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fundamentals of nursing review powershow

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    Funda mini movie clean Funda mini movie clean Presentation Transcript

    •  
    • Fundamentals of Nursing Christopher Sixto Casano, PTRP, RN National Licensure Examination Series Fundamentals of Nursing
      • Roles of the Professional Nurse
      • 1. Caregiver : “Mothering actions”
      • 2. Communicator : message + Feedback
      • 3. Teacher : health promotion & maintenance.
      • 4. Counselor : Emotional, intellectual & psychological support.
      • 5. Client advocate : “BEST for Patient”
      • 6. Change Agent : Initiate changes
      • 7. Leader : Influences the patient
      • 8. Manager : Organize, Coordinate and Dispense
      • 9. Researcher : Modify nursing practice
      • Concepts of Health & Illness
      • Health is a state of
      • complete physical, mental and social well-being, and not merely the absence of disease or infirmity.
      • characterized by soundness or wholeness of developed human structures and of bodily and mental functioning.
      • Health is a well-being and using one’s power to the fullest extent.
      • Health is maintained through the prevention of disease via environmental factors.
      • Health is viewed in terms of the individual’s ability to perform 14 components of nursing care unaided.
      • Health is a state and a process of being and becoming an integrated and whole person.
      • Questions:
      • 1. A new staff nurse refreshes the fact that nursing care is based on:
      • a. Nursing concepts
      • b. Nursing process
      • c. Nursing theory
      • d. Nursing problem
      • 2. Which of these statements LEAST describes nursing?
      • a. It is an art and science of caring for the health of the individual, family, or community in any setting.
      • b. It is a health-oriented profession which requires formal training committed to the ideals of service.
      • c. It is mainly dealing with the cure and treatment of health conditions affecting an individual, community, or family.
      • d. It is basically premised on the greatest human principle of “love thy neighbor”.
      • 3. The following are assessment activities EXCEPT:
      • a. Gathering and verifying data
      • b. Conferring and revalidating data
      • c. Using physical assessment tools
      • d. Determining nursing problems
      • 4. Which of the following statements INCORRECTLY describes the evaluation phase of the nursing process? It is the:
      • a. Process of determining the extent to which the plan and identifies goals are met.
      • b. Examination of the outcome of nursing interventions
      • c. Completion of the nursing process
      • d. Identification of client needs and designing of strategies to attain goals
      • 5. Nursing has evolved from a behavior that is in intuitive and based on charity to the broadest concept of being responsible for health. Which of these statements does not describe nursing at this age?
      • a. It is person and client oriented
      • b. It includes promotive, preventive, and rehabilitative aspects of care
      • c. Nursing activities are independent, interdependent and dependent
      • d. Nursing is focused on disease management and dependent care measures
      • 6. According to the Self-care model, when a nurse performs hygiene and nutritional activities to a comatose client, her services are regarded as:
      • a. Wholly compensatory
      • b. Partially compensatory
      • c. Supportive-educative
      • d. Imperical-specific
      • 7. Which of the following values is considered a foundation of nursing?
      • a. Caring
      • b. Commitment
      • c. Compassion
      • d. Perseverance
    • Nursing Theories
      • Florence Nightingale ( Environmental)
      • - H20, O2, drain, cleanliness & light
      • Jean Watson’s Human Caring
        • 10 Caring factors
      • Virginia Henderson
        • 14 Basic Needs
      • Dorothy Johnson
        • Behavioral Systems Model
    • Jean Watson’s 10 factors
      • Altruism
      • Faith & hope
      • Sensitivity
      • Trust
      • Acceptance
      • Decision-making
      • Teaching-learning
      • Supportive environment
      • Gratification of needs
      • Existential phenomenological
    • Virginia Henderson’s 14
      • Breathing
      • Eating & drinking
      • Elimination
      • Ambulation
      • Sleep & rest
      • Clothing
      • Temperature mgt
      • Hygiene
      • Safety
      • Communication
      • Religion
      • Productive work
      • Play
      • Learning
      • 5. Imogene King
        • Goal Attainment Theory
          • a. Personal system
          • b. Interpersonal system
          • c. Social system
      • 6. Madeleine Leninger
        • Transcultural Nursing
      • 7. Myra Levine
        • 4 Conservation Principles
          • a. Energy
          • b. Structural Integrity
          • c. Personal Integrity
          • d. Social Integrity
      • 8. Betty Neuman
        • Health Care System Model
            • a. Intravariable
            • b. Intervariable
            • c. Extravariable
      • 9. Dorothea Orem
        • Self Care / Self Care Deficit Theory
          • 3 compensatory systems:
            • a. Wholly Compensatory
            • b. Partially Compensatory
            • c. Supportive – educative
      • 10. Hildegard Peplau
        • Interpersonal Model
      • 11. Martha Rogers
        • Science of Unitary Human Beings
      • 12. Sister Callista Roy ( Adaptation)
          • Person as an adaptive system functions as a whole through interdependence of its parts.
      • 13. Lydia Hall
        • 3 C’s ( care, core & cure)
      • 4 concepts common in conceptual models:
        • a. Person
        • b. Environment
        • c. Health
        • d. Nursing
    • Benner’s Stages of Nursing Expertise
      • Novice (student) Rules > experience
      • Advance beginner (marginally acceptable) recognize meaningful aspects. Knows enough
      • Competent (2-3 yrs) organizes & plans
      • Proficient (3-5yrs)holistic, uses maxims
      • Expert : fluid, proficient & intuitive
    • Nursing Process A ssess D iagnose P lan I ntervene E valuate
    • Assessment of the Client
      • Collection of data related to health status
      • Subjective Data
      • What a client or family (SO) says
      • Objective Data
      • What the nurse observes
      • PE: inspect, percuss, palpate, & auscultate
      • Client's health record and the results of laboratory and diagnostic studies
    • Database Construction and Diagnosis
      • Types of Diagnoses
      • Actual nursing diagnosis : an existing problem
      • Risk diagnosis : no current problem but at risk
      • Wellness diagnosis : focuses on strengths and reflects ability to achieve a higher level of wellness
      • Collaborative problems : interdependent management (medical and nursing orders)
    • Database Construction and Diagnosis
      • Types of Databases
      • Complete : complete health history & full PE
      • Focused : limited or short-term problem, such as one problem or body system
      • Follow-up : focuses on evaluating progress 
      • Emergency : rapid collection of data, often during the provision of lifesaving measures
    • The Interview
      • Collect subjective data and observe the general state of health
      • Establish rapport and trust
      • Teach health promotion and disease prevention
      • General State of Health
      • Body features and physical characteristics
      • Body movements
      • Body posture
      • Level of consciousness
      • Nutritional status
      • Speech
    • Factors to Consider during an Interview
      • Explain procedure
      • Ensure privacy & Avoid interruptions
      • Note-Taking during the Interview
      • Keep note-taking to a minimum
        • can shift attention away
        • interrupt narrative flow 
        • threatening when discussing of sensitive issues
        • also impedes observation
    • Physical Environment During the Interview
      • Comfortable level: Temperature, lighting, & noise
      • Arrangement: Remove distracting objects or equipment, The distance between should be 4 to 5 feet (twice arm's length), Eye to eye, No Barriers, Face to Face
    • Communication Technique
      • Exchange info; should be clearly understood
      • Appropriate tone, one question at a time, and layman’s terms; allow time to answer
      • Open-ended questions: narrative information
      • Closed or direct questions: one-or two-word
      • Hearing-impaired may lip-read; May need sign-language interpreter
      • Observe nonverbal behavior
      • End the interview by providing an opportunity to ask questions
    • Guidelines for Measuring Vital Signs
      • Initial measurement for baseline data
      • May be delegated to assistive personnel, but the nurse is responsible for interpreting the results
      • RN collaborates with MD in determining the frequency of vital sign assessment
      • Documents and reports abnormal findings
    • Measuring Vital Signs
      • Should be done
      • On initial contact; during PE
      • Before and after an invasive diagnostic or surgical procedure
      • Before, during, and after Meds administration
      • Before, during, and after a blood transfusion
      • Upon condition changes
      • Whenever an intervention (e.g., ambulation) may affect a client’s condition
      • (+) Fever: measure every 2 to 4 hours
    • Temperature
      • Normal: 97.5  to 99.5  F (36.4  -37.5  C); Average adult is of 98.6  F (37.0  C)
      • Common: mouth, rectum, axilla, and ear
      • Rectal temp 1  F > Oral > axillary temp 1  F
      • Conversion
      • Fahrenheit to Celsius:
      • (Fahrenheit – 32) x 5/9 = Celsius
      • Formula to convert Celsius to Fahrenheit: (Celsius x 9/5) + 32 = Fahrenheit
    • VITAL SIGNS
      • A. Temperature
        • BT = Heat Produced – Heat Loss
      • Types:
      • 1. Core Temperature
        • deep tissues (peritoneum, cranium)
      • 2. Surface Temperature
        • skin, subcutaneous tissue and fat
      • Factors Affecting Heat Production:
        • 1. Basal Metabolic Rate (BMR)
        • 2. Muscle Activity
        • exercise, running or swimming
        • 3. Thyroxine Output
        • 4. Epinephrine & Norepinephrine
        • 5. SNS stimulation
        • 6. Fever
      • Processes of Heat Loss
      • a. Radiation
      • b. Conduction
      • c. Convection
      • d. Evaporation
      • Alterations in Body Temperature:
        • 1. Hyperthermia (Fever)
        • 2. Hypothermia
      • Types of Fever
        • 1. Intermittent
        • 2. Remittent
        • 3. Relapsing
        • 4. Constant
      • Decline of Fever
      • a. Crisis
      • b. Lysis
      • Nursing Interventions for Fever
        • Monitor V.S.
        • Assess skin color & temperature.
        • Monitor WBC, hct & other pertinent laboratory records.
        • Remove excess blankets when warm, provide when client has chills.
      • Provide well-balanced diet, increase fluid.
