Fundamentals in NURSING

NURSING · Promotion of Health – promoting a healthy lifestyle

· Prevention of illness – early detection and
treatment
· Restoration of health – curing and healing,
I. DEFINITION OF NURSING
rehabilitation
 
Care of the dying – maintaining dignity and peaceful
NURSING - is a profession focused on assisting
death
individuals, families, and communities in attaining,
 
maintaining, and recovering optimal health and
functioning. Modern definitions of nursing describes
III. SCOPE OF NURSING CARE
it as a science and an art that focuses on promoting
· Individual
quality of life as determined by persons and families,
· Families
throughout their life experiences from birth until the
Communities 
end of life.
 
IV. THEORETICAL FOUNDATIONS OF NURSING
NURSING - Assisting the individual (sick or well) in
& HISTORICAL PERSPECTIVE
the performance of those activities contributing to
 
health, or its recovery (or peaceful death) that he
 Metaparadigm of nursing – identifies the core
would perform unaided if he had the necessary
content of a discipline.
strength, will, or knowledge- and in doing so,
promote independence as much as possible.  Persons – recipient of nursing care. Represents
(Henderson) an individual, a family, or a community.
   Health – represents a state of well-being mutually
NURSING – is providing the most favorable decided and agreed upon by the client and the
environment to an individual for nature to act in order nurse.
to promote “reparativeness” and maintenance of  Environment – may be internal or external to the
health and well being. (Nightingale) person
   Nursing – is the science and art of the discipline.
NURSING – is an art, (ability to perform nursing acts  
skillfully), and a science (body of knowledge which
governs the profession)
 
NURSING - is caring (Watson)
 

II. GOALS OF NURSING

THEORISTS THEORY KEYWORD
 Florence Focused on organizing and manipulating the physical, social and psychological environment in order to Environmental Theory of
Nightingale put the person in the best possible conditions for nature to act Nursing
Hildegard Presents nursing as an interpersonal process of therapeutic interactions between the nurse and the Interpersonal Relationship
Peplau patient Nurse – Patient relationship
four phases of the nurse - patient relationship: orientation, identification, exploitation, and resolution
Virginia Views nursing as doing for patients what they cannot do for themselves, and she identifies 14 components 14 fundamental needs
Henderson of nursing care that need to be considered. Definition of Nursing
Lydia Hall Focus around the three components of care, core, and cure. Care, core, cure
 Care -represents nurturance and is exclusive to nursing. Primary Nursing
 Core -involves the therapeutic use of self and emphasizes the use of reflection. Holistic Nursing
 Cure -focuses on nursing related to the physician’s orders.

Dorothea Nursing consists of the three theories of self care, self care deficit and nursing systems. Theory of self - care
Orem  Self-care -includes the human’s ability to care for him- or herself (self-care agency), basic
conditioning factors, a totality of self-care actions needed (therapeutic self-care demand), and three
categories of self-care requisites: universal, developmental, and health deviation.
 Self-care deficit theory - identifies when nursing is needed because the person is incapable of or
provide continuous effective self -care
 Nursing systems theory- identifies three nursing systems as wholly compensatory, partly
compensatory, and supportive-educative
Dorothy E. Behavioral system model for nursing has seven subsystems: Behavioral System model
Johnson  Attachment or affiliation
 Dependence
 Ingestive
 Eliminative
 Sexual
 Aggressive
 Achievement

Faye G. focuses on problem-solving to move the patient toward health 21 nursing problems
Abdellah 21 common nursing problems relative to caring for patients
Ida Jean Orlando believes that nurses provide direct assistance to meet an immediate need for help in order to Nursing Process Discipline
Orlando avoid or to alleviate distress or helplessness. She emphasizes the importance of validating the need  
and evaluating care based on observable outcomes.
Ernestine Strongly believes that the nurse’s individual philosophy or central purpose lends credence to nursing care. Philosophy
Wiedenbach She believes that nurses help to meet the individual’s need for help through the identification of the Purpose
needs, ministration of help, and validation that the actions were helpful. Practice
Art
Perspective Theory
Myra Levine Views nursing as human interaction: the dependency of individuals on one another. Levine identifies four Conservation theory
principles of conservation: conservation of energy, conservation of structural integrity, conservation of
personal integrity, and conservation of social integrity

Imogene King Presents a theory of goal attainment from an open system conceptual framework that integrates personal Goal – attainment theory
systems, interpersonal systems, and social systems.
Martha Rogers Rogers developed the principles of homeodynamics, which focus on the wholeness of human beings, the Science of unitary man
unitary nature of human beings and their environment, and the nature and direction of human and
environment change.

Josephine Nursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to be Humanistic Nursing theory
Paterson and nursed. The essential characteristic of nursing is nurturance. Humanistic nursing cannot take place
Loretta Zderad without the authentic commitment of the nurse to being with and doing with the client.

Jean Watson Science of caring is built on a framework of seven assumptions and ten carative factors. She emphasizes Science of caring
the interpersonal nature of caring, describes the nurse as a co- participant with the client, and Carative factors
includes the soul as an important consideration.

Rosemarie Emphasizes free choice of personal meaning in relating value priorities, concreting of rhythmical pattern in Human becoming theory
Rizzo Parse exchange with the environment, and cotranscending in many dimensions as possibilities unfold.

Helen Erickson, The focus of this theory is on the person. The nurse models (assesses), role models (plans), and Modeling and Role-Modeling
Evelyn Tomlin, intervenes in this interpersonal and interactive theory
and Mary Ann
Swain
Madeleine focuses on the importance of understanding the similarities (universalities) and differences (diversities) Transcultural nursing
Leininger of peoples across cultures

Margaret Health as expanding consciousness. Humans are unitary being in whom disease is a manifestation of Expanding consciousness
Newman the pattern of health. Consciousness is the information capability of the system which is influenced
by time, space, and movement and is ever-expanding.

HEALTH, WELLNESS and ILLNESS


I.DEFINITION
HEALTH
Ability of the person to maintain a state of
wellness, and using every power an
individual possess to the fullest extent
(Nightingale, 1969)
Is a state of being that people define in
relation to their own value system
Is a state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity. (WHO
1948)
Is a "resource for everyday life, not the
objective of living", and "health is a
positive concept emphasizing social and
personal resources, as well as physical
capacities."( WHO "Ottawa Charter for
Health Promotion” 1986)
 
WELLNESS
Wellness is generally used to mean a
healthy balance of the mind-body and
spirit that results in an overall feeling of
well-bein
It is the physical state of good health as well
as the mental ability to enjoy and
appreciate being healthy and fit
Wellness is first and foremost a choice to
assume responsibility for the quality of
your life. It begins with a conscious
decision to shape a healthy lifestyle.
Wellness is a mind set, a predisposition
to adopt a series of key principles in
varied life areas that lead to high levels
of well-being and life satisfaction.
II. COMPONENTS OF HEALTH AND WELLNESS
Physical – body’s ability to function
efficiently and effectively in work and
leisure activities, to be healthy, to resist
hypokinetic diseases, and to meet
emergency situations.
Social - means being aware of, participating
in, and feeling connected to the
community
Emotional -is demonstrated by the overall
comfort with and acceptance of one’s
full range of feelings
Intellectual - involves lifelong learning
through formal education and informal
life experiences
Spiritual-refers to integrating beliefs and
values with actions.
Occupational - measures the satisfaction
gained from a career and the degree to
which you are enriched by that work.
Environmental - trying to live in harmony
with the earth by understanding the
impact of interaction with nature and
personal environment, and taking action
to protect the world around an
individual.
 
III. MODELS OF HEALTH AND WELLNES
CLINICAL MODEL – health is viewed as
absence of signs and symptoms
ADAPTIVE MODEL – a person is healthy if
he/she can adapt to the different
stressors of life.
ROLE PERFORMANCE MODEL – an
individual is healthy if he can satisfy
societal roles, or ability to fulfill his/her
duty or work
EUDEMONISTIC MODEL – refers to the
actualization of ones potentials
 HEALTH - ILLNESS CONTINUUM – a Environment -All factors external to
predictive grid that displays the the host that may or may not
likelihood of a person to participate in predispose the person to the
preventive health care development of the disease
   
 
D S S A E G HEALTH BELIEF MODEL - Helps
determine whether an individual is likely
  to participate in disease prevention and
health promotion activities.
Useful tools in developing programs
for helping people change to
healthier lifestyles and develop
a more positive attitude toward
preventive health measures.
Components
DISEASE / HIGH LEVEL OF Individual perceptions –
PREMATURE DEATH WELLNESS includes perceived
susceptibility,
Figure 1.2 Health-Illness Continuum, as shown seriousness, and threat
here, represents the process of achieving high modifying factors –
levels of wellness or the consequences of includes demographic
unhealthy lifestyle. In this figure, there are three variables,
parameters on how to achieve high levels of sociophysiologic
wellness. These are: (A) – Awareness, (E) – variables, structural
Education, and (G) Growth. Otherwise, an variables, and cues to
individual who continuously live an unhealthy action
lifestyle, will be on the other side of the grid, and Likelihood to action –
would develop the following: (S) – signs and depends on the
symptoms (S) –syndromes, and (D) – Disorder perceived benefit
or disability which may lead disease or versus the perceived
premature death. barriers.
   
AGENT - HOST - ENVIRONMENT MODEL  
– primarily used to predict an illness. HEALTH CARE ADHERENCE – the extent
Agent - Any environmental factor or to which behavior is congruent with
stressor, chemical, mechanical, medical or health advice, which is
physical, psychosocial that by affected by various factors such as
its presence or absence can client’s motivation, lifestyle change
lead to illness or disease necessary, severity of the disease,
Host -Persons who may or may not cultural factors,drug side effects,
be at risk of acquiring the duration of treatment and overall cost.
disease  
IV. ILLNESS and DISEASE Examples: frequent turning of an
ILLNESS – subjective state in which the immobilized client, ROM exercises,
person’s functional faculties are thought administration of medications directed
to be diminished towards recovery or prevention of
DISEASE – alteration in body’s physiology complications.
which reduces one’s capacities and  
shortens the normal life span.
ETIOLOGY – the cause of the disease
 
CLASSIFICATIONS OF ILLNESS AND DISEASE:
Acute illness – severe symptoms
but short duration which may or
may not require medical
interventions.
Chronic illness – longer duration
with periods of remission and
exacerbation.
 
STAGES OF ILLNESS:
STAGE 1 (Symptom experience)
STAGE 2 (Assumption of the sick role)
STAGE 3 (Medical Care contact)
STAGE 4 ( Dependent Client Role)
STAGE 5 ( Recovery or Rehabilitation)
 
V. PREVENTIVE HEALTH CARE
 
LEVELS OF PREVENTION
 
 PRIMARY PREVENTION - deals with promotion of
healthy lifestyle and maintenance of current health.
 Examples: immunization, adequate rest and sleep,
avoidance of stress, eating a well balanced diet, and
many more.
 SECONDARY PREVENTION – early detection
and prompt treatment
 Examples: diagnosis and prompt interventions to
reduce the effect of disease to achieve the possible
level of health for the client (e.g. chest x – ray, pap
smear, complete blood count, CT scan)
 TERTIARY PREVENTION – Directed towards
rehabilitation and prevention of complications
NURSING INFORMATICS and conscience.
 
The relationship between computer literacy,
Nursing Informatics – is the integration of
technological competence and a nurse's ability to
computer, information, and nursing science.
care is congruent for quality care. Computer literacy
Nursing informatics - assists the management and
represents a proactive response to technology which
processing of nursing data, information, and
enhances Caring in nursing
knowledge to support nursing practice, education,
 
research, and administration.
TELE-NURSING
Nursing Informatics - is the science of using
 
computer information systems in the practice of
Tele-nursing is the branch of telehealth that
nursing. (Kozier et.al)
involves actual nursing and client interaction through
 
the medium of information technology.
Nursing Informatics is a growing specialty and will be
 
of greater aid for nurses in the coming years. The
Benefits of Tele-nursing
advent of technological breakthrough creates a
· Nurses can actually view healing wounds, can
sudden shift of paradigm in practice disciplines such
access physiological monitoring equipment to
as nursing. The human – machine tandem have
measure physical indicators such as vital signs and
proven a lot of change in terms of efficiency,
provide routine assessment and follow-up care
accuracy and precision, cost effectiveness, time
without the client having to travel to the health care
value, and many more in various fields of science
agency for an appointment.
and commerce. If this process is carried on through
New technologies have added a visual component to
nursing, then we can assure of quality client care
the interactions that augments the historic audio
even in the most unlikely environment.
exchange.
 
 
"Computers are incredibly fast, accurate and stupid.
 
Human beings are incredibly slow, inaccurate and
E-HEALTH
brilliant. Together they are powerful beyond
 
imagination." - Albert Einstein
E-health is a client-centered World Wide Web-based
 
network where clients and health care providers
CARING AND INFORMATICS
collaborate through ICT mediums to research, seek,
 
manage, deliver, refer, arrange, and consult with
Technological proficiency in nurses is a desirable
others about health related information and concerns
attribute to function optimally in our changing health
 
care system: not as a substitute for nurses' care, but
Nurses can be primary actors in the virtual arena of
as an actual enhancement of care.
E-health, serving as health advisors, Internet guides
 
to help clients select reliable information resources,
The competent use of machine technology is
support group liaisons, web information providers,
becoming integral to nurses' work, in acute and
and so on
community settings. Nurses need to develop
 TERMS
technological know-how to keep pace with the rapid
development of new health technologies.
Technological competence requires intentionality,
along with compassion, Confidence, commitment,
active program or window - The
application or window at the front
(foreground) on the monitor.
alert (alert box) - a message that appears
on screen, usually to tell you something
went wrong.
application - a program in which you do
your work.
application menu - on the right side of the
screen header. Lists running
applications.
ASCII (pronounced ask-key ) - American
Standard Code for Information
Interchange. a commonly used data
format for
exchanging information between
computers or programs.
background - part of the multitasking
capability. A program can run and
perform tasks in the background while
another program is being used in the
foreground.
bit - the smallest piece of information used
by the computer. Derived from "binary
digit". In computer language, either a
one (1) or a zero (0).
backup - a copy of a file or disk you make
for archiving purposes.
boot - to start up a computer.   control panel - a program that allows you
bug - a programming error that causes a
program to behave in an unexpected
way.
bus - an electronic pathway through which
data is transmitted between components
in a computer.
byte - a piece of computer information
made up of eight bits.
card - a printed circuit board that adds
some feature to a computer.
cartridge drive - a storage device, like a
hard drive, in which the medium is a
cartridge that can be removed.
CD-ROM - an acronym for Compact Disc
Read-Only Memory.
Clipboard - A portion of memory where the
Mac temporarily stores information.
Called a Copy Buffer in many PC
applications because it is used to hold
information which is to be moved, as in
word processing where text is "cut" and
then "pasted".
command - the act of giving an instruction
to your Mac either by menu choice or
keystroke.
compiler - a program the converts
programming code into a form that can
be used by a computer.
compression - a technique that reduces
the size of a saved file by elimination or
encoding redundancies (i.e., JPEG,
MPEG, LZW, etc.)
control key - seldom used modifier key on
the Mac.
to change settings in a program or
change the way a Mac looks and/or
behaves.
CPU - the Central Processing Unit. The
processing chip that is the "brains" of a
computer.
crash - a system malfunction in which the
computer stops working and has to be
restarted.
cursor - The pointer, usually arrow or cross
shaped, which is controlled by the
mouse.
database - an electronic list of information
that can be sorted and/or searched.
data - (the plural of datum) information
processed by a computer.
defragment - (also - optimize) to
concatenate fragments of data into
contiguous blocks in memory or on a
hard drive.
desktop - 1. the finder. 2. the shaded or
colored backdrop of the screen.
desktop file - an invisible file in which the
Finder stores a database of information
about files and icons.   enhances its function.
dialog box - an on-screen message box
that appears when the Mac requires
additional information before completing
a command.
disk drive - the machinery that writes the
data from a disk and/or writes data to a
disk.
disk window - the window that displays the
contents or directory of a disk.
document - a file you create, as opposed
to the application which created it.
DOS - acronym for Disk Operating System -
used in IBM PCs.
download - to transfer data from one
computer to another. (If you are on the
receiving end, you are downloading. If
you are on the sending end, you are
uploading).
drag - to move the mouse while its button is
being depressed.
drag and drop - a feature on the Mac
which allows one to drag the icon for a
document on top of the icon for an
application, thereby launching the
application and opening the document.
driver - a file on a computer which tells it
how to communicate with an add-on
piece of equipment (like a printer).
expansion slot - a connector inside the
computer which allows one to plug in a
printed circuit board that provides new
or enhanced features.
extension - a startup program that runs
when you start the Mac and then
file - the generic word for an application,
document, control panel or other
computer data.
finder - The cornerstone or home-base
application in the Mac environment. The
finder regulates the file management
functions of the Mac (copying,
renaming, deleting...)
floppy - a 3.5 inch square rigid disk which
holds data. (so named for the earlier
5.25 and 8 inch disks that were flexible).
folder - an electronic subdirectory which
contains files.
font - a typeface that contains the
characters of an alphabet or some other
letterforms.
fragmentation - The breaking up of a file
into many separate locations in memory
or on a disk.
freeze - a system error which causes the
cursor to lock in place.
gig - a gigabyte = 1024 megabytes.
hard drive - a large capacity storage
device made of multiple disks housed in
a rigid case.
 hardware – physical parts of the computer.
Includes central processing unit, input
and output devices.
high density disk - a 1.4 MB floppy disk.
highlight - to select by clicking once on an
icon or by highlighting text in a
document.
icon - a graphic symbol for an application,
file or folder.
initialize - to format a disk for use in the
computer; creates a new directory and
arranges the tracks for the recording of
data.
insertion point - in word processing, the
short flashing marker which indicates
where your next typing will begin.
installer - software used to install a
program on your hard drive.
kilobyte - 1024 bytes.
landscape - in printing from a computer, to
print sideways on the page.
launch - start an application.
Measurements (summary) -
*a bit = one binary digit (1 or 0) *"bit" is
derived from the contraction b'it (binary
digit) -> 8 bits = one byte
*1024 bytes = one kilobyte
*K = kilobyte
*Kb = kilobit
*MB = megabyte
*Mb = megabit
*MB/s = megabytes per second
*Mb/s = megabits per second
*bps = bits per second
i.e., 155 Mb/s = 19.38 MB/s
MB - short for megabyte.
megabyte - 1024 kilobytes.
memory - the temporary holding
menu - a list of program commands listed
by topic.
menu bar - the horizontal bar across the
top of the Mac¹s screen that lists the
menus.
multi tasking - running more than one
application in memory at the same time.
operating system - the system software
that controls the computer.
optical disk - a high-capacity storage
medium that is read by a laser light.
palette - a small floating window that
contains tools used in a given
application.
partition - a subdivision of a hard drives
surface that is defined and used as a
separate drive.
paste - to insert text, or other material, from
the clipboard or copy buffer.
PC - acronym for personal computer,
commonly used to refer to an IBM or
IBM clone computer which uses DOS.
peripheral - an add-on component to your
computer.
point - (1/72") 12 points = one pica in
printing.
pop-up menu - any menu that does not
appear at the top of the screen in the
menu bar. (may pop up or down)
port - a connection socket, or jack on the
Mac.
RAM - acronym for Random-Access
Memory.
ROM - acronym for Read Only Memory;
memory that can only be read from and
not written to.
root directory - the main hard drive
window.
save - to write a file onto a disk.
save as - (a File menu item) to save a
previously saved file in a new location
and/or with a new name.
scroll box - the box in a scroll bar that is
used to navigate through a window.
serial port - a port that allows data to be
transmitted in a series (one after the
other), such as the printer and modem
ports on a Mac.
server - a central computer dedicated to
sending and receiving data from other
computers (on a network).
shut down - the command from the Special
menu that shuts down the Mac safely.
software - files on disk that contain
instructions for a computer.
spreadsheet - a program designed to look
like an electronic ledger.
start up disk - the disk containing system
software and is designated to be used to
start the computer.
System file - a file in the System folder that
allows your Mac to start and run.
System folder - an all-important folder that
contains at least the System file and the
Finder.
title bar - the horizontal bar at the top of a
window which has the name of the file
or folder it represents.
Uninterruptible Power Source (UPS)- a
constantly charging battery pack which
powers the computer. A UPS should
have enough charge to power your
computer for several minutes in the
event of a total power failure, giving you
time to save your work and safely shut
down.
WORM - acronym for Write Once-Read
Many; an optical disk that can only be
written to once (like a CD-ROM).
zoom box - a small square in the upper
right corner of a window which, when
clicked, will expand the window to fill the
whole screen.
 
