FUNDAMENTALS OF NURSING<br />Want MORE VISIT NURSING NOTES http://www.nursingnotes.info<br /><ul><li>DATA COLLECTION – is the process of gathering info about a client’s health status.
DATABASE – is all info about the client; includes nursing health history, physical assessment, doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed by other health personel.
CLIENT DATA – past history and current problems.
SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by the affected person.
Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of personal status and life situation.
OBJECTIVE DATA – signs or overt (obvious) data. It is detectable by the observer, can be measured or tested against accepted standard. They can be seen, heard and felt, or smelled, can be obtained by observation or physical exam.
PRIMARY DATA – from the CLIENT, it is the best source of data unless too ill, young, confused to communicate clearly.
SECONDARY DATA – are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social workers), LITERATURE (standards/norms,cultural and health practices, spiritual beliefs)
CLOSED QUESTION – (directive interview) restrictive and answered by YES/NO, questions begin by WHEN, WHERE, WHO, WHAT, DO or IS.
OPEN-ENDED QUESTIONS – (indirective interview) invite clients to discover, explore, elaborate, clarify, or illustrate their thoughts and feelings. It may begin with WHAT/HOW.
NEUTRAL QUESTION – (open ended and indirective) is a question a client can answer without direction or pressure from the nurse ( regarding feelings and point of views)
LEADING QUESTIONS – (closed and directive) directs the client’s answer. It gives the client less opportunity to decide whether the answer is true or not. (Ex. You’re stressed about the surgery tomorrow, aren’t you?)</li></ul>THEORETICAL FRAMEWORK of NURSING PRACTICE<br />Nursing<br />As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. It’s recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge.<br />Help the client gain independence as rapidly as possible.<br />CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE<br />TheoristDescriptionFLORENCE NIGHTINGALEDeveloped the first theory of nursing.Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.HILDEGARD PEPLAUIntroduced the Interpersonal Model. She defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate.FAYE ABDELLAHDefined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list 21 nursing problem areasIDA JEAN ORLANDODeveloped the three elements – client behavior, nurse reaction and nurse action – compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness.MYRA LEVINEDescribed the Four Conservation Principles. conservation of energyconservation of structured integrityconservation of personal integrityconservation of social integrityDOROTHY JOHNSONDeveloped the Behavioral System Model. Patient’s behavior as a system that is a whole with interacting parts how the client adapts to illnessgoal of nursing is to reduce so that the client can move more easily through recovery. MARTHA ROGERSConceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts.DOROTHEA OREMEmphasizes the client’s self care needs; nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs.IMOGENE KINGNursing process is defined as dynamic interpersonal process between nurse, client and health care system.BETTY NEUMANStress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of preventionSISTER CALLISTA ROY Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. LYDIA HALLIntroduced the notion that nursing centers around three components: person(core), pathologic state and treatment(cure) and body(care).JEAN WATSONConceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self-knowledge, self-control, self-care and self-healing.ROSEMARIE RIZZO PARSE Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold.MADELEINE LENINGERDeveloped the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition<br />ROLES AND FUNCTION OF A NURSE<br />Caregiver – the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial, developmental, cultural and spiritual levels.<br />Communicator – communication is an integral to all nursing roles. Nurses communicate with the client, support persons, other health professionals, and people in the community. In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health team. The quality of a nurse’s communication is an important factor in nursing care.<br />Teacher – as a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health. The nurse assesses the client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies and measures learning.<br />Client advocate – a client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health professionals, such as relaying the client’s wishes for information to the physician. They also assist clients in exercising their rights and help them speak up for themselves.<br />Counselor – counseling is a process of helping a client to recognize and cope with stressful psychologic or social problems, to developed improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychologic support.<br />Change agent – the nurse acts as a change agent when assisting others, that is, clients, to make modifications in their own behavior. Nurses also often act to make changes in a system such as clinical care, if it is not helping a client return to health.<br />Leader – a leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels; individual client, family, groups of clients, colleagues, or the community. Effective leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others.<br />Manager – the nurse manages the nursing care of individuals, families, and communities. The nurse-manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance.<br />Case manager – nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes.<br />Research consumer – nurses often use research to improve client care. In a clinical area nurses need to:<br />Have some awareness of the process and language of research<br />Be sensitive to issues related to protecting the rights of human subjects<br />Participate in identification of significant researchable problems<br />Be a discriminating consumer of research findings<br />Concepts of Health and Illness<br />Health – As defined by the World Health Organization (WHO): state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.<br />Characteristics<br />A concern for the individual as a total system<br />A view of health that identifies internal and external environment<br />An acknowledgment of the importance of an individual’s role in life<br />A dynamic state in which the individual adapts to <br />changes in internal and external environment to maintain a state of well being<br />Models of Health and Illness<br />Health-Illness Continuum (Neuman) – Degree of client wellness that exist at any point in time, ranging from an optimal wellness condition, with available energy at its maximum, to death which represents total energy depletion.<br />High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment.<br />Agent – Host – environment Model (Leavell) – The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment<br />Agent – any internal or external factor that disease or illness.<br />Host – the person or persons who may be susceptible to a <br /> particular illness or disease<br />Environment – consists of all factors outside of the host<br />Health – Belief Model – Addresses the relationship between a person’s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies.<br />Four Components<br />The individual is perception of susceptibility to an illness<br />The individual’s perception of the seriousness of the illness<br />The perceived threat of a disease<br />The perceived benefits of taking the necessary preventive <br />measures<br />Evolutionary – Based Model – Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individual’s function to promote survival and well-being. The model interrelates the following elements:<br />Life events<br />Life style determinants<br />Evolutionary viability within the social context<br />Control perceptions<br />Viability emotions<br />Health outcomes<br />Health Promotion Model – A “complimentary counterpart models of health protection”. Directed at increasing a client’s level of well being. Explain the reason for client’s participation health-promotion behaviors. The model focuses on three functions:<br />It identifies factors (demographic and socially) enhance or decrease the participation in health promotion<br />It organizes cues into pattern to explain likelihood of a client’s participation health-promotion behaviors<br />It explains the reasons that individuals engage in health activities<br />Illness – State in which a person’s physical, emotional, intellectual, social developmental or spiritual functioning is diminished or impaired. It is a condition characterized by a deviation from a normal, healthy state.<br />3 Stages of Illness<br />Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness.<br />Stage of Acceptance – Turns to professional help for assistance<br />Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss or impairment of function<br />Rehabilitation<br />A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest possible level of physical, mental, spiritual, social and economical functioning.<br />Abilities not disabilities, are emphasized.<br />Begins during initial contact with the patient<br />Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of function as short a time as possible<br />Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process.<br />Focuses of Rehabilitation<br />Coping pattern<br />Functional ability – focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dressing/grooming, toileting and mobility<br />Mobility<br />Integrity of skin<br />Control of bowel and bladder function<br />Concepts of Stress<br />Stress (Theory by Hans Selye)<br />Non specific response of the body to nay demand made upon it<br />Any situation in which a non specific demand requires an individual to respond or take action<br />Characteristics of Stress<br />Stress is not nervous energy. Emotional reactions are common stressors<br />Stress is not always the result of damage to the body<br />Stress does not always result in feelings of distress (harmful or unpleasant stress)<br />Stress is a necessary part of life and is essential for normal growth and development<br />Stress involves the entire body acting as a whole and is an integrated manner<br />Stress response is natural, productive and adaptive<br />Stressors – Factor or agent producing stress, maybe: physiological, psychological, social, environmental, developmental, spiritual or cultural and represent an unmet needs<br />Classification of Stressors<br />Internal Stressors – originate from within the body. E.g. fever, pregnancy, menopause, emotion such as guilt<br />External Stressors – originate outside a person. E.g. change in family or social role, peer pressure, marked change in environmental temperature<br /> <br />Factors influencing response to stressors<br />Physiological functioning<br />Personality<br />Behavioral characteristics<br />Nature of the stressor: integrity, scope, duration, number, and nature of other stressors<br />Homeostasis – Process of maintaining uniformity, stability and constancy with in the living organisms. (from Greek word homotos – like, and stasis – position)<br />Adaptation – Body’s adjustment to different circumstances and conditions. Process by the physiological or psychological dimensions change in response to stress; attempt to maintain optimal functioning<br />Adaptation to Stress-Physiological Response (Hans Selye)<br />Local Adaptation Syndrome (LAS) – Response of a body tissue, organ or part to the stress of trauma, illness or other physiological change<br />Characteristics<br />The response is localized, it does not involve entire body systems<br />The response is adaptive, meaning that a stressor is necessary to stimulate it<br />The response is short term. It does not persist indefinitely<br />The response is restorative, meaning that the LAS assists in restoring homeostasis to the body region or part<br />Two Localized Responses<br />Reflex Pain Response – is a localized response of the central <br />nervous system to pain. It is an adaptive response and protects tissue from further damage. The response involves a sensory receptor, a sensory nerve from the spinal cord, and an effector muscle. An example would be the unconscious, reflex removal of the hand from a hot surface.<br />Inflammatory Response – is stimulated by trauma or infection. This response localizes the inflammation, thus revenging its spread and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning.<br /> <br />Three Phases of Inflammatory Response<br />First Phase – Narrowing of blood vessels occurs at the injury to control bleeding. Then histamine is released at the injury, increasing the number of white blood cells to combat infection.<br />Second Phase – It is characterized by release of exudates from the wound<br />Third Phase – The last phase is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with identical or similar cells.<br />General Adaptation Syndrome (GAS) or Stress Syndrome – characterized by a chain or pattern of physiologic events.<br />3 Stages<br />Alarm Reaction – initial reaction of the body which alerts the body’s defenses. SELYE divided this stage into 2 parts:<br />The SHOCK PHASE<br />The COUNTERSHOCK PHASE<br />Stage of Resistance – occurs when the body’s adaptation takes place; the body attempts to adjust with the stressor and to limit the stressor to the smallest area of the body that can deal with it.<br />Stage of Exhaustion – the adaptation that the body made during the second stage cannot be maintained; the ways used to cope with the stressors have been exhausted<br />StressorEpinephrineTachycardia↑ Myocardial contractility↑ Blood clotting↑ MetabolismNorepinephrine↓ Blood to kidney↑ ReninCotisoneProtein catablismGluconeogenesisStage of ResistanceAdaptationShock PhaseStage of Exhaustion ↓ ↓ Rest DeathThe three stages of adaptation to stress: the alarm reaction, the stage of resistance and the stage of exhaustion.<br />STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic stimulation. Significant body responses to epinephrine include the following:<br />Increased myocardial contractility, which increases cardiac output & blood flow to active muscles<br />Bronchial dilation, which allows increased oxygen intake<br />Increased blood clotting<br />Increased cellular metabolism<br />Increased fat mobilization to make energy available & to synthesize other compounds needed by the body.<br />Physiologic Indicators of Stress<br />Pupils dilate to increase visual perception when serious threats to the body arise.<br />Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism.<br />The heart rate & cardiac output increase to transport nutrients and by-products of metabolism more efficiently.<br />Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine.<br />Sodium & water retention increase due to release of mineralocorticoids, which results in increased blood volume.<br />The rate & depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation.<br />Urinary output may increase or decreases.<br />The mouth may be dry.<br />Peristalsis of the intestines decreases, resulting in possible constipation and flatus.<br />For serious threats, mental alertness improves.<br />Muscle tension increases to prepare for rapid motor activity or defense.<br />Blood sugar increases because of release of glucocorticoids & gluconeogenesis.<br />Psychologic Indicators – psychologic manifestations of stress include anxiety, fear, anger, depression & unconscious ego defense mechanisms.<br />Anxiety – a common reaction to stress. It is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It can be experienced, subcutaneous or unconscious level. Can be manifested on 4 LEVELS:<br />Fear – an emotion or feeling of apprehension aroused by impending or seeming danger, or other perceived threat. The object of fear may or may not be based in reality.<br />Anger – an emotional state consisting of a subjective feeling of animosity or strong displeasure. People may feel guilty when they feel anger because they have been taught that to feel angry is wrong.<br />Depression – common reaction to events that seem overwhelming or negative. It is an extreme feeling of sadness, despair, dejection, lack of worth or emptiness.<br />Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness<br />Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance and social withdrawal.<br />Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness<br /> <br />Cognitive Indicators – are thinking responses that include problem-solving, structuring, <br /> self-control or self-discipline, suppression and fantasy<br />Problem solving – involves thinking through the threatening situation, using a specific steps to arrive at a solution<br />Structuring – arrangement or manipulation of a situation so that threatening events do not occur.<br />Self-Control (discipline) – assuming a manner of facial expression that convey a sense of being in control or in change.<br />Suppression – consciously and willfully putting a thought or feeling out of mind<br />Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality.<br /> <br />COPING STRATEGIES (COPING MECHANISMS)<br />Coping – dealing with problems & situations or contending with them successfully.<br />Coping Strategy – innate or acquired way of responding to a changing environment or specific problem or situation.<br />According to Folkman and Lazarus, coping is “the cognitive & behavioral effort to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person”.<br />Coping Strategies: 2 Types<br />Problem-focused coping – efforts to improve a situation by making changes or taking some action<br />Emotion-focused coping – does not improve the situation, but the person often feels better.<br />Coping strategies are also viewed as:<br />Long-term coping strategies – can be constructive & realistic<br />Short-term coping strategies – can reduce stress to a tolerable limit temporarily but are in the end od ineffective ways to deal with reality.<br />Coping can be adaptive or maladaptive:<br />Adaptive Coping – helps the person to deal effectively with stressful events & minimizes distress associated with them.<br />Maladaptive Coping – can result in unnecessary distress for the person & others associated with the person or stressful event.<br />*Effective coping results in adaptation; ineffective coping results in maladaptation. The effectiveness of an <br />individual’s coping is influenced by a number of factors:<br />The number, duration & intensity of the stressors<br />Past experiences of the individual<br />Support systems available to the individual<br />Personal qualities of the person<br />*If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problems.<br />*Reaction to long term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden & produces responses such as chronic fatigue, sleeping difficulties & high BP.<br />*Prolonged stress can also result in mental illness.<br />Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS).<br />Breathing Exercises<br />Massage<br />Progressive Relaxation<br />Imagery<br />Biofeedback<br />Yoga<br />Meditation<br />Therapeutic Touch<br />Music Therapy<br />Humor & Laughter<br />PSYCHOLOGICAL RESPONSE<br />Exposure to a stressor results in psychological and physiological and physiological adaptive responses. As people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the person’s ability to cope with stressors. These behaviors are directed at stress management and are acquired through learning and experience as a person identifies acceptable and successful behaviors.<br />Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:<br />Task – Oriented Behaviors – Involve using cognitive abilities to reduce stress, solve problems, resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a stressor.<br />Three General Types<br />Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a need<br />Withdrawal Behavior – Is removing the self physically or emotionally from the stressor<br />Compromise Behavior – Is changing the usual method of operating, substituting goals or omitting the satisfaction of needs to meet other needs or to avoid stress.<br />Defense Mechanisms – Unconscious behaviors that offer psychological protection from a stressful event. They are used by everyone and help protect against feelings of worthlessness and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric disorders.<br />TYPES OF NURSING DIAGNOSES<br />Formulating the Nursing Diagnosis<br />Actual<br />Clients demonstrates defining characteristics of a problem<br />Nurse intervenes to resolve or help client cope with the problem<br />High-risk<br />A problem is likely to develop based on assessment of risk factors<br />Nurse intervenes to reduce risk factors or increase protective factors<br />Example: encourage smoking cessation<br />Wellness<br />Client is presently healthy but wishes to achieve a higher level of function<br />Nurse intervenes to promote growth or maintenance of the healthy response<br />Collaborative Problems<br />Definition: a potential problem the nurse manages using both independent and interdependent interventions<br />Example: potential complication of head injury: loss of consciousness, epidural or subdural hematoma, seizures<br />Usually occurs when a disease is present or a treatment is prescribed<br />Clients with similar disease or treatment will have the same potential for complications, which must be managed collaboratively; however, their responses to the condition will vary, so a broad range of nursing diagnoses will apply.<br />Example: a client with asthma will always be at risk for lowered oxygen saturation; however, the client’s response to this condition will be unique based on his/her developmental level, past experiences and family configuration<br />Refer to Table for examples of collaborative problems<br /> Example:<br />Disease/SituationComplicationRelated toEtiologyPotential complication of childbirthPotential complication of diuretic therapyHemorrhageDysrhythmiaRelated toRelated to1.Uterine atony2. Retained placental fragment3. Bladder distentionLow serum potassium<br /> <br />METHODS USED for ASSESSMENT<br />Collaboration of Data: Objective & Subjective<br />Review of clinical record<br />Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations<br />Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.<br />Interview<br />The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support.<br />The goals of an interview are to develop a rapport with the client and to collect data<br />An interview has 3 major stages<br />Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time.<br />Body: during this phase, the client responds to open and closed-ended questions asked by the nurse.<br />Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.<br /> <br />Types of questions<br />Closed questions used in directive interview<br />Re____ short factual answers; e.g. “Do you have pain?”<br />Answers usually reveal limited amounts of information<br />Useful with clients who are highly stressed and/or have difficulty communicating<br />Open-ended questions used in nondirective interview<br />Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’<br />Specify the broad area to be discussed and invite longer answers<br />Useful at the start of an interview or to change the subject<br />Leading questions<br />Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”<br />Suggests what answer is expected<br />Can result in client giving inaccurate data to please the nurse<br />Can limit client choice of topic for discussion<br />Nursing History<br />Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response)<br />Subjective data<br />May be called “covert data”<br />Not measurable or observable<br />Obtained from client (primary source), significant others, or health professionals (secondary sources).<br />For example, the client states, “I have a headache”<br />Objective data<br />May be called “overt data”<br />Can be detected by someone other than the client<br />Includes measurable and observable client behavior<br />For example, a blood pressure reading of 190/110 mmHg.<br />Physical assessment<br />Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion<br />A body system format for physical assessment is found below:<br />General assessementIntegumentary systemHead, ears, eyes, nose, throatBreast and axillaeThorax and lungsCardiovascular systemNervous systemAbdomen and gastrointestinal systemAnus and rectumGenitourinary systemReproductive systemMusculoskeletal system<br />Psychosocial assessment<br />Helpful framework for organizing data<br />A suggested format for psychosocial assessment is found below:<br />Vocation/education/financialHome and FamilySocial, leisure, spiritual and culturalSexualActivities of daily livingHealth HabitsPsychological<br />The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection<br />Consultation<br />The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)<br />Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client<br />Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission<br />Review of literature<br />A professional nurse engages in continued education to maintain knowledge of current information related to health care<br />Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database<br />DOCUMENTING and REPORTING<br />Guidelines for Good Documentation and Reporting<br />Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells<br />Accuracy – information must be accurate so that health team members have confidence in it<br />Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand<br />Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:<br />Vital signs<br />Administration of medications and treatments<br />Preparation of diagnostic tests or surgery<br />Change in status<br />Admission, transfer, discharge or death of a client<br />Treatment fro a sudden change in status<br />Organization – the nurse communicate in a logical format or order<br />Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed<br />Documentation – anything written or printed that is relied on as a record of proof fro authorized persons.<br />Purposes of Records:<br />Communication<br />Planning Client Care<br />Auditing Health Agencies<br />Research<br />Education<br />Reimbursement<br />Legal Documentation<br />Health Care Analysis<br />Documentation Systems<br />Source – Oriented Record<br />The traditional client record<br />Each person or department makes notations in a separate section or sections of the client’s chart<br />It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information<br />Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes<br />NARRATIVE CHARTING is a traditional part of the source-oriented record<br />Problem – Oriented Medical Record (POMR)<br />Established by Lawrence Weed<br />The data are arranged according to the problems the client has rather than the source of the information.<br />The four (4) basic components:<br />Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data<br />Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved<br />Plan of Care – care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans<br />Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data<br />Example: SOAP Format Or SOAPIE and SOAPIER <br />S – Subjective data<br />O – Objective data<br />A – Assessment<br />P – Plan<br />I – Intervention<br />E – Evaluation<br />R- Revision<br />Advantages of POMR:<br />It encourages collaboration<br />Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.<br />Disadvantages of POMR:<br />Caregivers differ in their ability to use the required charting format<br />Takes constant vigilance to maintain an up-to-date problem list<br />Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.<br />PIE (Problems, Interventions, and Evaluation)<br />Groups information in to three (3) categories<br />This system consists of a client care assessment floe sheet & progress notes<br />FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns<br />Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes<br />Focus Charting<br />Intended to make the client & client concerns & strengths the focus of care<br />Three (3) columns fro recording are usually used: date & time, focus & progress notes<br />Charting by Exception<br />Documentation system in which only abnormal or significant findings or exceptions to norms are recorded<br />Incorporates three (3) key elements:<br />Flow sheets<br />Standards of nursing care<br />Bedside access to chart forms<br />Computerized Documentation<br />Developed as a way to manage the huge volume of information required in contemporary health care<br />Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.<br /> <br />Case Management<br />Emphasizes quality, cost-effective care delivered within an established length of stay<br />Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.<br />Nursing Care Plan (NCP)<br />Two Types:<br />Traditional Care Plan – written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & nursing interventions.<br />Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high quality of nursing care<br />KARDEX widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms. Information may be organized into sections:<br />Pertinent information about the client<br />List of medications<br />List of IVF<br />List of daily treatments & procedures<br />List of Diagnostic procedures<br />Allergies<br />Specific data on how the client’s physical needs are to be met<br />A problem list, stated goals & list of nursing approaches to meet the goals<br /> <br />Nursing Discharge / Referral Summaries – completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it include some or all of the following:<br />Description of client’s physical, mental & emotional state<br />Resolved health problems<br />Unresolved continuing health problems<br />Treatments that can be continued (e.g. wound care, oxygen therapy)<br />Current medications<br />Restrictions that relate to activity, diet & bathing<br />Functional/self-care abilities<br />Comfort level<br />Support networks<br />Client education provided in relation to disease process<br />Discharge destination<br />Referral Services (e.g. social worker, home health nurse)<br />PHYSICAL EXAMINATION<br />Purposes<br />The nurse uses physical assessment for the following reasons:<br />To gather baseline data about the client’s health<br />To supplement, confirm or refute data obtained in the nursing history<br />To confirm and identify nursing diagnoses<br />To make clinical judgments about a client’s changing health status and management<br />Preparation of Examination<br />Environment – A physical examination requires privacy. An examination room that is well equipped for all necessary procedures is preferable<br />Equipment – Hand washing is done before equipment preparation and the examination. Hand washing reduces the transmission of microorganisms<br />Client<br />Psychological Preparation – clients are easily embarrassed when forced to answer sensitive questions about bodily functions or when body parts are exposed and examined. The possibility that the examination will find something abnormal also creates anxiety so reduction of this anxiety may be the nurse’s highest priority before the examination<br />Physical Preparation – the client’s physical comfort is vital to the success of the examination. Before starting, the nurse asks if the client needs to use the toilet.<br />Positioning – during the examination, the nurse asks the clients to assume proper positions so that body parts are accessible and clients stay comfortable. Client’s abilities to assume positions will depend on their physical strength and degree of wellness.<br />Order of Examination<br />General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurement<br />Review of systems<br />Head to toe examination<br />Skills in Physical Examination<br />Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles:<br />Make sure good lighting is available<br />Position and expose body parts so that all surface can be viewed<br />Inspect each areas fro size, shape, color, symmetry, position and abnormalities<br />If possible, compare each area inspected with the same area of the opposite side of the body<br />Use additional light (for example, a penlight) to inspect body cavities<br />Palpation – the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement.<br />Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue<br />Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope.<br />Bowel sounds<br />Breath sounds<br />Vesicular<br />Bronchovesicular<br />Bronchial<br />Examples of Adventitious Breath Sounds<br />Crackles (previously called rales)<br />Rhonchi<br />Wheeze<br />Friction rub<br />Therapeutic Communication Techniques<br />Using silence<br />Providing general leads<br />Being specific & tentative<br />Using open-ended questions<br />Using touch<br />Restating to paraphrasing<br />Seeking clarification<br />Perception checking or seeking consensual validation<br />Offering self<br />Giving information<br />Acknowledging<br />Clarifying time or sequence<br />Presenting reality<br />Focusing<br />Reflecting<br />Summarizing & planning<br />Barriers to Communication<br />Stereotyping<br />Agreeing & disagreeing<br />Being defensive<br />Challenging<br />Probing<br />Testing<br />Rejecting<br />Changing topics & subjects<br />Unwarranted reassurance<br />Passing judgment<br />Giving common advice<br />Phases of the Helping Relationship<br />Pre-interaction Phase<br />Introductory Phase<br />a. Opening the relationship<br />b. Clarifying the problem<br />c. Structuring & formulating the contract<br />Working Phase<br />a. Exploring & understanding thoughts or feelings<br />b. Facilitating & taking action<br />Termination Phase<br />PRINCIPLES of ASEPSIS and INFECTION CONTROL<br />Chain of Infection<br />The chain of infection refers to those elements that must be present to cause an infection from a microorganism<br />Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in clients<br />Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen.<br />Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect<br />Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the person’s resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host. <br />Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract).<br />Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans. <br />Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract.<br />Modes of Transmission<br />Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks.<br />Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission<br />Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract<br /> <br />Course of Infection<br />Incubation: the time between initial contact with an infectious agent until the first <br />signs of symptoms - - > the incubation period varies from different <br />pathogens; microorganisms are growing and multiplying during this stage<br />Prodromal Stage: the time period from the onset of nonspecific symptoms to the <br />appearance of specific symptoms related to the causative pathogen<br /> - - > symptoms range from being fatigued to having a low-grade fever with <br />malaise; during this phase it is still possible to transmit the pathogen to <br />another host<br />Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent<br />Convalescence: time period that the host takes to return to the pre-illness stage; also called the recovery period; - - >the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host, however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection<br />Inflammation – The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic<br />Body’s response<br />The “inflammatory response” begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured tissue<br />WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation<br />Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves.<br />Immune Response<br />The immune response involves specific reactions in the body to antigens or foreign material<br />This specific response is the body’s attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes<br />Cell mediated immunity: T-lymphocytes are responsible for cellular immunity<br />When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen<br />Once theantigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen<br />After the antigen is gone, the lymphokines disappear<br />Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again.<br />Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response)<br />B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections<br />Active immunity is produced when the immune system is activated either naturally or artificially.<br />Natural immunity involves acquisition of immunity through developing the disease<br />Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity)<br />Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.<br />Nosocomial Infection<br />Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system<br />Iatrogenic infection: these nosocomial infections are directly related to the client’s treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning<br />Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection<br />Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish.<br /> <br />Factors Increasing Susceptibility to Infection<br />Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms<br />Young infants have reduced defenses related to immature immune systems<br />In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are:<br />Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages)<br />Decreased bladder muscle tone resulting in urinary retention<br />Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretions<br />Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying.<br />Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases<br />Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a person’s susceptibility to infectious diseases<br />Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the body’s immune system can respond to pathogens<br />Stress: stressors, both physical and emotional, affect the body’s ability to protect against invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection<br />Rest, exercise and personal health habits: altered rest and exercise patterns decrease the body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s response to pathogens<br />Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following:<br />Intact skin and mucous membranes<br />Adequate blood cell production and differentiation<br />A functional lymphatic system and spleen<br />An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing it’s own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies.<br />Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk<br />Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed.<br />Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery <br />Diagnostic Tests Used to Screen for Infection<br />Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth<br />Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes<br />Certain diagnostic tests are ordered to confirm the presence of an infection.<br /> <br />THEORIES OF PAIN<br />Specific Theory<br />Proposes that body’s neurons & pathways for pain transmission are specific, similar to other senses like taste<br />Free nerve endings in the skin act as pain receptors, accept input & transmit impulses along highly specific nerve fibers<br />Does not account for differences in pain perception or psychologic variables among individuals.<br />Pattern Theory<br />Identifies 2 major types of pain fibers; rapidly & slowly conducting<br />Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as painful<br />Does not account for differences in pain perception or psychologic variables among individuals.<br />Gate Control Theory<br />Pain impulses can be modulated by a transmission blocking action within the CNS.<br />Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching an area) and may inhibit smaller diameter fibers to prevent transmission of the impulse (“close the gate”).<br />Current Developments in Pain Theory – Indicate that pain mechanisms & responses are far more complex than believed to be in the past.<br />Pain may modulated at different points in the nervous system.<br />First-order neurons at the tissue level<br />Second-order neurons in the spinal cord that process nociceptor information<br />Third-order tracts & pathways in the spinal cord & brain that relay/process this information<br />The role of the pain experience in the development of new nociceptors and/or reducing the threshold of current nociceptor is also being investigate<br />TYPES OF PAIN<br />Acute Pain<br />Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue injury associated with trauma, surgery, or inflammation.<br />Types of Acute Pain<br />Somatic: arises from nerve receptors in the skin or close to body’s surface; may be sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting<br />Visceral: arises from body’s organs; dull & poorly localized because of minimal noriceptors; accompanied by nausea & vomiting, hypotension & restlessness<br />Referred pain: pain that is perceived in an area distant from the site of stimuli (e.g. pain in a shoulder following abdominal laparoscopic procedure).<br />Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous System and is characterized by the following symptoms:<br />Tachycardia<br />Rapid, shallow respirations<br />Increased BP<br />Sweating<br />Pallor<br />Dilated pupils<br />Fear & Anxiety<br />Chronic Pain<br />Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often unresponsive to medical treatment.<br />Types of Chronic Pain<br />Neuropathic: painfuil condition that results from damage to peripheral nerves caused by infection or disease; post-therapeutic neuralgia (shingles) is an example<br />Phantom: pain syndrome that occurs following surgical or traumatic amputation of a limb.<br />The client is aware that the body part is missing<br />Pain may result of stimulation of severed nerves at the site of amputation<br />Sensation may be experienced as an itching, pressure, or as stabbing or burning in nature<br />It can be triggered by stressors (fatigue, illness, emotions, weather)<br />This experience is limited for most clients because the brain adapts to amputated limb; however, some clients experience abnormal sensation or pain over longer periods<br />This type of pain requires treatment just as any other type of pain does.<br />Psychogenic: pain that is experienced in the absence of a diagnosed physiologic cause or event; the client’s emotional needs may prompt pain sensation.<br />Depression is a common associated symptom for the client experiencing chronic pain; feelings of despair & hopelessness along with fatigue are expected findings.<br />PAIN ASSESSMENT<br />TOOLS/INTRUMENTS USED<br />A VERBAL REPORT using an intensity scale is a fast, easy & reliable method allowing the client to state pain intensity & in turn, promotes consisted communication among the nurse, client & other healthcare professionals about the client’s pain status; the 2 most common scales used are “0 to 5” or “0 to 10”. With 0 specifying no pain & the highest number specifying the worst pain<br />A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at both ends of the scale, such as “no pain” at one end and “worst pain” at the other, clients are asked to point or mark along the line to convey the degree of pain being experienced<br />A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a numerical scale with the word modifiers, usually the numbers “0 to 10” are added to the scale.<br />FACES PAIN SCALE children, clients who do not speak English & clients with communication impairments may have difficulty using a numerical pain intensity scale; the FACES pain scale may be used for children as young as 3 years old; this scale provides facial expressions (happy face reflects no pain, crying face represents worst pain)<br />PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to assess pain for a non-communicating client, facial & vocal expression may be the initial manifestations of pain; expressions may include rapid eye blinking, biting of the lip, moaning, crying, screaming, either closed or clenched eyes, or stiff unmoving body position<br />A B C D E method of pain assessment<br />This acronym was developed for cancer pain; however, it is very appropriate for clients with any type of pain, regardless of the underlying disease.<br />A = Ask about pain<br />B = Believe the client & family reports pain<br />C = Choose pain control options appropriate for the client<br />D = Deliver interventions in a timely, logical &coordinated fashion<br />E = Empower clients & families<br />P Q R S T assessment for pain reception<br />This method is especially helpful when approaching a new pain problem<br />P = What precipitated the pain?<br />Q = What are the quality & quantity of the pain?<br />R = What is the region of the pain?<br />S = What is the severity of the pain?<br />T = What is the timing of the pain?<br />Pain History<br />Location – when clients report “pain all over”, this generally refers to total pain or existential distress (unless there is an underlying physiologic reason for pain all over the body, such as myalgias); assess the client’s emotional state for depression, fear, anxiety or hopelessness.<br />Intensity – It is important to quantify pain using a standard pain intensity scale. When clients cannot conceptualize pain using a number, simple word categorizes can be useful (e.g. no pain, mild, moderate, severe).<br />Quality<br />Nociceptive pain are usually related to damage to bones, soft tissues, or internal organs; nociceptive pain includes somatic & visceral pains.<br />Somatic pain is aching, throbbing pain; example arthritis<br />Visceral pain is squeezing, cramping pain; example: pain associated with ulcerative colitis<br />Pattern – pain may be always present for a client; this is often termed baseline pain. Additional pain may occur intermittently that is of rapid onset & greater intensity than the baseline pain; known as breakthrough pain. People at end-of-life often have both types of pain. Cultural beliefs regarding the meaning of pain should be examined<br />ADMINISTRATION OF MEDICATIONS<br />DRUG NOMENCLATURE and FORMS<br />Names<br />Chemical Name – provides an exact description of the drug’s composition. An example of chemical name acetylsalicylic known common as Aspirin<br />Generic Name – is given by the manufacturer who first develops the drug before it receives official approval. Protected by law, the generic name is given before a drug receives official publications.<br />Official Name – is the name under which drug is listed in official publication<br />Trade, Brand or Propriety Name – is the name under which a manufacturer markets.<br />Classification – Nurses categorized medications with similar characteristics by their class. Drug classification indicates the effects on a body system, the symptoms relieved or the desired effect. Each class contains drugs prescribed for similar types of health problems. The physical and chemical composition of drugs within a class is not necessarily the same. A drug may also belong to more than one class. For example, aspirin is an analgesic and antipyretic and an anti-inflammatory drug.<br /> <br />Forms – Drugs are available in a variety of forms preparations. The form of the drug determines its route o administration. For example, a capsule is taken orally and a solution may be given intravenously. The composition drug is designed to enhance its absorption and metabolism within the body. Many drugs are available in several forms such as tablets, capsules, elixirs and suppositories. When administering a medication, the nurse must be certain to give the metabolism in the proper form.<br />Principles in Administering Medications<br />Observe the 7 RIGHTS of Drug Administration:<br />Right Drug<br />Right Dose<br />Right Time<br />Right Route<br />Right Patient<br />Right Recording<br />Right Approach<br />Practice asepsis<br />Nurses who administer medications are responsible for their own actions. Question any order that you can consider incorrect.<br />Be knowledgeable about medications that you administer<br />Keep narcotics & barbiturates in locked place<br />Use only medications that are in clearly labeled containers<br />Return liquid that are cloudy or have changed in color to the pharmacy<br />Before administering a medication, identify the client correctly<br />Do not leave the medication at the bedside<br /> If the client vomits after taking an oral medication, report this to the nurse in charge and/or physician<br /> Preoperative medications are usually discontinued during the post operative period unless ordered to be continued<br /> When a medication is omitted for any reason, record the fact together with the reason<br /> When a medication error is made, report immediately to the nurse in charge and/or physician<br />BASIC HUMAN NEEDS<br />Abraham Maslow – developed the five (5) levels of human needs: <br />Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival<br />Safety and Security Needs – the need for safety has both physical and physiologic aspects<br />Love and Belonging Needs – the third level of needs includes giving and receiving affection, attaining a place in a group and maintaining the feeling of belonging<br />Self-Esteem Needs – the individual needs both self-esteem and esteem from others<br />Self-Actualization – when the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential and realize one’s abilities and qualities<br />Maslow’s Characteristics of a Self-Actualized Person<br />Is realistic, sees life clearly and is objective about his or her observations<br />Judges people correctly<br />Has superior perception, is more decisive<br />Has a clear notion of right or wrong<br />Is usually accurate in predicting future events<br />Understands art, music, politics and philosophy<br />Possesses humility, listens to others carefully<br />Is dedicated to some work, task, duty or vocation<br />Is highly creative, flexible, spontaneous, courageous, <br /> and willing to make mistakes<br />Is open to new ideas<br /> Is self-confident and has self-respect<br /> Has low degree of self-conflict; personality is integrated<br /> Respect self, does not need fame, possesses a feeling of self-control<br />Is highly independent, desires privacy<br /> Can appear remote or detached<br />is friendly, loving and governed more by inner directives than by society<br />Can make decisions contrary to popular opinion<br />Is problem centered rather than self-centered<br />Accepts the world for what it is<br />MEETING OXYGENATION NEEDS<br />Oxygenation – a basic human need & is required to sustain life.<br />Cardiovascular Physiology – the function of the cardiac system is to <br />deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products of cellular metabolism<br />Structure and Function – the heart pumps blood through the pulmonary circulation by way of the right ventricle and to the systemic circulation by way of the left ventricle<br />Myocardial Pump – the “pumping action” of the heart is essential to maintain oxygen delivery<br />Myocardial Blood Flow – to maintain adequate blood flow to the pulmonary and systemic circulations, myocardial blood flow must sufficiently supply oxygen and nutrients to the myocardium itself<br />Coronary Artery Circulation – blood flow to the atria and ventricles does not supply oxygen and nutrients to the myocardium itself. It is the branch of the systemic circulation that supplies oxygen and nutrients and removal of waste from the myocardium<br />Systemic Circulation – the arteries and veins of the systemic circulation deliver nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows from the left ventricle by way of of the aorta and into the large systemic arteries<br />Regulation of Blood Flow – the amount of blood ejected from the left ventricle each minute is the cardiac output. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. For example, during exercise, pregnancy and fever, the cardiac output increases but during sleep, the cardiac output decreases. <br />Steps in the Process of Oxygenation<br />Ventilation – process by which gases are moved into and out of the lungs. Adequate ventilation requires coordination of the muscular and elastic properties of the lung and thorax and intact innervation. The major inspiratory muscle is the “diaphragm” which is innervated by the “phrenic nerve”.<br />Perfusion – the primary function of pulmonary circulation is to move blood to and from the alveolar-capillary membrane so that gas exchange can occur<br />Exchange of Respiratory Gases – respiratory gases are exchanged in the alveoli of the lungs and the capillaries of the body tissues<br />Diffusion – movement of molecules from an area of higher concentration to an area of lower concentration<br />Oxygen Transport – delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of diffusion & capacity of the blood to carry oxygen.<br />Carbon Dioxide Transport – carbon dioxide diffuses into RBCs and I rapidly hydrated into carbonic acid because of the presence of carbonic hydrase<br />MEETING NUTRITIONAL NEEDS<br />Principles of Nutrition<br />Digestion – process by which food substances are changed into forms that can be absorbed through cell membranes<br />Absorption – the taking in of substance by cells or membranes<br />Metabolism – sum of all physical and chemical processes by which a living organism is formed and maintained and by which energy is made available<br />Storage – some nutrients are stored when not used to provide energy; e.g. carbohydrates are stored either as glycogen or as fat<br />Elimination – process of discarding unnecessary substances through evaporation, excretion<br />Nutrients<br />Carbohydrates – the primary sources are plant foods<br />Types of Carbohydrates<br />Simple (sugars) such as glucose, galactose, and fructose<br />Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the diet)<br />Proteins – organic substances made up of amino acids<br />Lipids – organic substances that are insoluble in water but soluble in alcohol and ether.<br />Fatty acids – the basic structural units of all lipids and are either saturated (all the carbon atoms are filled with hydrogen) or unsaturated (could accommodate more hydrogen than it presently contains)<br />Food sources of lipids are animal products (milk, egg yolks and meat) and plants and plant products (seeds, nuts, oils)<br />Vitamins – organic compounds not manufactured in the body and needed in small quantities to catalyze metabolic processes<br />Water-soluble vitamins include C and B-complex vitamins<br />Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the body<br />Minerals – compounds that work with other nutrients in maintaining structure and function of the body<br />Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium and sulfur<br />Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and fluoride<br />The best sources are vegetables, legumes, milk and some meats<br />Water – the body’s most basic nutrient need; it serves as a medium for metabolic reactions within cells and a transporter fro nutrients, waste products and other substances<br />MEETING URINARY ELIMINATION NEEDS<br />Normal Urinary Function<br />Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure continued normal kidney function<br />Urine normally consists of 96% water<br />Solutes found in urine include:<br />Organic solutes: urea, ammonia, uric acid and creatinine<br />Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus<br />Common Assessment Findings<br />Urgency – strong desire to void my be caused by inflammations or infections in the bladder or urethra<br />Dysuria – painful or difficult voiding<br />Frequency – voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hours<br />Hesitancy – undue delay and difficulty in initiating voiding<br />Polyuria – a large volume of urine or output voided at any given time<br />Oliguria – a small volume of urine or output between 100 to 500 mL/24 hr<br />Nocturia – excessive urination at night interrupting sleep<br />Hematuria – RBCs in the urine<br />URINARY CATHETERIZATION<br />Is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine.<br />Purposes<br />To relieve urinary retention<br />To obtain a sterile urine specimen from a woman<br />To measure the amount of residual urine in the bladder<br />To obtain a urine specimen when a specimen cannot secure satisfactory by other means<br />To empty bladder before and during surgery and before certain diagnostic examinations<br />***Several BASIC FACTS about the lower urinary tract system should be borne in mind when considering catheterization.<br />Necessary Equipment for Catheterization<br />Catheters are graded on the French scale according to the size of the lumen. For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not necessary and the size of the lumen is also so small that it increases the length of time necessary for emptying the bladder. Larger catheter distends the urethra and tends to increase the discomfort of the procedure. For male adult, No.18 and No. 20 French catheters usually used, but if this appears to be too large, smaller catheter should be used. No. 8 and No. 10 French catheters are commonly used for children.<br />Preparation of the Patient<br />Adequate exploration<br />Position – dorsal recumbent for the female and supine for the male using a firm mattress or treatment table, Sim’s or lateral position can be an alternate for the female patient<br />Provision for privacy<br />Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the following purposes:<br />The gradual decompression of an over distended bladder<br />For intermittent bladder drainage<br />For continuous bladder drainage<br />An indwelling catheter has a balloon which is inflated after the catheter is inserted into the bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is retained in the bladder.<br />Procedure for Insertion<br />Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon patency. Aspirate the fluid back into the syringe when it is determined that the balloon is patent.<br />Hold the catheter with one hand and inflate the balloon according to the manufacturer’s instructions, as soon as the catheter is in the bladder and urine has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is used<br />If the patient complains of pain after the balloon is inflated, allow it to empty and replace the catheter with another one. The balloon is probably located in the urethra and is causing discomfort owing to distention of the urethra<br />Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder<br />Connect the catheter to the drainage tubing and drainage bag if not already connected<br />Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure there is no tension on the catheter when it is taped to the patient<br />Hang the drainage bag on the frame of the bed below the level of the bladder<br />Caring for the Patient with an Indwelling Catheter<br />Be sure to wash hands before and after caring for a patient with an indwelling catheter<br />Clean the perineal area thoroughly, especially around the meatus, twice a day and after each bowel movement. This helps prevent organisms for entering the bladder<br />Use soap or detergent and water to clean the perineal area and rinse the area well<br />Make sure that the patient maintains a generous fluid intake. This helps prevent infection and irrigates the catheter naturally by increasing urinary output<br />Encourage the patient to be up and about as ordered<br />Record the patient’s intake and output<br />Note the volume and character of urine and record observations carefully<br />Teach the patient the importance of personal hygiene, especially the importance of careful cleaning after having bowel movement and thorough washing of hands frequently<br />Report any signs of infection promptly. These include a burning sensation and irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated temperature and chills<br />Plan to change indwelling catheters only as necessary. The usual length of time between catheter changes varies and can be anywhere from 5 days to 2 weeks. The less often a catheter is changed, the less the likelihood than an infection will develop <br />Removing the Indwelling Catheter and Aftercare of the Patient<br />Be sure the balloon is deflated before attempting to remove the catheter. This may be done by inserting a syringe into the balloon valve or by cutting the balloon valve<br />Have the patient take several deep breaths to help him relax while gently removing the catheter. Wrap the catheter in a towel or disposable, waterproof drape<br />Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed<br />See to it that the patient’s fluid intake is generous and record the patient’s intake and output. Instruct the patient to void into the bedpan or urinal<br />Observe the urine carefully for any signs of abnormality<br />Record and report any usual signs such as discomfort, a burning sensation when voiding, bleeding and changes in vital signs, especially the patient’s temperature. Be alert to any signs of infection and report them promptly<br />MEETING BOWEL ELIMINATION NEEDS<br />Factors that influence Bowel Elimination<br />Age<br />Diet<br />Position<br />Pregnancy<br />Fluid Intake<br />Activity<br />Psychological<br />Personal Habits<br />Pain<br />Medications<br />Surgery/Anesthesia<br />Characteristics of Normal Stool<br />Color – varies from light to dark brown foods & medications may affect color<br />Odor – aromatic, affected by ingested food and person’s bacterial flora<br />Consistency – formed, soft, semi-solid; moist<br />Frequency – varies with diet (about 100 to 400 g/day)<br />Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)<br />Common Bowel Elimination Problems<br />Constipation – abnormal frequency of defecation and abnormal hardening of stools<br />Impaction – accumulated mass of dry feces that cannot be expelled<br />Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence<br />Incontinence – involuntary elimination of feces<br />Flatulence – expulsion of gas from the rectum<br />Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation.<br />TYPES OF ENEMAS<br />Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by distention<br />Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 1000 ml of water<br />Tap water: Give caution o infants or to adults with altered cardiac and renal reserve<br />Saline: For normal saline enemas, use smaller volume of solution<br />Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further preparation<br />Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass<br />Carminative Enema: Provides relief from gaseous distention<br />Astringent Enema: Contracts tissue to control bleeding<br />Key Points: Administering Enema<br />Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, or solutions that are instilled too quickly, can cause cramping and damage to rectal tissues<br />Allow solution to run through the tubing so that air is removed<br />Place client on left side in Sim’s position<br />Lubricate the tip of the tubing with water-soluble lubricant<br />Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children), past the external and internal sphincters<br />Raise the water container no more than 12 to 18 inches above the client<br />Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client will also be able to tolerate and retain a greater volume of solution<br />After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes<br />Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.<br />NASOGASTRIC and INTESTINAL TUBES<br />Nasogastric Tubes<br />Levin Tube – single lumen<br />Suctioning gastric contents<br />Administering tube feedings<br />Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents suction on the gastric mucosa, maintains intermittent suction regardless of suction source)<br />Suctioning gastric contents<br />Maintaining gastric decompression<br />Key Points:<br />Prior to insertion, position the client in High-Fowler’s position if possible.<br />Use a water-soluble lubricant to facilitate insertion<br />Measure the tube from the tip of the client’s nose to the earlobe and from the nose to the xiphoid process to determine the approximate amount of tube to insert to reach the stomach<br />Flex the client’s head slightly forward; this will decrease the chance of entry into the trachea<br />Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress<br />Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares<br />Validating placement of tube.<br />Aspirate gastric contents via a syringe to the end of the tube<br />Measure ph of aspirate fluid<br />Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic sound of air entering the stomach from the tube should be heard<br />Characteristics of nasogastric drainage:<br />Normally is greenish-yellowish, with strands of mucous<br />Coffee-ground drainage – old blood that has been broken down in the stomach<br />Bright red blood – bleeding from the esophagus, the stomach or swallowed from the lungs<br />Foul-smelling (fecal odor) – occurs with reverse peristalsis in bowel obstruction; increase in amount of drainage with obstruction<br />Intestinal Tubes – provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstruction where decompression will occur<br />Types of Intestinal Tubes<br />Cantor and Harris Tubes<br />Approximately 6-10 feet long<br />Single lumen<br />Mercury placed in rubber bag prior to tube insertion<br />Miller-Abbot Tubes<br />Approximately 10 feet long<br />Double lumen<br />One lumen utilized for aspiration of intestinal contents<br />Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stomach<br />Nursing Implications<br />Maintain client on strict NPO<br />Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray<br />After the tube has been placed in the stomach, position client on the right side to facilitae passage through the pyloric valve<br />Advance the tube 2 to 4 inches at regular intervals as indicated by the physician<br />Encourage activity, to facilitate movement of the tube through the intestine<br />Evaluate the type of gastric secretions being aspirated<br />Do not tape or secure the tube until it has reached the desired position<br />Tubes may attached to suction and left in place for several days<br />Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst<br />Removal of the tube depends on the relief of the intestinal obstruction<br />May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth<br />May be allowed to progress through the intestines and expelled via the rectum.<br />LOSS AND GRIEF<br />Loss – absence of an object, person, body part, emotion, idea <br /> or function that was valued<br />Actual loss is identified and verified by others<br />Perceived Loss cannot be verified by others<br />Maturational Loss occurs in normal development<br />Situational Loss occurs without expectations<br />Ultimate Loss (Death) results in a lost for a dying person <br /> as well as for those left behind, can be viewed as a time of growth for all who<br /> experienced it<br />Grieving Process (Theories of Grief, Dying and Mourning)<br />3 Phases of Grief<br />Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence and crying<br />Despair: denial and acceptance occurs simultaneously causing disorganized behavior, characterized by crying and sadness<br />Detachment: loss is realized; characterized by hopelessness, accurately defining the relationship with the lost individual and energy to move forward in life.<br /> <br />Kubler-5 Stages of Grieving<br />Denial – characterized by shock and disbelief, serves as a buffer to mobilize defense mechanism<br />Anger: resistance of the loss occurs, anger is typically directed toward others<br />Bargaining = deals are sought with God or other higher power in an effort to postpone the loss<br />Depression: loss is realized; may talk openly or withdraw.<br />Acceptance: recognition of the loss occurs, disinterest may occur; future thinking may occur.<br /> <br />Worden’s 4 Tasks of Mourning<br />Accept the reality of the loss, the loss is accepted<br />Experience the pain of grief, healthy behaviors are accomplished to assist in the grieving process.<br />Adjust to the environment without the deceased, task are accomplished to reorient the environment, i.e. removing the clothes of the deceased from the closet.<br />Emotionally relocate the deceased and move forward with life, correctly align the past, the present & look towards the future <br /> <br />Anticipatory Grief – expression of the symptoms of grief prior to the actual loss, grief period following the lost may be shortened and the intensity lessened because of the previous of grief; for example, a child told that a family move is expected may grieve about losing friends prior to actually living<br />Complications of Bereavement<br />Chronic Grief – symptoms of grief occur beyond the expected time frame and the severity of symptoms is greater; depression may result.<br />Delayed Grief – when symptoms of grief are not expressed and are suppressed, a delayed reaction of grief occurs, the nurse should discuss the normal process of grieving with the client and give permission to express these symptoms<br />Symptoms of Normal Grief<br />Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and disorganization, preoccupation with the lost object or person, anxiety, depression.<br />Thought patterns include fear, guilt, denial, ambivalence, anger<br />Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia<br />Behaviors include crying, difficulty carrying out activities of daily living and insomia<br /> <br />Nursing Health Promotion (to facilitate mourning)<br />Help client accept that the loss is real by providing sensitive, factual information concerning the loss<br />Encourage the expression of feelings to support people; this build relationships and enhances the grief process<br />Support efforts to live without the diseased person or in the face of disability; this promotes a client’s sense of control as well as a healthy vision of the future<br />Encourage establishment with new relationships to facilitate healing.<br />Allow time to grief, the work of grief may take longer for some; observe for a healthy progression of symptoms. <br />Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that can be expected in the grief process<br />Provide continuing support in the form of the presence for therapeutic communication and resource information.<br />Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of depression, or lack of expression of grief.<br />NURSING NOTES http://www.nursingnotes.info/<br />