course audit on np 1 day 2

8/3/2019 Course Audit on NP 1 Day 2

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1. Eleven key areas of

responsibilities

2. Fields of nursing

3. Roles and functions

F. THE NURSE IN HEALTH CARE


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ROLES OF A PROFESSIONAL NURSE

Caregiver/ Care provider

the traditional and most essential role

functions as nurturer, comforter, provider

mothering actions of the nurse

provides direct care and promotes comfort of

client

activities involves knowledge and sensitivity to

what matters and what is important to clients

show concern for client welfare and acceptance of

the client as a person


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Teacher

provides information and helpsthe client to learn or acquirenew knowledge and technicalskills

encourages compliance withprescribed therapy.

promotes healthy lifestyles

interprets information to theclient


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Counselor

helps client to recognize and cope withstressful psychologic or social problems; todevelop an improve interpersonalrelationships and to promote personalgrowth

provides emotional, intellectual to andpsychologic support

focuses on helping a client to develop newattitudes, feelings and behaviors rather thanpromoting intellectual growth.

encourages the client to look at alternativebehaviors recognize the choices and develop asense of control.


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Change agent

initiate changes or assist clientsto make modifications in

themselves or in the system of

care.


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Client advocate

involves concern for and actions in

behalf of the client to bring about a

change.

promotes what is best for the client,

ensuring that the clients needs are

met and protecting the clients right.

provides explanation in clientslanguage and support clients

decisions.


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Researcher

participates in identifying significant

researchable problems

participates in scientific investigation

and must be a consumer of research

findings

must be aware of the research process,

language of research, a sensitive toissues related to protecting the rights of

human subjects.


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EXPANDED ROLES OF THE NURSE

1. Clinical Specialists- is a nurse

who has completed a masters

degree in specialty and hasconsiderable clinical expertise

in that specialty. She provides

expert care to individuals,

participates in educating health

care professionals andancillary, acts as a clinical

consultant and participates in

research.


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2. Nurse Practitioner- is a nurse

who has completed either as

certificate program or amasters degree in a specialty

and is also certified by the

appropriate specialty

organization. She is skilled at

making nursing assessments,performing P. E., counseling,

teaching and treating minor

and self- limiting illness.


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3. Nurse-midwife- a nurse who

has completed a program in

midwifery; provides prenataland postnatal care and delivers

babies to woman with

uncomplicated pregnancies.


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4. Nurse anesthetist- a nurse

who completed the course of

study in an anesthesia schooland carries out pre-operative

status of clients.


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5. Nurse Educator- A nurse

usually with advanced degree,

who beaches in clinical oreducational settings, teaches

theoretical knowledge, clinical

skills and conduct research.


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6. Nurse Entrepreneur- a nurse

who has an advanced degree,

and manages health-relatedbusiness.


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7. Nurse administrator- a nurse

who functions at various levels

of management in healthsettings; responsible for the

management and

administration of resources and

personnel involved in giving

patient care.


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TEACHING STRATEGIES

1. Explanation and Description

Address cognitive aspect of

learning


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2. One-to-one Discussion

Addresses affective andcognitive learning

3. Answering Questions

Cognitive


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4. Demonstration

Motor

5. Discovery

Cognitive and Affective


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6. Group Discussion

Affective and Cognitive

Sharing feelings during group

dynamics

7. Practice

Motor


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8.Printed and Audiovisual

Material

9. Role-playing

For pediatric and psychiatric

nursing settings


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10.Modeling

What you say is what you do

11. Computer Assisted Learning

Programs

Online review


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II. SAFE AND QUALITY CARE


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Video on the Nursing Process

05Ns_Bp


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A. THE NURSING PROCESS

The Nursing Process was

introduced by LYDIA HALL!

Definition:

The Nursing Process is a

systematic, organized, rationalmethod of planning and

providing individualized,

humanistic nursing care


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PURPOSES OF THE NURSING PROCESS:

To identify health status

Actual health problems

Potential health problems

To establish plans

To deliver specific nursingcare


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CHARACTERISTICS OF

NURSING PROCESS

Goal-oriented and client-

centered

Cyclical (no absolute beginning

and end), dynamic (moving)

rather than static


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Plan of care organized

according to client problems

rather than nursing goals

Basis of prioritizing nursing

activities would be the

problems and not the goals

CHARACTERISTICS OF

NURSING PROCESS


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Adaptation of problem-solving

techniques and principles

Problem-oriented, flexible,

open to new information

CHARACTERISTICS OF

NURSING PROCESS


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Allows creativity of nurse and

patient

CHARACTERISTICS OF

NURSING PROCESS


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BENEFITS DERIVED FROM THE

NURSING PROCESS

Concepts:

Both the nurse and the patient

benefit from the nursing process

Patient obtains greater benefit

Remember:

Nursing process is CLIENT-CENTERED

or PATIENT-CENTERED and NOT

NURSE-CENTERED


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Benefits from Nursing Process:

Improves quality of care

Ensures continuity and appropriatelevel of care

Facilitates client participation

through planning with patient

Enables nurse to maximize resources

Feedback allows nurse to evaluate

care

BENEFITS FROM THE

NURSING PROCESS


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Serves as a framework foraccountability through documentation

Promotes a positive workingatmosphere through collaboration

Helps the nurse define roles to thoseoutside the profession

For job satisfaction

Facilitates professional growth

Avoidance of legal action

Meeting standards of accreditedhospitals

BENEFITS FROM THE

NURSING PROCESS


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PARTS OR COMPONENTS OF

THE NURSING PROCESS

ASSESSMENT PHASE OF THE NURSINGPROCESS

Nursing Activities in the AssessmentPhase

Data collection

Data Organization

DataValidation

Data Recording

IMPORTANT CONCEPT!

No conclusion is developed in theassessment phase


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ASSESSMENT PHASE OF THE

NURSING PROCESS

Purposes of the Assessment

Phase

To create a data base of the

clients response to health and

illness

To determine the nursing care

needs of the patient


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FOUR (4) TYPES OF ASSESSMENT:

1. Initial Assessment

When performed:

At specified time after admission

Where done: Done at the ward

Where Admitted:

At the ward

Purpose of Initial Assessment:

To create a data base for problemidentification

For reference and future comparison


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2. Focus Assessment or On-going

Assessment

When performed:

Integrated throughout the nursing

process

Purpose of On-going Assessment:

To identify problems overlooked earlier

To determine the status of a health

problem (i.e. hydration status every

fifteen minutes)



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3. Emergency Assessment

When done:

During acute physiologic and psychologiccrisis

Where done:

Emergency Room

Comfort Room

Anywhere!!!

On site!!!



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4. Time-Lapsed Assessment

When done:

Several months after initialassessment

Purpose of Time-Lapsed

Assessment

To compare current status of patientwith base line data (initial assessment)



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ASSESSMENT PROCESS

Concepts:

Data is equivalent to information

What is the initial output of the

Assessment Phase?

Data or Recorded Data

Never validated data!!!


