Subject: Fundamentalof Nursing

Lecturer:Dr. Aveen Haji Fattah

Lesson objectives

• Discuss historical and contemporary factors

influencing the development of nursing

• Describe the roles of nurses

• Describe the expanded career roles and their

functions

• Describe criteria of a profession and

professionalization of nursing

• Nursing teaching programme

Historical perspectives

Nursing has changed dramatically in response to needs

and influences of society. For a long time it struggled for

autonomy and professionalization. Nursing practice has

been influenced by:

• Women’s roles

• Religion

• War

• Social attitudes

Nursing leaders were nurses who made important

contribution to nursing‘s and women’s history, for

example:

• Florence Nightingale – the founder of modern

nursing

• Clara Barton, Linda Richards, Mary Mahoney,

Lillian Wald, Lavinia Dock, Margaret Sanger, Mary

Breckinridge

Contemporary Nursing Practice

:

Definitions of nursing include

“The unique function of a nurse is to assist the individual,

sick or well, in the performance of those activities

contributing to health or its recovery (or to a peaceful

death) that he would perform unaided if he had the

necessary strength, will or knowledge, and to do this in

such a way as to help him gain independence as rapidly as

possible.”

(Virginia Henderson, 1966)

“Nursing is the protection, promotion and optimization of

health and abilities, preventions of illness and injury,

alleviation of suffering through the diagnosis and

treatment of human response, and advocacy in the care of

individuals, families, communities and populations.”

( ANA, 2003)

Common themes in definitions of nursing are:

Nursing is caring

Nursing is an art

Nursing is a science

Nursing is client centred

Nursing is holistic

Nursing is concerned with health promotion,

health maintenance, and health restoration.

Scope of Nursing

Nurses provide care for three types of clients:

Individuals

Families

Communities

Nursing practice involves four areas:

Promoting health and wellness

Preventing illness

Restoring health

Caring for the dying

Settings for nursing include:

Acute care hospitals, clients’ homes, community

agencies, ambulatory clinics, long-term care facilities

etc.

Nurse’s autonomy in this setting varies. Nurses

provide direct care, teach clients, support clients,

serve as nursing advocates, agents of change,

determine health policies etc.

Nurse practice acts are:

• legal acts for professional nursing practice that guide

nurses’ practice

• Acts that aim to protect the public.

Roles and functions of the nurse

• caregiver

• communicator

• teacher

• client advocate

• counsellor

• change agent

• leader

• manager

• case manager

• research consumer

Socialization to nursing

Socialization is a process by which people:

learn to become members of groups a and society

learn the social rules defining relationships into which

they will enter

Learn how to behave, feel and see the world in a manner

similar to other persons occupying the same role as oneself

The aim of professional socialization is to teach individuals

norms, values, attitudes and behaviours that are essential

for survival of the profession.

Critical values of nursing are:

• developed within nursing educational program

• stated in codes of ethics

• stated in standards of nursing practice

• stated in legal system

Nursing history in Iraq

Health system in Iraq started in early 2o’s of 20th century

when the first Ministry of health was established. During

the 1970s and early 1980s Iraq experienced improvements

in several health outcomes, such as infant mortality and

under-five mortality. During 1990s and early 2000s

situation worsened dramatically and health outcomes

became among the poorest in the region.

The public health system is organized almost

entirely by the Ministries of Health and Departments

of Health.

Private health sector is strong and is

supplementing the weaknesses of public sector

especially in curative services.

Nursing services are organised by the Ministry of

Health (MOH). The current situation in nursing

reflects the isolation and neglect of the past decades.

However, changes, especially in the Kurdistan

Region, such as establishment of Colleges of Nursing

and some professional organisations and

reorganisation of nursing departments at the MOH,

are gradually transforming nursing into profession in

its own right.

Distinguishing nursing from medical profession

The primary differences between nursing and medicine

are in:

• Purpose

• Goal

• Education

• In general, medicine is concerned with the diagnosis

and treatment, nursing with caring for the person in a

variety of health related situations.

• Medicine is concerned with cure, nursing is

concerned with care.

• Nursing involves teaching about health and

prevention of illness and caring for the sick individual.

• Nursing takes place in the community, client’s home, ,

schools, day centres etc.

Nursing ethics

Code of ethics is a formal statement of a group’s ideals

and values. It is a set of ethical principles that:

• Is shared by members of the group

• Reflects their moral judgement over time

• Serves as standard for their professional actions

Nurses are responsible for being familiar with the code

that governs their practice.

Nursing codes of ethics have the following purposes:

• Inform the public about the minimum standards of

the profession and help them understand professional

nursing conduct.

• Provide a sign of profession’s commitment to the

public it serves

• Outline the major ethical considerations of the

profession

• Provide ethical standards for professional behavior

• Guide the profession in self-regulation

• Remind nurses of the special responsibility they

assume when caring for the sick.

Origins of ethical problems in nursing are in:

• Social and technological changes

• Conflicting loyalties and obligations

Making ethical decisions should be rational and

systematic, and based on ethical principles and codes

rather than on emotions, intuition, fixed policies or

precedent (earlier similar occurrence).

Specific ethical issues

• AIDS

• Abortion

• Organ transplantation

• End-of-life issues (advance directives, euthanasia and

assisted suicide, termination of life-sustaining treatment,

withdrawing or withholding food and fluids)

• Allocation of scarce health resources

Concepts of health, wellness, wellbeing and illness

Health is “a state of complete physical, mental, and social

wellbeing, and not merely absence of disease or infirmity.”

Wellness is a state of wellbeing. Basic aspects of wellbeing

include: self-responsibility, an ultimate goal, a dynamic,

growing process, daily decision making in areas of

nutrition, stress management, physical fitness, preventive

health care, and emotional health, and the whole being of

individual.

To realize optimal wellness people must deal with the

factors within each of the following components:

• social

• emotional

• intellectual

• spiritual

• occupational

Variables influencing health status, beliefs and practices

Internal variables are:

• Biologic dimension

• Psychologic dimension

• Cognitive dimension

External variables are:

• Environment

• Standards of living

• Family and cultural beliefs

• Social support networks

Illness and disease

Illness is a highly personal state in which the person’s

physical, emotional, intellectual, social, developmental or

spiritual functioning is thought to be diminished.

Disease is an alteration in body functions resulting in a

reduction of capacities or shortening of normal life span.

Etiology is the causation of the disease.

Acute illness is typically characterised by severe symptoms

of relatively short duration

Chronic illness is one that lasts for an extended period,

usually 6 months or longer and often for the person’s life.

It usually has got periods when symptoms disappear

(remission) and reappear (exacerbation).

Communicating

Communication is any means of exchanging information

or feelings between two or more people. It is a critical

nursing skill.

The communication process involves:

Sender (source-encoder) – a person or a group who wishes

to convey a message to another. Encoding involves the

selection of specific signs or symbols (codes) to transmit a

message.

Message – what is actually said or written, the body

language that accompanies the words, and how the

message is transmitted. Channel is the medium to convey

the message (face-to-face contact, letter, telephone etc.

Receiver (decoder) – is the listener, who must listen,

observe and attend. Decoding means to relate the message

perceived to the receivers’ storehouse of knowledge and

experience and sort out the meaning of the message.

Response (feedback) – is the message that the receiver

returns to the sender.

Modes of communication include:

• Verbal communication -uses spoken or written word

• Non-verbal communication- uses gestures, facial

expressions, touch

Verbal communication is largely conscious because people

chose the words they use.

When choosing words nurses need to consider:

• Pace and intonation

• Simplicity

• Clarity and brevity

• Timing and relevance

• Adaptability

• Credibility

• Humor

Non-verbal communication (body language) is controlled

less consciously than verbal and either reinforces or

contradicts what is actually said. It includes:

• Personal appearance

• Posture and gait

• Facial expressions

• Gestures

Factors influencing the communication process

include:

• Development

• Gender

• Values and perceptions

• Personal space

• Territoriality

• Roles and relationships

• Environment

• Congruence

• Interpersonal attitudes

Therapeutic communication

Therapeutic communication is goal directed

communication that promotes understanding and can help

establish a constructive relationship between the nurse

and the client. Important aspects of therapeutic

communication are:

• Active listening

• Physical attending

Therapeutic communication techniques include:

• Using silence

• Providing general leads

• Being specific and tentative

• Using open-ended questions

• Using touch

• Restating or paraphrasing

• Seeking clarification

• Perception checking or seeking consensual validation

• Offering self

• Giving information

• Acknowledging

• Clarifying time or sequence

• Presenting reality

• Focusing

• Reflecting

• Summarizing and planning

Barriers to effective communication include:

• Failure to listen

• Improperly decoding the client’s intended message

• Placing nurse’s needs above the client’s needs

• Stereotyping

• Agreeing and disagreeing

• Challenging

• Probing

• Testing

• Rejecting

• Changing topics and subjects

• Unwarranted reassurance

• Passing judgment

• Giving common advice

Helping relationship

Nurse-client therapeutic relationship is sometimes called

helping relationship. Aim of helping relationship is to:

• Help clients manage their problems in living more

effectively and develop unused opportunities more fully.

• Help clients become better at helping themselves in

their everyday lives.

Teaching client education

Is a major aspect of nursing practice and an important

independent nursing action.

Teaching is a system of activities intended and

intentionally designed to produce specific learning. Nurses

teach a variety of learners in various settings:

• Teaching clients and their families

• Teaching in the community

• Teaching health personnel

Areas of client education include:

• Promotion of health

• Prevention of illness and injury

• Restoration of health

• Adapting to altered health and function

Learning

Learning is a change in human disposition or

capability that persists and cannot be solely

accounted for by growth.

Learning need is a desire or requirement to

know something that is precisely unknown to the

learner.

Learning theories include:

Behaviorism – nurses identify what is to be

taught, and then immediately identify and reward

correct responses

Cognitivism- nurses recognize the developmental

level of the learner and acknowledge the learners

motivation and environment

Humanism- nurses focus on the feelings and

attitudes of learners, of the importance of individual

in identifying learning needs and in taking

responsibility for them.

Factors affecting learning

Motivation

Readiness

Active involvement

Releance

Feedback

Non-judgmental support

Simple to complex

Repetition

Timing

Environment

Emotions

Physiologic events

Cultural aspects

Psychomotor ability

Internet and health information

The internet is an important source of health information,

and nurses need to know and be able to integrate this

technology into the teaching plans for those clients who

use the internet.

Nurse as educator

Being educator or teacher is important and

primary role for the nurse. Clients and families have

the right to health education in order to make

informed choices about their health.

Assessing

A comprehensive assessment of client’s learning

needs includes data from:

• Nursing history

• Physical assessment

Nursing history provides nurse educator following data:

• Age

• Client’s understanding of health problem

• Health beliefs and practices

• Cultural factors

• Economic factors

• Learning style

• Client’s support system

Other information needed for client education is:

• Readiness to learn

• Motivation

• Health literacy- the ability to read, understand and

act upon health information including such tasks as

comprehending prescriptions labels, appointment slips,

following instructions for diagnostic tests etc.

Asepsis and Infection Control

Asepsis

There are four major categories of microorganisms cause

infection in humans: - bacteria, viruses, fungi, and

parasites.

1. Bacteria: there are two types:

• Commensal bacteria found as normal flora

of healthy humans. These have a significant

protective role by preventing colonization of

pathogenic microorganisms.

• Pathogenic bacteria have greater virulence,

and cause infections

2. Viruses: such as hepatitis B, C viruses and

HIV, influenza viruses.

3. Fungi: include yeasts and molds.

4. Parasites: include protozoa.

Colonization and infection

Colonization is the multiplication of

microorganisms on or within a host that does not

result in cellular injury, an example of colonization is

the normal flora (microorganisms) in the intestines.

Infection is the invasion and multiplication of

pathogenic microorganisms in body tissue that results

in cellular injury. These microorganisms are called

infectious agents. Infectious agents capable of being

transmitted to a client by direct or indirect contact,

through a vehicle or airborne route are called

communicable agents. Diseases produced by these

agents are referred to as communicable diseases.

Nosocomial Infections

Nosocomial infections are infections acquired in the

hospital or other health care facilities that were not

present or incubating at the time of the client’s admission.

Types of Nosocomial Infections:

1. Nosocomial of urinary tract infection.

2. Nosocomial of respiratory tract infection.

3. Nosocomial of blood stream infection.

4. Nosocomial of surgical site infection.

Factors increasing susceptibility to infection:

1. Inadequate primary defenses- (broken skin).

2. Inadequate secondary defenses- (decrease

hemoglobin, leucopenia).

3. Inadequate acquired immunity.

4. Tissue destruction and increased environmental

exposure.

5. Chronic diseases.

6. Elderly.

7. Malnutrition.

8. Invasive procedures.

9. Trauma.

Infection control for health care workers:

1. Hand hygiene (hand washing).

2. Using personal protective equipment such as:

• Gloves

• Mask

• Gown

• Goggles

• Shoe covers

3. Vaccination –such as hepatitis B vaccine

Patient's positions

1. Prone Position: Position lying flat on the abdomen.

Prone position.

2. Dorsal (supine) Position : Position lying flat on the back

Supine position

3. Dorsal recumbent Position:

A dorsal recumbent position is called the back lying position. You lay on your

back with your knees flexed and feet flat on the bed. This position is used to do

medical exams of the vaginal and rectum. A dorsal recumbent position is called

the back lying position. You lay on your back with your knees flexed and feet

flat on the bed. This position is used to do medical exams of the vaginal and

rectum.

Dorsal recumbent

4. Fowler's Position: Head of the bed is raised 45 to 60 degree.

Fowler's Position

5. Semi Fowler's Position: Head of the bed is raised approximately 30

degrees.

Semi Fowler's Position

6. Orthopedic Position: Patient sitting up in bed at 90 degree angle, or resting

in forward tilt while supported by pillow on over bed table.

7. Sims' Position: Patient lies on their side with knee and thigh drawn up

toward the chest

Sims' Position

8. Lithotomy Position: Patient lies supine with hips and knees flexed and

thighs abducted and rotated externally(sometimes feet are in stirrups).

Lithotomy Position

9. Trendelenberg Position: Patient's head is low and the body and legs are on

an inclined plane.

Trendelenberg Position

Knee-chest Position

Position in which the individual rests on the knees and upper part of the chest,

assumed for gynecologic or rectal examination. Also called genupectoral

position.

Knee-chest position

Clinical Uses of Patient Position

Patient Positions: It is important to consider patient age, health status,

mobility, physical condition and energy level and privacy. Many positions need

assisting from others.

1. Standing position- to assess posture, gait and balance.

2. Sitting position- to visualize the upper part of the body, and to assess vital

signs, to assess the head, neck, posterior & anterior thorax, breasts, heart and

upper extremities, and to check extremities reflexes.

3. Supine position- to assess head, neck, anterior thorax, lungs, breasts, heart,

abdomen, extremities and peripheral pulses.

4. Dorsal-Recumbent position- similar to that of supine position in addition to

assessment to perineal area.

5. Prone position- to assess the hip joint, supine, posterior thorax, and for

intramuscular injection.

6. Sim's position- to assess the rectum and vagina.

7. Fowler position- for any condition requires maximal chest expansion as

cardiac or respiratory distress, also for oral hygiene and gastric feeding.

7. Lithotomy position- to assess the female rectum and vagina, and for

delivery.

8. Knee-Chest position- to assess rectum, hemorrhoids, ascitis.

9. Trendlenburg position- for shock and hemorrhage.

People at risk for physical injury

10.Age: children due to lack of experience and knowledge, and elderly people

also can have special problems protecting themselves from injury.

11.Life style: lifestyle factors that place people at risk are:

12.Mobility status: persons who have impaired nobility are obviously prone to

injury.

Vital Signs

Vital signs are measures of various physiological status, often taken by health

professionals, in order to assess the most basic body functions. When these

values are not zero, they indicate that a person is alive.

Are measurements of the body's most basic functions:

1. Body temperature (Temp).

2. Pulse/heart rate.

3. Respiration.

4. Blood pressure (BP).

When to Assess Vital Signs

1. Upon admission to any healthcare agency.

2. Based on agency institutional policy and procedures.

3. Any time there is a change in the patient’s condition.

4. Before and after surgical or invasive diagnostic procedures.

5. Before and after activity that may increase risk.

6. Before and after administering medications that affect cardiovascular or

respiratory functioning.

Assessing Body Temperature

The normal range of the body temperature is between 36.2 to 37.2 Cº.

Pyrexia: A body temperature above the usual range is called pyrexia,

hyperthermia, or ( in lay terms) fever. A very high temperature, e.g. 41Cº ( 105

ºF) is called hyperpyrexia.

Hypothermia : it is a core body temperature below the lower limit of normal.

The ability of hypothalamus to regulate temperature is greatly impaired when

the body temperature falls below 34.5Cº ( 94 ºF), and death usually occurs

when the temperature falls below 34 Cº (93.2 ºF).

Clinical signs of hypothermia

1. Decreased body temperature.

2. Pale, cool, waxy skin.

3. Hypotension.

4. Decrease urine output.

5. Lack of muscle coordination.

6. Disorientation.

7. Drowsiness may progressing to coma.

Sites for Assessing Body Temperature

1. Orally (common way). 37 C° (3 – 5 min).

2. Axillary (safe way). 36 C° + 0.5 C° (10 min).

3. Rectal (accurate reading).37 C° – 0.5 C° (2 – 3 min).

4. Tympanic membrane.

Contraindications of oral thermometer

1. The child under 6 years .

2. Unconscious patients .

3. Psychiatric patients .

4. Patient who cannot breath from his nose

5. Mouth surgery or infection .

6. Patient on oxygen mask.

Contraindications of rectal thermometer

1. With patients who have rectal surgery .

2. With patients who have any rectal disorders ( hemorrhoids. Rectal

fissure..etc.).

3. Patients complain from diarrhea.

Types of Thermometers

1. Electronic thermometer.

2. Glass thermometer.

3. Paper thermometer.

4. Tympanic membrane thermometer.

Pulse

Pulse is a wave of blood created by contraction of the left ventricle of the heart.

The heart is a pulsate pump and the blood enters the arteries with each

heartbeat, causing pressure pulses or pulse waves.

Pulse assessment is the measurement of a pressure pulsation created when the

heart contracts and ejects blood into the aorta.

Characteristics of Pulse

1. Quality.

2. Rate.

3. Rhythm, and

4. Volume (strength or amplitude).

1. Pulse quality refers to the ‘‘feel’’ of the pulse, its rhythm and forcefulness.

2. Pulse rate is an indirect measurement of cardiac output obtained by

counting the number of apical or peripheral pulse waves over a pulse point.

A normal pulse rate for adults is between 60 and 100 beats per minute.

Bradycardia is a heart rate less than 60 beats per minute in an adult.

Tachycardia is a heart rate in excess of 100 beats per minute in an

adult.

3. Pulse rhythm is the regularity of the heartbeat. It describes how evenly the

heart is beating:

Regular (the beats are evenly spaced) or,

Irregular (the beats are not evenly spaced).

Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early,

late, or missed heartbeat.

4. Pulse volume is a measurement of the strength or amplitude of force exerted

by the ejected blood against the arterial wall with each contraction.

It is described as normal (full, easily palpable).

Weak (thready and usually rapid), or

Strong (bounding).

Pulse Volume Scale

SCALE DESCRIPTION

0 Absent pulse1 Weak and thready pulse2 Normal pulse3 Bounding pulse

O

Factors Contribute to Increase Pulse Rate

1. Pain.2. Fever.3. Stress, exercise .4. Bleeding.5. Decrease in blood pressure .6. Some medications as (adrenalin, aminophylline).

Factors May Slow The Pulse

1.Rest .2.Increasing age.3.People with thin body size .4.Some Medications.5.Thyroid gland disturbances .

Pulse Point Assessment

Assessment CriteriaAnatomical locationPulse PointAccessible; used routinely for

infants and when radial is

Inaccessible.

over temporal bone, superior and

lateral to eye.

Temporal

Accessible; used routinely for

infants and during shock or

cardiac arrest when other

peripheral pulses are too weak to

palpate; also used to assess

cranial circulation.

bilateral, under lower jaw in neck

along medial edge of

sternocleidomastoid muscle.

Carotid

Used to auscultate heart sounds

and assess apical-radial deficit.

left midclavicular line at fourth to

fifth intercostal space.

Apical

Used in cardiac arrest for infants,

to assess lower arm

circulation,and to auscultate

blood pressure.

inner aspect between groove of

biceps and triceps muscles at

antecubital fossa.

Brachial

Accessible; used routinely in

adults to assess character of

peripheral pulse.

inner aspect of forearm on thumb

side of wrist.

Radial

Used to assess circulation to ulnar

side of hand and to perform the

Allen's test.

outer aspect of forearm on finger

side of wrist

Ulnar

Used to assess circulation to legs in groin, below inguinal ligament Femoral

and during cardiac arrest.(midpoint between symphysis

pubis and anterosuperior iliac

spine).

Used to assess circulation to legs

and to auscultate leg blood

pressure.

behind knee, at center in popliteal

fossa.

Popliteal

Used to assess circulation to feet.inner aspect of ankle between

Achilles tendon and tibia (below

medial malleolus).

Posterior

tibial

Used to assess circulation to feet.over instep, midpoint between

extension tendons of great and

second toe

Dorsalis

pedis

Peripheral Pulse Assessment

A peripheral pulse, usually the radial pulse, is assessed by palpation

for all individual except:

a. newborns and children up to 2 or 3 years. Apical pulse is assessed

in these clients.

b. very obese or elderly clients, whose radial pulse may be difficult to

palpate. Doppler equipment may be used for these clients, or the

apical pulse is assessed.

c. Individual with heart disease, who require apical pulse assessment.

d. Individuals in whom the circulation to a specific body part must be

assessed, e.g. following leg surgery the pedal ( dorsalis pedis) is

assessed.

Apical Pulse Assessment

Assessment of the apical pulse is indicator for clients whose

peripheral pulse is irregular as well as for clients with known

cardiovascular, pulmonary, and renal diseases. It is commonly

assessed prior to administering medications that effect heart rate. The

apical side is also used to assess the pulse for newborns, infants, and

children up to 2-3 years old.

Apical –Radial Pulse

An apical-radial pulse may need to be assessed for clients with certain

cardiovascular disorders. Normally the apical and radial rates are

identical.

An apical pulse rate greater than a redial pulse rate can indicate that

the thrust of the blood from the heart is too feeble for the wave to be

felt at the peripheral pulse site, or it can indicate the vascular disease

is preventing impulses from being transmitted. Any discrepancy

between the two pulse rates need to be reported promptly. In no

instance is the radial pulse greater than the apical pulse.

Pulse deficit

Pulse deficit is the difference in the apical pulse and the radial pulse. These

should be taken at the same time, which will require that 2 people take the

pulse. One with a stethoscope and one at the wrist. Count for 1 full minute.

Then subtract the radial from the apical. This is the Pulse Deficit.

Respiration

Pulmonary ventilation (breathing ): movement of air in and out of the

lungs.

Inspiration (inhalation) is the act of breathing in.

Expiration (exhalation ) _ is the act of breathing out .

Factors Affecting Respiration

1. Pain, anxiety, exercise .

2. Medications .

3. Trauma .

4. Infection.

5. Respiratory and cardiovascular disease .

6. Alteration in fluids, electrolytes, acid- base balances.

Assessing Respirations Inspection.

Listening with stethoscope.

Monitoring arterial _ blood gas results.

Using a pulse oximeter.

Control of Breathing

Respiration is controlled by:

1. Respiratory center in the medulla oblongata and the Pons of the brain.

2. Chemo receptors located centrally in the medulla in peripherally in the

carotid and aortic bodies.

These centers and receptors respond to changes in the concentration of oxygen (

O2), carbon dioxide ( Co 2), and hydrogen ( H+) levels in the arterial blood.

Characteristics of Normal and Abnormal Breathing Sounds

Eupnea: refers to easy respirations with a normal rate of breaths per

minute that is age specific.

Bradypnea: is a respiratory rate of 10 or fewer breaths per minute.

Hypoventilation: is characterized by shallow respirations.

Tachypnea: is a respiratory rate greater than 24 breaths per minute.

Hyperventilation: is characterized by deep, rapid respirations.

The nurse can also observe alterations in the movement of the chest wall:

Costal (thoracic) breathing: occurs when external intercostal muscles

and the other accessory muscles are used to move the chest upward and

outward.

Diaphragmatic(abdominal) breathing: occurs when the diaphragm

contracts and relaxes as observed by movement of

the abdomen.

Dyspnea: refers to difficulty in breathing as observed by labored or

forced respirations through the use of accessory muscles in the chest and

neck to breathe. Dyspnea clients are acutely aware of their respirations

and complain of shortness of breath.

Apnea : respirations cease for several seconds. Persistent cessation is

called respiratory arrest.

Cheyne –Stockes respiration: respiratory rhythm is irregular,

characterized by alternating periods of apnea and hyperventilation. The

respiratory cycle begins with slow, shallow breaths that gradually

increase to abnormal depth and rapidity. Gradually breathing slows and

becomes shallower, climaxing in a 10 to 20 seconds period of apnea

before respiration resumes.

Kussmaul respiration: respirations are abnormally deep but regular,

similar to hyperventilation. Characteristic of clients with diabetic

ketoacidosis.

Orthopnea: respiratory condition in which a person must sit or stand in

order to breathe deeply or comfortably.

Assessment of respiration includes; Depth [by assessing the degree of excursion or movement in the chest

wall; shallow, deep or normal.

Rhythm.

Rate the nurse observes a full inspiration & expirationwhen counting.

Normal range: 12 – 20 breath / minute

Sites of breathing measurementNormal breathing is slightly observable, effortless, quiet, automatic, and

regular. It can be assessed by observing chest wall expansion and bilateral

symmetrical movement of the thorax.

Another method the nurse can use to assess breathing is to place the back of the

hand next to the client’s nose and mouth to feel the expired air.

IMPORTANT NOTE :

(Nurse must not tell the patient that he or she will assess his

respiration because the patient can control his breathing so that will

give a wrong assessment).

a complete cycle of an inspiration composes one respiration .

Patterns of Respiration

Respiration Desperation

Normal 12 – 20 breath / minute

Tachypnea 24b / min shallow

Bradypnea 10 b / min Regular

Hyperventilation Increased rate and depth

Hypoventilation Decreased rate and depth Irregular

Blood PressureBlood pressure: is the force required by the heart to pump blood from the

ventricles of the heart into the arteries.

It is measured in systolic and diastolic pressure.

Systolic pressure : it is known as the force to pump blood out of the

Diastolic pressure: it is known as relaxation period of the heart

pump (ventricles ).

Sites for measurement of Blood Pressure

The most common site for indirect blood pressure measurement

is the client’s arm over the brachial artery.

When the client's condition prevents auscultation of the brachial artery, the

nurse should assess the blood pressure in the forearm or

leg sites .

When pressure measurements in the upper extremities are not accessible,

the popliteal artery, located behind the knee, becomes the site of choice.

The nurse can also assess the blood pressure in other sites, such as the

radial arteryin the forearm and the posterior tibial or dorsalispedis artery in

the lower leg.

Because it is difficult to auscultate sounds over the radial, tibial, and

dorsalispedis arteries, these sites are usually palpated to obtain a systolic

reading.

The normal BP is 120/ 80 mmHg.

Hypertension: refers to a systolic blood pressure more than 120 mm Hg or

20 to 30 mm Hg more the client’s normal systolic pressure.

Hypotension, refers to a systolic blood pressure less than 90 mm Hg or 20

to 30 mm Hg below the client’s normal systolic pressure.

Factors increasing blood pressure :

1. Age: in older adults, the diastolic pressure often increase as a result of

the reduced compliance of the arteries.

2. Exercise: physical activity increase both the cardiac output and hence

blood pressure, thus, a rest of 20 to 30 minutes following exercise is

indicated before the blood pressure can be reliably assessed.

3. Stress: stimulation of the sympathetic nervous system increases cardiac

output and vasoconstriction of the arterioles, thus increasing the blood

pressure reading, however, severe pain can decrease blood pressure

greatly and cause shock by inhibiting the vasomotor center and

producing vasodilatation.

4. Obesity.

5. Sex: after puberty , females usually have lower blood pressure than

males of the same age, this difference is thought to be due to hormonal

variations. After menopause , women generally have higher blood

pressure than before.

6. Medications: many medications may increase or decrease the blood

pressure.

7. Disease process: any condition affecting the cardiac output, blood

viscosity, and or compliance of the arteries has a direct effect on the

blood pressure.

Selected Conditions Affecting Blood Pressure

Possible causeEffectConditionIncreases metabolic rateIncreaseFeverIncreases cardiac outputIncreaseStressDecrease artery complianceIncreaseArteriosclerosisIncreases peripheral resistanceIncreaseobesityDecreases blood volumeDecreaseHemorrhageDecreases blood viscosityDecreaseLow hematocritIncreases vasodilation and thus decreases

peripheral vascular resistance.

DecreaseExternal heat

Causes vasoconstriction and thus increases

peripheral vascular resistance.

IncreaseExposure to cold

Equipment for Assessing Blood Pressure

Stethoscope and sphygmomanometer.

Electronic or digital devices.

Alcohol cotton swap.

Measurement of blood pressure

When taking a blood pressure using a stethoscope, the nurse identifies five

phases in the series of sound called Korotkoff's sounds.

First, the nurse pumps the cuff up to about 30 mmHg above the point where

the last sound is heard, that is the point when the blood flow in the artery is

stopped.

Then the pressure is released slowly ( 2 to 3 mmHg per sound), while the

nurse observes the pressure readings on the manometer and relates them to

the sounds heard through the stethoscope.

Phases (Korotkoff’s Sounds Correlated to Pressure Dynamics)

Phase I: The period initiated by the first faint clear taping sound. These sound

gradually become more intense.

Phase II: The period during which the sounds have a swishing quality.

Phase III: The period during which the sounds are crisper and more intense.

Phase IV: The period , during which the sounds become muffled and have a

soft, blowing quality.

Phase V: The period where the muffled, blowing sound disappear.

Pulse PressurePulse pressure is the numeric difference between the systolic and diastolic

blood pressure . For example, if the resting blood pressure is 120/80

millimeters of mercury (mm Hg), the pulse pressure is 40 .

a. A pulse pressure within 40 is the normal and healthy pulse pressure .

b. A pulse pressure greater than 40 mm Hg is abnormal. A high pulse pressure

may be a strong predictor of heart problems (valve regurgitation), especially

for older adults.

c. A pulse pressure lower than 40 may mean a patient have poor heart function.

Unit IV: Wound Care and Healing Process:

Wound care and Healing

Wound: is a disruption in the normal integrity of the skin.

Causes of Wound

1. Intentional wounds occur during treatment or therapy. These wounds are

usually made under aseptic conditions. Examples include surgical

incisions and venipunctures.

2. Unintentional wounds are unanticipated and are often the result of

trauma or an accident. These wounds are created in an unsterile

environment and therefore pose a greater risk of infection.

Types of wound

1. Bruise wound: also known as a contusion, results from damage to the

soft tissues and blood vessels, which causes bleeding beneath the skin

surface.

2. Abrasion wound: also known as a scrape or rug burn, results when the

outer layer of skin is scraped or rubbed away. Exposure of nerve endings

makes this type of wound painful, and the presence of debris from the

scraped surface (rug fibers, gravel, sand) makes abrasions highly

susceptible to infection.

3. Laceration wound: cut, or incision is caused by sharp objects such as

knives or glass or from trauma due to a strike from a blunt object that

opens the skin.

4. Avulsion wound: results when the skin or tissue is torn away from the

body, either partially or completely. The bleeding and pain will depend

on the depth of tissue affected.

5. Puncture wound: results when the skin is pierced by a sharp object such

as a pencil, nail, or bullet. If a piece of the object remains in the skin, or if

there is little bleeding due to the depth and location of the puncture,

infection is likely.

Wound healing:

The healthy body has the ability to protect and restore itself. Wound healing

process include:

1. Increase blood supply to the damage area.

2. Walling and removing cellular and foreign debris.

3. Initiating cellular development.

Types of Healing

Tissue may heal by one of three methods, which are characterized

by the degree of tissue loss.

1. Primary intention

healing occurs in wounds that have minimal tissue loss and edges that are

well approximated (closed).

If there are no complications, such as infection, necrosis, or abnormal

scar formation, wound healing occurs with minimal granulation tissue

and scarring.

2. Secondary intention

healing is seen in wounds with extensive tissue loss and wounds in which

the edges cannot be approximated.

The wound is left open, and granulation tissue gradually fills in the

deficit.

Repair time is longer, tissue replacement and scarring are greater, and,

the susceptibility to infection is increased because of the lack of an

epidermal barrier to microorganisms.

3. Tertiary intention healing

also known as delayed or secondary closure, is indicated when

primary closure of a wound is undesirable.

Conditions in which healing by tertiary intention may occur include

poor circulation or infection.

Suturing of the wound is delayed until the problems resolve

and more favorable conditions exist for wound healing.

Phases of wound healing

Hemostasis

Inflammation

Proliferation or Granulation

Remodeling or Maturation

1. Initial phase-Hemostasis ( Defensive Phase):

Immediately after injury; lasts 3 to 6 days

Hemostasis

Phagocytosis

a. Hemostasis, or cessation of bleeding, occurs by vasoconstriction of

large blood vessels in the affected area. Plug and fibrin clot formation.

b. Inflammation is the body’s defensive adaptation to tissue injury and

involves both vascular and cellular responses (phagocytosis).

2. Proliferative Phase ( Proliferation, Granulation and Contraction):

• From post injury day 3 or 4 until day 21.

• Collagen synthesis.

• Granulation tissue formation.

3. Remodeling or Maturation Phase:

• From day 21 until 1 or 2 years post injury.

• Collagen organization.

• Remodeling or contraction.

• Scar stronger.

Kinds of Wound Drainage

Exudates: Material such as fluid and cells that have escaped from blood vessels

during inflammatory process.

Types of exudates

1. Serous Exudate

a. Mostly serum.

b. Watery, clear of cells.

c. E.g. Fluid in a blister.

2. Purulent Exudate

a. Thicker

b. Presence of pus

c. Color varies with organisms.

3. Sanguineous (hemorrhagic) Exudate

a. Large numbers of RBCs

b. Indicates severe damage to capillaries

Mixed Sanguineous (hemorrhagic) Exudate

a. Serosanguineous Exudate : Clear and blood-tinged drainage

b. Purosanguineous Exudate: Pus and blood

Functions of Exudate

1. Dilution of toxins produced by bacteria and dying cells

2. Transport of leukocytes and plasma proteins, including antibodies, to

the site.

3. Transport of bacterial toxins, dead cells, debris, and other products of

inflammation away from the site.

Factors affecting wound healing:

1. Age: Blood circulation and oxygen delivery to the wound, clotting,

inflammatory response, and phagocytosis may be impaired in the very young

and in older adults; thus, the risk of infection is greater. Rate of cell growth

and epithelialization of open wounds is lower with advancing age, so wound

healing is slowed.

2. Nutrition: A balanced diet with adequate amounts of protein,

carbohydrates, fats, vitamins, and minerals is needed to increase the body’s

resistance to pathogens and to decrease the susceptibility of skin and mucous

membranes to infection and trauma.

3. Oxygenation: Decreased arterial oxygen tension alters the synthesis of

collagen and the formation of epithelial cells, causing wounds to heal more

slowly. Reduced hemoglobin levels (anemia) decrease oxygen delivery to

the tissues and interfere with tissue repair.

4. Smoking: Functional hemoglobin levels decrease, impairing oxygenation to

tissues.

5. Drug therapy:

Steroids reduce the inflammatory response and slow collagen synthesis.

Anti-inflammatory drugs suppress protein synthesis, wound

contraction, epithelialization, and inflammation.

Prolonged antibiotic use, with development of resistant strains of

bacteria, may increase the risk of super infection.

6. Diabetes mellitus : Elevated blood glucose levels impair leukocyte function

and phagocytosis. The high-glucose environment is an excellent medium for

the growth of bacterial, fungal, and yeast infections, which lead to delay

wound healing.

Wound complications:

1. Infection

2. Hemorrhage

3. Pain

4. Anxiety

5. Alteration in body image (deformity).

6. Dehiscence.

7. Evisceration.

Assessing the wound:

1. Appearance:

- wound edges must be well approximated

- color of the surrounding tissues must be slightly redness and the wound

edges should be clean

2. wound drainage: a normal inflammatory response is the presence of

exudates, which is composed of fluids and cells that escape from blood

vessels. The exudates may be:

- Serous: clean and watery, from serous portion of the blood

- Purulent: thick, bad odor, composed of dead tissues and live bacteria

(yellow or green).

3. Pain: degree and severity of pain depends on such factors as wound size,

wound site, and the causative agent.

4. Related assessment:

- Patient general condition

- Laboratory tests (infection or not)

- Temperature

- Signs and symptoms of acute hemorrhage, restlessness, thirst, drop

in systolic blood pressure, increase pulse and respiration rates,

decreases in urinary output.

Pressure Ulcers (Decubitus Ulcer)

Is any lesion caused by unrelieved pressure that results in damaging underlying

tissue . it is one of the most common skin disruption. It's incidence in

hospitalized patients. It can occur at any bone prominence of the body.

Factors affecting pressure ulcer development:

1. Immobility: causes prolonged pressure on body area, as unconscious and

paralyzed patients.

2. Inadequate nutritional status: as malnutrition.

3. Moisture of the skin: moisture reduces the skin resistance to trauma,

mainly if pressure is present.

4. Mental status: confused or comatose patients have diminished self-care

abilities and increase the probability of skin break down.

5. Age: older people are greater risk for pressure ulcers because the aging

skin is more susceptible to injury.

6. Friction and shearing.

7. Fecal and urinary incontinence.

8. Diminished sensation.

9. Excessive body heat.

10.Poor lifting and transferring techniques.

11.Incorrect positioning.

12.Hard support surfaces.

13.Incorrect application of pressure-relieving devices.

Stages of Pressure Ulcer Formation

Stage Characteristics

Stage I Non blanch able erythematic signals potential ulceration.

Stage II Partial-thickness skin loss (abrasion, blister, or shallow crater)

involves the epidermis and possibly the dermis.

Stage III

• Full-thickness skin loss involves damage or necrosis of

subcutaneous tissue that may extend down to, but not through,

underlying fascia.

• The ulcer presents clinically as a deep crater with or without

undermining of adjacent tissue.

Stage IV

• There is full-thickness skin loss with tissue necrosis or damage

to muscle, bone, or supporting structures such as tendons or

joint capsules.

• Undermining and sinus tracts may also be present.

Nursing Diagnosis

Impaired skin integrity (altered epidermis and/or dermis) related to skeletal

prominence; chemical substances; mechanical factors such as shearing

forces, pressure, restraint, or physical immobilization, etc.

Impaired tissue integrity related to surgical incision; decreased blood flow;

immobility; mechanical irritants, etc…

Risk for infection related to malnutrition and decreased defense

mechanisms.

Acute pain related to inflammation and infection.

Disturbed body image related to changes in body appearance secondary to

scars, drains, and removal of body parts.

Deficient knowledge (wound care) related to lack of exposure to

information, misinterpretation, and lack of interest in learning.

Wound care

The goal of wound care is to promote tissue repair and regeneration.

A dressing is used as protective cover over the wound, it purpose to:

1. Provide physical, psychological and anesthetic comfort.

2. Remove necrotic tissues.

3. Prevent and control infection.

4. Absorb drainage.

5. Keep the wound moist and therefore enhance epithelialization.

6. Clean the wound or keep it clean.

7. Protect the wound from physical trauma or bacterial invasion.

Unit V: Medication Administration:

Medication Administration

Overview

Safe and accurate administration of medications is one of the nurse's most

important responsibilities when caring for clients. The nurse's judgment is

critical to confirm that the right drug is being given to a client, that it is

administered properly, and that appropriate observations and measurements are

made to evaluate the drug's effect and the client's response.

Medication: Is a substance administered for the diagnosis, cure, treatment,

relief, or prevention of disease.

Factors affecting of drug metabolism

1. Personal attributes (body weight, age, and sex)

2. Physiological factors (state of health or disease process, acid-base

and fluid electrolyte balance)

3. Immunological factors

4. Psychological factors.

5. Illness and disease.

6. Time of administration.

7. Drug tolerance.

8. Rout of drug administration.

9. Developmental factors (pregnancy, Infant, Older people)

10. Diet.

Six Rights of Medication Administration

After paramedics have received the medication or fluid order, they should then

administer the drug in question. In performing drug administration, pre-hospital

care providers adhere to the six rights of medication administration:

1. Right patient

2. Right medication

3. Right dose

4. Right route

5. Right time

6. Right documentation

Basic principle of nurse on drugs administration1. The nurse must know the drug's prescribed dose, method of

administration, actions, expected therapeutic effect, possible interactions

with other drugs, and adverse effects.

2. The nurse must know the institution's administration procedures for the

client's welfare and the nurse's legal protection.

3. The nurse must Review physician's order for completeness the client's

name, date of the order, name of the drug, dose, rout, time of

administration, and the physician's signature.

4. The nurse discusses the medication and its actions with the client;

recheck the medication order if the client disagrees with the dose or the

physician's order.

5. The nurse must check the physician's order against the client's medication

administration record for accuracy.

6. The nurse gives the patient the right to know about the medication he is

receiving and the right to refuse it.

Routes of Administration

A: Enteral Tract Routes

The common enteral routes of administration used in general medical

practice are as follows:

1. Oral (PO): The best, and most convenient, way of administering drugs is

by mouth. Most medical drugs are available in oral preparations. The

effects of oral administration are often not seen until 30 to 45 minutes

after administration.

2. Orogastric/nasogstric tube (OG/NG): This route is generally used for oral

medications when the patient already has the tube in place for other reasons.

3. Sublingual (SL): Some drugs can be administered sublingually (i.e. Under

the tongue). When administered in this fashion, the drug is placed under the

tongue, where it quickly dissolves. The drug is then absorbed into the vast

capillary network present in the mucous membranes.

1. Buccal: Absorption through this route between the cheek and gum is

similar to sublingual absorption.

2. Rectal (PR): Rectal administration may have both local and systemic

effects. It may be necessary to administer some medications rectally,

especially if the patient is nauseated. The rectal route is frequently used

in infants and children, who may not be able to swallow oral

medications. Absorption of rectally administered drugs is generally

somewhat slower than by the oral route.

B: Parenteral Routes

Any method of administration that does not involve passage through the

digestive tract is termed parenteral. Parenteral routes include the following:

1. Topical: Certain drugs can be placed on the skin, where they are slowly

absorbed into the capillary network underneath the skin.

2. Intradermal: Drugs can be injected into the dermal layer of the skin.

3. Intranasal:The drug is aerosolized and instilled in the nose, whereby the

drug is rapidly absorbed through the massive vascular network in the nasal

tissues.

4. Subcutaneou:. With subcutaneous administration, medications are

injected into fatty, subcutaneous tissue under the skin and overlying the

muscle.

5. Intramuscula:. The most commonly used route of parenteral medication

administration is the intramuscular route.

6. Intravenous. Most medications used in emergency medicine are

designed to be administered intravenously.

7. Endotracheal: sometimes it is possible to administer emergency

medications down an endotracheal tube, which permits absorption into the

capillaries of the lungs.

8. Sublingual injection: certain drugs can be injected into the vast capillary

network immediately under the tongue.Lidocaine is the agent most

frequently given by this route.

9. Intracardiac: Injection of a medication directly into the ventricle of

theheart is referred to as intracardiac administration.

10.Intraosseous: When an IV line cannot be started in children under

6 years of age, many emergency medications can be administered

intraosseously. A needle can be placed in the anterior aspect of the

proximal tibia, through which medications and fluids can be

administered.

11.Inhalational: Medications can be administered directly into therespiratory

tree in cases of respiratory distress resulting from reversible airway disease

including asthma and certain types of chronic obstructive pulmonary

disease. These medications are usually nebulized into a water vapor and

breathed with normal respiration.

12. Umbilical: Both the umbilical vein and umbilical artery can provide an

alternative to IV administration in newborns.

13.Vaginal: Medications can be placed into the vagina, where they are

absorbed into surrounding tissues. Most vaginal medications are supplied in

creams or vaginal suppositories. The onset of action is slow, and the effects

are generally limited to the lower female genital tract.

Comparison of Enteral vs. Parenteral Routes

Route Advantages Disadvantages

Enteral

1. Simple.

2. Save.

3. Generally less expensive.

4. Low potential for infection

1. Slow rate of onset.

2. Cannot be given to

unconscious or nauseated

pattern..

3. Absorbed dosage may vary

significantly because of

actions of digestive enzymes

and the condition of the

intestinal tract

Parenteral

1. Rapid onset.

2. Can be given to

unconscious and nauseated

patients.

3. Absorbed dosage and

action are more predictable.

1. Administration often difficult

and painful.

2. Usually more expensive.

3. Side effects usually more

severe Potential for infection.

Non-parenteral Rout Medication Administration

Oral medication administration

Definition: is the most common and convenient type for most clients by which the drug

is swallowed to the stomach, or administrated under the tongue for slow action.

Purpose

1. To provide safe, effective drug therapy with minimal complications and

discomfort.

2. To provide a convenient route for drug therapy.

Advantages

1. It's the easiest, least expensive, safe, and most desirable type of drug to

administration.

2. Has the slowest onset of action because it is absorbed through the gastric

mucosa into the bloodstream for a systemic effect.

3. Can have a local effect (for example, anti-acids)

4. Is supplied in the form of tablets, capsules, enteric-coated tablets, liquids,

syrups, and suspensions

5. Administration of medication by oral rout can be in many approaches

(swallowing, chewing, sublingual and by nasogastric tube NG tube).

Disadvantage

1. Unpleasant taste of the drugs.

2. Irritation of the gastric mucosa.

3. Irregular absorption from the gastrointestinal tract.

4. Slow absorption.

5. Harm to the client's teeth.

6. Is contraindicated in a client who is vomiting or cannot swallow food or fluids,

who is having gastric suctioning, or who lacks mental awareness.

Topical Administering Skin Application

Definition: is the applied of substance to a circumscribed surface area of the body.

Purpose

1. To facilitate absorption through the skin or mucous membranes.

2. Provide local anesthetic effect

3. To stop slow, or prevent microbial growth.

Advantages

1. Is applied externally to the skin or mucous membranes.

2. The pharmaceuticals forms used in topical and skin administration are including

(lotions, liniments, ointments, pastes, powders, patches, creams, gels, jellies,

foams, Aerosol spray).

3. It requires use of sterile supplies and sterile techniques when applied on open skin

lesion such as sterile and applicators.

4. Can create systemic and local effects if absorbed through the skin.

5. Can be applied into body cavities or orifices, such as the urinary bladder,

eyes, ear, nose, rectum, or vagina.

6. Can be administered by inhalation into the respiratory tract by a

nebulizer.

Disadvantage: Not absorbed well (completely)

Administration of vaginal and rectal instillations

Purpose

1. To provide an alternative route of administration.

2. To promote bowel elimination.

3. To treat vaginal infection, pain, or itching (local effect).

4. To treat rectal hemorrhoid and fissure (local effect).

Characteristics

1. It's a safe, alternative method of medication administration.

2. It's usually supplied as a solid cone- or oval shaped mass of medication dissolved

in a wax like substance; body heat melts the wax and release the medication to be

absorbed.

3. Provide a local or systemic effect.

4. Rectal suppository is contraindicated with cases of rectal surgery or active rectal

bleeding.

5. It has many types forms as:

a. Rectal suppository is used mainly when the client is nauseated or vomiting,

this rout dose not irritate the upper GI (Gastrointestinal) tract.

b. Vaginal suppository is used to deliver medication directly when treating

vaginal infection or inflammation.

Administration of Eye(ophthalmic) medication.

Definition: medications that instilled in the form of liquid or ointment and indicated for

ophthalmic use.

Purpose

1. To provide local anesthetic effect.

2. To decrease intraocular pressure.

3. To dilate the pupil for eye examination.

4. To treat ophthalmic infection.

Characteristics of Eye medication administration:

1. It's instilled the medication as a sterile liquid, drops, or an ointment.

2. It's supplied as liquid in a plastic or glass container with a dropper; or as ointment, in

a small tube.

3. Sterile preparation and sterile technique are indicated.

Administration of Ear (otic) medication.

Purpose

1. To relive ear pain.

2. To provide local therapy to reduce inflammation by otic antibiotic medication.

3. To soften ear wax for removed at later time.

Characteristics of Ear medication administration

1. It's supplied as drops in plastic or glass container with dropper.

2. Requires a sterile technique to instill medication special if tympanic membrane is

damaged.

Administration of nasal medication

Definition: medications that instilled for shrink swollen mucous membranes, loosen

secretion and facilitate drainage or to treat infection of sinuses.

Characteristics of nasal medication administration:

1. Nasal drops are used to treat sinus infection.

2. Small doses are needed.

3. Nebulizer bronchodilator medication can be administrated in emergency cases.

Parenteral Rout Medication Administration

Parenteral medication: is the rout by which injections are used to instill

medications into body tissues. Injected drugs act more quickly than oral

medications because they reach the bloodstream either directly or by rapid

absorption through the tissues, thus the client's condition can change rapidly.

Parenteral drugs can be administered through four different routes:

1. Intradermal (ID) is an injection into the dermis.

2. Subcutaneous is an injection into the subcutaneous tissue.

3. Intramuscular (IM) is an injection into the muscle.

4. Intravenous (IV) is an injection into a vein.

only five intramuscular injection sites that allow for administration with lowest risk of damage to adjacent nerves and blood vessels

injection sites LocationDeltoid m. Locate on upper arm, lateral aspect

Ventroglutea m. located on the side of the hip over gluteus

muscle between anterior and superior spines of

the iliac crest.

Dorsogluteal m. Located over gluteus minimum and edge of

gluteus maximum muscles in upper outer

quadrant .

Vastuslateralis m. located on mid thigh, lateral aspect.

Rectus femoral m. located on mid thigh, anterior aspect.

I: Intramuscular Injection( IM)

It is an injection of medications into the muscle.

Sites selected for Intramuscular injection.

1. Ventrogluteal muscle.

Involves the gluteus Medias and minimums it is situated deep and away from

major nerves and blood vessels and is a safe site for all clients.

It's the preferred injection site for adults and for children younger than 7 months.

It lies over the gluteus minimums, and it preferred site for (IM) injection because

the area had no large nerve or blood vessels, provides greatest thickness of

muscle, no fat and no bone.

2. Dorsogluteal muscle

It is composed of the thick gluteal muscle of the buttocks.

the Dorsogluteal site can be used for adult and children with well develop gluteal

muscle witch develop by walking.

The muscle is in the posterior superior iliac spine, the injection site is then lateral

and superior site by positioning the patient on prone position or side – lying

position.

Dorsogluteal m

3. Deltoid muscle

The deltoid muscle is in the edge of the acromion process, which forms the base

of a triangle in line with the midpoint of the lateral aspect of the upper arm.

The injection site is in the center of the triangle, about 2.5 to 5 cm (1 to 2 inches)

below the acromion process.

Is easily accessible, the muscle is not well developed in many adults.

Should be use this site only for small medication volumes (0.5 to 1.0 ml) and

when other sites are inaccessible because of dressings or casts.

Deltoid muscle

4. Vast us lateral is muscle

It is located on the anterior lateral aspect of the thigh; in an adult it extends from a

Handbreadth above the knee to a handbreadth below the greater trochanter of the

femur.

The middle third of the muscle is the suggested site for injection.

The width of the muscle usually extends from the midline of the thigh to the

midline of the thigh's outer side.

This injection site used in the adult client and is the preferred site for infants

under 7 months; the muscle is thick and well developed.

5. Rectus femur is muscle.

The muscle belong to quadriceps muscle group it is used only occasionally for

(IM) injection. It is situated on the anterior aspect of the thigh; its advantage the

patient can reach this site easily. Disadvantage is considerable discomfort for

some people.

Advantage of Intramuscular Injection (IM)

1. Muscle is less sensitive to irritating and viscous drugs.

2. A normal, well-developed adult client can safely tolerate as much as

4 ml of medication in larger muscles such as the gluteus medius

without discomfort than subcutaneous tissue.

3. Older infants and small children (e.g., under the age of 2) receiving

IM injections should receive no more than 1 ml of medication.

4. Safe method than other parenteral administration rout.

5. Slow action of medication can be achieved by this rout of

administration.

6. Some medication need to absorbed slowly and harm if given

intravenous such as oily hormone, long acting penicillin.

Disadvantage of Intramuscular Injection (IM)

1. Tissue injury (burn, wound).

2. Presence of nodules.

3. Lumps.

4. Abscesses.

5. Tenderness.

6. Other pathology such as (viral hepatitis B), (cross infection) .

7. Sciatic nerve injury (nerve damage).

8. Sterile abscess.

9. Gangrene.

II: Subcutaneous Injection( SC )

Depositing medication into the loose connective tissue underlying the dermis

which is not richly supplied with blood vessels muscles; thus drug are not

absorbed as quickly as those given intramuscularly.

Sites selected for SC injection.

1. Outer aspect of the upper arms.

2. Outer aspects of the abdomen below the costal margin to the iliac crests.

3. The anterior aspects of the thigh.

4. The scapular areas of the upper back

5. Upper ventrogluteal and dorsogluteal areas.

Advantage of SC injection

1. Drug given subcutaneously are isotonic, nonirritating, no viscous, and

water soluble, example of medication given SC (epinephrine, heparin,

insulin, tetanus toxoid, allergy medications, vaccine, narcotics and

heparin).

2. Small doses of medication (0.5 – 1 ml) should be given SC.

3. Area of injection can easily accessible.

4. Patient can do self – administration SC injection (Insulin).

5. Multiple areas of injections may be rotated to avoid drug administration

complication.

6. Needle 25 gauge ⅝ inches with medium bevel inserted at 45° degree

angle.

Disadvantage of Subcutaneous Injection (SC) administration:

1- Tissue is sensitive to irritating solution and large volume of medication.

2- Medication collecting within the tissues can cause sterile abscesses witch

appear as hardened, painful lump.

III: Intradermal Injection (ID)

It is the administration of a drug into the dermal layer of the skin just beneath

the epidermis.

Sites selected for Intradermal injection

1. Inner aspect of lower arm.

2. Upper site of chest.

3. Back site of chest beneath the scapulae.

4. Commonly the left arm is used for tuberculin test and the right arm is used

for all other test.

Characteristics Intradermal of Injection (ID) administration (Advantage)This

method is used for skin test (tuberculin test) and allergy test.

1. Drug absorption occurs slowly.

2. Common used to antibiotic screening test.

3. Tuberculin syringe 1 ml and with needle (¼ - ½ inches) 26 or 27 gauge is used.

4. The needle inserted at 15 ° degree angle of injection

5. Small amount of medication (0.01 – 0.1ml) are injected intradermally.

6. Bleb should be appearing after needle withdrawal.

Disadvantage of Intradermal Injection (ID) administration

1. Negative result if bleb does not appear or if the site bleeds after injection.

2. Irritation of skin due to large amount of drug administration.

IV: Intravenous Injection ( IV)

It is the administration of medication to the client's bloodstream directly by the

vein.

Characteristics Intravenous of Injection (IV) administration (Advantage)

1. When rapid effect is required.

2. Rout is appropriate when medications are too irritating to the tissue when

given by other routes.

3. When there are contraindications to give medication by other rout such as

abscesses on gluteal muscles occur.

4. When large volume infusion or medication are indicated.

5. When there are multi dose of drug administration for long period.

6. Easy to perform venipunctures by needle to administration of medication

or by introduce continuous line as cannula.Disadvantage of Intravenous Injection (IV) administration

1. Rapid severe reactions to the medication (anaphylactic shock).

2. Infection transmission.

3. Fluid volume overload.

4. Transmission of infection by contaminated syringe such as (HIV, viral

hepatitis B).

5. Thrombophlebitis repeated injection on the same vein.

Angle of Injections

Drugs orders

All orders should be written clearly and legibly, and the drug

order should contain seven parts:

1. The name of the client.

2. The date and time when the order is written.

3. The name of the drug to be administered.

4. The dosage.

5. The route by which it is to be administered and special directives about its

administration.

6. The time of administration and frequency.

7. The signature of the prescribing practitioner writing the order (e.g., the

prescribing practitioner or advanced practice registered nurse).

Medication Administration and Documentation

Record all information concerning the patient and medication including:

a. Indication for drug administration

b. Dosage and route delivered

c. Patient response to the medication, Both positive and negative.

Equipment of Parenteral drugs administration

A: Syringe: A syringe consists of a cylindrical barrel, a tip designed to fit the

hub of a hypodermic needle, and a close-fitting plunger.

Characteristics of syringe:

1. Syringes are single -use and disposable or descried.

2. They are packaged separately, with or without a sterile needle, in a paper

wrapper or rigid plastic container.

3. Syringes in general classified as (non-Luer-lok) or (Luer-lok) on the

design of the syringe tip.

4. Syringe comes in various sizes, ranging from (1- 60ml) in capacity.

5. Syringe has scales along the barrel called (Milliliter), (Unit).

6. Syringe are used to administration of medication, or liquid food by

Nasogastric tube or used for diagnostic measures such as pull-up sample

of blood or abscess.

B: Needles: A needle has 3 parts: the hub, the shift, and the bevel.

Characteristics of needles:

1. Needles come in sheaths to allow flexibility in choosing the right needle

for a client.

2. Needles kept in sterile technique with cap intact.

3. Gentle force is used in dealing with needle.

4. Size of needles varies in length from ¼ inch to 3 inches. (1inch to 1½

inches for IM injection, ⅜ to ⅝ inches for SC or ID injection,

5. As the needles gauge gets smaller the needle diameter becomes larger.

6. Selection of needles gauge depends on the viscosity of fluid.

7. Chooses of needles length according to the client's size and weight and

type of tissue into which the drugs is to be injected.

Principle of prevention needles – stick injury.

1. Use strict aseptic technique during all steps of preparation and

administration.

2. Avoid touching the tip of the needle, the inside of the barrel, the

shaft of the plunger, or the needle with an unsterile object.

3. Protect the nurse's fingers and face from being cut by glass of

ampoule through place a piece of sterile gauze between thumb and

the ampule neck or around the ampule neck.

4. Perform hand hygiene to reduce transmission of microorganisms.

5. Cleans site of injection with antiseptic swab from center and rotate

outward in circular direction to prevent insertion of microorganism

inside human body.

6. Discard equipment in appropriate area (disposal container).

7. Careful insert the needle into the upright vial through the center of

the rubber cap.

8. Never bend or break needles before disposal.

9. Recap used needles under specified circumstance by inserting the

needle into cap using one hand.

Part VIII: Blood Transfusion

Blood transfusion (BT) therapy involves transfusing whole blood or blood

components (specific portion or fraction of blood lacking in patient). Learn the

concepts behind blood transfusion therapy and the nursing management and

interventions before, during and after the therapy.

Objectives of BT

1. To increase circulating blood volume after surgery, trauma, or hemorrhage.

2. to increase the number of RBC s and to maintain hemoglobin levels in

clients with anemia.

3. to provide selected cellular components as replacements therapy ( e.g.

clotting factors, platelets, albumin).

Principles of blood transfusion therapy

1. Whole blood transfusion

Generally indicated only for patients who need both increased oxygen-carrying

capacity and restoration of blood volume when there is no time to prepare or

obtain the specific blood components needed.

2. Packed RBCs

Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a

maximum of 4 hours, it may be necessary for the blood bank to divide a unit

into smaller volumes, providing proper refrigeration of remaining blood until

needed. One unit of packed red cells should raise hemoglobin approximately

1%, hematocrit 3%.

3. Platelets

Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each

unit of platelets should raise the recipient’s platelet count by 6000 to

10,000/mm3: however, poor incremental increases occur with all immunization

from previous transfusions, bleeding, fever, infection, autoimmune destruction,

and hypertension.

4. Granulocytes

May be beneficial in selected population of infected, severely granulocytopenic

patients not responding to antibiotic therapy and who are expected to

experienced prolonged suppressed granulocyte production.

5. Plasma

Fresh frozen plasma should be administered as rapidly as tolerated because

coagulation factors become unstable after thawing.

6. Albumin

Indicated to expand to blood volume of patients in hypovolemic shock and to

elevate level of circulating albumin in patients with hypoalbuminemia.

7. Cryoprecipitate

Indicated for treatment of hemophilia A, Von Willebrand’s disease,

disseminated intravascular coagulation (DIC), and uremic bleeding.

8. Factor IX concentrate

Indicated for treatment of hemophilia B; carries a high risk of hepatitis because

it requires pooling from many donors.

9. Factor VIII concentrate

Indicated for treatment of hemophilia A; heat-treated product decreases the risk

of hepatitis and HIV transmission.

10. Prothrombin complex

Indicated in congenital or acquired deficiencies of these factors.

Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components.

2. Provides optimal therapeutic benefit while reducing risk of volume overload.

3. Increases availability of needed blood products to larger population.

Complications of Blood Transfusion

1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor

antibody, which reacts with recipient antigen.

Assess for:

Flushing Rash, hives Pruritus Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white

cells, platelets or plasma proteins. This is the most symptomatic complication of

blood transfusion

Assess for:

Sudden chills and fever

Flushing

Headache

Anxiety

3. Septic Reaction – it is caused by the transfusion of blood or components

contaminated with bacteria.

Assess for:

Rapid onset of chills

Vomiting

Marked Hypotension

High fever

4. Circulatory Overload – it is caused by administration of blood volume at a

rate greater than the circulatory system can accommodate.

Assess for:

Rise in venous pressure

Dyspnea

Crackles or rales

Distended neck vein

Cough

Elevated BP

5. Hemolytic reaction - it is caused by infusion of incompatible blood products.

Assess for:

Low back pain (first sign). This is due to inflammatory response of the

kidneys to incompatible blood.

Chills

Feeling of fullness

Tachycardia

Flushing

Tachypnea

Hypotension

Bleeding

Vascular collapse

Acute renal failure

Nursing Care Plan for Blood Transfusion

A: Assessment findings

1. Clinical manifestations of transfusions complications vary depending on the

precipitating factor.

2. Signs and symptoms of hemolytic transfusion reaction include:

1. Fever, Chills.

2. low back pain, flank pain.

3. headache

4. nausea

5. flushing

6. tachycardia. tachypnea

7. hypotension

8. hemoglobinuria (cola-colored urine)

B: Possible Nursing Diagnosis

Ineffective breathing pattern

Decreased Cardiac Output

Fluid Volume Deficit

Fluid Volume Excess

Impaired Gas Exchange

Hyperthermia

Hypothermia

High Risk for Infection

High Risk for Injury

Pain

Impaired Skin Integrity

Altered Tissue Perfusion.

C: Planning and Implementation

1. Help prevent transfusion reaction by, verifying patient identification

beginning with type and cross match sample collection and labeling to

double check blood product and patient identification prior to transfusion.

2. Inspecting the blood product for any gas bubbles, clothing, or abnormal color

before administration.

3. Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient

closely, particularly during the first 15 minutes (severe reactions usually

manifest within 15 minutes after the start of transfusion).

4. Transfusing blood within 4 hours, and changing blood tubing every 4 hours

to minimize the risk of bacterial growth at warm room temperatures.

5. Preventing infectious disease transmission through careful donor screening or

performing pretest available to identify selected infectious agents.

6. Preventing hypothermia by warming blood unit to 37 C before transfusion.

7. On detecting any signs or symptoms of reaction:

Stop the transfusion immediately, and notify the physician.

Disconnect the transfusion set-but keep the IV line open with 0.9% saline

to provide access for possible IV drug infusion.

Send the blood bag and tubing to the blood bank for repeat typing and

culture.

Draw another blood sample for plasma hemoglobin, culture, and retyping.

Collect a urine sample as soon as possible for hemoglobin determination.

Nursing Interventions for Complications

If blood transfusion reaction occurs:

1. Stop the Transfusion Immediately.

2. Start IV line (0.9% Na Cl)

3. Place the client in fowler’s position if with SOB and administer O2 therapy.

4. The nurse remains with the client, observing signs and symptoms and

monitoring vital signs as often as every 5 minutes.

5. Notify the physician immediately.

6. The nurse prepares to administer emergency drugs such as antihistamines,

vasopressor, fluids, and steroids as per physician’s order or protocol.

7. Obtain a urine specimen and send to the laboratory to determine presence of

hemoglobin as a result of RBC hemolysis.

8. Blood container, tubing, attached label, and transfusion record are saved and

returned to the laboratory for analysis.

Nursing Procedure of blood transfusion

The following is a step-by-step checklist of things to do and other

responsibilities to ensure proper blood transfusion and prevent any unwanted

reactions and errors.

1. Verify the physician’s written order and make a treatment card according to

hospital policy

2. Observe the 10 Rs when preparing and administering any blood or blood

components

3. Explain the procedure/rationale for giving blood transfusion to reassure

patient and significant others and secure consent. Get patient histories

regarding previous transfusion.

4. Explain the importance of the benefits on Voluntary Blood Donation (RA

7719- National Blood Service Act of 1994).

5. Request prescribed blood/blood components from blood bank to include

blood typing and cross matching and blood result of transmissible Disease.

6. Using a clean lined tray, get compatible blood from hospital blood bank.

7. Wrap blood bag with clean towel and keep it at room temperature.

8. Have a doctor and a nurse assess patient’s condition. Countercheck the

compatible blood to be transfused against the cross matching sheet noting the

ABO grouping and RH, serial number of each blood unit, and expiry date

with the blood bag label and other laboratory blood exams as required before

transfusion.

9. Get the baseline vital signs- BP, RR, and Temperature before transfusion.

Refer to MD accordingly.

10.Give pre-meds 30 minutes before transfusion as prescribed.

11.Do hand hygiene before and after the procedure

12.Prepare equipment needed for BT (IV injection tray, compatible BT set, IV

catheter/ needle G 19/19, plaster, tourniquet, blood, blood components to be

transfused, Plain NSS 500cc, IV set, needle gauge 18 (only if needed), IV

hook, gloves, sterile 2×2 gauze or transplant dressing, etc.

13.If main IV fluid is with dextrose 5% initiate an IV line with appropriate IV

catheter with Plain NSS on another site, anchor catheter properly and regulate

IV drops.

14.Open compatible blood set aseptically and close the roller clamp. Spike blood

bag carefully; fill the drip chamber at least half full; prime tubing and remove

air bubbles (if any). Use needle g.18 or 19 for side drip (for adults) or g.22

for pediatric (if blood is given to the Y-injection port, the gauge of the needle

is disregarded).

15.Transfuse the blood via the injection port and regulate at 10-15 drips/min

initially for the first 15 minutes of transfusion and refer immediately to the

physician for any adverse reaction.

16.Observe/Assess patient on an on-going basis for any untoward signs and

symptoms such as flushed skin, chills, elevated temperature, itchiness,

urticaria, and dyspnea. If any of these symptoms occur, stop the transfusion,

open the IV line , and report to the doctor immediately.

17.Swirl the bag gently from time to time to mix the solid with the plasma.

18. Continue to observe and monitor patient post transfusion, for delayed

reaction could still occur.

19.Re-check Hgb and Hct, bleeding time, serial platelet count within specified

hours as prescribed and/or per institution’s policy.

20.Discard blood bag and BT set and sharps according to Health Care Waste

Management .

21.Fill-out adverse reaction sheet as per institutional policy.

22.Remind the doctor about the administration of Calcium Gluconate if patient

has several units of blood transfusion (3-5 more units of blood).

Part VI: Hot and Cold Application

Examples of Hot Applications

1. Heating Pad: place a towel over the area to be treated, apply for up to 10

minutes checking regularly that the skin is not becoming too hot.

2. Wax Baths (Paraffin Wax): within a commercially temperature controlled

unit, dip hand or foot into paraffin wax 6 to 10 times, allowing wax to cool

between each dip; then place plastic bag over the hand or foot to protect

surfaces from the wax; wrap in a towel to retain the heat for up to 20

minutes; peel off wax.

3. Full Body Baths: keep temperature below 38 degrees to reduce a

stimulating effect especially before bed; keep a cool cloth handy for the

forehead and a glass of drinking water to keep you hydrated; herbal extracts,

Epsom or Dead Sea Salts(1/2cup – 2 cups) can be added to the water; soak

up to 20 minutes.

4. Steam Inhalations: sit in front of bowl filled with water that had been

brought to boiler stand at stove over pot of water - herbal extracts may also

be added; cover head, shoulders and pot with a large towel; close the eyes

and inhale steam for up to 10minutes; allow cool air in as needed if too hot;

keep a cool cloth handy to wipe the face

Local Effects of Heat

1. vasodilatation and increases blood flow to the affected area.

2. Bringing (oxygen, nutrients, antibodies, and leukocytes).

3. Promote soft tissue healing process.

4. Sedative effect .

5. Increase inflammation.

6. Facilitate removal of waste.

7. Promote relaxation of muscles, so it relieves muscle pain.

8. Systemic effects: include , increase cardiac output, increase heart rate and

decrease blood pressure.

Disadvantage of Heat Application

1. Increase capillary permeability.

2. Extra cellular fluid and substance as plasma to pass through the capillary

walls.

3. Edema.

Contraindications to the use of heat application

1. The first 24 hours after traumatic injury (heat increase bleeding and

swelling).

2. Active hemorrhage (heat causes vasodilatation and increase bleeding.

3. Non inflammatory edema (heat increases capillary permeability and

edema).

4. Skin disorder (heat can burn or cause further damage to the skin).

5. Localized malignant tumor (heat increase cell growth and accelerate

metastases ).

6. Hypertension or other circulatory issues are present.

Cold application

Temperature is between 0 to 12 deg. Celsius; cool is considered between 13 to

18 degree Celsius, not a topical room-temperature cream or lotion with cooling

effect.

Effect of cold application

1. When applied locally (to affected area) it reduces the temperature of the

skin, then the muscles and joints.

2. Effect may last up to 45 minutes after cold source is removed.

3. Restricts blood flow to the area by narrowing the blood vessels

(vasoconstriction).

4. Decrease inflammation, swelling and muscle spasm.

5. Reduces bleeding.

6. Decreases pain.

7. Causes a temporary stimulating effect.

Indications for cold application

1. Acute and severe injuries – from the moment of the injuring up to 3 days

after.

2. As long as pain, heat and swelling are still present.

3. Sprains, strains and bruises.

4. Repetitive use conditions/Overuse injuries and flare-ups i.e.) tendinitis.

5. Carpal tunnel syndrome.

6. Migraine headaches.

7. During exercise in hot environment - cool down with fans, ice packs and

cold towels

Examples of cold applications

Cold applications should not be used for longer than 30 minutes at a time.

1. Cold Gel Pack/Ice pack: wrap in a towel to prevent frost bite, place and

hold over the area, ice packs contain crushed or chipped ice and are more

efficient than commercial gel packs.

2. Cold Arm/Foot Bath: size of container depends on body part, great for

awkward bony areas such as elbows, hands and ankles; immerse the body

part for up to 1 minute; dry thoroughly afterwards. Wrapping body part in a

towel can help insulate it while in the cold water.

3. Ice Cup: take a paper cup filled with water and put it in the freezer; when

frozen tear a way paper to expose ice as you massage/stroke it over affected

area. Best suited for muscle injury and larger area.

Contraindications of cold application

1. Reynaud's Disease or decreased skin sensitivity to temperature is present.

2. The person feels chilled .

3. Impaired circulation.

4. Do not use over new wounds.

CONTRAST - Heat then Cold Application

Alternating heat then cold causes a flushing effect – blood vessels dilate then

constrict, causing an overall increase of circulation to the area, tissue healing

and reduces swelling.

It is also thought that the brain is momentarily distracted away from sending or

receiving pain messages through the use of contrasting temperatures.

1. Applied in a ratio of 3:1, 3 minutes of heat to 1 minute of cold and repeat

3 times for maximum effect.

2. The greater the difference in temperature of the application, the greater

the effect on the local circulation.

3. Always end with cold application to prevent congestion

Indications of Contrast application

1. Approximately 2 days to 2 weeks after an injury.

2. The presence of inflammation, swelling and heat should be diminishing.

Examples of contrast applications

1. Arm/Foot Baths: for contrast, fill one sink with warm/hot water and the

other side with cool/cold water ( use plastic bins for feet); place body

part(s) in warm side first then the cool side; repeat 3 times.

2. Compresses: have both a hot water basin and a cold water basin

available; dip one cloth in hot water, wring out and place on area; dip the

other cloth in the cold water, wring out and replace the hot compress with

the cold one.

Temperature for hot and cold applications

Description Temperature Application

Very cold Below 15C Ice bag

Cold 15-18 C Cold packs

Cool 18 – 27 C Cold compresses

Tepid 27 – 37 C Alcohol sponge bath

Warm 37 – 40 C Warm bath

Hot 40 – 46 C Hot soak, hot

compresses

Very Hot Above 46 C Hot water bag for adult

Therapeutic Effects of Heat and Cold Applications

Physiological response Therapeutic benefits

Heat therapy Promotes vasodilation.

Decreases blood viscosity.

Increases tissue metabolism.

Increases capillary

permeability.

Reduces muscle tension.

Improves blood flow.

Increases delivery of oxygen and

nutrients, leukocytes, and antibodies to

facilitate the inflammatory process.

Facilitates removal of wastes and

toxins.

Produces a local warming effect.

Decreases venous congestion in

injured tissues.

Increases absorption of fluid by

capillaries and promotes removal of

excess fluid from interstitial spaces,

thereby reducing edema.

Promotes muscle relaxation and

decreases pain from spasm or stiffness.

Cold therapy

Promotes vasoconstriction.

Increases blood viscosity.

Decreases tissue

metabolism.

Has a local anesthetic effect.

Decreases muscle tension.

Decreases blood flow to site of injury,

thereby decreasing inflammation and

edema formation.

Decreases blood flow, facilitating

clotting and control of bleeding.

Reduces the tissues’ oxygen

consumption.

Raises the threshold of pain receptors,

thereby decreasing pain.

Precautions in the use of heat and cold applications

1. Neurosensory impairment: Clients with reduced perception of sensory or

painful stimuli (e.g., spinal cord injuries)are at an increased risk for tissue

injury.

2. Impaired mental status: Clients who are confused or unconscious need to

be monitored and assessed frequently to ensure safety.

3. Impaired circulation: Clients with cardiovascular and peripheral vascular

problems or diabetes may not have the ability to dissipate heat through

dilation of blood vessels and are at an increased risk for tissue injury.

4. Skin and tissue integrity (open wounds, broken skin, scar formation,

edema): Subcutaneous tissues are more sensitive to temperature variations

than are superficial tissues. (e.g., cold can decrease blood flow to an open

wound, thereby inhibiting healing).

Common Methods of Applying heat and cold

1. Hot water bag (bottle)

• More Common source of dry heat

• In expensive

• Improper use leads to burning

2. Hot and cold packs

• Commercially prepared hot and cold packs provide heat or cold for a

designated time

3. Electrical Pads

– Provide constant heat

– Are light weight

– Some have water proof covers to place over a moist dressing

4. Ice Bags,

– Filled either with ice chips .

5. Compresses

– Can be either warm or cold

– Are moist gauze dressing applied to a wound

6. Soak

– Refers to immersing a body part in a solution

– Sterile technique is generally indicated for open wound

7. Sits Bath or hip bath

– Used to soak a client’s pelvic area

– The client’s sit on the chair and immersed in the solution

8. Cooling Sponge Bath

– Promoting heat loss through conduction

– Companied by antipyretic medication

Part VII: Diagnostic Testing

Diagnostic tests

Overview of noninvasive and invasive diagnostic testing

Diagnostic tests are either noninvasive or invasive.

Noninvasive means the body is not entered with any type of instrument.

The skin and other body tissues, organs, and cavities remain intact.

Invasive means accessing the body’s tissue, organ, or cavity through some

type of instrumentation procedure.

