5 Rights to Delegation
1. Right Task
2. Right Circumstance
3. Right Person
4. Right Direction/Communication
5. Right Supervision
$ ( $ 6
1. Initial and ongoing assessment.
2. Planning, nursing diagnosis formulation and evaluation.
3. Education and supervision of the nursing personnel.
4. Special activities ± like Sterile procedures.
5. Speech and signing of names.
urpose:
To appraise the extent to which goals and
outcome criteria of nursing care have been
achieved.
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1. Ongoing
2. Intermittent
3. Terminal
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1. Goal met
2. Goal partially met
3. Goal not met
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1. Cognitive
2. Psychomotor
3. Affective
4. Physiologic
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- physical settings, condition through which care is
given.
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- pertains to any changes in the client¶s health status
as a result of the nursing intervention.
OXYGENATION
Am1
- provides information regarding the anatomical
location and appearance of the lungs.
Ô-Am1
Assess presence of pregnancy.
Remove jewelries and metals on the client¶s chest.
Instruct the client to inhale and hold breath.
- Am1
Assist the client to dress up.
PULSE OXIMETER:
- device that measures O0 saturation level before signs and
symptoms of hypoxemia develops.
> level: 9 -100%
> hypoxemia: Ļ O0 in the blood
> brain: most sensitive organ in hypoxia/hypoxemia
(1st sign: restlessness
0 Types of Pulse Oximeter:
1. Adhesive
0. Clip
> after thoracentesis, the doctor will order CXR to rule out
PNEUMOTHORAX
(deadliest complication
CHEST PHYSIOTHERAPY
- dependent nursing action of using positioning,
vibrating, and percussing to remove tenacious
respiratory secretions.
1. Dependent nursing action
- needs doctor¶s order to know if the client can
tolerate the procedure.
0. Correct sequence of CPT
Positioning
Percussion
Vibrating
--- POPE VI
3. Gravitational force: force that drains the secretion
^. Positioning
> Orthopneic: to drain secretions from APEX POSTERIOR
SEGMENT
> Trendelenburg, leaning/lying on abd: to drain secretions
from lower lobe posterior segment
. Position is around 10 mins.
6. Max. time of CPT: 30 mins.
7. Best time in performing postural drainage: early in the
morning upon waking up before meals
*risk for aspiration (same in general anesthesia
Percussing:
-- striking of the skin using a cupped hand like
scooping H0O to dislodge client¶s tenacious
secretions.
* If the
upper lobe of the lungs is affected:
side lying with head Ĺ to 30
SUCTIONING:
-- removal of secretion using a catheter connected
to a suctioning machine.
**suctioning is done as needed (PRN because it is
hassle & can cause hypoxemia & stimulation of the
vagus nerve
> positioning:
conscious: semi-fowler¶s
unconscious: side-lying
>lubrication:
nose: sterile, water-based
mouth: PNSS
Measurement for Suctioning:
> oropharyngeal:
- mouth to earlobe
> orotracheal:
- mouth to midsternum
> nasopharyngeal:
- nose to earlobe
> nasotracheal:
- nose to earlobe to neck
* duration:
- 10-1 seconds
* if repeated, interval is:
- 00 to 30 seconds
patient suction
.G*" /
> Drainage Bottle
> Water-seal Bottle
> Suction Control bottle
7. Specific gravity
> 1.01-1.00 or 1.030
> Ĺ specific gravity: greater than 1.030
Ĺ in particles/solute: dark in color dehydrated
> Ļ specific gravity: less than 1.01
fluid with light: overdehydration, diabetes insipidus
Collecting Urine Specimen for C/S:
1. Clean catch: midstream clean catch
> cleaning the urinary meatus
a. Female: use povidone iodine
> wipe front to back
b. Male: use povidone iodine
> circular motion; inner to outer;
hold the penis firmly
0. Collect: 30cc
3. Contaminated after 30 mins.
^. Sterile technique
Urinary Catheter
1. self-sealing rubber catheter:
type of catheter wherein collection can be done
0. wipe the collection part with alcohol
3. 30-^ : angle of needle insertion
^. 30cc of urine for urinalysis: 3cc of urine for C/S
. if there¶s no urine: clamp below the insertion point; 30
mins.
put the syringe above the clamp part
CATHETERIZATION
> contraindicated with pelvic fx, perineal herniation,
urethral stricture
> French 16-18:
00-0^: gross hematuria
1. Coude catheter:
> 0^ hour Foley catheter
> contraindicated: 1^ French Foley catheter
> #1 complication: UTI
> #1 cause: Nosocomial infection
> #1 causative agent: E.coli
Position:
Female: dorsal recumbent
> knees are flexed & avoid extending knees
Male: supine
Lubricant: sterile water-based
> Female: until urine begins to flow; insert 1-0 inches
further/3-^ inches
> Male: 6-8 inches
During insertion & withdrawal:
> act as if voiding
> exhale
Male: hold the penis 90 against the body
Position in taping:
Female: inner thigh
Male: inner thigh
> abdomen (prevent pressure at scrotum & erection
COMPUTATION
TEMPERATURE COMPUTATION:
1. C ĺ F
= C x 18 + 30
F ĺ C
= F ± 30 / 1.8
DRUGS
IV = mL/hr hours = mL
gtts/min
Drugs: > D x Q
S * ³U ^0´ = ^0 units/mL
> D = SxQ
> S = D/Q
Drop Factor:
IV= vol(mL x drop factor > Adult: 1
hrs > Pedia: 60
c. 300,000 X = 1, 00,000
3,000,000 units 300,000
d. X = 1 0
30
e. X = mL
Administration of Medication:
Medication
- a substance administered for diagnosis, cure, treatment,
relief or prevention of disease.
