NURSING LICENSURE EXAM REVIEWER

ATIENZA, MARICHAR A., RN, MAN, Ph.D TOP THE BOARD EXAM
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TABLE OF CONTENTS I. III. FUNDAMENTALS OF NURSING II. NURSING RESEARCH LEADERSHIP AND MANAGEMENT V. IMCI VI. COMMUNICABLE DISEASES VII. MATERNAL AND CHILD NURSING VIII. PEDIATRIC NURSING IX. MEDICAL SURGICAL NURSING X. EMERGENCY NURSING XI. PSYCHIATRIC NURSING XII. PATHOGNOMONIC SIGN
XIII.

IV. COMMUNTIY HEALTH NURSING

ANTIDOTES
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FUNDAMENTALS OF NURSING
Evolution of Nursing
1. PERIOD OF INTUITIVE NURSING - since prehistoric times through early Christian era - Nursing was untaught & instinctive, performed out of compassion for others Beliefs and Practices of Prehistoric Man - Nursing was a function that belonged to women taking care of the children, the sick and the aged. - Believed that illness causes the invasion of evil spirit through the use of black magic or voodoo. - Believed that medicine man was called shaman or witch doctor having the power to heal using white magic. - They also practiced trephining or drilling a hole in the skull with a rock or stone without anesthesia as a last resort to drive evil spirits from the body. 2. PERIOD OF APPRENTICE NURSING - extends from founding or religious nursing orders and ended in 1836 when KAISERWERTH INSTITUTE for the training of DEACONESSES in Germany was established - Called Period of On-the-Job training 3. DARK PERIOD OF NURSING - extends from period of reformation until US Civil War (17th to 19th century) - Unity of Christian faith destroyed by Martin Luther - No provisions for the sick - Nursing became work of least desirable women 4. PERIOD OF EDUCATED NURSING - begin when Florence Nightingale School of nursing opened - Strongly influenced by the war, social consciousness, emancipation of women & increased educational opportunities offered to women 5. PERIOD OF CONTEMPORARY NURSING - covers after WorldWarII to present - Scientific & technological developments & social changes mark this period Early Beliefs and Practices a. Beliefs about causation of disease (evil spirits, enemy or a with) b. People believed that evil spirits could be driven away by persons with powers to expel demons c. People believed in special gods of healing, with the priest-physician and Herbolarios

d.Superstitious beliefs and practices in relation to health and sickness such as Herbmen or Herbicheros as one who practiced witchcraft e. Persons suffering from diseases without identified cause were believed to be bewitched by mangkukulam. Spanish Period a. The religious orders exerted their efforts to care for the sick by building hospitals in the different parts of the Philippines b. Earliest hospitals established: Hospital real de Manila (1577) built to care for the Spanish kings soldiers San Lazaro Hospital (1578) built exclusively for patients with leprosy Hospital de Indio (1586) established by Franciscan Order; service was in general supported by alms and contributions from charitable individuals. Hospital de Aguas Santas (1590) founded by Brother J. Bautisita of the Franciscan Order. San Juan de Dios Hospital (1596) Founded by the Brotherhood of Misericordia and administered by the Hospitalliers of San Juan de Dios; support was derived from alms and rents; rendered general health service to the public. Nursing Leaders in the Philippines 1. Anastacia Giron-Tupas First Filipino nurse to hold the position of Chief Nurse Superintendent; founder of Philippine Nurses Association 2. Cesaria Tan First Filipino to receive a Masters degree in Nursing abroad 3. Socorro Sirilan pioneered in hospital social service 4. Rosa Militar a pioneer in school health education 5. Sor Ricarda Mendoza pioneer in nursing education 6. Conchita Ruiz first full-time editor of the newly named PNA magazine The Filipino Nurse 7. Loreto Tupaz Dean of the Philippine Nursing; Florence Nightingale of Iloilo

Concept of Health and Illness

WHO (World Health Organization) Health is a state of complete physical, mental & social well-being, and not merely the absence of disease/infirmity CLAUDE BERNARD Health is the ability to maintain the internal milieu. Illness is the result of failure to maintain the internal environment. WALTER CANNON Health is the ability to maintain homeostasis or dynamic equilibrium. NIGHTINGALE Health is being well & using ones power to the fullest extent. Health is maintained through prevention of disease via environmental health factors. HENDERSON

Health is maintained through the individuals ability to perform 14 components of nursing care unaided. ROGERS Positive health symbolizes wellness. ROY Health is a state & process of being & becoming an integrated & whole person. OREM Health is a state characterized by soundness or wholeness of developed human structures & of bodily & mental functioning KING Health is a dynamic state in the life cycle, illness is an interference in the life cycle. NEUMAN Wellness is the condition in which all parts & subparts of an individual are in harmony with the whole system JOHNSON Health is reflected by the organization, interaction, interdependence & integration of the subsystems of the behavioral system.

- Nursing assists individuals & groups to attain, maintain & restore health MADELEINE LEININGER - Transcultural Nursing Model - Nursing is humanistic & scientific mode of helping client thru specific cultural caring processes to improve or maintain health condition MYRA LEVIN - Four Conservation Principles - Conservation of energy, structural integrity, personal integrity and social integrity BETTY NEUMAN - Health Care System Model - Nursing is a unique because it is concerned with all variables affecting response to stresses which are intra, inter and extrapersonal in nature DOROTHEA OREM - Self Care & Self-Care Deficit Theory - Conceptualized 3 Nursing Systems: - Wholly Compensatory, Partially Compensatory & Supportive-Educative HILDEGARD PEPLAU - Interpersonal Model - Nursing as interpersonal process of therapeutic interactions between an individual who is sick and a nurse who is especially educated to recognize & respond to the need - 4 Phases on Nurse-Client Relationship: Orientation, Identification, Exploitation, Resolution MARTHA ROGERS - Science of Unitary Human Beings - Man is an energy field in constant interaction with the environment - Humans are more than & different from the sum of their parts SISTER CALLISTA ROY - Adaptation Model - Each person is a unified biopsychosocial system in constant interaction wit a changing environment - Man has needs with 4 Modes: physiological, self-concept, role function, interdependence - Believed that adaptive human behavior is directed at an attempt to maintain homeostasis LYDIA HALL - Introduced model on Nursing:What Is It?

