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Fundamentals Of Nursing Fundamentals Of Nursing Document Transcript

  • NURSING AS A PROFESSION
    PROFESSION
    Calling that requires special knowledge, skill and preparation.
    Generally distinguished from other kinds of occupation by:
    Its requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed.
    An orientation of the individual toward service , either to a community or to an organization
    Critical attributes of professionalism in nursing:
    Gaining a body of knowledge in a university setting and a science orientation at the graduate in nursing.
    Attaining competence derived from the theoretical base wherein the “diagnosis and the treatment of human responses to actual or potential health problems ” can be accomplished.
    Delineating and specifying the skills and competencies that are the boundaries of expertise.
    Growth of professionalism:
    specialized education
    body of knowledge
    ethics
    autonomy
    Professional behaviours of nurses:
    Assesses, plans, implements and evaluates theory, research and practice in nursing.
    Accepts, promotes and maintains the interdependence of theory, research and practice. These 3 elements make nursing a profession and not a task-centered activity.
    Communicates and disseminates theoretical knowledge, practical knowledge and research findings to the nursing community.
    Upholds the service orientation of nursing in the eyes of the public. This orientation differentiates nursing from an occupation pursued primarily for profit.
    Many consider altruism (selfless concern for others)
    Nursing has a tradition of service to others
    Preserve and promotes the professional organization as the major referent
    Socialization:
    A process in which a person learns the ways of a group or society in order to become a functioning participant
    a reciprocal learning process that occurs through interaction with other people
    Types of Nursing Knowledge:
    Carper(1978)- identified 4 “patterns of knowing” that make up the basic core of nursing knowledge
    Nursing science
    scientific knowledge
    Is the “cognitive brain” of nursing and includes knowledge obtained through nursing research and research done in other disciplines.
    Nursing esthetics
    the way in which nursing knowledge is expressed
    it is the art or the “heart of nursing”
    involves feelings gained by subjective experience
    it is through the art of nursing that nurses express caring
    Esthetics includes
    Attitudes
    Beliefs
    Values
    Sensitivity and empathy
    enable the nurse to be aware of the client’s perspective and to be attentive to verbal and nonverbal cues to the clients psychologic state
    Nursing ethics
    refers to the knowledge of accepted professional standards of conduct
    concerned with matters of obligation , or what ought to be done
    consist of information about basic moral principles and processes for determining “right” actions
    e.g. Nurses are accountable to consumers and each other for the ethical performance of their work.
    A personal knowledge
    Concerned with knowing oneself
    having a conscious awareness of one’s own values, beliefs, attitudes and abilities
    Involves knowing of self in relation to another and interacting on a person-person, rather than a role to role basis.
    Five levels of proficiency:
    Novice
    a nursing student or any nurse entering a clinical setting where that person has no experience.
    Ability is extremely limited, inflexible and governed by structures rules and protocols.
    Advanced beginner
    Can demonstrate marginally accepted performance.
    Has had experience with enough real situations to be aware of the meaningful aspects of a situation
    The ability to recognize a client’s readiness to learn how to manage a treatment plan.
    Competent
    Competence is manifested by the nurse who has been on the job in a similar situation for 2 or 3 years.
    Competence develops when the nurse consciously and deliberately plans nursing care and coordinates multiple complex care demands
    At this stage the nurse demonstrate organizational ability but lacks the speed and flexibility of the proficient nurse.
    Knows how to prioritize care requirements for an individual or groups of client’s
    e.g.
    The competent nurse will ensure that intravenous infusions are running , that clients are receiving required medications, and that client’s are receiving required medications
    Proficient
    The proficient nurse perceives a situation as a whole rather than just its individual aspects.
    The nurse focuses on long-term goals and is oriented toward managing the nursing care of a client rather than performing specific tasks
    Uses maxims as guides but applies then only after acquiring a deep understanding of the situation.
    The nurse makes the decision according to the demands of the situation and the lessons of past experiences
    Expert
    The expert performer no longer relies on rules , guidelines or maxims to connect an understanding of the situation to an appropriate action
    The expert nurse intuitively grasps each situation and focuses on the accurate area of the problem without wasteful consideration of large ranges of unnecessary alternative diagnoses and solutions
    Expert nurses have highly developed perceptual acuity or recognitional ability , flexible and highly proficient
    The nurse’s highly skilled analytic ability can be transferred to situations with which the nurse has had no previous experience.
    Roles of professional nurse:
    Each role is describe as a separate entity for the sake of clarity
    Care provider
    Caring involves knowledge and sensitivity to what matters and what is important to clients.
    The nurse supports the client by attitudes and actions that show concern for client welfare and acceptance of the client as a person, not merely mechanical being.
    Caring Is central to most nursing interventions and an essential attribute of the expert nurse
    Communicator
    The nurse communicates to other health care personnel the nursing interventions planned and implemented for each client
    Nurses communicate pertinent information verbally at change of shift reports , when clients are transferred to another unit and when clients are discharged to another health care agency.
    The nurse communicates to other health care personnel the nursing interventions planned and implemented for each client
    Teacher
    Teaching -activity by which the teacher helps the students to learn
    -it is an interactive process between a teacher and one or more learners in which specific learning objectives are achieved
    Counsellor
    Is the process of helping a client to recognize and cope with stressful psychologic or social problems, to develop improved interpersonal relationships, and to promote personal growth.
    It involves providing emotional, intellectual and psychologic support.
    The nurse focuses on helping the person develop new attitudes , feelings and behaviors rather than on promoting intellectual growth.
    The nurse encourages the client to look at alternative behaviors , recognize the choices and develop a sense of control
    Counseling requires therapeutic communication skills.
    e.g.The nurse must be a skilled leader able to analyze the situation, synthesize the information and experiences and evaluate the progress and productivity of the individual or group
    client advocate
    pleads for a cause or proposal
    Advocacy- involves concern for and defined actions in behalf of another person or organization to bring about a change
    Promoting what is best for the client
    CLIENT ADVOCATE- An advocate of the client’s rights.
    Social Advocacy- Entails advocating on behalf of a population or a community to effective positive change.
    Change agent
    A person or group who initiates changes or who assists others in making modifications in themselves or in the system.
    One who identifies the problem
    assess the clients modifications capacities for change
    Determines alternativeness
    Assess resources
    Determines appropriate nursing roles
    Maintains a helping relationship
    Leader
    Leadership role can be applied at many different levels
    Individuals
    Family
    Group
    Communities
    society
    Nursing Leadership:
    A process of interpersonal influence through which the nurse helps a client make decisions in establishing and achieving goals to improve the client’s well being.
    Leadership validates the professional nurse’s practice and enhances professional growth.
    Purposes:
    Improving the health status and potential of individuals and families
    Increasing the effectiveness and level of satisfaction among professional colleagues providing care
    Raising citizens and legislators attitudes toward and expectations of the nursing profession
    Nursing Management:
    planning, giving direction , developing staff , monitoring operations giving rewards fairly , representing both staff members and administration as needed
    occurs within an organizational environment
    delegates nursing activities to ancillary workers and other nurses and supervises and evaluates their performance
    researcher
    According to the standards of clinical nursing practice ,all nurses should select nursing interventions that are substantiated by research and further that all nurses may participate in research activities based on their level of education, their position and their practice setting
    CONCEPT OF MAN AND HIS BASIC NEEDS
    Four major attributes of human being:
    The capacity to think or conceptualize on the abstract level
    Family formation
    The tendency to seek and maintain territory
    The ability to use verbal symbols as language, a means of developing and maintaining culture
    Nursing concepts of man:
    Man is a biopsychosocial and spiritual being who is in constant contact with the environment
    Biologic being- All men have the same basic human needs.
    Psychologic being- Man is unique, irreplaceable, one-time being. No two persons are exactly alike. Man is rational but at times irrational; mature with core of immaturity; with limited and unlimited nature; a being of contradictions; a being who is usually at the crossroads of indecisiveness.
    Social being- man is like some other men. Group of people have some common attributes.
    Culture, age,a groups, social status, educational status, etc
    Spiritual being- All men are spiritual in nature; all men are endowed with virtues of faith, hope and charity. Men believe in the existence of Supreme Power who guides our fate and destiny.
