Blood loss-hypothalamus-PPG-ADH-decrease U/O-oliguria and conservation of circulating volume-prevention of hypovolemic shock
Inflammants- cause of inflammation
Neutrophils- first launch in the site of injury
Monocytes- perform phagocytosis in chronic tse.
Lymphocytes-responsible for immune response
Margination/pavementation- phagocytes line up at the injury sites
Chemotaxis- injured site release substances and bring them to the site of injury
emigration/diapedesisphagocytosis shift out of the blood vessels
REDNESS- first manifestation after injury
The primary cause of pain at the injury site- compression of nerve endings by edema fluids
First intention: primary union/ healing
second intention with tse. Loss; the scarring is greater
third intention: surgical closure(tertiary intention)
Fever- hypothalamus release interferon to protect from viral invasion- inc. phagocytic activity
REDUCE SWELLING- by hot and cold application and levating the extremity to promote venous return
Cold application- during 72 hrs.
Hot application- after 72 hrs.
HEAT APPLICATION-promotes vasodilation-reduces stiffness in joints, relieves edema,promotes muscle relaxation and relieves pain by inc. bld. Flow to an area.
COLD APPLICATION-vasoconstriction- controls bleeding,numbs the nerve endings and has a local anesthetic effect,
Dec. cellular metabolism,relieves edema and slows bacterial growth
Heat application-usually requires DOCTORS order
Heat and cold application- is done in 30 mins. At max. 7 average of 15-20 mins. > 30 mins. Is rebound effects
Check application q 15-20 mins
Heat cradle & HEAT LAMP- <25 watts & positioned @least 18” away from the sit to be treated if 40 watts bulb is used, inc. the distance to 24”
apply topical med. After the tx
Hot water bag- temp. of water is <125F, fill only the bag to ½ to 2/3 full and expel the air, hold it upside/down
Warm soak- the temp. of water should be 105-115F
SITZ BATH or HIP BATH– SOAK up the pelvic area, the temp. of water should be 105-115F check the BP and PR before and after 5 mins. w/c result to dizziness and or fainting, it promotes vasodilation and thus causing dizziness and fainting
ICE COLLAR- neck application of crushed ice, fill ½ or 2/3 full
Ice cap-fill the bag 1/3 full application over the chest & ½ full over the abd.
3 levels of prevention:
Primary: health promotion & health protection (immunization)
Secondary: early detection &prompt tx (reg. pap smear test & monthly BSE)
Tertiary: rehab.(attend self-mgt educ for diabetes)
ENHANCE PEOPLE QLTY. OF LIFE- nsg. Activities in health promotion
Accident prevention prog.- for coy. Nses.
Coordinating health educ.-primary purpose of health promotion
Knowledge on ill effects of smoking-strong way to quit smoking
Smoking cessation prog. Is more likely be successful-if intervention focuses on the behavior most concern
Behavior change- is the key to effective health educ.
The PHN should be a model of health-as an effective health promoter
REHAB-begins when a pt is admitted to hosp.
Self-responsibility-is imp. When implementing health promotion plan
Pt shoud be MOTIVATED- as best result in rehab
Adaptability-involves ADJUSTMENT on what the nse says
COMMUNICATION-is the basic component of human relationship & nse-client relationship
NONVERBAL COMM. Is more accurate expression than verbal comm.
In nonverbal-consider CULTURAL influences
Effective comm.- is a reciprocal interaction
TRUST- is the foundation of NSE-PT RELATIONSHIP
COVERT COMM. –inner feelings and VALIDATION is most effective skill
Nursing audit-monitor the qlty. of care received by the client and competence of health care givers
TYPES OF RECORDS;
1. SOURCE ORIENTED MEDICAL RECORD-traditional client record 5 components: admission sheet; physician’s order sheet; medical hx sheet,nse’s notes,labs,dx findings, V/S,I/O
2.PROBLEM ORIENTED MED. RECORD-DATA PROB. 4 components: data base,prob. List,soapie,flowsheets and discharge notes or referral summaries.