 LEVEL OF EXPERTISE AND COMPETENCIES IN  GENERAL CONCEPTS IN NURSING
NURSING INFORMATICS INFORMATICS
  (Adopted from Fundamentals of Nursing by Kozier
Levels of Expertise: et.al)
   
Beginner, entry or user level - indicates Computer in Nursing Education
nurses who demonstrate core nursing Just as computers have become standard
informatics competencies. instructional tools in the primary and secondary
Intermediate or modifier level - indicates school systems, they are used extensively in all
nurses who demonstrate intermediate aspects of nursing education. Nursing programs
nursing informatics competencies. require computerized libraries, faculty members use
Advanced or innovator level of technological teaching strategies in the classroom
competency - indicates nurses who and for outside assignments, and academic record
demonstrate advanced and specialized keeping is facilitated by database programs.
nursing informatics competencies  
  Teaching and Learning
Competencies: Computers enhance academics for both students
  and faculty in at least four ways. These include
Technical - are related to the actual access to literature, CAI, classroom technologies,
psychomotor use of computers and and strategies for learning at a distance.
other technological equipment.  
Utility - related to the process of using
computers and other technological
equipment within nursing practice,
education, research and administration
Leadership - are related to the ethical and
management issues related to using
computers and other technological
equipment within nursing practice,
education, research and administration
 
Each of the three competency levels includes both
knowledge and skills required to:" use information
and communication technologies to enter, retrieve
and manipulate data; interpret and organize data
into information to affect nursing practice; and
Combine information to contribute to knowledge
development in nursing" (Hebert, 1999, p.6). "The
need to adopt a culture in nursing that promotes
acceptance and use of information technology has
been identified as an important parallel initiative to
establishing Nursing Informatics competencies and
educational strategies" (Hebert, 1999, p. 6).
NURSING PROCESS
DEFINITIONS ASSESSMENT
Purpose: To establish database
 is a systematic, rational and cyclical method of Activities:
planning and providing nursing care  Collection of Data
   Organizing Data
PURPOSE  Validating Data
 Solve nursing problems Documenting Data 
 Understand a nursing conditions

Systematic → ADPIE EVALUATION DIAGNOSING

Individualized → Unique Purpose: to determine the effectiveness of the care Purpose: To identify and develop a list
Rationale → Science plan and its corresponding actions whether to of nursing and collaborative problems
Circular/Cycle → sequence continue, terminate, or modify the care plan. Activities:
Activities Analysis of Data
 Collects and compare data with the outcome Identify strengths, risks, and health
problems
 Relate nursing actions to client’s goals Formulate diagnostic statements duly
 Conclude problem status approved by NANDA
 Continue, modify or terminate the nursing care

IMPLEMENTATION PLANNING
Purpose: To assist client meet desired Purpose: To develop an
goals/outcomes and promote maximum level of individualized, goal oriented and
functioning therapeutic care plan
Activities: Activities:
Reassessment of Clients and their response to care Prioritizing needs
Determination of any need for assistance Formulation of Goals
Implementation of nursing interventions Selection of Nursing Interventions
Supervising delegated care Writing Nursing Orders
Documenting Nursing actions
 STEPS OF THE NURSING PROCESS
ASSESSMENT
 
The vital first phase in the nursing process,
assessment consists of the patient history,
consultations, lab findings, pharmacological
requisites, and the nurse’s physical examination
 
Nursing assessment is the systematic process of
gathering, verifying and communicating data
about a patient. It includes 2 steps (1) collection
of data from a primary source (patient), and (2)
collection of data from a secondary source
(family, health professionals).
 
