Ncm101

FUND AMENTALS OF NUR SING

CONC EPT OF MA N

MAN  Forms the foundation of Nursing

FOUR COMPONENTS OR ATTRIBUTES OF MAN  Capacity to think on an Abstract Level  Establish a family  Establish a territory  Ability to use verbal symbols as language

CONCEPT  Animals form a family by instinct  Via hormonal scents

NURSING CONCEPTS OF MAN  Biopsychosocial Being  Open System  Unified Whole  Vital Reparative Process  Man is a whole. Man is complete

BIOPSYCHOSOCIAL BEING  By Sister Calista Roy  Man interacts with the environment

OPEN SYSTEM  By Martha Rogers  Man interacts with the environment  Exchanges matter with energy  Exchanges energy with environment

UNIFIED WHOLE  By Martha Rogers  Man is composed certain parts

of

 Total of those parts is more than the sum of all parts  This is because man has attributes

VITAL REPARATIVE PROCESS  By Florence Nightingale  Man is passive in influencing the nurse or the environment

MAN IS A WHOLE. MAN IS COMPLETE  By Virginia Henderson  Man has fourteen (14) fundamental needs

HUMAN NEEDS  Needs are physiologic and psychologic.  Both these needs must be met in order to maintain wellbeing.

KEY CONCEPT  Basic Human Needs are equivalent to COMMON NEEDS

CHARACTERISTICS OF HUMAN NEEDS  Universal  Interrelated  One need is related to another need  May be stimulated by internal or external factors  May be deferred (but not indefinitely)

ABRA HAM MASLOW ’S HIERARCHY OF NE EDS  Why do we study this?  In order to prioritize nursing actions

ABRAHAM MASLOW’S HIERARCHY OF NEEDS  Physiologic needs  Food  Air  Drink  Shelter  Warmth  Sex  Sleep  Maintenance of homeostasis

ABRAHAM MASLOW’S HIERARCHY OF NEEDS  Safety and security  Protection  Security  Order  Law  Limits  Stability

ABRAHAM MASLOW’S HIERARCHY OF NEEDS  Love and Belongingness  Family  Affection  Relationships  Work group

ABRAHAM MASLOW’S HIERARCHY OF NEEDS  Self-esteem  Feeling good about one’s self  Two factors affecting Self-esteem Yourself • Sense of adequacy • Accomplishment Others • Appreciation • Recognition • Admiration

ABRAHAM MASLOW’S HIERARCHY OF NEEDS  Self-actualization  Personal growth and fulfillment  Able to fulfill needs and ambitions  Maximizing one’s full potential

ABRAHAM MASLOW’S MODIFIED HIERARCHY OF EIGHT NEEDS (1990)  Additional needs:  Need to know understand  Aesthetic needs  Transcendence

and

ABRAHAM MASLOW’S MODIFIED HIERARCHY OF EIGHT NEEDS (1990)  Need to know and understand or Cognitive needs is supported by Richard Kalish who says that:  Man needs stimulation  Needs to explore Sex Activity Novelty • Stimulator • Desire to come up with something of your own

ABRAHAM MASL OW’ S M OD IF IE D HIE RARC HY OF EIGH T N EE DS ( 1990 )  Aesthetic needs:  Beauty  Balance  Form

ABRAHAM MASL OW’ S M OD IF IE D HIE RARC HY OF EIGH T N EE DS ( 1990 )  Transcendence:  Helping others to selfactualize

CHARACTERISTICS OF SELF-ACTUALIZED PERSONS  Judges people correctly  Superior perception  Decisive  Capable of making decisions  Clear notion as to what is right and wrong

CHARACTERISTICS OF SELF-ACTUALIZED PERSONS  Open to new ideas  Not adopts new ideas  Not one track mind  Highly creative and flexible  Does not need fame  Problem-centered rather than self-centered

CONC EPT  Self-Actualization is very difficult to attain  It is impossible to attain  New needs come after getting one need

ILLNES S, WELLNES S A ND HEALTH

ILLNESS  Highly subjective feeling of being sick or ill

TWO TYPES OF ILLNESS  Acute Illness  Chronic Illness

ACUTE ILLNESS  Sudden in onset (most of the time, but not always)  Less than six (6) months

CHRONIC ILLNESS  Gradual in onset (most of the time, but not always)  Types of Chronic Illness  Exacerbation Period characterized by active signs and symptoms of the illness  Remission Periods where no signs and symptoms are present

DISEASE  Objective pathologic process

CONCEPTS ON DISEASE  Illness without disease is possible  Disease without illness is possible  Illness may or may not be related to a disease  One can have a disease without necessarily feeling ill

DEVIANCE  Any behavior that goes against social norms  Shortens life span  Results to disrupted family and community

CONCEPT  Deviant behavior can be considered a disease

RATIONALE  Because it also shortens the life span like a disease

EXAMPLE OF DEVIANCE  Alcoholism  A disease rather than a social problem

WELLNESS  Feeling of being well

DEFINITIONS OF HEALTH Object 5

 World Organization

Health

 Health is the complete physical, mental, social (totality) well-being and not merely the absence of disease or infirmity  A high-level wellness!

DEFINITIONS OF HEALTH  Claude Barnard  Ability to maintain internal milieu

DEFINITIONS OF HEALTH  Walter Cannon  Ability to homeostasis

maintain

 A dynamic equilibrium  A state of balance of the internal environment while external environment is changing

DEFINITIONS OF HEALTH  Florence Nightingale  Health is using one’s power to the fullest  Being well  Can be maintained by manipulating the environment

DEFINITIONS OF HEALTH  Virginia Henderson  Viewed in terms of ability to perform the fourteen (14) fundamental needs or components of nursing care UNAIDED

DEFINITIONS OF HEALTH  Martha Rogers  Positive health symbolizes wellness  Health is a value term defined by a certain culture

DEFINITIONS OF HEALTH  Sister Calista Roy  A state and process of being and becoming an INTEGRATED PERSON

DEFINITIONS OF HEALTH  Dorothea Orem  Characterized by soundness and wholeness of DEVELOPED HUMAN STRUCTURES and FUNCTIONS

DEFINITIONS OF HEALTH  Imogene King  A dynamic state in the life cycle (contrasted with illness)  Illness is interference in the life cycle

DEFINITIONS OF HEALTH  Betty Neuman  Wellness is that all parts and subparts are in harmony with each other and the whole system

DEFINITIONS OF HEALTH  Dorothy Johnson  Elusive dynamic state influenced by biologic, psychologic and social factors

MODELS OF HEALTH AND ILLNESS  Health-Illness Continuum: Dunn’s High-level Wellness and Grid Model  Health Belief Model by Rosentock  Four Levels of Health by Smith  Agent, Host and Environment Model by Leavell and Clark

DUNN’S HIGH-LEVEL WELLNESS AND GRID MODEL  X-axis is HEALTH  Y-axis is environment  Quadrant 1  High-level wellness in favorable environment  Quadrant 2  Protected poor health in favorable environment  Quadrant 3  Poor health in unfavorable environment  Quadrant 4  Emergent high-level wellness in unfavorable environment

HEALTH BELIEF MODEL BY ROSENTOCK  Based on a motivational theory  It assumed that good health is an objective common to all people  Consider perceptions (influences individuals motivation toward results)  Perceived susceptibility  Perceived seriousness  Perceived threat  Likelihood of Action influenced by:  Perceived benefit out of the action  Perceived barriers

FOUR LEVELS OF HEALTH BY SMITH  1. Clinical Model  Man is viewed as a Physiologic Being  If there are no signs and symptoms of a disease, then you are healthy  Against WHO definition of health  This is the NARROWEST concept of health

FOUR LEVELS OF HEALTH BY SMITH  2. Role Performance Model  As long as you are able to perform SOCIETAL functions and ROLES you are healthy

FOUR LEVELS OF HEALTH BY SMITH  3. Adaptive Model  Health is viewed in terms of capacity to ADAPT.  Therefore, goal of treatment is to restore capacity to adapt.  Failure to adapt is disease

FOUR LEVELS OF HEALTH BY SMITH  4. Eudaemonistic Model  This is the BROADEST concept of health  Because health is viewed in terms of Actualization

AGENT, HOST, ENVIRONMENT MODEL BY LEAVELL AND CLARK  Also known as the Ecologic Model  Expands to the MULTI-CAUSATION of a DISEASE  Definitions of a disease as to its cause is expanded to a multi-causation of a disease (i.e. cancer is a multifactorial disease)  Triad is composed of the agent, host and environment  Based on the interplay of three components of the model

DEFINITIONS OF NURSING

DEFINIT ION S OF NU RSING  American Association

Nurses

 Nursing is the diagnosis and treatment of human responses to illness (to actual and potential health problems)

DEFINIT ION S OF NU RSING

 Canadian Nurses Association  The same definition as that of the American Nurses Association plus…  … includes the supervision of functions and services in collaboration with others to promote health

DEFINIT ION S OF NU RSING  Florence Nightingale  Nursing is the act of utilizing the ENVIRONMENT for the following purposes:

Recovery Reparative process

DEFINIT ION S OF NU RSING  Virginia Henderson  The unique function of the nurse is to assist individuals, sick or well, with the activities towards health that he would do unaided, if with strength and knowledge. If that is not possible, towards a PEACEFUL DEATH

DEFINIT ION S OF NU RSING  Martha Rogers  Nursing is a HUMANISTIC SCIENCE dedicated to compassionate concern for the promotion of health, prevention of illness and rehabilitation of the sick

DEFINIT ION S OF NU RSING  Sister Calista Roy  Nursing is a THEORETICAL SYSTEM OF KNOWLEDGE that prescribes analysis and action related to the care of the sick or ill  It is a set of knowledge

DEFINIT ION S OF NU RSING  Dorothea Orem  Nursing is a helping service to any individual who is sick  It comprises of wholly dependent or partly dependent care when the person is unable to do so.  Defines nursing in terms of a NEED!

DEFINIT ION S OF NU RSING  Imogene King  Nursing is a helping profession that assists a person (same with Henderson) towards a DIGNIFIED DEATH

DEFINIT ION S OF NU RSING  Betty Neuman  Nursing is a profession that is concerned with INTRAPERSONAL, INTERPERSONAL, and EXTRAPERSONAL VARIABLES affecting a person’s response to stressors

DEFINIT ION S OF NU RSING  Dorothy Johnson  Nursing is an EXTERNAL REGULATORY FORCE that regulates the ACTION or BEHAVIOR of a person when such behavior constitutes a threat, in order to preserve his organization

DEFINIT ION S OF NU RSING  Dorothy Johnson  Example:

In a COPD patient who remains a smoker, the nurse who encourages the patient not to smoke, serves as an external regulatory force

DEFINIT ION S OF NU RSING  Faye Abdella  Nursing is a service to individuals, families… and therefore, to society  Conceptualized nursing as an ART and SCIENCE of MOLDING THE INTELLECT, ATTITUDE and SKILLS of the nurse  Nursing in terms of providing education

DEFINIT ION S OF NU RSING  Hildegard Peplau  Nursing is the INTERPERSONAL process of THERAPEUTIC INTERACTION between the nurse and the patient.