- also called drug.
Effects of the Drug.
1. Therapeutic effect ± primary effect/positive effect.
0. Side effect ± secondary effect/negative effect/unintended effect.
3. Drug tolerance ± usually low physiologic response to a drug which
requires additional dosage to achieve the desired
effect.
^. Drug abuse ± inapropriate use of the drug either continually or
habitually.
. Drug dependence ± client¶s reliance on the drug.
Principles in Administering Medications
1. Observe the 10 ³rights´ of drug administration.
1. Right Medication
0. Right Dosage
3. Right Client
^. Right Time
. Right Route
6. Right Documentation
7.
8.
9.
10.
0. Practice asepsis; wash hands before and after preparing
medications.
3. Be knowledgeable and accountable about the medications that
you administer.
^. Before administering the medication, identify the client correctly.
. Do not leave the medication at bedside.
6. The nurse who prepares the drug administers it.
7. If the client vomits, report this to the nurse in-charge or
physicians.
8. When a medication error is made, assess the client and report it
immediately to the nurse in charge or physician.
Routes of Drug
ORAL
Advantages:
1. Most accessible
0. Safe
3. Cost effective
Disadvantages:
1. Inappropriate for client with nausea and vomiting.
0. Inappropriate for client¶s with difficulty of swallowing.
3. Inappropriate for patient¶s with decrease gastric motility.
^. May have unpleasant taste or discolor the teeth.
. May cause aspiration.
Different Forms of Oral Medications:
1. Solid ± tablet, capsule, pills, caplet, powdered
0. Liquid
> Syrup ± sugar-based > Emulsion ± oil-based
> Suspension ± water-based > Elixir ± alcohol-based
* Allow 30 minutes to elapse before giving a glass of water.
3. Sublingual
^. Buccal
. Rectal
6. Vaginal
7. Topical
8. Transdermal
Parenteral Routes
1. Intradermal
Advantage: slow absorption rate, used for drug testing.
Disadvantage: requires sterile technique, causes anxiety, can
only
administer small amount of drug.
Sites: inner forearm, anterior chest, underneath of the scapula
Angle of needle: 10-1 angle, almost parallel to the skin
Gauge: 0 , 06, 07
Length: 3/8, /8, ½ inch
Maximum cc: 0.1cc to 0.0cc
0. Subcutaneous
Advantage: faster than oral routes.
Disadvantage: expensive, requires sterile technique, slower than
IM
and IV, can cause anxiety, some drugs can cause pain
and
irritation, breaks the client skin integrity.
Sites: upper arm, outer thigh, abdomen, ventrogluteal, dorsogluteal
Angle of needle: ^ angle; obese and insulin administration - 90
angle
Gauge: 0 , 06, 07
Length: 3/8, /8, ½ inch
Maximum cc: 1-3 ml
3. Intramuscular
Advantage: faster absorption, can reduce pain and irritation from
irritating drugs.
Disadvantage: requires sterile technique, can cause anxiety, it
breaks the client¶s skin integrity
Sites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris,
deltoid
Angle of needle: 90 angle
Z-track«
> retract the skin laterally away from the site
> pierce the skin quickly and smoothly at 90
> aspirate ( -10cc
> inject the drug slowly and steadily (10 sec/ml
> wait for 10 secs and allow the medication to disperse
> do not massage
3. Intravenous
Advantage: rapid effect
Disadvantage: limited for highly soluble solutions only, poor
circulation can interfere absorption
** Intravascular
Gauge: 0^, 03, 00, 01, 00
Length: 1, 1 ½, 0 inches
Maximum cc: IV push ± 10 ml
IV infusion ± ^L per day
BLOOD
TRANSFUSION
> Unit of blood = depends on agency
- ^ 0 cc, 00 cc, 0 0 cc, 0^0 cc
> PNSS:
- only fluid compatible during BT
> gauge: 19, 18, 17, 16
> Ļ bacteria; administered within 30 mins.
> max. time: ^ hours
> RN to check: 0 RN
> if blood is too cold:
- cover the blood with a dry cloth
> best way to check client¶s identity before transfusion
- through ID Band/bracelet
> mix the bag of blood by tilting the blood from side to side
> Adverse reaction: during the first 00 mins
(1 mins at 00 gtts/min
> S/Sx of adverse rxn:
- itchiness, hives, Ĺ temp., chills, fever, & pain.
1st adverse rxn: dizziness/headache
IV: STOP, RUN PNSS, NOTIFY THE DOCTOR
- bring blood to the laboratory
- get a urine specimen
$$ $%&