LEARNING-a change in human disposition or capabilty that persist over a period of time
Theories of learning-humanism=natural of people to learn,cogniitism=is a complex cognive act.(LEWIN)
Behaviorism-transfer of knowledge if the new situation closely resembled the old situation
1. clean catch/midstream urine specimen-for culture and sensitivity test and routine u/a
-best time is EARLY IN THE MORNING, FIRST VOIDED
-do perineal care b4 collection to reduce microorganism at external genitalia
-discard the first flow to ensure it is uncontaminated
COLLECT tHE MIDSTREAM: 30-50mL for routine U/A & 5-10mL for C/S
-discard the last flow of urine in MALES- maybe contaminated by semen
2.24hrs specimen- for kidney fxn
-discard the first voided,start collecting to the next void of the day and cont. to collect until the next day at the same time
-soak specimen in a container w/ ice
-discard the first voided- give the pt. one glass of water-after few mins. Ask the pt to void again and collect the specimen
-this type of specimen-to test for glucose in urine
4. catheterized urine specimen-clamp the catheter for 30 mins- 1 hr.
Test Indiaction Antigen skin Test to rule out cancer of the lungs Benedict’s test For glucose monitoring
Bentonite flacculation test Test for filiariasis Beutler’s test Test for galactosemia Blanching test Determines the impairment in circulation Bronsulpthlein test Liver angiography Caloric test Test done by placing water in the ear canal causes nystagmus. A test for inner ear
Cd4 determination Checking the immune status to AIDS pt Cerebral perfusion test Test used to check the cerebral fxn Coomb’s test Determines the prod. Of the antibodies. RhoGAM is given (1 st &@ hrs CPK BB Test for brain muscles CPK MB Test for cardiac muscles for MI CPK MM Test for muscle injury
Dark field illuination test and kalm test Determination for the presence of syphilis Dick test Detect scarlet fever Doll’s eye test Determines the presence .of blindness. Done in 1 st ten days (+) normal (-) abnormal ELISA Test Determines presence of HIV Gram staining& culture of cervical &urethral smear Determination for the presence of gonorrhea Gross hearing test Test used by whispering words or spoken voice test
Guthrie test Test for PKU Heat and acetic acid test For protein or album detection Immunochromatographic test A rapid assessment method done for filariasis. The antigen test that can be done at daytime Jones criteria One way of diagnosing Rheumatic heart fever Lepronin test A screening test for leprosy Liver enzyme test For SGOT & SGPT Liver profile test Determines hepa B surface antigen
Lumbar puncture Determines for the presence of meningitis &encephalitia.position in side lying Malaria smear Test to confirm malaria;specimen is taken 2 the lht. Or peak of fever Mantoux test Determinetion for TB exposure Menire’s test Test vestibular fxn Methylene blue test For ketone detection Moloney test Hypersensitivity test for diphtheria
Oxytocin challenge test Determine if the fetus can tolearte uterine contraction Pandy’s test Determine the presence of protein in the csf Phenosulpthalein test Kidney angiogram Queckkenstedt’s Test the compression of jugular vein Rectal swab Done in pt. w/ cholera.pinworm detection Rinne test Shifted b/w mastoid bone & 2” from the ear canal opening
Romberg’s test Assess gait & station such as ataxia Schick test Susceptibility test for diphtheria(+) no immunity(-) w/ immunity Schiller’s test Staining the cervix w/ an iodine sol.. Healthy tses. Will turn brown while cancerous tse resist tha stain Schilling test Used to pt w/ severe chilling sensation; for confirmation of pernicious anemia Schwabach test Differentiate b/w conductive & sensorineuraldeafness, mastoid of pt and examiner Shake test Determines jthe amt of surfactant in tha lungs
Skin test Purpose it to produce antigen reaction Slit skin smear A confirmatory test for leprosy Specific gravity test FOR DM & DI as well as for dehydration Sperm count test For male infertility(Low spermlow sperm count –OVERSEX!) Sputum exam For detection and sensitivity of causative microorganism, for pneumonia and TB Sulkowitch test Urine test detection for Ca deficiency an Ca in the urine
Sweat chloride test Used to diagnose cystic fibrosis Tensilon (endophonium) test For rapid detection of MG Tonometer Test used to measure ocular tension & helping in detecting early glaucoma N=12-20mmHg Tournuquet test Done to determine presence of petechiae in DHF
TZANK test Determination for the presenceof herpes simplex Weber test Evaluation of bone conduction. Tuning fork is placed on pt.’s forehaed or teeth Widal’s test For typhoid fever determunation Western blot test A confirmatory for aids
Cardiac catheterization – insertion of a radiopaque catheter into a vein to study the heart great vessels.