      • MIO
      • IVF
      • Rest
      • Oral Hygiene
      • Cool circulating air with a fan
      • TSB
      • Antipyretics as ordered
    • Factors That Affect Body Temperature
      • Time of Day
      • Environmental Temperature
      • Age
      • - Fluctuates during 1st year of life
      • Physical Exercise
      • - Use of the large muscles creates heat
      • Menstrual Cycle
      • - Temp decreases slightly just before ovulation; increase to 1  F during ovulation
      • Pregnancy
      • - high normal because of an increase in the body’s metabolic rate
      • Stress
      • - Emotions increase hormonal secretion
      • Illness
      • - Infective agents and the inflammatory response may cause an increase in temperature
    • The Glass Thermometer
      • An elongated bulb: oral or axillary use, a stubby bulb: any site, and a red bulb: rectal use 
      • Shake down the mercury before using the thermometer
      • Oral only for alert, cooperative, and able to breathe while holding the thermometer in the mouth
      • Not used if unconscious, uncooperative, confused, or agitated, at risk for biting the thermometer, or at risk for seizures
      • To read, hold horizontally at eye level and rotate
    • Oral Temperature
      • If a glass thermometer is used, it must be left in place for 3 minutes or for as long as agency procedures dictate
      • If recently taken hot or cold foods or liquids or has smoked or chewed gum, must wait 15 to 30 minutes
      • Placed under the tongue in the posterior sublingual pocket; ask keep the tongue down and the lips closed and to not bite down on the thermometer
    • Rectal Temperature
      • Place client in Sims' position
      • Done if oral not possible, nasal congestion, nasal or oral surgery, has NGT in place, is unable to keep the mouth closed, or is at risk for seizures
      • No rectal in cardiac, rectal surgery, diarrhea, fecal impaction, or rectal bleeding
      • Bulb is lubricated, 1.5 inches inserted into the rectum (til 0.5 inch in an infant); 2 mins
    • Axillary Temperature
      • Taken when taking the temperature orally or rectally is contraindicated
      • Not as reliable a measurement as the oral, rectal, or tympanic method
      • Placed in dry axilla, and the client to hold the arm tightly against the chest, resting the arm on the chest
      • kept in place for 3 minutes or for as long as agency procedure dictates
    • The Electronic Thermometer
      • Portable battery-operated device; measures body temperature in 5 seconds to 1 minute
      • The probe is placed in a plastic cover or sheath that is used one time and then discarded
      • A light will stop flashing or the unit will beep when the temperature registers
      • Always return the unit to its holder after use to maintain the battery's charge 
    • The Tympanic Thermometer
      • Portable battery-operated device that registers the temperature in 1 to 2 seconds
      • the probe should not be inserted if the client has an inflammatory condition of the auditory canal or if there is discharge from the ear
      • After the mode (infant/toddler or child/adult) is selected, the thermometer probe is inserted into the auditory canal
      • Reading may be affected by an ear infection or excessive wax blocking the ear canal
    • Disposable Thermometers
      • Various types of single-use disposable thermometers are available
      • Most disposable thermometers will measure temperature in 2 minutes
    • Pulse
      • Average pulse rate: 60-100 bpm
      • Evaluate PR changes in tolerance of ADL
      • Pedal pulses are checked to determine whether the circulation is blocked in the artery up to that pulse point
      • When the pedal pulse is difficult to locate, a Doppler-ultrasound stethoscope (ultrasonic stethoscope) may be needed to amplify the sounds of a pulse wave
      • Assessment
      • a. Rate
      • 0 – 1 month: 120 – 160 beats/min Adult: 60 – 100 beats/min
      • b. Rhythm
      • c. Volume (Amplitude)
    • Factors Affecting the Pulse Rate
      • Pulse rate diminishes with age
      • Exercise, pain & emotions increases the pulse rate
      • Increased body temperature causes the heart rate to increase
      • Stimulant medications increase the heart rate and depressants decrease it
      • Low blood pressure= increase the heart rate
      • Hemorrhage increases the heart rate
    • Pulse Characteristics
      • When the pulse is being counted, note the rate, rhythm, and strength (force or amplitude)
      • Grading Scale for Pulses
      • 4+ = strong and bounding
      • 3+ = full pulse, increased
      • 2+ = normal, easily palpable
      • 1+ = weak, barely palpable
      • 0 = absent, not palpable
    • Pulse Points and Their Locations
      • Temporal artery
      • Carotid artery
      • Apical: left midclavicular, 5th intercostal space
      • Radial pulse
      • Brachial pulse
      • Femoral pulse
      • Popliteal pulse: behind the knee  
      • Posterior tibial pulse
      • Dorsalis pedis pulse
      • Apical Heartbeat
      • Left midclavicular, 5th intercostal space
      • Warm the diaphragm of the stethoscope
      • Count for 1 full minute
      • Assessed if with an irregular radial pulse or a heart condition, before administering cardiac medications such as digoxin (Lanoxin) and  -blockers, and in children younger than 2 years
      • Pulse Deficit= Radial less than apical pulse
      • Indicates a lack of peripheral perfusion
      • Requires two people
    • Respirations
      • Normal adult respiratory rate is 12 to 20 bpm
      • Factors That Affect the Respiratory Rate
      • An increased level of carbon dioxide or a lower level of oxygen in the blood causes an increase in respiratory rate
      • Head injury or increased ICP will depress the respiratory center and result in shallow respirations or slowed breathing
      • Narcotic analgesics depress respirations
      • C. Respiration
      • Medulla Oblongata
          • primary respiratory center
        • 3 Processes:
      • a. Ventilation
      • b. Diffusion
      • c. Perfusion
      • Factors Affecting Respiratory Rate
      • 1. Exercise
      • 2. Stress
      • 3. Environment
          • Temperature is inversely proportional with RR
      • 4. Increase Altitude
      • 5. Medications
          • Narcotics decreases RR
      • Assessment
      • a. Rate
      • b. Depth – Movement of the chest (Normal, Deep or Shallow)
      • c. Rhythm
      • d. Quality
      • e. Character
      • Rhythm Problems
      • a. Cheyne-Stokes
        • Increasing depth & frequency of respirations with intervals of apnea.
      • b. Biot’s
        • several short breaths followed by long irregular periods of apnea.
      • c. Kussmaul’s
        • Increased rate & depth associated with metabolic acidosis & renal failure.
      • d. Apneustic
        • Prolonged gasping inspiration followed by a very short, usually inefficient, expirations.
    • Measuring the Respiratory Rate
      • Count respirations after measuring the radial pulse
      • **One respiration includes both inspiration and expiration
      • Counted for 30 secs and multiplied by 2, except in very ill client or has irregular respirations, in which case the respirations are counted for 1 full minute
      • The rate, depth, pattern, and sounds are assessed
    • Oxygen Saturation
      • Pulse oximeter measures oxygen saturation by determining the percentage of hemoglobin that is bound to oxygen
      • Sensor pad (adult: earlobe or nose bridge; infant:) or probe (finger or earlobe) infrared or red light can reach the capillary bed
      • Normally the oxygen-saturation reading is greater than 90% (normal is 95% to 100%)
      • Monitoring may be intermittent or continuous
    • Factors Affecting Oxygen Saturation
      • Outside light sources
      • Client movement
      • Jaundice
      • Carbon monoxide poisoning
      • Peripheral vascular disease
      • Medications
      • Hypotension
      • Hypothermia
      • Dark nail polish
    • Measuring Oxygen Saturation
      • Determine the most appropriate site
      • Not on sites with Edema
      • Hypothermic fingers are not used
      • PVD: ear or bridge of the nose
      • No latex if allergic
      • If a finger: fingernail polish must be removed
      • Monitor until constant (10 to 30 seconds)
      • Verify alarm limits (low: 85% & high: 100%) and relocate the probe at least every 4 hours
      • Report O2 sat level of less than 90%
    • Blood Pressure
      • Force on artery wall by the pulsating blood under pressure from the heart
      • Systolic: Max. pressure ejection from ventricles
      • Diastolic: Ventricles relax
      • Systolic – diastolic= pulse pressure
      • Prehypertension: systolic BP:120-139 mmHg; diastolic: 80-89 mmHg
      • if 50 y/o, systolic more important in Tx determination
      • Postural (orthostatic) hypotension
      • Orthostatic vital-sign: check BP & PR in supine, sitting, and standing; measure 1 to 3 minutes after
      • BP increases as person ages
      • Stress > sympathetic stimulation > ↑ BP
      • Antihypertensives & narcotics > ↓ BP
      • Diurnal variation: BP lowest in AM, gradually increases, & peaks in PM and evening
      • After puberty, ♂>♀ ; after menopause, ♀>♂
      • D. Blood Pressure
        • Korotkoff Sound
        • Systolic Pressure
        • Diastolic Pressure
        • Pulse pressure
        • Hypertension
        • Hypotension
      • Factors Affecting Blood Pressure
      • 1. Age
      • 2. Exercise
      • 3. Stress
      • 4. Race
      • 5. Obesity
      • 6. Sex/Gender
          • Males (BP elevated after puberty and before age 65)
          • Females (BP elevated after 65)
      • Medications
      • Diurnal Variations
        • BP is lowest in am, highest in late afternoon/early evening
      • Disease Process
        • DM,
        • renal failure,
        • hyperthyroidism,
        • Cushing’s Disease
      • Assessment
      • Ensure that the client is rested
      • Allow 30 minutes to pass if smoked or ingested caffeine.
      • Use appropriate size of BP cuff.
      • Position in sitting or supine.
      • Position arm at the level of the heart, with the palm of the hand facing up.
      • Apply BP cuff snugly, 1 inch above the antecubital space.
      • Determine palpatory BP before auscultatory BP to prevent auscultatory gap.
      • Use the bell-shaped diaphragm of the stethoscope since the blood pressure is a low-frequency sound.
      • Inflate and deflate BP cuff slowly,
      • 2-3 mmHg at a time.
      • Wait 1-2 minutes before making further determinations.
    • Guidelines for Measuring the Blood Pressure
      • Not to arm with IV fluids, with AV shunt or fistula, with breast or axillary surgery, or to traumatized or diseased arm
      • The lower extremity can be used
      • Select appropriate cuff; too small= falsely high, and too large= falsely low
      • No smoke or exercise for 30 minutes before the measurement ( falsely high readings)
    • Guidelines for Measuring the Blood Pressure
      • Sitting or lying position; 5 minutes rest, no speaking
      • Cuff should be fully deflated, evenly wrapped
      • Use Stethoscope’s Bell, Diaphragm if obese
      • 1st Korotkoff sound:
      • systolic pressure
      • 5th Korotkoff sound:
      • diastolic pressure
    • Physical Assessment
      • Building block of Nursing process
      • Provides database for intervention
      • Measuring stick for goal achievement & quality care
    • Communication Techniques
      • Therapeutic
      • Clarification
      • Empathy
      • Explanation
      • Facilitation
      • Interpretation
      • Reflection
      • Silence
      • Summarizing
      • Nontherapeutic
      • "why" questions
      • Giving advice
      • Placing feelings on hold
      • false reassurance
      • Using authority
      • Using avoidance language
      • Using leading or biased questions
      • Using jargon
    • The Physical Assessment
      • Use inspection, palpation, percussion, and auscultation; (except for the abdominal assessment)
      • Inspection
      • Requires good lighting, adequate exposure, and possibly the use of such instruments as an otoscope, ophthalmoscope, penlight, and nasal or vaginal speculum
    • Palpation
      • Warm the hands first
      • Identify tender areas, palpate them last
      • Start with light palpation to detect surface characteristics, then perform deeper palpation
      • Assess texture, temperature, and moisture of the skin, as well as organ location and size
      • Assess swelling, vibration or pulsation, rigidity or spasticity, and crepitation
      • Assess lumps or masses, as well as the presence of tenderness or pain
      • Percussion
      • Tapping the client's skin to assess underlying structures
      • Auscultation
      • Listening to sounds produced by the body (e.g., heart and blood vessels, lungs, abdomen)
      • Vital Signs
      • Temperature, Respirations, Radial pulse Respirations & Blood pressure
      • Height and weight
    • The Integumentary System
    • Subjective Data
      • History of skin disease
      • Medications being taken
      • Changes in skin color
      • Change in mole or a Non-healing sore?