    Man is an open system in constant interaction with a changing environment.
    An open system is one that allows input and output.
    Foods, energy, microorganism
    Man is a unified whole
    Composed of parts which are interdependent and interrelated with each other
    To have adequate oxygenation, there should be normal functioning of the respiratory system, cardiovascular system, and nervous system
    Man is composed of parts which are greater than and different from the sum of all its parts.
    Man is greater than the sum of all its parts because man is simply a composite of physiologic body parts. Man is endowed with intellect, will, judgment ability, decision-making ability, talents, strengths, etc.
    Man is different from the sum of all his parts because at times his responses are predictable but at times unpredictable. Sometimes he responds favourably to some factors (food, medications, treatments) but at times he responds unfavorably.
    Man is an individual with vital reparative processes to deal with disease and desirous of health. (Nightingale)
    Maslow’s Hierarchy of Basic Needs
    Physiologic- oxygen, food, fluids, body temperature, elimination, rest and sleep, sex
    Sex is not necessary for individual survival but it is necessary for survival of mankind
    Safety and security- physical safety, psychological safety, freedom from harm and danger
    Love and belongingness- the need to love and be loved; the need to care and be cared for; the need for affection, to associate or to belong; the need to establish fruitful and meaningful relationship with people, institution or organization
    Self-esteem- self-worth; self-identity; self-respect; body image
    Self-actualization- the need to learn, create and understand or comprehend; the need to be self-fulfilled; the need for spiritual fulfilment
    Characteristics of basic human needs:
    Needs are universal- all human beings have the same basic human needs
    Needs maybe met in different ways
    If a person is unable to eat through the mouth, nutrition may be administered through nasogastric tube or intravenous route
    Needs maybe stimulated by external and internal factors
    Smelling a seemingly delicious food will trigger hunger in person. Internal factors such as low blood glucose level will stimulate sensation of hunger.
    Needs maybe deferred
    A person who is confined in the hospital has to forego his need for independence and privacy
    Needs are interrelated
    When the needs of an infant are adequately met, he associates this with satisfaction of his needs for love and belongingness.
    When a person has self-esteem, he is more capable of loving and appreciating other people
    Characteristics of self-actualized person:
    Is realistic, sees life clearly, and is objective about his or her observations.
    Judges people correctly
    More decisive
    Has clear notion to what is right or wrong
    Is usually accurate in predicting future events
    Understands art, music, politics, and philosophy
    Possesses humility, listens to others carefully
    Is dedicated to some work, task, duty or vocation
    Is highly creative, spontaneous, courageous, and willing to make mistakes
    Is open to new ideas
    Is self-confident and has self-respect
    Has low degree of self-conflict; personality is integrated
    Respects self
    Is highly independent, desires privacy
    Can appear remote and detached
    Is friendly, loving, and governed more by inner directives than society
    Can make decisions contrary to popular opinion
    Is problem-centered than self-centered
    Accepts the world for what it is
    CONCEPT OF HEALTH AND ILLNESS
    INTRODUCTION
    Health is a fundamental right of every human being
    Across the lifespan, man moves from the health spectrum to the illness spectrum.
    Health and illness are highly individualized perceptions.
    Meanings and descriptions vary among people in relation to geography and culture.
    DEFINITIONS OF HEALTH
    Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO)
    Health is being well and using one’s power to the fullest extent. Health is maintained through prevention of disease via environmental health factors. (Nightingale)
    HEALTH is the ability to maintain the internal milieu. Illness is the result of failure to maintain the internal environment. (Claude Bernard)
    ILLNESS AND DISEASE
    Illness is a personal (physical, emotional, intellectual, social, developmental or spiritual) state in which the person feels unhealthy.
    Disease is an alteration in body functions resulting in reduction of capacities or shortening of normal life span.
    PRECURSORS OF ILLNESS
    1. Heredity- family history for diabetes mellitus; hypertension; cancer
    2. Behavioral factors- cigarette smoking; alcohol abuse; high animal fat intake
    3. Environmental factors- overcrowding; poor sanitation; poor supply of potable water
    COMMON CAUSES OF DISEASE
    1. Biologic agents- microorganisms
    2. Inherited genetic defects- cleft palate
    3. Developmental defects- imperforate anus
    4. Physical agents- hot and cold substances; radiation; UV rays
    5. Chemical agents- lead; emissions from smoke-belching cars
    6. Tissue response to irritation/injury- inflammation
    7. Faulty chemical/metabolic process- inadequate insulin in diabetes mellitus; inadequate iodine causing goiter.
    8. Emotional/physical reaction to stress- anxiety or fear
    STAGES OF ILLNESS
    1. Symptom Experience- the person believes something is wrong
    Experiences some symptoms
    3 aspects:
    Physical- fever; muscle aches; malaise; headache
    Cognitive- perception of having “flu”
    Emotional- worry on consequence of illness
    2. Assumption of the Sick Role- acceptance of the illness
    Seeks advice, support for decision to give up some activities
    3. Medical Care Contact- seeks advice of health professionals for the following reasons:
    : validation of real illness
    : explanation of symptoms
    : reassurance or prediction of outcomes
    4. Dependent Patient Role- the client becomes dependent on the health professional for help
    Accepts/rejects health professional’s suggestions.
    Becomes more passive and accepting
    5. Recovery/Rehabilitation- gives up the sick role and returns to former roles and functions.
    RISK FACTORS
    Any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident.
    Presence of risk factors does not mean that a disease will develop, but risk factors increases the chances that the individual will experience a particular dysfunction.
    RISK FACTORS OF A DISEASE
    1. Genetic and Physiologic- heredity or genetic predisposition
    2. Age- age increases or decreases susceptibility to certain illnesses (e.g. the risk of heart diseases increases with age for both sexes; the risk of birth defects and complications of pregnancy increases in women bearing children after age 35.
    3. Environment- can increase the likelihood that certain illnesses will occur. (e.g. when workers are exposed to certain chemicals or when people live near toxic waste disposal sites.
    4. Lifestyle- behaviors and practices can have positive or negative effects on health.
    e.g. risk for illness include tobacco use, alcohol or drug abuse
    e.g. threat to injury such as skydiving or mountain climbing
    Stress can threaten mental & physical health
    What is the importance of identifying these risk factors?
    “The goal of risk factor identification is to merely assist the clients in visualizing the areas in their life that can be modified or even eliminated to promote wellness and prevent illness”
    TERMINOLOGIES
    Disease- disturbance of structure or of function of the body or its constituent parts.
    Morbidity- condition of being diseased.
    Morbidity rate- the proportion of disease to health in a community.
    Mortality- condition or quality of being subject to death
    Ecology- the science of organisms as affected by factors in their environment; deals with the relationship between disease and geographical environment
    Epidemiology- study of patterns of health and disease, its occurrence and distribution in man, for the purpose of control and prevention of disease.
    Susceptibility- the degree of resistance the potential host has against the pathogen.
    Etiologic agent- one that possesses the potential for producing injury or disease
    Virulence- degree of pathogenicity; ability to produce poison that repel or destroY phagocytes.
    Symptomatology- study of symptoms
    Symptom- manifestation of perceptible changes in the body which indicate the presence of a disease or disorder. It is subjective in nature.
    Sign- an objective symptom or objective evidence or physical manifestation made apparent by special methods of examination or use of senses.
    Syndrome- a set of signs and symptoms, which when considered together characterize a disease
    Pathology- branch of medicine which deals with the cause, nature, treatment and resultant structural and functional changes of disease
    Pathogenesis- method of origin and development of a disease
    Diagnosis- art or act of determining the nature of a disease; recognition of a diseased state
    Sequela- consequences that follows the normal course of an illness
    Complication- a condition that occurs during or after the course of an illness
    Prognosis- prediction of the course and end of a disease process. Good prognosis means that there is great possibility to recover from the disease and poor prognosis means that there is great risk for morbidity or mortality
    Recovery- implies that there is apparent restoration to the pre-illness state
    CLASSIFICATION OF DISEASE
    A. According to Etiologic Factors
    B. According to Duration or Onset
    C. Others
    According to Etiologic Factors
    Hereditary- due to defects in the genes
    Congenital- due to defect in the development, hereditary factors, prenatal infection; present at birth (e.g. cleft lip, cleft palate)
    Metabolic- due to disturbances or abnormality in the intricate processes of metabolism (e.g. diabetes mellitus, hyperthyroidism)
    Deficiency- results from inadequate intake or absorption of essential dietary factors.