- Used to confirm diagnosis of heart disease and determine extent of disease, measure pressures in the heart chamber and great vessels, obtain estimate of cardiac output, and obtain blood samples to measure oxygen content.
a. Right heart catheterization – catheter is inserted through a cut-down in the antecubital vein into the superior vena cava, through the right atrium and ventricle and into the pulmonary activity.
b. Left-heart catheterization- catheter maybe passed retrograde to the left ventricle through the brachial and femoral artery, it can be passed through the left
atrium after right-heart catherization by means of a special needle that punctures the septa; or it may be passed directly into the left ventricle by means of a posterior puncture.
Specific nursing considerations:
1. Preprocedure patient teaching:
a. Fatigue is a common complaint due to lying still for 3 hr
b. Feeling of fluttery sensation while the catheter is passed back into the left ventricle
c. Flushed, warm feeling may occur when contrast medium is injected.
2. Postprocedure observations:
a. monitor ECG pattern for arrhythmias
b. check extremities for color and temperature, peripheral pulses for quality.
3. Angiography (Arteriography) – injection of a contrast medium in to the arteries to study the vascular tree.
-Used to determine obstructions or narrowing of peripheral arteries
Catheterized urine specimen clamp the catheter for 30 minutes to 1 hour
Clean the drainage port with alcohol/cotton swab
DONT’S: collect the urine from the urinary drainage bag and detach it from the bag
NOTE: introduce the needle diagonally to allow self sealing of the rubber material of the catheter.
Benedict’s test: test for glucose
Collect urine before meals
Put 5 ml of solution in the test tube
Heat ht Benedict’s solution ( if color change it is contaminated)
Add 8-10 drops of urine
Heat the benedict’s solution with urine ( do not boil)
Blue (-) , green ( +) ; yellow ( ++) ; orange ( +++) and red ( ++++)
Clinitest test for glucose
collect urine specimen before meals
put 1 clinitest tablet in a test tube
add 5 drops of urine and 10 drops of water
compare with the standard of color inn the chart
HEAT and ACETIC ACID test for the albumin in the urine; collect urine before meals
Divide the test tube in 3 parts (imaginary)
PUR 2/3 PARTS of urine in the test tube and 1/3 acetic acid ( DONOT HEAT because it may explodes)
CLOUDINESS indicates ALBUMINURIA
ROUTINE ANALYSIS to asses gross appearance and presence of ova / parasites ; use tounge depressor in collecting ; collect one teaspoon or 1 inch well formed stool. Allow the patient to void first , discard and wash the bedpan. Label it and send immediately to lab warm specimen helps detect ova and parasite
STOOL C & S for Gastroenteritis and bacterial sensitivity to various abx; use test tube and cotton-tipped applicator
GUAIAC STOOL occult blood determination provide hgb-free diet for 3 days ( no meat for 3 days) ; discontinue IRON therapy ; (+) means PUD and gastric CA
SPUTUM SPECIMEN collect in the morning ; rinse mouth with water only, no stringent or mouthwash . ensure pt deep breath and hack up sputum
C&S sputum for respi disease ; collect it before the first dose of antimicrobials
AFB staining to asses presence of ACTIVE PTB ( collect sputum for 3 consecutive morning)
CYTOLOGIC/PAPANICOLAU to assess the CA cells
BLOOD SPECIMEN for FASTING collect before meals in finger pin pricks ; insulin injecton should be administered before meals
Palms down in taking the radial pulse
STRESS is the primary factor that affects BP
BROMHIDROSIS foul smelling perspiration
In doing tracheostomy keep AMBUBAG at the bedside: