Fundamentals

of Nursing

Christopher Sixto Casano, PTRP, RNChristopher Sixto Casano, PTRP, RN

National Licensure Examination Series

Fundamentals

of Nursing

Roles of the Professional NurseRoles of the Professional Nurse1. 1. CaregiverCaregiver: “Mothering actions”: “Mothering actions”2. 2. CommunicatorCommunicator: message + Feedback: message + Feedback3. 3. TeacherTeacher: health promotion & : health promotion &

maintenance. maintenance. 4. 4. CounselorCounselor: Emotional, intellectual & : Emotional, intellectual &

psychological support.psychological support.5. 5. ClientClient advocateadvocate: “BEST for Patient”: “BEST for Patient”6. 6. ChangeChange AgentAgent: Initiate changes: Initiate changes7. 7. LeaderLeader: Influences the patient: Influences the patient8. 8. ManagerManager: Organize, Coordinate and : Organize, Coordinate and

DispenseDispense9. 9. ResearcherResearcher: Modify nursing practice: Modify nursing practice

Concepts of Health & IllnessConcepts of Health & Illness

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

social well-being, and not merely social well-being, and not merely the absence of disease or the absence of disease or infirmity. infirmity.

characterized by soundness or characterized by soundness or wholeness of developed human wholeness of developed human structures and of bodily and structures and of bodily and mental functioning.mental functioning.

Health is a well-being and using Health is a well-being and using one’s power to the fullest extent. one’s power to the fullest extent.

Health is maintained through the Health is maintained through the prevention of disease via prevention of disease via environmental factors.environmental factors.

Health is viewed in terms of the Health is viewed in terms of the individual’s ability to perform 14 individual’s ability to perform 14 components of nursing care components of nursing care unaided.unaided.

Health is a state and a process of Health is a state and a process of being and becoming an integrated being and becoming an integrated and whole person.and whole person.

Questions:Questions:

1. A new staff nurse refreshes the 1. A new staff nurse refreshes the fact that nursing care is based fact that nursing care is based on:on:

a. Nursing conceptsa. Nursing concepts

b. Nursing processb. Nursing process

c. Nursing theoryc. Nursing theory

d. Nursing problemd. Nursing problem

2. Which of these statements LEAST 2. Which of these statements LEAST describes nursing?describes nursing?

a. It is an art and science of caring for the a. It is an art and science of caring for the health of the individual, family, or health of the individual, family, or community in any setting.community in any setting.

b. It is a health-oriented profession which b. It is a health-oriented profession which requires formal training committed to requires formal training committed to the ideals of service.the ideals of service.

c. It is mainly dealing with the cure and c. It is mainly dealing with the cure and treatment of health conditions affecting treatment of health conditions affecting an individual, community, or family.an individual, community, or family.

d. It is basically premised on the greatest d. It is basically premised on the greatest human principle of “love thy neighbor”.human principle of “love thy neighbor”.

3. The following are assessment 3. The following are assessment activities EXCEPT:activities EXCEPT:

a. Gathering and verifying dataa. Gathering and verifying data

b. Conferring and revalidating datab. Conferring and revalidating data

c. Using physical assessment toolsc. Using physical assessment tools

d. Determining nursing problemsd. Determining nursing problems

4. Which of the following statements 4. Which of the following statements INCORRECTLY describes the evaluation INCORRECTLY describes the evaluation phase of the nursing process? It is the:phase of the nursing process? It is the:

a. Process of determining the extent to a. Process of determining the extent to which the plan and identifies goals which the plan and identifies goals are met.are met.

b. Examination of the outcome of b. Examination of the outcome of nursing nursing interventionsinterventions

c. Completion of the nursing processc. Completion of the nursing process

d. Identification of client needs and d. Identification of client needs and designing of strategies to attain designing of strategies to attain

goalsgoals

5. Nursing has evolved from a behavior that 5. Nursing has evolved from a behavior that is in intuitive and based on charity to the is in intuitive and based on charity to the broadest concept of being responsible for broadest concept of being responsible for health. Which of these statements does not health. Which of these statements does not describe nursing at this age?describe nursing at this age?

a. It is person and client orienteda. It is person and client oriented

b. It includes promotive, preventive, and b. It includes promotive, preventive, and rehabilitative aspects of carerehabilitative aspects of care

c. Nursing activities are independent, c. Nursing activities are independent, interdependent and dependentinterdependent and dependent

d. Nursing is focused on disease d. Nursing is focused on disease management and dependent care management and dependent care measuresmeasures

6. According to the Self-care model, 6. According to the Self-care model, when a nurse performs hygiene and when a nurse performs hygiene and nutritional activities to a comatose nutritional activities to a comatose client, her services are regarded as:client, her services are regarded as:

a. Wholly compensatorya. Wholly compensatory

b. Partially compensatoryb. Partially compensatory

c. Supportive-educativec. Supportive-educative

d. Imperical-specificd. Imperical-specific

7. Which of the following values is 7. Which of the following values is considered a foundation of considered a foundation of nursing?nursing?

a. Caringa. Caring

b. Commitmentb. Commitment

c. Compassionc. Compassion

d. Perseveranced. Perseverance

Nursing TheoriesNursing Theories Florence Nightingale (Florence Nightingale (Environmental)Environmental)

- H20, O2, drain, cleanliness & - H20, O2, drain, cleanliness & lightlight

Jean Watson’s Human CaringJean Watson’s Human Caring– 10 Caring factors10 Caring factors

Virginia HendersonVirginia Henderson– 14 Basic Needs14 Basic Needs

Dorothy JohnsonDorothy Johnson– Behavioral Systems ModelBehavioral Systems Model

Jean Watson’s 10Jean Watson’s 10 factorsfactors

AltruismAltruismFaith & hopeFaith & hopeSensitivitySensitivityTrust Trust AcceptanceAcceptanceDecision-makingDecision-making

Teaching-learningTeaching-learningSupportive Supportive

environmentenvironmentGratification of Gratification of

needsneedsExistential Existential

phenomenologicalphenomenological

Virginia Henderson’s 14Virginia Henderson’s 14

BreathingBreathingEating & drinkingEating & drinkingEliminationEliminationAmbulationAmbulationSleep & restSleep & restClothingClothingTemperature mgtTemperature mgt

HygieneHygieneSafetySafetyCommunicationCommunicationReligionReligionProductive workProductive workPlayPlayLearningLearning

5. Imogene King5. Imogene King– Goal Attainment TheoryGoal Attainment Theory

a. Personal systema. Personal systemb. Interpersonal systemb. Interpersonal systemc. Social systemc. Social system

6. Madeleine Leninger6. Madeleine Leninger– Transcultural NursingTranscultural Nursing

7. Myra Levine7. Myra Levine4 Conservation Principles4 Conservation Principles

a. Energya. Energyb. Structural Integrityb. Structural Integrityc. Personal Integrityc. Personal Integrityd. Social Integrityd. Social Integrity

8. Betty Neuman8. Betty NeumanHealth Care System ModelHealth Care System Model

a. Intravariablea. Intravariableb. Intervariableb. Intervariablec. Extravariablec. Extravariable

9. Dorothea Orem9. Dorothea Orem

Self Care / Self Care Deficit Self Care / Self Care Deficit TheoryTheory

3 compensatory systems:3 compensatory systems:

a. Wholly Compensatorya. Wholly Compensatory

b. Partially Compensatoryb. Partially Compensatory

c. Supportive – educativec. Supportive – educative

10. Hildegard Peplau10. Hildegard Peplau

Interpersonal ModelInterpersonal Model

11. Martha Rogers11. Martha Rogers

Science of Unitary Human BeingsScience of Unitary Human Beings

12. Sister Callista Roy (12. Sister Callista Roy (Adaptation)Adaptation)Person as an adaptive system Person as an adaptive system functions as a whole through functions as a whole through interdependence of its parts.interdependence of its parts.

13. Lydia Hall13. Lydia Hall3 C’s ( care, core & cure)3 C’s ( care, core & cure)

4 concepts common in conceptual 4 concepts common in conceptual models:models:a. Persona. Personb. Environmentb. Environmentc. Healthc. Healthd. Nursingd. Nursing

Benner’s Stages of Nursing Benner’s Stages of Nursing Expertise Expertise

Novice Novice (student) Rules > experience(student) Rules > experienceAdvanceAdvance beginnerbeginner (marginally (marginally

acceptable) recognize meaningful acceptable) recognize meaningful aspects. Knows enoughaspects. Knows enough

CompetentCompetent (2-3 yrs) organizes & plans (2-3 yrs) organizes & plansProficientProficient (3-5yrs)holistic, uses maxims (3-5yrs)holistic, uses maximsExpertExpert: fluid, proficient & intuitive: fluid, proficient & intuitive

Nursing Nursing ProcessProcess

Assess

Diagnose

Plan

Intervene

Evaluate

Assessment of the ClientAssessment of the Client

Collection of data related to health statusCollection of data related to health status

Subjective DataSubjective DataWhat a client or family (SO) saysWhat a client or family (SO) says

Objective DataObjective DataWhat the nurse observesWhat the nurse observesPE: inspect, percuss, palpate, & auscultate PE: inspect, percuss, palpate, & auscultate Client's health record and the results of Client's health record and the results of

laboratory and diagnostic studieslaboratory and diagnostic studies

Database Construction and Database Construction and DiagnosisDiagnosis

Types of DiagnosesTypes of DiagnosesActual nursing diagnosisActual nursing diagnosis: an existing problem: an existing problemRisk diagnosisRisk diagnosis: no current problem but at risk : no current problem but at risk Wellness diagnosisWellness diagnosis: focuses on strengths : focuses on strengths

and reflects ability to achieve a higher level and reflects ability to achieve a higher level of wellnessof wellness

Collaborative problemsCollaborative problems: interdependent : interdependent management (medical and nursing orders)management (medical and nursing orders)

Database Construction and DiagnosisDatabase Construction and Diagnosis

Types of DatabasesTypes of Databases

CompleteComplete: complete health history & full : complete health history & full PE PE

FocusedFocused: limited or short-term problem, : limited or short-term problem, such as one problem or body system such as one problem or body system

Follow-upFollow-up: focuses on evaluating : focuses on evaluating progress  progress 

EmergencyEmergency: rapid collection of data, : rapid collection of data, often during the provision of lifesaving often during the provision of lifesaving measuresmeasures

The InterviewThe InterviewCollect subjective Collect subjective

data and observe data and observe the the general state general state of healthof health

Establish rapport Establish rapport and trustand trust

Teach health Teach health promotion and promotion and disease disease preventionprevention

General State of HealthGeneral State of HealthBody features and Body features and

physical physical characteristics characteristics

Body movements Body movements Body posture Body posture Level of Level of

consciousness consciousness Nutritional status Nutritional status SpeechSpeech

Factors to Consider during an Factors to Consider during an InterviewInterview

Explain procedure Explain procedure Ensure privacy & Avoid interruptions Ensure privacy & Avoid interruptions

Note-Taking during the InterviewNote-Taking during the InterviewKeep note-taking to a minimum Keep note-taking to a minimum

– can shift attention away can shift attention away – interrupt narrative flow interrupt narrative flow – threatening when discussing of sensitive threatening when discussing of sensitive

issuesissues– also impedes observationalso impedes observation

Physical Environment During Physical Environment During the Interviewthe Interview

Comfortable level: Temperature, Comfortable level: Temperature, lighting, & noise lighting, & noise

Arrangement: Remove distracting Arrangement: Remove distracting objects or equipment, The distance objects or equipment, The distance between should be 4 to 5 feet between should be 4 to 5 feet (twice arm's length), Eye to eye, No (twice arm's length), Eye to eye, No Barriers, Face to FaceBarriers, Face to Face

Communication TechniqueCommunication Technique

Exchange info; should be clearly understood Exchange info; should be clearly understood Appropriate tone, one question at a time, Appropriate tone, one question at a time,

and layman’s terms; allow time to answerand layman’s terms; allow time to answerOpen-ended questions: narrative Open-ended questions: narrative

informationinformationClosed or direct questions: one-or two-wordClosed or direct questions: one-or two-wordHearing-impaired may lip-read; May need Hearing-impaired may lip-read; May need

sign-language interpretersign-language interpreterObserve nonverbal behavior Observe nonverbal behavior End the interview by providing an End the interview by providing an

opportunity to ask questionsopportunity to ask questions

Guidelines for Measuring Vital Guidelines for Measuring Vital SignsSigns

Initial measurement for baseline data Initial measurement for baseline data May be delegated to assistive personnel, but May be delegated to assistive personnel, but

the the nurse is responsible for interpreting the nurse is responsible for interpreting the resultsresults

RN collaborates with MD in determining the RN collaborates with MD in determining the frequency of vital sign assessment frequency of vital sign assessment

Documents and reports abnormal findingsDocuments and reports abnormal findings

Measuring Vital SignsMeasuring Vital Signs

Should be doneShould be doneOn initial contact; during PEOn initial contact; during PEBefore and after an invasive diagnostic or Before and after an invasive diagnostic or

surgical proceduresurgical procedureBefore, during, and after Meds administration Before, during, and after Meds administration Before, during, and after a blood transfusionBefore, during, and after a blood transfusionUpon condition changesUpon condition changesWhenever an intervention (e.g., ambulation) Whenever an intervention (e.g., ambulation)

may affect a client’s conditionmay affect a client’s condition(+) Fever: measure every 2 to 4 hours(+) Fever: measure every 2 to 4 hours

TemperatureTemperature

Normal: 97.5Normal: 97.5 to 99.5 to 99.5F (36.4F (36.4-37.5-37.5C); C); Average adult is of 98.6Average adult is of 98.6F (37.0F (37.0C)C)

Common: mouth, rectum, axilla, and ear Common: mouth, rectum, axilla, and ear Rectal temp 1Rectal temp 1F > Oral > axillary temp 1F > Oral > axillary temp 1 F F

ConversionConversionFahrenheit to Celsius:Fahrenheit to Celsius: (Fahrenheit – 32) x 5/9 = Celsius(Fahrenheit – 32) x 5/9 = Celsius Formula to convert Celsius to Fahrenheit: Formula to convert Celsius to Fahrenheit:

(Celsius x 9/5) + 32 = Fahrenheit(Celsius x 9/5) + 32 = Fahrenheit

VITAL SIGNSVITAL SIGNSA. TemperatureA. Temperature

– BT = Heat Produced – Heat LossBT = Heat Produced – Heat Loss

Types:Types:

1. Core Temperature1. Core Temperature– deep tissues (peritoneum, deep tissues (peritoneum,

cranium)cranium)

2. Surface Temperature 2. Surface Temperature – skin, subcutaneous tissue and fatskin, subcutaneous tissue and fat

Factors Affecting Heat Factors Affecting Heat Production:Production:

1. Basal Metabolic Rate (BMR) 1. Basal Metabolic Rate (BMR)

2. Muscle Activity2. Muscle Activity– exercise, running or swimmingexercise, running or swimming

3. Thyroxine Output 3. Thyroxine Output

4. Epinephrine & Norepinephrine4. Epinephrine & Norepinephrine

5. SNS stimulation5. SNS stimulation

6. Fever6. Fever

Processes of Heat LossProcesses of Heat Loss

a. Radiation a. Radiation

b. Conductionb. Conduction

c. Convection c. Convection

d. Evaporation d. Evaporation

Alterations in Body Temperature:Alterations in Body Temperature:– 1. Hyperthermia (Fever)1. Hyperthermia (Fever)– 2. Hypothermia2. Hypothermia

Types of FeverTypes of Fever

1. Intermittent 1. Intermittent

2. Remittent 2. Remittent

3. Relapsing3. Relapsing

4. Constant4. Constant

Decline of FeverDecline of Fever

a. Crisisa. Crisis

b. Lysis b. Lysis

Nursing Interventions for Nursing Interventions for FeverFever

– Monitor V.S.Monitor V.S.– Assess skin color & Assess skin color &

temperature.temperature.– Monitor WBC, hct & other Monitor WBC, hct & other

pertinent laboratory records.pertinent laboratory records.– Remove excess blankets when Remove excess blankets when

warm, provide when client has warm, provide when client has chills.chills.

Provide well-balanced diet, Provide well-balanced diet, increase fluid.increase fluid.

MIOMIOIVFIVFRestRestOral HygieneOral HygieneCool circulating air with a fanCool circulating air with a fanTSBTSBAntipyretics as orderedAntipyretics as ordered

Factors That Affect Body Factors That Affect Body TemperatureTemperature

Time of DayTime of DayEnvironmental TemperatureEnvironmental TemperatureAgeAge

- Fluctuates during 1st year - Fluctuates during 1st year of life of life

Physical ExercisePhysical Exercise

- Use of the large muscles - Use of the large muscles creates heatcreates heat

Menstrual CycleMenstrual Cycle- Temp decreases slightly just before - Temp decreases slightly just before ovulation; increase to 1ovulation; increase to 1 F during ovulation F during ovulation

PregnancyPregnancy- high normal because of an increase in the - high normal because of an increase in the body’s metabolic ratebody’s metabolic rate

StressStress- Emotions increase hormonal secretion- Emotions increase hormonal secretion

IllnessIllness- Infective agents and the inflammatory - Infective agents and the inflammatory response may cause an increase in response may cause an increase in temperaturetemperature

The Glass ThermometerThe Glass ThermometerAn elongated bulb: oral or axillary use, a An elongated bulb: oral or axillary use, a

stubby bulb: any site, and a red bulb: rectal stubby bulb: any site, and a red bulb: rectal use  use 

Shake down the mercury before using the Shake down the mercury before using the thermometer thermometer

Oral only for alert, cooperative, and able to Oral only for alert, cooperative, and able to breathe while holding the thermometer in the breathe while holding the thermometer in the mouth mouth

Not used if unconscious, uncooperative, Not used if unconscious, uncooperative, confused, or agitated, at risk for biting the confused, or agitated, at risk for biting the thermometer, or at risk for seizures thermometer, or at risk for seizures

To read, hold horizontally at eye level and To read, hold horizontally at eye level and rotaterotate

Oral TemperatureOral Temperature

If a glass thermometer is used, it must be If a glass thermometer is used, it must be left in place for 3 minutes or for as long as left in place for 3 minutes or for as long as agency procedures dictate agency procedures dictate

If recently taken hot or cold foods or liquids If recently taken hot or cold foods or liquids or has smoked or chewed gum, must wait or has smoked or chewed gum, must wait 15 to 30 minutes15 to 30 minutes

Placed under the tongue in the posterior Placed under the tongue in the posterior sublingual pocket; ask keep the tongue sublingual pocket; ask keep the tongue down and the lips closed and to down and the lips closed and to not bite not bite down on the thermometerdown on the thermometer

Rectal TemperatureRectal Temperature

Place client in Sims' position Place client in Sims' position Done if oral not possible, nasal congestion, Done if oral not possible, nasal congestion,

nasal or oral surgery, has NGT in place, is nasal or oral surgery, has NGT in place, is unable to keep the mouth closed, or is at risk unable to keep the mouth closed, or is at risk for seizures for seizures

No rectal in cardiac, rectal surgery, diarrhea, No rectal in cardiac, rectal surgery, diarrhea, fecal impaction, or rectal bleeding fecal impaction, or rectal bleeding

Bulb is lubricated, 1.5 inches inserted into Bulb is lubricated, 1.5 inches inserted into the rectum (til 0.5 inch in an infant); 2 minsthe rectum (til 0.5 inch in an infant); 2 mins

Axillary TemperatureAxillary TemperatureTaken when taking the temperature orally or Taken when taking the temperature orally or

rectally is contraindicated rectally is contraindicated Not as reliableNot as reliable a measurement as the oral, a measurement as the oral,

rectal, or tympanic method rectal, or tympanic method Placed in dry axilla, and the client to hold Placed in dry axilla, and the client to hold

the arm tightly against the chest, resting the the arm tightly against the chest, resting the arm on the chest arm on the chest

kept in place for 3 minutes or for as long as kept in place for 3 minutes or for as long as agency procedure dictatesagency procedure dictates

The Electronic ThermometerThe Electronic ThermometerPortable battery-operated device; measures Portable battery-operated device; measures

body temperature in 5 seconds to 1 minutebody temperature in 5 seconds to 1 minuteThe probe is placed in a plastic cover or The probe is placed in a plastic cover or

sheath that is used one time and then sheath that is used one time and then discardeddiscarded

A light will stop flashing or the unit will beep A light will stop flashing or the unit will beep when the temperature registerswhen the temperature registers

Always return the unit to its holder after use Always return the unit to its holder after use to maintain the battery's charge to maintain the battery's charge 

The Tympanic ThermometerThe Tympanic Thermometer

Portable battery-operated device that Portable battery-operated device that registers the temperature in 1 to 2 seconds registers the temperature in 1 to 2 seconds

the probe should not be inserted if the client the probe should not be inserted if the client has an inflammatory condition of the has an inflammatory condition of the auditory canal or if there is discharge from auditory canal or if there is discharge from the ear the ear

After the mode (infant/toddler or child/adult) After the mode (infant/toddler or child/adult) is selected, the thermometer probe is is selected, the thermometer probe is inserted into the auditory canal inserted into the auditory canal

Reading may be affected by an ear infection Reading may be affected by an ear infection or excessive wax blocking the ear canalor excessive wax blocking the ear canal

Disposable ThermometersDisposable Thermometers

Various types of single-use disposable Various types of single-use disposable thermometers are availablethermometers are available

Most disposable thermometers will Most disposable thermometers will measure temperature in 2 minutes measure temperature in 2 minutes

PulsePulseAverage pulse rate: 60-100 bpmAverage pulse rate: 60-100 bpmEvaluate PR changes in tolerance of ADL Evaluate PR changes in tolerance of ADL Pedal pulses are checked to determine Pedal pulses are checked to determine

whether the circulation is blocked in the whether the circulation is blocked in the artery up to that pulse point artery up to that pulse point

When the pedal pulse is difficult to locate, a When the pedal pulse is difficult to locate, a Doppler-ultrasound stethoscope (ultrasonic Doppler-ultrasound stethoscope (ultrasonic stethoscope) may be needed to amplify the stethoscope) may be needed to amplify the sounds of a pulse wavesounds of a pulse wave

AssessmentAssessment

a. Ratea. Rate

0 – 1 month: 120 – 160 0 – 1 month: 120 – 160 beats/minbeats/min Adult: 60 – Adult: 60 – 100 beats/min100 beats/min

b. Rhythm b. Rhythm c. Volume (Amplitude)c. Volume (Amplitude)

Factors Affecting the Pulse RateFactors Affecting the Pulse Rate

Pulse rate diminishes with agePulse rate diminishes with ageExercise, pain & emotions increases the Exercise, pain & emotions increases the

pulse ratepulse rate Increased body temperature causes the Increased body temperature causes the

heart rate to increaseheart rate to increaseStimulant medications increase the heart Stimulant medications increase the heart

rate and depressants decrease itrate and depressants decrease itLow blood pressure= increase the heart rateLow blood pressure= increase the heart rateHemorrhage increases the heart rateHemorrhage increases the heart rate

Pulse CharacteristicsPulse Characteristics

When the pulse is being counted, note the When the pulse is being counted, note the rate, rhythm, and strength (force or rate, rhythm, and strength (force or amplitude) amplitude)

Grading Scale for PulsesGrading Scale for Pulses4+ = strong and bounding 4+ = strong and bounding 3+ = full pulse, increased 3+ = full pulse, increased 2+ = normal, easily palpable 2+ = normal, easily palpable 1+ = weak, barely palpable 1+ = weak, barely palpable 0 = absent, not palpable0 = absent, not palpable

Pulse Points and Pulse Points and Their LocationsTheir Locations

Temporal arteryTemporal arteryCarotid arteryCarotid arteryApical: left midclavicular, Apical: left midclavicular,

5th intercostal space 5th intercostal space Radial pulseRadial pulseBrachial pulseBrachial pulseFemoral pulseFemoral pulsePopliteal pulse: behind the Popliteal pulse: behind the

knee   knee   Posterior tibial pulsePosterior tibial pulseDorsalis pedis pulseDorsalis pedis pulse

Apical Heartbeat Apical Heartbeat Left midclavicular, 5th intercostal space Left midclavicular, 5th intercostal space Warm the diaphragm of the stethoscope Warm the diaphragm of the stethoscope Count for 1 full minute Count for 1 full minute Assessed if with an irregular radial pulse Assessed if with an irregular radial pulse

or a heart condition, before administering or a heart condition, before administering cardiac medications such as digoxin cardiac medications such as digoxin (Lanoxin) and (Lanoxin) and -blockers, and in children -blockers, and in children younger than 2 yearsyounger than 2 years

Pulse Deficit= Radial less than apical Pulse Deficit= Radial less than apical pulsepulse

Indicates a lack of peripheral perfusion Indicates a lack of peripheral perfusion Requires two peopleRequires two people

RespirationsRespirations

Normal adult respiratory rate is 12 to 20 bpmNormal adult respiratory rate is 12 to 20 bpm

Factors That Affect the Respiratory RateFactors That Affect the Respiratory RateAn An increased level of carbon dioxideincreased level of carbon dioxide or a or a

lower level of oxygenlower level of oxygen in the blood causes an in the blood causes an increase in respiratory rateincrease in respiratory rate

Head injury or increased ICPHead injury or increased ICP will depress the will depress the respiratory center and result in respiratory center and result in shallow shallow respirations or slowed breathingrespirations or slowed breathing

Narcotic analgesics depress respirationsNarcotic analgesics depress respirations

C. Respiration C. Respiration Medulla Oblongata Medulla Oblongata

primary respiratory centerprimary respiratory center

– 3 Processes:3 Processes:

a. Ventilation a. Ventilation

b. Diffusionb. Diffusion

c. Perfusionc. Perfusion

Factors Affecting Respiratory Factors Affecting Respiratory Rate Rate

1. Exercise 1. Exercise

2. Stress 2. Stress

3. Environment3. EnvironmentTemperature is inversely Temperature is inversely proportional with RRproportional with RR

4. Increase Altitude 4. Increase Altitude

5. Medications5. MedicationsNarcotics decreases RRNarcotics decreases RR

AssessmentAssessmenta. Rate a. Rate b. Depth – Movement of the b. Depth – Movement of the

chest chest (Normal, Deep or (Normal, Deep or Shallow)Shallow)

c. Rhythm c. Rhythm d. Qualityd. Qualitye. Character e. Character

Rhythm ProblemsRhythm Problems

a. Cheyne-Stokesa. Cheyne-Stokes– Increasing depth & frequency of Increasing depth & frequency of

respirations with intervals of respirations with intervals of apnea.apnea.

b. Biot’sb. Biot’s– several short breaths followed by several short breaths followed by

long irregular periods of apnea.long irregular periods of apnea.

c. Kussmaul’sc. Kussmaul’s – Increased rate & depth associated Increased rate & depth associated

with metabolic acidosis & renal with metabolic acidosis & renal failure.failure.

d. Apneusticd. Apneustic– Prolonged gasping inspiration Prolonged gasping inspiration

followed by a very short, usually followed by a very short, usually inefficient, expirations.inefficient, expirations.

Measuring the Respiratory RateMeasuring the Respiratory RateCount respirations after measuring the radial Count respirations after measuring the radial

pulse pulse **One respiration includes both inspiration and **One respiration includes both inspiration and

expiration expiration Counted for 30 secs and multiplied by 2, Counted for 30 secs and multiplied by 2,

except in very ill client or has irregular except in very ill client or has irregular respirations, in which case the respirations respirations, in which case the respirations are counted for 1 full minute are counted for 1 full minute

The rate, depth, pattern, and sounds are The rate, depth, pattern, and sounds are assessedassessed

Oxygen SaturationOxygen Saturation

Pulse oximeter measures oxygen saturation Pulse oximeter measures oxygen saturation by determining the percentage of by determining the percentage of hemoglobin that is bound to oxygen hemoglobin that is bound to oxygen

Sensor pad (adult: earlobe or nose bridge; Sensor pad (adult: earlobe or nose bridge; infant:) or probe (finger or earlobe) infrared infant:) or probe (finger or earlobe) infrared or red light can reach the capillary bedor red light can reach the capillary bed

Normally the oxygen-saturation reading is Normally the oxygen-saturation reading is greater than 90% (normal is 95% to 100%) greater than 90% (normal is 95% to 100%)

Monitoring may be intermittent or continuous Monitoring may be intermittent or continuous

Factors Affecting Oxygen Factors Affecting Oxygen SaturationSaturation

Outside light sources Outside light sources Client movement Client movement Jaundice Jaundice Carbon monoxide Carbon monoxide

poisoning poisoning Peripheral vascular disease Peripheral vascular disease MedicationsMedicationsHypotension Hypotension Hypothermia Hypothermia Dark nail polishDark nail polish

Measuring Oxygen SaturationMeasuring Oxygen Saturation

Determine the most appropriate site Determine the most appropriate site Not on sites with EdemaNot on sites with EdemaHypothermic fingers are not used Hypothermic fingers are not used PVD: ear or bridge of the nose PVD: ear or bridge of the nose No latex if allergicNo latex if allergic If a finger: fingernail polish must be removed If a finger: fingernail polish must be removed

Monitor until constant (10 to 30 seconds) Monitor until constant (10 to 30 seconds) Verify alarm limits (low: 85% & high: 100%) Verify alarm limits (low: 85% & high: 100%)

and relocate the probe at least every 4 hours and relocate the probe at least every 4 hours Report O2 sat level of less than 90%Report O2 sat level of less than 90%

Blood PressureBlood PressureForce on artery wall by the pulsating blood Force on artery wall by the pulsating blood

under pressure from the heartunder pressure from the heartSystolic: Max. pressure ejection from Systolic: Max. pressure ejection from

ventriclesventriclesDiastolic: Ventricles relax Diastolic: Ventricles relax Systolic – diastolic= pulse pressureSystolic – diastolic= pulse pressurePrehypertension: systolic BP:120-139 Prehypertension: systolic BP:120-139

mmHg; diastolic: 80-89 mmHgmmHg; diastolic: 80-89 mmHg if 50 y/o, systolic more important in Tx if 50 y/o, systolic more important in Tx

determination determination Postural (orthostatic) hypotensionPostural (orthostatic) hypotension

Orthostatic vital-sign: check BP & PR in Orthostatic vital-sign: check BP & PR in supine, sitting, and standing; measure 1 to 3 supine, sitting, and standing; measure 1 to 3 minutes afterminutes after

BP increases as person agesBP increases as person agesStress > sympathetic stimulation > Stress > sympathetic stimulation > ↑ BP↑ BPAntihypertensives & narcotics > Antihypertensives & narcotics > ↓ BP↓ BPDiurnal variation: BP lowest in AM, gradually Diurnal variation: BP lowest in AM, gradually

increases, & peaks in PM and eveningincreases, & peaks in PM and eveningAfter puberty, After puberty, ♂>♀♂>♀; after menopause, ; after menopause, ♀>♂♀>♂

D. Blood PressureD. Blood Pressure

– Korotkoff Sound Korotkoff Sound – Systolic Pressure Systolic Pressure – Diastolic Pressure Diastolic Pressure – Pulse pressurePulse pressure– Hypertension Hypertension – Hypotension Hypotension

Factors Affecting Blood PressureFactors Affecting Blood Pressure1. Age 1. Age

2. Exercise 2. Exercise 3. Stress3. Stress4. Race 4. Race 5. Obesity5. Obesity

6. Sex/Gender6. Sex/GenderMales (BP elevated after Males (BP elevated after puberty and before age 65)puberty and before age 65)

Females (BP elevated after 65)Females (BP elevated after 65)

Medications Medications Diurnal Variations Diurnal Variations

– BP is lowest in am, highest in BP is lowest in am, highest in late afternoon/early eveninglate afternoon/early evening

Disease Process Disease Process – DM, DM, – renal failure, renal failure, – hyperthyroidism, hyperthyroidism, – Cushing’s DiseaseCushing’s Disease

AssessmentAssessmentEnsure that the client is restedEnsure that the client is restedAllow 30 minutes to pass if Allow 30 minutes to pass if

smoked or smoked or ingested caffeine.ingested caffeine.Use appropriate size of BP cuff.Use appropriate size of BP cuff.Position in sitting or supine.Position in sitting or supine.Position arm at the level of the Position arm at the level of the

heart, heart, with the palm of the with the palm of the hand facing up.hand facing up.

Apply BP cuff snugly, 1 inch Apply BP cuff snugly, 1 inch above the above the antecubital space.antecubital space.

Determine palpatory BP before Determine palpatory BP before auscultatory BP to prevent auscultatory BP to prevent auscultatory gap.auscultatory gap.

Use the bell-shaped diaphragm of Use the bell-shaped diaphragm of the the stethoscope since the blood stethoscope since the blood

pressure is a low-frequency pressure is a low-frequency sound.sound.

Inflate and deflate BP cuff slowly, Inflate and deflate BP cuff slowly,

2-3 mmHg at a time.2-3 mmHg at a time.Wait 1-2 minutes before making Wait 1-2 minutes before making

further further determinations.determinations.

Guidelines for Measuring the Guidelines for Measuring the Blood PressureBlood Pressure

Not to arm with IV fluids, with AV shunt or Not to arm with IV fluids, with AV shunt or fistula, with breast or axillary surgery, or to fistula, with breast or axillary surgery, or to traumatized or diseased armtraumatized or diseased arm

The lower extremity can be used The lower extremity can be used Select appropriate cuff; too small= falsely Select appropriate cuff; too small= falsely

high, and too large= falsely low high, and too large= falsely low

No smoke or exercise for 30 minutes before No smoke or exercise for 30 minutes before the measurement ( falsely high readings) the measurement ( falsely high readings)

Guidelines for Measuring the Guidelines for Measuring the Blood PressureBlood Pressure

Sitting or lying position; 5 minutes rest, no Sitting or lying position; 5 minutes rest, no speaking speaking

Cuff should be fully deflated, evenly wrappedCuff should be fully deflated, evenly wrappedUse Stethoscope’s Bell, Diaphragm if obeseUse Stethoscope’s Bell, Diaphragm if obese1st Korotkoff sound: 1st Korotkoff sound:

systolic pressure systolic pressure 5th Korotkoff sound:5th Korotkoff sound:

diastolic pressure diastolic pressure

Physical AssessmentPhysical Assessment

Building block of Nursing Building block of Nursing processprocess

Provides database for Provides database for interventionintervention

Measuring stick for goal Measuring stick for goal achievement & quality careachievement & quality care

Communication TechniquesCommunication Techniques

Therapeutic Therapeutic Clarification Clarification Empathy Empathy Explanation Explanation Facilitation Facilitation Interpretation Interpretation Reflection Reflection Silence Silence SummarizingSummarizing

NontherapeuticNontherapeutic"why" questions "why" questions Giving adviceGiving advicePlacing feelings on holdPlacing feelings on hold false reassurancefalse reassuranceUsing authorityUsing authorityUsing avoidance Using avoidance

languagelanguageUsing leading or biased Using leading or biased

questionsquestionsUsing jargonUsing jargon

The Physical AssessmentThe Physical Assessment

Use inspection, palpation, percussion, Use inspection, palpation, percussion, and auscultation; (except for the and auscultation; (except for the abdominal assessment)abdominal assessment)

Inspection Inspection Requires good lighting, adequate Requires good lighting, adequate

exposure, and possibly the use of such exposure, and possibly the use of such instruments as an otoscope, instruments as an otoscope, ophthalmoscope, penlight, and nasal or ophthalmoscope, penlight, and nasal or vaginal speculumvaginal speculum

PalpationPalpationWarm the hands firstWarm the hands first Identify tender areas, palpate them last Identify tender areas, palpate them last Start with light palpation to detect Start with light palpation to detect

surface characteristics, then perform surface characteristics, then perform deeper palpation deeper palpation

Assess texture, temperature, and Assess texture, temperature, and moisture of the skin, as well as organ moisture of the skin, as well as organ location and size location and size

Assess swelling, vibration or pulsation, Assess swelling, vibration or pulsation, rigidity or spasticity, and crepitation rigidity or spasticity, and crepitation

Assess lumps or masses, as well as the Assess lumps or masses, as well as the presence of tenderness or pain presence of tenderness or pain

PercussionPercussionTapping the client's skin to assess Tapping the client's skin to assess

underlying structures underlying structures

AuscultationAuscultationListening to sounds produced by the Listening to sounds produced by the

body (e.g., heart and blood vessels, body (e.g., heart and blood vessels, lungs, abdomen)lungs, abdomen)

Vital SignsVital SignsTemperature, Respirations, Radial pulse Temperature, Respirations, Radial pulse

Respirations & Blood pressureRespirations & Blood pressureHeight and weight Height and weight

The Integumentary SystemThe Integumentary System

Subjective DataSubjective Data

History of skin disease History of skin disease Medications being taken Medications being taken Changes in skin color Changes in skin color Change in mole or a Non-healing sore?Change in mole or a Non-healing sore?Seborrhea: oily; xerosis: dry) Seborrhea: oily; xerosis: dry) Excessive bruising, itching, rash, or lesions Excessive bruising, itching, rash, or lesions Hair loss (alopecia) or a change in the nails Hair loss (alopecia) or a change in the nails Environmental or occupational hazards and Environmental or occupational hazards and

exposure to toxic substances exposure to toxic substances

Objective DataObjective Data Includes inspection and palpation of the skin, Includes inspection and palpation of the skin,

hair, and nails hair, and nails

Skin Skin Lesions: Wood's light Scars or birthmarksLesions: Wood's light Scars or birthmarksMoisture (diaphoresis or dryness)Moisture (diaphoresis or dryness)Texture (smoothness, firmness)Texture (smoothness, firmness)Temperature (hypothermia or hyperthermia)Temperature (hypothermia or hyperthermia)TurgorTurgorVascularity or bruisesVascularity or bruises

Skin-Color ChangesSkin-Color Changes

Cyanosis: mottled bluish coloration Cyanosis: mottled bluish coloration Erythema: redness Erythema: redness Pallor: pale, whitish coloration Pallor: pale, whitish coloration Jaundice: yellow colorationJaundice: yellow colorationNoteNote: In a dark-skinned person check: : In a dark-skinned person check: Conjunctiva & sclera, Conjunctiva & sclera, Under the tongue, buccal mucosaUnder the tongue, buccal mucosa

Assessing EdemaAssessing Edema

+1 > mild pitting, slight indentation +1 > mild pitting, slight indentation +2 > moderate pitting , indentation +2 > moderate pitting , indentation

subsides rapidly subsides rapidly +3 > deep pitting; indentation remains +3 > deep pitting; indentation remains

for a short time and leg is swollen for a short time and leg is swollen +4 > very deep pitting; indentation +4 > very deep pitting; indentation

remains for a long time and leg is very remains for a long time and leg is very swollenswollen

HairHairColor, texture, Color, texture,

distribution, lesions distribution, lesions on the scalp, on the scalp, dryness or oiliness, dryness or oiliness, nits or licenits or lice

NailsNailsColor, shape and Color, shape and

contour, size, angle, contour, size, angle, flexibility, flexibility, consistency, lesions, consistency, lesions, capillary-filling timecapillary-filling time

Assessing Capillary-Filling Assessing Capillary-Filling TimeTime

Depress the nail bed to produce Depress the nail bed to produce blanching blanching

Release and observe for the return Release and observe for the return of color of color

Color will return within 3 seconds if Color will return within 3 seconds if arterial capillary perfusion is normalarterial capillary perfusion is normal

The Head, Neck, and Lymph The Head, Neck, and Lymph NodesNodes

Subjective DataSubjective DataHeadaches, dizziness, vertigo Headaches, dizziness, vertigo History of head injury, loss of History of head injury, loss of

consciousness, or seizures; consciousness, or seizures; Medications?Medications?

Neck pain, limitations of range of Neck pain, limitations of range of motion, numbness or tingling motion, numbness or tingling

Lumps or swelling in the neck Lumps or swelling in the neck Difficulty swallowingDifficulty swallowing

Objective DataObjective DataInfo from inspection and palpationInfo from inspection and palpationHeadHeadInspect and palpate: size, shape, Inspect and palpate: size, shape,

masses or tenderness, and masses or tenderness, and symmetry of the skullsymmetry of the skull

Palpate temporal arteriesPalpate temporal arteriesTemporomandibular joint: palpate Temporomandibular joint: palpate

as mouth opens & note crepitation, as mouth opens & note crepitation, tenderness, or limited range of tenderness, or limited range of motionmotion

Face: inspect facial structuresFace: inspect facial structures

NeckNeck Inspect symmetry of accessory neck Inspect symmetry of accessory neck

musclesmusclesAssess ROM (not if (+) neck injury)Assess ROM (not if (+) neck injury)Test cranial nerve XI (spinal accessory Test cranial nerve XI (spinal accessory

nerve) to assess neck muscle strengthnerve) to assess neck muscle strengthCheck for swollen glands at the site of the Check for swollen glands at the site of the

carotid arterycarotid arteryPalpate the trachea: it should be midlinePalpate the trachea: it should be midlineThyroid glandThyroid gland: inspect the neck during sip of : inspect the neck during sip of

water and swallows (moves up with a water and swallows (moves up with a swallow); palpate using an anterior-and-swallow); palpate using an anterior-and-posterior approachposterior approach

Lymph NodesLymph Nodes Palpate using gentle pressure and a circular Palpate using gentle pressure and a circular

motion of the finger pads motion of the finger pads Palpate with both hands, comparing the two Palpate with both hands, comparing the two

sides for symmetry sides for symmetry If nodes are palpated, note their size, If nodes are palpated, note their size,

shape, location, mobility, consistency, and shape, location, mobility, consistency, and tenderness tenderness

Client TeachingClient TeachingNotify MD if persistent headache, dizziness, Notify MD if persistent headache, dizziness,

or neck pain, if swelling or lumps are noted, or neck pain, if swelling or lumps are noted, or if a neck or head injury occursor if a neck or head injury occurs

The Eye: The Eye: Subjective DataSubjective Data

Difficulty with vision (e.g., Difficulty with vision (e.g., decreased acuity, double vision, decreased acuity, double vision, blurring, blind spots) blurring, blind spots)

Pain, redness, swelling, watering Pain, redness, swelling, watering or discharge from the eye or discharge from the eye

Use of glasses or contact lenses Use of glasses or contact lenses Medications being taken Medications being taken History of eye problemsHistory of eye problems

Objective DataObjective Data

Inspection, palpation, vision-testing Inspection, palpation, vision-testing procedures, and the use of an procedures, and the use of an ophthalmoscope ophthalmoscope

Inspect the external eye structures, Inspect the external eye structures, including eyebrows, eyelashes, including eyebrows, eyelashes, ptosis, & the eyeballs ( Enoph or ptosis, & the eyeballs ( Enoph or exophthalmos ) the conjunctiva, exophthalmos ) the conjunctiva, sclera, and lacrimal apparatussclera, and lacrimal apparatus

Objective DataObjective Data

Inspect the anterior eyeball structures, Inspect the anterior eyeball structures, including the cornea and lens (should be including the cornea and lens (should be smooth and clear), iris (should be flat, smooth and clear), iris (should be flat, with a round regular shape and even with a round regular shape and even coloration), eyelids, and pupilscoloration), eyelids, and pupils

Assessing Pupillary ResponsesAssessing Pupillary Responses

Pupillary Light ReflexPupillary Light ReflexDarken the room (dilate the client's Darken the room (dilate the client's

pupils) and ask the client to look forward pupils) and ask the client to look forward Test each eye Test each eye Advance a light in from the side to note Advance a light in from the side to note

constriction of the same-side pupil constriction of the same-side pupil (direct light reflex) and simultaneous (direct light reflex) and simultaneous constriction of the other pupil constriction of the other pupil (consensual light reflex)(consensual light reflex)

Assessing Pupillary ResponsesAssessing Pupillary Responses

Accommodation Accommodation focus on distant object (dilates pupil) focus on distant object (dilates pupil) shift gaze to a object 3 inches from the shift gaze to a object 3 inches from the

nose nose Normal response includes pupillary Normal response includes pupillary

constriction and convergence of the constriction and convergence of the axes of the eyeaxes of the eye

Assessing Pupillary ResponsesAssessing Pupillary Responses

PERRLAPERRLAP = pupils P = pupils E = equal E = equal R = round R = round RL = reactive to light RL = reactive to light A = reactive to accommodationA = reactive to accommodation

Snellen Eye ChartSnellen Eye Chart Position in a well-lit spot 20 feet from Position in a well-lit spot 20 feet from

the chart, at eye level, and ask client to the chart, at eye level, and ask client to read the smallest line he or she can read the smallest line he or she can discern. Test one eye at a timediscern. Test one eye at a time

Record result using the fraction at the Record result using the fraction at the end of the last line successfully read on end of the last line successfully read on the chart; normal visual acuity is 20/20 the chart; normal visual acuity is 20/20 (distance, in feet, at which the subject is (distance, in feet, at which the subject is standing from the chart/distance, in standing from the chart/distance, in feet, at which a normal eye could have feet, at which a normal eye could have read that particular line)read that particular line)

Near VisionNear Vision Use a hand-held vision screener (held Use a hand-held vision screener (held

about 14 inches from the eye) about 14 inches from the eye) containing various sizes of print or ask containing various sizes of print or ask the client to read from a magazinethe client to read from a magazine

Test each eye separately with the Test each eye separately with the client's glasses on or contact lenses in; client's glasses on or contact lenses in; normal result is 14/14 (distance, in normal result is 14/14 (distance, in inches, at which the subject holds the inches, at which the subject holds the card from the eye/distance, in inches, at card from the eye/distance, in inches, at which a normal eye could have read which a normal eye could have read that particular line)that particular line)

Confrontation TestConfrontation TestUsed to measure peripheral vision and Used to measure peripheral vision and

compare the client's peripheral vision compare the client's peripheral vision with the normalwith the normal

Client covers one eye and looks Client covers one eye and looks straight ahead; the nurse, positioned 2 straight ahead; the nurse, positioned 2 feet away, covers his or her eye feet away, covers his or her eye opposite the client's covered eyeopposite the client's covered eye

Nurse advances a finger or other small Nurse advances a finger or other small object in from the periphery from object in from the periphery from several directions; the client sees the several directions; the client sees the object at the same time the nurse doesobject at the same time the nurse does

Corneal Light ReflexCorneal Light ReflexUsed to assess client for parallel Used to assess client for parallel

alignment of the axes of the eyealignment of the axes of the eyeClient is asked to gaze straight ahead Client is asked to gaze straight ahead

as the nurse holds a light about 12 as the nurse holds a light about 12 inches from the clientinches from the client

The nurse looks for reflection of the The nurse looks for reflection of the light on the corneas in exactly the light on the corneas in exactly the same spot in each eyesame spot in each eye

Cover TestCover Test   Used to check for slight degrees of Used to check for slight degrees of

deviated alignment deviated alignment Each eye is tested separately Each eye is tested separately The nurse asks the client to gaze The nurse asks the client to gaze

straight ahead and cover one eye straight ahead and cover one eye The nurse examines the uncovered The nurse examines the uncovered

eye, expecting to note a steady, fixed eye, expecting to note a steady, fixed gazegaze

Cardinal Positions of GazeCardinal Positions of Gaze Used to check for muscle weakness in the Used to check for muscle weakness in the

eyes eyes The client is asked to hold the head steady, The client is asked to hold the head steady,

then follow movement of an object through then follow movement of an object through the positions of gaze the positions of gaze

The client should follow the object in a The client should follow the object in a parallel manner with the two eyes parallel manner with the two eyes

Assess for nystagmus, an oscillating Assess for nystagmus, an oscillating movement of the eye, best seen around the movement of the eye, best seen around the irisiris

Color VisionColor Vision Ishihara chart is a tool used to assess Ishihara chart is a tool used to assess

color vision; it determines the client's color vision; it determines the client's ability to distinguish a pattern of color (a ability to distinguish a pattern of color (a number) in a series of color plates number) in a series of color plates

The nurse tests each eye separately The nurse tests each eye separately and asks the client to identify the and asks the client to identify the number that he or she sees on the number that he or she sees on the chart chart

The ability to read the number correctly The ability to read the number correctly depends on the normal functioning of depends on the normal functioning of color visioncolor vision

Examination of the Internal StructuresExamination of the Internal Structures

Ophthalmoscope Ophthalmoscope Performed in a darkened room Performed in a darkened room Remove? Eyeglasses: Yes; Contacts: No Remove? Eyeglasses: Yes; Contacts: No How: face each other, eyes at the same How: face each other, eyes at the same

height, the ophthalmoscope light on, rotate height, the ophthalmoscope light on, rotate lens to 0 lens to 0

Client gazes straight ahead with both eyes Client gazes straight ahead with both eyes open, stand 10 inches infront; 25 open, stand 10 inches infront; 25 °° lateral to lateral to central line of vision) shines the light on the central line of vision) shines the light on the pupil; (+) red reflexpupil; (+) red reflex

Client TeachingClient Teaching

Instruct the client to notify the health-Instruct the client to notify the health-care provider if alterations in vision care provider if alterations in vision occur or any redness, swelling, or occur or any redness, swelling, or drainage from the eye is noteddrainage from the eye is noted

Inform the client of the importance of Inform the client of the importance of regular eye examinationsregular eye examinations

The Ear: Subjective DataThe Ear: Subjective Data

Difficulty hearing Difficulty hearing Earaches, drainage from the ears, Earaches, drainage from the ears,

dizziness, ringing in the ears dizziness, ringing in the ears Exposure to environmental noise Exposure to environmental noise Use of a hearing aid Use of a hearing aid Medications being taken Medications being taken History of ear problems or infectionsHistory of ear problems or infections

Objective DataObjective Data Includes inspection, palpation, hearing Includes inspection, palpation, hearing

tests, and the use of an otoscopetests, and the use of an otoscopeExternal StructuresExternal Structures Inspect and palpate the external ear, Inspect and palpate the external ear, Inspect the external auditory meatus: Inspect the external auditory meatus:

swelling, discharge, and foreign bodies; swelling, discharge, and foreign bodies; some cerumen (ear wax)some cerumen (ear wax)

Voice TestVoice TestCheck hearing loss Check hearing loss One ear is tested at a time while the client One ear is tested at a time while the client

occludes the other ear with a finger occludes the other ear with a finger

Objective DataObjective Data1 to 2 feet away, mouth 1 to 2 feet away, mouth

covered,whispers two-syllable words covered,whispers two-syllable words in the direction of the unoccluded earin the direction of the unoccluded ear

A ticking watch: tests hearing acuityA ticking watch: tests hearing acuity

Pure-tone audiometry testing: precise Pure-tone audiometry testing: precise quantitative measure of hearing by quantitative measure of hearing by assessing the client's ability to hear assessing the client's ability to hear sounds of varying frequenciessounds of varying frequencies

Tuning-Fork TestsTuning-Fork Tests

Weber TestWeber Test•Vibrating tuning Vibrating tuning fork on skull’s fork on skull’s midline; midline; •Normal bone Normal bone Conduction: tone Conduction: tone bilaterally equalbilaterally equal

Rinne TestRinne Test• fork is placed on fork is placed on

mastoid process mastoid process • As sound As sound

disappears, disappears, quickly invert fork quickly invert fork near the ear canal; near the ear canal; should still hear a should still hear a sound sound

• Normal: air > bone Normal: air > bone conductionconduction

Examination of Internal StructuresExamination of Internal StructuresOtoscopeOtoscope examines for foreign bodies before examines for foreign bodies before

inserting inserting Moving during examination may damage Moving during examination may damage

canal and tympanic membranecanal and tympanic membraneHow? tilt head slightly to the opposite How? tilt head slightly to the opposite

shoulder. Adults: pulls the pinna up & shoulder. Adults: pulls the pinna up & back, holds otoscope upside down, and back, holds otoscope upside down, and inserts the speculum, approx. half an inch inserts the speculum, approx. half an inch

Normal tympanic membrane: translucent, Normal tympanic membrane: translucent, shiny, and pearly grayshiny, and pearly gray

Client TeachingClient Teaching

Instruct to notify MD if an alteration in Instruct to notify MD if an alteration in hearing or ear pain occurs or redness, hearing or ear pain occurs or redness, swelling, or drainage swelling, or drainage

Instruct in proper cleaning of ear canalInstruct in proper cleaning of ear canal- Cleanse ear canal w/ moist washcloth - Cleanse ear canal w/ moist washcloth

- Never insert sharp objects or cotton - Never insert sharp objects or cotton buds into the ear canalbuds into the ear canal

The Nose, Mouth, and ThroatThe Nose, Mouth, and Throat

Subjective Data on noseSubjective Data on nose

Discharge or nosebleed (epistaxis)Discharge or nosebleed (epistaxis)Facial or sinus painFacial or sinus painHistory of frequent colds History of frequent colds Altered sense of smell Altered sense of smell AllergiesAllergiesMedications being taken Medications being taken History of nose trauma or surgeryHistory of nose trauma or surgery

The Nose, Mouth, and ThroatThe Nose, Mouth, and Throat

Subjective Data on Mouth and ThroatSubjective Data on Mouth and Throat

Presence of sores or lesionsPresence of sores or lesionsBleeding from the gums or elsewhereBleeding from the gums or elsewhereAltered sense of taste Altered sense of taste Toothaches, & dentures Toothaches, & dentures Tooth- and mouth-care hygiene habitsTooth- and mouth-care hygiene habitsAt-risk behaviors (e.g., smoking, alcohol)At-risk behaviors (e.g., smoking, alcohol)History of infection, trauma, or surgeryHistory of infection, trauma, or surgery

Objective Data (inspection and palpation)Objective Data (inspection and palpation)NoseNoseExternal nose: midline and in proportion External nose: midline and in proportion Nostril Patency: pushing each nasal Nostril Patency: pushing each nasal

cavity closed and asking to sniff inward cavity closed and asking to sniff inward through the other nostrilthrough the other nostril

Nasal cavity: inspected with speculum & Nasal cavity: inspected with speculum & light (otoscope possible) light (otoscope possible)

Sinus AreasSinus AreasPress frontal sinuses (below eyebrows) & Press frontal sinuses (below eyebrows) &

maxillary sinuses (below cheekbones)maxillary sinuses (below cheekbones)The client should feel firm pressure but The client should feel firm pressure but

no painno pain

LipsLips Inspect the external and inner surfacesInspect the external and inner surfaces

TeethTeeth Inspect the teeth for condition and number, Inspect the teeth for condition and number, Normal: White, spaced, straight, and clean Normal: White, spaced, straight, and clean

JawJawAssess alignment by having client bite downAssess alignment by having client bite down

GumsGums Inspect for swelling, bleeding, discoloration, Inspect for swelling, bleeding, discoloration,

and retraction of gingival marginsand retraction of gingival margins

TongueTongue Inspect color, surface, moisture, white Inspect color, surface, moisture, white

patches, nodules, and ulcerationspatches, nodules, and ulcerationsDorsal: rough; ventral: smooth & glisteningDorsal: rough; ventral: smooth & glisteningBuccal MucosaBuccal MucosaRetract with tongue depressor, note color, Retract with tongue depressor, note color,

nodules or lesionsnodules or lesionsNormal: glistening, pink, soft, & moistNormal: glistening, pink, soft, & moistPalatePalateUsing penlight & tongue depressor, inspect Using penlight & tongue depressor, inspect

the hard and soft palates the hard and soft palates Hard:anterior, white and dome-shapedHard:anterior, white and dome-shapedSoft: pink and smooth Soft: pink and smooth

Inspect for midline location Inspect for midline location CNX (Vagus) test: say "ahhh" & soft palate CNX (Vagus) test: say "ahhh" & soft palate

and uvula to rise in the midline and uvula to rise in the midline

ThroatThroatUsing a penlight and tongue depressor, Using a penlight and tongue depressor,

inspect for color, the presence of exudate or inspect for color, the presence of exudate or lesions, and odorlesions, and odor

Check for the presence of tonsilsCheck for the presence of tonsilsTest CN XII (hypoglossal): stick tongue out Test CN XII (hypoglossal): stick tongue out

(should protrude in the midline)(should protrude in the midline)

Client TeachingClient Teaching

Emphasize Emphasize hygienehygiene and tooth care, need for and tooth care, need for regular dental examinations and the use of regular dental examinations and the use of fluoridated water or fluoride supplementsfluoridated water or fluoride supplements

Encourage to avoid at-risk behaviors (e.g., Encourage to avoid at-risk behaviors (e.g., smoking, alcohol consumption)smoking, alcohol consumption)

Stress the importance of reporting pain or Stress the importance of reporting pain or abnormal occurrences (e.g., nodules, abnormal occurrences (e.g., nodules, lesions, signs of infection)lesions, signs of infection)

The LungsThe LungsSubjective DataSubjective Data CoughCoughExpectoration of sputumExpectoration of sputumDyspnea & Chest pain Dyspnea & Chest pain Respiratory disease or Respiratory disease or

infection, Meds, vice infection, Meds, vice historyhistory

Last tuberculosis test, Last tuberculosis test, chest x-ray, pneumonia chest x-ray, pneumonia and influenza and influenza immunizationsimmunizations

Objective DataObjective Data

Inspecting the Posterior Chest; NoteInspecting the Posterior Chest; NoteSkin color and condition and look for lumps or Skin color and condition and look for lumps or

lesions lesions Chest wall shape and configuration Chest wall shape and configuration position to breatheposition to breathe

Palpating the Posterior ChestPalpating the Posterior Chestnoting skin temperature and moisture and noting skin temperature and moisture and

looking for areas of tenderness and lumps or looking for areas of tenderness and lumps or lesions lesions

ExcursionExcursion

Chest ExcursionChest Excursion Places thumbs along 10Places thumbs along 10thth rib spinal rib spinal

processes with the palms in light contact with processes with the palms in light contact with the posterolateral surfaces the posterolateral surfaces

Thumbs 2 inches apart, pointing toward the Thumbs 2 inches apart, pointing toward the spine, with the fingers pointing laterally spine, with the fingers pointing laterally

Instructs client to take a deep breath after Instructs client to take a deep breath after exhaling; notes thumb movement exhaling; notes thumb movement

Normal: Symmetrical mov’t: separating the Normal: Symmetrical mov’t: separating the thumbs approximately 2 inches  thumbs approximately 2 inches  

FremitusFremitus  Tactile or Vocal FremitusTactile or Vocal FremitusPlaces the ball or lower palm over chest Places the ball or lower palm over chest Begins at the lung apices & palpates from Begins at the lung apices & palpates from

one side to the other for comparison one side to the other for comparison Use a firm light touch; have client to repeat Use a firm light touch; have client to repeat

the word "ninety-nine" the word "ninety-nine" Normally there is a faint vibration as the Normally there is a faint vibration as the

client speaksclient speaks

Percussing the Posterior ChestPercussing the Posterior ChestStart at the apices, percuss across the top of Start at the apices, percuss across the top of

the shoulders, moving to the interspaces, the shoulders, moving to the interspaces, making a side-to-side comparison all the making a side-to-side comparison all the way down the lung area way down the lung area

Determine note; Hyper & Hypo resonance  Determine note; Hyper & Hypo resonance  AuscultationAuscultation Monitor for dizziness: ask to breath thru Monitor for dizziness: ask to breath thru

mouth mouth Use Stet flat diaphragm: listen to 1 full Use Stet flat diaphragm: listen to 1 full

breath in each location breath in each location Start at the apices and move side to side for Start at the apices and move side to side for

comparisoncomparison  

Normal Breath SoundsNormal Breath Sounds

Bronchial (tracheal)Bronchial (tracheal) : high-pitched, : high-pitched, with a harsh, hollow, tubular quality with a harsh, hollow, tubular quality heard over the trachea and larynx heard over the trachea and larynx

BronchovesicularBronchovesicular: moderately : moderately pitched; pitched; heard over the major heard over the major bronchibronchi

VesicularVesicular: low-pitched rustling; heard : low-pitched rustling; heard over the peripheral lung fieldsover the peripheral lung fields

Adventitious SoundsAdventitious Sounds CracklesCrackles

- - FineFine: discontinuous high-pitched crackling : discontinuous high-pitched crackling at inspiration; not cleared with coughat inspiration; not cleared with cough- - CoarseCoarse: loud, low-pitched bubbling and : loud, low-pitched bubbling and gurgling on inspiration; may decrease with gurgling on inspiration; may decrease with coughing or suctioning but reappear coughing or suctioning but reappear

RhonchiRhonchi: loud, low-pitched, coarse rumbling : loud, low-pitched, coarse rumbling during breathing; cleared by coughing during breathing; cleared by coughing

WheezesWheezes: high-pitched, continuous musical : high-pitched, continuous musical sounds during inspiration or expiration sounds during inspiration or expiration

Pleural friction rubPleural friction rub: dry, grating heard best : dry, grating heard best during inspiration; not cleared with coughduring inspiration; not cleared with cough

Voice SoundsVoice Sounds

Auscultate spoken word over the chest wallAuscultate spoken word over the chest wall

BronchophonyBronchophony ( Repeat “99”)( Repeat “99”)Normal: soft, muffled, and indistinct Normal: soft, muffled, and indistinct

EgophonyEgophony ( (repeat a long "ee-ee-ee“)repeat a long "ee-ee-ee“) Nurse would hear the "ee-ee-ee" sound Nurse would hear the "ee-ee-ee" sound

Whispered PectoriloquyWhispered Pectoriloquy (whisper “99" ) (whisper “99" )Normal transmission: faint, muffled, and Normal transmission: faint, muffled, and

almost inaudiblealmost inaudible

Inspecting the Anterior ChestInspecting the Anterior Chest Inspect shape and configurationInspect shape and configurationNote skin color; Respiratory rate and quality Note skin color; Respiratory rate and quality Palpating the Anterior ChestPalpating the Anterior ChestCheck for lumps, masses, and tendernessCheck for lumps, masses, and tendernessPalpate chest excursionPalpate chest excursionPercussing & Auscultating the Anterior ChestPercussing & Auscultating the Anterior ChestPalpate then auscultate from apices in the Palpate then auscultate from apices in the

supraclavicular area to the interspaces and supraclavicular area to the interspaces and down to 6down to 6thth rib; do bilateral comparison rib; do bilateral comparison

Avoid percussion and auscultation over Avoid percussion and auscultation over female breast tissue (displace this tissue) female breast tissue (displace this tissue) because a dull sound will be producedbecause a dull sound will be produced

Client TeachingClient Teaching

Avoid exposure to environmental Avoid exposure to environmental hazards, including smokinghazards, including smoking

Undergo periodic examinations as Undergo periodic examinations as prescribed (e.g., chest x-ray, prescribed (e.g., chest x-ray, tuberculosis skin testing)tuberculosis skin testing)

Pneumonia and influenza Pneumonia and influenza immunizationsimmunizations

Notify MD if client experiences Notify MD if client experiences persistent cough, shortness of breath, persistent cough, shortness of breath, or other respiratory symptomsor other respiratory symptoms

The Heart and Peripheral The Heart and Peripheral Vascular SystemVascular System

Subjective DataSubjective DataChest pain, Dyspnea, Cough & Fatigue Chest pain, Dyspnea, Cough & Fatigue Edema, Nocturia & ObesityEdema, Nocturia & ObesityLeg pain or cramps (claudication) Leg pain or cramps (claudication) Changes in skin color Changes in skin color Medications, Cardiovascular risk factors Medications, Cardiovascular risk factors Personal & Family history of cardiac or Personal & Family history of cardiac or

vascular problems vascular problems

Objective DataObjective DataHeartHeart Inspect apical impulse created as the left Inspect apical impulse created as the left

ventricle rotates against the chest wall ventricle rotates against the chest wall during systole; not always visible during systole; not always visible

Palpate the apical impulse at 4th or 5th Palpate the apical impulse at 4th or 5th interspace, medial to the midclavicular interspace, medial to the midclavicular line (not palpable in obese clients or line (not palpable in obese clients or clients with thick chest walls) clients with thick chest walls)

Palpate the apex, left sternal border, and Palpate the apex, left sternal border, and base for pulsations; normally absentbase for pulsations; normally absent

Percussion to outline the heart's borders Percussion to outline the heart's borders and to check for cardiac enlargementand to check for cardiac enlargement

Objective DataObjective DataHeart Heart AuscultationAuscultation BicuspidBicuspid: 5th interspace, left midclavicular : 5th interspace, left midclavicular

line line AorticAortic: 2nd right interspace : 2nd right interspace PulmonicPulmonic: 2ndnd left interspace : 2ndnd left interspace TricuspidTricuspid: left lower sternal border: left lower sternal borderAuscultate rate and rhythm; check for a Auscultate rate and rhythm; check for a

pulse deficit (auscultate the apical beat pulse deficit (auscultate the apical beat while palpating an artery) if an irregularity while palpating an artery) if an irregularity is notedis noted

Assess S1 ("lub") and S2 ("dub") sounds Assess S1 ("lub") and S2 ("dub") sounds and listen for extra heart sounds, as well and listen for extra heart sounds, as well as the presence of murmursas the presence of murmurs

Objective DataObjective DataPeripheral Vascular SystemPeripheral Vascular SystemPalpate arterial pulses for equality and Palpate arterial pulses for equality and

symmetry and checking the condition of the symmetry and checking the condition of the skin and nailsskin and nails

Check for pretibial edema and measure calf Check for pretibial edema and measure calf circumference  circumference 

Measure blood pressure Measure blood pressure Palpate superficial inguinal nodes from Palpate superficial inguinal nodes from

groin area and moving down groin area and moving down An ultrasonic stethoscope may be needed An ultrasonic stethoscope may be needed

to amplify the sounds of a pulse wave if the to amplify the sounds of a pulse wave if the pulse cannot be palpated pulse cannot be palpated

Objective DataObjective Data

Carotid ArteryCarotid Artery Located in the groove between the trachea Located in the groove between the trachea

and sternocleidomastoid muscle, medial to and sternocleidomastoid muscle, medial to and alongside the muscleand alongside the muscle

Palpate one carotid artery at a time; avoid Palpate one carotid artery at a time; avoid compromising blood flow to the braincompromising blood flow to the brain

Auscultate each carotid artery for the Auscultate each carotid artery for the presence of a bruit (a blowing, swishing presence of a bruit (a blowing, swishing sound), which indicates blood-flow sound), which indicates blood-flow turbulence; turbulence; normally a bruit is not presentnormally a bruit is not present

Arteries in the Arms and HandsArteries in the Arms and Hands Radial pulseRadial pulseUlnar pulseUlnar pulseBrachial pulse Brachial pulse

Arteries in the LegsArteries in the Legs Femoral pulseFemoral pulsePopliteal pulse Popliteal pulse Dorsalis pedis pulseDorsalis pedis pulsePosterior tibial pulsePosterior tibial pulse

Grading the Force (Amplitude) of Grading the Force (Amplitude) of PulsesPulses

4+ = strong and bounding4+ = strong and bounding3+ = full pulse, increased3+ = full pulse, increased2+ = normal, easily palpable2+ = normal, easily palpable1+ = weak, barely palpable1+ = weak, barely palpable0 = absent, not palpable0 = absent, not palpableClient TeachingClient Teachingmodify risk factors, regular physical examsmodify risk factors, regular physical examsseek medical assistance for signs of heart seek medical assistance for signs of heart

or vascular diseaseor vascular disease

The BreastsThe Breasts

Subjective DataSubjective DataPain or tenderness, Rash or swellingPain or tenderness, Rash or swellingLumps or thickening; swollen axillary Lumps or thickening; swollen axillary

lymph nodes & Nipple dischargelymph nodes & Nipple dischargeMedications being takenMedications being takenPersonal or family history of breast Personal or family history of breast

disease, Meds & prev. medical historydisease, Meds & prev. medical historyBreast self-examination compliance Breast self-examination compliance Mammograms as prescribedMammograms as prescribed

Objective DataObjective Data

InspectionInspectionPerformed with the client's arms raised Performed with the client's arms raised

above the head, the hands pressed against above the head, the hands pressed against the hips, and the arms extended straight the hips, and the arms extended straight ahead while the client sits and leans ahead while the client sits and leans forward  forward 

Assess size and symmetry (one breast is Assess size and symmetry (one breast is often larger than the other); masses, often larger than the other); masses, flattening, retraction, or dimpling; color and flattening, retraction, or dimpling; color and venous pattern; size, color, shape, and venous pattern; size, color, shape, and discharge in nipple and areola; and the discharge in nipple and areola; and the direction in which nipples pointdirection in which nipples point

PalpationPalpationBreast tissueBreast tissue

- Client lies supine, arm on the side - Client lies supine, arm on the side being examined behind the head and a being examined behind the head and a small pillow under the shouldersmall pillow under the shoulder- Use pads of the 1st 3 fingers to - Use pads of the 1st 3 fingers to compress the breast tissue gently compress the breast tissue gently against the chest against the chest - Palpate systematically - Palpate systematically - Gently palpates nipple & areola; - Gently palpates nipple & areola; compress nipple, noting any compress nipple, noting any dischargedischarge       

PalpationPalpationAxillary lymph nodesAxillary lymph nodes

– Stand on the side being examined, Stand on the side being examined, support client's arm in a slightly flexed support client's arm in a slightly flexed position, and abducts the arm away from position, and abducts the arm away from the chest wallthe chest wall

– Places the free hand against the chest Places the free hand against the chest wall and high in the axillary hollow, then, wall and high in the axillary hollow, then, with the fingertips, gently presses down, with the fingertips, gently presses down, rolling soft tissue over the surface of the rolling soft tissue over the surface of the ribs and musclesribs and muscles

– Lymph nodes are normally not palpableLymph nodes are normally not palpable

Client TeachingClient Teaching

Encourage client to perform breast Encourage client to perform breast self-examinationself-examination

Regular physical examinations and Regular physical examinations and mammograms should be obtained mammograms should be obtained as prescribedas prescribed

Client should report lumps or Client should report lumps or masses to the health-care provider masses to the health-care provider immediatelyimmediately

The AbdomenThe Abdomen

Subjective DataSubjective DataChanges in appetite or weightChanges in appetite or weightDifficulty swallowingDifficulty swallowingDiet intake; Intolerance to certain foodsDiet intake; Intolerance to certain foodsNausea or vomiting; PainNausea or vomiting; PainBowel habitsBowel habitsMedications currently takingMedications currently takingHistory of abdominal problems or History of abdominal problems or

abdominal surgeryabdominal surgery

Objective Data (IAPP) Objective Data (IAPP) Ask the client to empty the bladder Ask the client to empty the bladder Warm hands & steth endpieceWarm hands & steth endpieceExamine painful areas lastExamine painful areas lastInspection Inspection Contour: flat, rounded, or protuberant Contour: flat, rounded, or protuberant Symmetry: note any bulging or masses Symmetry: note any bulging or masses Umbilicus: should be midline and inverted Umbilicus: should be midline and inverted Skin surface: should be smooth and even Skin surface: should be smooth and even Pulsations from the aorta may be noted in Pulsations from the aorta may be noted in

the epigastric area, and peristaltic waves the epigastric area, and peristaltic waves may be noted across the abdomenmay be noted across the abdomen

Auscultation Auscultation  Performed before percussion and palpationPerformed before percussion and palpationHold steth lightly against the skin and listen Hold steth lightly against the skin and listen

for bowel sounds in all four quadrants; begin for bowel sounds in all four quadrants; begin in the right lower quadrant in the right lower quadrant

Normal bowel sounds: high-pitched gurgling Normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30/min sounds occurring irregularly from 5 to 30/min

Identify as normal, hypoactive, or Identify as normal, hypoactive, or hyperactive (borborygmus) hyperactive (borborygmus)

Absent sounds: auscultate for 5 minutes Absent sounds: auscultate for 5 minutes before determining that sounds are absent before determining that sounds are absent

Auscultate over the aorta, renal arteries, iliac Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular arteries, and femoral arteries for vascular sounds or bruits  sounds or bruits  

PercussionPercussionAll four quadrants are percussed lightly All four quadrants are percussed lightly Borders of the liver and spleen are Borders of the liver and spleen are

percussedpercussedTympany should predominate over the Tympany should predominate over the

abdomen with dullness over the liver and abdomen with dullness over the liver and spleen spleen

Percussion over the kidney at the 12 ribs Percussion over the kidney at the 12 ribs (costovertebral angle) should produce no (costovertebral angle) should produce no painpain

PalpationPalpation Begin with light palpation of all four Begin with light palpation of all four

quadrants, using the fingers to depress the quadrants, using the fingers to depress the skin about 1 cm; next perform deep skin about 1 cm; next perform deep palpation, depressing 5 to 8 cm palpation, depressing 5 to 8 cm