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TYPES OF DATA:

1. Subjective or Covert Data

Felt by the patient

During the recording of data,

this should be stated using the

patients own words

These are the symptoms felt bythe patient


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2. Objective or Overt Data

Capable of being observed byuse of senses sight, touch,

smell, taste, hearing

These are the signs which are

observable

TYPES OF DATA:


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SOURCES OF DATA:

1. Primary Source

Patient himself except when: He is unconscious

Patient is a baby

Patient is insane


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2. Secondary Source

Patients record

Health care members

Related literature or journals

Significant others (they becomeprimary source when patient isunconscious

Family or relatives

The person who brought the patient tothe hospital


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3. Environment of the

Patient

Example:

Patient with diabetes mellitus

exhibits acetone breath

Assess for diabetic ketoacidosis


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METHODS OF DATA COLLECTION

Observing

Interviewing

Examining


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1. OBSERVING

1. Observing

It should be deliberate

Exert effort

Two (2) aspects of observation

process:

Noticing the stimuli

Do an interpretation of the stimuli


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TWO (2) TYPES OF INTERVIEW:

1. Directive Type of Interview

Structured

Uses closed-ended questions callingfor specific data

When used:

When you need to elicit specific data

When there is little time available


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Characteristics of Closed-endedquestions:

Yes or No questions

Asks when or asks for the time whenevent happened

Asks how many

Point with finger when asking to provide

clarity

Therefore, they call for highly specificanswers


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2. Non-Directive Type or

Rapport-Building Interview

Uses more open-ended

questions

Advantage is that it allows the

patient to volunteer

information

TWO (2) TYPES OF INTERVIEW:


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TYPES OF INTERVIEW QUESTIONS:

1. Open-Ended Questions

Questions not answerable byyes or no

Questions that elicit

information or explanation


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2. Closed-Ended Questions

Questions answerable by yes

or no

Leading Questions

Phrasing of question suggests

what answer the interviewer isexpecting



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3. Neutral Questions

Phrasing allows patient to

answer with least pressure

Usually NOT addressed to

patient personally (i.e. what is

your opinion about)

Raised as a general topic



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PLANNING THE INTERVIEW SETTING

Concepts:

Before the interview, determine

what information you already

know or what information is

available

An interview is a planned

conversation with a purpose


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An interview is a two-way process

When is it done? When patient is available

When patient is comfortable

Recommended distance from thepatient is three (3) to four (4)feet.

PLANNING THE INTERVIEW SETTING


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STAGES OF THE INTERVIEW

1. Opening Stage

Key Concept!!!

This is the most important part of the

interview

Rationale

What was said and done during the

opening stage sets the tone allthroughout the interview


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2.Body of the Interview

Occurs when patient responds to

questioning

3. Closing Stage

How to close the interview:

Summarizing Technique

STAGES OF THE INTERVIEW


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VALIDATION OF DATA

Act of double-checking the data

Purposes of DataValidation

To ensure the:

Correctness

Completeness

Accuracy of the data


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GUIDELINES IN VALIDATING DATA

Compare subjective and objective data

Be familiar with word usage(particularly if the patient is a child)

Reassess / double-check data which areextremely abnormal

Be sure that your data contains CUESand not INFERENCES

Be sure that your data is FREE OFBIASES

Avoid jumping to conclusions


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DATA RECORDING

Concepts:

Data Recording COMPLETES the

Assessment Phase

Initial Output of the Assessment

Phase is DATA

Final Output of the Assessment Phase

is RECORDED DATA

DIAGNOSING PHASE OF THE


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DIAGNOSING PHASE OF THE

NURSING PROCESS

Activities during the Diagnosing

Phase:

This involves sorting, clustering,analyzing and interpreting data

Concept:

The final output in the Diagnosing

Phase is a NURSING DIAGNOSIS!!!

DIFFERENT TYPES OF


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DIFFERENT TYPES OF

NURSING DIAGNOSES:

1. Actual Nursing Diagnosis

Problem present at the time the

statement was made

DIFFERENT TYPES OF


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2. High-Risk Nursing Diagnosis

A diagnosis that a patient is

more vulnerable or susceptible

compared with others in the

same situation

DIFFERENT TYPES OF

NURSING DIAGNOSES:

DIFFERENT TYPES OF


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3. Possible Nursing Diagnosis

There is an evidence of a health

problem but the causes are NOT

fully understood

DIFFERENT TYPES OF

NURSING DIAGNOSES:


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DOMAINS OF NURSING DIAGNOSIS

Key Concept!

It only includes health

problems that a nurse is

capable and licensed to treat


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PARTS OF A NURSING DIAGNOSIS

1. Problem Statement

Example: FluidVolume Deficit


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2. Presumed Etiology

Example:

related to frequent loss of

bowel movement



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3. Defining Characteristics

Example: as manifested by decreased

skin turgor


ADVANTAGES OF USING STANDARDIZED


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ADVANTAGES OF USING STANDARDIZED

DIAGNOSTIC TERMINOLOGY

Provides professional accountability and

autonomy by defining and describing the

independent areas of practice

Provides effective vehicle of

communication

Provides an organizing principle for

meaningful research

Facilitates continuity and individualized

care

PLANNING PHASE OF THE


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PLANNING PHASE OF THE

NURSING PROCESS

Concept:

Planning means:

Determining ahead of time

Forecasting a course of action


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Key Concept!!!

For your plans to be effective,

involve the patient and the

family


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IMPORTANT CONCEPT!!!

Final output of the Planning

Phase is a NURSING CARE PLAN

or a WRITTEN CARE PLAN


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TYPES OF PLANNING

1. Initial Planning Done by the nurse

When done:

At specified time upon or afteradmission of the patient


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2. On-going Planning

Who are involved: Done by all nurses who worked

with the patient

The patient himself

The family

But primarily, the NURSE

TYPES OF PLANNING


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Purposes of On-going Planning

To determine if the clients healthstatus has changed

To decide which problems to focus onduring the shift

To set priorities for client care duringthe shift

To coordinate the patient care andactivities so that more than oneproblem can be addressed at the same

time


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3. Discharge Planning

Purpose of DischargePlanning

To ensure continuity of care

TYPES OF PLANNING

CHARACTERISTICS OR THE


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CHARACTERISTICS OR THE

PLANNING PROCESS

S Specific

M Measurable

A Attainable

R Realistic

T Time bound


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ACTIVITIES DURING PLANNING PROCESS

Set priorities

Set goals

Identify alternatives of nursing care

Select nursing measures

Write nursing orders (supervisors

do this)

Write the nursing care plan


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PURPOSES OF GOAL-SETTING

To set direction

To provide a time span

To have a criteria for evaluation

To enable the nurse and the patient to

determine whether the problem has

been resolved or not

To help motivate the client and thepatient by providing a sense of

accomplishment


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Key Concept!!!

For your goal to be useful

during evaluation, it should be

stated in BEHAVIORAL TERMS

IMPLEMENTING PHASE OF THE


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IMPLEMENTING PHASE OF THE

NURSING PROCESS

Implementation

Putting the care plan into action

Purpose of Implementation

To carry out planned activities

To help the client


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Concept!!!

The implementation phase ends

upon recording of the care

given and the response of the

patient to that procedure

REQUIREMENTS FOR


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IMPLEMENTATION

Adequate knowledge

Technical Skills

Communication skills

Therapeutic use of self

Right attitude as a requirement

NURSING ACTIVITIES DURING THE


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IMPLEMENTATION PHASE

Reassess the patient

Rationale

To determine if the procedure is still

needed

Determine the need for nursing

assistance

Implement the nursing

strategies



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Communicate the procedure

performed by documenting

the procedure

Understand orders

Clarify / verify doctors orders

Encourage patient toparticipate actively


IMPLEMENTATION PHASE

GUIDELINES FOR IMPLEMENTATION OF


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THE NURSING STRATEGIES

Key Concept!!!

It should be based on scientific

knowledge, research,

professional standards ofpractice (care)

Rationale:

This is done to ensure safe nursing

care

It should be adapted to the

individual patient



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It should always be safe. Do not

compromise

It should be holistic

It should be accompanied by

support, comfort and teaching


THE NURSING STRATEGIES

EVALUATION PHASE OF THE


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EVALUATION PHASE OF THE

NURSING PROCESS

Purpose of the Evaluation Phase

To determine clients progress

To determine the effectiveness

of the care plan

To determine as to what extent

the nursing goals have beenmet


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IMPORTANCE OF DOING AN EVALUATION

It determines if the care plan

will be:

Continued

Modified

Discontinued

ACTIVITIES DURING THE


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ACTIVITIES DURING THE

EVALUATION PHASE

Identify the OUTCOME CRITERIA to be

used as measurement

Gather information (data) relevant

to the outcome criteria

Compare outcome (data) with the

criteria

Assess the reasons for the outcome

Revise the nursing care plan as

needed


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TYPES OF EVALUATION

1. On-going Evaluation

When done:

During or immediately after the

intervention

Importance:

Allows the nurse to decide and

make on-the-spot modification/s

in an intervention


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2. Intermittent Evaluation

When done:

At a specified time

Purpose:

It shows the extent of progress of

the patient

Importance:

Enables the nurse to correct

deficiencies and modify the nursing

care plan

TYPES OF EVALUATION

T E


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3.Terminal Evaluation

When done:

At or immediately before discharge

Importance:

States the status of a healthproblem at the time of discharge

It determines whether the goals are:

Met

Partially met

Unmet

TYPES OF EVALUATION

B BASIC NURSING SKILLS


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B. BASIC NURSING SKILLS

1. Admission and

discharge

1 ADMISSION AND DISCHARGE


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1. ADMISSION AND DISCHARGE

Admission

Entry of a patient into the healthcare facility

Health Care Facility

Any agency that provides healthcare

The patient is usually veryconcerned about health problemsor potential health problems and

the potential outcome oftreatment.


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The first contact with health

care workers is important;

anxiety and fears can belessened

and a positive attitude

regarding the care to be

received can be initiated.


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Admission routines that are

efficient and show appropriate

concern for the patient canease anxiety

and promote cooperation and

positive response to treatment.


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The Nurse can anticipate some

common reactions:

Fear of the unknown

Loss of identity

Disorientation

Separation anxiety

Loneliness


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The Nurse may help reduce the severity

of common reactions by doing what?

Have a warm, caring attitude and be

courteous Show empathy

Treat patients with respect

Maintain their dignity

Involve them in the plan of care

Whenever possible, adjust hospital

routine to meet their desires


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Secure an interpreter when

needed.

Respect the patient as anindividual.

Avoid treating these patients

differently than other patients;

special treatment may be

interpreted as patronizing.


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Do not assume they are angry,

aggressive, or hostile if they

speak loudly or moreemotionally than most patients.

Use titles such as Mr. or

Mrs.


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Never attempt to use ethnic

dialects with patients.

Avoid trying to impresspatients by saying you have

friends of the same racial

background.


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Be attentive to the patients

nonverbal communication.

If you do not understand whata patient is saying, ask for

clarification.


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Information usually includes

Name, address, telephone number

Age, birth date

Social Security number

Next of kin

Insurance company, policynumber

Place of employment

Physicians name

Reason for admission


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ID band is prepared and put on

patients wrist.

Information includes

Patients name

Age

Admitting number

Physicians name

Room number


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Telephone Admission

The day before a planned

admission, a clerk from theadmitting office calls the

patient at home and gathers all

the information needed to

begin the records.


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Emergency Department

People brought to the emergency

department may be admitted

directly to a patient care room or a

special care unit, intensive care

unit, coronary care unit, or burn

unit.

A family member goes to the

admitting office to provide thenecessary information.


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Of appropriate temperature

Have personal care items in

place

Any special equipment should

be placed and ready when the

patient arrives


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Greeting the patient by name and

making the patient feel welcome is

one of the most important aspects of

the admission procedure.

Regardless of the time or activity

occurring on the unit, the PT should

be courteous to, interested in, and

receptive of the new patient.

The new patient should be given an

orientation to the unit and the room


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When the physician usually

makes rounds

Policy on use of side rails

Many hospitals have booklets

for the patient that explain

these routine


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Admitting Procedure on thePatient

Care Unit Check the ID band and verify the

information with the patient.

Assess immediate needs such aspain, shortness of breath, or severe

anxiety.

Introduce roommate, if one ispresent.


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Jewelry, money, and medications

should be given to the family to

take home.

If no family is present

Valuables must be put in the

hospital safe. Follow the hospital

policy.

Some facilities require allmedications brought in by the

patient be sent to the pharmacy to

be identified; they are then

returned to the patient upon

dismissal.


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The patient is usually asked to put

on pajamas or hospital gown; the PT

may need to help the patient

change clothes.

Clothing should be inventoried

along with other personal items the

patient uses.


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TRANSFER


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TRANSFER

The changing condition of a

patient, whether improved or more

critical, may require transfer

either to another unit in the

hospital or to another health careinstitution.

TRANSFER


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The patient transfer requires

thorough preparation and careful

documentation.

Preparation

Explain transfer to patient and

family;

discuss the patients condition andplan of care with the staff of the

receiving unit or facility;

arrangements for transportation.

TRANSFER

TRANSFER


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Documentation of the

patients condition

before and during transfer andadequate communication with

staff receiving patient ensures

continuity of care

TRANSFER


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Ideally, Discharge PlanningBegins Shortly AfterAdmission.

Teach the patient and familyabout the patients illness andits effect on his or her lifestyle.

Provide instructions for home

care.

Communicate dietary oractivity instructions.


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Risk Factors Should Be

Identified.

Older adults

Multisystem disease processes

Major surgical procedure

Chronic or terminal disease

Mental Illness


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Discharge planning involves

multidisciplinary action with

participation by all members of the

health care team, the patient, and

the patients family.

Many larger hospitals have

discharge planners or coordinators;

they orchestrate the discharge

planning.

TRANSITIONAL CARE


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Another approach to

discharge planning using

transition specialists

Transitional specialists begin

discharge planning and usually

makes a home visit before the

patient is discharged.


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Following discharge to the

home, this specialist is available

to patient and family.

It has proved to be cost-

effective and has improved the

quality of care.

DISCHARGE SUMMARY


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DISCHARGE SUMMARY

Includes patients learning

needs, how well they were met,

the patient teaching completed,

short- and long-term goals of

care, referrals made, andcoordinate care plan to be

implemented after discharge


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A patient may require the

services of various disciplines

within a hospital.

The Nurse is often the first to

recognize the patients needs.

In many agencies, a

physicians order is needed fora referral.


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Dietitian

Social worker

Physical therapist

Occupational therapist

Speech therapist

Clinical nurse specialist

Home health care nurse

Respiratory Therapist


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Many hospitals have a form with

written instructions and

teaching documentation for the

patient to sign and acknowledge

understanding of the

instructions.

These instructions serve as a

guide for the patient to use athome.

DAMA


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Discharge: Against Medical

Advice (AMA) Notify the

physician immediately.

If the physician fails to

convince the patient to remain

in the facility, the physician will

ask the patient to sign an AMA

form, releasing the facilityfrom


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legal responsibility for any

medical problems the patient

may experience after

discharge.

Do not detain the patient; this

violates his or her legal rights


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Note the following upon discharge

1. How client left: form of

Transportation

2. With whom he/she left residence

3. Name address phone # where

client is being placed (transferred)

4. Type, amount and dosage of

medication sent with client.

B. BASIC NURSING SKILLS


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2.Vital signs


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There are four vital signs which arestandard in most medical settings:

Body temperature

Pulse rate (or heart rate)

Blood pressure

Respiratory rate

The equipment needed isathermometer, a sphygmomanometer,and a watch.

Though a pulse can often be taken byhand, a stethoscope may be requiredfor a patient with a very weak pulse.

TEMPERATURE


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Oral

Axillary

Rectal


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Oral Method

Most convenient

Most accessible

Nursing Alert!

Applicability is for children

aged six (6

) years and above Not applicable for children

below six (6) years old


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Contraindicated in patients with:

Oral surgery

Mouth breathers

History of convulsive seizures

Unconscious

Incoherent

Irrational

Mentally disrupted

Insane


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Procedure

Nothing Per Orem for about thirty(30) minutes before taking

temperature

No food intake

No drinks

No smoking

No chewing gum

No whistling

No gargling


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Rationale:

Any of the above would alter the

result

Placement:

Under the tongue, beside thefrenulum (right or left)

Total Time:

Two (2) to three (3) minutes


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Axillary Method

Least realiable

Safest method

Nursing Alert!

During application, be sure thataxilla is dry

Dry using a patting motion

Nursing Alert!

Do NOT RUB!!!


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Rationale:

This increases heat due to friction

Rubbing increases blood supply to thearea

Therefore, there will be increase intemperature reading

Rubbing provides a false-positiveelevation of temperature reading

Duration:

In adults nine (9) minutes

In children five (5) minutes


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Rectal Method

Most reliable (except for

tympanic thermometer)

Most accurate (except fortympanic thermometer)

Concept!

If tympanic method is used using atympanic thermometer, the rectal

method is only second most reliable

and second most accurate


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Disadvantage:

Placement on a different site yields adifferent reading

Therefore, ensure that the bulb of the

rectal thermometer rests on themucous membrane

Contraindications:

Hemorrhoids

Rectal Surgery

Certain Cardiac ailments due tostimulation of the vagus nerve;

valsalva maneuver leads toarrhythmias


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Position of Patient when taking thereading:

Sims left position

Sims right position

For Newborn, lift up ankles to keepbuttocks up

In Toddlers, set on prone position onadults lap

Duration:

Two (2) minutes


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Conversion of Centigrade to

Fahrenheit

Centigrade = (5/9)F 32

Centigrade = (F/1.8) 32

Conversion of Fahrenheit to

Centigrade

Fahrenheit = (9/5)C + 32

Fahrenheit = (1.8)C + 32


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Concepts!!!

Peak body temperature occurs

at 12NN to 3PM or 4PM

Lowest body temperature

occurs in the early morning

hours of the day

FEVER


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Normally, the hypothalamus is able toadjust body temperatures between37C to 40C

But due to the presence of pyrogenicmaterials like the following:

Pathogenic microorganisms

Toxins

Foreign substances

Any substance capable of increasingbody temperature

Creates a deficiency of -3C, making aperson enter the FIRST STAGE OFFEVER

FIRST STAGE OF FEVER


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Typical signs and symptoms indicate

the bodys compliance mechanism to

increase and conserve heat:

Chills

Shivering

Gooseflesh

Contraction of arectores pilorum or pilo

arecti muscles

Vasoconstriction

Decreases blood supply to the skin

Cyanotic nail beds


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Key Concept!!!

Patient complains of feeling cold

Sweating will stop because body will

minimizes heat loss

Also called:

Onset Stage

Chill Stage

Cold Stage

This stage is characterized by

low febrile temperatures


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Nursing Management

Key Concept

Aim is to minimize heat loss

Key Concept

Do NOT apply TEPID SPONGE

BATH because this would make

patient progress to SHOCK


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Provide additional clothing asnecessary

Provide additional blankets asnecessary

Provide something warm to drink

These measures would result to agradual increase in body temperature

Question:

When will you start application of TSB?

Answer:

If there is a 1C to 2C increase in bodytemperature


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Second Stage of Fever

Also called:

Coarse Stage of Fever

Peak Stage of Fever

Key Concept! Patient does not feel hot or cold

Skin is warm to touch

Skin is flushed

Fever blisters are present Herpetic lesions

Absence of shivering

Possible dehydration


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Important Concept!!!

For every increase of temperature,there is a corresponding increase inpulse rate

Rationale:

Increase in temperature results in anincrease in pulse rate due toincreased metabolic rate

Increased metabolic rate increasesoxygen demand

Due to increased oxygen demand ofsusceptible brain cells, CONVULSIVESEIZURES may occur. These may alsobe due to irritation of nerve cells FEBRILE CONVULSIONS


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Increased oxygen demand alsoleads to an increase in respiratoryrate

Patient complains of:

Loss of appetite

Myalgia or muscle pains due toincreased catabolism

Nursing Management

Tepid Sponge Bath

Cooling Bed Bath


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Tepid Sponge Bath

Temperature of water is 32C

This temperature is maintainedthroughout the procedure

How to apply:

Done by patting

Rationale:

To avoid friction, which increasestemperature


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Important Concept!

Do NOT use ALCOHOL when applying TSB

Rationale:

Alcohol dries the skin and leads toirritation

Key Concept!

TSB should not be done hurriedly

Rationale:

When done hurriedly, TSB will stimulateshivering

Shivering would lead to increased muscleactivity

Increased muscle activity would lead toincreased temperature


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Cooling Bed Bath

Water temperature will start at

32C

Procedure will go on with gradualdecrease in water temperature

until it is maintained at 18C

Therefore, to achieve this drop in

temperature, utilize ice

Same procedure of application as

in Tepid Sponge Bath


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Types of Fever

1. Intermittent Fever

A fever that is alternated at regularintervals by periods of normal andsubnormal temperature

2. Remittent Fever

Fever alternated by wide range offluctuations in temperature, all of

them are ABOVE NORMAL.

Duration is within a 24-hour period


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3. Relapsing Fever

Short periods of febrile episodesalternated by one (1) to two (2) daysof normal temperature

4. Constant Fever

Minimal fluctuations of temperature,all of which are ABOVE NORMAL

5. Staircase or Spiking Fever

Common in patients with TYPHOIDFEVER

PULSE ASSESSMENT


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Concepts!

If pulse is regular, count or

monitor pulse for thirty (30)seconds and multiply by two

(2). This is legal!

If pulse is irregular, count ormonitor the pulse for one (1)

FULL minute


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Assessment of the Pulse Deficit

This is the most accurate method

Involves two nurses using onewatch

Starts at the same time

Ends at the same time

Comparison of results ensues

Count is done for one (1) fullminute


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Scale in Pulse Assessment

0 - Absent or cannot be felt

1+ - Weak or thready

2+ - Normal

3+ - Grounding

BLOOD PRESURE


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Systolic

Produced by ventricular contraction

Pressure on blood vessels duringdepolarization or ventricularcontraction

Diastolic

Pressure that remains in the walls ofthe blood vessels during relaxationor repolarization or resting


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Auscultatory Method

Uses Korotkoff sound

A popping sound

NOT the heart beat

It is a phenomenon an

unknown phenomenon!


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Determining Amount of Inflation

Using auscultatory method

Ask patient what is his last BPreading and then add 30 40 mmHgfrom last systolic reading.

Deflate gradually rate isapproximately 2 3 mmHg persecond

Alternative auscultatory method

Auscultate for the last sound as yougo up. Then add 30 40 mmHg

Then deflate


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Concepts!!!

Take systolic on loudest sound if patient is anadult

If patient is pediatric or up to ten (10) yearsold, take the first sound, whether it is faint orloud

If, for example, first sound is at 190 mmHgand there is silence up to 140 mmHg and then

there is a sound at 130 mmHg down to 80mmHg then

Use the PALPATORY METHOD in combinationwith the AUSCULTATORY METHOD because

there is an auscultatory gap


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Repeat using:

Auscultatory method

Palpatory method


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How to do the Palpatory Method

Inflate

Determine up to what point to inflate

Palpate pulse

If pulse is absent, add 30 40 mmHg

Deflate

First palpable pulse is true systolicpressure

For diastolic pressure, proceedusing the auscultatory method

Fl h M th d


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Flush Method

Represents the mean blood pressure

Represents the average of the systolic anddiastolic pressures

When done:

When you have a BP apparatus without a stethoscope

Used for pediatric patients

How done:

Inflate up to the point where extremity becomes pale

Deflate slowly and look for a REBOUND FLUSH when

extremity becomes red again

This is the true reading!!

Note that there is only ONE reading!!!


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3. HEALTH ASSESSMENT

METHODS USED FOR ASSESSMENT


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Review of Clinical Record

Client records contain information

collected by many members of the

health care team e.g. demographics,

past medical history, diagnostic testresults and consultations

Reviewing the clients record before

beginning assessment prevents the

nurse from repeating questions

that had been asked already



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Interview

Opening

Body

closing



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Nursing History

Collecting information about the

effect of the clients illness on daily

functioning and the ability of the

patient to cope with the stressor



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Physical Assessment

Systematic collection of information

about the body systems through the

use of inspection, auscultation,

palpation and percussion

Format:Body Systems, Head to Toe,

Focused assessment



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Psychosocial Assessment

Vocational/education/financial

Home and family

Social/leisure/spiritual and cultural

Sexual

Activities of Daily Living

Health Habits

Psychological



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Consultation

The nurse collects data from

multiple sources

(primary/secondary-family

members, support persons,healthcare professionals and

records



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Review of Literature

A professional nurse engages in

continued education to maintain

knowledge of current information

related to healthcare

Reviewing professional journals and

textbooks can help provide

additional data to support or help

analyze the clients database

PHYSICAL

ASSESSMENT


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Purpose

Gather baseline data aboutclients health

Supplement, confirm or refutedata obtained in history

Confirm and identify nursigndiagnosis

Make clinical judgment aboutclients changing health statusand management

PREPARATION:

FOR PA


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Environment requires privacy,

well equipped, well lit.

Equipment Handwashing is done

before handling equipments

Client Psychological Prep.

(reduce anxiety before PA);

Physical prep. (Does the Pt. Need to

use the toilet?)

Positioning for accessibility.Depends on comfort and degree of

wellness

ORDER OF EXAMINATION


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General Survey general

appearance and behaviour, vital

signs, Ht. and Wt.

Review of systems

Head to Toe examination

SKILLS IN PA


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Inspection to detect normalcharacteristics or significantphysical signs. To inspect bodyparts

Inspect for size, shape, color,symmetry, position andabnormalities

Compare each area with the samearea on opposite side

For body cavities use additionallight


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Palpation Using the hands to

make delicate and sensitive

measurements of specific

physical signs.

Detect characteristics such as

texture, temperature and the

perception of movement


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Percussion done by striking

the bodys surface with a

finger, vibration and sounds are

produced.

The vibration is transmitted

through the body tissues and

the character of sounds

depends on the density of the

underlyingtissues


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Auscultation listening to thesound created in the bodyorgans to detect variations

from normal. Some sounds canbe heard with the unassistedear, although most sounds canbe heard only through astethoscope.

Bowel sounds

Breath sounds/Adventitioussounds


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Breath sounds vesicular,

bronchovesicular and bronchial

Adventitious sounds crackles/rales, Rhonchi, Wheeze,

Friction rub


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4. Administration of

medications


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Medication

A substance administered for the

diagnosis, cure, treatment, relief or

prevention of disease.


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Principles in Administering

Medications:

Observe the 10 Rights of

drug administration.


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5 Traditional Rights 5Additional Rights

right client 1. right assessment

right drug 2. right documentation

right dose 3. right to education

right time 4. right evaluation

right route 5. right to refuse


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Right Client

Nurse must do:

verify client check ID bracelet

& room number

have client state his name

distinguish between 2 clientswith same last names


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Right Drug

medication order may be

prescribed by:

Physician

Dentist

Advanced practice registerednurse (APRN)


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Components of a drug order:

date & time the order is written

drug name (generic preferred)

drug dosage

frequency & duration of administration

any special instructions for withholding

or adjusting dosage

physician or other health care

providers signature or name if TO orVO

signature of licensed practitioner

taking TO or VO


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Nurse must do:

check med order is complete &

legible.

know general purpose or action,

dosage & route of drug

compare drug card with drug label

three times.

at time of contact with drug bottle/container

before pouring drug

after pouring drug


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4 Categories of Drug Orders:

Standing Order / Routine Order

ongoing order

may have special instructions tobase administration

include PRN orders

ex. digoxin 0.2 mg PO q.i.d.,maintain blood level at 0.5 2.0mg/ml


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One-time (single) order

given only once, at a specific

time

ex. Cefixime 2mg IM at 7AM

on 12-1-05


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STAT order

given once, immediately

ex.Morphine 2mg IV STAT


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Right Dose

Nurse must do:

Calculate and check drug dose

accurately.

Check, drug package insert or drug

handbook for recommended range

of specific drugs.

Check heparin, insulin and IVdigitalis doses with another nurse.

Stock- method vs Unit-dose method


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Right Time

Nurse must do:

Administer drugs at specified times.

Administer drugs that are affected by

foods, before meals.

Administer drugs that can irritatestomach, with food.

Drug administration may be adjusted tofit schedule of clients lifestyle, &

activities. & diagnostic procedures.

Check expiration date.

Antibiotics should be administered ateven intervals.


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Right Route

Nurse must do:

assess ability to swallow beforegiving oral meds.

Do not crush or mix meds in othersubstances before consultation withphysician or pharmacist

Use aseptic technique whenadministering drugs.

Administer drug at appropriatesites.

Stay with client until oral drugs havebeen swallowed.


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Right Assessment

get baseline data before drug

administration.

Right Documentation


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Immediately record appropriate info

Name, dose, route,time & date, nurses initialor signature

Clients response:

narcotics

analgesics

antiemetics

sedatives

unexpected reactions to meds.

Use correct abbreviations & symbols.


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Right to Education

Client teaching :

therapeutic purpose

side-effects

diet restrictions or requirements

skill of administration

laboratory monitoring

Principle of Informed Consent


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Right Evaluation

clients response to meds.

effectiveness

extent of side-effects or any

adverse reactions.


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Right to Refuse

Nurse must do:

determine, when possible, reason for

refusal.

facilitate pxs compliance.

explain risk for refusing meds &

reinforce the reason for medication.

Refusal should be documented

immediately.

Head nurse or health care provider

should be informed when omission

pose threat to px.


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ALL MEDICATION ERRORS ARE

SERIOUS OR POTENTIALLY

SERIOUS!!!!!!!!

Medication Misadventures include:


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Medication Misadventures include:

administration of wrong medication &IV fluid.

incorrect dose or rate

administration to the wrong patient

incorrect route

incorrect schedule interval

administration of known allergic drugor IV fluid

omission of dose or discontinuation ofmed or IV fluid that was notdiscontinued.


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By harm or not harm to patient

A survey of more than 10,000 physicians

in the United States came to the results

that, on the question "Are there times

when it's acceptable to cover up or avoid

revealing a mistake if that mistake wouldnot cause harm to the patient?", 19%

answeredyes,60% answered no and 21%

answered it depends. On the

question "Are there times when it is

acceptable to cover up or avoid revealing

a mistake if that mistake would

potentially or likely harm the patient?",

2% answered yes, 95% answered noand

3% answered it depends.[72]

ADMINISTRATION


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Administer only those drugs thatyou have prepared.

1. Identify the client by ID band or ID

photo.

2. Offer ice chips when giving badtasting medicine.

3. Assist client to appropriateposition.

4. Provide only liquids allowed on thediet.


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1. Stay with client until meds aretaken.

2. Administer no more than 2.5 to 3ml of solution by IM at one site.

3. Infants receive no more than 1 ml ofsolution by IM at 1 site & no more

than 1 ml subcutaneously. NEVERrecap needles.

4. Give drugs last to client who need

extra assistance.

5. Discard needles & syringes inappropriate containers.

Follow appropriate drug disposal based


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on institution policy.

Discard unused solutions fromampules.

Store appropriately unused solutionsfrom open vials.

Write date & time opened & initials onlabel.

Keep narcotics in a double-lockeddrawer or closet.Med cart locked atall times when nurse is not around.

Keys to narcotics drawer must be keptby the nurse & not stored in drawer.

Avoid contamination of ones own skinor inhalation to minimize chances ofallergy.

C. Recording


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Report drug error immediately to nursemanager & physician. Complete an incidentreport.

Charting: record drug given, dose, time,route & your initials.

Record drugs promptly after given, esp STATdoses.

Record effectiveness & results of medsgiven, esp PRN meds.

Report to physician & record drugs that

were refused with reason for refusal. Record amount of fluid taken with

medications on input & ouput chart.


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Behaviors to Avoid During MedicationAdministration:

Do not be distracted when preparingmeds.

Do not give drugs poured by others.

Do not pour drugs from containerswhose labels are partially removed orhave fallen off.

Do not transfer drugs from one

container to another.

Do not pour drugs into the hand.

Do not give expired medications.


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Do not guess about drugs & drug doses.Ask when in doubt.

Do not use drugs that have sediment,are discolored, or are cloudy (& shldnot be).

Do not leave medications by thebedside or with visitors.

Do not leave prepared medications outof sight.

Do not give drugs if the px says he hasallergies to the drug or drug group.

Do not call the pxs name as the solemeans of identification.


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Do not give drug if the client

states the drug is different

from drug he has been

receiving. Check the order.

Do not recap needles. Use

universal precautions.

FORMS & ROUTES FOR

DRUG ADMINISTRATION


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Tablets & Capsules

oral meds not given to pxs

who are: vomiting

lack gag reflex

comatose

FORMS & ROUTES FOR

DRUG ADMINISTRATION


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Enteric- coated & timed-releasecapsules must be swallowed whole.

Administer irritating drugs with

food to lessen GI discomfort.

Administer drugs on empty stomachif food interferes with absorption.

Drugs given sublingually or bucally

must remain in place until fully

absorbed.

Encourage use of child-resistant

caps.

FORMS & ROUTES FOR

DRUG ADMINISTRATION


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Transdermal

systemic effect

more consistent blood levels &avoid GI absorption problems

associated with oral products.

patches should NOT be cut.


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Liquids

Forms : elixir, emulsions,

suspensions

read label if dilution or shaking

is required.

read the MENISCUS.

refrigerate once reconstituted.


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Topical

Applied to skin with a glove, tongueblade or cotton - tipped applicator.

Apply to clean dry skin when

possible.

Do not contaminate the medicationin a container.

Do not double dipped .

Observed sterile technique whenskin is broken.

Use firm strokes if medication is tobe rubbed in.


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administer drops into center of

the sac

gently press lacrimal duct with

sterile cotton ball or tissue for1 to 2 mins after instillation

keep eyes closed for 1 to 2 mins

following application


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Eye Ointment

1, 2, 3, 4,- same as above

5 . squeeze strip of ointment(abt inch, unless stated

otherwise).

keep eyes close for 2-3 mins.

instruct px for blurred visionfor a short time.

apply at bedtime, if possible.


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Ear Drops

wash hands.

med should be at room temp.

sit up with head tilted slightly toward

unaffected side.

child: pull auricle down & back. (after3yo ,same as adult)

adult: pull up & back.

instill prescribed drops.

do not contaminate dropper.

maintain position for 2-3 minutes.


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Nose Drops & sprays have client blow nose.

tilt head back for drops to reach

frontal sinus.

tilt head to affected side to reachethmoid sinus.

Administer prescribed number of

drops or sprays.

Some sprays, close 1 nostril, tilt

head to closed side & hold breath or

breathe thru nose for 1 minute.

Keep head tilted backward for 5

minutes after instillation.


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Inhalations

Semi-fowlers or high-fowlers

position.

Teach correct use of nebulizer &

inhalers.


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E i t


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Equipment.

Nurses use syringes and needlesto withdraw medications fromampoules and vials.

Syringes

Have three parts: the tip, whichconnects with the needle; thebarrel, or outside part, on which

the scales are printed; and the

plunger which fits inside thebarrel.


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Needles

Have three parts: the hub,

which fits into the syringe; the

cannula, or shaft, which is

attached to the hub; and the

bevel, which is the slanted part

at the tip of the needle

Sl t l th f b l


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Slant or length of bevel

The bevel of the needle may be

short or long. Longer bevels

provide the sharpest needles and

cause less discomfort. They arecommonly used for subcutaneous

and intramuscular injections.

Short bevels are used for

intradermal and intravenous

injections because a long bevel canbecome occluded if it rests against

the side of the blood vessel.

L th f th h ft


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Length of the shaft.

The shaft length of commonly

used needle varies from to 2

inches.

Gauge

The gauge varies from #18 to

#28. The larger the gauge the

smaller the diameter of the shaft.

Smaller gauges produces less tissuetrauma, but larger gauges are

necessary for viscous medications

such as penicillin

ANGLES OF INSERTION FOR

VARIOUS INJECTIONS


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Intradermal (ID)


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Intradermal (ID)

- indicated for allergy and

tuberculin testing and for

vaccination.

SITES:

- inner lower arm

*Left arm- for tuberculin test

* Right arm- for all other test

- Upper chest

- Back, beneath the Scapula

What to observe?


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What to observe?

- less hairy Needle gauge #

- less pigmented - #25,26,27

- less vascularized Needle length

- less keratinized - 3/8, 5/8,1/2

The site are the inner lower arm, upper

chest and back and beneath the


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chest and back, and beneath thescapula.

Indicated for allergy and tuberculintesting

Use the needle gauge 25, 26, 27: needlelength 3/8, 5/8 or

Needle at 1015 degree angle; bevel up.

Inject a small amount of drug slowlyover 3 to 5 seconds to form a wheal or

bleb.

Do not massage the site of injection. Toprevent irritation of the site, and toprevent absorption of the drug into thesubcutaneous.

Subcutaneous vaccines heparin


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Subcutaneous vaccines, heparin,preoperative medication, insulin,

narcotics.

The site:

outer aspect of the upper arms

anterior aspect of the thighs

Abdomen

Scapular areas of the upper back

Ventrogluteal

Dorsogluteal


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(A) The ventrogluteal site is locatedby placing the palm on the greatertrochanter and the index fingertoward the anterosuperior iliacspine.


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(B) The vastus lateralis site is identifiedby dividing the thigh into thirds,horizontally and vertically.


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(C) The deltoid muscle site is located bypalpating the lower edge of theacromion process.

Only small doses of medication shouldbe injected via SC route


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Only small doses of medication shouldbe injected via SC route.

Rotate site of injection to minimizetissue damage.

Needle length and gauge are the same

as for ID injections Use 5/8 needle for adults when the

injection is to administer at 45 degreeangle; is use at a 90 degree angle.

For thin patients:45 degree angle ofneedle

For obese patient: 90 degree angle ofneedle


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For insulin injection:


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For insulin injection:

Do not massage to prevent rapid

absorption which may result to

hypoglycemic reaction.

Always inject insulin at 90 degreesangle to administer the medication

in the pocket between the

subcutaneous and muscle layer.

Adjust the length of the needle

depending on the size of the client.


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For other medications, aspirate

before injection of medication

to check if the blood vessel had

been hit. If blood appears onpulling back of the plunger of

the syringe, remove the needle

and discard the medication and

equipment.


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Intramuscular

Needle length is 1, 1 , 2 toreach the muscle layer

Clean the injection site withalcoholized cotton ball toreduce microorganisms in thearea.

Inject the medication slowly toallow the tissue toaccommodate volume.

Sites:


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Sites:

Ventrogluteal site

The area contains no large nerves, or

blood vessels and less fat. It is fartherfrom the rectal area, so it lesscontaminated.

Position the client in prone or side-lying.

When in prone position, curl the toesinward.


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(A) The ventrogluteal site is locatedby placing the palm on the greater

trochanter and the index fingertoward the anterosuperior iliacspine.

When side-lying position, flex the knee


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When side lying position, flex the kneeand hip. These ensure relaxation of

gluteus muscles and minimize

discomfort during injection.

To locate the site, place the heel of the

hand over the greater trochanter,point the index finger toward the

anterior superior iliac spine, then

abduct the middle (third) finger. The

triangle formed by the index finger,

the third finger and the crest of theilium is the site.

Dorsogluteal site


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Dorsogluteal site Position the client similar to the

ventrogluteal site

The site should not be use in infant

under 3 years , because the glutealmuscles are not well developed yet.

To locate the site, the nurse draw animaginary line from the greater

trochanter to the posterior

superior iliac spine. The injectionsite id lateral and superior to thisline.


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Another method of locatingthis site is to imaginary dividethe buttock into fourquadrants. The upper most

quadrant is the site ofinjection. Palpate the crest of

the ilium to ensure that the siteis high enough.

Avoid hitting the sciatic nerve,

major blood vessel or bone bylocating the site properly.


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(B) The vastus lateralis site is identifiedby dividing the thigh into thirds,horizontally and vertically.

Deltoid site


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Not used often for IM injectionbecause it is relatively smallmuscle and is very close to theradial nerve and radial artery.

To locate the site, palpate the loweredge of the acromion process and

the midpoint on the lateral aspectof the arm that is in line with theaxilla. This is approximately 5 cm

(2 in) or 2 to 3 fingerbreadthsbelow the acromion process.


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(C) The deltoid muscle site is located bypalpating the lower edge of theacromion process.

IM

injection Z tract injection


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j j Used for parenteral iron preparation.

To seal the drug deep into the musclesand prevent permanent staining of

the skin.

Retract the skin laterally, inject themedication slowly. Hold retraction ofskin until the needle is withdrawn

Do not massage the site of injection to

prevent leakage into thesubcutaneous.