    Traumatic – due to injury (e.g. fractures)
    Allergic- due to abnormal response of the body to chemical or protein substances or to physical stimuli (asthma, skin allergy)
    Neoplastic- due to abnormal or uncontrolled growth of cells
    Idiopathic- cause is unknown; self-originated (e.g. cancer)
    Degenerative- results from degenerative changes that occur in tissue or organ (osteoporosis, osteoarthritis)
    Iatrogenic- results from the treatment of a disease (e.g. hypothyroidism after thyroid surgery; alopecia after chemotherapy)
    B. According to Duration or Onset
    Acute- has short duration and usually severe; s/sx appear abruptly, are intense and subside after a relatively short period
    Chronic- persists usually longer than 6 months
    Client may fluctuate between maximal functioning and serious relapses
    Remission– dse is controlled and exacerbation– dse becomes more active again
    e.g. hypertension
    C. OTHERS
    Familial- occurs in several individuals of the same family (e.g. hypertension and cancer)
    Venereal- acquired through sexual relation
    Epidemic- attacks a large number of individuals in a community at the same time (e.g. SARS)
    Endemic- recurs in a community (e.g. malaria in Palawan; goiter in mountain province)
    Pandemic- extremely widespread involving entire country or continent
    Sporadic- dse in which only occasional cases occur (Dengue during rainy seasons, leptospirosis during floods)
    THREE LEVELS OF PREVENTION
    PRIMARY PREVENTION
    To encourage optimal health and to increase the person’s resistance to illness
    Seeks to prevent a disease
    To stop something from ever happening
    Health promotion
    Specific protection
    SECONDARY PREVENTION
    Also known as health maintenance
    Seeks to identify specific illnesses or conditions at an early stage
    Early diagnosis/ detection/ screening
    Prompt treatment to limit disability
    TERTIARY PREVENTION
    To support client towards successful adaptation to known risks, optimal reconstitution, and/or establishment of high-level wellness
    Occurs after a dse or disability has occurred and the recovery process has begun
    Intent is to halt the dse or injury process
    Rehabilitation
    COMMUNICATING IN NURSING
    Communication- The interchange of information between 2 or more people; the exchange of ideas and thoughts.
    Transmission of feelings or a more personal and social interaction between people.
    Any means of exchanging information or feelings between 2 or more people.
    Intent of communication is to elicit a response.
    Communication is a process.
    Has 2 purposes
    To influence others
    To obtain information
    May be helpful and unhelpful
    Communication can occur in an intrapersonal level within a single individual as well as interpersonal and group levels.
    Intrapersonal communication
    -communication that you have with yourself(self talk)
    Communication process
    Face to face communication involves a sender, a message, a receiver and a response, or feedback.
    Communication is a 2 way process involving the sending and receiving the message.
    Sender
    A person or group who wishes to convey a message to another, considered the source –encoder.
    Encoding- involves the selection of specific signs or symbols (codes)to transmit message, such as which language and words to use, how to arrange the words, and what tone of voice and gestures to use.
    Message
    The second component of the communication process is the message itself—what is actually said or written ,the body language that accompanies the words and how the message is transmitted.
    Receiver
    The 3rd component of communication process is the listener who must listen, observe and attend. The person is the decoder, who must perceive what the sender intended(interpretation)
    To decode– to relate the message perceived to the receiver’s storehouse of knowledge and experience and to sort out the meaning of the message.
    Response
    The 4th component of the communication process, the response, is the message that the receiver returns to the sender.
    Also called the feedback
    Can either be verbal or nonverbal or both
    Modes of communication
    Verbal communication- uses the spoken or written word.
    Largely conscious because people choose the words, they use.
    Pace and intonation
    Simplicity
    Clarity and brevity (briefness)
    Timing and relevance
    Adaptability
    Credibility
    humor
    nonverbal communication-
    Sometimes called body language.
    Nonverbal communication
    Uses other forms,such as:
    Facial expressions
    Posture, gait
    Gestures
    General physical appearance
    Mode of dress and grooming
    Sounds
    Silence
    Therapeutic communication
    Promotes understanding and can help establish a constructive relationship between the nurse and the client
    It is client and goal oriented
    Nurses need to respond not only to the content of the client’s verbal message but also to the feelings expressed
    Nurses have to understand the client views to the situation and feels about it before responding
    Active listening-
    Listening actively, using all the senses as opposed to listening passively with just one ear.
    Most important technique in nursing and basic to all other techniques
    An active process that requires energy and concentration.
    Involves paying attention to the total message , both verbal and non verbal and noting whether these communications are congruent.
    Means absorbing both the content and the feeling the person is conveying without selectivity.
    S – Sit facing the client
    O – Open Posture
    L – Lean forward towards client
    E – Establish eye contact
    R- Relax!!
    SILENCE
    PROVIDING GENERAL LEADS
    BEING SPECIFIC AND TENTATIVE
    USING OPEN-ENDED QUESTIONS
    USING TOUCH
    RESTATING OR PARAPHRASING
    SEEKING CLARIFICATION
    PERCEPTION CHECKING
    OFFERING SELF
    GIVING INFORMaTION
    ACKNOWLEDGING
    CLARIFYING TIME OR SEQUENCE
    PRESENTING REALITY
    FOCUSING
    REFLECTING
    SUMMARIZING AND PLANNING
    Barriers to communication:
    Stereotyping
    Agreeing and disagreeing-
    Being defensive-
    Challenging-
    Probing-
    Testing
    Rejecting
    Changing topics and subjects
    Unwarranted reassurance
    Passing Judgments
    Giving common advice
    Helping relationships:
    Helping- a growth-facilitating process that strives to achieve 2 basic goals.
    1. Help clients manage their problems in living more effectively and develop unused or underused opportunities more fully
    2. Help clients become better at helping themselves in their everyday lives
    Phases of helping relationship
    PREINTERACTION PHASE- try to learn as much as possible about your client, including reasons for seeking care
    Review medical record and nursing notes
    Note hx of previous hospitalizations as well as procedures that he had undergone in the past
    Note cc (chief complaint)
    Speak with other healthcare who may have cared for the client
    The nurse must also examine self’s culturally-based beliefs and values.
    INTRODUCTORY/ ORIENTATION PHASE- it is important to show the client respect and to establish trust and rapport (understanding/ connection)
    WORKING/ MAINTAINING PHASE-
    TERMINATION PHASE-
    Therapeutic Technique
    1. Offering Self
    making self-available and showing interest and concern.
    “I will walk with you”
    2. Active listening
    paying close attention to what the patient is saying by observing both verbal and non-verbal cues.
    Maintaining eye contact and making verbal remarks to clarify and encourage further communication.
    3. Exploring
    “Tell me more about your son”
    4. Giving broad openings
    What do you want to talk about today?
    5. Silence
    Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.
    6. Stating the observed
    verbalizing what is observed in the patient to, for validation and to encourage discussion
    “You sound angry”
    7. Encouraging comparisons
    · asking to describe similarities and differences among feelings, behaviors, and events.
    · “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”
    8. Identifying themes
    asking to identify recurring thoughts, feelings, and behaviors.
    “When do you always feel the need to check the locks and doors?”
    9. Summarizing
    reviewing the main points of discussions and making appropriate conclusions.
    “During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include…”
    10. Placing the event in time or sequence
    asking for relationship among events.
    “When do you begin to experience this ticks? Before or after you entered grade school?”
    11. Voicing doubt
    voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.
    “I find it hard to believe…”
    12. Encouraging descriptions of perceptions
    asking the patients to describe feelings, perceptions and views of their situations.
    “What are these voices telling you to do?”
    13. Presenting reality or confronting
    stating what is real and what is not without arguing with the patient.