Palpate the liver and spleen (may not be Palpate the liver and spleen (may not be palpable) palpable)

Palpate the aortic pulsation in the upper Palpate the aortic pulsation in the upper abdomen slightly to the left of midline; abdomen slightly to the left of midline; normally it pulsates in an forward direction normally it pulsates in an forward direction (pulsation expands laterally if an aneurysm is (pulsation expands laterally if an aneurysm is present)present)

Client TeachingClient TeachingEncourage client to consume a balanced dietEncourage client to consume a balanced dietSubstances that can cause gastric irritation Substances that can cause gastric irritation

should be avoidedshould be avoidedThe regular use of laxatives is discouragedThe regular use of laxatives is discouragedLifestyle behaviors that can cause gastric Lifestyle behaviors that can cause gastric

irritation (e.g., smoking) should be modifiedirritation (e.g., smoking) should be modifiedRegular physical examinations are importantRegular physical examinations are importantThe client should report gastrointestinal The client should report gastrointestinal

problems to the health-care providerproblems to the health-care provider

The Musculoskeletal SystemThe Musculoskeletal System

Subjective DataSubjective DataJt pain or stiffness; swelling or warmth Jt pain or stiffness; swelling or warmth Limited motion of  joints Limited motion of  joints Muscle/bone pain, cramps, or weakness Muscle/bone pain, cramps, or weakness ADL Limitations; Exercise patterns ADL Limitations; Exercise patterns Occupational hazards (e.g., heavy lifting) Occupational hazards (e.g., heavy lifting) Meds; History of joint, muscle, or bone Meds; History of joint, muscle, or bone

injuries & surgeryinjuries & surgery

Objective DataObjective Data

InspectionInspectionGait and posture, spinal curvesGait and posture, spinal curves

PalpationPalpationPalpate all bones, joints, & musclesPalpate all bones, joints, & muscles

Range of MotionRange of MotionDo Active & passive ROM exercises Do Active & passive ROM exercises Check for pain, limited mobility, spastic Check for pain, limited mobility, spastic

movement, joint instability, stiffness, and movement, joint instability, stiffness, and contracturescontractures

Muscle Tone and StrengthMuscle Tone and StrengthDone during ROM assessmentDone during ROM assessmentHypertonicity or Hypotonicity Hypertonicity or Hypotonicity Grading Muscle StrengthGrading Muscle Strength (0-5) (0-5)

Client TeachingClient TeachingConsume a balanced diet, weight mgtConsume a balanced diet, weight mgtModerate activities; do regular Moderate activities; do regular

exercise exercise Contact MD if joint or muscle pain or Contact MD if joint or muscle pain or

problems occur or if limitations in ROM problems occur or if limitations in ROM or muscle strength developor muscle strength develop

The Neurological SystemThe Neurological System

Subjective DataSubjective DataHeadaches; Dizziness or vertigoHeadaches; Dizziness or vertigoTremors, Weakness & IncoordinationTremors, Weakness & IncoordinationParesthesia, Dysarthria & dysphagiaParesthesia, Dysarthria & dysphagiaMedications currently takingMedications currently takingHistory of seizures, injury or surgeryHistory of seizures, injury or surgeryExposure to environmental or Exposure to environmental or

occupational hazards (chemicals & vices)occupational hazards (chemicals & vices)

Objective DataObjective Data

Assess cranial nerves, level of Assess cranial nerves, level of consciousness, pupils, motor function, consciousness, pupils, motor function, cerebellar function, coordination, cerebellar function, coordination, sensory function, and reflexes sensory function, and reflexes

OOOTTAFAGVAHOOOTTAFAGVAHNote mental and emotional status, Note mental and emotional status,

behavior and appearance, language behavior and appearance, language ability, and intellectual functioning, ability, and intellectual functioning, including memory, knowledge, abstract including memory, knowledge, abstract thinking, association, and judgmentthinking, association, and judgment

Cranial Nerve AssessmentCranial Nerve Assessment

Cranial Nerve I (Olfactory: sensory, smell)Cranial Nerve I (Olfactory: sensory, smell) close eyes with one occluded nostril close eyes with one occluded nostril identify nonirritating odors identify nonirritating odors Repeat the test on the other nostrilRepeat the test on the other nostrilCranial Nerve II (Optic: sensory, vision)Cranial Nerve II (Optic: sensory, vision) visual acuity: Snellen chart or others visual acuity: Snellen chart or others Check visual fields by confrontation Check visual fields by confrontation Check color vision Check color vision Cranial Nerves III , IV, and VI Cranial Nerves III , IV, and VI Motor functions overlap; Test togetherMotor functions overlap; Test together

1st inspect: ptosis then eye movements 1st inspect: ptosis then eye movements 22ndnd : Accommodation/ direct light reflexes : Accommodation/ direct light reflexes

Cranial nerve III (oculomotor): motorCranial nerve III (oculomotor): motor; ; controls  pupillary constriction, upper-controls  pupillary constriction, upper-eyelid elevation, and most eye movementeyelid elevation, and most eye movement

Cranial nerve IV (trochlear): motorCranial nerve IV (trochlear): motor; ; downward and inward eye movementdownward and inward eye movement

Cranial nerve VI (abducens): Motor;Cranial nerve VI (abducens): Motor;

controls lateral eye movementcontrols lateral eye movement

Cranial Nerve VCranial Nerve V (Trigeminal: Both) (Trigeminal: Both) Sensation: Cornea, nasal and oral mucosa, Sensation: Cornea, nasal and oral mucosa,

and facial skin, as well as mastication (motor)and facial skin, as well as mastication (motor)Cranial Nerve VIICranial Nerve VII (Facial: Both) (Facial: Both)Taste: ant. 2/3 of the tongueTaste: ant. 2/3 of the tongueCheck: smile, frown, and show the teeth   Check: smile, frown, and show the teeth   Close eyes against resistance, puff cheeksClose eyes against resistance, puff cheeksCranial Nerve VIII (Acoustic: sensory)Cranial Nerve VIII (Acoustic: sensory)hearing (cochlear); equilibrium (vestibular) hearing (cochlear); equilibrium (vestibular) Cranial Nerve IX ( Glossopharyngeal: Both)Cranial Nerve IX ( Glossopharyngeal: Both)Motor: swallowing; sensation: soft palate & Motor: swallowing; sensation: soft palate &

tonsils, taste on tongue’s posterior 3tonsils, taste on tongue’s posterior 3rdrd and and salivation; Gag reflexsalivation; Gag reflex

Cranial Nerve X (Vagus: Both)Cranial Nerve X (Vagus: Both)Swallowing & phonation, sensation in the Swallowing & phonation, sensation in the

exterior ear exterior ear thoracic and abdominal viscera sensationthoracic and abdominal viscera sensationCranial Nerve XI (Spinal accessory: motor)Cranial Nerve XI (Spinal accessory: motor)Sternocleidomastoid & Trapezius: Sternocleidomastoid & Trapezius:

movement against resistance  movement against resistance  Cranial Nerve XII (Hypoglossal: motor)Cranial Nerve XII (Hypoglossal: motor)Tongue movts; swallowing and speechTongue movts; swallowing and speechcheck asymmetry, atrophy, deviation, and check asymmetry, atrophy, deviation, and

fasciculations (uncontrollable twitching) fasciculations (uncontrollable twitching)

Level of ConsciousnessLevel of Consciousness(alertness, confusion, delirium, (alertness, confusion, delirium,

unconsciousness, stupor, coma)unconsciousness, stupor, coma)Appropriateness of behavior & talkAppropriateness of behavior & talkCerebellar FunctionCerebellar FunctionMonitor gait; Romberg test; knee bends/hopsMonitor gait; Romberg test; knee bends/hopsCoordinationCoordinationperform rapid alternating movements of the perform rapid alternating movements of the

hands (turning hands over & patting knees)  hands (turning hands over & patting knees)  Touch finger exercise  Touch finger exercise  Heel-to-shin test: supine positionHeel-to-shin test: supine position

Sensory FunctionSensory Function Pain: sharp vs a dull feelings  Pain: sharp vs a dull feelings  Light touch: piece of cotton Light touch: piece of cotton Vibration: tuning fork Vibration: tuning fork Position (kinesthesia): movt perceptionPosition (kinesthesia): movt perceptionStereognosis & GraphesthesiaStereognosis & GraphesthesiaTwo-point discriminationTwo-point discriminationDeep Tendon ReflexesDeep Tendon ReflexesLimb relaxed,tapped quickly with a reflex Limb relaxed,tapped quickly with a reflex

hammer hammer Plantar Reflex  vs Babinski's signPlantar Reflex  vs Babinski's sign

Client TeachingClient Teaching

Client should avoid exposure to Client should avoid exposure to environmental hazards (e.g., environmental hazards (e.g., insecticides, lead)insecticides, lead)

High-risk behaviors that can result in High-risk behaviors that can result in head and spinal-cord injuries should be head and spinal-cord injuries should be avoidedavoided

Protective devices (e.g., a helmet) Protective devices (e.g., a helmet) should be worn during participating in should be worn during participating in high-risk behaviorshigh-risk behaviors

The Mental-Status ExaminationThe Mental-Status ExaminationDone during the health history interview Done during the health history interview AppearanceAppearanceNote appearance; posture, body movts, Note appearance; posture, body movts,

dress, hygiene & groomingdress, hygiene & grooming inappropriate appearance & poor hygiene inappropriate appearance & poor hygiene

indicative of Mental problem indicative of Mental problem BehaviorBehaviorLevel of consciousnessLevel of consciousnessFacial expression and body languageFacial expression and body languageSpeechSpeech

Cognitive Level of FunctioningCognitive Level of Functioning

OrientationOrientation: person, place, and time : person, place, and time AttentionAttention spanspan: concentration : concentration RecentRecent memorymemory: recent occurrence : recent occurrence RemoteRemote memorymemory: verifiable past event: verifiable past eventNewNew learninglearning: select four words & ask to : select four words & ask to

recall 5, 10, and 30 minutes later recall 5, 10, and 30 minutes later JudgmentJudgment: decisions are realistic? : decisions are realistic? ThoughtThought processesprocesses andand perceptionsperceptions: the : the

way of thinking and words should be way of thinking and words should be logical, coherent, and relevant; should logical, coherent, and relevant; should be consistently aware of reality be consistently aware of reality

HealthHealth

Level of wellness & Level of wellness & well-beingwell-being

Physiological, Physiological, psychological, psychological, sociological, and sociological, and spiritual well-being spiritual well-being alter the level of alter the level of wellnesswellness

Health PromotionHealth Promotion Maintain or enhance well-Maintain or enhance well-

being as a protection being as a protection against illnessagainst illness

Disease PreventionDisease PreventionProtect from actual or Protect from actual or

potential threats to health potential threats to health and assist in maintaining and assist in maintaining an optimal level of healthan optimal level of health

The role of the nurse? The role of the nurse?

Levels of Preventive CareLevels of Preventive CarePrimary prevention: Primary prevention:

– health-education programs and wellness health-education programs and wellness activities activities

Secondary prevention: Secondary prevention: – screening techniques and treatment of screening techniques and treatment of

disease disease Tertiary prevention:Tertiary prevention:

– focuses on rehabilitation to achieve as focuses on rehabilitation to achieve as high a level of function as possiblehigh a level of function as possible

Health ScreeningHealth ScreeningSubjective and objective data: past & current Subjective and objective data: past & current

health status, family health historyhealth status, family health historyChildhood diseases & immunizations, Childhood diseases & immunizations,

accidents & injuries, serious or chronic accidents & injuries, serious or chronic illnesses, hospitalizations and surgeries, illnesses, hospitalizations and surgeries, obstetric history, allergies, last examination obstetric history, allergies, last examination date, current lifestyle practices, and date, current lifestyle practices, and medications being takenmedications being taken

Health of close family members such as Health of close family members such as spouse and childrenspouse and children

A genogram or family treeA genogram or family tree

Perception of Health StatusPerception of Health Status

Determine personal practices for Determine personal practices for maintaining healthmaintaining health

Obtain a family history; a history of Obtain a family history; a history of health habits such as smoking, alcohol, health habits such as smoking, alcohol, and drug use; history of exposure to and drug use; history of exposure to environmental hazards; and any high-environmental hazards; and any high-risk behaviorsrisk behaviors

what illness means to the client? and what illness means to the client? and what is done when ill?what is done when ill?

Identify client's health goalsIdentify client's health goals

Self-Care AbilitiesSelf-Care Abilities

Assess ADL needs especially related to Assess ADL needs especially related to basic needs basic needs

Instrumental activities needed for Instrumental activities needed for independent living? independent living?

Physical and cognitive ability to care for Physical and cognitive ability to care for self? self?

Assess the home environment for Assess the home environment for barriers? barriers?

family or friends assistance?family or friends assistance? Identify and initiate referrals for resourcesIdentify and initiate referrals for resources

Risk Factors for DiseaseRisk Factors for Disease PhysiologicalPhysiologicalGenetic or hereditaryGenetic or hereditaryEthnicity and cultureEthnicity and cultureAge: can increase or decrease Age: can increase or decrease

susceptibility to certain diseasessusceptibility to certain diseasesEnvironment: exposure to health Environment: exposure to health

hazards in the home or work hazards in the home or work Lifestyle: practices with potential Lifestyle: practices with potential

negative effectsnegative effects

Negative Lifestyle PracticesNegative Lifestyle Practices

Overeating or poor nutritionOvereating or poor nutrition Insufficient rest or sleepInsufficient rest or sleepPoor personal hygienePoor personal hygieneTobacco useTobacco useAlcohol or drug useAlcohol or drug useExtreme sportsExtreme sportsStress Stress

Teaching-Learning PrinciplesTeaching-Learning PrinciplesReadiness & motivation to learn; Consider Readiness & motivation to learn; Consider

health beliefs, age & education health beliefs, age & education use existing knowledge, Physical and use existing knowledge, Physical and

cognitive abilities as base for teaching cognitive abilities as base for teaching Learning objectives facilitate the teaching Learning objectives facilitate the teaching

process process Include family members in the learning Include family members in the learning

processprocessAllow ample time for to understand teachingsAllow ample time for to understand teachingsReturn demo Return demo

Considerations in TeachingConsiderations in TeachingInfantInfant ToddlerToddler Learns by associating words with objects Learns by associating words with objects Allow toddler to handle examination Allow toddler to handle examination

equipment equipment Preschooler Preschooler Asks questions; Asks questions; Use role-playing and Use role-playing and

imitationimitation School-Age Child School-Age Child Makes judgments, is InquisitiveMakes judgments, is InquisitiveUse independent projects and gamesUse independent projects and games

Considerations in TeachingConsiderations in Teaching

Adolescent Adolescent Learns best with benefit is gained Learns best with benefit is gained Allow decisions; use problem-solving to help Allow decisions; use problem-solving to help

the child make these choices the child make these choices Young or Middle AdultYoung or Middle Adult Offer info & encourage participation and Offer info & encourage participation and

independent learning independent learning Older AdultOlder Adult learns best: info presented in small amounts learns best: info presented in small amounts

at a slow pace at a slow pace Teach when alert and restedTeach when alert and rested

Teaching ToolsTeaching Tools

Pamphlets, booklets, brochuresPamphlets, booklets, brochuresDiagrams, graphs, charts, picturesDiagrams, graphs, charts, picturesSlides, audiotapes, videotapes, Slides, audiotapes, videotapes,

televisiontelevisionPhysical objectsPhysical objectsProgrammed instructionProgrammed instructionComputer instructionComputer instruction

Lifestyle Choices and Health Lifestyle Choices and Health Practices Practices 

How the client manages his or her life How the client manages his or her life The client's awareness of healthy The client's awareness of healthy

versus non-healthy living patterns versus non-healthy living patterns How the client incorporates healthy How the client incorporates healthy

living patterns into his or her lifestyle living patterns into his or her lifestyle Strengths and supports that the client Strengths and supports that the client

has or uses has or uses

Assessment of Lifestyle PatternsAssessment of Lifestyle Patterns

Client's typical dayClient's typical dayNutritional and Nutritional and

weight mgtweight mgtActivity & exerciseActivity & exerciseSleep & rest Sleep & rest Medication useMedication useEnvironmentEnvironmentSelf-care Self-care

responsibilitiesresponsibilities

Relationships and Relationships and social activitiessocial activities

Values and belief Values and belief systemsystem

Education and workEducation and workStress levels and Stress levels and

coping stylescoping styles

Nutritional Patterns, Elimination, Nutritional Patterns, Elimination, and Weight Managementand Weight Management

Record as an average 24-hour intake Record as an average 24-hour intake Record foods eaten and their amountsRecord foods eaten and their amountsAre finances adequate? prepares the food? Are finances adequate? prepares the food?

when and where meals are eaten when and where meals are eaten Identify food allergies and intolerances Identify food allergies and intolerances Ask client about bowel and bladder habits Ask client about bowel and bladder habits Weigh client and identify nutritional patterns Weigh client and identify nutritional patterns

used to manage weight used to manage weight

Food-Guide PyramidFood-Guide Pyramid

Clear-Liquid DietClear-Liquid Diet Prevents dehydrationPrevents dehydration

Nursing ConsiderationsNursing ConsiderationsClear liquid is deficient in Clear liquid is deficient in

energy and most energy and most nutrients; 1-2 days only nutrients; 1-2 days only

Foods: transparent to Foods: transparent to light; liquid at room and light; liquid at room and body temperature (e.g., body temperature (e.g., broth, gelatin, clear fruit broth, gelatin, clear fruit juices, Popsicles)juices, Popsicles)

2nd diet, after clear liquids, surgery; or 2nd diet, after clear liquids, surgery; or unable to chew or swallowunable to chew or swallow

Nursing ConsiderationsNursing ConsiderationsNutritionally deficient; Clear & opaque liquid Nutritionally deficient; Clear & opaque liquid

foods (e.g., custard, refined cooked cereal); foods (e.g., custard, refined cooked cereal); may also include liquid dietary supplementsmay also include liquid dietary supplements

Full Full Liquid Liquid

DietDiet

Soft DietSoft DietDental problems or poor-fitting dentures, Dental problems or poor-fitting dentures,

difficulty chewing or swallowing, and difficulty chewing or swallowing, and impaired digestion or absorption impaired digestion or absorption

Nursing ConsiderationsNursing ConsiderationsPlenty of fluids with meals to ease Plenty of fluids with meals to ease

chewing and swallowing chewing and swallowing All foods and seasonings are permitted; All foods and seasonings are permitted;

however, however, liquid, chopped, or pureedliquid, chopped, or pureed foods and regular foods with a soft foods and regular foods with a soft consistency are best toleratedconsistency are best tolerated

Bland DietBland DietGastritis, ulcers, reflux esophagitis, Gastritis, ulcers, reflux esophagitis,

congestive heart failure, or myocardial congestive heart failure, or myocardial infarction infarction

Nursing ConsiderationsNursing ConsiderationsEliminates gastric-acid stimulating and Eliminates gastric-acid stimulating and

gastric irritating foods gastric irritating foods Avoided include: alcohol; caffeine and Avoided include: alcohol; caffeine and

caffeine-containing beverages; fried foods; caffeine-containing beverages; fried foods; pepper and other spicy foodspepper and other spicy foods

Low-Residue DietLow-Residue Diet Non-obstructive Non-obstructive

food; GIT food; GIT inflammation or inflammation or scarring scarring

NursingNursing ConsiderationsConsiderations

High carbohydrate High carbohydrate (e.g., white bread, (e.g., white bread, cereals, pasta)cereals, pasta)

High-Residue Diet High-Residue Diet Constipation; alternating Constipation; alternating

C&D ; & asymptomatic C&D ; & asymptomatic diverticular diseasediverticular disease

Regulates blood glucose Regulates blood glucose and cholesterol and cholesterol

NursingNursing ConsiderationsConsiderationsConsists of fruits and Consists of fruits and

vegetables and whole-vegetables and whole-grain productsgrain products

Fat-Controlled DietFat-Controlled Diet

DM, atherosclerosis, DM, atherosclerosis, hyperlipidemia, Htn, MI, hyperlipidemia, Htn, MI, nephrotic syndrome, & nephrotic syndrome, & renal failure renal failure

Reduces the risk of Reduces the risk of heart diseaseheart disease

Nursing ConsiderationsNursing ConsiderationsLimits the total amount Limits the total amount

of fats and cholesterolof fats and cholesterol

High-Calorie DietHigh-Calorie DietSevere stress, burns, Severe stress, burns,

cancer, HIV infection, cancer, HIV infection, AIDS, COPD, respiratory AIDS, COPD, respiratory failure, and any other type failure, and any other type of debilitating diseaseof debilitating disease

Nursing ConsiderationsNursing Considerationshigh in protein for body-high in protein for body-

building building Encourage snacks Encourage snacks

between meals (e.g., between meals (e.g., milkshakes, instant milkshakes, instant breakfasts)breakfasts)

Sodium-Restriction DietSodium-Restriction Diet

HTN, CHF, kidney diseases, HTN, CHF, kidney diseases, cardiac disease, and cardiac disease, and cirrhosis cirrhosis

Nursing ConsiderationsNursing Considerations

Mild: 2000 to 4000 mgMild: 2000 to 4000 mg

Moderate: 1000 mg Moderate: 1000 mg

Strict: 500 mg (seldom) Strict: 500 mg (seldom)

Cereals allowed on a sodium-Cereals allowed on a sodium-restricted diet restricted diet

Protein-Restriction DietProtein-Restriction DietUsed in cases of acute or Used in cases of acute or

chronic renal disease, chronic renal disease, cirrhosis of the liver, and cirrhosis of the liver, and hepatic comahepatic coma

Nursing ConsiderationsNursing ConsiderationsSmaller protein allowed; Smaller protein allowed;

high qualityhigh quality(protein will be used for (protein will be used for

energy rather than protein energy rather than protein synthesis)synthesis)

Consumption of milk, Consumption of milk, meat, and bread and meat, and bread and other starches is limitedother starches is limited

High-Protein DietHigh-Protein Diet

fracture, burn, fracture, burn, elderly, and elderly, and pregnantpregnant

Nursing Nursing ConsiderationsConsiderations

legumes, eggs, legumes, eggs, meat, fish, fowl, and meat, fish, fowl, and dairy productsdairy products

Needs protein Needs protein supplementssupplements

Low-Calcium DietLow-Calcium Diet

Prevent renal calculi Prevent renal calculi

Nursing ConsiderationsNursing ConsiderationsDecrease the client's Decrease the client's

total intake of calcium to total intake of calcium to prevent further stone prevent further stone formation; avoid whole formation; avoid whole grains, dairy products, grains, dairy products, and green, leafy and green, leafy vegetablesvegetables

High-Calcium DietHigh-Calcium Dietbone growth and in bone growth and in

adulthood to prevent adulthood to prevent osteoporosisosteoporosis

Nursing ConsiderationsNursing ConsiderationsDairy products; other Dairy products; other

sources include turnip sources include turnip greens, sardines, greens, sardines, salmon, tofu, and salmon, tofu, and spinach spinach

Lactose intolerance?Lactose intolerance?

Low-Purine DietLow-Purine Diet

Used to treat goutUsed to treat gout

Nursing ConsiderationsNursing ConsiderationsThe client needs to avoid consuming The client needs to avoid consuming

fish such as anchovy, herring, fish such as anchovy, herring, mackerel, and sardine; scallops; mackerel, and sardine; scallops; glandular meats; gravies; meat extracts; glandular meats; gravies; meat extracts; wild game; and goosewild game; and goose

High-Iron DietHigh-Iron DietUsed in cases of Used in cases of

anemiaanemia

Nursing ConsiderationsNursing Considerations Includes organ meats, Includes organ meats,

meat, egg yolks, whole-meat, egg yolks, whole-wheat products, leafy wheat products, leafy vegetables, dried fruit, vegetables, dried fruit, and legumesand legumes

Diets for Diverticular Diets for Diverticular DiseaseDisease

Symptomatic diverticulitis: No high-Symptomatic diverticulitis: No high-fiber fiber

Asymptomatic diverticular Asymptomatic diverticular disease: yes to high-fiber diet; disease: yes to high-fiber diet; prevent constipation prevent constipation

2500 to 3000 mL per day unless 2500 to 3000 mL per day unless this is contraindicatedthis is contraindicated

Fluid RestrictionFluid Restriction Oliguric phase of acute Oliguric phase of acute

renal failure and in cases of renal failure and in cases of chronic renal disease, chronic renal disease, cirrhosis of the liver, cirrhosis of the liver, congestive heart failure, congestive heart failure, hepatic coma, and hepatic coma, and myocardial infarctionmyocardial infarction

Nursing ConsiderationsNursing ConsiderationsUsually this diet restricts Usually this diet restricts

consumption of foods that consumption of foods that are composed largely of are composed largely of waterwater

Carbohydrate-Controlled DietCarbohydrate-Controlled Diet

Maintain normal glucose levels in clients Maintain normal glucose levels in clients Used in cases of diabetes mellitus, Used in cases of diabetes mellitus,

hypoglycemia, lactose intolerance, hypoglycemia, lactose intolerance, galactosemia, dumping syndrome, and galactosemia, dumping syndrome, and obesityobesity

Nursing ConsiderationsNursing ConsiderationsUse Exchange System groups Use Exchange System groups Major food groups: carbohydrate, the meat Major food groups: carbohydrate, the meat

and meat-substitute, and the fat groupand meat-substitute, and the fat group

Vegetarian DietsVegetarian Diets

Lacto-Ovo VegetarianLacto-Ovo VegetarianConsumes plant, dairy, and eggs Consumes plant, dairy, and eggs Eats fish and, occasionally, poultry Eats fish and, occasionally, poultry

Lacto VegetarianLacto VegetarianConsumes plant and dairy products but not Consumes plant and dairy products but not

eggs eggs

VeganVeganFollows a strict vegetarian diet that includes Follows a strict vegetarian diet that includes

no animal-based foodsno animal-based foods

Enteral NutritionEnteral NutritionDescriptionDescription Introduces liquefied foods into the Introduces liquefied foods into the

gastrointestinal tract by way of a tubegastrointestinal tract by way of a tubeIndicationsIndicationsUsed when the gastrointestinal tract is Used when the gastrointestinal tract is

functional but functional but oral intake is not feasibleoral intake is not feasibleNursing ConsiderationsNursing ConsiderationsClients with lactose intolerance must be Clients with lactose intolerance must be

given lactose-free formulasgiven lactose-free formulas

Medication and Substance UseMedication and Substance Use

Affects health, cause function loss, or Affects health, cause function loss, or impairs senses impairs senses

May increase risk for disease May increase risk for disease Note all prescription & OTC meds taken Note all prescription & OTC meds taken Ask about the vitamins and herbalsAsk about the vitamins and herbalsAsk about the use of tobacco, alcohol, and Ask about the use of tobacco, alcohol, and

street drugs; and its effects work or family street drugs; and its effects work or family Provide info about rehab programsProvide info about rehab programs

EnvironmentEnvironmentNote hazards in the home Note hazards in the home

and workplace; safety and workplace; safety Alone? knows neighbors? Alone? knows neighbors?

involved in community? involved in community? Identify healthy Identify healthy

environmental patterns, environmental patterns, such as the use of seat such as the use of seat belts belts

Teach about hazards and Teach about hazards and preventive measurespreventive measures

Self-Concept/ Care Self-Concept/ Care ResponsibilitiesResponsibilities

Attitudes about self, Attitudes about self, perception of personal perception of personal abilities, body image, and abilities, body image, and general sense of worthgeneral sense of worth

Provide with information Provide with information regarding activities that regarding activities that will promote healthwill promote health

Behaviors That Promote HealthBehaviors That Promote Health

Basic hygiene practices Basic hygiene practices Regular health care check-ups Regular health care check-ups Breast self-examination Breast self-examination Testicular self-examination Testicular self-examination Accident prevention (e.g., use of seat belts) Accident prevention (e.g., use of seat belts) Hazard protection (e.g., use of smoke Hazard protection (e.g., use of smoke

alarms, sunscreen) alarms, sunscreen) Sexual responsibilitySexual responsibility

Relationships & Social ActivitiesRelationships & Social Activities

Composition of family and current Composition of family and current relationships? relationships?

Potential support systems Potential support systems level of social development level of social development Social activities and Community Social activities and Community

involvementinvolvementAssist the client in identifying Assist the client in identifying

community groups and activities and community groups and activities and encourage participationencourage participation

Values and Belief SystemValues and Belief SystemValues, goals, & beliefs that guide health-Values, goals, & beliefs that guide health-

related lifestyle choices related lifestyle choices Spiritual or cultural beliefs on health and Spiritual or cultural beliefs on health and

illness and how they affect health practices illness and how they affect health practices Perception of personal strengths related to Perception of personal strengths related to

maintaining health or coping with illness maintaining health or coping with illness Identify any complementary (alternative) Identify any complementary (alternative)

health-care practices used by the client and health-care practices used by the client and evaluate their effect on health maintenanceevaluate their effect on health maintenance

Education and WorkEducation and Work  Determine education level and Determine education level and

financial status; income is adequate financial status; income is adequate for lifestyle and health concerns?for lifestyle and health concerns?

areas of stress and satisfaction in areas of stress and satisfaction in lifelife

Ask on future educational plans and Ask on future educational plans and provide information as appropriateprovide information as appropriate

Stress Levels & Coping StylesStress Levels & Coping Styles

What events cause stress and how What events cause stress and how the client copes with the stressthe client copes with the stress

Methods to relieve stress and if Methods to relieve stress and if these methods are helpful these methods are helpful

Teach about stress management Teach about stress management techniquestechniques

Adaptation Adaptation Types of AdaptationTypes of Adaptation

1. General Adaptation 1. General Adaptation Syndrome (GAS)Syndrome (GAS)

Stages of GASStages of GAS

1. Alarm1. Alarm

2. Resistance 2. Resistance 3. Exhaustion3. Exhaustion

2. Local Adaptation Syndrome 2. Local Adaptation Syndrome (LAS)(LAS)

Purpose:Purpose:

1. Localize tissue injury1. Localize tissue injury

2. Protect tissue from injury2. Protect tissue from injury

3. Prepare tissue for repair3. Prepare tissue for repair

Inflammatory Response:Inflammatory Response:

1. Vascular response 1. Vascular response

2. Cellular response2. Cellular response–Neutrophils Neutrophils

3. Healing process (Reparative)3. Healing process (Reparative)Regeneration Regeneration Scar FormationScar Formation

First Intention (Primary union)First Intention (Primary union)–minimal or no tissue lossminimal or no tissue loss

Second IntentionSecond Intention–Great amount of tissue loss, repair Great amount of tissue loss, repair

time is longer and scarring is greatertime is longer and scarring is greaterThird Intention Third Intention

–Delayed surgical closure of infected Delayed surgical closure of infected woundwound

Nursing Intervention for Nursing Intervention for InflammationInflammation

1. Rest1. Rest

2. Reduce swelling2. Reduce swelling

Elevate the affected part Elevate the affected part

Cold then Heat applicationCold then Heat application

3. Relieve pain3. Relieve pain

4. Increase fluid intake4. Increase fluid intake

5. Adequate nutrition5. Adequate nutrition

6. Medications:6. Medications:

AnalgesicsAnalgesics

Anti-inflammatory Anti-inflammatory

Antibiotics Antibiotics

7. Surgery7. Surgery

Incision & Drainage Incision & Drainage

DebridementDebridement

Comfort InterventionsComfort InterventionsTypes of PainTypes of PainAcute Acute Injury, medical condition, or surgical Injury, medical condition, or surgical

procedure; lasts hours to a few days procedure; lasts hours to a few days Chronic Chronic months or even years months or even years Phantom Phantom Occurs after the loss of a body part Occurs after the loss of a body part

(amputation); feel pain in the amputated (amputation); feel pain in the amputated part for years after the amputationpart for years after the amputation

AssessmentAssessmentDescribe Pain: degree, quality, Describe Pain: degree, quality,

area, and frequency; Consider area, and frequency; Consider culture culture

Observable indicators: moaning; Observable indicators: moaning; crying; irritability; restlessness; crying; irritability; restlessness; grimacing or frowning; inability to grimacing or frowning; inability to sleep, rigid posture; increase BP, sleep, rigid posture; increase BP, heart rate, or respirations; heart rate, or respirations; nausea; and diaphoresis nausea; and diaphoresis

Use a number-based pain scale Use a number-based pain scale (a picture-based scale may be (a picture-based scale may be used in children)used in children)

Nonpharmacological InterventionsNonpharmacological Interventions TNS versusTNS versus PercutaneousPercutaneous Electrical NSElectrical NS Binders Binders Heat and Cold ApplicationHeat and Cold Application

Complementary and Alternative MeasuresComplementary and Alternative Measures Relaxation and repositioning techniques Relaxation and repositioning techniques Biofeedback & MusicBiofeedback & MusicDistraction techniques & hypnosisDistraction techniques & hypnosisGuided-imagery and meditation techniques Guided-imagery and meditation techniques Massage & therapeutic touchMassage & therapeutic touchAcupuncture & acupressure; Chiropractic TXAcupuncture & acupressure; Chiropractic TX

Pharmacological InterventionsPharmacological Interventions

Nonnarcotic and NSAIDs, narcotics, and Nonnarcotic and NSAIDs, narcotics, and adjuvants adjuvants

Routes: oral, subcutaneous, intramuscular, Routes: oral, subcutaneous, intramuscular, intravenous, topical, or by the epiduralintravenous, topical, or by the epidural

Epidural RouteEpidural RouteAdministered into the spinal epidural space Administered into the spinal epidural space Patient-Controlled AnalgesiaPatient-Controlled AnalgesiaA programmable pump contains a cartridge A programmable pump contains a cartridge

or syringe; client can push a button to self-or syringe; client can push a button to self-administer a dose of medication within the administer a dose of medication within the limitations prescribed by the physician limitations prescribed by the physician

Heat and ColdHeat and Cold ApplicationsApplications

Effects of HeatEffects of Heat

1. Vasodilation1. Vasodilation

2. 2. ↑ ↑ cell cell metabolismmetabolism

3. Muscle 3. Muscle relaxantrelaxant

4. Relieves pain4. Relieves pain

5. Reduces 5. Reduces edemaedema

6. Sedative effect6. Sedative effect

Effects of ColdEffects of Cold

1. 1. VasoconstrictioVasoconstrictionn

2. 2. ↓ ↓ cell cell metabolismmetabolism

3. Local 3. Local anesthetic anesthetic effecteffect

4. Bacteriostatic4. Bacteriostatic

5. Reduces 5. Reduces edemaedema

Principles in Heat and Cold Principles in Heat and Cold ApplicationApplication1. Cold application is safer than 1. Cold application is safer than heat heat application. application. 2. Heat & cold application needs 2. Heat & cold application needs doctor’s order.doctor’s order.3. Cold application for 1st 72H then 3. Cold application for 1st 72H then hot hot application for the next 72H.application for the next 72H.4. Heat & cold application: max of 4. Heat & cold application: max of 30 30 mins; average 15-20 mins.mins; average 15-20 mins.5. Check the area every 5 – 20 5. Check the area every 5 – 20 minutes.minutes.

Methods of Dry Heat ApplicationMethods of Dry Heat Application1. Hot Water Bags or Bottles1. Hot Water Bags or Bottles– Not exceed 52Not exceed 5200CC– 1/2 - 2/3 full 1/2 - 2/3 full

2. Disposable Hot Packs2. Disposable Hot Packs– Avoid puncture of the outer Avoid puncture of the outer

coveringcovering

3. Heat Lamp, Perilight & Droplight3. Heat Lamp, Perilight & Droplight– 25 watts, 18 inches away25 watts, 18 inches away– 40 watt bulb, 24 inches40 watt bulb, 24 inches

Methods of Moist Heat Methods of Moist Heat ApplicationApplication

Temperature: 40 – 46Temperature: 40 – 4600CC

1. Warm Moist Compress1. Warm Moist Compress

2. Warm Soak2. Warm Soak– Pat dry after procedurePat dry after procedure

3. Hot sitz Bath3. Hot sitz Bath– Check BP & PR before procedure Check BP & PR before procedure

& 5 minutes after& 5 minutes after

Methods of Dry ApplicationMethods of Dry Application1. Ice Collar1. Ice Collar– 1/3 full 1/3 full

2. Ice Cap2. Ice Cap– 1/3 full – Chest1/3 full – Chest– 1/3-1/2 full – Rest of the Body1/3-1/2 full – Rest of the Body

3. Disposable Cold Pack3. Disposable Cold Pack

Personal HygienePersonal HygieneAssess the client's personal-hygiene habits Assess the client's personal-hygiene habits Wash hands and wear gloves and other Wash hands and wear gloves and other

protective items as appropriate protective items as appropriate Ensure privacy & explain procedures Ensure privacy & explain procedures Determine health status and readiness Determine health status and readiness Encourage, Assist or Provide basic hygiene Encourage, Assist or Provide basic hygiene

& grooming& groomingUse proper body mechanicsUse proper body mechanicsAssess skin integrity  Assess skin integrity  Teach about required adaptations Teach about required adaptations

Laboratory & Diagnostic Laboratory & Diagnostic ExamsExams

a. Urinea. Urine

Specimen CollectionSpecimen Collection 1.) Clean-catch, midstream urine 1.) Clean-catch, midstream urine

collectioncollection– Urinalysis and Culture & SensitivityUrinalysis and Culture & Sensitivity– Collect early morningCollect early morning– Instruct importance of perineal careInstruct importance of perineal care

– Discard 1st and last urine flowDiscard 1st and last urine flow– Collect the midstreamCollect the midstream– 30-50 ml for urinalysis; 30-50 ml for urinalysis; – 5-10 ml for urine C&S5-10 ml for urine C&S

2.) 24 H urine collection2.) 24 H urine collection– Discard 1st voided urine & Discard 1st voided urine &

collect the 2nd voided until on collect the 2nd voided until on the same time the following daythe same time the following day

– Add preservatives or Soak in Add preservatives or Soak in iceice

3.) Second-voided urine specimen3.) Second-voided urine specimen– Ask to void, discard first urine Ask to void, discard first urine

collectioncollection– Let patient drink 1 glass of waterLet patient drink 1 glass of water– After a few minutes, ask pt to After a few minutes, ask pt to

voidvoid– Test for GlycosuriaTest for Glycosuria

4.) Catheterized urine specimen4.) Catheterized urine specimen– Before withdrawing, clamp Before withdrawing, clamp

catheter 30 min before procedurecatheter 30 min before procedure– Withdraw urine from catheterWithdraw urine from catheter

b. Stoolb. Stool1. Routine Fecalysis 1. Routine Fecalysis

– Use sterile specimen containerUse sterile specimen container– Fresh warm specimen helps Fresh warm specimen helps

detect ova/parasitesdetect ova/parasites– Collect 1 inch of well-formed Collect 1 inch of well-formed

stool & send directly to stool & send directly to laboratorylaboratory

c. Sputumc. Sputum

1. Gross Appearance of the 1. Gross Appearance of the SputumSputum– Collect early morningCollect early morning– Place in a sterile containerPlace in a sterile container– Rinse mouth with plain water Rinse mouth with plain water

before collectionbefore collection– Instruct to hack-up sputum to Instruct to hack-up sputum to

ensure it comes from the lungsensure it comes from the lungs

d. Blood Specimen d. Blood Specimen

FastingFasting– FBS, BUN, S. CreatinineFBS, BUN, S. Creatinine– S. Lipids (Serum Choleserol; S. Lipids (Serum Choleserol;

S. triglycerides)S. triglycerides)

No FastingNo Fasting

– CBCCBC– HemoglobinHemoglobin– HematocritHematocrit– Clotting studiesClotting studies– Enzyme studiesEnzyme studies– Serum ElectrolytesSerum Electrolytes

OXYGENATION OXYGENATION Maintaining Respiratory Maintaining Respiratory

function:function:A. Deep breathing & coughing A. Deep breathing & coughing

exercisesexercisesB. Semi to High Fowler’s position B. Semi to High Fowler’s position C. Patent AirwayC. Patent Airway

Causes of Airway ObstructionCauses of Airway Obstruction1. Mucus secretion1. Mucus secretion

2. Edema of airways2. Edema of airways–Asthma, post surgeryAsthma, post surgery

3. Spasm of airways3. Spasm of airways–Asthma, epiglottitis, Asthma, epiglottitis, anaphylaxisanaphylaxis

4. Foreign bodies4. Foreign bodies

D. Adequate hydrationD. Adequate hydration

E. Avoid environment pollutants, E. Avoid environment pollutants,

alcohol & smokingalcohol & smoking

F. Chest PhysiotherapyF. Chest Physiotherapy

1. Percussion1. Percussion

2. Vibration 2. Vibration

3. Postural drainage3. Postural drainage– 10-15 minutes in one position.10-15 minutes in one position.

Prevent exhaustion and Prevent exhaustion and hypotension.hypotension.

– Bronchodilators or nebulization Bronchodilators or nebulization given to loosen mucus.given to loosen mucus.

– Best done before meals & at Best done before meals & at bedtime. bedtime.

– Entire CPT: 30 minutes only.Entire CPT: 30 minutes only.

G. Steam Inhalation G. Steam Inhalation – Before procedure, instruct to Before procedure, instruct to

perform coughing & deep perform coughing & deep breathing breathing exercises (Facilitate exercises (Facilitate expectoration expectoration of mucus)of mucus)

– Place in semi-fowler’s positionPlace in semi-fowler’s position– Eyes covered with wash cloth to Eyes covered with wash cloth to

prevent irritationprevent irritation– 12-18 inches away from the client’s 12-18 inches away from the client’s

nose.nose.– Done for 15-20 minutesDone for 15-20 minutes

H. SuctioningH. Suctioning– Hyperoxygenate or Hyperoxygenate or

HyperventilateHyperventilate– 5-10 seconds, max 15 seconds5-10 seconds, max 15 seconds– 20-30 secs interval between 20-30 secs interval between

suctioningsuctioning– Total: 5 minutes onlyTotal: 5 minutes only

KK. Incentive Spirometry. Incentive Spirometry L. Supplemental O2L. Supplemental O2

Signs of HypoxemiaSigns of Hypoxemia1. Restlessness1. Restlessness2. Rapid shallow respiration2. Rapid shallow respiration3. Increased PR3. Increased PR4. Nasal flaring4. Nasal flaring5. Substernal or intercostal 5. Substernal or intercostal

retractionsretractions6. Cyanosis6. Cyanosis

ELIMINATIONELIMINATION

1. Fecal elimination1. Fecal eliminationNormal characteristics of stools:Normal characteristics of stools:

Color: yellow or golden brownColor: yellow or golden brownOdor: AromaticOdor: Aromatic

Deviation:Deviation:– Acholic stoolAcholic stool

biliary obstructionbiliary obstruction

– HematocheziaHematocheziapassage of fresh bright blood.passage of fresh bright blood.

– MelenaMelenablack tarry stoolblack tarry stool

– SteatorrheaSteatorrheafatty stool fatty stool (Hepatobiliary – pancreatic (Hepatobiliary – pancreatic obstruction)obstruction)

Fecal Eliminations problems:Fecal Eliminations problems:

1. Constipation1. Constipation

Mngt: Mngt: – Adequate fluid intake Adequate fluid intake – High fiberHigh fiber– Respond to the urge to defecateRespond to the urge to defecate– Minimize stressMinimize stress– Laxatives as orderedLaxatives as ordered

2. Fecal impaction2. Fecal impaction– Putty-like feces at the folds of Putty-like feces at the folds of

the rectum.the rectum.– Hardened fecal mass palpated Hardened fecal mass palpated

during digital examination.during digital examination.

Mngt: Mngt: – Manual extractionManual extraction– Increase fluid intakeIncrease fluid intake– Adequate activity & exercise Adequate activity & exercise

Digital Removal of StoolDigital Removal of Stool

Take baseline vital signs, Sims’ positionTake baseline vital signs, Sims’ positionWear gloves and other protective items as Wear gloves and other protective items as

appropriate appropriate Gently loosen the hardened mass by Gently loosen the hardened mass by

massaging around it and working the feces massaging around it and working the feces downward downward

Monitor heart rate closely; if the heart rate Monitor heart rate closely; if the heart rate drops or the rhythm changes, stop the drops or the rhythm changes, stop the procedure (vagal response from stimulation procedure (vagal response from stimulation of the sphincter and rectal wall can occur)of the sphincter and rectal wall can occur)

3. 3. DiarrheaDiarrhea

Mngt:Mngt:– Replace fluid & electrolyte lossReplace fluid & electrolyte loss– Good perineal hygiene Good perineal hygiene – Promote restPromote rest– Low fiberLow fiber– BRAT (potassium rich foods)BRAT (potassium rich foods)– Meds: antidiarrhealMeds: antidiarrheal

4. Flatulence4. Flatulence

Mngt: Mngt: – Avoid gas forming foods Avoid gas forming foods – Early ambulation & adequate Early ambulation & adequate

activity.activity.– Limit carbonated beveragesLimit carbonated beverages– Cholinergics: prostigmineCholinergics: prostigmine

Fecal EliminationFecal Elimination AssessmentAssessmentIdentify usual elimination pattern & stool Identify usual elimination pattern & stool

characteristics and any recent changescharacteristics and any recent changesRoutines used to promote elimination Routines used to promote elimination

(e.g., diet, fluid intake, exercise) (e.g., diet, fluid intake, exercise) Identify medications, laxatives or enemas Identify medications, laxatives or enemas Ask about surgeries or illnesses that Ask about surgeries or illnesses that

have affected the gastrointestinal tract have affected the gastrointestinal tract Determine the client's emotional statusDetermine the client's emotional status

Fecal Elimination FactorsFecal Elimination FactorsAge; Age; infant versus Elderly, Pregnancyinfant versus Elderly, PregnancyDiet; hDiet; high in fiber igh in fiber Fluid Intake; 6Fluid Intake; 6 to 8 to 8

glasses glasses Physical; & Psychological activities; Physical; & Psychological activities;

StressStress» » diarrhea; Depressiondiarrhea; Depression»» constipation constipation Surgery and Anesthesia; PainSurgery and Anesthesia; Pain Diagnostic Tests; NPO & Bowel EvacuationDiagnostic Tests; NPO & Bowel EvacuationPersonal Habits; Personal Habits; sched or environ changesched or environ changePosition; sitting versus supinePosition; sitting versus supine

Medications Affecting Fecal Medications Affecting Fecal EliminationElimination

Laxative and cathartic agents Laxative and cathartic agents (long-term: intestinal muscle tone loss) (long-term: intestinal muscle tone loss) Antispasmodic, narcotics and Antispasmodic, narcotics and

anticholinergic, can slow peristalsis anticholinergic, can slow peristalsis and delay gastric emptying time, and delay gastric emptying time,

Antibiotic drugs can cause diarrhea Antibiotic drugs can cause diarrhea (e.g., Clostridium difficile), (e.g., Clostridium difficile),

NSAID &ASA cause gastric irritationNSAID &ASA cause gastric irritation

Methods to Promote Methods to Promote EliminationElimination

Maintain normal elimination routines & Maintain normal elimination routines & exercise patternsexercise patterns

Initiate a bowel-retraining programInitiate a bowel-retraining programAvoid constipation-causing medications Avoid constipation-causing medications Diet: high-fiber foods and adequate fluids Diet: high-fiber foods and adequate fluids For bedpan, position to promote For bedpan, position to promote

defecation and prevent muscle strain and defecation and prevent muscle strain and discomfortdiscomfort

Bowel-Retraining Program Bowel-Retraining Program ComponentsComponents

Compatible time Compatible time Prescribed stool softeners daily or a Prescribed stool softeners daily or a

cathartic suppository at least 30mins before cathartic suppository at least 30mins before defecationdefecation

Hot drink or juice for peristalsis Hot drink or juice for peristalsis Position, privacy and time for defecation Position, privacy and time for defecation

EnemaEnema

Purpose: Purpose: – To relieve constipationTo relieve constipation– To administer medicationsTo administer medications– To relieve flatulence To relieve flatulence – To evacuate fecesTo evacuate feces

Enema AdministrationEnema Administration Principles Principles

MD order; Wears gloves, Clean technique MD order; Wears gloves, Clean technique adult>Sims‘ ; child>dorsal recumbent position adult>Sims‘ ; child>dorsal recumbent position Check temp (105Check temp (105 F, or 40.5 F, or 40.5 C) C)Lubricated tube: Adult: 3- 4 in, Child: 2- 3 in, Lubricated tube: Adult: 3- 4 in, Child: 2- 3 in,

Infant: 1 to 1.5 inInfant: 1 to 1.5 inEnema container: raised slowly Enema container: raised slowly

(High:12-18 in, Regular: 12 in, Low: 3 in) (High:12-18 in, Regular: 12 in, Low: 3 in) Lower or clamp if cramping or if fluid escapes Lower or clamp if cramping or if fluid escapes

the rectal tubethe rectal tubeEnema til clear. if 3 & still unclear, consult MDEnema til clear. if 3 & still unclear, consult MD

Retention Retention enemaenema– Solution: 90-Solution: 90-

120ml of 120ml of Mineral oilMineral oil

– Carminative Carminative solutionsolution

– Ht: 12 inches Ht: 12 inches above rectumabove rectum

– 40 – 4440 – 4400CC– Retention: 1-Retention: 1-

3H3H

Non-retention Non-retention EnemaEnema– Solution: tap Solution: tap

water, soap water, soap suds, NSS suds, NSS

– Height : 18 Height : 18 inches above inches above rectumrectum

– 46 – 5246 – 5200CC– Retention: 5-Retention: 5-

10 mins10 mins

Cleansing Enema: Cleansing Enema: – stimulate peristalsis.stimulate peristalsis.

a. High Flow a. High Flow

d. Low Flow d. Low Flow

Solutions:Solutions:•Soap sudsSoap suds•Carminative solutionCarminative solution•NSSNSS

Carminative EnemaCarminative Enema– 60-180 ml of fluid is introduced to 60-180 ml of fluid is introduced to

expel flatus.expel flatus.

Return flow enemaReturn flow enema– 100-200 ml of fluid is introduce 100-200 ml of fluid is introduce

into the large colon to stimulate into the large colon to stimulate peristalsis.peristalsis.

– inflow and outflow process inflow and outflow process repeated 5-6 times.repeated 5-6 times.

Bowel DiversionBowel DiversionStoma that diverts the flow of fecal Stoma that diverts the flow of fecal

contents contents Wear stomal pouch continuously Wear stomal pouch continuously Local irritation and skin breakdown are Local irritation and skin breakdown are

possible, possible, Ileostomy is at risk for fluid and Ileostomy is at risk for fluid and

electrolyte imbalance electrolyte imbalance Threat to body image;lead to social Threat to body image;lead to social

isolationisolation

2. Urine elimination:2. Urine elimination:

color: amber/straw:color: amber/straw:odor: aromaticodor: aromaticpH: 4.6-8pH: 4.6-8Specific gravity: 1.010 – 1.025Specific gravity: 1.010 – 1.025

Urinary EliminationUrinary EliminationAssess urination patterns (frequency & times) Assess urination patterns (frequency & times) Identify any urination factors:Identify any urination factors:- Age; continence by 1- Age; continence by 18-24 mo.s, aging impairs 8-24 mo.s, aging impairs - Sociocultural: Sociocultural: privacy & positionprivacy & position- Psychological: Psychological: Anxiety and emotional stressAnxiety and emotional stress- Muscle tone: keagel’sMuscle tone: keagel’s- Fluid Balance: Fluid Balance: fluid intake; Caffeine, Alcohol, fluid intake; Caffeine, Alcohol,

Fruits, & metabolismFruits, & metabolism- Surgery: Surgery: stress response, NPO status, & drugstress response, NPO status, & drug

Urine PromotionUrine PromotionDaily fluid intake of 2000 to 2500 mL Daily fluid intake of 2000 to 2500 mL Provide privacy & time; assist into position Provide privacy & time; assist into position Prevent urinary-tract infection Prevent urinary-tract infection Acid Ash diet Acid Ash diet Sensory stimuli ( running water; placing Sensory stimuli ( running water; placing

hand in warm water; warming the bedpan; hand in warm water; warming the bedpan; pouring warm water over the perineum)pouring warm water over the perineum)

Initiate a bladder-retraining programInitiate a bladder-retraining program

Components of a Bladder-Components of a Bladder-Retraining ProgramRetraining Program

Teach keagel’s exercises Teach keagel’s exercises Initiate an individualized toileting schedule Initiate an individualized toileting schedule

(on awakening, every 2 hours during the day (on awakening, every 2 hours during the day and evening, and every 4 hours at night) and evening, and every 4 hours at night)

Alternative methods to relax and stimulate Alternative methods to relax and stimulate urination urination

Diuretics in the morning; increase day Diuretics in the morning; increase day diuresisdiuresis

Alterations in Urine Alterations in Urine CompositionComposition

HematuriaHematuriaBacteriuriaBacteriuriaAlbuminuriaAlbuminuriaProteinuriaProteinuriaGlycosuriaGlycosuriaKetonuriaKetonuria

Altered Urine ProductionAltered Urine ProductionPolyuriaPolyuriaOliguria Oliguria AnuriaAnuria

Altered Urine EliminationAltered Urine EliminationFrequency Frequency Nocturia Nocturia Urgency Urgency

Dysuria Dysuria Enuresis Enuresis Incontinence Incontinence

Nsg Management to induce VoidingNsg Management to induce Voiding

1. Provide privacy1. Provide privacy2. Provide fluids to drink2. Provide fluids to drink3. Serve bed pan and urinal3. Serve bed pan and urinal4. Running water sound4. Running water sound

5. Pour warm water over the 5. Pour warm water over the perineumperineum

6. Promote relaxation6. Promote relaxation7. Provide adequate time for 7. Provide adequate time for

voidingvoiding8. Urinary catheterization 8. Urinary catheterization

– Last resort Last resort

Urinary CatheterizationUrinary CatheterizationIntermittent or indwelling Intermittent or indwelling

catheterization catheterization Physician's order is required Physician's order is required Aseptic technique; Maintain closed Aseptic technique; Maintain closed

drainage system, bag maintained drainage system, bag maintained below the bladder level below the bladder level

Monitors patency and checks for tubing Monitors patency and checks for tubing kinks or bendskinks or bends

Perineal hygiene ( soap and water) at Perineal hygiene ( soap and water) at least 3X daily and after defecation least 3X daily and after defecation

Urinary DiversionUrinary DiversionCreation of a temporary or permanent Creation of a temporary or permanent

stoma stoma Wear stomal pouch continuously; No Wear stomal pouch continuously; No

sphincter controlsphincter controlLocal irritation & skin breakdown are Local irritation & skin breakdown are

possible possible Poses a threat to body imagePoses a threat to body image

Rest and SleepRest and Sleep

AssessmentAssessmentRegular sleep pattern? sleep Regular sleep pattern? sleep

problems?problems?Any illness or injury affecting Any illness or injury affecting

sleep? sleep? Diet, exercise, and medications?Diet, exercise, and medications?sleep aids?sleep aids?