The purpose of assessment is to establish a data
base about the client’s perceived needs, health
problems and risks, related experiences, health
practices, goals, values, and lifestyle.
 
The information contained in the DATA BASE is the
basis for an individualized plan of nursing care,
developed and refined throughout the time the
nurse cares for the client.
Interview
Purpose: To gather information, identify health
concerns and provide health teaching.
Goal: To develop rapport and trust with the client and
to collect data.
 
Stages:
1. Opening: The purpose is to establish rapport that
is achieved through self-introduction, non-verbal
gestures (e.g. handshake) etc. The purpose of the
interview is explained at this stage.
2. Body: The nurse tries to ask the client using open
and close-ended questions.
3. Closing: After the needed information has been
gathered either parties may close the interview.
Types of data:
Subjective
Covert data or symptoms
Client’s perceptions about his health
problems.
Subjective data usually include feelings of
anxiety, physical discomfort, or mental
stress.
 
Objective
Overt data or signs
Observations or measurements made by the
data collector. The measurement of
objective data is based on an accepted
standard, such as the Fahrenheit or
Celsius measure on a thermometer.
In the physical examination of a patient –
involving inspection, palpation,
percussion and auscultation – objective
data is collected about client’s condition
and underlying pathology.
 
 
NURSING DIAGNOSIS
Nursing diagnosis is a “clinical judgment about
individual, family, or community responses to
actual or potential health problems or life
processes. Nursing diagnoses provide the basis
for selection of nursing interventions to achieve
outcomes for which the nurse is accountable.”-
North American Nursing Diagnosis Association
(NANDA)
 
A nursing diagnosis is a statement that describes the
patient’s actual or potential response to a health
problem that the nurse is licensed and
competent to intervene.
 
Components of a nursing diagnosis: Problem +
Etiology + signs and symptoms / risk factors
The client’s actual and potential responses are
obtained from the assessment data base, a
review of pertinent literature, the client’s past
medical records, and consultation with other
professional, all of which are collected during
assessment.
The purpose is to identify client strengths and health
problems that can be prevented or resolved by
collaborative and independent nursing
interventions.
 
Types of Nursing Diagnoses:
 
Actual: the client shows manifestations of a health
problem or condition.
e.g. ineffective airway clearance
High-Risk: A health problem or condition is likely to
develop as a result of risk factors being assessed
unless the nurse intervenes.
e.g. Risk for injury
Wellness: The client is healthy as assessed but he
wishes to achieve a higher level of functioning.
e.g. Readiness for enhanced social
well being
Possible – a nursing diagnosis is which evidence is
unclear unless further provided, but existing
condition may predict a possible health problem
e.g. Possible for alteration in
nutrition r/t unknown etiology
Syndrome – a clustered nursing diagnosis.
e.g. –Disuse Syndrome
 
PLANNING
 
The nursing plan of care refers to a WRITTEN PLAN
of action designed to help nurses deliver quality
patient care. It usually becomes part of the
permanent part of the patient’s health record and
will be used by other members of the nursing
team.
The purpose is to develop individualized care plan
that specifies client goals and expected
outcomes.
 
PLANNING STAGES
Assign priorities to the nursing diagnosis
Establish client goals / outcome
Select appropriate nursing interventions
Document the nursing diagnosis, expected
outcomes and interventions.
Evaluate the effectiveness of the plan of care
 
BENEFITS OF A WRITTEN CARE PLAN
A care plan that is well conceived & properly written
helps decrease the risk of incomplete or
incorrect patient care by:
giving direction for individualized care
providing continuity of care
establishing professional communication
serving as a key for patient assignments
 
GOALS/EXPECTED OUTCOMES
An expected outcome is the specific, step-by-
step measurable criterion that leads to
attainment of the goal & the resolution of the
etiology for the nursing diagnosis.
Outcomes are the desired responses of a
client’s condition in the physiological, social,
emotional, developmental, or spiritual
dimensions. This change in condition is
documented through observable or
measurable client responses.
Patient goals may be either short term or long
term.
SPECIFIC How the nurse will know the client’s response
has changed.
MEASURABLE What the client will do, when it will be done,
and to what extent.
APPROPRIATE Relate with the client in formulating expected
outcomes.
REALISTIC Includes client’s health capabilities.
TIMELY Time estimate for outcome attainment.
 IMPLEMENTATION
A nursing intervention is any action taken by the
nurse to help the client move from a present
health state to the health state described in the
expected outcomes. The client may require
intervention in the form of support, medication,
treatment for the current condition, client-family
education, or treatment to prevent future health
problems.
· The purpose is to assist the client meet desired
goals or expected outcomes; promote wellness;
prevent illness and disease; restore health and
rehabilitation.
Consists of carrying out the interventions or
delegating nursing interventions, which involves
assigning care for a client to another professional or
individual while retaining accountability for certain
care.
Types:
1. Independent: nurses are licensed to act related to
their knowledge and skills.
2. Interdependent/ Collaborative: carried out by a
nurse with collaboration of other healthcare team.
3. Dependent: carried out by a nurse in collaboration
with the physician.
EVALUATION
Measures the client’s response to nursing actions
and the client’s progress toward achieving goals.
The purpose is to determine whether to continue,
modify, or terminate the nursing interventions
The nurse evaluates whether the client’s behaviors
or responses reflect a reversal or improvement
in a nursing diagnosis or maintenance of a
health state.
Evaluation may be:
Ongoing: done while or immediately after
implementing the nursing intervention.
Intermittent: performed at specified
intervals, such as thrice a week.
Terminal: performed to indicate the client’s
condition at the time of discharge.
 
Evaluative statements compare the data with the
expected outcomes supported by evidences.
Goal met – client’s response is the same
with goals
Goal partially met – only part of the desired
outcome is met
Goal unmet – failure to achieve desired
outcome in expected time.
 
PHYSICAL ASSESSMENT PURPOSES FOR PERFORMING A PHYSICAL
EXAMINATION
To determine the patient's physiological
Physical assessment - is an organized systemic
function.
process of collecting objective data based upon a
To arrive at a tentative diagnosis when there
health history and head-to-toe or general systems
is a health problem or disease. Provides
examination.
data for planning intervention
It provides the foundation for the nursing care plan in
To confirm a diagnosis of disease or
which observations play an integral part in the
dysfunction.
assessment, intervention, and evaluation phases.
To evaluate the effectiveness of prescribed
It is performed in an organized, systematic manner,
medical treatment and therapy.
instead of a random manner.
 
 
EQUIPMENT AND SUPPLIES USED FOR
CONSIDERATIONS IN PREPARING A PATIENT
PHYSICAL EXAMINATION:
FOR A PHYSICAL ASSESSMENT
Establish a Positive Nurse/Patient Rapport.
1. Aromatic substances - Test functioning of first
This relationship will decrease the stress
cranial nerve (olfactory) (ex. vanilla, coffee)
the patient may have in anticipation of
2. Cotton balls - Assess sensory system for light
what is about to be done to him.
touch
Explain the Purpose for the Physical
3. Gloves reduce risk for transmission of
Assessment. The purpose of the nursing
microorganism
assessment is to gather information
4. Laryngeal mirror - Metal instrument with mirror to
about the patient's health in order to plan
inspect pharynx and oral cavity
for individualized care.
5. Ophthalmoscope - Lighted instrument attached to
Obtain an Informed, Verbal Consent for the
a battery tube to visualize the eye’s interior
Assessment. The chief source of data is
6. Otoscope - Special ear speculum that attaches to
usually the patient unless the patient is
an ophthalmoscope to visualize external and middle
too ill, too young, or too confused to
ear (eardrum)
communicate clearly.
7. Penlight / Flashlight to test pupillary reaction to
Ensure Confidentiality of All Data. If possible,
light and third, fourth, and sixth cranial nerves
choose a private place where others
(oculomotor, trochlear, and abducens)
cannot overhear or see the patient.
8. Percussion hammer- Instrument with rubber head
Explain what information is needed and
to test reflexes
how it will be used.
9. Safety pin - Disposable sharp object to assess
Provide Privacy From Unnecessary
pain, sensory system
Exposure. Assure as much privacy as
10. Tape measure - Calibrated in cm to measure
possible by using drapes appropriately
circumference
and closing doors.
Tongue depressor - Wooden tongue blade to inspect
Communicate Special Instructions to the
oral cavity and stimulate gag reflex to assess ninth
Patient.
and tenth (glossopharyngeal and vagus) cranial
 
nerves
12. Tuning fork - Metal fork that vibrates when percussion
tapped and is used to perform Rinne test to assess assess for vibration with the use of fingers
eighth (acoustic) cranial nerve The finger of one hand taps the finger of the
13. Lubricant - Facilitates insertion of instruments other hand to generate vibration which can
into body cavities be used to determine a diagnostic sound.
Drape - Covers exposed body parts
 
TONE QUALITY PITCH EXAMPLE
ASSESSMENT TECHNIQUES:
  Resonance Hollow Low Healthy Lungs
“IPPA” – Inspection, Palpation, Hyperresonance Booming Very Loud Empysema
Percussion, Auscultation Tymphany Drum – like High GI Bubbling,Empty
inspection stomach or Large
use of sense of sight intestine
visual inspection/examination Dullness Thud – like high kidney, full bladder,
Example, the skin is inspected for color, feces filled intestine
tone, and texture, as well as scars, Flatness Very Dull Soft - Bones and muscles
lesions, abrasions, and rashes. moderate ( very dense
Throughout the examination the nurse tissue ) , heart,
should visually observe the client’s spleen, liver
general body appearances such as
movement, motor dexterity, contour and auscultation
symmetry of the body, and deformities. use of sense of hearing with the use of
palpation the unaided ear or a stethoscope
use of sense of touch frequently assessed organs: heart,
The back of the hand can be used to assess lungs, abdomen, and blood vessels
skin temperature over an inflamed joint  
or a leg with impaired circulation
because the skin at the back of the hand HEALTH HISTORY:
is thinner and sensitive to temperature Biographic information
changes Chief complaint
The finger pads are also sensitive and are Present health status
used to palpate the size, position, and Health history
consistency of various body parts, such Family history
as lymph nodes and breast tissue Psychosocial factors
Types of palpation: Nutrition
Light palpation – detects superficial  
mass ( 1 “ depth ) History of Present illness includes:
Deep palpation – palpates organ Statement of general health before
enlargement like liver, mass and illness
pulsations ( 3 – 4” in depth) Date of onset
Characteristics at onset
Severity of symptoms
Course since onset
 Associated signs and symptoms
Aggravating or relieving factors
Effect on activities
Treatments tried and results
Additional assessment question:
What do you think caused this
problem?
Is anyone else in the household
sick?
 
Past Health History – any diseases and illness
experienced in the past
which includes childhood
illnesses and immunization
status, any recent surgeries,
admission, or recurrent
illnesses.
Family Health History – any hereditary condition
which makes the client
susceptible of developing a
disease.
 
Vital SIGNS
Also called Cardinal signs Factor Temperature Pulse Respiration Blood Pressure

PURPOSE: Exercise Increases Short Term: Rate and Increases

To obtain baseline measurement of and increases depth
the patient’s vital signs metabolis Long – term : increases
To assess patient’s response to m lowers the
treatment or medication resting rate
To monitor patient’s condition after and return
invasive procedures time to the
Refers to the measurement of “ TPR – BP ” resting rate
Temperature post exercise
Pulse Rate Anxiety Increases Increases Increases Increases
Respiratory Rate and stress
Blood Pressure Postural No change Increases Decreases Decrease with
changes with sitting or with stooped sitting or
standing ; or slumped standing
 Variations in Vital Signs By Age Decrease positions
when lying due to
Age Temp. Pulse Respiratory BP down decreased
( ° C) Cycles/min ( mmHg) chest
expansion
Diurnal Lowest level: Decreases None Lowest level:
Newborn 36 . 8 80 – 180 30 – 80 73 / 55 variations / 4:00 AM – during sleep early morning
circadian 6:00AM Highest level:
rhythm Highest level: late afternoon or
1 Year 36 . 8 80 – 140 20 – 40 90 / 55
8:00 PM – early evening
12:00 AM
5–8 37 75 – 120 15 – 25 95 / 57
years old
10 years 37 50 – 90 15 – 25 102 / 62
old
Teen 37 50 – 90 15 – 20 120/80

Adult 37 60 - 100 12 - 20 120/80

Elderly 37 60 - 100 15 – 20 130 / 90

FACTORS INFLUENCING VITAL SIGNS

TEMPERATURE
Reflects the balance between heat produced
and heat lost from the body.
 
 
HEAT PRODUCTION
Heat is produced in the body’s cells
through food metabolism that
results in the release of energy
ENERGY – measured in terms of  
heat
1 kilocalorie equals 1000 calories
(the amount of heat required to
raise the temperature of 1
kilogram of water 1°C).
Body continually produces heat as a
by product of metabolism
Factors that affect metabolism :
Food metabolism
Muscle Activity
Increased thyroxine
production
Fever
basal metabolic rate, or BMR - the
rate of energy use in the body
needed to maintain essential
activities
age and exercise
Thyroxine output - Increases rate of
cellular metabolism throughout
the body(Chemical
Thermogenesis)
Epinephrine, Norepinephrine, &
symphatetic Nervous System
Stimulation - Increase cellular
metabolism
HEAT LOSS
Radiation
transfer of heat from the
surface of one object to
another without contact
between objects
ex. Warming through a drop
light
Evaporation
Continuous insensible loss
from the skin and lungs
when water is converted
from liquid to gas
ex. Natural drying after
excessive sweating
Convection
Dispersion of heat by air
currents. The body
usually has a small
amount of warm air
adjacent to it. The air
rises and is replaced by
cooler air
ex. Facing a fan for cooling
Conduction
transfer of heat from one
molecule to a molecule
of lower temperature
-( with contact)
ex.Tepid Sponge Bath
Insensible heat loss - is the heat
that is lost through the
continuous, unnoticed water
loss that occurs with
vaporization, accounting for
10% of basal heat production.
Evaporation accounts for the
greatest heat loss when body
heat increases.
 TYPES of TEMPERATURE
1. Core Temperature
Measured thru tympanic and rectal routes
2. Surface Temperature
Measured thru oral and axillary routes, skin
patch or temperature – sensitive tape
 
Alterations in Body Temperature:
Pyrexia- temperature above the usual
range. (hyperthermia)- Above 40°C
– hyperpyrexia
Fever
Intermittent - fluctuation of body
temp. at regular intervals
between periods of fever
and periods of Normal or
subnormal Temperature
Remittent- fluctuations above
Normal of more than 2 °C
Relapsing – a fever that
subsides and after few days
returns.
Constant – a fever with minimal
temperature fluctuations
Hypothermia – a body temperature of
35 degrees Celsius or lower
resulting from cold weather
exposure or artificial induction
Frostbite – freezing of the body’s
surface areas (earlobes, fingers,and
toes) in extremely low temperatures
Heat Stroke - a critical increase In
body temperature ( 41 degree
Celsius to 44 degree Celsius)
resulting from exposure to high
environmental temperatures
ROUTES FOR ASSESSING BODY
TEMPERATURE:
Oral – accessible and convenient
Contraindications:
1. Infants and very young children
2. Patients with oral surgery
3. Unconscious or irrational patients
4. Seizure-prone patients
5. Mouth breathers and pts. with oxygen
Equipment : oral thermometer Slim tip
Axilla - safest and non invasive
- Least accurate
Rectal – most reliable measurement
Contraindications:
1. Rectal abnormalities
2. Diarrhea
3. Certain heart conditions
4. Immunosuppressed
Equipment: rectal thermomter
Stubby, pear-shaped tip
electronic thermometer : Battery-powered
display unit with a sensitive probe(blue for
oral and red for rectal) covered with a
disposable plastic sheath for individual use
Tympanic – accessible, less invasive
Contraindications:
Conversion: 1. Presence of ear ache
Fahrenheit to Celsius 2. Significant ear drainage
3. Scarred tympanic membrane
°C= (°F-32) x 5/9
Celsius to Fahrenheit
°F= (°C x 9/5) + 32
 PULSE
Wave of blood created by contraction of the
left ventricle of the heart.
 
Sites
 Temporal – accessible; used
routinely for infants and when radial
pulse is not accessible
 Carotid - used routinely for infants
and during shock or cardiac arrest
when other peripheral pulses are
too weak to palpate ; used to
assess for cranial circulation
 Apical – used to auscultate heart
sounds and assess apical - radial
pulse =pulse deficit
 Femoral – assess circulation to the
legs and during cardiac arrest
 Brachial – used in cardiac arrest of
infants and used to asses for lower
arm circulation and to auscultate for
BP
 Radial – used routinely to assess
for character of peripheral pulses in
adults
 Popliteal – used to assess
circulation to the legs and to
auscultate leg blood pressure
 Posterior tibial – used to assess
circulation to the feet
 Dorsalis Pedis - used to assess
circulation to the feet
 