    “I know you hear these voices but I do not hear them”.
    “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
    14. Seeking clarification
    asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.
    “I am not familiar with your work, can you describe it further for me”.
    “I don’t think I understand what you are saying”.
    15. Verbalizing the implied
    Rephrasing patient’s words to highlight an underlying message to clarify statements.
    Patient: I won’t be bothering you anymore soon.
    Nurse: Are you thinking of killing yourself?
    16. Reflecting
    Throwing back the patient’s statement in a form of question helps the patient identify feelings.
    Patient: I think I should leave now.
    Nurse: Do you think you should leave now?
    17. Restating
    Repeating the exact words of patients to remind them of what they said and to let them know they are heard.
    Patient: I can’t sleep. I stay awake all night.
    Nurse: You can’t sleep at night?
    18. General leads
    Using neutral expressions to encourage patients to continue talking.
    “Go on…”
    “You were saying…”
    19. Asking question
    using open-ended questions to achieve relevance and depth in discussion.
    “How did you feel when the doctor told you that you are ready for discharge soon?”
    20. Empathy
    Recognizing and acknowledging patient’s feelings.
    “It’s hard to begin to live alone when you have been married for more than thirty years”.
    21. Focusing
    Pursuing a topic until its meaning or importance is clear.
    “Let us talk more about your best friend in college”
    “You were saying…”
    22. Interpreting
    Providing a view of the meaning or importance of something.
    Patient: I always take this towel wherever I go.
    Nurse: That towel must always be with you.
    23. Encouraging evaluation
    Asking for patients views of the meaning or importance of something.
    “What do you think led the court to commit you here?”
    “Can you tell me the reasons you don’t want to be discharged?
    24. Suggesting collaboration
    Offering to help patients solve problems.
    “Perhaps you can discuss this with your children so they will know how you feel and what you want”.
    25. Encouraging goal setting
    Asking patient to decide on the type of change needed.
    “What do you think about the things you have to change in yourself?”
    26. Encouraging formulation of a plan of action
    Probing for step by step actions that will be needed.
    “If you decide to leave home when your husband beat you again what will you do next?”
    27. Encouraging decisions
    Asking patients to make a choice among options.
    “Given all these choices, what would you prefer to do.
    28. Encouraging consideration of options
    Asking patients to consider the pros and cons of possible options.
    “Have you thought of the possible effects of your decision to you and your family?”
    29. Giving information
    Providing information that will help patients make better choices.
    “Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore”.
    30. Limit setting
    Discouraging nonproductive feelings and behaviors, and encouraging productive ones.
    “Please stop now. If you don’t, I will ask you to leave the group and go to your room.
    31. Supportive confrontation
    acknowledging the difficulty in changing, but pushing for action.
    “I understand. You feel rejected when your children sent you here but if you look at this way…”
    32. Role playing
    practicing behaviors for specific situations, both the nurse and patient play particular role.
    “I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.
    33. Rehearsing
    asking the patient for a verbal description of what will be said or done in a particular situation.
    “Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.
    34. Feedback
    Pointing out specific behaviors and giving impressions of reactions.
    “I see you combed your hair today”.
    35. Encouraging evaluation
    Asking patients to evaluate their actions and their outcomes.
    “What did you feel after participating in the group therapy?”.
    36. Reinforcement
    Giving feedback on positive behaviors.
    “Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak”.
    Avoid pitfalls:
    Giving advise
    Talking about your self
    Telling client is wrong
    Entering into hallucinations and delusions of client
    False reassurance
    Giving approval
    Asking WHY?
    Changing subject
    Defending doctors and other health team members.
    Non-therapeutic Technique
    1. Overloading
    Talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.
    “What’s your name? I see you like sports. Where do you live?”
    2. Value Judgments
    giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
    “You shouldn’t do that, its wrong”.
    3. Incongruence
    sending verbal and non-verbal messages that contradict one another.
    The nurse tells the patient “I’d like to spend time with you” and then walks away.
    4. Underloading
    remaining silent and unresponsive, not picking up cues, and failing to give feedback.
    The patient ask the nurse, simply walks away.
    5. False reassurance/ agreement
    Using cliché to reassure client.
    “It’s going to be alright”.
    6. Invalidation
    Ignoring or denying another’s presence, thought’s or feelings.
    Client: How are you?
    Nurse responds: I can’t talk now. I’m too busy.
    7. Focusing on self
    responding in a way that focuses attention to the nurse instead of the client.
    “This sunshine is good for my roses. I have beautiful rose garden”.
    8. Changing the subject
    introducing new topic
    inappropriately, a pattern that may indicate anxiety.
    The client is crying, when the nurse asks “How many children do you have?”
    9. Giving advice
    telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility.
    “If I were you… Or it would be better if you do it this way…”
    10. Internal validation
    making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into conclusion).
    The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.
    Other ineffective behaviors and responses:
    Defending – Your doctor is very good.
    Requesting an explanation – Why did you do that?
    Reflecting – You are not suppose to talk like that!
    Literal responses – If you feel empty then you should eat more.
    Looking too busy.
    Appearing uncomfortable in silence.
    Being opinionated.
    Avoiding sensitive topics
    Arguing and telling the client is wrong
    Having a closed posture-crossing arms on chest
    Making false promises – I’ll make sure to call you when you get home.
    Ignoring the patient – I can’t talk to you right now
    Making sarcastic remarks
    Laughing nervously
    Showing disapproval – You should not do those things.
    FECAL ELIMINATION
    Defecation: expulsion of feces
    Feces enters the rectum
    Local distention and pressure pressure gives rise to sensory impulses
    Internal anal sphincter relaxes
    Feces moves into the anal canal
    External sphincter relaxes voluntarily
    Fecal expulsion
    Valsalva maneuver: contraction of the abdominal muscles by forceful expiration with the glottis (The middle part of the larynx, the area where the vocal cords are located) closed. This increases abdominal pressure and thus facilitates defecation.
    100-400 grams of feces are produced daily.
    Feces consist of 75% water and 25% solid.
    If the feces are moved rapidly through the large intestine, less water is absorbed and the stool is liquid.
    If the movement of feces and elimination are delayed, an excessive amount of water is absorbed and the stool becomes hard and dry.
    Normal Characteristics of Stool:
    Color: brown (adult)—due to bile and yellow (infants)
    Consistency: formed, soft, semisolid, moist
    Shape: cylindrical
    Odor: aromatic
    Constituents: small amounts of undigested roughage; sloughed dead bacteria; inorganic matter (calcium and phosphates)
    Alterations in the characteristics of stool:
    Hematochezia- passage of stool with bright red blood. Due to lower GI bleeding
    Melena- black, tarry stool due to upper GI bleeding
    Steatorrhea- greasy, bulky, foul-smelling stool due to undigested fats
    Factors that affect defecation:
    Age and development- control of defecation starts at 1 ½ to 2 years of age (children learned to walk and nervous and muscular systems are sufficiently well-developed to permit bowel control)
    Daytime control is normally attained by age 2 ½.
    Desire to control daytime bowel movement starts when the child becomes aware of a discomfort (a) discomfort caused by a soiled diaper (b) sensation that indicates the need for a bowel movement.
    Diet- sufficient bulk (fiber) is necessary
    Spicy foods can produce diarrhea and flatus
    Gas-producing foods: cabbage, onions, cauliflower, bananas, apples
    Laxative-producing foods: prunes, chocolate and alcohol
    Constipation-producing foods: cheese, pasta, eggs, lean meats
    Fluid: healthy fecal elimination usually requires a daily fluid intake of 2000-3000 ml
    When fluid intake is inadequate or output is excessive, the body continues to absorb fluid from the chyme (the semi fluid mass into which food is converted by gastric secretion and which passes from the stomach into the small intestine.) as it passes along the colon—resulting in hard feces.