NURSING THEORIES

1) FLOREN CE NIG HTIN GALE: EN VIRON MENT AL NU RS ING THEORY  Often considered the first nurse theorist  Defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery”.  Nightingale’s theory remains an integral part of nursing and healthcare today.

1) FLOREN CE NIG HTIN GALE: EN VIRON MENT AL NU RS ING THEORY  5 Environmental Factors:  Pure or fresh air  Pure water  Efficient drainage  Cleanliness  Light, especially direct sunlight

1) FLOREN CE NIG HTIN GALE: EN VIRON MENT AL NU RS ING THEORY  Nightingale’s concepts are:  Ventilation  Cleanliness  Quiet  Warmth  Diet

general

CONC EPT  First Nursing School – Florence Nightingale

2) D OROT HY J OHNS ON : BEHAVIORA L S YST EM S M OD EL  Seven Subsystems  Attachment and Affiliative  Dependency  Ingestive  Eliminative  Sexual Achievement  Aggressive

3) VIRGI NIA H EN DERS ON: FOU RT EEN F UNDAMENTA L NEE DS  Fourteen (14) Fundamental Needs focusing on PHYSIOLOGIC SOCIAL RECREATION

3) VIRGI NIA H EN DERS ON: FOU RT EEN F UNDAMENTA L NEE DS  1) Breathing normally  2) Eating and drinking adequately  3) Eliminating body waste  4) Moving and maintaining a desirable position  5) Sleeping and resting  6) Selecting suitable clothes  7) Maintaining body temperature within normal range by adjusting clothing and modifying the environment

3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS  8) Keeping the body clean and well groomed to protect the integument.  9) Avoiding dangers in the environment and avoiding injuring others.  10) Communicating with others in expressing emotions, needs, fears, or opinions  11) Worshipping according to one’s faith

3) VIRGI NIA H EN DERS ON: FOU RT EEN F UNDAMENTA L NEE DS  12) Working in a such way that one feels a sense of accomplishment  13) Playing or participating in various forms of recreation  14) Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS  Focus is on PROPER IDENTIFICATION of the problem  Particularly about the proper nursing diagnosis

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS 1.To maintain good hygiene. 2.To promote optimal activity: exercise, rest, and sleep. 3.To promote safety. 4.To maintain good body mechanics. 5.To facilitate the maintenance of supply of oxygen.

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS 6.To facilitate maintenance of nutrition. 7.To facilitate maintenance of elimination. 8.To facilitate the maintenance of fluid and electrolytes balance. 9.To recognize the physiologic response of the body to disease conditions.

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS 10.To facilitate the maintenance of regulatory mechanisms and functions. 11.To facilitate the maintenance of sensory function. 12.To identify and accept positive and negative expressions, feelings and reactions. 13.To identify and accept the interrelatedness of emotions and illness.

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS 14.To facilitate the maintenance of effective verbal and non-verbal communication. 15.To promote the development of productive interpersonal relationship. 16.To facilitate progress toward achievement of personal spiritual goals. 17.To create and maintain a therapeutic environment.

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS 14.To facilitate the maintenance of effective verbal and non-verbal communication. 15.To promote the development of productive interpersonal relationship. 16.To facilitate progress toward achievement of personal spiritual goals. 17.To create and maintain a therapeutic environment.

4) F AYE A BDEL LA: PROB LEM SOL VI NG A PP ROA CH TO 21 NU RSIN G PROB LEMS 18.To facilitate awareness of self as an individual with varying needs. 19.To accept the optimum possible goals. 20.To use community resources as an aid in resolving problems arising from illness. 21.To understand the role of social problems as influencing factors.

5) M ARJORIE GORDON : HUMAN F UNC TI ONA L H EALTH PATT ERNS  Focus is on Eleven (11) Health Patterns  Advantage to the nurse:

It enables the nurse to determine the client’s response as functional or dysfunctional

5) M ARJORIE GORDON : HUMAN F UNC TI ONA L H EALTH PATT ERNS  Eleven Functional Health Patterns  Health perception  Nutritional / Metabolic  Elimination  Activity and Exercise Pattern  Cognitive Perceptual Pattern

5) M ARJORIE GORDON : HUMAN F UNC TI ONA L H EALTH PATT ERNS  Eleven Functional Health Patterns  Sleep and Rest  Self perception / Self concept  Role Relationship Pattern  Sexuality / Reproductive  Coping-StressTolerance  Value Belief Patterns

6) IM OG ENE KING : GOA L A TT AINM EN T TH EO RY  Patient has three interacting systems:

(3)

 Individuals / Personal systems  Group systems / Interpersonal systems fraternity  Social systems

7) MADELEINE LEH NING ER: TRA NS CULTURA L NU RSING THEORY  Nursing is a HUMANISTIC and SCIENTIFIC mode of helping through CULTURE-SPECIFIC PROCESS

8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING  1. Conservation of Energy  Example: complete bed rest without bathroom privileges  2. Conservation of Structural Integrity  Example: turn patient from side to side every two hours to avoid bed sores

8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING  3. Conservation of Personal Integrity  Example: maintain patient’s privacy  4. Conservation of Social Integrity  Example: maintenance of patient’s relationships

9) BETTY NE UMAN: HEALTH CARE SYST EM S M OD EL  The concern of nursing is to PREVENT STRESS INVASION

10) D OROTH EA OREM : SE LF C ARE AN D SELF C ARE DEFIC IT T HEORY  Three (3) Nursing Systems based on Art of Care of Patient Needs

10) D OROTH EA OREM : SE LF C ARE AN D SELF C ARE DEFIC IT T HEORY  1. Partial Compensatory  Patient performs some of nursing care needs  2. Wholly Compensatory or Total Compensatory  For paralyzed patients, for ICU patients  3. Supportive-Educative  For up and about patient

11) H IL DEGA ARD P EP LAU: INT ERP ERS ONA L MODEL  Four (4) Phases of Nurse-Patient Interaction  1. Orientation

Nurse and patient test the role each one assumes Prepares patient for termination Patient identifies areas of difficulty

11) H IL DEGA ARD P EP LAU: INT ERP ERS ONA L MODEL  2. Identification Phase

Patient identifies with the personnel who can satisfy his needs  3. Exploitation Phase

Nurse maximizes all the resources to benefit the patient

11) H IL DEGA ARD P EP LAU: INT ERP ERS ONA L MODEL  4. Resolution Phase or Termination Phase

Occurs when patient’s needs have been met

CONC EPT S!  Various settings for application of:  Pre-Interaction Phase In psychiatric setting, this consists of gathering data  Pre-Entry Phase In community health nursing, this consists of a courtesy call

12) MART HA ROG ERS: SCIENC E OF UNIT ARY HUMAN BEINGS  Man is composed of energy fields, which are in constant interaction with the environment

CON CEP T!  The most reliable method of identification is the Energy Field.  This is better than the fingerprints as a person’s energy field is absolutely unique!

13) SIS TE R CALIS TA ROY: AD APTA TION MODEL  Man is a BIOPSYCHOSOCIAL BEING  Four (4) modes of Adaptation  Physiologic Mode Compatible with Hans Selye  Self Consent  Role Function  Interdependence

14) LYDIA HALL: CARE, CORE, CURE Care Comfort measures given by the nurse to a patient Nurturance aspect of Nursing Core Therapeutic use of self Cure Activities in relation to doctors’ orders Dependent orders

15) JEA N WATSON : HUMAN CARING MODEL  Nursing involves the application of ART and HUMAN SCIENCE through TRANSPERSONAL TRANSACTIONS in order to help the person achieve mind, body and soul harmony

16) ROSE MARIE RIZ ZO PARSE : THEORY OF HUMAN BECOM ING  Emphasis is a FREE CHOICE (with personal meaning)  Actions of patients may either be:  Revealing or concealing  Enabling or limiting  Therefore, there is a consequence  This pertains to behavior and action

17) J OSE PH INE PA TTE RSON & LORE TA ZDERA D: HUMANIS TIC NU RSIN G PRA CTIC E THEORY

 Nursing is an EXISTENTIAL EXPERIENCE between the nurse and the patient (nagkataon-nagkatagpo!)  Nursing is a LIVE DIALOGUE between the patient who wants to be nursed and the nurse who has the skill to nurse

18) H ELEN TOM LIN, EVEL YN TOM LYN & MARY ANN SW AIN: MOD ELING A ND R EMODELIN G THEORY  Focus is on the PERSON  Emphasis is on the UNCONDITIONAL ACCEPTANCE of the PATIENT

19) A NN BOY KIN & SAVINA SCHOE NH OFER: GRA ND T HEO RY OF NU RSIN G AS A CARIN G TH EORY

 Nursing is NOT BASED on a DEFICIT but rather it is an EGALITARIAN MODE of helping  This theory is against the theory of OREM

19) A NN BOY KIN & SAVINA SCHOE NH OFER: GRA ND T HEO RY OF NU RSIN G AS A CARIN G TH EORY

 Nursing is an obligation towards humanity, whether there is a need or NOT!

20 ) M ARG ARET NEW MAN: HEALTH A S E XPA NDING CON SC IOU SN ES S  Humans are Unitary Human Beings  The nurse is a NOT A GOAL-SETTER or an OUTCOME PREDICTOR, rather is a PARTNER OF THE PATIENT

21 ) JOYC E TRAVE LBEE: INTERP ERS ONA L PRO CESS TH EORY  Nurse needs to go beyond nursing roles to establish therapeutic relationship  TRANSPERSONAL COMMUNICATION as the means to establish therapeutic relationship  This implies that the nurse should not be rigid in the nursing role

22) ID A JE AN ORL AND O: DYNA MIC NU RSE -PA TIEN T REL AT ION SH IP M OD EL

 There is movement, the relationship is not static  If the patient’s condition improved, then the intervention is effective and the patient moves on to new problems

23) NOL A PE NDER: HEALTH PROM OT ION M OD EL  Motivation to participate in health care activities influenced by COGNITIVE and PERCEPTUAL FACTORS:  Importance of health to the person  Perceived control of health  Self-efficiency  Perceived health status  Definition of health  Perceived barriers to

24) PHIL B ARK ER & POP PY BUCHANA NBARK ER: TID AL MOD EL  Helping patients recall their own personal stories of DISTRESS is the FIRST STEP in helping them regain control of their lives again!