      • Seborrhea: oily; xerosis: dry)
      • Excessive bruising, itching, rash, or lesions
      • Hair loss (alopecia) or a change in the nails
      • Environmental or occupational hazards and exposure to toxic substances
    • Objective Data
      • Includes inspection and palpation of the skin, hair, and nails
      • Skin
      • Lesions: Wood's light Scars or birthmarks
      • Moisture (diaphoresis or dryness)
      • Texture (smoothness, firmness)
      • Temperature (hypothermia or hyperthermia)
      • Turgor
      • Vascularity or bruises
    • Skin-Color Changes
      • Cyanosis: mottled bluish coloration
      • Erythema: redness
      • Pallor: pale, whitish coloration
      • Jaundice: yellow coloration
      • Note : In a dark-skinned person check:
      • Conjunctiva & sclera,
      • Under the tongue, buccal mucosa
    • Assessing Edema
      • +1 > mild pitting, slight indentation
      • +2 > moderate pitting , indentation subsides rapidly
      • +3 > deep pitting; indentation remains for a short time and leg is swollen
      • +4 > very deep pitting; indentation remains for a long time and leg is very swollen
      • Hair
      • Color, texture, distribution, lesions on the scalp, dryness or oiliness, nits or lice
      • Nails
      • Color, shape and contour, size, angle, flexibility, consistency, lesions, capillary-filling time
    • Assessing Capillary-Filling Time
      • Depress the nail bed to produce blanching
      • Release and observe for the return of color
      • Color will return within 3 seconds if arterial capillary perfusion is normal
    • The Head, Neck, and Lymph Nodes
      • Subjective Data
      • Headaches, dizziness, vertigo
      • History of head injury, loss of consciousness, or seizures; Medications?
      • Neck pain, limitations of range of motion, numbness or tingling
      • Lumps or swelling in the neck
      • Difficulty swallowing
      • Objective Data
      • Info from inspection and palpation
      • Head
      • Inspect and palpate: size, shape, masses or tenderness, and symmetry of the skull
      • Palpate temporal arteries
      • Temporomandibular joint: palpate as mouth opens & note crepitation, tenderness, or limited range of motion
      • Face: inspect facial structures
    • Neck
      • Inspect symmetry of accessory neck muscles
      • Assess ROM (not if (+) neck injury)
      • Test cranial nerve XI (spinal accessory nerve) to assess neck muscle strength
      • Check for swollen glands at the site of the carotid artery
      • Palpate the trachea: it should be midline
      • Thyroid gland : inspect the neck during sip of water and swallows (moves up with a swallow); palpate using an anterior-and-posterior approach
      • Lymph Nodes
      • Palpate using gentle pressure and a circular motion of the finger pads
      • Palpate with both hands, comparing the two sides for symmetry
      • If nodes are palpated, note their size, shape, location, mobility, consistency, and tenderness
      • Client Teaching
      • Notify MD if persistent headache, dizziness, or neck pain, if swelling or lumps are noted, or if a neck or head injury occurs
      • The Eye: Subjective Data
      • Difficulty with vision (e.g., decreased acuity, double vision, blurring, blind spots)
      • Pain, redness, swelling, watering or discharge from the eye
      • Use of glasses or contact lenses
      • Medications being taken
      • History of eye problems
    • Objective Data
      • Inspection, palpation, vision-testing procedures, and the use of an ophthalmoscope
      • Inspect the external eye structures, including eyebrows, eyelashes, ptosis, & the eyeballs ( Enoph or exophthalmos ) the conjunctiva, sclera, and lacrimal apparatus
    • Objective Data
      • Inspect the anterior eyeball structures, including the cornea and lens (should be smooth and clear), iris (should be flat, with a round regular shape and even coloration), eyelids, and pupils
    • Assessing Pupillary Responses
      • Pupillary Light Reflex
      • Darken the room (dilate the client's pupils) and ask the client to look forward
      • Test each eye
      • Advance a light in from the side to note constriction of the same-side pupil (direct light reflex) and simultaneous constriction of the other pupil (consensual light reflex)
    • Assessing Pupillary Responses
      • Accommodation
      • focus on distant object (dilates pupil)
      • shift gaze to a object 3 inches from the nose
      • Normal response includes pupillary constriction and convergence of the axes of the eye
    • Assessing Pupillary Responses
      • PERRLA
      • P = pupils
      • E = equal
      • R = round
      • RL = reactive to light
      • A = reactive to accommodation
      • Snellen Eye Chart
      • Position in a well-lit spot 20 feet from the chart, at eye level, and ask client to read the smallest line he or she can discern. Test one eye at a time
      • Record result using the fraction at the end of the last line successfully read on the chart; normal visual acuity is 20/20 (distance, in feet, at which the subject is standing from the chart/distance, in feet, at which a normal eye could have read that particular line)
      • Near Vision
      • Use a hand-held vision screener (held about 14 inches from the eye) containing various sizes of print or ask the client to read from a magazine
      • Test each eye separately with the client's glasses on or contact lenses in; normal result is 14/14 (distance, in inches, at which the subject holds the card from the eye/distance, in inches, at which a normal eye could have read that particular line)
      • Confrontation Test
      • Used to measure peripheral vision and compare the client's peripheral vision with the normal
      • Client covers one eye and looks straight ahead; the nurse, positioned 2 feet away, covers his or her eye opposite the client's covered eye
      • Nurse advances a finger or other small object in from the periphery from several directions; the client sees the object at the same time the nurse does
      • Corneal Light Reflex
      • Used to assess client for parallel alignment of the axes of the eye
      • Client is asked to gaze straight ahead as the nurse holds a light about 12 inches from the client
      • The nurse looks for reflection of the light on the corneas in exactly the same spot in each eye
      • Cover Test  
      • Used to check for slight degrees of deviated alignment
      • Each eye is tested separately
      • The nurse asks the client to gaze straight ahead and cover one eye
      • The nurse examines the uncovered eye, expecting to note a steady, fixed gaze
      • Cardinal Positions of Gaze
      • Used to check for muscle weakness in the eyes
      • The client is asked to hold the head steady, then follow movement of an object through the positions of gaze
      • The client should follow the object in a parallel manner with the two eyes
      • Assess for nystagmus, an oscillating movement of the eye, best seen around the iris
      • Color Vision
      • Ishihara chart is a tool used to assess color vision; it determines the client's ability to distinguish a pattern of color (a number) in a series of color plates
      • The nurse tests each eye separately and asks the client to identify the number that he or she sees on the chart
      • The ability to read the number correctly depends on the normal functioning of color vision
      • Examination of the Internal Structures
      • Ophthalmoscope
      • Performed in a darkened room
      • Remove? Eyeglasses: Yes; Contacts: No
      • How: face each other, eyes at the same height, the ophthalmoscope light on, rotate lens to 0
      • Client gazes straight ahead with both eyes open, stand 10 inches infront; 25 ° lateral to central line of vision) shines the light on the pupil; (+) red reflex
    • Client Teaching
      • Instruct the client to notify the health-care provider if alterations in vision occur or any redness, swelling, or drainage from the eye is noted
      • Inform the client of the importance of regular eye examinations
    • The Ear: Subjective Data
      • Difficulty hearing
      • Earaches, drainage from the ears, dizziness, ringing in the ears
      • Exposure to environmental noise
      • Use of a hearing aid
      • Medications being taken
      • History of ear problems or infections
    • Objective Data
      • Includes inspection, palpation, hearing tests, and the use of an otoscope
      • External Structures
      • Inspect and palpate the external ear,
      • Inspect the external auditory meatus: swelling, discharge, and foreign bodies; some cerumen (ear wax)
      • Voice Test
      • Check hearing loss
      • One ear is tested at a time while the client occludes the other ear with a finger
    • Objective Data
      • 1 to 2 feet away, mouth covered,whispers two-syllable words in the direction of the unoccluded ear
      • A ticking watch: tests hearing acuity
      • Pure-tone audiometry testing: precise quantitative measure of hearing by assessing the client's ability to hear sounds of varying frequencies
      • Tuning-Fork Tests
      • Weber Test
      • Vibrating tuning fork on skull’s midline;
      • Normal bone Conduction: tone bilaterally equal
      • Rinne Test
      • fork is placed on mastoid process
      • As sound disappears, quickly invert fork near the ear canal; should still hear a sound
      • Normal: air > bone conduction
      • Examination of Internal Structures
      • Otoscope
      • examines for foreign bodies before inserting
      • Moving during examination may damage canal and tympanic membrane
      • How? tilt head slightly to the opposite shoulder. Adults: pulls the pinna up & back, holds otoscope upside down, and inserts the speculum, approx. half an inch
      • Normal tympanic membrane: translucent, shiny, and pearly gray
    • Client Teaching
      • Instruct to notify MD if an alteration in hearing or ear pain occurs or redness, swelling, or drainage
      • Instruct in proper cleaning of ear canal - Cleanse ear canal w/ moist washcloth - Never insert sharp objects or cotton buds into the ear canal
    • The Nose, Mouth, and Throat
      • Subjective Data on nose
      • Discharge or nosebleed (epistaxis)
      • Facial or sinus pain
      • History of frequent colds
      • Altered sense of smell
      • Allergies
      • Medications being taken
      • History of nose trauma or surgery
    • The Nose, Mouth, and Throat
      • Subjective Data on Mouth and Throat
      • Presence of sores or lesions
      • Bleeding from the gums or elsewhere
      • Altered sense of taste
      • Toothaches, & dentures
      • Tooth- and mouth-care hygiene habits
      • At-risk behaviors (e.g., smoking, alcohol)
      • History of infection, trauma, or surgery
      • Objective Data (inspection and palpation)
      • Nose
      • External nose: midline and in proportion
      • Nostril Patency: pushing each nasal cavity closed and asking to sniff inward through the other nostril
      • Nasal cavity: inspected with speculum & light (otoscope possible)
      • Sinus Areas
      • Press frontal sinuses (below eyebrows) & maxillary sinuses (below cheekbones)
      • The client should feel firm pressure but no pain
      • Lips
      • Inspect the external and inner surfaces
      • Teeth
      • Inspect the teeth for condition and number,
      • Normal: White, spaced, straight, and clean
      • Jaw
      • Assess alignment by having client bite down
      • Gums
      • Inspect for swelling, bleeding, discoloration, and retraction of gingival margins
      • Tongue
      • Inspect color, surface, moisture, white patches, nodules, and ulcerations
      • Dorsal: rough; ventral: smooth & glistening
      • Buccal Mucosa
      • Retract with tongue depressor, note color, nodules or lesions
      • Normal: glistening, pink, soft, & moist
      • Palate
      • Using penlight & tongue depressor, inspect the hard and soft palates
      • Hard:anterior, white and dome-shaped
      • Soft: pink and smooth
      • Inspect for midline location
      • CNX (Vagus) test: say "ahhh" & soft palate and uvula to rise in the midline
      • Throat
      • Using a penlight and tongue depressor, inspect for color, the presence of exudate or lesions, and odor
      • Check for the presence of tonsils
      • Test CN XII (hypoglossal): stick tongue out (should protrude in the midline)
    • Client Teaching
      • Emphasize hygiene and tooth care, need for regular dental examinations and the use of fluoridated water or fluoride supplements