    Activity: it promotes muscle tone and peristalsis
    Psychologic factors: anxiety and feelings of anger may increase peristalsis; depression may slow intestinal motility
    Lifestyle: postponing defecation, schedule, availability of toilet facilities
    Medications: tranquilizers, morphine and codeine may cause constipation; laxatives stimulate bowel activity and assist fecal elimination
    Diagnostics procedures: cleansing enema; barium (contrats medium used in radiologic exams) can cause constipation
    Anesthesia and surgery: general anesthesia causes decreased peristalsis; surgery that involves direct handling of intestines cause temporary cessation of intestinal movement (called paralytic ileus lasts 24-48 hours)
    Listening to bowel sounds (intestinal motility) is an important nursing assessment following surgery
    Pathologic conditions: spinal cord injuries and head injuries can decrease sensory stimulation for defecation
    Irritants: spicy foods, bacterial toxins, poisons can irritate intestinal tract and produce diarrhea and large amount of flatus
    Pain: clients who experience discomfort when defecating often suppresses the urge—constipation results
    Common fecal elimination problems:
    Constipation: passage of small, dry, hard stool or the passage of no stool for a period of time.
    Nursing Interventions:
    Adequate fluid intake
    High fiber diet
    Establish regular pattern of defecation (routine, rituals)
    Respond immediately to the urge of defecation
    Minimize stress
    Adequate activity and exercise
    Assume sitting or semi-squatting position
    Administer laxatives (see types below) as ordered
    Chemical irritants- provide chemical stimulation to intestinal wall thereby increasing peristalsis; eg Dulcolax (Bisacodyl), castor oil, Senokot (Senna)
    Stool lubricants- lubricates feces; eg mineral oil
    Stool softeners- softens stool; eg Colace (Na docusate)
    Bulk formers- increase bulk of feces, increasing pressure and distention of the intestines; eg Metamucil (Psyllium hydrophilic)
    Osmotic agent- they attract fluids from intestines; eg Duphalac (lactulose)
    Fecal Impaction: mass or collection of hardened, puttylike feces in the folds of rectum (large, hard, dry stool in the rectum)
    Assessment:
    Absence of BM for 3-5 days
    Passage of liquid fecal seepage
    Hardened fecal mass can palpated in the rectum during digital examination
    Anorexia, body malaise
    Subjective feeling of abdominal fullness or bloating
    Nausea and vomiting
    Nursing interventions:
    Increase fluid intake
    Sufficient bulk in the diet
    Adequate activity and exercise
    Diarrhea: frequent evacuation of watery stools; associated with increased GI motility and rapid passage of fecal contents to the lower GI tract
    Nursing Interventions:
    Replace fluid and electrolyte lossess
    Provide good perineal care (diarrheal stools are often acidic—this can cause anal soarness)
    Diet: small amount of bland food (nonirritating); low fiber diet; BRAT diet (banana, rice, apple, toast)
    Avoid excessively hot or cold fluids (these are stimulants)
    Potassium-rich foods (banana, Gatorade)
    Caution: Do not administer anti diarrheal at the start of diarrhea. Diarrhea is the body’s protective mechanism to rid itself of bacteria and toxins
    Flatulence: presence of excessive gas in the intestines
    Common causes:
    Constipation
    Anxiety
    Rapid food or fluid ingestion
    Improper use of drinking straw
    Excessive drinking of carbonated beverages
    Gum chewing, candy sucking, smoking
    Abdominal surgery. This causes decreased peristalsis
    Nursing Interventions:
    Avoid gas-forming foods
    Provide warm fluids to drink
    Early ambulation among post-op clients
    Limit carbonated beverages, use of drinking straws, and chewing gum
    Rectal tube insertion as ordered:
    Place client in left lateral position
    Insert 3-4 inches of lubricated rectal tube, gently in rotating motion
    Use rectal tube Fr. 22-30
    Retain rectal tube for maximum of 30 mins.
    Carminative enema as ordered
    Fecal incontinence: loss of voluntary ability to control fecal and gaseous discharges; often associated with neurological, mental, or emotional impairments
    Enemas:
    Purposes:
    To relieve constipation and fecal impaction
    To relieve flatulence
    To administer medications
    To evacuate feces in preparation for diagnostics procedure or sugery
    Principles:
    Protection: consider your contact with body fluids
    Tube: lubricate insertion tube 3-4 inches
    Position: left lateral
    Administration: deliver slowly to minimize discomfort
    Height of container:
    Retention enema: 12” above the rectum
    Non retention: 18: above the rectum
    Temperature: not more than 42 degrees Celsius
    Types of Enema:
    Cleansing enema: height of the container is 18 inches from the point of entry; instruct the client to hold the fluid for 10-15 minutes or as long as he possibly can
    High enema- to clean as much of the colon as possible 1000 ml of solution is introduced to an adult
    Low enema- to clean the rectum and the sigmoid colon; 500 ml of solution is introduced to an adult
    If client complains of cramping, clamp the tube for 30 seconds
    Carminative enema: to expel gas; it distends the rectum and colon and stimulates peristalsis; uses about 60-180 ml of fluid
    Retention enema: introduces oil into the rectumand sigmoid colon; oil (mineral or cotton seed oil) is retained in 1-3 hours; softens the stool
    Non-retention enema:
    Solutions used:
    Tap water: 500-1000ml
    Soap suds: 20 ml of soap to 500-1000ml of water
    Normal saline solution: 9 ml of NaCl to 1000ml of water
    Hypertonic solution/Fleet enema: 90-120 ml of solution
    Nursing Interventions in Enema Administration:
    Check doctor’s order
    Provide privacy. To prevent feeling of embarrassment.
    Promote relaxation. To relax anal sphincter and facilitate insertion of rectal tube.
    Position the client:
    Adult- left lateral
    Infants and small children- dorsal recumbent
    Sizes of tube:
    Adults- Fr 22-32
    Children- Fr 14-18
    Infants- Fr 12
    Lubricate 5 cm (2 inches) of rectal tube
    Allow air to flow through the connecting tube and rectal tube to expel air before insertion. This prevents introduction of air into the colon.
    Insert 7-10 cm (3-4 inches) of rectal tube in a rotating motion. This is to prevent irritation of anal and rectal tissues.
    If abdominal cramps occur during introduction of solution, stop the flow by clamping the tube until peristalsis relaxes.
    After introduction of solution, press buttocks together to inhibit the urge to defecate.
    Do perianal care.
    Make relevant documentation.
    Nursing Diagnoses: Clients with Fecal Elimination problem
    Constipation related to:
    inadequate fiber in diet
    immobility/ inadequate physical activity
    inadequate fluid intake
    pain on defecation
    change in routine (diet intake)
    delaying defecation when urge is present
    Diarrhea related to:
    Dietary alteration
    Stress/anxiety
    Inflammation/irritation of the bowel
    Spoiled foods
    Allergy
    Potential fluid volume deficit related to:
    Diarrhea
    Excessive fluid loss in stool
    Potential for impaired skin integrity related to:
    Prolonged diarrhea
    Bowel incontinence
    URINARY ELIMINATION
    Main fxn of urinary system is to maintain homeostasis by maintaining body fluid composition and volume
    Kidneys, ureters, urinary bladder and urethra
    Review of Anatomy and Physiology:
    Kidneys- nephrons are its functional units
    Through the formation of urine, kidneys remove waste products from the body, regulate fluid volume, and maintain electrolyte concentration, blood pressure and pH within the body.
    About 1,200 ml of blood flows to the kidneys per minute which is 20-25% of the cardiac output.
    The glomerular filtration rate (GFR) is 125 ml/minute. From this, the kidneys form 0.5 to 1 ml/minute, 60 ml/hour, approximately 1,500 ml per day
    Ureters- 2 small tubes about 25 cm long
    They transport urine from the renal pelvis to the urinary bladder
    Urinary bladder- reservoir for urine
    Contraction of detrusor muscles expels urine from the bladder
    Approximate maximum capacity of the bladder is 1,000ml
    Urethra- passageway of the urine into the external environment
    Internal urethral sphincter is an involuntary muscle, while the external urethral sphincter is a voluntary muscle
    Female: 1 ½ to 2 ½ inches in length (the shorter urethra among females increase their susceptibility to urinary tract infection)
    Male: 5 ½ to 6 ½ or up to 8 inches in length
    Micturition- the act of expelling urine from the bladder (also urination or voiding)
    Parasympathetic nervous system initiates voiding
    Sympathetic nervous system inhibits voiding
    Normal Characteristics of the Urine:
    Color: amber/straw
    Odor: aromatic upon voiding
    Transparency: clear
    pH: slightly acidic (range 4.6 to 8; average of 6)
    Specific gravity (ratio of the density of a substance to the density of water): 1.010-1.025
    Factors Affecting Voiding:
    Growth and Development:
    Fetus: excrete urine between 11th and 12th week of development
    Infant: ability to concentrate urine is minimal; therefore, urine appears light yellow
    Children: full urinary control is not gained until age 4 or 5 years; daytime control is usually achieved by age 2 years
    Adults: kidneys reach maximum size between 35 and 40 years of age
    After age 50, the kidneys begin to diminish in size and function
    Elderly adults: renal blood flow decreases because of vascular changes and a decrease in cardiac output
    Residual urine may increase due to diminished bladder muscle tone and contractibility, which increases the risk of bacterial growth and infection and increases voiding frequency
    Psychosocial conditions: privacy, normal position, sufficient time, and occasionally running water
    Fluid and food intake:
    Fluids that contain caffeine (eg coffee, tea and cola drinks) increase urine production
    Foods high in fluid content (eg lettuce, milk and cooked cereals) also increase fluid output
    Food and fluids high in sodium can cause fluid retention.
    Foods containing carotene can cause urine to appear yellower than usual
    Medications:
    Diuretics (eg furosemide), which are commonly taken for HPN and cardiac disease, increase urine formation.
    Muscle tone and activity:
    People who exercise regularly will like have good muscle tone, increased body metabolism, and good urine production.
    Poor muscle tone can lead to impaired bladder muscle contraction and poor urination control.
    Presence of an indwelling catheter can lead to poor bladder muscle tone; the bladder does not fill and stretch; and external sphincter does not completely close--- thus when the catheter is removed, client may have difficulty in regaining urinary control.
    Pathologic conditions:
    Diabetes insipidus increase urine formation
    Diseases that impair blood flow to the kidneys (eg atherosclerosis—plaque builds up on the inside of arteries) can decrease urine formation
    Altered Urine Production:
    Polyuria/ dieresis- production of excessive of urine such as 100ml/hr or 2500ml/day (maybe due to excessive fluid intake, ingestion of substances containing caffeine and alcohol, or deficiency of ADH)
    Oliguria- production of decreased amount of urine such as less than 30ml/hr or less than 500 ml/24 hours (may sometime accompany fever and heavy perspiration—because excessive fluid is lost via the skin, urine production may also decrease)
    Anuria- the absence of production of urine by kidneys such as a 0-10ml/hr or less than 100ml/day.
    Altered Urinary Elimination:
    Frequency- voiding at frequent intervals
    Maybe due to increased fluid intake, cystitis (inflammation of the bladder), stress, or pressure on the bladder (because of pregnancy for example)
    Nocturia- increased frequency at night
    Not a result of increased fluid intake
    Can occur if kidneys cannot concentrate urine normally or having a different 'body clock', which causes a normal daytime urination pattern to occur at night.
    Urgency- the strong feeling that the person wants to void.
    May accompany psychologic stress
    Common in young children who have poor external sphincter urine control
    Dysuria- voiding that is painful or difficult
    Due to the irritation of the urethra
    Enuresis- repeated involuntary urination in children beyond 4-5 years of age.
    Voluntary bowel control is normally acquired by 4-5 years of age
    Incontinence-
    Total incontinence- continuous and unpredictable loss of urine
    Constant flow of urine at unpredictable times or uninhibited bladder contractions/spasms
    Functional incontinence- the involuntary unpredictable passage of urine
    Urge to void or bladder contractions sufficiently strong to result in loss of urine before reaching an appropriate receptacle
    Stress incontinence- leakage of less than 50 ml of urine as a result of sudden increase in the intra-abdominal pressure eg when one coughs, sneezes, laughs or exerts physically
    Urge incontinence- follows a sudden strong desire to urinate and leads to involuntary detrusor contraction
    Retention- accumulation of urine in the bladder with associated inability of the bladder to empty itself
    250-450 ml of urine in the bladder triggers micturition reflexes
    Clinical signs of urinary retention:
    Discomfort in the pubic area
    Bladder distention
    Smooth, firm, ovoid (shape like an egg) mass at the suprapubic area
    Inability to void or frequent voiding of small volumes 25-50 ml at a time
    Increasing restlessness and feeling of need to void.
    Pelvic Muscle Exercise (Kegels):
    Helps strengthen pelvic floor muscles and can reduce or eliminate episodes of incontinence.
    Done as if by stopping urination midstream or by tightening the anal sphincteras if to hold a bowel movement.
    Sit or lie in a comfortable position.
    Contract your pelvic muscles whereby you pull your rectum, urethra and vagina up inside, and hold for 3 to 5 seconds. Then relax the same muscles for a count of 3 to 5 seconds.
    Initially perform each contraction 10 times, three times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation.
    To control stress incontinence, perform this when initiating any activity that increases intra-abdominal pressure, such as coughing, laughing, sneezing, or lifting.
    Maintaining skin integrity:
    Skin that is continuously moist becomes macerated (softened).
    Urine that accumulates on the skin is converted in to ammonia, which is very irritating to the skin.
    Incontinence requires meticulous skin care.
    Wash client’s perineal area with mild soap and water. Rinse thoroughly. Dry gently. Provide clean, dry clothing or bed linen.
    Managing Urinary Retention:
    Clients who have flaccid bladder (weak, soft and lax bladder muscles) may use manual pressure on the bladder to promote bladder emptying.
    This is known as Crede’s , maneuver or Crede’s method.—not advised without a physician’s order.
    Nursing interventions to induce voiding:
    Provide privacy. This is the most effective measure to induce voiding.
    Provide fluids to drink.
    Assist the patient in anatomical position of voiding; male—standing; female—squatting or slightly leaning forward
    Allow the patient to listen to sound of running water
    Dangle fingers in warm water.
    Pour warm water over the perineum
    Promote relaxation
    Provide adequate time for voiding
    Last resort- urinary catheterization—one of the most common cause of nosocomial infection
    Measuring urinary output:
    Wear clean gloves to prevent contact with microorganism.
    Ask client to void in a clean urinal, bedpan, or commode.
    Instruct client to keep urine separate from feces
    Pour the voided urine in a calibrated container
    Hold the container at eye level and read the amount on the container.
    Calculate and document total output at the end of each shift and at the end of 25 hours on the client’s chart.
    Measuring urinary output from a client with urinary catheter:
    Put on clean gloves.
    Take the calibrated container to the bedside.
    Place container under the urine collection bag so that the spout of bag is above the container but not touching it. The calibrated container is not sterile, but the inside of the collection bad is sterile.
    Open the spout and permit urine to flow to the container.
    Close the spout. Document.
    Measuring residual urine:
    Residual urine- urine remaining in the bladder following the voiding is normally 50 to 100ml
    Urinary stasis and urinary tract infection are possible consequences of incomplete bladder emptying.
    To measure the residual urine, the nurse catheterizes the patient per doctor’s order.
    Urinary Catheterization:
    Introduction of catheter into the urinary bladder.
    Single catheterization: straight catheter
    Retention catheter: two-way Foley catheter
    Continuous bladder irrigation (Cystoclysis: 3-way Foley catheter)
    Purposes of urinary Catheterization:
    Relieve bladder distention
    Instill medications into the bladder
    Irrigate the bladder
    Measure hourly urine output accurately
    Collect urine specimen
    Measure residual urine
    Maintain continence among incontinent clients
    Promote healing of the genito-urinary structures post-operatively
    Empty the bladder in preparation for diagnostic procedure and surgery
    Nursing Interventions in urinary Catheterization:
    Verify doctor’s order and identify client
    Explain procedure and purpose to client
    Provide privacy. Invasive procedures cause feelings of embarrassment
    Promote relaxation to relax urethral sphincter
    Practice strict asepsis to prevent ascending UTI
    Do perineal care before the procedure. To minimize microorganisms at the external genitals.