25) C ORB IN A ND ST RAU SS: TRA JE CTORY M OD EL

 The patient moves in a TRAJECTION of Eight (8) Phases  Nurse needs to follow the patient along the eight phases of trajection

EIGH T P HASES OF TRA JECTION BY CORB IN A ND ST RA USS  1. Pre-Trajectory Phase  Patient shows no signs and symptoms of illness  No sickness  2. Trajectory Onset Phase  Patient now has signs and symptoms of illness  3. Crisis Phase  Patient is unstable  Patient is in a life-threatening situation  Patient is critical  4. Acute Phase  Patient is in a state of active illness

EIGH T P HASES OF TRA JECTION BY CORB IN A ND ST RA USS  5. Stable Phase  Patient’s illness is controlled  Patient may still be in the hospital  6. Unstable Phase  Patient is on a critical period  Signs and symptoms are present  Patient is NOT in the hospital  Patient is NOT under control  Patient is OUT of the hospital  7. Downward Phase  Patient is in a deteriorating phase  8. Death

26 ) BONNIE WEAVER D ULDT BATTE Y: HUMAN IST IC NURS ING COMMUNIC ATIO N THEORY  Emphasis is on the interpersonal relationship between the nurse, the patient, the peers and colleagues

27 ) MCGIL L: MOD EL OF NURSI NG  Emphasis is to encourage and engage the patient and the family to actively participate in learning about health

28 ) KATH RYN B ARNARD : PA RENT -CHIL D IN TE RA CTIO N MOD EL  In order to produce a healthy person, the baby’s need should be ADDRESSED AT ONCE!  Application: Bonding

29) A LFRE D ADLER: THEORY OF PE RSON ALIT Y

 The personality of an individual is affected by the BIRTH ORDER

30) GLADYS H UST ED & JA MES H USTE D: SYM PHONOL OGIC AL-B IOET HIC AL THEORY

 Symphono- means harmony and agreement

 Governed by ethical standards, which influence nursing actions.

LEVELS OF PREVENTION

LEVEL S OF P REVEN TION  Primary Prevention  Secondary Prevention  Tertiary Prevention

PRIM ARY PREV ENT ION  Emphasis on:  Generalized health promotion and specific protection  Recipients are GENERALLY HEALTHY PEOPLE  When given:  Before onset of illness or before onset of disease

PRIM ARY PREV ENT ION  Examples:  Generalized health education Prevention of accidents Standards of nutrition  Immunizations Specific preventions  Risk Assessment for specific disease  Family Planning Services and Marriage Counseling  Environmental Sanitation  Recreation and Housing

SE COND ARY PRE VEN TION  Emphasis placed on:  Early detection / diagnosis  Prompt treatment  Health maintenance of persons already having health problems  Prevention of complications  When given:  During illness

SE COND ARY PRE VEN TION  Examples:  Screening survey  Encouraging regular check-ups  Complying with regular check-ups  Teaching Breast-self-examination  Teaching Testicular-self-examination

CON CEP T!  Most effective method of teaching is DEMONSTRATION

SE COND ARY PRE VEN TION  Additional Examples of Secondary Prevention  Assessment of growth and development  General nursing assessment and care at the hospital, community and the home

TERT IA RY PREV ENT ION  Emphasis placed on:  Support of the client to achieve the following: Successful re-adaptation Optimal reconstitution Regain high-level wellness  Therefore, the purpose is more of REHABILITATION  When given:  Begins after the illness or when a defect or disability is fixed or irreversible

TERT IA RY PREV ENT ION  Examples:  Referring a client to support groups  Teaching a diabetic client how to inject insulin

ROLES OF A NURSE

ROLES OF A NU RSE  1. Caregiver / Care Provider  To convey understanding and support  Activities: Support and comfort measures (mothering aspect of nursing / nurturance aspect of nursing)

ROLES OF A NU RSE  2. Counselor  Involves helping patient identify and avoid stressful and psychological problems  Focuses on: Helping client establish capacity for successful interpersonal relations Helping the patient develop new coping skills

CON CEP T!  Do not give advice!  This is meant to facilitate decision-making on the part of the client  This is observed so that the client would not develop DEPENDENCY

ROLES OF A NU RSE  3. Client Advocate  Protects rights of patients  Activity: Speaking on behalf of the patient

ROLES OF A NU RSE  4. Change Agent  Brings change or adjustments  Nurse only influences a patient  Nurse does not change the patient

ROLES OF A NU RSE  5. Teacher  Teaching  Imparting of knowledge

ROLES OF A NU RSE  6. Leader  Application of interpersonal influence to bring out desired behavior (leadership)

ROLES OF A NU RSE  7. Manager  Decision-making  Planning  Giving directions  Monitoring operations  Facilitating staff development  Therefore, this is done on the supervisory level of organization

ROLES OF A NU RSE  8. Researcher  After graduation, nurse cannot yet be a researcher  He can only be a researcher after he receives his Master of Arts in Nursing (M.A.N) degree

TEACHING AND LEARNING STRATEGIES

TE ACHIN G AN D LEARNIN G STRA TEG IE S  Basic Guidelines  Develop a well-defined objective  Assess client’s readiness to learn  Start with what the client is concerned about

TE ACHIN G AN D LEARNIN G STRA TEG IE S  Basic Guidelines  Assess and start with what the client already knows; proceed from the known to the unknown  Start with the simple proceeding to the complex  Schedule a review of the content

CON CEP T!  Areas of Learning Domain  Knowledge – cognitive  Skills – motor  Attitude – emotional

TEA CHING ST RA TE GIE S  1. Explanation and Description  Address cognitive aspect of learning

TEA CHING ST RA TE GIE S  2. One-to-one Discussion  Addresses affective and cognitive learning

TEA CHING ST RA TE GIE S  3. Answering Questions  Cognitive

TEA CHING ST RA TE GIE S  4. Demonstration  Motor

TEA CHING ST RA TE GIE S  5. Discovery  Cognitive and Affective

CON CEP T!  Learning is more effective if the learner discovers the content for himself. (That is, through experience!)

TEA CHING ST RA TE GIE S  6. Group Discussion  Affective and Cognitive  Sharing feelings during group dynamics

TEA CHING ST RA TE GIE S  7. Practice  Motor

TEA CHING ST RA TE GIE S  8.Printed and Audiovisual Material

TEA CHING ST RA TE GIE S  9. Role-playing  For pediatric and psychiatric nursing settings

TEA CHING ST RA TE GIE S  10. Modeling  What you say is what you do

TEA CHING ST RA TE GIE S  11. Computer Assisted Learning Programs  Online review

NURSING PROCESS

TH E NU RSING PROC ES S

 Definition:

 The Nursing Process is a systematic, organized, rational method of planning and providing individualized, humanistic nursing care

PURPOSES OF THE NURSING PROCESS  To identify health status  Actual health problems  Potential health problems  To establish plans  To deliver specific nursing care

CHARACTERISTICS OF THE NURSING PROCESS 

Goal-oriented and client-centered



Cyclical (no absolute beginning and end), dynamic (moving) rather than static



Plan of care organized according to client problems rather than nursing goals

CHARACTERISTICS OF THE NURSING PROCESS 

Basis of prioritizing nursing activities would be the problems and not the goals



Follows a logical sequence



Universally applicable (to any type of patient)



Interpersonal and collaborative  Work with patients and relatives  Work with colleagues and other members of the health team

CHARACTERISTICS OF THE NURSING PROCESS 

Adaptation principles

of

problem-solving

techniques



Problem-oriented, flexible, open to new information



Allows creativity of nurse and patient

and

BENEFITS DERIVED FROM THE NURSING PROCESS  Concepts:  Both the nurse and the patient benefit from the nursing process  Patient obtains greater benefit  Remember: Nursing process is PATIENT-CENTERED CENTERED

CLIENT-CENTERED or and NOT NURSE-

BENEFITS DERIVED FROM THE NURSING PROCESS  Improves quality of care  Ensures continuity and appropriate level of care  Facilitates client participation through planning with patient  Enables nurse to maximize resources

BENEFITS DERIVED FROM THE NURSING PROCESS  Feedback allows nurse to evaluate care  Serves as a framework for accountability through documentation  Promotes a positive working atmosphere through collaboration  Helps the nurse define roles to those outside the profession

BENEFITS DERIVED FROM THE NURSING PROCESS  For job satisfaction  Facilitates professional growth  Avoidance of legal action  Meeting standards of accredited hospitals

PARTS OR COMPONENTS OF THE NURSING PROCESS  Assessment Phase  Diagnosing Phase  Planning Phase  Intervention Phase  Evaluation Phase

ASSESSMENT PHASE OF THE NURSING PROCESS

ASSESSMENT PHASE OF THE NURSING PROCESS  Nursing Activities in the Assessment Phase  Data Collection  Data Organization  Data Validation  Data Recording

IMPORTANT CONCEPT!  No conclusion is developed in the assessment phase

ASSESSMENT PHASE OF THE NURSING PROCESS  Purposes of the Assessment Phase  To create a data base of the client’s response to health and illness  To determine the nursing care needs of the patient

FOUR TYPES OF ASSESSMENT  Initial Assessment  Focus Assessment or On-going Assessment  Emergency Assessment  Time-Lapsed Assessment

FOUR TYPES OF ASSESSMENT  1. Initial Assessment  When performed: At specified time after admission  Where done: Done at the ward  Where Admitted: At the ward  Purpose of Initial Assessment: To create a data base for problem identification For reference and future comparison

FOUR TYPES OF ASSESSMENT  2. Focus Assessment or On-going Assessment  When performed: Integrated throughout the nursing process  Purpose of On-going Assessment: To identify problems overlooked earlier To determine the status of a health problem (i.e. hydration status every fifteen minutes)

FOUR TYPES OF ASSESSMENT  3. Emergency Assessment  When done: During acute physiologic and psychologic crisis  Where done: Emergency Room Comfort Room Anywhere!!! On site!!!  Purpose of Emergency Assessment To identify life-threatening condition

FOUR TYPES OF ASSESSMENT  3. Emergency Assessment  Framework or Principle in Emergency Assessment A – Airway B – Breathing C – Circulation  Utilize either Maslow’s Hierarchy of Needs or ABC principle

FOUR TYPES OF ASSESSMENT  4. Time-Lapsed Assessment  When done: Several months after initial assessment  Purpose of Time-Lapsed Assessment To compare current status of patient with base line data (initial assessment)

ASSESSMENT PROCESS  Concept:  Data is equivalent to information

ASSESSMENT PROCESS  What is the initial output of the Assessment Phase?  Data or Recorded Data  Never validated data!!!

TYPES OF DATA  1. Subjective or Covert Data  Felt by the patient  During the recording of data, this should be stated using the patient’s own words  These are the symptoms felt by the patient

TYPES OF DATA  2. Objective or Overt Data  Capable of being observed by use of senses – sight, touch, smell, taste, hearing  These are the signs which are observable

SOURCES OF DATA  1. Primary Source  Patient himself except when: He is unconscious Patient is a baby Patient is insane

SOURCES OF DATA  2. Secondary Source  Patient’s record  Health care members  Related literature or journals  Significant others (they become primary source when patient is unconscious)  Family or relatives  The person who brought the patient to the hospital

SOURCES OF DATA  3. Environment of the Patient  Example: Patient with diabetes mellitus exhibits acetone breath • Assess for diabetic ketoacidosis

METHODS OF DATA COLLECTION  Observing  Interviewing  Examining

METHODS OF DATA COLLECTION: OBSERVING  It should be deliberate  Exert effort!!!