NURSING THEORIES
FLORENCE NIGHTINGALE - developed First Theory of Nursing - Focused on changing & manipulating environment to put patient in best possible condition - Environment includes noise, nutrition, light, hygiene, comfort socialization and hope VIRGINIA HENDERSON - Nature of Nursing Model - Identified 14 basic needs - Nurses assists sick and well clients FAYE ABDELLAH - Patient-Centered Approach to Nursing - Identified 21 nursing problems - Nursing is service to individuals, families and therefore to society DOROTHY E. JOHNSON - Behavioral System Model - Each person has 7 subsystems: ingestive, eliminative, affiliative, aggressive, dependence, achievement, sexual & role identity behavior IMOGENE KING - Goal Attainment Theory

- Focused on 3 Components: CARE(nurturance,exclusive to nursing, CORE(therapeutic use of self, uses reflection) & CURE (nursing related to physicians orders) IDA JEAN ORLANDO - Dynamic Nurse-Patient Relationship Model - Nurse helps patients meet a perceived need that patients cannot meet for themselves - Emphasized need of validating need & evaluating care based on outcomes - 3 Elements of Nursing Situation: client behavior, nurse reaction and nurse action ERNESTINE WEIDENBACH - Clinical Nursing A Helping Art Model - Components of Clinical Practice are: Philosophy, purpose, practice and art - Nurses meet individual needs thru identification of need, administration of help and validation of action JEAN WATSON - Human Caring Model - Nursing is an art & science thru transpersonal transactions to help persons achieve mind-body-soul harmony which will generate self-knowledge, self-control, self-care, self-healing ROSEMARIE RIZZO PARSE - Theory of Human Becoming - Emphasized free choice in value priorities - Believes that each choice opens certain opportunities while closing others - Referred as: revealing-concealing, enabling-limiting & connecting-separating - Each has own choice, therefore nurse acts as guide NOT decision-maker MODELS OF HEALTH & ILLNESS 1. Health Illness Continuum 2. Health Belief Model (HBM) 3. Smiths Models of Health 4. Leavell & Clarks Agent-Host-Environment Model (Ecologic Model) 5. Health Promotion Model

4. Person should be seated quietly in a chair for at least five minutes with feet on the floor and arms supported at heart level 5. At least two measurements should be done, two minutes apart 6. Pre-hypertensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction, exercise, diet, and smoking cessation 7. SBP > 140 and / or DBP > 90 should be referred to a health care provider for antihypertensive drug therapy B. Breast self-examinations 1. Should be started by age twenty 2. Done at the same time of the month - preferably seven days after onset of the menstrual cycle; if no menstrual cycles, do at the same time each month 3. Technique should be reviewed by a health care provider to ensure effectiveness 4. Limited effectiveness, but when done regularly helps a woman understand how her breasts normally feel. 5. Most changes are benign, but unusual or spontaneous changes should be checked by a health a. lump or thickening (breast or underarm) b. red or hot skin c. orange peel skin d. dimpling or puckering e. itch or rash, especially in nipple area f. retracted nipple g. change in direction of nipple h. bloody or spontaneous discharge i. unusual pain j. a sore on the breast that does not heal C. Risky behaviors - assist in assessment of behaviors that impact the health of individuals in the following developmental stages 1. Adolescents (age 13-19) a. eating disorders - restrictive eating - binge eating followed by purging b. injury prevention

Health Promotion Programs and Health Screening

A. Blood pressure screening 1. Screening should be done annually beginning at age 21 for both males and females 2. Screening for children and adolescents is also recommended but optimal interval has yet to be determined 3. Auscultatory method with a properly calibrated and fitting cuff should be used icide c. substance abuse

d. sexual behavior

exposure to sexually transmitted diseases 2. Young adult (age 20-35) a. eating disorders - onset of obesity b. injury prevention

c. substance abuse

c. substance abuse 1. tobacco 2. alcoholism 3. illicit drug use d. injury prevention 1. falls 2. seatbelts 3. suicide 4. multiple medications D. Scoliosis screening 1. Recommendations vary but generally accepted to perform screening at onset of adolescence 2. Significantly more prevalent in girls than boys 3. Early intervention important because untreated scoliosis can lead to disfigurement, impaired mobility, and cardiopulmonary complications 4. Technique: clothing should be removed from upper body a. while standing, check adolescent for asymmetry of shoulders, scapula, hips, or waist b. assess for misalignment of spinous processes - lateral curvature and convexity of thoracic spine indicate scoliosis c. with feet together and legs straight, have adolescent bend forward until back is parallel to floor; check for prominence of ribs on one side only and hip and leg asymmetry - chest wall on side of convexity is prominent and scapula on side of convexity is elevated 5. Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures E. Testicular self-examinations 1. Monthly self-examination should begin in adolescence, since this is the highest risk group 2. Best time to perform exam is during or after a bath or shower when the scrotum is relaxed 3. Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as a. family history of testicular cancer b. cryptochidism c. previous germ cell tumor in one testicle 4. Findings that should be reported to a health care provider include a. hard lumps or nodules b. change in size, shape, or consistency of the testes Health locus of Control Model a. To know whether the clients are likely to take action regarding their health A. External those who believe in charms and lucks

d. sexual behavior - use of condoms e. stress 1. changing roles a. marriage b. beginning a new family c. starting a new job 2. depression 3. middle adult (age 35-65) a. obesity b. lack of exercise c. substance abuse 1. tobacco 2. alcoholism 3. illicit drug use d. lack of preventative health care e. stress 1. job 2. family / divorce 3. acceptance of aging 4. older adult (age 65 and older) a. obesity b. lack of exercise

B. Internal recognizes that they are the reason for their illness STAGES OF HEALTH BeHAVIOR a. Pre contemplation Stage - not on the point to change in the next 6 months - we ask them if they know the consequences - assess the patient for their readiness to change b. Contemplation Stage - thinking of changing in the near future c. Preparation planning d. Action execute the plan e. Maintenance provide positive reinforcement\ f. Termination no relapse Illness and Disease ILLNESS - personal state in which the person feels unhealthy - State where the persons physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired - Not synonymous with DISEASE DISEASE - alteration in body functions resulting in reduction of capacities or shortening of normal life span Four ASPECTS OF SICK ROLE N NOT HELD RESPONSIBLE FOR THE CONDITION O OBLIGED TO GET WELL SOON S SEEK COMPETENT HELP E EXCUSE FROM SOCIETAL ROLE STAGES OF ILLNESS 1. SYMPTOM EXPERIENCE - Transition stage - 3 aspects: physical, cognitive, emotional 2. ASSUMPTION OF SICK ROLE - Acceptance of the illness - Seeks advice, support, decision 3. MEDICAL CARE CONTACT - Seeks advice of health professionals: validation, explanation, reassurance 4. DEPENDENT PATIENT ROLE - Person becomes client dependent on health professional - Accepts / rejects HPs suggestions