Phases of Diagnostic testing

1. Pretest Phase: this phase focuses on client preparation.

2. Intra-test Phase: this phase focuses on specimen collection and

performing or assisting with certain diagnostic testing, the nurse uses

standard precautions and sterile technique as appropriate.

3. Post-test Phase: the focus of this phase is on nursing care of the client

and follow- up activities and observation. As appropriate, the nurse

compares the previous and current test results and modifies nursing

interventions as needed.

Preparing the Client for Diagnostic Testing

A: Assessment

1. Check to be sure the client is wearing an identification band.

2. Review the medical record for herbal supplements, allergies, and previous

adverse reactions to dyes and other contrast media; a signed consent form;

and the recorded findings of diagnostic tests relative to the procedure.

3. Assess for presence, location, and characteristics of physical and

communicative limitations or pre-existing conditions.

4. Monitor the client’s knowledge of why the test is being performed and what

to expect during and after testing.

5. Monitor vital signs for clients scheduled for invasive testing to establish

baseline data.

6. Assess client outcome measures relative to the practitioner’s preferences

for pre-procedure preparations.

7. Monitor level of hydration and weakness for clients who are NPO (nothing

by mouth), especially geriatricand pediatric populations.

B: Client teaching

Discuss the following with the client and family as appropriate to the specific

test:

1. Explain reason for test and what to expect.

2. An estimation of how long the test will take.

3. NPO (if oral medication to be taken, how much water to drink).

4. Cathartics or laxative: how much, how often.

5. Sputum: cough deeply, do not clear throat.

6. Urine: voided, clean-catch specimen, time to collect.

7. No objects (jewelry or hair clips) to obscure x-ray film.

8. Barium: taste, consistency, aftereffects (stools lightly colored for 24–72

hours, can cause obstruction or impaction).

9. Iodine: metallic taste, delayed allergic reaction (itching, rashes, hives,

wheezing and breathing difficulties).

10.Positioning during the test.

11.Positioning posttest (e.g., angiography)—immobilize limb

12.Posttest, encourage fluids if not contraindicated.

Blood Tests

Blood tests are one of the most commonly used diagnostic tests and can provide

valuable information about the hematologic system and many other body

systems. A venipuncture (puncture of a vein for collection of a blood specimen)

can be performed by various members of the health care team.

Types of Blood Tests

1. A complete blood count (CBC).

The CBC is one of the most common blood tests. It's often done as part of a

routine checkup. CBC, include the following:

Red Blood Cells

White Blood Cells

Platelets

Hemoglobin

Hematocrit

Mean Corpuscular Volume

2. Blood Chemistry Tests/Basic Metabolic Panel

The basic metabolic panel (BMP) is a group of tests that measures different

chemicals in the blood. These tests usually are done on the fluid (plasma)

part of blood. The BMP includes:

Blood glucose.

Calcium.

Electrolyte: They include sodium, potassium, bicarbonate, and

chloride.

Kidney function tests: They include blood urea nitrogen (BUN) and

creatinine.

3. Blood enzyme tests

These tests include troponin and creatine kinase (CK) tests, etc…

4. Arterial Blood Gases: These tests include:

PO2.

PCO2.

pH 7.35–7.45.

5. Blood clotting tests: they include:

Prothrombin time (PT) and ,

activated partial thromboplastin time (APTT).

Stool specimens

Analysis of stool specimens can provide information about a client’s health

condition. Some of the reasons for testing feces include the following:

To determine the presence of occult (hidden) blood.

To analyze for dietary products and digestive secretion.

To detect the presence of ova and parasites.

To detect the presence of bacteria or viruses.

Urine specimens

The nurse is responsible for collecting urine specimens (clean voided-

midstream urine specimens) for a number of tests:

Routine urinalysis

Urine culture.

Types of Urine Collection Methods

Urine specimens may be collected in a variety of ways according to the type of

specimen required, the collection site and patient type.

1. Randomly Collected Specimens: are not regarded as specimens of choice because

of the potential for dilution of the specimen when collection occurs soon

after the patient has consumed fluids.

2. First Morning Specimen: is the specimen of choice for urinalysis and microscopic

analysis, since the urine is generally more concentrated.

3. Midstream Clean Catch Specimens: are strongly recommended for

microbiological culture and antibiotic susceptibility testing because of the

reduced incidence of cellular and microbial contamination.

4. Timed Collection Specimens: may be required for quantitative measurement of

certain analytes (creatinine, urea, potassium, sodium, uric acid, cortisol,

calcium, citrate, amino acids, etc..).

5. Collection from Catheters(e.g. Foley catheter): Alternatively, urine can be

drawn directly from the catheter to an evacuated tube using an appropriate

adaptor.

6. Supra-pubic Aspiration: may be necessary when a non-ambulatory patient

cannot be catheterized or where there are concerns about obtaining a sterile

specimen by conventional means.

7. Pediatric Specimens: For infants and small children, a special urine collection

bag can be adhered to the skin surrounding the urethral area.

 Sputum specimens

Sputum is the mucus secretion from the lung, bronchi, and trachea. It is

important to differentiate it from saliva, the clear liquid secreted by the salivary

glands in the mouth, sometimes referred to as (spit). Healthy individuals do not

produce sputum.

Sputum specimens are usually collected for one or more of the following

reasons:

For culture and sensitivity to identify a specific microorganism and its

drug sensitivities.

For cytology to identify the origin, structure, function and pathology of

cells.

To identify the presence of tuberculosis (TB).

To assess the effectiveness of therapy.

Throat culture.

Nursing responsibilities during Specimen collection

1. Provide client comfort, privacy, and safety.

2. Explain the purpose of the specimen collection and the procedure for

obtaining the specimen.

3. Use the correct procedure for obtaining a specimen or ensure that the

client or staff follows the correct procedure.

4. Note relevant information on the laboratory requisition slip, for example,

medications the client is taking that may affect the results.

5. Transport the specimen to the laboratory promptly.

6. Report abnormal laboratory findings to the health care provider in a

timely manner consistent with the severity of the abnormal results.

Visualization procedures

Visualization procedures include indirect visualization (noninvasive) and direct

visualization (invasive) techniques for visualizing body organ and system

functions.

Non-invasive Diagnostic Methods

They are include:

1. Laboratory Exams

Such exams can evidence abnormal blood values, such as an infarct enzyme, or changes in the blood electrolyte.

2. Electrocardiogram (ECG)

This test evidences the characteristics and duration of the heart's electrical activity.

3. Stress ECG

4.Electroencephalography ( EEG)

It is a test to measure the electrical activity of the brain.

5. Holter ECG

A portable recording device monitors the time of occurrence of the extra-systoles over twenty-four hours.

6. Chest X-Ray

This test determines the heart's size and position, and whether the lungs are functioning properly.

7. Cardiac Ultrasonography (Echocardiography)

This test checks both the heart valves and the movement and thickness of the heart walls. 

Invasive Diagnostic Tests

A: Endoscopic Procedures, include the followings:

1. Arthroscopy: examines joint structures, primarily the knee.

2. Bronchoscopy: examines the bronchus and bronchial tree.

3. Colonoscopy: examines the large intestine.

4. Colposcopy: examines the cervix and vagina following a positive Pap

smear.

5. Cystourethroscopy: uses two instruments:

a. Cystoscope: to examine the bladder and ureter openings, and

b. Urethroscope: to examine the bladder neck and the urethra

6. Esophagogastroduodenoscopy (EGD): examines the esophagus, stomach,

and upper duodenum.

7. Laparoscopy: examines the peritoneal cavity: pelvis and abdomen.

8. Proctoscope: to examine the lower rectum and anal canal.

9. Arthroscopy: It is a surgical procedure use to visualize, diagnose, and treat

problems inside a joints.

B: Biopsy procedures

There are various kinds of biopsy procedure, including:

1. Bone marrow biopsy: a small sample of bone marrow (usually from the

hip) is removed via a slender needle. This type of biopsy helps to diagnose

diseases such as leukemia.

2. Colposcopy-directed biopsy: a colposcope is a small microscope used to

examine a woman’s cervix while a tissue sample is taken. This biopsy is

usually performed to investigate the reasons for an abnormal Pap test result.

3. Endoscopic biopsy: the endoscope is a flexible tube that can be inserted

into an orifice (such as the mouth or anus) or through a small skin incision.

Once the lump is reached, cutting tools are threaded through the endoscope

so that a sample of tissue can be taken.

4. Excisional biopsy: This type of biopsy may be used for breast lumps.

5. Incisional biopsy: This type of biopsy may be used for lumps located in

connective tissue such as muscle.

6. Needle biopsy:. This type of biopsy may be used to diagnose conditions of

the liver or thyroid.

7. Punch biopsy: This type of biopsy can help diagnose various skin

conditions.

8. Stereotactic biopsy: This type of biopsy is usually performed whenever

the lump is hard to see or feel.

9. Lumbar Puncture: CSF is withdrawn through a needle inserted in to the

subarachnoid space of the spinal canal between the third and fourth lumbar

vertebrae or between the fourth and fifth lumbar vertebrae.

Some diagnostic procedures that may require analgesia or sedation

1. Bone marrow aspiration or biopsy.

2. Endoscopy.

3. Lumbar puncture.

4. Placement of catheters, tubing.

5. Radiologic procedures (CT and MRI).

6. Tissue biopsies.

Documentation of diagnostic Procedures

Record in the client’s medical record:

1. Who performed the procedure.

2. Reason for the procedure.

3. Type of anesthesia, dye, or other medications administered.

4. Type of specimen obtained and where it was delivered.

5. Vital signs and other assessment data, such as client’s tolerance of the

procedure or pain and discomfort level.

6. Any symptoms of complications.

7. Who transported the client to another area (designate the names of persons

who provided transport and place of destination).

References:

Delaune, S., Landner, P., Fundmentals of Nursing standerds and

practice, Chapter 35, Fourth edition, Delmar Cengage Learning,

United States of American, 2011.

Sue C. DeLaune and Patricia K. Ladner, Fundamentals of Nursing

Standards & Practice, 4th Edition 2010.

Kozier B, Erb, G, Berman A, et al . Fundmentals of Nursing ,

chapter 46, Eight Edition, Person Education, 2012.

Kozier B, Erb, G, Berman A, etal. Fundamentals of Nursing, 6th Ed, New

York, Pearson Education, 2000

Kozier B, Erb, G, Berman A, etal. Fundamentals of Nursing, 7th Ed,

New York, Pearson Education, 2004.

Lois White & others, Foundations of Basic Nursing, third edition,

Delmar, 2011.

Perry, A. & Potter P.: Clinical Nursing Skills Techniques, 5th ed. London,

Mosby, 2002.

Sue C. DeLaune and Patricia K. Ladner, Fundamentals of Nursing:

Standards and Practice, Fourth Edition, Delmar, 2011.

Timby B., Fundamental Nursing Skill & Concepts , Philadelphia ,

Lippincott Williams, Wilkins, 2005 .

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Chapter 27, Third Edition, Delmar Cengage Learning, United States of

American, 2011.