METHODS OF DATA COLLECTION: OBSERVING  Two (2) aspects of observation process:  Noticing the stimuli  Do an interpretation of the stimuli

METHODS OF DATA COLLECTION: INTERVIEWING

Two types of Interview Directive Type of Interview Non-directive Type of Interview or Rapportbuilding Interview

DIRECTIVE TYPE OF INTERVIEW  Structured  Uses closed-ended questions calling for specific data  When used:  When you need to elicit specific data  When there is little time available

CONCEPT!  Characteristics of Closed-ended questions:  Yes or No questions  Asks when or asks for the time when event happened  Asks how many  Point with finger when asking to provide clarity  Therefore, they call for highly specific answers

NON-DIRECTIVE TYPE OR RAPPORT-BUILDING INTERVIEW  Uses more open-ended questions  Advantage is that it allows the patient to volunteer information

TYPES OF INTERVIEW QUESTIONS  Open-Ended Questions  Closed-Ended Questions  Neutral Questions

TYPES OF INTERVIEW QUESTIONS  1. Open-Ended Questions  Questions not answerable by “yes” or “no”  Questions that elicit information or explanation

TYPES OF INTERVIEW QUESTIONS  2. Closed-Ended Questions  Questions answerable by “yes” or “no”  Leading Questions  Phrasing of question suggests what answer the interviewer is expecting

TYPES OF INTERVIEW QUESTIONS  3. Neutral Questions  Phrasing allows patient to answer with least pressure  Usually NOT addressed to patient personally (i.e. what is your opinion about…)  Raised as a general topic

PLANNING THE INTERVIEW SETTING  Concepts:  Before the interview, determine what information you already know or what information is available  An interview is a planned conversation with a purpose  An interview is a two-way process

PLANNING THE INTERVIEW SETTING  Concepts:  When is it done? When patient is available When patient is comfortable  Recommended distance from the patient is three (3) to four (4) feet.

STAGES OF THE INTERVIEW  1. Opening Stage  Key Concept!!! This is the most important part of the interview  Rationale What was said and done during the opening stage sets the tone all throughout the interview

THE INTERVIEW  2. Body of the Interview  Occurs when patient responds to questioning

THE INTERVIEW  3. Closing Stage  How to close the interview: Summarizing Technique

VALIDATION OF DATA  Act of double-checking the data  Purposes of Data Validation  To ensure the: Correctness Completeness Accuracy of the data

GUIDELINES IN VALIDATION OF DATA  Compare subjective and objective data  Be familiar with word usage (particularly if the patient is a child)  Reassess / double-check data which are extremely abnormal  Be sure that your data contains CUES and not INFERENCES  Be sure that your data is FREE OF BIASES  Avoid jumping to conclusions

DATA RECORDING  Concepts:  Data Recording COMPLETES the Assessment Phase  Initial Output of the Assessment Phase is DATA  Final Output of the Assessment Phase is RECORDED DATA

DIAGNOSING PHASE OF THE NURSING PROCESS

DIAGNOSING PHASE OF THE NURSING PROCESS  Activities during the Diagnosing Phase:  This involves sorting, interpreting data

clustering,

analyzing

and

DIAGNOSING PHASE OF THE NURSING PROCESS  Concept:  The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!!

DIFFERENT TYPES OF NURSING DIAGNOSES  1. Actual Nursing Diagnosis

Problem present at the time the statement was made  Describes a clinical judgment that the nurse has validated because of the presence of major defining characteristics.  Example: Ineffective Airway Clearance related to excessive and tenacious secretions

DIFFERENT TYPES OF NURSING DIAGNOSES  2. High-Risk Nursing Diagnosis

A diagnosis that a patient is more vulnerable or susceptible compared with others in the same situation  Example: Risk for Impaired Skin Integrity related to immobility secondary to fractured hip.

DIFFERENT TYPES OF NURSING DIAGNOSES  3. Possible Nursing Diagnosis

There is an evidence of a health problem but the causes are NOT fully understood  An option to indicate that some data are present to confirm a diagnosis but are insufficient as of this time  Example: Possible Self Care Deficit related to impaired ability to use left hand secondary to presence of intravenous therapy.

DIFFERENT TYPES OF NURSING DIAGNOSES  4. Wellness Nursing Diagnosis  A positive statement  Indicates a healthy response  Examples: Potential for increased compliance related to increased level of knowledge Potential for enhanced body image related to regular exercise Potential for effective coping related to adequate support systems

DOMAINS OF NURSING DIAGNOSES  Key Concept!  It only includes health problems that a nurse is capable and licensed to treat

PARTS OF A NURSING DIAGNOSIS  1. Problem Statement  Example: Fluid Volume Deficit  2. Presumed Etiology  Example: …related to frequent loss of bowel movement  3. Defining Characteristics  Example: …as manifested by decreased skin turgor

ADVANTAGES OF USING A STANDARDIZED DIAGNOSTIC TERMINOLOGY  Provides professional accountability and autonomy by defining and describing the independent areas of practice  Provides effective vehicle of communication  Provides an organizing principle for meaningful research  Facilitates continuity and individualized care

PLANNING PHASE OF THE NURSING PROCESS

PLANNING PHASE OF THE NURSING PROCESS  Concept:  Planning means: Determining ahead of time Forecasting a course of action

PLANNING PHASE OF THE NURSING PROCESS  Key Concept!!!  For your plans to be effective, involve the patient and the family

PLANNING PHASE OF THE NURSING PROCESS  IMPORTANT CONCEPT!!!  Final output of the Planning Phase is a NURSING CARE PLAN or a WRITTEN CARE PLAN

TYPES OF PLANNING  1. Initial Planning  Done by the nurse  When done: At specified time upon or after admission of the patient

TYPES OF PLANNING  2. On-going Planning  Who are involved: Done by all nurses who worked with the patient The patient himself The family But primarily, the NURSE

TYPES OF PLANNING  2. On-going Planning  Purposes of On-going Planning To determine if the client’s health status has changed To decide which problems to focus on during the shift To set priorities for client care during the shift To coordinate the patient care and activities so that more than one problem can be addressed at the same time

TYPES OF PLANNING  3. Discharge Planning  Purpose of Discharge Planning To ensure continuity of care

CHARACTERISTICS OF THE PLANNING PROCESS  S – Specific  M – Measurable  A – Attainable  R – Realistic  T – Time bound

ACTIVITIES DURING THE PLANNING PROCESS  Set priorities  Set goals  Identify alternatives of nursing care  Select nursing measures  Write nursing orders (supervisors do this)  Write the nursing care plan

PURPOSES OF GOAL-SETTING  To set direction  To provide a time span  To have a criteria for evaluation  To enable the nurse and the patient to determine whether the problem has been resolved or not  To help motivate the client and the patient by providing a sense of accomplishment

KEY CONCEPT IN GOAL SETTING!  For your goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS

IMPLEMENTATION PHASE OF THE NURSING PROCESS

IMPLEMENTING PHASE OF THE NURSING PROCESS  Implementation  Putting the care plan into action

IMPLEMENTING PHASE OF THE NURSING PROCESS  Purpose of Implementation  To carry out planned activities  To help the client

IMPLEMENTING PHASE OF THE NURSING PROCESS  Concept!!!  The implementation phase ends upon recording of the care given and the response of the patient to that procedure

IMPLEMENTING PHASE OF THE NURSING PROCESS  Requirements for Implementation  Adequate knowledge  Technical Skills  Communication skills  Therapeutic use of self  Right attitude as a requirement

NURSING ACTIVITIES DURING THE IMPLEMENTATION PHASE  Reassess the patient  Rationale To determine if the procedure is still needed  Determine the need for nursing assistance  Implement the nursing strategies

NURSING ACTIVITIES DURING THE IMPLEMENTATION PHASE  Communicate the procedure performed by documenting the procedure  Understand orders  Clarify / verify doctors’ orders  Encourage patient to participate actively

GUIDELINES FOR IMPLEMENTATION OF NURSING STRATEGIES  It should be based on scientific knowledge, research, professional standards of practice (care)  Rationale: This is done to ensure safe nursing care  It should be adapted to the individual patient

GUIDELINES FOR IMPLEMENTATION OF NURSING STRATEGIES  It should always be safe. Do not compromise  It should be holistic  It should be accompanied by support, comfort and teaching

EVALUATION PHASE OF THE NURSING PROCESS

EVALUATION PHASE OF THE NURSING PROCESS  Purpose of the Evaluation Phase  To determine client’s progress  To determine the effectiveness of the care plan  To determine as to what extent the nursing goals have been met

EVALUATION PHASE OF THE NURSING PROCESS  Importance of doing an Evaluation  It determines if the care plan will be: Continued Modified Discontinued

EVALUATION PHASE OF THE NURSING PROCESS  Activities during the Evaluation Phase  Identify the OUTCOME CRITERIA to be used as measurement  Gather information (data) relevant to the outcome criteria  Compare outcome (data) with the criteria  Assess the reasons for the outcome  Revise the nursing care plan as needed

TYPES OF EVALUATION  1. On-going Evaluation  When done: During or immediately after the intervention  Importance: Allows the nurse to decide and make on-the-spot modification/s in an intervention

TYPES OF EVALUATION  2. Intermittent Evaluation  When done: At a specified time  Purpose: It shows the extent of progress of the patient  Importance: Enables the nurse to correct deficiencies and modify the nursing care plan

TYPES OF EVALUATION  3. Terminal Evaluation  When done: At or immediately before discharge  Importance: States the status of a health problem at the time of discharge It determines whether the goals are: • Met • Partially met • Unmet

DOCUMENTATION

DOCUMENTATION  It is a written, formal document  A record of client’s progress

PURPOSES OF DOCUMENTATION  Planning Care  Communication  For legal documentation purposes  For research  For education  Reimbursements  For statistics, reporting, epidemiology  Accreditation, licensing

GUIDELINES ON DOCUMENTATION  Timing  Document patient care as soon as possible  Observe confidentiality  Observe permanence  Use non-erasable ink  Do not use sign pen

GUIDELINES ON DOCUMENTATION  Signature  Sign full name and append R.N.  Accuracy  Ensure that data is correct  Avoid biases  Avoid ambiguous terms  Appropriateness  Write only appropriate information

GUIDELINES ON DOCUMENTATION  Completeness  Use standard terminology  Brevity  Make it concise yet meaningful  Legal Awareness  Cross out erroneous entry  Write “Error”  Countersign

TYPES OF RECORDS  Source-Oriented Clinical Record  Problem-Oriented Clinical Record

SOURCE-ORIENTED CLINICAL RECORD  Accumulation of chronological, variative notations that are difficult to follow because they are not assembled into an orderly or scientific manner  Classification of information is based on SOURCE  Each person or department maintains a different section on chart

COMPONENTS OF A SOURCE-ORIENTED CLINICAL RECORD  Admission Sheet  Face Sheet  Medical History and Physical Examination Sheet  Diagnostic Findings Sheet  TPR Graphic Sheet  Doctor’s Treatment and Order Sheet  Therapeutic Sheet

PROBLEM-ORIENTED CLINICAL RECORD  Same as Problem Oriented Medical Record  Entry of data is based on CLIENT’S PROBLEM  Example: Problem No. 1: constipation • Increase fluid intake: doctor • Diatabs: pharmacist • NPO:  Includes observations about the patient  Example: Radiologist’s notes are with doctor’s notes under one problem

FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD

 1. Baseline Data  All information gathered from a patient when he first entered the agency

FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD

 2. Problem List  Contains only ACTIVE problems information about the problem)

(and

relevant

 No potential problems (these are contained only in the progress notes)

FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD

 3. Initial list of orders or Care Plans

FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD

 4. Progress Notes  Includes: Nurses’ narrative notes (SOAPIE) Flow sheets Discharge Notes and Referral Summaries  Formats: SOAPIE – for revisions

COMMON METHODS OF COMMUNICATION AMONG NURSES  1. Referring  To endorse patient’s special concern to a higher authority or a specialized department or personnel

COMMON METHODS OF COMMUNICATION AMONG NURSES  2. Confer  Verifying information

COMMON METHODS OF COMMUNICATION AMONG NURSES  3. Reporting  Giving information to a concerned person

KARDEX  Is the Kardex a part of the patient’s record?  No, it is not!!!  It is just a bulletin board

PURPOSES OF THE KARDEX  To make valuable information readily available  Allergies are written in red ink  It is a reminder  It is not a record

IMPORTANT CONCEPT  A Nursing Care Plan is not a record!!!