- Becomes more passive and accepting - May regress to an earlier behavioral stage 5. RECOVERY / REHABILITATION - Gives up sick role & returns to former roles/functions CLASSIFICATION OF DISEASES ACCORDING TO ETIOLOGIC FACTORS 1. Hereditary defect in genes of 1 or both parent transmitted to offspring 2. Congenital present at birth; defect in development, hereditary factors, prenatal infection 3. Metabolic disturbance in the process of metabolism 4. Deficiency from inadequate intake or absorption of essential dietary factors 5. Traumatic due to injury 6. Allergic abnormal response of body to chemical or protein subs or physical stimuli 7. Neoplastic abnormal or uncontrolled growth of cells 8. Idiopathic unknown cause, self-originated, spontaneous origin 9. Degenerative from degenerative changes that occur in tissues or organs 10. Iatrogenic from treatment of a disease ACCORDING TO DURATION OR ONSET 1. Acute Illness - has short duration & severe - S/S occurs abruptly , are intense & subsides after a relatively short period of time 2. Chronic Illness - persists, longer than 6 months and can affect functioning & may fluctuate between maximal functioning & serious relapses that may be life threatening & characterized by remission & exacerbation - REMISSION- period where the disease is controlled & symptoms are not obvious - EXACERBATION- disease becomes active again with pronounced symptoms 3. Sub- Acute symptoms are pronounced but more prolonged than in acute disease SPACE Intimate Personal Social Public Touching 1.5 ft 1.5 4 ft 4 12 ft 12 15 ft

LEVELS OF PREVENTION 1. PRIMARY PREVENTION - before illness - encourage optimal health & increase persons resistance to illness

- seeks to prevent disease or condition at a prepathologic state - Health Promotion, Specific Protection - ACTIVITIES: quit smoking, avoid alcohol, regular exercise, well-balanced diet, reduce fat, increase fiber, adequate fluids, maintain ideal body weight, complete immunization program 2. SECONDARY PREVENTION = during illness - known as health maintenance - seeks to identify specific illness/condition at an early stage with prompt intervention to prevent or limit disability - Early Diagnosis, Detection, Screening, Prompt Treatment - ACTIVITIES: annual physical exam, regular PAP smear, monthly BSE, sptum exam for TB 3. TERTIARY PREVENTION after illness - support clients achievement of successful adaptation to known risks, optimal reconstitution or establishment of high-level wellness - occurs after a disease or disability has occurred & recovery process has begun - seeks to halt the disease or injury process & obtain optimal health status - ACTIVITIES: self monitoring of CBG among diabetics, PT after CVA, cardiac rehab, attending selfmanagement education, speech therapy after laryngectomy PHYSICAL EXAMINATION - CEPHALOCAUDAL approach - Determine mental status and LOC - Protect clients privacy during entire procedure - Prepare needed materials before starting procedure MODES OF EXAMINATION: 1. INSPECTION uses sense of sight 2. PALPATION uses sense of touch 3. PERCUSSION tapping body parts to produce sounds 4. AUSCULTATION listening to body sounds with a stethoscope POSITIONS 1. DORSAL RECUMBENT back-lying position with knees flexed, hips externally rotated 2. DORSAL/SUPINE- back-lying with or without pillow 3. SITTING OR SEATED- back unsupported & legs hanging freely 4. LITHOTOMY- back-lying with feet supported in stirrups 5. FOWLERSa. Semi-Fowlers head of bed elevated at 15-45 degrees angle b. High Fowlers head of bed raised at 80-90 degrees angle 6. GENUPECTORAL/KNEE-CHEST- kneeling with torso at 90 degrees angle to hips 7. LATERAL side-lying position

8. SIMS semi prone 9. PRONE-face lying position with head turned to sides/abdomen-lying position

CLASSIFYING HEART MURMURS BY INTENSITY

Grade I: Difficult to hear, even with stethoscope Grade II: Quiet, heard with stethoscope Grade III: Moderately loud, no thrill Grade IV: Loud, may have a thrill Grade V: Very loud, heard with a stethoscope partially off chest; has thrill Grade VI: Can be heard with a stethoscope off chest; has a thrill

Range of normal blood pressure

1. child under age 2 weighing at least 2700g: use flush technique, 30-60mg Hg child over age two: 8595/50-65 mm Hg 2. school age: 100-110/50-65 mm Hg 3. adolescent: 110-120/65-85 mm Hg 4. adult: <130 mm Hg Systolic / <85 mm Hg diastolic BLOOD PRESSURE (BP) Common Mistakes during Upper Extremity BP Checks

a false low systolic reading

Peripheral BP Measurement in the legs exed -40 mmHg higher than in the brachial artery rtery Internal carotid arteries in neck a. palpate each separately along margin of sternocleidomastoid b. normal findings: strong thrusting pulse c. auscultate both sides d. normal findings: no sound heard

e. constriction causes bruit 3. Jugular veins a. client in supine position with head elevated at 45 degrees b. normal findings: pulsations not evident c. jugular venous pressure (JVP): not to exceed 3 cm above level of sternal angle 4. Peripheral arteries and veins a. Pulse - locations LOCATIONS OF PULSES Head - Neck 1. Temporal: over temporal bone lateral to eye 2. Carotid: over the carotid artery in neck Chest 3. Apical: between 4th and 5th intercostal space usually mid-clavicular line Arm 4. Brachial: in the antecubital area of arm 5. Radial: on thumb side of wrist 6. Ulnar: medial wrist Leg 7. Femoral: below the inguinal ligament 8. Popliteal: behind the knee 9. Posterior tibial: on inner side of each ankle 10. Dorsalis pedis: along top of foot b. Normal range of peripheral pulses - infants: 120 to 160 beats/minutes - toddlers: 90 to 140 beats/minutes - preschool/school-age: 75 to 110 beats/ minute - adolescent/adult: 60 to 100 beats/minute

Pitting Edema Grading Scale 1+ Barely detectable-0 to inch pitting(mild) 2+ Indentation of <5mm- to inch pitting(moderate) 3+ Indentation of 5-10mm- to 1 inch pitting(severe) 4+ Indentation of >10mm- greater than 1 inch(severe) Normal rates of Respiration newborn: 35 to 40 breaths/minute