    Use appropriate size of catheter. To prevent trauma to the mucous membrane:
    Male: Fr 16-18
    Female: Fr 12-14
    Have adequate lighting. To visualize urethral meatus properly.
    Position of the patient during urinary catheterization:
    Male: supine, legs adbducted and extended
    Female: dorsal recumbent
    Don sterile gloves. Inflate the balloon of the catheter with air to check that it is intact and deflate.
    Locate urinary meatus properly.
    Male: at the tip of the glans penis
    Female: between clitoris and the vaginal orifice
    Cleanse urinary meatus with antiseptic solution using downward stroke.
    Lubricate catheter with water-soluble lubricant before insertion, to reduce friction and to prevent trauma.
    Insert catheter gently, in rotating motion. Instruct the client to take slow deep breaths to relax sphincter, or strain as if attempting to void to open urinary meatus.
    Length of catheter insertion:
    Male: 6-9 inches
    Female: 3-4 inches
    During insertion of the catheter in male, hold the penis at 90 degrees angle or perpendicular to the body. This is to straighten the urethra and facilitate catheter insertion.
    If the purpose of catheterization is to relieve bladder distention, practice gradual decompression to prevent shock, hemorrhage or bladder atony. Gradual decompression maybe done by the following actions:
    Empty the bladder slowly by pinching the catheter to reduce the size of the lumen.
    Elevate urine receptacle at the level of symphysis pubis to slow down expulsion of urine.
    Do not remove more than 1,000 ml of urine at a time.
    For retention catheterization, inflate the balloon with 5 ml sterile NSS
    Gwently pull on the catheter. If resistance is felt, the catheter balloon is properly inflated in the bladder.
    Anchor catheter properly.
    Male: laterally or upward over the lower abdomen tp prevent penoscrotal pressure
    Female: inner aspect of the thigh
    Attach drainage bag to the bed frame ensuring that tubing does not fall into dependent loops. Dependent loops fill with urine and can prevent free drainage of urine.
    Keep client comfortable
    Do after care of the equipments and articles.
    Make relevant documentation.
    Nursing Interventions for clients with retention catheter:
    Practice asepsis. Proper handwashing should be done before and after manipulating the device eg emptying the urinary drainage bag. To prevent infection.
    Increase fluid intake to enhance excretion of microorganisms.
    Acidify the urine (diet: meat, fish, eggs and cereals). Acidic urine prevent proliferation of microorganisms.
    Maintain closed drainage system. Do not detach catheter from the connecting tubing, unnecessarily.
    Meticulous perineal care. To prevent ascending UTI.
    Ensure patency of urinary catheter. Avoid kinks.
    Ensure that gravity drainage of urine is maintained. Hold the urinary drainage bag below the level of the bladder when ambulating.
    Monitor I and O.
    Change urinary catheter, tubing and urinary bag when sediment accumulates, if leakage is present or if a strong odor is evident.
    Nursing Interventions for Clients with Urinary Incontinence:
    Bladder retraining program. Determine the client’s voiding pattern or establish a regular voiding time eg every 1-2 hours during the day and evening before retiring at night; every 4 hours at night
    Lengthen the intervals of voiding once the client’s voiding can be controlled.
    Regulate the fluid intake, particularly before the client retires. To prevent nocturia.
    Avoid large amounts of fruit juices and carbonated beverages. Fruit juices produce alkaline urine which enhances proliferation of microorganisms. Carbonated beverages irritate the bladder wall.
    Avoid stimulants at bedtime.
    Schedule diuretics in the morning. To prevent nocturia.
    Adequate fluid intake in the morning. To produce adequate urine and to prevent UTI.
    Kegel’s exercise. This is done by alternate tension and relaxation of the pubococcygeal muscles. It helps regain control of voiding.
    Removal of indwelling catheter:
    Check doctor’s order.
    Wash hands. Remove the tape that has secured the catheter to the client’s body.
    Don clean disposable gloves. Handwashing and use of gloves prevent transfer of microorganisms.
    Insert hub of the syringe into balloon inflation port and draw out all liquid (NSS). The balloon must be completely deflated to prevent trauma to the urethra as the catheter is removed.
    Instruct the client to inhale, and then pinch and remove the catheter slowly and carefully as the client exhales. Breathing provides distraction and exhalation prevent tightening of abdominal and perineal muscles as catheter is withdrawn. Pinching the catheter prevents urine from dribbling onto the bed linens.
    After removal of the catheter, allow the urine to drain into collection bag. Measure and record amount of urine.
    Assess client’s perineum and meatus for any signs of redness or irritation.
    Assist client to do perineal care and dry genitals. To ensure client comfort.
    Discard contaminated equipments and articles in appropriate container. To prevent contamination of the environment.
    Make relevant documentation.
    Voiding should be expected within 6 to 8 hours from the time of removal of catheter. Some dribbling of uirne maybe experienced.
    Continue to assess I and O.
    If client has not voided in 8 hours, assess for urinary retention.
    If client has difficulty establishing voluntary control of voiding, notify the physician. It maybe necessary to reinsert the catheter.
    ACTIVITY AND EXERCISE
    Four Basic Elements of Normal Movement:
    Body alignment (posture)
    Joint mobility
    Balance
    Coordinated movement
    Body Alignment/Posture:
    Brings body parts into position that promotes optimal balance and body function
    Person maintains balance as long as line of gravity passes through center of gravity and base of support
    Joint Mobility
    ROM is maximum movement possible for joint
    ROM varies and determined by:
    Genetic makeup
    Developmental patterns
    Presence or absence of disease
    Physical activity
    Balance
    Smooth, purposeful movement
    Result of proper functioning of:
    Cerebral cortex
    Initiates voluntary movement
    Cerebellum
    Coordinates motor activity
    Basal ganglia
    Maintains posture
    Coordinated Movement
    Complex mechanisms
    Proprioception
    Awareness of posture, movement, changes in equilibrium
    Knowledge of position, weight, resistance of objects in relation to body
    Isotonic (Dynamic) Exercise
    Muscle shortens to produce muscle contraction and active movement
    Increase muscle tone, mass, and strength
    Maintain joint flexibility and circulation
    HR and CO quicken increase
    Isometric (Static or Setting) Exercise
    Muscle contraction without moving the joint (muscle length does not change)
    Involve exerting pressure against a solid object
    Produce a mild increase in HR and CO
    No apparent increase in blood flow to other parts of the body
    Isokinetic (Resistive) Exercise
    Muscle contraction or tension against resistance
    Can either be isotonic or isometric
    Person moves (isotonic) or tenses (isometric) against resistance
    An increase in blood pressure and blood flow to muscles occurs
    Aerobic Exercise
    Activity during which the amount of oxygen taken in the body is greater than that used to perform the activity
    Improve cardiovascular conditioning and physical fitness
    Anaerobic Exercise
    Activity in which the muscles cannot draw enough oxygen from the bloodstream
    Anaerobic pathways are used to provide additional energy for a short time
    Used in endurance training for athletes
    Effect on Musculoskeletal System
    Exercise
    Maintain size, shape, tone, and strength of muscles (including the heart muscle)
    Nourish joints
    Increase joint flexibility, stability, and ROM
    Maintain bone density and strength
    Immobility
    Disuse osteoporosis
    Disuse atrophy
    Contractures (shortening of muscles)
    Stiffness and pain in the joints
    Effects on the Cardiovascular System
    Exercise
    Increases HR, strength of contraction, and blood supply to the heart and muscles
    Mediates harmful effects of stress
    Immobility
    Diminished cardiac reserve (The work that the heart is able to perform beyond that required of it under ordinary circumstances)
    Increased use of the Valsalva maneuver
    Orthostatic hypotension (abnormal decrease in blood pressure when a person stands up)
    Venous vasodilation and stasis
    Dependent edema
    Effect on the Respiratory System
    Exercise
    Increase ventilation and oxygen intake improving gas exchange
    Prevents pooling of secretions in the bronchi and bronchioles
    Immobility
    Decreased respiratory movement
    Pooling of respiratory secretions
    Atelectasis (collapse of lunds)
    Hypostatic pneumonia (a type seen in the weak or elderly, due to excessive lying on the back.)
