Common Signs And Symptoms Report - Chn Rle

Intervention for Common Signs and Symptoms Objectives: After 4 hours of varied lecture discussion, the level II students will be able to: 1. define the following terms: a. chest tapping

h. hematochezia

b. chest vibration

i. hemoptysis

c. cough

j. interventions

d. diarrhea

k. melena

e. dehydration

l. sign

f. expectorate

m. sputum

g. hematemesis

n. symptom

2. differentiate the types of : a. cough b. diarrhea c. fever d. oresol preparation

3. state the importance of the following: a. chest tapping b. chest vibration c. tepid sponge bath d. oresol preparation

4. explain the principles involve in:

a. chest tapping

b. chest vibration c. tepid sponge bath d. oresol preparation

5. enumerate the different nursing interventions of the ff: a. cough b. diarrhea c. fever

6. identify the different guidelines in performing: a. chest tapping/chest vibration b. tepid sponge bath c. oresol preparation

7. discuss the nursing responsibilities before, during, after performing the following: a. chest tapping/chest vibration b. tepid sponge bath c. oresol preparation

8. show beginning skills in: a. chest tapping/chest vibration b. tepid sponge bath c. oresol preparation

DEFINITION OF TERMS: a. chest tapping - also called chest percussion, involves striking the chest wall of the area being drained. The hand is positioned so that the fingers and the thumb touch and the hand is cupped. b. chest vibration - is a fine, shaking pressure applied to the chest wall only during exhalation c. cough

- is a sudden, audible expulsion of air from the lungs d. diarrhea - is an increase in the number of stools and the passage of liquid, unformed feces e. dehydration - insufficient fluid in the body f. expectorate - to spit; to eject saliva, mucus or other fluid from the mouth g. hematemesis - also be spelled haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. h. hematochezia - is the passage of maroon colored stool. It is distinguished from melena, which is stool with blood that has been altered by the gut flora and appears black. i. hemoptysis - blood sputum, haemoptysis is the expectoration of blood or of bloodstained sputum from the bronchi, larynx, trachea, or lungs j. intevention - an effort to promote good health behavior or to prevent bad health behavior k. melena - refers to the black feces that are associated with gastrointestinal hemorrhage l. sign - any objective evidence of disease or dysfunction m. sputum - contains mucous; cellular debris and microorganisms and it may contain blood pus n. symptoms

- a change in the physical/ mental state of a person that he is able to recognize and frequently bring to physician’s attention

TYPES OF COUGH: A. CHESTY COUGH

- characterized by the presence of mucus or phlegm on the chest - the action of coughing is therefore of benefit in the case of the chesty cough as the mucus needs to be moved from the chest.

a.1 PRODUCTIVE - notice the presence of mucus on the chest - results in sputum production, material coughed up from the lungs that may be swallowed or expectorated - sputum contains mucus, cellular debris, and microorganisms and it may contain pus or blood a.2 NON-PRODUCTIVE - mucus is not being removed from the chest despite of the coughing action done

B. DRY COUGH - a cough that does that produce sputum.

TYPES OF FEVER: a. SUSTAINED or CONSTANT - a constant body temperature continuously at 38°C that demonstrate the fluctuation b. INTERMITTENT

- fever spikes interspersed with usual temperature levels: temperature returns to acceptable values at least once in 24 hrs. c. REMITTENT - fever spikes and falls without a return to normal temperature levels at 2°C d. PRELAPSING - periods of febrile episodes interspersed with acceptable temperature values. - temperature from high to normal.

FACTORS AFFECTING BODY TEMPERATURE •

AGE – the normal temperature range gradually drops as individuals approach older adult has a narrower range of the body temperature than the younger adult.

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EXERCISE – muscle activity requires an increased blood supply and increased carbohydrate and for breakdown. Thus increase metabolism causes an increase in heart production.

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HORMONE LEVEL – women generally experience greater fluctuation in the body temperature than men. Hormonal variations during menstrual cycle caused temperature fluctuation.

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STRESS – physical and emotional stress increased body temperature through hormonal and neural stimulations.

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ENVIRONMENT – if temperature is assessed in a very warm room, client maybe unable to regulate body temperature by heat loss mechanism and the body temperature will be elevated.

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GREADIAN RHYTHM – body temperature ranges 0.5°C – 1°C during 24 hours period

TYPES OF DIARRHEA: A. ACUTE DIARRHEA - starts suddenly and lasts shorts - is a sudden onset of abnormally frequent, watery stools accompanied weakness, flatulence, abdominal pain, and sometimes fever and vomiting - it may be caused by eating spoiled food

B. CHRONIC DIARRHEA - diarrhea that lasts for more than two weeks is considered persistent or chronic, a life threatening illness - is associated with weight loss and anemia, this is usually caused by chronic use of laxatives or amoebiasis

IMPORTANCE OF CHEST TAPPING -

facilitates clearance of retained secretions through increased coughing effort and force decrease adventitious lung sound increase oxygen exchange reduce shortness of breath helps in the treatment of asthma, it promote respiratory function

IMPORTANCE OF CHEST VIBRATION -

-

incorporates the velocity and turbulence of exhaled air, facilitating secretion removal increase in exhalation of trapped air and may shake mucus loose promotes expectoration

IMPORTANCE OF TEPID SPONGE BATH -

simple but effective way to decrease the body’s elevated temperature maintain personal hygiene provides relaxation used to avoid chilling effect relieves tension