Range of motion - normal findings: able to move joints through required range of motion
a. Abduction - Lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk b. Adduction - Movement of a limb or eye toward the median plane of the body or, in the case of digits, toward the axial line of a limb. c. Dorsiflexion - Movement of a part at a joint to bend the part toward the dorsum, or posterior aspect of the body. d. Eversion - Turning outward e. Extension - A movement that brings the members of a limb into or toward a straight position f. Flexion - The act of bending or condition of being bent in contrast to extension. g. Hyperextension - Extreme or abnormal extension. h. Inversion - A turning inside out of an organ (e.g., the uterus). i. Plantar flexion - Extension of the foot so that the forepart is depressed with respect to the position of the ankle j. Pronation - The act of lying prone or face downward. k. Supination - The condition of being on the back or having the palm of the hand facing upward or the foot turned inward and upward CRANIAL NERVE FUNCTION 1. Olfactory (CN I)

PULSE GRADING SCALE

No pulse-0 Weak pulse-1+ Difficult to palpate-2+ Normal-3+ Bounding-4+

2. Optic (CN II)

- total or partial blindness of one or both eyes 3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) ation: Unequal or absent rise of uvula and soft palate as the client says, "ah" Deviation: inability to taste or identify taste on the posterior tongue 11. Spinal accessory (CN XI)

5. Trigeminal (CN V) bilateral pressure

12. Hypoglossal (CN XII)

Absent or one-sided blinking of eyelids 7. Facial (CN VII)

Level of consciousness (LOC) normal findings 1. alert 2. responds appropriately to visual, auditory, tactile and painful stimuli 3. able to carry out simple commands 4. Glasgow Coma Scale 5. Alterations in LOC ALTERATIONS IN LEVEL OF CONSCIOUSNESS 1. Awake and aware of person, place, time, and situation 2. Responds appropriately and to verbal stimuli 1. Sleeps but easily aroused 2. Speaks and responds slowly and appropriately 1. Difficult to arouse 2. Returns to sleep quickly; may respond inappropriately 1. Aroused only through pain 2. No verbal response 1. Responds only to pain 2. Gag and blink reflexes intact 1. No response to pain

anterior two-thirds of the tongue smile symmetrically 8. Acoustic (CN VIII) -2 feet -2 feet

ity to hear spoken word 9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)

2. No reflexes or muscle tone Note: dying clients will proceed through these levels in this above-listed sequence. THE NURSING PROCESS - cornerstone of nursing profession - Problem-solving tool in utilizing clinical application of knowledge & theory in nursing practice - 6-Step Process Assessment, Diagnosis, Outcome, Identification, Planning, Implementation & Evaluation The Nursing Process History Lydia Hall originated term Nursing Process. 3-Step Process: note observation, ministration of care, validation Dorothy Johnson- introduced 3-Step Process:assessment, decision, nursing action Ida Jean Orlando 3-Step Process:clients behavior, nurses reaction, nurses actions Yura & Walsh suggested 4 components of the process:assessing, planning, implementing and evaluating Knowles- nursing process as: discover, delve, decide, do, discriminate American Nurses Association innovations introduced: (1) diagnosis as separate step, (2) diagnosis of actual & potential health problems as integral part of nursing practice, (3) outcome identification as distinct step, (4) 6 steps- assessment, diagnosis, outcome identification, planning, implementation, evaluation a. ASSESSMENT TYPES OF DATA 1. Subjective Data (symptoms) 2. Objective Data (signs) METHODS OF DATA COLLECTION 1. Interview A. STRUCTURED emergency situation / limited time - OPD or clinic B. UNSTRUCTURED establish rapport C. SEMI STRUCTURED put follow up questions on the list - therapeutic communication 2. Observation SOURCES OF DATA 1. Primary 2. Secondary b. NURSING DIAGNOSIS

5 TYPES a. Wellness diagnosis b. Actual Diagnosis c. Risk Diagnosis D. Possible Diagnosis e. Syndrome Format: P problem / diagnostic label E etiology / risk factors S s/s or defining characteristics *collaborative problems focused on complications and bothe nurses and doctors work C. PLANNING Steps: a. establishing priorities framework used are: Maslows Hierachgy; ABC; nursing process b. identify outcomes and goals - based on the problem c. selecting nursing interventions based on the etiology DEPENDENT: A - ACTIVITY D - DIET M - MEDICATION I - IVT T - TREATMENT

d. writing the NCP e. IMPLEMENTATION 1. Technical Skills - hands on skill 2. Cognitive Skills - decision making/ critical thinking 3. Affective skills communication skills d. EVALUATION purpose: 1. Goals and objectives are met 2. effectiveness of interventions done 3 aspect: a. outcome evaluation b. structure evaluation c. process evaluation

DOCUMENTATION 1. SOURCE OREINTED MEDICAL RECORD Narrative charting Each page each department 2. PROBLEM ORIENTED MEDICAL RECORD 4 papers only a. Databse b. Problem List 1st page c. Plan of Care d. Progress Notes 3. CHARTING BY EXCEPTION Chart only abnormal or significant findings Consists of : FLOW SHEET; STANDARDS OF NURSING CARE; BEDSIDE ACCESS TO CHART FORMS 4. FDAR NURSING INFORMATICS OCTOBER 1995 first ANA certification exam in nursing informatics 1977 first nursing information system conference was held in USA 1. MANAGEMENT INFORMATION SYSTEM the mngt. & treatment of data pertaining to organizational process 2. HOSPITAL INFORMATION SYSTEM - the mngt. & treatment of data pertaining to patient care process TELEMEDICiNE ABLE TO GIVE MEDICAL ORDERS AT A DISTANCE

FACTORS AFFECTING BODY HEAT PRODUCTION 1. Basal Metabolic Rate (BMR) 2. Muscle Activity 3. Thyroxine Output 4. Epinephrine, norepinephrine & sympathetic stimulation 5. Increased temperature of body cells PROCESSES INVOLVED IN HEAT LOSS 1. Radiation transfer of heat from one surface to another without contact 2. Conduction transfer of heat from one surface to another with difference of temperature 3. Convection dissipation of heat by air currents 4. Evaporation continuous vaporization of moisture from the skin, oral mucous, respiratory tract ALTERATIONS IN BODY TEMPERATURE 1. PYREXIA body temperature above normal range 2. HYPERPYREXIA very high fever, 41degrees & above 3. HYPOTHERMIA subnormal core body temperature