COMMUNICATION

COMMUNICATION  Exchange of ideas, information, feelings, data between two communicators

CONCEPT!  Communication is the basic component of Human Relationships

ELEMENTS OF COMMUNICATION  1. Message Data  2. Sender Encoder  3. Receiver Decoder  4. Feedback  5. Context Setting Overall environment where the communication takes place

MODES OF COMMUNICATION  1. Verbal Oral Spoken Written communication Text communication Cable communication Telex communication Facsimile communication

MODES OF COMMUNICATION  2. Non-verbal communication Facial expression Grimacing Posture Gait Adornment Make-up Gestures

FACTORS AFFECTING COMMUNICATION  Ability of the communicator  Perceptions  Proxemics  Distances between communicators Intimate Distance • Actual physical contact to 1.5 feet Personal Distance • 1.5 feet to 4 feet • 3 feet to 4 feet for interview Social Distance • 4 feet to 12 feet Public Distance • 12 feet and beyond

FACTORS AFFECTING COMMUNICATION  Territoriality  One person believes that the space and all the things in that space belongs to him  Do not enter abruptly; this may result in breach of privacy  Roles and relationships

THERAPEUTIC COMMUNICATION IN NURSING  Using Silence  Supplement with non-verbal communication  Provide General Leads  Examples: “…go on” “…tell me more”  Open-ended questions

THERAPEUTIC COMMUNICATION IN NURSING  Use Touch  But assess the culture of the patient  If the patient is a child, touch the patient on the top of the head  If the patient is an elderly, touch the patient on the hand  If the patient is of the same age level, touch the patient on the shoulder  Offering yourself  For autistic child Stay nearby or stay beside the patient

THERAPEUTIC COMMUNICATION IN NURSING  Presenting Reality  Example: “You are in the hospital”  Reflecting  Example: “What do you think will make you happy”  Never agree nor disagree  Reflect it back or throw it back

NON-THERAPEUTIC COMMUNICATION  Stumbling blocks to effective communication  Stereotyping  Generalizing  Agreeing and Disagreeing  No confrontation  No argument  Being defensive  Moralizing or Passing Judgment  Giving Common Advise Examples: • “If I were you…” • “You should have done it…”

PROMOTING REST AND SLEEP

CIRCADIAN RHYTHM  A biological rhythm  A biological clock  Regulated from outside the person’s body

TYPES OF SLEEP  1. Rapid Eye Movement Sleep (REM Sleep)  Increased brain metabolism and activity  Also called PARADOXICAL SLEEP  Characterized by: Vivid dreams Easily recalled upon awakening

TYPES OF SLEEP: REM SLEEP

 Colorful, dramatic, emotional, implausible dream  Characterized by rapid eye movements  Almost complete loss of muscle control

TYPES OF SLEEP: REM SLEEP

 Penile erection (males) and vaginal moistening (females)  Easy to awaken  Usually a time for more intensive, vivid dreams

TYPES OF SLEEP: REM SLEEP

 REM sleep varies

 Adolescents spend 30% of total sleep time in REM sleep  Adults spend 15% of total sleep in REM sleep

CONCEPTS!  REM sleep is NOT AS RESTFUL as NON-REM sleep  However, REM sleep is NEEDED  Dreaming is a psychological outlet of pent up emotions

NURSING ALERT!  Deprivation of REM sleep results to:  Irritability  Restlessness  Poor concentration

TYPES OF SLEEP  2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)  Deep restful sleep  Benefit is that it restores the body physically and psychologically (especially for post-operative patients)

TYPES OF SLEEP: NON-REM SLEEP STAGE 1

    

Stage of very light sleep The eyes roll from side to side Heart and respiratory rates drop slightly The sleeper can be readily awakened Stage only lasts for a few minutes

TYPES OF SLEEP: NON-REM SLEEP STAGE 2

 Stage of light sleep in which the body processes continue to slow down  The eyes are generally still  The heart and respiratory rates decrease slightly  The body temperature falls  Lasts only about 10 to 15 minutes but constitutes 40 – 45% of total sleep

TYPES OF SLEEP: NON-REM SLEEP STAGE 3

 The heart and respiratory rates, as well as other body processes, slow further because of the domination of the parasympathetic nervous system  The sleeper becomes more difficult to arouse  The person is not disturbed by sensory stimuli  The skeletal muscles are very relaxed  The reflexes are diminished and snoring may occur

TYPES OF SLEEP: NON-REM SLEEP STAGE 4

 Delta sleep or deep sleep  Heart and respiratory rates drop 20 – 30% below that exhibited during waking hours  Sleeper is very relaxed, rarely moves and is difficult to arouse  This stage is thought to restore the body physically  The eyes usually roll and some dreaming occurs

CONCEPT!  Deprivation of Non-REM sleep causes:  Physical exhaustion  Decreased resistance against infection

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Establish a regular routine  Have adequate exercise at daytime  Avoid stimulating activity by bedtime

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Avoid all types of stimulants  Caffeine-containing foods Coffee Cocoa Chocolate Tea Cola  Nicotine  Alcohol Prolongs the REM stage of sleep It excites the patient like an anesthetic Not a stimulant

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Avoid shabu  Use the bed mainly for sleep  If unable to sleep, get up and pursue satisfying activity

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Drink something warm or hot (except stimulants)  Milk contains L-tryptophan  L-tryptophan is an amino acid with a natural sedative effect that induces one to sleep

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Do something HOT!  Twice-a-week masturbation is ideal  Facilitates release of tension of the day

WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP  Side-to-side turning every two hours with back tapping  Support bedtime rituals  Remove all music in order to sleep

PROMOTING OXYGENATION

DEEP BREATHING

Two (2) types of Deep Breathing: Apical Deep Breathing Basal Deep Breathing

APICAL DEEP BREATHING  Done to expand the upper portion of the lungs  Let the patient place palms on the upper chest  Concentrate on that area  Take a slow deep breath at a count of 1,2,3  Release it slowly through the nose or a pursed lip at a count of 4,5,6,7  Therefore, expiration is longer than inspiration  Rationale: To prevent respiratory alkalosis

APICAL DEEP BREATHING  Taught to patients who will undergo:  Upper abdominal surgery  Cholecystectomy Incision site on diaphragm Patient does not want to breathe Predisposed to hypostatic pneumonia

BASAL DEEP BREATHING  Same procedure  Area of concentration is the lower ribcage  When to teach patient:  Before surgery  Before pain is present  Rationale:  If pain is already present, it would be difficult for patient to follow

BASAL DEEP BREATHING  When done:  Done q2 hours together with turning

COUGHING EXERCISES  Purpose  To expand the lungs  To facilitate expectoration of secretions  How often done:  At least every two (2) hours

COUGHING EXERCISES  Procedure  Teach the patient to inhale and exhale  Tell the patient to inhale and exhale a second time  Tell the patient to inhale and cough out

NURSING ALERT!  Coughing patients:

is

contraindicated

in

the

following

With increased intracranial pressure (ICP) With increased intraoptical pressure (IOP) With cardiac arrhythmias (but are allowed to do deep breathing)

CONCEPTS!  Deep Breathing and Coughing  Purpose is to stimulate surfactant production  Yawning and production

sneezing

also

stimulate

surfactant

OXYGEN INHALATION AND ADMINISTRATION  Practical Application Concept!  When administering oxygen, be sure to open the valve of the oxygen tank first.  Be certain that the valve on the regulator is closed so that the flow meter would not break!

CONCEPTS!  Humidifier moistens oxygen administered

the

 Purpose

 To avoid drying and irritation of the mucosal lining  Also traps particulates from the tank Iron oxide may be present in the tank (iron plus oxygen produces iron oxide or rust)

CONCEPTS!  Fire Precaution  Place ‘NO SMOKING’ sign at the door or at the head part of the patient  Tank and oxygen do not explode  They merely support combustion

OTHER CONCEPTS!  Do not use volatile substances  Acetone and alcohol can react with oxygen and lead to toxicity of patient  Do not use oil based or grease on any part of the oxygen set  Do not allow the patient to use an electric razor as sparks may trigger combustion

NURSING ALERT!  Retrolental Fibroplasia occurs if there is excess oxygen administration in infants.  Excess oxygen leads to destruction of the retina and blindness

MODES OF ADMINISTRATION  1. Low Flow Administration

 Utilizes nasal cannula or nasal prongs or nasal catheters  Given to COPD patients

 2. High Flow Administration

 Uses a venturi mask

NEBULIZATION  With sodium chloride and salbutamol  A physiologic solution  Water liquefies secretions  Sodium chloride stimulates coughing  Salbutamol is a bronchodilator  Purpose:  For expectoration of secretions

NURSING PRE-THERAPY ASSESSMENT PRIOR TO NEBULIZATION  Have baseline data of patient’s breath sounds  Assess again after nebulization to assess effectiveness of the procedure

SPIROMETRY  Purpose is to expand the lungs  Done when inhaling  Instruction to the patient:

 Inhale from the spirometer and NOT blow to the spirometer  Procedure:  Inhale – exhale  Inhale – exhale fully  Place mouthpiece between teeth  Hold breath for four (4) seconds  Then inhale, fully rising the ball  Upon inhalation, the ball rises

CHEST PHYSIOTHERAPY  This is a dependent procedure  There are no absolute contraindications procedure  Contraindicated for the following patients with:  Pacemakers  Lung abscess  Hemoptysis  Dangerous Arrhythmias  Active PTB (which goes to the other lobe)  Lung CA (malignancy goes to other lung)

to

this

THREE COMPONENTS OF CHEST PHYSIOTHERAPY  Percussion  Vibration  Postural Drainage

THREE COMPONENTS OF CHEST PHYSIOTHERAPY  1. Percussion

Use cupped hands Hands alternate in rising and coming into contact with chest or back of patient

THREE COMPONENTS OF CHEST PHYSIOTHERAPY  2. Vibration

Palms of your hand are placed on chest or back of patient giving quivering motions Palms remain in contact with the chest or back

THREE COMPONENTS OF CHEST PHYSIOTHERAPY  3) Postural Drainage  Drain secretions by gravity  Change positions

POSTURAL DRAINAGE POSITIONS

IMPORTANT CONCEPT!  Rule out contraindications before performing chest physiotherapy

PRE-THERAPY ASSESSMENT FOR VIBRATION AND PERCUSSION  Assess breath sounds to know which lung fields have secretions  Then

assess

again

after

effectiveness of the procedure.

procedure

to

check

CONCEPTS!

Vibration and percussion are mechanically dislodge secretions

done

to

Nebulization is done to liquefy secretions Suctioning is done to clear secretions Postural Drainage is done to drain secretions using gravity

POSTURAL DRAINAGE  When done:  Before meals  Two (2) hours after meals  Before doing the procedure, the following baseline data are needed:  Breath sounds  Vital signs  Continuous ECG monitoring

POSTURAL DRAINAGE  During the procedure:  Ensure the comfort of the patient  Provide a kidney basin and tissue paper

NURSING ALERT!  Watch out for signs of symptoms which may require stopping of the procedure: Sudden dyspnea Cyanosis Extreme diaphoresis Sudden alteration of blood pressure, respiratory rate, pulse rate Appearance of arrhythmias Hemoptysis General intolerance of the procedure

IMPORTANT CONCEPT!  If any of those written on the previous slide occurs, STOP THE PROCEDURE and inform the physician

CONCEPT!  After the procedure assess the following:  Breath sounds  Vital signs  Quantity and quality of sputum  Overall response of the patient to the procedure  Give oral hygiene  Rationale: To eliminate phlegm from the mouth

IMPORTANT CONCEPT!  Patients with cystic fibrosis benefit much from postural drainage

SUCTIONING

SUCTIONING  Purpose is to seek out secretions

CONCEPTS ON SUCTIONING  Question:  If you have only one (1) suction catheter, which will you suction first, the nose or the mouth?  Answer:  If the patient is an infant or a newborn: Start on the mouth then proceed to the nose  Rationale:  If you start on the nose, you will trigger the sneezing reflex and this would result into aspiration

CONCEPTS ON SUCTIONING  Question:  If you have only one (1) suction catheter, which will you suction first, the nose or the mouth?  Answer:  If the patient is an adult, suction the mouth first, then proceed to the nose  Rationale:  This is done for aesthetic reasons

TYPES OF SUCTIONING TYPE OF SUCTIONING: OROPHARYN -GEAL SUCTIONING

POSITION OF THE PATIENT WHILE SUCTIONING

DEPTH

DURATION

INTERVAL WITH EACH PASS OF SUCTION

TOTAL TIME

If the patient is conscious

Fowler’s (high or moderate); Head turned to one side (towards the nurse)

10 – 15 cm

Not more than 10 – 15 seconds

20 – 30 seconds

Not more than 5 minutes

If the patient is unconscious

Place on one side (facing the nurse); Tilt neck to move head slightly forward towards the basin to avoid aspiration during suctioning

10 – 15 cm

Not more than 10 – 15 seconds

20 – 30 seconds

Not more than 5 minutes

TYPES OF SUCTIONING TYPE OF SUCTIONING: NASOPHARYNGEAL SUCTIONING

POSITION OF THE PATIENT WHILE SUCTIONING

DEPTH

DURATION

INTERVAL WITH EACH PASS OF SUCTION

TOTAL TIME

If the patient is conscious

Neck should be hyperextended; Fowler’s position

From tip of the nose to tip of the earlobe

Not more than 10 – 15 seconds

20 – 30 seconds

Not more than 5 minutes

If the patient is unconscious

Flat on bed with head turned to the nurse Lateral position may be assumed

From tip of the nose to tip of the earlobe

Not more than 10 – 15 seconds

20 – 30 seconds

Not more than 5 minutes

TYPES OF SUCTIONING TYPE OF SUCTIONING: OROTRACHEAL SUCTIONING

POSITION OF THE PATIENT WHILE SUCTIONING

DEPTH

DURATION

INTERVAL WITH EACH PASS OF SUCTION

TOTAL TIME

If the patient is conscious

Low to semifowler’s position

Measure from mouth to midsternum

Not more than 10 seconds

20 – 30 seconds

Not more than 5 minutes

If the patient is unconscious

Flat on bed; Suction trachea through the mouth

Measure from mouth to midsternum

Not more than 10 seconds

20 – 30 seconds

Not more than 5 minutes

TYPES OF SUCTIONING TYPE OF SUCTIONING: NASOTRACHEAL SUCTIONING

POSITION OF THE PATIENT WHILE SUCTIONING

DEPTH

DURATION

INTERVAL WITH EACH PASS OF SUCTION

TOTAL TIME

If the patient is conscious

Low to semifowler’s position

From tip of the nose to earlobe to dominating side of neck to the thyroid cartilage

Not more than 10 seconds

20 – 30 seconds

Not more than 5 minutes

If the patient is unconscious

Flat on bed; Suction trachea through the nose

From tip of the nose to earlobe to dominating side of neck to the thyroid cartilage

Not more than 10 – 15 seconds

20 – 30 seconds

Not more than 5 minutes

TYPES OF SUCTIONING TYPE OF SUCTIONING:

POSITION OF THE PATIENT WHILE SUCTIONING

DEPTH

DURATION

INTERVAL WITH EACH PASS OF SUCTION

TOTAL TIME

ENDOTRACHEAL TUBE SUCTIONING

Semi-Fowler’s not contraindicated

if

12.5 cms. or 6 inches; Insert as far as it goes until you meet resistance or until patient coughs

5 – 10 seconds

2 – 3 minutes

Not more than 5 minutes

TRACHEOSTOMY TUBE SUCTIONING

Semi-Fowler’s not contraindicated

if

Insert as far as it gets until you meet resistance or until the patient coughs

5 – 10 seconds

2 – 3 minutes

Not more than 5 minutes

IMPORTANT CONCEPTS ON SUCTIONING!!!  For Endotracheal suctioning:  NO TUBE IS USED HERE  This is suctioning of the trachea through the mouth or through the nose  Two (2) types of Endotracheal Suctioning:  Orotracheal Suctioning Oral approach  Nasotracheal Suctioning Nasal approach

GENERAL CONDITIONS FOR SUCTIONING  For Endotracheal and Tracheostomy (Naso and Oral and Tube)  Before suctioning, HYPEROXYGENATE the patient  During intervals, HYPEROXYGENATE the patient

GENERAL CONDITIONS FOR SUCTIONING  For ET, Tracheostomy, ET tube:  Nursing Alert! During insertion, if you encounter resistance, withdraw the catheter about one centimeter (1 cm) before applying suction  Rationale: To avoid trauma on the mucous membrane

GENERAL CONDITIONS FOR SUCTIONING  For ET, Tracheostomy, ET Tube:  Do suctioning intermittently  Suctioning should not be continuous  Rotate the catheter (between the thumb and the index finger) as you withdraw  Apply suction only when you are ready to withdraw (i.e. keep finger away from suction port if you are still not ready)

HOW TO HYPEROXYGENATE THE PATIENT  Give two (2) to three (3) blows by ambubag  Increase flow rate and concentration of oxygen  Nursing Alert!  If the patient has thick, tenacious secretions, DO NOT USE AN AMBUBAG  Use an OXYGEN INSUFFLATION SUCTION CATHETER instead!!!  This is a two-lumen catheter (one lumen brings oxygen to the patient, the other lumen brings out secretions from the patient)

HOW TO HYPEROXYGENATE THE PATIENT  In the event of encrustations, PERFORM TRACHEAL LAVAGE  Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy the mucous plug  Instill 2.0 ml Normal Saline Solution for children to liquefy the mucous plug  Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the mucous plug

VITAL SIGNS

TEMPERATURE

TEMPERATURE  Oral Temperature  Axillary Temperature  Rectal Temperature

ORAL TEMPERATURE  Most convenient  Most accessible  Nursing Alert!  Applicability is for children aged six (6) years and above  Not applicable for children below six (6) years old

ORAL TEMPERATURE  Contraindicated in the patients with:  Oral surgery  Mouth breathers  History of convulsive seizures  Unconscious  Incoherent  Irrational  Mentally disrupted  Insane

ORAL TEMPERATURE  Procedure  Nothing Per Orem for about thirty (30) minutes before taking temperature  No food intake  No drinks  No smoking  No chewing gum  No whistling  No gargling  Rationale  Any of the above would alter the results

ORAL TEMPERATURE  Placement:  Under the tongue, beside the frenulum (right or left)  Total Time:  Two (2) to three (3) minutes

AXILLARY TEMPERATURE  Least reliable  Safest method  Nursing Alert!  During application, be sure that axilla is dry  Dry using a patting motion

AXILLARY TEMPERATURE  Nursing Alert!  Do not RUB!  Rationale  This increases heat due to friction  Rubbing increases blood supply to the area Therefore, there will be increase in temperature reading  Rubbing provides a false-positive elevation of temperature reading

AXILLARY TEMPERATURE  Duration:  In adults – nine (9) minutes  In children – five (5) minutes

RECTAL TEMPERATURE  Most reliable (except for Tympanic Thermometer)  Most accurate (except for Tympanic Thermometer)  Concept!  If tympanic method is used using a tympanic thermometer, the rectal method is only second most reliable and second most accurate

RECTAL TEMPERATURE  Disadvantage:  Placement on a different site yields a different reading  Therefore, ensure that the bulb of the rectal thermometer rests on the mucous membrane.  Contraindications:  Hemorrhoids  Rectal Surgery  Certain Cardiac ailments due to stimulation of the vagus nerve; valsalva maneuver leads to arrhythmias

RECTAL TEMPERATURE  Position of the patient when taking the reading:  Sim’s left position  Sim’s right position  For Newborn, lift up ankles to keep buttocks up  In Toddlers, set on prone position on adult’s lap  Duration:  Two (2) minutes

TEMPERATURE SCALES  Conversion of Centigrade to Fahrenheit Centigrade = (5/9)F – 32 Centigrade = (F/1.8) – 32

TEMPERATURE SCALES  Conversion of Fahrenheit to Centigrade Fahrenheit = (9/5)C + 32 Fahrenheit = (1.8)C + 32

CONCEPTS ON HUMAN BODY TEMPERATURE  Highest body temperature is usually reached between 8:00 PM to 12:00 MN  Lowest body temperature occurs in the early morning hours of the day at around 4:00 AM to 6:00 AM

FEVER  Normally, the hypothalamus is able to adjust body temperatures between 37°C to 40°C  But due to the presence of pyrogenic materials like the following:  Pathogenic microorganisms  Toxins  Foreign substances  Any substance capable of increasing body temperature  Creates a deficiency of -3°C, making a person enter the FIRST STAGE OF FEVER

FIRST STAGE OF FEVER  Typical signs and symptoms indicate the body’s compliance mechanism to increase and conserve heat:  Chills  Shivering  Gooseflesh Contraction of arectores pilorum or pilo arecti muscles  Vasoconstriction Decreases blood supply to the skin  Pallid Skin  Cyanotic nail beds

FIRST STAGE OF FEVER  Key Concept!!!  Patient complains of feeling cold  Sweating will stop because body will minimizes heat loss  Also called: Onset Stage Chill Stage Cold Stage  This stage is characterized by low febrile temperatures

FIRST STAGE OF FEVER  Nursing Management:  Aim is to minimize heat loss  Do NOT apply TEPID SPONGE BATH because this would make patient progress to SHOCK  Provide additional clothing as necessary  Provide additional blankets as necessary  Provide something warm to drink  These measures would result to a gradual increase in body temperature

FIRST STAGE OF FEVER  Question:  When will you start application of TSB?  Answer:  If there is a 1°C to 2°C increase in body temperature

SECOND STAGE OF FEVER  Also called:  Coarse Stage of Fever  Peak Stage of Fever  Key Concepts!  Patient does not feel hot or cold  Skin is warm to touch  Skin is flushed  Fever blisters are present Herpetic lesions  Absence of shivering  Possible dehydration

SECOND STAGE OF FEVER  Important Concept!!!  For every increase of temperature, there is a corresponding increase in pulse rate  Rationale:  Increase in temperature results in an increase in pulse rate due to increased metabolic rate  Increased metabolic rate increases oxygen demand  Due to increased oxygen demand of susceptible brain cells, CONVULSIVE SEIZURES may occur. These may also be due to irritation of nerve cells – FEBRILE CONVULSIONS

SECOND STAGE OF FEVER  Increased oxygen demand also leads to an increase in respiratory rate  Patient complains of:  Loss of appetite  Myalgia or muscle pains due to increased catabolism  Nursing Management  Tepid Sponge Bath  Cooling Bed Bath

TEPID SPONGE BATH  Temperature of water is 32°C  This temperature is maintained procedure

throughout

 How to apply:  Done by patting  Rationale:  To avoid friction, which increases temperature

the

TEPID SPONGE BATH  Important Concept!  Do NOT use ALCOHOL when applying TSB  Rationale:  Alcohol dries the skin and leads to irritation  Key Concept!  TSB should not be done hurriedly  Rationale:  When done hurriedly, TSB will stimulate shivering  Shivering would lead to increased muscle activity  Increased muscle activity would lead to increased temperature

COOLING BED BATH  Water temperature will start at 32°C  Procedure will go on with gradual decrease in water temperature until it is maintained at 18°C  Therefore, to achieve this drop in temperature, utilize ice  Same procedure of application as in Tepid Sponge Bath

TYPES OF FEVER  1. Intermittent Fever  A fever that is alternated at regular intervals by periods of normal and subnormal temperature

TYPES OF FEVER  2. Remittent Fever  Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE NORMAL.  Duration is within a 24-hour period

TYPES OF FEVER  3. Relapsing Fever  Short periods of febrile episodes alternated by one (1) to two (2) days of normal temperature

TYPES OF FEVER  4. Constant Fever  Minimal fluctuations of temperature, all of which are ABOVE NORMAL

TYPES OF FEVER  5. Staircase or Spiking Fever  Common in patients with TYPHOID FEVER

PULSE RATE

PULSE ASSESSMENT  Concepts!  If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by two (2). This is legal!  If pulse is irregular, count or monitor the pulse for one (1) FULL minute

ASSESSMENT OF THE PULSE DEFICIT  Pulse Deficit is the difference between the apical pulse and the radial pulse.  Obtained by having one person count the apical pulse as heard through a stethoscope over the heart and another person count the radial pulse at the same time.

ASSESSMENT OF THE PULSE DEFICIT  This is the most accurate method  Involves two nurses using one watch  Starts at the same time  Ends at the same time  Comparison of results ensues  Count is done for one (1) full minute

SCALE IN PULSE ASSESSMENT 0

-

Absent or cannot be felt

 1+

-

Weak or thready

 2+

-

Normal

 3+

-

Bounding

BLOOD PRESSURE

BLOOD PRESSURE  Systolic  Produced by ventricular contraction  Pressure on blood vessels during depolarization or ventricular contraction  Diastolic  Pressure that remains in the walls of the blood vessels during relaxation or repolarization or resting

BLOOD PRESSURE  Broadly two (2) types:  Direct By insertion of a catheter  Indirect Method Auscultatory method Palpatory method Flush Method

AUSCULTATORY METHOD  Uses Korotkoff sound  A popping sound  NOT the heart beat  It is a phenomenon – an unknown phenomenon!

AUSCULTATORY METHOD  Determining Amount of Inflation  Using auscultatory method Ask patient what is his last BP reading and then add 30 – 40 mmHg from last systolic reading. Deflate gradually – rate is approximately 2 – 3 mmHg per second  Alternative auscultatory method Auscultate for the last sound as you go up. Then add 30 – 40 mmHg Then deflate

AUSCULTATORY METHOD  Tripartite Blood Pressure  Done if patient is an adult.  Example: 140 mmHg systolic – first loudest sound 100 mmHg 1st diastolic – muffling 70 mmHg 2nd diastolic – last sound Therefore, the tripartite blood pressure is 140 / 100 / 70  If there is no muffling, an example would be: 160 / no muffling / 110

AUSCULTATORY METHOD  Concepts!!!  Take systolic on loudest sound if patient is an adult  If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or loud  If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then there is a sound at 130 mmHg down to 80 mmHg then… Use the PALPATORY METHOD in combination with the AUSCULTATORY METHOD because there is an auscultatory gap  Repeat using:  Auscultatory method  Palpatory method

HOW TO DO THE PALPATORY METHOD  Inflate  Determine up to what point to inflate  Palpate pulse  If pulse is absent, add 30 – 40 mmHg  Deflate  First palpable pulse is true systolic pressure  For diastolic pressure, proceed using the auscultatory method

FLUSH METHOD  Represents the mean blood pressure  Represents the average of the systolic and diastolic pressures

FLUSH METHOD  When done:  When you have a BP apparatus without a stethoscope  Used for pediatric patients

FLUSH METHOD  How done:  Inflate up to the point where extremity becomes pale  Deflate slowly and look for a REBOUND FLUSH – when extremity becomes red again

 This is the true reading!!  Note that there is only ONE reading!!!

PULSE PRESSURE  It is the difference between systolic and diastolic pressures  Normal is 30 – 40 mmHg

HYPERTENSION  This is an abnormally high blood pressure over140 mmHg systolic and or above 90 mmHg diastolic for at least two consecutive readings

HYPOTENSION  This is an abnormally low blood pressure, systolic pressure below 100 mmHg and diastolic pressure below 60 mmHg

RESPIRATORY RATE

THREE PROCESSES IN RESPIRATION  Ventilation  The movement of gases in and out of the lungs  Involves inhalation or inspiration and exhalation or expiration  Diffusion  The exchange of gases from an area of higher pressure to an area of lower pressure  It occurs at the alveolo-capillary membrane  Perfusion  The availability and movement of blood for transport of gases, nutrients, and metabolic waste products

ASSESSING RESPIRATIONS  Rate  Normal is 12 – 20 cycles per minute in an adult  Depth  Observe the movement of the chest.  May be normal, deep, or shallow

ASSESSING RESPIRATIONS  Rhythm  Observe for regularity of exhalations and inhalations  Quality or Characteristic  Refers to respiratory effort and sound of breathing

MAJOR FACTORS AFFECTING THE RESPIRATORY RATE Exercise  Increases respiratory rate

Stress  Increases respiratory rate

Environment  Increased temperature of the environment decreases RR; Decreased temperature, increases RR  Increased altitude  Increases RR  Medications (e.g., narcotics decrease RR)

SKIN INTEGRITY

DECUBITUS ULCERS  Decubitus ulcers are caused by:  Unrelieved, sustained pressure  Localized ischemia  Shearing force  Pressure plus friction

DECUBITUS ULCERS  Predisposing Factors:  Unconsciousness  Incontinence  Loss of Sensation  Hypoproteinemia Decreased lean muscle mass Increase in fluid shifting leads to edema Dependent position is the skin attached to or facing the bed  Emaciation

STAGES OF DECUBITUS ULCER FORMATION

 Stage 1

 Involves the epidermis  Manifestation Non-blanchable erythema of INTACT SKIN This is the first heralding sign of decubitus ulceration

STAGES OF DECUBITUS ULCER FORMATION

 Stage 2

 Partial Thickness Skin Loss  Involves epidermis and dermis  Manifestation Blister formation Shallow craters Shallow abrasion and ulceration

STAGES OF DECUBITUS ULCER FORMATION

 Stage 3

 Full Thickness Skin Loss Ulceration  There is skin loss already  Involves necrosis of the skin and subcutaneous tissues EXTENDING TO but NOT THROUGH the underlying fascia

STAGES OF DECUBITUS ULCER FORMATION

 Stage 4

 Formations and manifestations of Stage 3 plus… Involvement of bones, supporting structures (tendons), joint capsules Massive damage

TOOLS TO ASSESS RISK OF ULCERATION  Norton’s Pressure Area Risk Assessment Form  Shannon’s Scoring System  Branden Scale of Predicting Ulceration  Waterlow Risk Assessment Cards  Most important tool  Most common tool  Most often used tool

EDEMA

EDEMA  Caused by shifting of fluid into the interstitial tissues

MANAGEMENT OF EDEMA  1) Elevation of the edematous part  Nursing Alert! If edema is due to Congestive Heart Failure (Right Sided), NEVER ELEVATE THE LOWER EXTREMITIES  Rationale: This increases the workload of the right side of the heart  Concept! If edema is due to prolonged standing, DO THE ELEVATION

MANAGEMENT OF EDEMA  2) Wear elastic stockings

MANAGEMENT OF EDEMA  3) Use warm compress alternated with cold compress  Rationale: Vasoconstriction and circulation of fluid

vasodilation

causes

 Concept! This is contraindicated if there is inflammation

re-

ASSESSMENT OF EDEMA  Induration 1+ 2+ 3+ 4+ 5+

-

1 cm induration 2 cm induration 3 cm induration 4 cm induration 5 cm induration

PAIN MANAGEMENT

PAIN

 A noxious stimulation of actual or threatened / potential tissue damage

CATEGORIES OF PAIN ACCORDING TO ORIGIN  1) Cutaneous  Skin  2) Deep Somatic  Tendons, ligaments  Bones  Blood Vessels  3) Visceral Pain  Organs of the body

CATEGORIES OF PAIN BASED ON CAUSE  1) Acute  Due to trauma or surgery  Persists for less than six (6) months  2) Chronic Malignant Pain  Related to cancer  On and off  Persists for more than six (6) months  3) Chronic Non-malignant Pain  Persists for more than six (6) months

CATEGORIES OF PAIN ACCORDING TO WHERE IT IS EXPERIENCED  1) Radiating Pain  Felt on the source and is extending to nearby tissues  2) Referred Pain  Felt on other parts detached from the source  Example: Pain on a lacerated liver may be felt on the right shoulder and not on the right upper quadrant

CATEGORIES OF PAIN ACCORDING TO WHERE IT IS EXPERIENCED  3) Intractable Pain  Highly resistant to pain-relief methods  4) Phantom Pain  Pain that is felt on a MISSING BODY PART or a PART THAT IS PARALYZED by SPINAL CORD INJURY.