      • Encourage to avoid at-risk behaviors (e.g., smoking, alcohol consumption)
      • Stress the importance of reporting pain or abnormal occurrences (e.g., nodules, lesions, signs of infection)
    • The Lungs
      • Subjective Data
      • Cough
      • Expectoration of sputum
      • Dyspnea & Chest pain
      • Respiratory disease or infection, Meds, vice history
      • Last tuberculosis test, chest x-ray, pneumonia and influenza immunizations
    • Objective Data
      • Inspecting the Posterior Chest; Note
      • Skin color and condition and look for lumps or lesions
      • Chest wall shape and configuration
      • position to breathe
      • Palpating the Posterior Chest
      • noting skin temperature and moisture and looking for areas of tenderness and lumps or lesions
    • Excursion
      • Chest Excursion
      • Places thumbs along 10 th rib spinal processes with the palms in light contact with the posterolateral surfaces
      • Thumbs 2 inches apart, pointing toward the spine, with the fingers pointing laterally
      • Instructs client to take a deep breath after exhaling; notes thumb movement
      • Normal: Symmetrical mov’t: separating the thumbs approximately 2 inches  
    • Fremitus
      •  
      • Tactile or Vocal Fremitus
      • Places the ball or lower palm over chest
      • Begins at the lung apices & palpates from one side to the other for comparison
      • Use a firm light touch; have client to repeat the word "ninety-nine"
      • Normally there is a faint vibration as the client speaks
      • Percussing the Posterior Chest
      • Start at the apices, percuss across the top of the shoulders, moving to the interspaces, making a side-to-side comparison all the way down the lung area
      • Determine note; Hyper & Hypo resonance 
      • Auscultation
      • Monitor for dizziness: ask to breath thru mouth
      • Use Stet flat diaphragm: listen to 1 full breath in each location
      • Start at the apices and move side to side for comparison  
    • Normal Breath Sounds
      • Bronchial (tracheal) : high-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx
      • Bronchovesicular : moderately pitched; heard over the major bronchi
      • Vesicular : low-pitched rustling; heard over the peripheral lung fields
    • Adventitious Sounds
      • Crackles - Fine : discontinuous high-pitched crackling at inspiration; not cleared with cough
      • - Coarse : loud, low-pitched bubbling and gurgling on inspiration; may decrease with coughing or suctioning but reappear
      • Rhonchi : loud, low-pitched, coarse rumbling during breathing; cleared by coughing
      • Wheezes : high-pitched, continuous musical sounds during inspiration or expiration
      • Pleural friction rub : dry, grating heard best during inspiration; not cleared with cough
    • Voice Sounds
      • Auscultate spoken word over the chest wall
      • Bronchophony ( Repeat “99”)
      • Normal: soft, muffled, and indistinct
      • Egophony ( repeat a long "ee-ee-ee“)
      • Nurse would hear the "ee-ee-ee" sound
      • Whispered Pectoriloquy (whisper “99" )
      • Normal transmission: faint, muffled, and almost inaudible
      • Inspecting the Anterior Chest
      • Inspect shape and configuration
      • Note skin color; Respiratory rate and quality
      • Palpating the Anterior Chest
      • Check for lumps, masses, and tenderness
      • Palpate chest excursion
      • Percussing & Auscultating the Anterior Chest
      • Palpate then auscultate from apices in the supraclavicular area to the interspaces and down to 6 th rib; do bilateral comparison
      • Avoid percussion and auscultation over female breast tissue (displace this tissue) because a dull sound will be produced
    • Client Teaching
      • Avoid exposure to environmental hazards, including smoking
      • Undergo periodic examinations as prescribed (e.g., chest x-ray, tuberculosis skin testing)
      • Pneumonia and influenza immunizations
      • Notify MD if client experiences persistent cough, shortness of breath, or other respiratory symptoms
    • The Heart and Peripheral Vascular System
      • Subjective Data
      • Chest pain, Dyspnea, Cough & Fatigue
      • Edema, Nocturia & Obesity
      • Leg pain or cramps (claudication)
      • Changes in skin color
      • Medications, Cardiovascular risk factors
      • Personal & Family history of cardiac or vascular problems
      • Objective Data
      • Heart
      • Inspect apical impulse created as the left ventricle rotates against the chest wall during systole; not always visible
      • Palpate the apical impulse at 4th or 5th interspace, medial to the midclavicular line (not palpable in obese clients or clients with thick chest walls)
      • Palpate the apex, left sternal border, and base for pulsations; normally absent
      • Percussion to outline the heart's borders and to check for cardiac enlargement
      • Objective Data
      • Heart Auscultation
      • Bicuspid : 5th interspace, left midclavicular line
      • Aortic : 2nd right interspace
      • Pulmonic : 2ndnd left interspace
      • Tricuspid : left lower sternal border
      • Auscultate rate and rhythm; check for a pulse deficit (auscultate the apical beat while palpating an artery) if an irregularity is noted
      • Assess S1 ("lub") and S2 ("dub") sounds and listen for extra heart sounds, as well as the presence of murmurs
    • Objective Data
      • Peripheral Vascular System
      • Palpate arterial pulses for equality and symmetry and checking the condition of the skin and nails
      • Check for pretibial edema and measure calf circumference 
      • Measure blood pressure
      • Palpate superficial inguinal nodes from groin area and moving down
      • An ultrasonic stethoscope may be needed to amplify the sounds of a pulse wave if the pulse cannot be palpated
    • Objective Data
      • Carotid Artery
      • Located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle
      • Palpate one carotid artery at a time; avoid compromising blood flow to the brain
      • Auscultate each carotid artery for the presence of a bruit (a blowing, swishing sound), which indicates blood-flow turbulence; normally a bruit is not present
      • Arteries in the Arms and Hands
      • Radial pulse
      • Ulnar pulse
      • Brachial pulse
      • Arteries in the Legs
      • Femoral pulse
      • Popliteal pulse 
      • Dorsalis pedis pulse
      • Posterior tibial pulse
    • Grading the Force (Amplitude) of Pulses
      • 4+ = strong and bounding
      • 3+ = full pulse, increased
      • 2+ = normal, easily palpable
      • 1+ = weak, barely palpable
      • 0 = absent, not palpable
      • Client Teaching
      • modify risk factors, regular physical exams
      • seek medical assistance for signs of heart or vascular disease
    • The Breasts
      • Subjective Data
      • Pain or tenderness, Rash or swelling
      • Lumps or thickening; swollen axillary lymph nodes & Nipple discharge
      • Medications being taken
      • Personal or family history of breast disease, Meds & prev. medical history
      • Breast self-examination compliance
      • Mammograms as prescribed
    • Objective Data
      • Inspection
      • Performed with the client's arms raised above the head, the hands pressed against the hips, and the arms extended straight ahead while the client sits and leans forward 
      • Assess size and symmetry (one breast is often larger than the other); masses, flattening, retraction, or dimpling; color and venous pattern; size, color, shape, and discharge in nipple and areola; and the direction in which nipples point
      • Palpation
      • Breast tissue
      • - Client lies supine, arm on the side being examined behind the head and a small pillow under the shoulder - Use pads of the 1st 3 fingers to compress the breast tissue gently against the chest - Palpate systematically
      • - Gently palpates nipple & areola; compress nipple, noting any discharge     
      • Palpation
      • Axillary lymph nodes
        • Stand on the side being examined, support client's arm in a slightly flexed position, and abducts the arm away from the chest wall
        • Places the free hand against the chest wall and high in the axillary hollow, then, with the fingertips, gently presses down, rolling soft tissue over the surface of the ribs and muscles
        • Lymph nodes are normally not palpable
    • Client Teaching
      • Encourage client to perform breast self-examination
      • Regular physical examinations and mammograms should be obtained as prescribed
      • Client should report lumps or masses to the health-care provider immediately
    • The Abdomen
      • Subjective Data
      • Changes in appetite or weight
      • Difficulty swallowing
      • Diet intake; Intolerance to certain foods
      • Nausea or vomiting; Pain
      • Bowel habits
      • Medications currently taking
      • History of abdominal problems or abdominal surgery
    • Objective Data (IAPP)
      • Ask the client to empty the bladder
      • Warm hands & steth endpiece
      • Examine painful areas last
      • Inspection
      • Contour: flat, rounded, or protuberant
      • Symmetry: note any bulging or masses
      • Umbilicus: should be midline and inverted
      • Skin surface: should be smooth and even
      • Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves may be noted across the abdomen
      • Auscultation 
      • Performed before percussion and palpation
      • Hold steth lightly against the skin and listen for bowel sounds in all four quadrants; begin in the right lower quadrant
      • Normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30/min
      • Identify as normal, hypoactive, or hyperactive (borborygmus)
      • Absent sounds: auscultate for 5 minutes before determining that sounds are absent
      • Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits  
      • Percussion
      • All four quadrants are percussed lightly
      • Borders of the liver and spleen are percussed
      • Tympany should predominate over the abdomen with dullness over the liver and spleen
      • Percussion over the kidney at the 12 ribs (costovertebral angle) should produce no pain
      • Palpation
      • Begin with light palpation of all four quadrants, using the fingers to depress the skin about 1 cm; next perform deep palpation, depressing 5 to 8 cm
      • Palpate the liver and spleen (may not be palpable)
      • Palpate the aortic pulsation in the upper abdomen slightly to the left of midline; normally it pulsates in an forward direction (pulsation expands laterally if an aneurysm is present)
      • Client Teaching
      • Encourage client to consume a balanced diet
      • Substances that can cause gastric irritation should be avoided
      • The regular use of laxatives is discouraged
      • Lifestyle behaviors that can cause gastric irritation (e.g., smoking) should be modified
      • Regular physical examinations are important
      • The client should report gastrointestinal problems to the health-care provider
    • The Musculoskeletal System
      • Subjective Data
      • Jt pain or stiffness; swelling or warmth
      • Limited motion of  joints
      • Muscle/bone pain, cramps, or weakness
      • ADL Limitations; Exercise patterns
      • Occupational hazards (e.g., heavy lifting)
      • Meds; History of joint, muscle, or bone injuries & surgery
      • Objective Data
      • Inspection
      • Gait and posture, spinal curves
      • Palpation
      • Palpate all bones, joints, & muscles
      • Range of Motion
      • Do Active & passive ROM exercises
      • Check for pain, limited mobility, spastic movement, joint instability, stiffness, and contractures
      • Muscle Tone and Strength
      • Done during ROM assessment
      • Hypertonicity or Hypotonicity
      • Grading Muscle Strength  (0-5)
      • Client Teaching
      • Consume a balanced diet, weight mgt
      • Moderate activities; do regular exercise
      • Contact MD if joint or muscle pain or problems occur or if limitations in ROM or muscle strength develop
    • The Neurological System
      • Subjective Data
      • Headaches; Dizziness or vertigo
      • Tremors, Weakness & Incoordination
      • Paresthesia, Dysarthria & dysphagia
      • Medications currently taking
      • History of seizures, injury or surgery
      • Exposure to environmental or occupational hazards (chemicals & vices)
      • Objective Data
      • Assess cranial nerves, level of consciousness, pupils, motor function, cerebellar function, coordination, sensory function, and reflexes
      • OOOTTAFAGVAH
      • Note mental and emotional status, behavior and appearance, language ability, and intellectual functioning, including memory, knowledge, abstract thinking, association, and judgment
      • Cranial Nerve Assessment
      • Cranial Nerve I (Olfactory: sensory, smell)
      • close eyes with one occluded nostril
      • identify nonirritating odors
      • Repeat the test on the other nostril
      • Cranial Nerve II (Optic: sensory, vision)
      • visual acuity: Snellen chart or others
      • Check visual fields by confrontation
      • Check color vision
      • Cranial Nerves III , IV, and VI
      • Motor functions overlap; Test together
      • 1st inspect: ptosis then eye movements
      • 2 nd : Accommodation/ direct light reflexes
      • Cranial nerve III (oculomotor): motor ; controls  pupillary constriction, upper-eyelid elevation, and most eye movement
      • Cranial nerve IV (trochlear): motor ; downward and inward eye movement
      • Cranial nerve VI (abducens): Motor;
      • controls lateral eye movement
      • Cranial Nerve V (Trigeminal: Both)
      • Sensation: Cornea, nasal and oral mucosa, and facial skin, as well as mastication (motor)
      • Cranial Nerve VII (Facial: Both)
      • Taste: ant. 2/3 of the tongue
      • Check: smile, frown, and show the teeth  
      • Close eyes against resistance, puff cheeks
      • Cranial Nerve VIII (Acoustic: sensory)
      • hearing (cochlear); equilibrium (vestibular)
      • Cranial Nerve IX ( Glossopharyngeal: Both)
      • Motor: swallowing; sensation: soft palate & tonsils, taste on tongue’s posterior 3 rd and salivation; Gag reflex
      • Cranial Nerve X (Vagus: Both)
      • Swallowing & phonation, sensation in the exterior ear
      • thoracic and abdominal viscera sensation
      • Cranial Nerve XI (Spinal accessory: motor)
      • Sternocleidomastoid & Trapezius: movement against resistance 
      • Cranial Nerve XII (Hypoglossal: motor)
      • Tongue movts; swallowing and speech
      • check asymmetry, atrophy, deviation, and fasciculations (uncontrollable twitching)
      • Level of Consciousness
      • (alertness, confusion, delirium, unconsciousness, stupor, coma)
      • Appropriateness of behavior & talk
      • Cerebellar Function
      • Monitor gait; Romberg test; knee bends/hops
      • Coordination
      • perform rapid alternating movements of the hands (turning hands over & patting knees) 
      • Touch finger exercise 
      • Heel-to-shin test: supine position
      • Sensory Function
      • Pain: sharp vs a dull feelings 
      • Light touch: piece of cotton
      • Vibration: tuning fork
      • Position (kinesthesia): movt perception
      • Stereognosis & Graphesthesia
      • Two-point discrimination
      • Deep Tendon Reflexes
      • Limb relaxed,tapped quickly with a reflex hammer
      • Plantar Reflex  vs Babinski's sign
    • Client Teaching
      • Client should avoid exposure to environmental hazards (e.g., insecticides, lead)
      • High-risk behaviors that can result in head and spinal-cord injuries should be avoided
      • Protective devices (e.g., a helmet) should be worn during participating in high-risk behaviors
    • The Mental-Status Examination
      • Done during the health history interview
      • Appearance
      • Note appearance; posture, body movts, dress, hygiene & grooming
      • inappropriate appearance & poor hygiene indicative of Mental problem
      • Behavior
      • Level of consciousness
      • Facial expression and body language
      • Speech
    • Cognitive Level of Functioning
      • Orientation : person, place, and time
      • Attention span : concentration
      • Recent memory : recent occurrence
      • Remote memory : verifiable past event
      • New learning : select four words & ask to recall 5, 10, and 30 minutes later
      • Judgment : decisions are realistic?
      • Thought processes and perceptions : the way of thinking and words should be logical, coherent, and relevant; should be consistently aware of reality
    • Health
      • Level of wellness & well-being
      • Physiological, psychological, sociological, and spiritual well-being alter the level of wellness
      • Health Promotion
      • Maintain or enhance well-being as a protection against illness
      • Disease Prevention
      • Protect from actual or potential threats to health and assist in maintaining an optimal level of health
      • The role of the nurse?
    • Levels of Preventive Care
      • Primary prevention:
        • health-education programs and wellness activities
      • Secondary prevention:
        • screening techniques and treatment of disease
      • Tertiary prevention:
        • focuses on rehabilitation to achieve as high a level of function as possible
    • Health Screening
      • Subjective and objective data: past & current health status, family health history
      • Childhood diseases & immunizations, accidents & injuries, serious or chronic illnesses, hospitalizations and surgeries, obstetric history, allergies, last examination date, current lifestyle practices, and medications being taken
      • Health of close family members such as spouse and children
      • A genogram or family tree
    •  
    • Perception of Health Status
      • Determine personal practices for maintaining health
      • Obtain a family history; a history of health habits such as smoking, alcohol, and drug use; history of exposure to environmental hazards; and any high-risk behaviors
      • what illness means to the client? and what is done when ill?
      • Identify client's health goals
    • Self-Care Abilities
      • Assess ADL needs especially related to basic needs
      • Instrumental activities needed for independent living?
      • Physical and cognitive ability to care for self?
      • Assess the home environment for barriers?
      • family or friends assistance?
      • Identify and initiate referrals for resources
    • Risk Factors for Disease
      • Physiological
      • Genetic or hereditary
      • Ethnicity and culture
      • Age: can increase or decrease susceptibility to certain diseases
      • Environment: exposure to health hazards in the home or work
      • Lifestyle: practices with potential negative effects
    • Negative Lifestyle Practices
      • Overeating or poor nutrition
      • Insufficient rest or sleep
      • Poor personal hygiene
      • Tobacco use
      • Alcohol or drug use
      • Extreme sports
      • Stress
    • Teaching-Learning Principles
      • Readiness & motivation to learn; Consider health beliefs, age & education
      • use existing knowledge, Physical and cognitive abilities as base for teaching
      • Learning objectives facilitate the teaching process
      • Include family members in the learning process
      • Allow ample time for to understand teachings
      • Return demo
    • Considerations in Teaching
      • Infant
      • Toddler
      • Learns by associating words with objects
      • Allow toddler to handle examination equipment
      • Preschooler
      • Asks questions; Use role-playing and imitation
      • School-Age Child
      • Makes judgments, is Inquisitive
      • Use independent projects and games
    • Considerations in Teaching
      • Adolescent
      • Learns best with benefit is gained
      • Allow decisions; use problem-solving to help the child make these choices
      • Young or Middle Adult
      • Offer info & encourage participation and independent learning
      • Older Adult
      • learns best: info presented in small amounts at a slow pace
      • Teach when alert and rested
    • Teaching Tools
      • Pamphlets, booklets, brochures
      • Diagrams, graphs, charts, pictures
      • Slides, audiotapes, videotapes, television
      • Physical objects
      • Programmed instruction
      • Computer instruction
    • Lifestyle Choices and Health Practices 
      • How the client manages his or her life
      • The client's awareness of healthy versus non-healthy living patterns
      • How the client incorporates healthy living patterns into his or her lifestyle
      • Strengths and supports that the client has or uses
    • Assessment of Lifestyle Patterns
      • Client's typical day
      • Nutritional and weight mgt
      • Activity & exercise
      • Sleep & rest
      • Medication use
      • Environment
      • Self-care responsibilities
      • Relationships and social activities
      • Values and belief system
      • Education and work
      • Stress levels and coping styles
    • Nutritional Patterns, Elimination, and Weight Management
      • Record as an average 24-hour intake
      • Record foods eaten and their amounts
      • Are finances adequate? prepares the food? when and where meals are eaten
      • Identify food allergies and intolerances
      • Ask client about bowel and bladder habits
      • Weigh client and identify nutritional patterns used to manage weight
    • Food-Guide Pyramid
      • Clear-Liquid Diet
      • Prevents dehydration
      • Nursing Considerations
      • Clear liquid is deficient in energy and most nutrients; 1-2 days only
      • Foods: transparent to light; liquid at room and body temperature (e.g., broth, gelatin, clear fruit juices, Popsicles)
      • 2nd diet, after clear liquids, surgery; or unable to chew or swallow
      • Nursing Considerations
      • Nutritionally deficient; Clear & opaque liquid foods (e.g., custard, refined cooked cereal); may also include liquid dietary supplements
      Full Liquid Diet
    • Soft Diet
      • Dental problems or poor-fitting dentures, difficulty chewing or swallowing, and impaired digestion or absorption
      • Nursing Considerations
      • Plenty of fluids with meals to ease chewing and swallowing
      • All foods and seasonings are permitted; however, liquid, chopped, or pureed foods and regular foods with a soft consistency are best tolerated
    • Bland Diet
      • Gastritis, ulcers, reflux esophagitis, congestive heart failure, or myocardial infarction
      • Nursing Considerations
      • Eliminates gastric-acid stimulating and gastric irritating foods
      • Avoided include: alcohol; caffeine and caffeine-containing beverages; fried foods; pepper and other spicy foods
      • Low-Residue Diet
      • Non-obstructive food; GIT inflammation or scarring
      • Nursing Considerations
      • High carbohydrate (e.g., white bread, cereals, pasta)
      • High-Residue Diet
      • Constipation; alternating C&D ; & asymptomatic diverticular disease
      • Regulates blood glucose and cholesterol
      • Nursing Considerations
      • Consists of fruits and vegetables and whole-grain products
    • Fat-Controlled Diet
      • DM, atherosclerosis, hyperlipidemia, Htn, MI, nephrotic syndrome, & renal failure
      • Reduces the risk of heart disease
      • Nursing Considerations
      • Limits the total amount of fats and cholesterol
    • High-Calorie Diet
      • Severe stress, burns, cancer, HIV infection, AIDS, COPD, respiratory failure, and any other type of debilitating disease
      • Nursing Considerations
      • high in protein for body-building
      • Encourage snacks between meals (e.g., milkshakes, instant breakfasts)
    • Sodium-Restriction Diet
      • HTN, CHF, kidney diseases, cardiac disease, and cirrhosis
      • Nursing Considerations
      • Mild: 2000 to 4000 mg
      • Moderate: 1000 mg
      • Strict: 500 mg (seldom)
      • Cereals allowed on a sodium-restricted diet
    • Protein-Restriction Diet
      • Used in cases of acute or chronic renal disease, cirrhosis of the liver, and hepatic coma
      • Nursing Considerations
      • Smaller protein allowed; high quality
      • (protein will be used for energy rather than protein synthesis)
      • Consumption of milk, meat, and bread and other starches is limited
    • High-Protein Diet
      • fracture, burn, elderly, and pregnant
      • Nursing Considerations
      • legumes, eggs, meat, fish, fowl, and dairy products
      • Needs protein supplements
    • Low-Calcium Diet
      • Prevent renal calculi
      • Nursing Considerations
      • Decrease the client's total intake of calcium to prevent further stone formation; avoid whole grains, dairy products, and green, leafy vegetables
    • High-Calcium Diet
      • bone growth and in adulthood to prevent osteoporosis
      • Nursing Considerations
      • Dairy products; other sources include turnip greens, sardines, salmon, tofu, and spinach
      • Lactose intolerance?
    • Low-Purine Diet
      • Used to treat gout
      • Nursing Considerations
      • The client needs to avoid consuming fish such as anchovy, herring, mackerel, and sardine; scallops; glandular meats; gravies; meat extracts; wild game; and goose
    • High-Iron Diet
      • Used in cases of anemia
      • Nursing Considerations
      • Includes organ meats, meat, egg yolks, whole-wheat products, leafy vegetables, dried fruit, and legumes
    • Diets for Diverticular Disease
      • Symptomatic diverticulitis: No high-fiber
      • Asymptomatic diverticular disease: yes to high-fiber diet; prevent constipation
      • 2500 to 3000 mL per day unless this is contraindicated
    • Fluid Restriction
      • Oliguric phase of acute renal failure and in cases of chronic renal disease, cirrhosis of the liver, congestive heart failure, hepatic coma, and myocardial infarction
      • Nursing Considerations
      • Usually this diet restricts consumption of foods that are composed largely of water
    • Carbohydrate-Controlled Diet
      • Maintain normal glucose levels in clients
      • Used in cases of diabetes mellitus, hypoglycemia, lactose intolerance, galactosemia, dumping syndrome, and obesity
      • Nursing Considerations
      • Use Exchange System groups
      • Major food groups: carbohydrate, the meat and meat-substitute, and the fat group
    • Vegetarian Diets
      • Lacto-Ovo Vegetarian
      • Consumes plant, dairy, and eggs
      • Eats fish and, occasionally, poultry
      • Lacto Vegetarian
      • Consumes plant and dairy products but not eggs
      • Vegan
      • Follows a strict vegetarian diet that includes no animal-based foods
    • Enteral Nutrition
      • Description
      • Introduces liquefied foods into the gastrointestinal tract by way of a tube
      • Indications
      • Used when the gastrointestinal tract is functional but oral intake is not feasible
      • Nursing Considerations
      • Clients with lactose intolerance must be given lactose-free formulas
    • Medication and Substance Use
      • Affects health, cause function loss, or impairs senses
      • May increase risk for disease
      • Note all prescription & OTC meds taken
      • Ask about the vitamins and herbals
      • Ask about the use of tobacco, alcohol, and street drugs; and its effects work or family
      • Provide info about rehab programs
    • Environment
      • Note hazards in the home and workplace; safety
      • Alone? knows neighbors? involved in community?
      • Identify healthy environmental patterns, such as the use of seat belts
      • Teach about hazards and preventive measures
    • Self-Concept/ Care Responsibilities
      • Attitudes about self, perception of personal abilities, body image, and general sense of worth
      • Provide with information regarding activities that will promote health
    • Behaviors That Promote Health
      • Basic hygiene practices
      • Regular health care check-ups
      • Breast self-examination
      • Testicular self-examination
      • Accident prevention (e.g., use of seat belts)
      • Hazard protection (e.g., use of smoke alarms, sunscreen)
      • Sexual responsibility
    • Relationships & Social Activities
      • Composition of family and current relationships?
      • Potential support systems
      • level of social development
      • Social activities and Community involvement
      • Assist the client in identifying community groups and activities and encourage participation
    • Values and Belief System
      • Values, goals, & beliefs that guide health-related lifestyle choices
      • Spiritual or cultural beliefs on health and illness and how they affect health practices
      • Perception of personal strengths related to maintaining health or coping with illness
      • Identify any complementary (alternative) health-care practices used by the client and evaluate their effect on health maintenance
    • Education and Work  
      • Determine education level and financial status; income is adequate for lifestyle and health concerns?
      • areas of stress and satisfaction in life
      • Ask on future educational plans and provide information as appropriate
    • Stress Levels & Coping Styles
      • What events cause stress and how the client copes with the stress
      • Methods to relieve stress and if these methods are helpful
      • Teach about stress management techniques
      • Adaptation
      • Types of Adaptation
      • 1. General Adaptation Syndrome (GAS)
      • Stages of GAS
      • 1. Alarm
      • 2. Resistance
      • 3. Exhaustion
      • 2. Local Adaptation Syndrome (LAS)
      • Purpose:
      • 1. Localize tissue injury
      • 2. Protect tissue from injury
      • 3. Prepare tissue for repair
      • Inflammatory Response:
      • 1. Vascular response
      • 2. Cellular response
            • Neutrophils
      • 3. Healing process (Reparative)
      • Regeneration
      • Scar Formation
          • First Intention (Primary union)
            • minimal or no tissue loss
          • Second Intention
            • Great amount of tissue loss, repair time is longer and scarring is greater
          • Third Intention
            • Delayed surgical closure of infected wound
      • Nursing Intervention for Inflammation
      • 1. Rest
      • 2. Reduce swelling
      • Elevate the affected part
      • Cold then Heat application
      • 3. Relieve pain
      • 4. Increase fluid intake
      • 5. Adequate nutrition
      • 6. Medications:
      • Analgesics
      • Anti-inflammatory
      • Antibiotics
      • 7. Surgery
      • Incision & Drainage
      • Debridement
    • Comfort Interventions
      • Types of Pain
      • Acute
      • Injury, medical condition, or surgical procedure; lasts hours to a few days
      • Chronic
      • months or even years
      • Phantom
      • Occurs after the loss of a body part (amputation); feel pain in the amputated part for years after the amputation
    • Assessment
      • Describe Pain: degree, quality, area, and frequency; Consider culture
      • Observable indicators: moaning; crying; irritability; restlessness; grimacing or frowning; inability to sleep, rigid posture; increase BP, heart rate, or respirations; nausea; and diaphoresis
      • Use a number-based pain scale (a picture-based scale may be used in children)
      • Nonpharmacological Interventions
      • TNS versus Percutaneous Electrical NS
      • Binders
      • Heat and Cold Application
      • Complementary and Alternative Measures
      • Relaxation and repositioning techniques
      • Biofeedback & Music
      • Distraction techniques & hypnosis
      • Guided-imagery and meditation techniques
      • Massage & therapeutic touch
      • Acupuncture & acupressure; Chiropractic TX
    • Pharmacological Interventions
      • Nonnarcotic and NSAIDs, narcotics, and adjuvants
      • Routes: oral, subcutaneous, intramuscular, intravenous, topical, or by the epidural
      • Epidural Route
      • Administered into the spinal epidural space
      • Patient-Controlled Analgesia
      • A programmable pump contains a cartridge or syringe; client can push a button to self-administer a dose of medication within the limitations prescribed by the physician
    • Heat and Cold Applications
      • Effects of Heat
      • 1. Vasodilation
      • 2. ↑ cell metabolism
      • 3. Muscle relaxant
      • 4. Relieves pain
      • 5. Reduces edema
      • 6. Sedative effect
      • Effects of Cold
        • 1. Vasoconstriction
        • 2. ↓ cell metabolism
        • 3. Local anesthetic effect
        • 4. Bacteriostatic
        • 5. Reduces edema
      • Principles in Heat and Cold Application
      • 1. Cold application is safer than heat application.
      • 2. Heat & cold application needs doctor’s order.
      • 3. Cold application for 1st 72H then hot application for the next 72H.
      • 4. Heat & cold application: max of 30 mins; average 15-20 mins.
      • 5. Check the area every 5 – 20 minutes.
      • Methods of Dry Heat Application
      • 1. Hot Water Bags or Bottles
        • Not exceed 52 0 C
        • 1/2 - 2/3 full
      • 2. Disposable Hot Packs
        • Avoid puncture of the outer covering
      • 3. Heat Lamp, Perilight & Droplight
        • 25 watts, 18 inches away
        • 40 watt bulb, 24 inches
      • Methods of Moist Heat Application
      • Temperature: 40 – 46 0 C
      • 1. Warm Moist Compress
      • 2. Warm Soak
        • Pat dry after procedure
      • 3. Hot sitz Bath
        • Check BP & PR before procedure
        • & 5 minutes after
      • Methods of Dry Application
      • 1. Ice Collar
        • 1/3 full
      • 2. Ice Cap
        • 1/3 full – Chest
        • 1/3-1/2 full – Rest of the Body
      • 3. Disposable Cold Pack
    • Personal Hygiene
      • Assess the client's personal-hygiene habits
      • Wash hands and wear gloves and other protective items as appropriate
      • Ensure privacy & explain procedures
      • Determine health status and readiness
      • Encourage, Assist or Provide basic hygiene & grooming
      • Use proper body mechanics
      • Assess skin integrity 
      • Teach about required adaptations
    • Laboratory & Diagnostic Exams
      • a. Urine
      • Specimen Collection
      • 1.) Clean-catch, midstream urine collection
        • Urinalysis and Culture & Sensitivity
        • Collect early morning
        • Instruct importance of perineal care
        • Discard 1st and last urine flow
        • Collect the midstream
        • 30-50 ml for urinalysis;
        • 5-10 ml for urine C&S
      • 2.) 24 H urine collection
        • Discard 1st voided urine & collect the 2nd voided until on the same time the following day
        • Add preservatives or Soak in ice
      • 3.) Second-voided urine specimen
        • Ask to void, discard first urine collection
        • Let patient drink 1 glass of water
        • After a few minutes, ask pt to void
        • Test for Glycosuria
      • 4.) Catheterized urine specimen
        • Before withdrawing, clamp catheter 30 min before procedure
        • Withdraw urine from catheter
      • b. Stool
      • 1. Routine Fecalysis
        • Use sterile specimen container
        • Fresh warm specimen helps detect ova/parasites
        • Collect 1 inch of well-formed stool & send directly to laboratory
      • c. Sputum
      • 1. Gross Appearance of the Sputum
        • Collect early morning
        • Place in a sterile container
        • Rinse mouth with plain water before collection
        • Instruct to hack-up sputum to ensure it comes from the lungs
      • d. Blood Specimen
      • Fasting
        • FBS, BUN, S. Creatinine
        • S. Lipids (Serum Choleserol;
        • S. triglycerides)
      • No Fasting
        • CBC
        • Hemoglobin
        • Hematocrit
        • Clotting studies
        • Enzyme studies
        • Serum Electrolytes
    • OXYGENATION
      • Maintaining Respiratory function:
      • A. Deep breathing & coughing exercises
      • B. Semi to High Fowler’s position
      • C. Patent Airway
      • Causes of Airway Obstruction
          • 1. Mucus secretion
          • 2. Edema of airways
            • Asthma, post surgery
          • 3. Spasm of airways
            • Asthma, epiglottitis, anaphylaxis
          • 4. Foreign bodies
      • D. Adequate hydration
      • E. Avoid environment pollutants,
      • alcohol & smoking
      • F. Chest Physiotherapy
      • 1. Percussion
      • 2. Vibration
      • 3. Postural drainage
        • 10-15 minutes in one position.
          • Prevent exhaustion and hypotension.
        • Bronchodilators or nebulization given to loosen mucus.
        • Best done before meals & at bedtime.
        • Entire CPT: 30 minutes only.
      • G. Steam Inhalation
        • Before procedure, instruct to perform coughing & deep breathing exercises (Facilitate expectoration of mucus)
        • Place in semi-fowler’s position
        • Eyes covered with wash cloth to prevent irritation
        • 12-18 inches away from the client’s nose.
        • Done for 15-20 minutes
      • H. Suctioning
        • Hyperoxygenate or Hyperventilate
        • 5-10 seconds, max 15 seconds
        • 20-30 secs interval between suctioning
        • Total: 5 minutes only
      • K . Incentive Spirometry
      • L. Supplemental O2
      • Signs of Hypoxemia
        • 1. Restlessness
        • 2. Rapid shallow respiration
        • 3. Increased PR
        • 4. Nasal flaring
        • 5. Substernal or intercostal retractions
        • 6. Cyanosis
    • ELIMINATION
      • 1. Fecal elimination
      • Normal characteristics of stools:
      • Color: yellow or golden brown
      • Odor: Aromatic
      • Deviation:
        • Acholic stool
          • biliary obstruction
        • Hematochezia
          • passage of fresh bright blood.
        • Melena
          • black tarry stool
        • Steatorrhea
          • fatty stool
          • (Hepatobiliary – pancreatic obstruction)
      • Fecal Eliminations problems:
      • 1. Constipation
      • Mngt:
        • Adequate fluid intake
        • High fiber
        • Respond to the urge to defecate
        • Minimize stress
        • Laxatives as ordered
      • 2. Fecal impaction
        • Putty-like feces at the folds of the rectum.
        • Hardened fecal mass palpated during digital examination.
      • Mngt:
        • Manual extraction
        • Increase fluid intake
        • Adequate activity & exercise
    • Digital Removal of Stool
      • Take baseline vital signs, Sims’ position
      • Wear gloves and other protective items as appropriate
      • Gently loosen the hardened mass by massaging around it and working the feces downward
      • Monitor heart rate closely; if the heart rate drops or the rhythm changes, stop the procedure (vagal response from stimulation of the sphincter and rectal wall can occur)
      • 3. Diarrhea
      • Mngt:
        • Replace fluid & electrolyte loss
        • Good perineal hygiene
        • Promote rest
        • Low fiber
        • BRAT (potassium rich foods)
        • Meds: antidiarrheal
      • 4. Flatulence
      • Mngt:
        • Avoid gas forming foods
        • Early ambulation & adequate activity.
        • Limit carbonated beverages
        • Cholinergics: prostigmine
    • Fecal Elimination
      • Assessment
      • Identify usual elimination pattern & stool characteristics and any recent changes
      • Routines used to promote elimination (e.g., diet, fluid intake, exercise)
      • Identify medications, laxatives or enemas
      • Ask about surgeries or illnesses that have affected the gastrointestinal tract
      • Determine the client's emotional status
    • Fecal Elimination Factors
      • Age; infant versus Elderly, Pregnancy
      • Diet; h igh in fiber Fluid Intake; 6 to 8 glasses
      • Physical; & Psychological activities;
      • Stress » diarrhea; Depression » constipation
      • Surgery and Anesthesia; Pain
      • Diagnostic Tests; NPO & Bowel Evacuation
      • Personal Habits; sched or environ change
      • Position; sitting versus supine
    • Medications Affecting Fecal Elimination
      • Laxative and cathartic agents
      • (long-term: intestinal muscle tone loss)
      • Antispasmodic, narcotics and anticholinergic, can slow peristalsis and delay gastric emptying time,
      • Antibiotic drugs can cause diarrhea (e.g., Clostridium difficile),
      • NSAID &ASA cause gastric irritation
    • Methods to Promote Elimination
      • Maintain normal elimination routines & exercise patterns
      • Initiate a bowel-retraining program
      • Avoid constipation-causing medications
      • Diet: high-fiber foods and adequate fluids
      • For bedpan, position to promote defecation and prevent muscle strain and discomfort
      • Bowel-Retraining Program Components
      • Compatible time
      • Prescribed stool softeners daily or a cathartic suppository at least 30mins before defecation
      • Hot drink or juice for peristalsis
      • Position, privacy and time for defecation
    • Enema
      • Purpose:
        • To relieve constipation
        • To administer medications
        • To relieve flatulence
        • To evacuate feces
    • Enema Administration Principles
      • MD order; Wears gloves, Clean technique
      • adult>Sims‘ ; child>dorsal recumbent position
      • Check temp (105  F, or 40.5  C)
      • Lubricated tube: Adult: 3- 4 in, Child: 2- 3 in, Infant: 1 to 1.5 in
      • Enema container: raised slowly
      • (High:12-18 in, Regular: 12 in, Low: 3 in)
      • Lower or clamp if cramping or if fluid escapes the rectal tube
      • Enema til clear. if 3 & still unclear, consult MD
      • Retention enema
        • Solution: 90-120ml of Mineral oil
        • Carminative solution
        • Ht: 12 inches above rectum
        • 40 – 44 0 C
        • Retention: 1-3H
      • Non-retention Enema
        • Solution: tap water, soap suds, NSS
        • Height : 18 inches above rectum
        • 46 – 52 0 C
        • Retention: 5-10 mins
      • Cleansing Enema:
        • stimulate peristalsis.
      • a. High Flow
      • d. Low Flow
      • Solutions:
              • Soap suds
              • Carminative solution
              • NSS
      • Carminative Enema
        • 60-180 ml of fluid is introduced to expel flatus.
      • Return flow enema
        • 100-200 ml of fluid is introduce into the large colon to stimulate peristalsis.
        • inflow and outflow process repeated 5-6 times.
    • Bowel Diversion
      • Stoma that diverts the flow of fecal contents
      • Wear stomal pouch continuously
      • Local irritation and skin breakdown are possible,
      • Ileostomy is at risk for fluid and electrolyte imbalance
      • Threat to body image;lead to social isolation
      • 2. Urine elimination:
      • color: amber/straw:
      • odor: aromatic
      • pH: 4.6-8
      • Specific gravity: 1.010 – 1.025
    • Urinary Elimination
      • Assess urination patterns (frequency & times)
      • Identify any urination factors:
      • - Age; continence by 1 8-24 mo.s, aging impairs
      • Sociocultural: privacy & position
      • Psychological: Anxiety and emotional stress
      • Muscle tone: keagel’s
      • Fluid Balance: fluid intake; Caffeine, Alcohol, Fruits, & metabolism
      • Surgery: stress response, NPO status, & drug
    • Urine Promotion
      • Daily fluid intake of 2000 to 2500 mL
      • Provide privacy & time; assist into position
      • Prevent urinary-tract infection
      • Acid Ash diet
      • Sensory stimuli ( running water; placing hand in warm water; warming the bedpan; pouring warm water over the perineum)
      • Initiate a bladder-retraining program
    • Components of a Bladder-Retraining Program
      • Teach keagel’s exercises
      • Initiate an individualized toileting schedule (on awakening, every 2 hours during the day and evening, and every 4 hours at night)
      • Alternative methods to relax and stimulate urination
      • Diuretics in the morning; increase day diuresis
      • Alterations in Urine Composition
      • Hematuria
      • Bacteriuria
      • Albuminuria
      • Proteinuria
      • Glycosuria
      • Ketonuria
      • Altered Urine Production
      • Polyuria
      • Oliguria
      • Anuria
      • Altered Urine Elimination
      • Frequency
      • Nocturia
      • Urgency
      • Dysuria
      • Enuresis
      • Incontinence
      • Nsg Management to induce Voiding
      • 1. Provide privacy
      • 2. Provide fluids to drink
      • 3. Serve bed pan and urinal
      • 4. Running water sound
      • 5. Pour warm water over the perineum
      • 6. Promote relaxation
      • 7. Provide adequate time for voiding
      • 8. Urinary catheterization
        • Last resort
    • Urinary Catheterization
      • Intermittent or indwelling catheterization
      • Physician's order is required
      • Aseptic technique; Maintain closed drainage system, bag maintained below the bladder level
      • Monitors patency and checks for tubing kinks or bends
      • Perineal hygiene ( soap and water) at least 3X daily and after defecation
    • Urinary Diversion
      • Creation of a temporary or permanent stoma
      • Wear stomal pouch continuously; No sphincter control
      • Local irritation & skin breakdown are possible
      • Poses a threat to body image
    • Rest and Sleep
      • Assessment
      • Regular sleep pattern? sleep problems?