GENERAL PRINCIPLES INPARENTERAL ADMINISTRATION OF


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PARENTERAL ADMINISTRATION OFMEDICATIONS

1. Check doctors order.

2. Check the expiration formedication drug potency mayincrease or decrease if outdated.

3. Observe verbal and non-verbalresponses toward receiving

injection. Injection can be painful.client may have anxiety, which canincrease the pain.


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4. Practice asepsis to preventinfection. Apply disposable gloves.

5. Use appropriate needle size. Tominimize tissue injury.

6. Plot the site of injectionproperly. To prevent hitting nerves,blood vessels, bones.

7. Use separate needles for

aspiration and injection ofmedications to prevent tissueirritation.


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8. Introduce air into the vial beforeaspiration. To create a positivepressure within the vial and alloweasy withdrawal of the medication.

9. Allow a small air bubble (0.2 ml)in the syringe to push themedication that may remain.

10. Introduce the needle in quickthrust to lessen discomfort.

11. Either spread or pinch musclewhen introducing the medication.Depending on the size of the client.

12.M

inimized discomfort byapplying cold compress over the


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applying cold compress over theinjection site before introductionof medicati0n to numb nerveendings.

13. Aspirate before theintroduction of medication. Tocheck if blood vessel had been hit.

14. Support the tissue with cottonswabs before withdrawal of needle.

To prevent discomfort of pullingtissues as needle is withdrawn.


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15.Massage the site of

injection to haste absorption.

16. Apply pressure at the site

for few minutes. To preventbleeding.

17. Evaluate effectiveness of

the procedure and make

relevant documentation.

Intravenous


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The nurse administer medicationintravenously by the followingmethod:

As mixture within large volumes ofIV fluids.

By injection of a bolus, or smallvolume, or medication through anexisting intravenous infusion line

or intermittent venous access(heparin or saline lock)

By piggyback infusion of solutioncontaining the prescribed medication


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and a small volume of IV fluid throughan existing IV line.

Most rapid route of absorption ofmedications.

Predictable, therapeutic blood levels ofmedication can be obtained.

The route can be used for clients withcompromised gastrointestinal functionor peripheral circulation.

Large dose of medications can beadministered by this route.


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y

The nurse must closely observe the

client for symptoms of adverse

reactions.

The nurse should double-check the six

rights of safe medication.

If the medication has an antidote, it

must be available during

administration.

When administering potent

medications, the nurse assesses vital

signs before, during and after infusion.

Nursing Interventions in IV Infusion


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Verify the doctors order

Know the type, amount, and

indication of IV therapy.

Practice strict asepsis.

Inform the client and explain the

purpose of IV therapy to alleviate

clients anxiety.

Prime IV tubing to expel air. This

will prevent air embolism.

Clean the insertion site of IV

needlefrom center to the periphery with


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p p yalcoholized cotton ball to preventinfection.

Shave the area of needle insertion if

hairy.

Change the IV tubing every 72hours. To prevent contamination.

Change IV needle insertion site

every 72 hours to preventthrombophlebitis.


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Regulate IV every 15-20

minutes. To ensure

administration of proper

volume of IV fluid as ordered.

Observe for potential

complications.


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Types of IV Fluids

Isotonic solution has the same

concentration as the body fluid

D5W

Na Cl 0.9%

plainRingers lactate

Plain Normosol M

H t i h l


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Hypotonic has lowerconcentration than the body fluids.

NaCl 0.3%

Hypertonic has higherconcentration than the body fluids.

D10W

D50W

D5LR D5NM


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Complication of IV Infusion

Infiltration the needle is out

of nein, and fluids accumulate

in the subcutaneous tissues.

Assessment:

Pain, swelling, skin is cold at

needle site, pallor of the site,

flow rate has decreases or

stops.


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Nursing Intervention:

Change the site of needle

Apply warm compress. This willabsorb edema fluids and reduce

swelling.

Circulatory Overload Results

from administration of


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excessive volume of IV fluids.

Assessment:

Headache

Flushed skin

Rapid pulse

Increase BP

Weight gain

Syncope and faintness


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Pulmonary edema

Increase volume pressure

SOB

Coughing

Tachypnea

shock


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Drug Overload the patient

receives an excessive amount of

fluid containing drugs.

Assessment:

Dizziness

Shock

Fainting

i t ti


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Nursing Intervention

Slow infusion to KVO.

Take vital signs

Notify physician

Superficial Thrombophlebitis it is due

to o0veruse of a vein, irritating

l ti d l t f ti l


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solution or drugs, clot formation, large

bore catheters.

Assessment:

Pain along the course of vein

Vein may feel hard and cordlike

Edema and redness at needle insertion

site.

Arm feels warmer than the other arm

Nursing Intervention:

Change IV site every 72 hours


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Change IV site every 72 hours

Use large veins for irritating fluids.

Stabilize venipuncture at area offlexion.

Apply cold compress immediately

to relieve pain and inflammation;

later with warm compress to

stimulate circulation and

promotion absorption.

Air Embolism Air manages to get

into the circulatory system; 5 ml ofair or more causes air embolism.


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Assessment:

Chest, shoulder, or backpain

Hypotension

Dyspnea

Cyanosis

Tachycardia

Increase venous pressure

Loss of consciousness



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Do not allow IV bottle to rundry

Prime IV tubing beforestarting infusion.

Turn patient to left side in thetrendelenburg position. To allow

air to rise in the right side ofthe heart. This preventpulmonary embolism.

Nerve Damage may result


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Nerve Damage may result

from tying the arm too tightly

to the splint.

Assessment

Numbness of fingers and hands

Nursing Interventions


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Nursing Interventions

Massage the are and move shoulder

through its ROM

Instruct the patient to open and

close hand several times each hour.

Physical therapy may be required

Note: apply splint with the fingers

free to move.

Speed Shock may result from


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Speed Shock may result from

administration of IV push

medication rapidly.

To avoid speed shock, andpossible cardiac arrest, give

most IV push medication over 3

to 5 minutes.

BLOOD TRANSFUSION THERAPY


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Objectives:

To increase circulating blood volumeafter surgery, trauma, or hemorrhage

To increase the number of RBCs and tomaintain hemoglobin levels in clientswith severe anemia

To provide selected cellularcomponents as replacements therapy

(e.g clotting factors, platelets,albumin)

Nursing Interventions:

Verify doctors order. Inform the


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Verify doctor s order. Inform the

client and explain the purpose of

the procedure.

Check for cross matching andtyping. To ensure compatibility

c. Obtain and record baseline vital

signs

d. Practice strict Asepsis

e. At least 2 licensed nurse check

the label of the blood transfusion

Check the following:

Serial number


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Blood component

Blood type

Rh factor

Expiration date

Screening test (VDRL, HBsAg, malarial

smear)

- this is to ensure that the blood is free

from blood-carried diseases and

therefore, safe from transfusion.

Warm blood at room temperature

before transfusion to prevent chills.

Identify client properly Two Nurses

course audit on np 1 day 2

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