PAIN THRESHOLD  Amount of pain stimulation that is required in order to feel pain

PAIN TOLERANCE  Maximum amount of pain and duration that a person is willing to endure

PAIN MANAGEMENT STRATEGIES  1) Pharmacologic Methods  Narcotics  NSAIDs  Adjuvants or Co-analgesics  2) Non-Pharmacologic Methods  Physical Interventions  Cognitive / Behavioral Interventions

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1A) Massage Effleurage Soft massage Gentle stroking

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation

 1B) Petrissage Hard massage Large and quick pinches Also done by striking

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1C) Application of Counter-Irritant Bengay Menthol Omega Pain Killer Flax Seeds Poultices

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1D) Heat and Cold Application Nursing Alert!

• Rebound Phenomenon  When you apply heat (usually done for 20 minutes), vasodilation is produced  If heat is applied for more than 20 minutes, there is vasoconstriction  This is an inherent defense mechanism from burning of tissues

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1E) Cold Application Maximum vasoconstriction is reached when skin reaches 15°C If there is further drop in temperature, there is vasodilation (skin becomes reddish) This is the inherent defense mechanism from being frozen

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1F) Accupressure Pressure on certain points of the body Stimulates release of endorphins, which have natural analgesic effects This started in Ancient China

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1F) Accupuncture Insertion of long slender needles on certain chemical pathways Origin is also Ancient china

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  1) Cutaneous Stimulation  1G) Contralateral Stimulation Example: Injury on left side and massage is done on the right side Useful when patient cannot be accessed: • For patients in a cast

• For patients with burns • For patients with phantom pain

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  2) Immobilization  Application of splints

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  3) Transcutaneous Electrical Nerve Stimulation  Composed of electrodes  Operated by battery  Electrodes are applied on painful site or over the spinal cord

NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN  4) Administration of a Placebo  Relieves pain because of its intent and not because of physical or chemical properties

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN  Purpose:  To alter pain perception  To alter pain behavior  To provide client with a greater sense of control over the pain

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN  1) Distraction  Purpose is to divert attention from pain  Slow Rhythmic Breathing Stare at a certain object Take deep breath slowly Release or exhale slowly Concentrate on breathing Picture a peaceful scene Establish a rhythmic pattern

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN  2) Massage and Rhythmic Breathing

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN  3) Rhythmic Singing and Tapping  Key Concept! Faster beat music is more preferable

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

 4) Guided Imagery  Imagine that you are walking along a peaceful shore  Eyes are closed and suggestions are given

COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN  5) Hypnosis  The success of hypnosis depends on the ability of the patient to concentrate and the capacity of the hypnotist to suggest  Based on suggestion  Progressive relaxation

URINARY ELIMINATION

URINARY ELIMINATION  Oliguria  Renal output of less than 500 ml per day  Anuria  Renal output of less than 100 ml per day  Retention  Positive for distended bladder  May also occur in the absence of bladder distention

ALTERED URINARY ELIMINATION  Enuresis  Common among pediatric patients  Age 4 – 5 years old child has adequate bladder control  Primary Enuresis Never had a dry period  Secondary Enuresis Acquired enuresis At age 7, bladder control is present for at least one year Then, enuresis comes back Urinating could NOT be controlled again

ALTERED URINARY ELIMINATION  Incontinence  Involuntary passage of urine

TYPES OF INCONTINENCE  1) Functional Incontinence  Involuntary passage  Unpredictable time

TYPES OF INCONTINENCE  2) Reflex Incontinence  Occurs at somewhat predictable times when specific bladder volume is reached  No awareness of bladder filling  No urge to void  It may be related to neurologic impairment

TYPES OF INCONTINENCE  3) Stress Incontinence  Loss of urine is less than 50 ml occurring with increased intraabdominal pressure  Occurs when laughing  Occurs when sneezing  Occurs when smiling

TYPES OF INCONTINENCE  4) Total Incontinence  Continuous flow of urine  No bladder distention  No bladder spasm  No awareness of bladder filling

TYPES OF INCONTINENCE  5) Urge Incontinence  Urine flows as soon as a strong sense of feeling to void occurs  Strong bladder spasm

MANAGEMENT OF INCONTINENCE  1) Kegel’s Exercises  Also called: Pubococcygeal Muscle Exercises Pelvic Floor Muscle Exercises  Applicable for: Functional Incontinence Stress Incontinence  How done: Advise patient to stand with legs slightly apart Concentrate on perineum Draw perineum upward slowly

MANAGEMENT OF INCONTINENCE  1) Kegel’s Exercises  Alternative way: When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing  Advantage of Kegel’s Exercises Increases muscle tone of the pelvis Increases muscle control

MANAGEMENT OF INCONTINENCE  2) Clean Intermittent Self Catheterization  Applicable for Reflex Incontinence  How done: Use a mirror for: • Obese male patients • Female patients

MANAGEMENT OF INCONTINENCE  2) Clean Intermittent Self Catheterization

 Question: Is your Clean Intermittent Self Catheterization procedure a sterile procedure?  Answer: No, it is just a clean procedure. Therefore, you can just wash the catheter for the next use.

MANAGEMENT OF INCONTINENCE  3) Crede’s Maneuver  Application of a steady but gentle pressure on the supra-pubic region to force urine out of the bladder  Nursing Alert! Do not use if there is OBSTRUCTION (i.e. renal obstruction in the form of renal stones) This is done only for patients who are no longer expected to regain control (Reflex incontinence and retention)

MANAGEMENT OF INCONTINENCE  4) Prompted Voiding or Scheduled Toileting  For Reflex Incontinence

MANAGEMENT OF INCONTINENCE

 5) Application of Adult Catheter and External Condom Catheter  For elderly with Total Incontinence

MANAGEMENT OF INCONTINENCE  6) Catheterization

MIDSTREAM CLEAN CATCH URINE SPECIMEN  How is this done?  If patient is a Male… Clean the penis Do this from the meatus down to the shaft Let the patient urinate Discard the first or the initial urine Collect midstream urine Purpose is to attain sterile specimen for urine culture and sensitivity testing

MIDSTREAM CLEAN CATCH URINE SPECIMEN  If patient is a Female…  Let patient wash genitals  Dry the genitals  Get to bed  Place patient in semi-Fowler’s position when she is ready to void  Clean and spread labia with two fingers  Remain holding labia  Then let patient urinate  Let go of first flow  Collect next flow

CATHETERIZATION

TYPES OF URINARY CATHETERS  1) Coude Catheter  Elbowed catheter for Benign Prostatic Hypertrophy patients

TYPES OF URINARY CATHETERS

 2) Robinson Catheter  Straight catheter

TYPES OF URINARY CATHETERS  Multi-Lumen Retention Catheter  Foley catheter  One lumen is for inflation  One lumen is for drainage of urine  One lumen is for irrigation  A three-way catheter  Aspirate using syringe and needle  This is made with a self-sealing rubber

CONCEPTS IN MALE CATHETERIZATION  Procedure for Insertion:  See to it that penis is perpendicular to body to straighten up the urethra to bladder  While inserting the catheter, ask the patient to breathe through the mouth  Cleanse the penis before insertion  Grasp penis firmly to avoid stimulating erections

CONCEPTS IN MALE CATHETERIZATION  Where to tape catheter  Tape it upward on the abdomen  Rationale:  To avoid scrotal excoriation  Tape on the inner thigh (with penis sideways either on left or right and follow the normal contour of the penis

CONCEPTS IN MALE CATHETERIZATION  Length of Catheter  40 centimeters  Depth of Insertion  While inserting, the point at which urine starts to flow, insert further by five (5) centimeters and then inflate the balloon – KOZIER  Insert up to a the Y-point, retract after inflating (this method is more prone to infection

CONCEPTS IN FEMALE CATHETERIZATION  Area of Insertion  Insert at female Urethra  Length of Catheter  22 centimeters  Depth of Insertion  Point at which urine starts to flow, insert further by five (5) centimeter before inflating balloon

GIT – FECAL ELIMINATION

WELLNESS TEACHINGS  Fluid intake of at least 2,000 ml per day  Regular exercise  High fiber diet  Avoid ignoring the urge to defecate  Do not abuse laxatives

CONCEPTS FOR FLATULENCE  Avoid carbonated drinks  Do not use straw  Avoid chewing gum  Avoid gas-forming foods:  Camote  Cabbage  Cauliflower  Onions

CONCEPTS FOR CONSTIPATION  Increase fluid intake  Take prune juice  Eat papaya  Increase fiber in the diet  Use METAMUCIL (natural fiber) instead of laxatives

SPECIAL GASTRO-INTESTINAL LABORATORY PROCEDURES  1) Guiac Test  To determine the presence of occult blood  Concepts!!! Have a meat-less diet three (3) days before examination Withhold oral iron supplements Injectable iron is allowed Avoid any food that discolors the stool.

SPECIAL GASTRO-INTESTINAL LABORATORY PROCEDURES  2) GI SERIES  2A) Upper GI Series – Barium Swallow Nursing Considerations: • Elimination of contrast medium How: • Increase fluid intake • Increase fiber in the diet Rationale: • To offset the risk of constipation Inform patient that the color of the stool will be WHITE

SPECIAL GASTRO-INTESTINAL LABORATORY PROCEDURES  2) GI SERIES  2B) Lower GI Series – Barium Enema Done at the radiology department Nursing Concern:

• Elimination of Barium How: • Cleansing enema may be needed after barium enema

DIFFERENT TYPES OF ENEMA  1) Cleansing Enema  Soap suds enema  Alkaline solution  Nursing Alert! Contraindicated in patients with liver cirrhosis and with increased ammonia in the blood  Rationale: Alkaline solution facilitates transfer of ammonia from the GI tract to the bloodstream Therefore, use lemon juice or dilute vinegar instead!!!

DIFFERENT TYPES OF ENEMA  1) Cleansing Enema  Nursing Alert! Also contraindicated in possible appendicitis or appendicitis patients  Rationale: Can lead to rupture of the appendix

DIFFERENT TYPES OF ENEMA  2) Carminative Enema  Used to expel out flatus  Burned sugar  Now commercially available

DIFFERENT TYPES OF ENEMA  3) Oil Retention Enema  To lubricate the colon and to soften the feces  Retention time is one (1) to three (3) hours

DIFFERENT TYPES OF ENEMA  4) Retention Flow Enema  Also called Harish Flush Enema  Solution is continually administered until what comes out of the body is clear.

POSITIONS IN ENEMA  High Cleansing Enema  Clean as much of the colon as possible  On introduction, Sim’s Left position facilitates flow of enema to sigmoid colon  Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse colon  Then, Right Side-Lying position to facilitate flow of enema to the descending colon

POSITIONS IN ENEMA  Low Cleansing Enema  For cleaning of rectum and colon only