TYPES OF FEVER 1. INTERMITTENT FEVER on and off fever fluctuates w/in 24 hrs 2. REMITTENT FEVER wide fluctuating temp that happens w/in 24 hrs but all above normal 3. RELAPSING FEVER on and off fever w/in days 4. CONSTANT FEVER abrupt increase in temp. METHODS OF TEMPERATURE TAKING ORAL ROUTE MOST ACCESSIBLE - Most accessible & convenient method - allow 15 mins when pt took food, drank hot/cold beverage or smoked - Wash thermometer before & after use utilizing proper technique - Take temperature 2-3 minutes RECTAL ROUTE BEST CORE TEMP.; reliable - Most accurate measurement - Assist in assuming lateral position - Lubricate before insertion, do not force. - Insert 0.5-1.5 inches - Instruct to take deep breath during insertion - Let stay for 2 mins AXILLARY ROUTE safe and non invasive - Safest & non-invasive

Vital Signs
BODY TEMPERATURE The balance between heat production and heat loss * Body heat is primarily produced by metabolism & regulated by hypothalamus Lowest temp : 4-6am and Highest temp: 4-6 pm TYPES OF BODY TEMPERATURE 1. Core Temperature-temperature of deep tissues of the body (oral/rectal) 2. Surface Temperature- temperature of the skin, subcutaneous tissue and fat (Axilla)

- Pat dry the axilla before placing thermometer. Do not rub. - Place arm tightly for 9 minutes TYMPANIC - Reflects core temp

easily obliterated ARTERIAL WALL ELASTICITY- artery feels straight, smooth, soft & pliable PRESENCE/ABSENCE OF BILATERAL EQUALITY- absence indicates CV disorder Temporal pulse perfusion f face Carotid pulse pulse during cardiac arrest; circulation in the brain o Carotid massage stimulates vagal nerve decrease HR Brachial pulse assess BP; cardiac arrest in infants; ABG specimen Radial pulse normal routine; assessment pulse for adults; used in checking pulse deficit; ABG specimen Apical pulse children </= 3 yrs. Old and older adults; checking for pulse deficit; cardio medicine drugs Femoral pulse perfusion in the lower extremities; ABG specimen Popliteal pulse perfusion of the lower leg; alternative site for BP taking Posterior Tibial and Dorsalis Pedis perfusion of the foot

RESPIRATORY RATE
- Act of breathing Pulse Rate - represent stroke volume

PROCESSES: 1. Ventilation - Inhalation/ inspiration 1.5 secs - Exhalation 3 secs 2. Diffusion 3. Perfusion Costal thoraxic muscle 7 years old Diaphragmatic abdominal muscle CHEST MOVEMENTS 1. INTERCOSTAL RETRACTION outline of the ribs; pneumonia 2. SUBSTERNAL RETRACTION under breast bone 3. SUPRASTERNAL RETRACTION above clavicle; ASTHMA RESPIRATORY CENTERS 1. Medulla Oblongata primary 2. Pons contains: - Pneumotaxic Center-responsible for rhythmic quality - Apneustic Center- responsible for deep, prolonged inspiration 3. Carotid & Aortic bodies-contains peripheral chemoreceptors

Tachycardia- above 100 bpm (adult) Bradycardia below 60 bpm (adult) RHYTHM pattern & intervals of beat VOLUME strength of pulse felt with moderate pressure obliterated with great pressure

4. Muscle & joints contains proprioreceptors ASSESSMENT OF THE RESPIRATORY RATE RATE Normal is 12-20 in adult DEPTH may be normal, deep or shallow RHYTHM observe for regularity of exhalations and inhalations QUALITY / CHARACTER respiratory effort & sound of breathing

Single Order carried out for only once STAT Order carried out at once PRN Order only as patient requires or needed Parts of A Legal Doctors Order 1. Name of Patient 2. Date and Time 3. Name of Drug 4. Dose of Drug 5. Route of Administration 6. Time or Frequency 7. Signature of Physician Effects of Drug Therapeutic Effect intended primary effect. AKA desired effect. Side Effect Unintended effect of the drug. AKA secondary effect. Drug Allergy immunologic reaction to the drug Anaphylactic Reaction severe allergic reaction Drug Tolerance decreased physiologic response to repeated administration of a drug Cumulative Effect increased response to repeated doses of drug that occurs when the rate of administration exceeds the rate of metabolism or excretion Idiosyncratic Effect- unexpected peculiar response to the drug Drug Abuse inappropriate intake of a substance, either continually or periodically Drug Dependence persons reliance to take a drug/substance which will produce an intense reaction upon withdrawal Addiction due to biochemical changes in body tissues esp. of the nervous system. Tissues come to require the substance to function normally. AKA physical dependence. Habituation emotional reliance on a drug to maintain sense of well being. AKA psychological dependence. Drug Interaction effects of one drug are modified by the prior or concurrent administration of another drug, thereby increasing or decreasing the pharmacological action Drug Antagonism conjoint effect of two drugs is less that the drugs acting separately Summation combined effect of two drugs produces result that equals the sum of the individual effects of each agent Synergism combined effects of drugs is greater than the sum of each individual agent acting independently Potentiation concurrent administration of two drugs in which one drug increases the effect of the other drug Therapeutic Actions of Drugs Palliative relieves symptoms of disease but does not affect the disease itself

BLOOD PRESSURE
- Measure of pressure exerted by blood as it pulsates through arteries Systolic Pressure- pressure of blood due to contraction of ventricles Diastolic Pressure pressure when ventricles are at rest Pulse Pressure difference bet. Systolic & diastolic pressures Hypertension abnormally high BP over 140 systolic or over 90 diastolic for at least 2 consecutive readings Hypotension abnormally low BP, below 100/60

ASSESSMENT OF BLOOD PRESSURE

1. Ensure client is rested 2. Allow 30 mins after exercise, smoking,caffeine intake before taking BP 3. Use appropriate size of BP cuff 4. Position in supine or sitting 5. Arm must be at the level of the heart 6. Apply cuff 1 inch above antecubital space snugly and smoothly 7. Use bell of the stethoscope 8. The sound during BP taking is called KOROTKOFF sound 9. Read lower meniscus of mercury level of sphygmomanometer at eye level to prevent Error of Parallax 10. ERROR OF PARALLAX if eye level is higher than level of lower meniscus of mercury, it may cause false low reading

Medication Administration
Medications substance administered for diagnosis, cure, treatment, relief or prevention of disease. AKA as drug Prescription Name name given to a drug before it becomes official Official Name name after which the drug is listed in one of the official publications Chemical Name- name that describes precisely the constituents of drugs Brand name- name given to a drug by the manufacturer. AKA trademark. Pharmacology study of effects of drugs on living organisms Posology study of dosage or amount of drugs given in the treatment of diseases Types of Doctors Orders Standing Order carried out until the specified period of time or until discontinued by an order

Curative treats the disease condition Supportive sustains body functions until other treatment of the bodys response can take over Substitutive replaces body fluids / substances Chemotherapeutic destroys malignant cells Restorative returns/repairs body to health Principles of Drug Administration 1. Observe the 7 Rights of drug administration. -RIGHT drug,dose,time,route,patient, recording, approach 2. Practice asepsis. 3. Nurses administering medications are responsible for their own actions. 4. Be knowledgeable about the meds you administer. 5. Keep narcotics locked. 6. Use only medications that are clearly labeled. 7. Return liquid that are cloudy in color. 8. Identify patient correctly before administering medications. 9. Do not leave medications at the bedside. 10. The nurse who prepares the drug must be the one to administer it. 11. If patient vomits, report to nurse in charge or physician. 12. Preoperative meds are usually discontinued during postop unless ordered to be continued. 13. When meds is omitted for any reason, record the fact & the reason. 14. When med error is made, report ASAP. Routes of Drug Administration I. ORAL ADVANTAGES: most convenient, less expensive, safe & does not break the skin barrier DISADVANTAGES: inappropriate for those with nausea & vomiting, dysphagia, reduced GIT motility, seriously ill May give unpleasant odor/taste, discolor teeth, irritate gastric mucosa Oral Drug Forms 1. SOLID tablet, capsule, pill, powder 2. LIQUID syrup, suspension, emulsion, elixir, milk, other alkaline substance SYRUP-sugar-based SUSPENSION-water-based EMULSION- oil-based ELIXIR- alcohol-based - Never crush enteric-coated or sustained-release medication II. SUBLINGUAL - Drugs placed under the tongue

ADVANTAGES: for local effect, rapid absorption in the bloodstream DISADVANTAGES: if swallowed, may be inactivated by gastric juices, must remain under the tongue until dissolved/absorbed III. BUCCAL -held in the mouth against mucous membranes of the cheek. Should not be chewed, swallowed or placed under the tongue ADVANTAGES: local effect, greater potency because drug directly enters blood & bypass the liver DISADVANTAGES: if swallowed, may be inactivated by gastric juices IV. TOPICAL -application of medications to a circumscribed area of the body 1. Dermatologic-lotions, liniments, ointment Pat dry area, use surgical asepsis, thin layer needed, use gloves over large areas 2. Ophthalmic instillations, irrigations - Instillations-provides meds, Irrigations-flush eye of noxious/foreign material 3. Otic instillations, irrigations Instillations-softens earwax, reduce inflammation & treat infection, relieve pain Irrigations- remove cerumen, apply heat, remove foreign body 4. Nasal for astringent effect, loosen secretions, facilitate drainage, treat infections - Parkinsons position-frontal/maxillary - Proetz position-ethmoid/sphenoid 5. Inhalation- nebulizers, MDI 6. Vaginal local therapeutic effect but has limited use FORMS: tablet, liquid, cream, jelly, foam & suppository Vaginal Irrigation washing of vagina by liquid at low pressure. AKA douche. Empty bladder first, position Irrigating can shld be 12 in higher Remain in bed for 5-10 mins after V. RECTAL ADVANTAGE: Used when odor/taste is not favorable DISADVANTAGE: absorption is unpredictable REMINDERS: needs refrigeration, use gloves for insertion, position- lie on left & breathe thru mouth, must remain on the side for 20 minutes for absorption VI. PARENTERAL - Administration by needle 1. INTRADERMAL thru the dermis beneath epidermis

SITES: inner lower arm, upper chest & back, beneath the scapulae INDICATIONS: for allergy & tuberculin testing & vaccinations Needle at 10-15 degrees angle, bevel up Inject over 3-5 sec to form a wheal/bleb Do not massage the site 2. SUBCUTANEOUS SITES: outer aspects of UA, anterior aspect of thighs, abdomen, scapular area of the back, ventrogluteal & dorsogluteal areas INDICATIONS: vaccines, preoperative meds, narcotics, insulin, heparin Small doses only 0.5-1 ml & rotate sites Use 5/8 needle for adults when given at 45 degrees (thin pts.), for 90 degrees (obese pts) Insulin Injection- do not massage & give at 90 3. INTRAMUSCULAR use 1 2 needle to reach the muscle layer SITES: ventrogluteal, dorsogluteal (<3 y/o), vastus lateralis, rectus femoris, deltoid, Z-track 4. INTRAVENOUS direct IV, IV push or infusion - Most rapid route, predictable INDICATIONS: pts with compromised GI function, rapid introduction of medications TYPES OF IV FLUIDS: A. Isotonic Solution- same concentration as body fluids (D5W, NaCl 0.9%, plain LR, plain NM) B. Hypotonic has lower concentration than body fluids (NaCl 0.3%) C. Hypertonic has higher concentration than body fluids (D10W, D50W, D5LR, D5NM) Nursing Interventions: 1. Know the type, amount, indications of IV. 2. Inform client & explain purpose of IV therapy. 3. Prime IV tubing to expel air. 4. Change IV tubing every 72 hours. 5. Change /alter IV needle insertion site every 72 hours. 6. Regulate every 15-20 minutes. 7. Observe for complications. Intradermal mL Gauge 1 mL 25 -27 Subcutaneous 1 or 2 mL 25 Intramuscular 1,2,3 or 5 mL p to 10 mL Deltoid Non deltoid 23 -25 21-22 1 in 1.5 inch

degree

Almost parallel to the skin 15 degress

Average = 45 degrees Fat = 90 degress

Average = 90 degrees Thin= 45 degrees

Complications of IV Infusion: 1. Infiltration needle out of vein, fluids accumulate in the subcutaneous tissues S/S: pain, swelling, cold skin, pallor at site, IV rate decreases/stops, no backflow NSG.INT: change IV site, apply warm compress 2. Circulatory Overload from administration of excessive volume of IV fluids S/S: headache, flushed skin, increased PR,BP,RR, weight, SOB, syncope, cough, increased venous pressure, pulmonary edema, shock NSG. INT: slow IV infusion (KVO), high fowlers position, administer diuretic, bronch odilator as ordered 3. Drug Overload excessive amount of drugs in the fluids S/S: dizziness, fainting, shock NSG. INT.: slow IV infusion (KVO), inform physician 4. Superficial Thrombophlebitis due to overuse of vein, irritating soln/drugs, clot formation, large bore catheter S/S: pain along the vein, vein feels hard & cordlike, edema & redness over site, affected arm warmer than the other NSG. INT: change IV site every 72H, use large veins for irritating fluids, stabilize area, apply cold compress immediately then warm compress after 5. Air Embolism - air enters the system (at least 5 ml or more) S/S: chest/shoulder/back pain, hypotension, dyspnea, tachycardia, cyanosis, increases venous pressure, LOC NSG.INT: do not allow bottle to run dry, prime tubings before starting IV, turn to left side in Trendelenburg position 6. Nerve Damage due to overly tight tying of the splint S/S: numbness of fingers/hands NSG.INT: massage area & move shoulders thru ROM, open/close hands several times each hour, PT if required 7. Speed Shock D/T rapid administration of IV fluids NSG.INT: to avoid speed shock & cardiac arrest, give most IV push meds over 3-5 minutes