      • Any illness or injury affecting sleep?
      • Diet, exercise, and medications?
      • sleep aids?
    • Adequate Rest and Sleep
      • aids in healing and maintain health
      • inadequate sleep= daytime drowsiness & fatigue, irritability, depression, poor concentration & memory, & an increased likelihood of accident or injury
      • hours of sleep: Infants>16 ; Adolescent: 8 , Adults: 5 to 10
      • Aging> night sleep decrease; Elderly day naps
    • Factors Affecting Sleep
      • Lifestyle; nightshift, travelers, and students
      • Caffeine and nicotine delays sleep
      • Alcohol can cause nocturnal awakening
      • Stress and illness can prevent sleep
      • Hospitalization; environmental factors, & treatments & procedures
      • Lack of exercise or exercising too close to bedtime can interfere with sleep
    • Interventions: Rest and Sleep
      • Exercise; eliminate alcohol & nicotine
      • no caffeine at least 2 hours before bedtime
      • Get up same time each day and no day nap; sched treatments in day time
      • Avoid going to bed hungry or overfull; give light dairy snack
      • Adjust room temp; eliminate lights, noise, and distractions
      • Use only prescribed Sedatives or hypnotics
    • BED MAKING
      • Types of Bed
      • 1. Closed Bed: Covered to the top
      • 2. Open Bed: Top sheet fanfolded,
      • 3. Occupied Bed:
        • made with the client in it
      • Special considerations
      • 1. Wash hands before and after
      • 2. Practice good body mechanics
      • 3. Prevent contamination from soiled linens
      • 4. Order: Bottom sheet, rubber sheet, draw sheet, blanket, top sheet & pillow case
      • 5. siderails up
      • 6. Provide privacy; use drapes
    • Mobility
      • Ability to move freely with or without the use of an assistive device
      • Assessment of Mobility
      • Coordination and balance to walk & ADL
      • Range of motion (ROM), gait, & activity tolerance
      • ROM: Assessed if (+) joint stiffness, swelling, pain, limited movement, unequal movement, & strength
      • Gait: info on balance, posture, and ability to walk without assistance; assistive device
    • Immobility Complications
      • Respiratory
      • Atelectasis
      • Pneumonia
      • Decreased gas exchange
      • Cardiovascular
      • Thrombus formation
      • Thrombophlebitis
      • Pulmonary embolism
      • Orthostatic hypotension
      • Musculoskeletal
      • Generalized weakness and fatigue
      • Stiff joints & Diminished coordination
      • Joint contracture, atrophy & Foot drop
      • Bone pain & Osteoporosis
      • Gastrointestinal
      • Abdominal distention, & constipation
      • Decreased appetite and weight loss
      • Protein deficiency & Negative nitrogen balance
      • Integumentary
      • Skin breakdown & Pressure ulcers
      • Renal
      • Urinary stasis & UTI, Frequency, Dysuria
      • Precipitation of calcium salts and formation of renal calculi
      • Metabolic
      • Decrease in metabolic rate
      • Altered metabolism of carbohydrates, fats, and proteins
      • Fluid, electrolyte, and calcium imbalances
      • Psychological
      • Disorientation, Confusion, Boredom, Anxiety, Depression & Loneliness
      • Maintaining Body Alignment
      • Body alignment: positioning of joints, tendons, ligaments, and muscles while the client is standing, sitting, or lying
    • Interventions to Prevent Complications
      • Ensure client safety
      • Turn and reposition every 2 hours; prevent skin breakdown 
      • Provide exercise as appropriate
      • Encourage coughing and deep breathing every 1 to 2 hours
      • Elastic or sequential-compression stockings
      • high-fiber diet, stool softeners,& fluids
      • Maintain client's orientation, & Provide diversional activities
    • Body Mechanics: Guidelines for Moving and Lifting Clients
      • Obtain assistance whenever possible
      • Ask the client to help when able
      • Bend and flex the knees not back
      • Wide base; feet: shoulders'-width apart
      • Use smooth, coordinated movements
      • Work at the same level as the object
      • Trunk straight, No twisting when lifting and pulling; Elbows close to the body
    • Exercise
      • a. Active range of motion (ROM)
      • b. Passive range of motion (PROM)
      • c. Active – resistance ROM
        • Done by the client against a weight or force
      • d. Active – assistive ROM
        • Done by the stronger arm & leg to the weaker arm & leg
      • e. Isotonic
        • change and muscle length and tension
      • f. Isometric
        • change in muscle tension only
    • DECUBITUS ULCER
      • Causes:
      • 1. Pressure
      • 2. Friction
      • 3. Shearing Force
      • Risk Factors
        • 1. Immobility and Inactivity
        • 2. Inadequate Nutrition
        • 3. Excessive Body Heat
        • 4. Decreased mental status
        • 5. Diminished sensation
      • Stages:
      • I – Erythema on bony prominence
      • II – Necrosis of the epidermis or dermis
          • shallow crater
      • III – Necrosis extending to the subcutaneous tissue
          • deep crater
      • IV – Necrosis extending to the muscle.
      • Mgt:
      • Use pressure relieving devices
      • Change position every 2H
      • Meticulous skin care
      • Keep skin clean and dry
      • Avoid massaging bony prominences with soap when bathing
      • Treatment:
      • Clean pressure sores daily
      • Clean and dress the sore using surgical asepsis
      • Care for the Body after Death
      • a. Rigor mortis
        • stiffening of the body 2 – 4 H after death
        • Lack or absence of ATP
        • Position the body & place dentures in mouth, close eyes and mouth
      • b. Algor mortis
        • gradual loss of body temperature
        • 10C/min until room temperature
      • c. Livor mortis
        • discoloration of the skin after death
    • Documentation Points
      • Reason; if alternatives were used
      • Method & procedure for application
      • Condition of the restrained body part
      • Client's response to application
      • Date and time of application of the restraint
      • Assessment of circulatory, neurovascular, and skin integrity; if continued need exists
      • Release & periodic mov’t or ROM exercise
      • Duration of use & response on removal
      • Risk Management
      • A planned method of identifying, analyzing, and evaluating risks followed by a plan for reducing the frequency of accidents & injuries.
      • Programs are based on a systematic reporting system for incidents or unusual occurrences
      • Incident Reports
      • A tool for identifying risk situations and improving client care
      • Follows specific documentation guidelines
      • Filled out completely, accurately,& factually
      • Not be copied or placed in the client's record or referenced should be made in the client's record
      • Not a substitute for a complete entry in the client's record regarding an incident
    • Types of Incidents
      • Accidental omission of ordered therapies
      • Circumstances leading to injury
      • Client falls
      • Medication-administration errors
      • Needle-stick injuries
      • Procedure-or equipment-related accidents
      • A visitor having symptoms of an illness
    • Safeguarding Valuables
      • Client's valuables given to family or secured for safekeeping in a designated stored and locked location. Document
      • Sign a release to free the agency of responsibility for lost valuables
      • Wedding band taped in place unless swelling of the hands or fingers is a risk
      • Religious items (e.g., medals, scapulars) may be pinned to gown if this is permitted by agency policy
    • Physicians' Orders
      • Obligation : nurse is to carry out MD's order except when order is inappropriate
      • Clarify an unclear or inappropriate order, or one in question, with the physician
      • If no resolution occurs with regard to the order in question, contact the nurse manager or supervisor
      • Accountability : Nurse who carries out an inaccurate order may be legally responsible for any harm suffered by the client
    • Telephone Orders
      • Write down the date and time of the entry
      • Repeat the order to the physician and record the order, beginning with "t.o." (telephone order); next write the physician's name and sign the order
      • If another nurse witnessed the order, that person's signature follows the signature of the nurse who took the order
      • The physician must countersign the order within a certain time frame, set forth in agency policy
    • Components of a Medication Order  
      • Date and time order was written
      • Name of medication
      • Dosage
      • Route of administration
      • Frequency of administration
      • Physician or health-care provider's signature
    • Documentation
      • Legally required by accrediting agencies, state licensing laws, and state nurse- and medical-practice acts
      • Follow agency guidelines and procedures [ Guidelines ]
    • Documentation Guidelines
      • Narrative
      • black pen; Note date and time on entry
      • Objective, factual, and complete
      • Document care, meds, tx, & procedures ASAP after administered
      • Document client responses to interventions; Tx consent or refusal
      • Document calls made to other health-care providers
      • Don’t document or change for others
    • Documentation Guidelines
      • Narrative ( cont.)
      • Sign for each entry; No Blanks
      • verbatim for subjective data; no judgmental quotes
      • No text msg; Avoid unofficial abbrevs
      • Follow agency policies when an error is made (draw one line through the error, initial, and date)
      • Follow agency guidelines regarding late entries
    • Documentation Guidelines
      • Computerized
      • Use only the user identification (ID) code, name, or password
      • Never lend access ID to another
      • Maintain privacy and confidentiality of documented information printed from the computer
    • Client/Family Teaching
      • Provide complete instructions in a language client or family can understand
      • Document client and family teaching, what was taught, evaluation of understanding, and who was present during the teaching
      • Inform what would happen if information shared during teaching were not followed
      • Reporting Responsibilities  
      • Required to report certain communicable diseases and criminal activities (e.g., abuse, gunshot or stab wound, assault, homicide, suicide) to the appropriate authorities
      • The Impaired Nurse
      • If coworker is suspected of abusing chemicals, report to nursing admin in a confidential manner
      • Priority Issue: treatment for nurse
      • Nursing administration then notifies BON regarding the nurse's behavior
    • Informed Consent and Releases
      • Consent = Approval to have body touched
      • Permission for surgery, tx, or info to 3rd party
        • Understandable terms, risks and benefits of the surgery or treatment, consequences for non-compliance,
        • treatment options, and the name of the health-care provider performing the surgery or procedure
    • Types of Consent
      • Admission Agreement
      • Blood-Transfusion Consent
      • Surgical Consent
      • Research Consent
      • Special Consent
      • Restraints, photographs, body part disposal, organ donation after death, or autopsy
    • Preventing Errors
      • Follow agency policies & procedures on administering meds and IV therapy, and for providing treatments.
      • Verify the identity before providing care by asking to state name & checking ID band
      • Ask about allergies (medications, food, environmental) & document accdg to policy
      • Check physician's orders for accuracy
      • When transcribing a MD's orders, be accurate & clear on order and transcription
      • Always clarify or question MD's order with the physician who wrote it
    • -fin-
      • The Quest for knowledge has just begun.
      • the true test is not in the board exam but in your career.