    Effects on the Metabolic/Endocrine System
    Exercise
    Elevates the metabolic rate
    Decreases serum triglycerides and cholesterol
    Stabilizes blood sugar and make cells more responsive to insulin
    Immobility
    Decreased metabolic rate
    Negative nitrogen balance
    Anorexia
    Negative calcium balance
    **nitrogen balance-- the relationship between the amount of nitrogen taken into the body, usually as food, and that excreted from the body in urine and feces. Most of the body's nitrogen is incorporated into protein. Positive nitrogen balance, which occurs when the intake of nitrogen is greater than its excretion, implies tissue formation and growth. Negative nitrogen balance, which occurs when more nitrogen is excreted than is taken in, indicates wasting or destruction of tissue
    Effects on the GI System
    Exercise
    Improves the appetite
    Increases GI tract tone
    Facilitates peristalsis
    Immobility
    Constipation
    Effect on the Urinary System
    Exercise
    Promotes blood flow to the kidneys causing body wastes to be excreted more effectively
    Prevents stasis (stagnation) of urine in the bladder
    Immobility
    Urinary stasis
    Renal calculi
    Urinary retention
    Urinary infection
    Effect on the Immune System
    Exercise
    Pumps lymph fluid from tissues into lymph capillaries and vessels
    Increases circulation through lymph nodes
    Strenuous exercise may reduce immune function
    Leaving window of opportunity for infection during recovery phase
    Effect on the Psychoneurologic System
    Exercise
    Elevates mood
    Relieves stress and anxiety
    Improves quality of sleep for most individuals
    Immobility
    Decline in mood elevating substances
    Perception of time intervals deteriorates
    Problem-solving and decision-making abilities may deteriorate
    Loss of control over events can cause anxiety
    Effect on Cognitive Function
    Exercise
    Positive effects on decision-making and problem solving processes, planning, and paying attention
    Induces cells in the brain to strengthen and build neuronal connections
    Other Effects of Exercise and Immobility
    Evidence that certain types of exercise increase spiritual health
    Immobility causes reduced skin turgor and skin breakdown
    Body Mechanics- is the efficient, coordinated and safe use of the body to produce motion and maintain balance during the activity. Effective use of body mechanics prevents injury to self and clients.
    Principles of Body Mechanics
    Balance is maintained and muscle strain is avoided as long as the line of gravity passess through the base of support.
    Start body movement with proper alignment
    Stand as close as possible to the object to be moved
    Avoid stretching, reaching and twisting
    The wider the base of support and the lower the center of gravity, the greater the stability. Before moving objects, put your feet apart, flex the knees, hips and ankles.
    Balance is maintained with minimal effort when the base of support is enlarged in the direction in which the movement will occur.
    When pushing an object, enlarge the base of support by moving the front foot forward
    When pulling an object, enlarge the base of support either by moving the rear leg back if facing the object or moving the front foot forward when facing away from the object
    Objects that are close to the center of gravity are moved with least effort. Adjust the working are to waist level and keep the body close to the object.
    The greater the preparatory isometric tensing or contraction of muscles before moving an object, the less the energy required to move it and the less the likelihood of musculoskeletal strain injury.
    Before moving objects, contract your gluteal, abdominal, leg and arm muscles to prepare them for action.
    The synchronized use of as many large muscle groups as possible during the activity, increases overall strength and prevents muscle fatigue and injury.
    To move objects below your center of gravity, begin with the hip and knees flexed
    Use gluteal and leg muscles rather than the sacrospinal muscles of the back to exert an upward thrust when lifting weight.
    Face the direction of the movement to prevent twisting of the spine.
    The closer the line of gravity to the center of the base of support, the greater its stability.
    When moving or carrying objects, hold them as close as possible to the center of gravity
    Pull an object toward self whenever possible rather than pushing it away.
    The greater the friction against the surface beneath an object, the greater the force required to move an object. Provide a firm, smooth foundation before moving the client in bed.
    Pulling creates less friction than pushing.
    The heavier an object, the greater the force needed to move an object.
    Encourage the client to assist as much as possible by pushing or pulling themselves by the use of arms as levers to increase lifting power.
    Use own body weight to counteract the weight of the client.
    Obtain the assistance of other person or use mechanical device to move objects that are too heavy.
    Moving an object along a level surface requires less energy than moving an object up an inclined surface or lifting it against the force of gravity.
    Pull, push, or turn objects instead of lifting them
    Lower the head of the client’s bed before moving the client up in bed.
    Continuous muscle exertion can result in muscle strain and injury. Alternate rest periods with periods of muscle use to help prevent fatigue.
    COMFORT, REST AND SLEEP
    PAIN
    INTRODUCTION
    Of all the signs and symptoms of illness, PAIN is perhaps the most common form of discomfort.
    People differ remarkably in their ability to tolerate pain.
    Ability to withstand pain varies according to mood, personality, and circumstances.
    CONCEPTS ASSOCIATED WITH PAIN
    Pain Threshold- the amount of pain stimulation a person requires before feeling pain (also pain sensation)
    Generally fairly uniform among people
    Pain Tolerance- the maximum amount and duration of pain that an individual is willing to endure
    Varies greatly among people
    Pain perception- the actual feeling of pain
    Hyperalgesia- excessive sensitivity to pain
    CLASSIFICATIONS OF PAIN
    TYPES OF PAIN
    Cutaneous or Superficial- occurs over the body surface or skin segment
    Somatic- occurs in the skin, muscles or joints
    Visceral- pain in the abdominal cavity and thorax
    Referred- pain is perceived other than the site of injury
    Intractable- resistant to cure or relief
    Phantom- actual pain that is felt in a body part that is no longer present.
    Radiating- felt at the source and extends to surrounding tissues.
    Psychogenic- primarily due to emotional factors.
    Intermittent- stops and starts again.
    LOCATION
    DURATION
    Acute- lasts for less than 6 months
    Chronic- lasts for more than 6 months
    CHARACTER
    Whatever description the client gives, accept it as it is!
    Pricking
    Stabbing
    Dull
    Throbbing
    INTENSITY/SEVERITY
    Use scale of 0-10
    1-3 mild pain
    4-6 moderate pain
    7-10 severe pain
    Applying the Nursing Process
    Obtain the pain history (P,Q,R,S,T)
    P - Provocation / Palliation 
    what were you doing when the pain started? What caused it? What makes it better? worse? What seems to trigger it? Stress? Position? Certain activities? Arguments? Does it seem to be getting better, or getting worse, or does it remain the same? What relieves it: changing diet? changing position? taking medications? being active? resting? What makes (the problem) worse?
    Q – Quantity/ Quality
    What does it feel like? Is it sharp? Dull? Stabbing? Burning? Crushing? throbbing? nauseating? shooting? twisting? stretching? Other? (The person who is suffering the pain should describe the pain, rather than saying what they think you would like to hear.) How does it feel, look or sound? How much of it is there?
    R - Region / Radiation 
    Where is the pain located? Does the pain radiate (i.e. spread to another location, eg. pain source is from thumb but pain spreads to elbow)? Where does it radiate? Is it all in one place? Does it go anywhere else? Did it start elsewhere and now localised to one spot? Does it feel like it travels/moves around?
    S - Severity Scale 
    How severe is the pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever? Does it interfere with activities? How bad is it when it's at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?
    Pain Scale
    Wong/Baker Faces Rating Scales
    T - Timing 
    When did the pain start, at what time? How long did it last? How often does it occur? Is it sudden or gradual? What were you doing when you first experienced or noticed it? How often do you experience it: hourly? daily? weekly? monthly? When do you usually experience it: daytime? night? in the early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?
    For infants and preschoolers, assess nonverbal cues
    Rest and Sleep
    rest – condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed
    sleep – state of rest accompanied by altered consciousness and relative inactivity
    - complex rhythmic state involving progression of repeated cycles, each a different phase of body and brain activity
    - sleep loss that results in fatigue and decreased competence may be a contributing factor in accidents
    - discomfort produced by illness and need for hospitalization and treatment my interfere dramatically with a patient’s ability to sleep