Blood Transfusion
4 objectives / Purpose 1) To replace circulating blood volume 2) To increase oxygen carrying capacity of the blood 3) Combat infection if decrease WBC 4) Prevent bleeding if decrease platelet

length

- 5/ 8

3/8 5/8

NURSING MANAGEMENT 1.Proper Refrigeration - 250 cc packed of RBC, refrigerate 3-5 days - 1 platelet bag refrigerate 5-6 days 2. Proper blood typing & cross matching - Type O universal donor - AB- universal recipient - 85% of people is RH RH (+) 3. Aseptical assemble all materials needed for BT 4. With filter (BT set) 5. Gauge 18 of needle 6. Check for name of the client 7. Check for expiration date 8. Check for serial number 9. Use RED ballpen when charting 10. Check blood unit for presence of bubbles, cloudiness, and dark color 11. Never warm the BLOOD - It may destroy vital product of the blood - Let the room temperature warm the blood @ 30minutes 12. Avoid mixing the drugs at BT line 13. Regulate @ KVO or 100 cc/hr to prevent circulatory overload for first 30 minutes - Start at slow rate (10 gtts/min)& remain at bedside for 15-30 mins 14. BT should be done less than 4hrs for WB & PRBC and 20 minutes for plasma, platelets, cryoprecipitate 15. Monitor VS before. During & after BT 10 especially q15minns. For 1st hour - Majority of BT reaction occurs within 1hr. 16. Administer 0.9% NaCl before, during or after BT. Never administer IV with dextrose 17. Observe for Complication

C- itrate intoxication H- yperkalemia

BT REACTION
H- emolytic A- llergic P- yrogenic C- irculatory overload A- ir embolism T- hrombo cytophenia

Asepsis and Infection Control

INFECTION invasion of body tissue by microorganismsASEPSIS absence of disease-producing microorganisms; being free from infection MEDICAL ASEPSIS practices designed to reduce number & transfer of microorganisms SURGICAL ASEPSIS practices that render & keep objects/areas free from microorganisms; sterile technique SEPSIS presence of infection SEPTICEMIA transport of infection throughout the body or blood CARRIER person / animal, with or without signs of illness but who harbors pathogens within his body that can be transferred to another CONTACT person / animal known or believed to have been exposed to a disease RESERVOIR natural habitat for growth & multiplication of microorganisms TRANSIENT FLORA microorganisms picked up as a result of normal activities & can be removed easily. RESIDENT FLORA microorganisms that normally live on a persons skin STERILIZATION process by which all microorganisms including spores are destroyed DISINFECTANT substance that destroys pathogens but generally not including spores ANTISEPTIC substance that inhibits growth of pathogens but does not necessarily destroy them BACTERICIDAL chemical that kills microorganisms BACTERIOSTATIC agent that prevents bacterial multiplication but does not kill all forms of organisms CONTAMINATION process by which something is rendered unclean / unsterile DISINFECTION process by which pathogens but not their spores are destroyed COMMUNICABLE DISEASE results if infectious agent can be transmitted to another by direct/indirect contact thru vector/vehicle INFECTIOUS DISEASE results from invasion & multiplication of microorganisms in a host PATHOGEN disease-producing microorganism PATHOGENICITY ability to produce a disease VIRULENCE vigor with which the organism can grow & multiply SPECIFICITY organisms attraction to a specific host OPPORTUNISTIC PATHOGEN causes disease only in susceptible individuals NOSOCOMIAL INFECTION hospital-acquired infection ISOLATION separation of persons with communicable disease from another so that transmission is prevented ISOLATION TECHNIQUES practices designed to prevent transfer of specific microorganisms ETIOLOGY study of causes

STAGES OF INFECTIOUS PROCESS

Incubation Period from entry of microorganism to the body to onset of S/S Prodromal Period from onset of non-specific S/S to appearance of specific S/S Illness Period specific S/S develop & become evident

Convalescent Period S/S start to abate until client returns to normal state of health ETIOLOGIC AGENT may be bacteria, virus, fungi or parasites RESERVOIR humans, animals, plants, environment PORTAL OF EXIT (from reservoir) - Respiratory Tract- droplet,sputum - GIT-vomitus, feces, saliva, drainage tubes - Urinary Tract urine, urethral catheter - Reproductive Tract- semen, vaginal discharge - Blood needle puncture, open wound

-30 seconds each hand 2. CLEANING, DISINFECTION & STERILIZATION physical removal of dirt & debris by washing, dusting or mopping fection chemical or physical process to reduce number of potential pathogens on a surface but not necessarily the spores complete destruction of all microorganisms including spores

METHODS OF STERILIZATION
STEAM STERILIZATION autoclaving uses supersaturated steam under pressure - non-toxic , inexpensive, sporicidal & penetrates fabric - Color indicator strips change color to indicate sterilization GAS STERILIZATION ethylene oxide is colorless gas that can penetrate plastic, rubber, cotton or other subs. Used for oxygen, suction gauges, BP apparatus, stethoscope, catheter - Expensive & requires 2-5 hours - Ethylene oxide is toxic to humans RADIATION - ionizing radiation penetrates deeply to objects - Used for drugs, food & other heat-sensitive items CHEMICALS are effective disinfectants - Attacks all types of microorganisms rapidly, inexpensive & stable in light & heat. Chlorine is used. BOILING WATER least expensive, at least 15 minutes 3. USE OF BARRIERS a. Masks b. Gowns c. Caps & shoe covers d. Gloves e. Private rooms f. Equipment & refuse handling 4. ISOLATION SYSTEMS

MODES OF TRANSMISSION
- CONTACT TRANSMISSION direct/indirect - DROPLET TRANSMISSION when MM are exposed to secretions of an infected personwho is coughing, sneezing, laughing within 3 feet - VEHICLE TRANSMISSION transfer by way of vehicles or contaminated items (food, water, milk, utensils, pillows, mattress) - AIRBORNE TRANSMISSION when fine particles are suspended in the air for a long time & dispersed by air current then inhaled/deposited to a host VECTOBORNE TRANSMISSION - vectors can be biologic or mechanical - Biologic animals (rats, snails, mosquitoes) - Mechanical infected inanimate objects (contaminated needles/syringes) PORTAL OF ENTRY - permits organism to enter host - Through body orifice such as mouth, nose, vagina, rectum OR breaks in the skin or MM SUSCEPTIBLE HOST host is a person who is at risk for infection, whose body defense mechanism are unable to withstand the invasion of the pathogen

TYPES OF IMMUNIZATION
ACTIVE IMMUNIZATION- antibodies are produced by the body in response to infection NATURAL antibodies formed in presence of active infection in the body. It is lifelong. ARTIFICIAL antigens (vaccines/toxoid) are administered to stimulate Ab production PASSIVE IMMUNIZATION antibodies are produced by another source (animal/human) NATURAL Ab from mother to baby ARTIFICIAL Immune serum (antibody) from an animal or another human is injected

CLASSIFICATIONS:
A. Standard Precautions - Universal Precaution & Body-Substance Isolation - Prevent transmission of bloodborne & moist body substance pathogens

ASEPTIC PRACTICES
1. HANDWASHING an the elbows

1. Wear clean gloves 2. Perform handwashing 3. Wear masks, goggles, face shield if sprays/splashes are expected 4. Wear gown if soiling & splashes are expected 5. Remove soiled protective items immediately 6. Clean & reprocess all equipment 7. Discard all single-used items 8. Prevent injuries 9. Use private room or consult with Infection Control Department B. Transmission-Based Precautions 1. AIRBORNE PRECAUTION - for small-particle droplet that may remain suspended in the air & dispersed by air current (varicella, TB, measles -Private room, negative airflow, wear masks 2. DROPLET PRECAUTION - for large-particle droplet & dispersed by air current (H. influenza, diphtheria, rubella, mycoplasma pneumoniae) - Private room, wear masks within 3 ft. 3. CONTACT PRECAUTION - for those transferred by hand-or skin-to-skin contact (clostridium difficile, shigella, impetigo) - Private room, use gloves, gowns & other protective barriers when exposure to infected material is likely C. Protective Isolation - prevent infection for people with compromised resistance (leukopenia, undergoing chemoRx, extensive burns) - Private room, restrict visitors, no fresh fruits/flowers, raw foods, potted plants allowed, only cooked/canned foods allowed 5. SURGICAL ASEPSIS PRINCIPLES: a. Moisture causes contamination. b. Never assume that an object is sterile. c. Always face the sterile field. d. Sterile articles may touch only sterile surface/articles to maintain sterility. e. Sterile equipment/areas must be kept above the waist & on top of the sterile field. f. Prevent unnecessary traffic & air currents around sterile area g. open, unused sterile articles are no longer sterile after the procedure h. A person who is considered sterile who becomes contaminated must reestablish sterility i. Surgical technique is team effort.

Wound Care
TYPES OF WOUNDS: According to contamination 1. Clean Wounds uninfected, minimal inflammation, closed - respiratory, GIT & urinary tract are not entered 2. Clean-contaminated Wounds also surgical wounds, no infection - respiratory, GIT & urinary tract entered 3. Contaminated Wounds- open, fresh, accidental wounds, with evidence of inflammation 4. Dirty/Infected Wounds with dead tissue & evidence of infection TYPES OF WOUND: According to cause 1. Incision 2. Contusion 3. Abrasion 4. Puncture 5. Laceration 6. Penetrating wound TYPES OF WOUND HEALING 1. Primary Intention healing 2. Secondary Intention healing PHASES OF WOUND HEALING 1. Inflammatory Phase immediate, 3-6 days 2. Proliferative Phase 3rd to 21 days 3. Maturation Phase 21 days to 2 years STAGES OF PRESSURE ULCER FORMATION Stage 1 non-blanchable erythema signaling potential ulceration Stage 2 partial-thickness skin loss (abrasion, blister or shallow crater) involving epidermis & dermis Stage 3 full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down but not thru fascia. Deep crater. Stage 4 full-thickness skin loss with necrosis or damage to muscle, bone, structures, tendon, joints KINDS OF WOUND DRAINAGE EXUDATE material that escapes from blood vessels during the inflammatory process 1. SEROUS EXUDATE blister from burns 2. PURULENT EXUDATE 3. SANGUINEOUS (Hemorrhagic) EXUDATE

Oxygenation
Kinds of Chest Physiotherapy 1. Percussion (clapping) 2. Vibration 3. Postural drainage

Bronchial Hygiene Measures 1. Steam Inhalation semifowlers position & position spout 12-18 inches away from nose 2. Aerosol Inhalation 3. Medimist Inhalation

- Increased pulse rate - Rapid, shallow breathing, DOB, nasal flaring - Light headedness - Substernal / intercostals retractions - Cyanosis ALTERATIONS IN RESPIRATORY FUNCTION HYPOXIA Insufficient oxygenation of tissues CLINICAL SIGNS:

SUCTIONING
1. Assess indications for suctioning. 2. Position properly: a. conscious: semi-fowlers b. unconscious: lateral position 3. Apply proper pressure 4. Use appropriate size of catheter Adult: Fr 12-18 Child: Fr 8-10 Infant: Fr 5-8 5. Don sterile gloves 6. Insert proper length of catheter 7. Lubricate catheter 8. Apply suction during withdrawal of catheter 9. Apply suction for 5-10 seconds (max 15) 10. Hyperventilate 100% before & after 11. Allow 20-30 sec interval between each suction 12. Provide oral & nasal hygiene 13. Dispose contaminated equipment/matls safely 14. Assess effectiveness / document INCENTIVE SPIROMETRY -Enhance deep inspiration INTERMITTENT POSITIVE PRESSURE BREATHING Administer oxygen at pressures higher than the atmospheric pressure OXYGEN SYSTEMS 1. Low flow administration devices 2. High flow administration devices ADMINISTRATION OF OXYGEN Indications: hypoxemia Signs of Hypoxemia: - Restlessness

RHYTHM
CHEYNE-STOKES marked rhythmic waxing & waning of respirations from very deep to very shallow and temporary apnea KUSSMAULS (Hyperventilation) increased rate & depth of respiration APNEUSTIC prolonged gasping inspiration followed by very short inefficient expiration BIOTS shallow breaths interrupted by apnea