IMPORTANCE OF ORESOL PREPARATION -

to regain strength to fluid and erythrocytes balance provides immediate care for dehydration to prevent further dehydration to regain patient’s normal condition

PRINCIPLES INVOLVED IN: A. CHEST TAPPING/CHEST VIBRATION a.1. Anatomy and physiology – human lungs are enclosed by rib cage which gives the shape of the thorax a.2. Microbiology – perform medical hand washing before and after the procedure to prevent spread of microorganism a.3. Psychology – the nurse should be considerate on the patient’s feeling and his or her right to privacy since this adds comfort to the patient a.4. Physics – percussion on the chest wall sends waves of varying amplitude and frequency through the chest, changing consistency and location of the sputum a.5 Time and Energy – the nurse should be systematic in performing chest tapping/chest vibration so that time and energy will be efficiently utilized a.6 Body Mechanics – the nurse should observe proper body positioning to prevent muscle strain and stress.

B.

TEPID SPONGE BATH

b.1 Anatomy and physiology – the axilla and groin are areas containing the large superficial blood vessel the application of sponge provides cooler temperature of the body’s core by conduction, immersion provides effective heat loss. b.2 Body Mechanics – client should assume a comfortable position and nurse should also maintain body, thus, this aids nurse access to the client. b.3 Microbiology – dispose equipment that need to dispose and change bed lines if soiled. b.4 Chemistry – use of alcohol increase the evaporated heat loss b.5 Psychology – provide privacy by closing the curtains and doors to prevent drafts in the room.

C.

ORESOL PREPARATION

c.1 Chemistry – the composition of oresol is recommended by DOH and UNICEF. c.2 Anatomy and physiology – diarrhea occurs in our digestive system and the frequent production of stools caused by the diarrhea occurs in arms c.3 Psychology – healthy vowel movement and regular loss stools per day eases the feeling of person preventing him to think any abnormalities and enhances self-esteem. c.4 Microbiology – negative behaviors help the entrance of pathogens to spread and thus increase the risk of diarrhea.

NURSING INTERVENTIONS OF THE FOLLOWING: COUGH  assess and document client’s respiratory status

 monitor client’s respiratory status at least every four hours  encourage client to drink at least 2000ml/8 glasses of fluid every day  encourage physical activity  assist the client to assume on appropriate breathing and coughing position  ask prescription from the doctor for medication to be given DIARRHEA  replacing loss fluid and prevent dehydration is the only treatment necessary  do not take over-the- counter anti- diarrheal medications for the first few hours since the diarrhea may be ridding your body of infections agent or irritants  limit or avoid milk products, alcohol, and food rich in fiber during recovery  for infants: while diarrhea persist feed them an electrolytes solution available from pharmacist FEVER monitor vital signs assess skin color and temperature monitor WBC count, hematocrit value, and other laboratory records remove blanket when patient fells warm but provide extra warmth when patient fells chilled  provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration to the client  provide oral hygiene to keep mucus membranes moist  administer antipyretic drugs that reduce the level of fever as ordered    

GUIDELINES: A. CHEST TAPPING / CHEST PERCUSSION - to mobilize mucus secretion - know the clients medical history - do medical wand washing before, during and after procedure - it is important to know client’s posture - percussion is done ½ - 5 mins. over each area but usually 1 – 2 mins. - hands must remain cupped (less pain) so that air caution the impact to avoid injury

- hold your fingers and thumb together and flex them slightly to form a cup, as you would scoop water - do not tap the scapula, only the contours of the lung and spine and sternum B. TEPID SPONGE BATH - prepare necessary materials needed on the procedure - provide privacy during procedure - explain the procedure to the patient - check room and warm water temperature for cold compress - be gentle and sensitive to the needs of the patient C. ORESOL PREPARATION - to be used little by little in 24 hrs. - no leftovers - must be prepared at room temperature - use with only enough salt to provide needed electrolytes but it must not influence the taste of sugar - for an adult, give as much oresol as he can tolerate but for children give only up to one glass

NURSING RESPONSIBILITIES: A. CHEST TAPPING 1. 2. 3. 4. 5.

Before: Read patients chart with the physicians order Do medical hand washing Explain the procedure to the patient Ask patient to do a diaphragmatic breathing Position patient

1. 2. 3. 4.

During: Provide privacy to patient Cover area to be percussed with a gown or towel Avoid clapping over spines, liver and spleen Ask patient to inhale slowly and deeply

After: 1. Document properly or record in patient’s chart for change in patients physical condition 2. Do medical hand washing

B. TEPID SPONGE BATH Before: 1. Read patients chart with physicians order 2. Prepare the necessary materials 3. Protect patients bed with moisture proof materials 1. 2. 3. 4. 5.

During: Observe proper body mechanics Sponge one body part at a time Sponge the face, face, arms, legs, back and buttocks slowly and gently Pat dry each area Discontinue bath if client shivers or when body temperature is slightly above normal

1. 2. 3. 4.

After: Perform medical hand washing Dispose equipments and change linens if soiled Check patient’s TPR again Record time when procedure was started and terminated, vital signs changes and response

C. ORESOL PREPARATION Before: 1. Perform medical hand washing 2. Use clean materials for preparation During: 1. Give the exact amount of oresol according to patient’s age 2. If the child vomits, wait for 10 mins. then give the oresol again 3. Give child alternately other fluids such as breast milk or juices 1. 2. 3. 4.

After: Document properly Store solutions in a cool place Do medical hand washing If diarrhea increases or vomiting persists, take the child to health clinic