Adequate Rest and SleepAdequate Rest and Sleep

aids in healing and maintain health aids in healing and maintain health inadequate sleep= daytime drowsiness & inadequate sleep= daytime drowsiness &

fatigue, irritability, depression, poor fatigue, irritability, depression, poor concentration & memory, & an increased concentration & memory, & an increased likelihood of accident or injury likelihood of accident or injury

hours of sleep: Infants>16 ; Adolescent: 8 , hours of sleep: Infants>16 ; Adolescent: 8 , Adults: 5 to 10 Adults: 5 to 10

Aging> night sleep decrease; Elderly day Aging> night sleep decrease; Elderly day napsnaps

Factors Affecting SleepFactors Affecting SleepLifestyle; nightshift, travelers, and Lifestyle; nightshift, travelers, and

students students Caffeine and nicotine delays sleep Caffeine and nicotine delays sleep Alcohol can cause nocturnal awakening Alcohol can cause nocturnal awakening Stress and illness can prevent sleep Stress and illness can prevent sleep Hospitalization; environmental factors, Hospitalization; environmental factors,

& treatments & procedures & treatments & procedures Lack of exercise or exercising too close Lack of exercise or exercising too close

to bedtime can interfere with sleepto bedtime can interfere with sleep

Interventions: Rest and SleepInterventions: Rest and Sleep

Exercise; eliminate alcohol & nicotine Exercise; eliminate alcohol & nicotine no caffeine at least 2 hours before bedtime no caffeine at least 2 hours before bedtime Get up same time each day and no day nap; Get up same time each day and no day nap;

sched treatments in day timesched treatments in day timeAvoid going to bed hungry or overfull; give Avoid going to bed hungry or overfull; give

light dairy snacklight dairy snackAdjust room temp; eliminate lights, noise, Adjust room temp; eliminate lights, noise,

and distractions and distractions Use only prescribed Sedatives or hypnoticsUse only prescribed Sedatives or hypnotics

BED MAKING BED MAKING

Types of BedTypes of Bed

1. Closed Bed: 1. Closed Bed: Covered to the Covered to the toptop

2. Open Bed: 2. Open Bed: Top sheet Top sheet fanfolded, fanfolded, 3. Occupied Bed: 3. Occupied Bed: – made with the client in itmade with the client in it

Special considerationsSpecial considerations

1. Wash hands before and after 1. Wash hands before and after

2. Practice good body mechanics2. Practice good body mechanics

3. Prevent contamination from 3. Prevent contamination from soiled soiled linenslinens

4. Order: Bottom sheet, rubber 4. Order: Bottom sheet, rubber sheet, draw sheet, blanket, top sheet, draw sheet, blanket, top sheet & pillow casesheet & pillow case

5. siderails up5. siderails up

6. Provide privacy; use drapes6. Provide privacy; use drapes

MobilityMobilityAbility to move freely with or without the Ability to move freely with or without the

use of an assistive deviceuse of an assistive deviceAssessment of MobilityAssessment of MobilityCoordination and balance to walk & ADLCoordination and balance to walk & ADLRange of motion (ROM), gait, & activity Range of motion (ROM), gait, & activity

tolerancetoleranceROM: Assessed if (+) joint stiffness, ROM: Assessed if (+) joint stiffness,

swelling, pain, limited movement, unequal swelling, pain, limited movement, unequal movement, & strengthmovement, & strength

Gait: info on balance, posture, and ability to Gait: info on balance, posture, and ability to walk without assistance; assistive devicewalk without assistance; assistive device

Immobility ComplicationsImmobility ComplicationsRespiratoryRespiratory AtelectasisAtelectasisPneumoniaPneumoniaDecreased gas exchangeDecreased gas exchange

CardiovascularCardiovascular Thrombus formationThrombus formationThrombophlebitisThrombophlebitisPulmonary embolismPulmonary embolismOrthostatic hypotensionOrthostatic hypotension

MusculoskeletalMusculoskeletalGeneralized weakness and fatigueGeneralized weakness and fatigueStiff joints & Diminished coordinationStiff joints & Diminished coordinationJoint contracture, atrophy & Foot drop Joint contracture, atrophy & Foot drop Bone pain & OsteoporosisBone pain & OsteoporosisGastrointestinalGastrointestinalAbdominal distention, & constipationAbdominal distention, & constipationDecreased appetite and weight lossDecreased appetite and weight lossProtein deficiency & Negative nitrogen Protein deficiency & Negative nitrogen

balancebalanceIntegumentaryIntegumentarySkin breakdown & Pressure ulcersSkin breakdown & Pressure ulcers

RenalRenalUrinary stasis & UTI, Frequency, DysuriaUrinary stasis & UTI, Frequency, DysuriaPrecipitation of calcium salts and formation Precipitation of calcium salts and formation

of renal calculi of renal calculi MetabolicMetabolicDecrease in metabolic rateDecrease in metabolic rateAltered metabolism of carbohydrates, fats, Altered metabolism of carbohydrates, fats,

and proteinsand proteinsFluid, electrolyte, and calcium imbalancesFluid, electrolyte, and calcium imbalancesPsychologicalPsychologicalDisorientation, Confusion, Boredom, Anxiety, Disorientation, Confusion, Boredom, Anxiety,

Depression & LonelinessDepression & Loneliness

Maintaining Body Maintaining Body AlignmentAlignment

Body alignment:Body alignment: positioning of positioning of joints, tendons, joints, tendons, ligaments, and ligaments, and muscles while the muscles while the client is standing, client is standing, sitting, or lying sitting, or lying

Interventions to Prevent Interventions to Prevent ComplicationsComplications

Ensure client safetyEnsure client safetyTurn and reposition every 2 hours; prevent Turn and reposition every 2 hours; prevent

skin breakdown skin breakdown Provide exercise as appropriate Provide exercise as appropriate Encourage coughing and deep breathing Encourage coughing and deep breathing

every 1 to 2 hours every 1 to 2 hours Elastic or sequential-compression stockings Elastic or sequential-compression stockings high-fiber diet, stool softeners,& fluidshigh-fiber diet, stool softeners,& fluidsMaintain client's orientation, & Provide Maintain client's orientation, & Provide

diversional activitiesdiversional activities

Body Mechanics: Guidelines Body Mechanics: Guidelines for Moving and Lifting Clientsfor Moving and Lifting Clients

Obtain assistance whenever possibleObtain assistance whenever possibleAsk the client to help when able Ask the client to help when able Bend and flex the knees not back Bend and flex the knees not back Wide base; feet: shoulders'-width apartWide base; feet: shoulders'-width apartUse smooth, coordinated movements Use smooth, coordinated movements Work at the same level as the object Work at the same level as the object Trunk straight, No twisting when lifting Trunk straight, No twisting when lifting

and pulling; Elbows close to the bodyand pulling; Elbows close to the body

ExerciseExercise

a. Active range of motion (ROM) a. Active range of motion (ROM)

b. Passive range of motion (PROM) b. Passive range of motion (PROM)

c. Active – resistance ROMc. Active – resistance ROM

Done by the client against a weight Done by the client against a weight or forceor force

d. Active – assistive ROMd. Active – assistive ROM

Done by the stronger arm & leg to Done by the stronger arm & leg to the weaker arm & legthe weaker arm & leg

e. Isotonice. Isotonic– change and muscle length and change and muscle length and

tensiontensionf. Isometricf. Isometric

– change in muscle tension onlychange in muscle tension only

DECUBITUS ULCERDECUBITUS ULCER

Causes:Causes:

1. Pressure1. Pressure

2. Friction2. Friction

3. Shearing Force3. Shearing Force

Risk FactorsRisk Factors

1. Immobility and Inactivity1. Immobility and Inactivity

2. Inadequate Nutrition2. Inadequate Nutrition

3. Excessive Body Heat3. Excessive Body Heat

4. Decreased mental status4. Decreased mental status

5. Diminished sensation5. Diminished sensation

Stages:Stages:

I – Erythema on bony prominence I – Erythema on bony prominence II – Necrosis of the epidermis or II – Necrosis of the epidermis or

dermisdermisshallow cratershallow crater

III – Necrosis extending to the III – Necrosis extending to the subcutaneous tissuesubcutaneous tissue

deep craterdeep craterIV – Necrosis extending to the muscle.IV – Necrosis extending to the muscle.

Mgt:Mgt:

Use pressure relieving devicesUse pressure relieving devicesChange position every 2HChange position every 2HMeticulous skin careMeticulous skin careKeep skin clean and dryKeep skin clean and dryAvoid massaging bony prominences Avoid massaging bony prominences

with soap when bathingwith soap when bathing

Treatment:Treatment:

Clean pressure sores dailyClean pressure sores dailyClean and dress the sore using Clean and dress the sore using

surgical asepsissurgical asepsis

Care for the Body after DeathCare for the Body after Deatha. Rigor mortisa. Rigor mortis– stiffening of the body 2 – 4 H after stiffening of the body 2 – 4 H after

deathdeath– Lack or absence of ATPLack or absence of ATP– Position the body & place dentures Position the body & place dentures

in mouth, close eyes and mouthin mouth, close eyes and mouth

b. Algor mortisb. Algor mortis– gradual loss of body temperaturegradual loss of body temperature– 10C/min until room temperature10C/min until room temperature

c. Livor mortisc. Livor mortis– discoloration of the skin after deathdiscoloration of the skin after death

Documentation Points Documentation Points

Reason; if alternatives were usedReason; if alternatives were usedMethod & procedure for applicationMethod & procedure for applicationCondition of the restrained body part Condition of the restrained body part Client's response to application Client's response to application Date and time of application of the restraintDate and time of application of the restraintAssessment of circulatory, neurovascular, Assessment of circulatory, neurovascular,

and skin integrity; if continued need existsand skin integrity; if continued need existsRelease & periodic mov’t or ROM exercise Release & periodic mov’t or ROM exercise Duration of use & response on removalDuration of use & response on removal

Risk ManagementRisk Management

A planned method of identifying, A planned method of identifying, analyzing, and evaluating risks analyzing, and evaluating risks followed by a plan for reducing the followed by a plan for reducing the frequency of accidents & injuries. frequency of accidents & injuries.

Programs are based on a Programs are based on a systematic reporting system for systematic reporting system for incidents or unusual occurrencesincidents or unusual occurrences

Incident ReportsIncident Reports

A tool for identifying risk situations and A tool for identifying risk situations and improving client care improving client care

Follows specific documentation guidelines Follows specific documentation guidelines Filled out completely, accurately,& factually Filled out completely, accurately,& factually Not be copied or placed in the client's Not be copied or placed in the client's

record or referenced should be made in the record or referenced should be made in the client's record client's record

Not a substitute for a complete entry in the Not a substitute for a complete entry in the client's record regarding an incident client's record regarding an incident

Types of IncidentsTypes of Incidents

Accidental omission of ordered therapies Accidental omission of ordered therapies Circumstances leading to injury Circumstances leading to injury Client falls Client falls Medication-administration errors Medication-administration errors Needle-stick injuries Needle-stick injuries Procedure-or equipment-related accidents Procedure-or equipment-related accidents A visitor having symptoms of an illnessA visitor having symptoms of an illness

Safeguarding ValuablesSafeguarding ValuablesClient's valuables given to family or secured Client's valuables given to family or secured

for safekeeping in a designated stored and for safekeeping in a designated stored and locked location. Document locked location. Document

Sign a release to free the agency of Sign a release to free the agency of responsibility for lost valuables responsibility for lost valuables

Wedding band taped in place unless Wedding band taped in place unless swelling of the hands or fingers is a risk swelling of the hands or fingers is a risk

Religious items (e.g., medals, scapulars) Religious items (e.g., medals, scapulars) may be pinned to gown if this is permitted may be pinned to gown if this is permitted by agency policyby agency policy

Physicians' OrdersPhysicians' Orders

ObligationObligation: nurse is to carry out MD's order : nurse is to carry out MD's order except when order is inappropriate except when order is inappropriate

Clarify an unclear or inappropriate order, or Clarify an unclear or inappropriate order, or one in question, with the physicianone in question, with the physician

If no resolution occurs with regard to the If no resolution occurs with regard to the order in question, contact the nurse order in question, contact the nurse manager or supervisormanager or supervisor

AccountabilityAccountability: Nurse who carries out an : Nurse who carries out an inaccurate order may be legally responsible inaccurate order may be legally responsible for any harm suffered by the clientfor any harm suffered by the client

Telephone OrdersTelephone OrdersWrite down the date and time of the entry Write down the date and time of the entry Repeat the order to the physician and Repeat the order to the physician and

record the order, beginning with "t.o." record the order, beginning with "t.o." (telephone order); next write the physician's (telephone order); next write the physician's name and sign the order name and sign the order

If another nurse witnessed the order, that If another nurse witnessed the order, that person's signature follows the signature of person's signature follows the signature of the nurse who took the order the nurse who took the order

The physician must countersign the order The physician must countersign the order within a certain time frame, set forth in within a certain time frame, set forth in agency policyagency policy

Components of a Medication Components of a Medication Order Order   

Date and time order was written Date and time order was written Name of medication Name of medication Dosage Dosage Route of administration Route of administration Frequency of administration Frequency of administration Physician or health-care provider's Physician or health-care provider's

signaturesignature

DocumentationDocumentation

Legally required by accrediting Legally required by accrediting agencies, state licensing laws, agencies, state licensing laws, and state nurse- and medical-and state nurse- and medical-practice acts practice acts

Follow agency guidelines and Follow agency guidelines and procedures [procedures [GuidelinesGuidelines]]

Documentation GuidelinesDocumentation Guidelines

Narrative Narrative black pen; Note date and time on entryblack pen; Note date and time on entryObjective, factual, and complete Objective, factual, and complete Document care, meds, tx, & procedures Document care, meds, tx, & procedures

ASAP after administeredASAP after administeredDocument client responses to Document client responses to

interventions; Tx consent or refusal interventions; Tx consent or refusal Document calls made to other health-care Document calls made to other health-care

providers providers Don’t document or change for others Don’t document or change for others

Documentation GuidelinesDocumentation GuidelinesNarrative ( cont.)Narrative ( cont.)

Sign for each entry; No BlanksSign for each entry; No Blanksverbatim for subjective data; no verbatim for subjective data; no

judgmental quotesjudgmental quotesNo text msg; Avoid unofficial abbrevsNo text msg; Avoid unofficial abbrevsFollow agency policies when an error is Follow agency policies when an error is

made (draw one line through the error, made (draw one line through the error, initial, and date)initial, and date)

Follow agency guidelines regarding late Follow agency guidelines regarding late entriesentries

Documentation GuidelinesDocumentation GuidelinesComputerizedComputerized Use only the user identification (ID) code, Use only the user identification (ID) code,

name, or passwordname, or passwordNever lend access ID to anotherNever lend access ID to anotherMaintain privacy and confidentiality of Maintain privacy and confidentiality of

documented information printed from the documented information printed from the computercomputer

Client/Family TeachingClient/Family Teaching

Provide complete instructions in a Provide complete instructions in a language client or family can understand language client or family can understand

Document client and family teaching, what Document client and family teaching, what was taught, evaluation of understanding, was taught, evaluation of understanding, and who was present during the teaching and who was present during the teaching

Inform what would happen if information Inform what would happen if information shared during teaching were not followed shared during teaching were not followed

Reporting ResponsibilitiesReporting Responsibilities  Required to report certain communicable Required to report certain communicable

diseases and criminal activities (e.g., abuse, diseases and criminal activities (e.g., abuse, gunshot or stab wound, assault, homicide, gunshot or stab wound, assault, homicide, suicide) to the appropriate authorities suicide) to the appropriate authorities

The Impaired NurseThe Impaired Nurse If coworker is suspected of abusing If coworker is suspected of abusing

chemicals, report to nursing admin in a chemicals, report to nursing admin in a confidential manner confidential manner

Priority Issue: treatment for nursePriority Issue: treatment for nurseNursing administration then notifies BON Nursing administration then notifies BON

regarding the nurse's behavior regarding the nurse's behavior

Informed Consent and ReleasesInformed Consent and Releases

Consent = Approval to have body touched Consent = Approval to have body touched Permission for surgery, tx, or info to 3rd party Permission for surgery, tx, or info to 3rd party

– Understandable terms, risks and benefits of Understandable terms, risks and benefits of the surgery or treatment, consequences for the surgery or treatment, consequences for non-compliance, non-compliance,

– treatment options, and the name of the treatment options, and the name of the health-care provider performing the surgery health-care provider performing the surgery or procedureor procedure

Types of ConsentTypes of Consent

Admission AgreementAdmission AgreementBlood-Transfusion ConsentBlood-Transfusion Consent Surgical ConsentSurgical ConsentResearch ConsentResearch Consent Special ConsentSpecial Consent Restraints, photographs, body part Restraints, photographs, body part

disposal, organ donation after disposal, organ donation after death, or autopsydeath, or autopsy

Preventing ErrorsPreventing ErrorsFollow agency policies & procedures on Follow agency policies & procedures on

administering meds and IV therapy, and for administering meds and IV therapy, and for providing treatments.providing treatments.

Verify the identity before providing care by Verify the identity before providing care by asking to state name & checking ID bandasking to state name & checking ID band

Ask about allergies (medications, food, Ask about allergies (medications, food, environmental) & document accdg to policyenvironmental) & document accdg to policy

Check physician's orders for accuracyCheck physician's orders for accuracyWhen transcribing a MD's orders, be When transcribing a MD's orders, be

accurate & clear on order and transcriptionaccurate & clear on order and transcriptionAlways clarify or question MD's order with Always clarify or question MD's order with

the physician who wrote itthe physician who wrote it

-fin--fin-The Quest for knowledge has just begun.

the true test is not in the board exam but in your career.