CHARACTERISTICS OF PULSE
Rate – number of beats per minute; assess
this by compressing an artery with the
pads of three fingers.
*A client in pain will have elevated pulse; an
athletic may be lower.
*Bradycardia: a pulse that is below normal
*Tachycardia: a pulse that is above normal
Rhythm – pattern or regularity of beats and
interval between each beat. Pulse
rhythm is the spacing of the heartbeats.
When the intervals between the beats
are the same, the pulse is described as
normal or regular. When the pulse skips
a beat occasionally, it is described as
intermittent or irregular
Volume/amplitude – amount of blood pumped
with each heartbeat. Pulse volume
describes the force with which the heart
beats. The volume of the pulse varies
with the volume of blood in the arteries,
the strength of the heart contractions,
and the elasticity of the blood vessels.
Pulse Force/ Pulse Volume Grading:
+3: bounding pulse
+2: normal
+1: thready pulse, weak or
difficult to feel
0: absent pulse
Cardiac Output – 5-6 Liters of blood is
forced out of the left ventricle per minute
Pulse Deficit – difference between the apical
and radial counts taken simultaneously
Equipment used to assess pulse rate:
Alcohol swab
Stethoscope
Watch with second
hand
Measuring Radial Pulse:
1. Inform client of the site at which you will
measure the pulse rate
2. Flex client’s elbow and place lower part of
arm across chest.
3. Place your index and middle finger on inner
aspect of client’s wrist over the radial artery
and apply light but firm pressure until pulse
is palpated
4. Count pulse rate by using second hand on a
watch:
a. For a regular rhythm, count number
 of beats for 30 seconds and multiply
by 2.
b. For an irregular rhythm, count
number of beats for a full minute,
noting number of irregular beats.
5. When counting for the first time, count for a
full minute
Measuring Apical Pulse
1. Raise client’s gown to expose sternum and
left side of chest.
2. Locate Apex of heart:
3. With client lying on left side, locate
suprasternal notch.
4. Palpate second intercostal space to left of
sternum.
5. Place index finger in intercostal
space,counting downward until fifth
intercostal space is located.
6. Move index finger along fourth intercostal
space left of the sternal border and to the
fifth intercostal space, left of the
midclavicular line to palpate the point of
maximal impulse (PMI)
7. Keep index finger of nondominant hand on
the PMI.
8. With dominant hand, put earpiece of the
stethoscope in your ears and grasp
diaphragm of the stethoscope in palm of
your hand for 5 to 10 seconds to warm.
9. Place diaphragm of stethoscope over the
PMI and auscultate for sounds S1 and S2 to
hear lub-dub sound
10. Start to count while looking at second hand
of watch. Count lub-dub sound as one beat:
11. For a regular rhythm, count rate for 60
seconds.
12. For an irregular rhythm, count rate for a full
minute, noting number of irregular beats.
13. Document
RESPIRATORY RATE
 
Respiratory assessment is the
measurement of the breathing
pattern. Assessment of respirations
provides clinical data regarding the
pH of arterial blood.
Normal breathing is slightly observable,
effortless, quiet, automatic, and
regular.
 
Method of Assessment:
Observing chest wall expansion and
bilateral symmetrical
movement of the thorax.
Place the back of the hand next to the
client’s nose and mouth to
feel the expired air.
Should assess by counting the number of
breaths per minute
Equipment for Assessment: watch with
second hand
External Respiration- refers to the interchange of
oxygen and CO2 in the alveolo-
capillary membrane
Internal Respiration - exchange of gasses
between the Blood and the cells
Inhalation/inspiration –active process
Exhalation/Expiration – passive process due to
elastic recoil
Normal respiratory rate: 12-20 breaths per minute
in adult (eupnea).
Respiratory Controls:
Medulla Oblongata: Central Chemoreceptor
Carotid and Aortic bodies: Peripheral
Chemoreceptor
 Characteristics of Respiratory Wave BLOOD PRESSURE
Pattern “RAR”  
Rate Pressure exerted by blood to the blood
Amplitude/depth vessel wall
Rhythm / Pattern SYSTOLIC - ventricular contraction
  DIASTOLIC - Ventricular relaxation
  AVERAGE: 120/80 mmHg
Breathing Pattern and Sounds  
Kussmaul’s - Faster and deeper respiration DETERMINANTS;
without pauses in between panting Pumping action of the heart
Apneustic - Prolonged grasping breathing Peripheral vascular resistance
followed by extremely short inefficient Blood volume
exhalation Blood viscosity
Dyspnea - difficulty of breathing  
Orthopnea -DOB unless patient is sitting; can Techniques :
breathe only when in an upright The direct method requires an invasive
position. procedure in which an intravenous
Cheyne-Stokes is the term for cycles of catheter with an electronic sensor is
breathing characterized by deep, inserted into an artery and the
rapid breaths for about 30 seconds, artery-transmitted pressure on an
followed by absence of respirations for 10 to electronic display unit is read. -CVP
30 seconds. It usually precedes death in The indirect method requires use of the
cerebral hemorrhage, uremia, or heart sphygmomanometer and
disease. stethoscope for auscultation and
Wheezing - narrowing of airways, causing palpation are needed.
whistling or sighing sounds Common site : brachial artery
Stridor - high-pitched sounds heard on inspiration Contraindications for brachial artery:
with laryngeal obstruction Venous access devices, such as an
Crackles/ Rales - sound caused by air passing intravenous infusion or
thru fluid or arteriovenous fistula for renal
mucus in the airways usually heard on dialysis
inhalation Surgery involving the breast, axilla,
Gurgles/ Rhonchi- sound caused by air passing thru shoulder, arm, or hand
airways narrowed by fluids, edema, muscle spasm Injury or disease to the shoulder,
usually heard during exhalation ; course , dry, arm, or hand, such as trauma,
wheezy or whistling sou burns, or application of a cast or
bandage
 
 Factors affecting Blood Pressure:
Age -Children normally have lower
blood pressure at birth (80/60),
which gradually increases until the
age of 18 when it becomes equal to
the normal adult pressure. Older
adults frequently have higher blood
pressure due to a decrease in blood
vessel elasticity.
Sex - Men have higher blood pressure
than women of the same age.
Body Built-Blood pressure is usually
elevated in an obese person.
Exercise- Muscular exertion will
temporarily elevate the blood
pressure. A regular exercise
program can eventually decrease
the resting blood pressure.
Pain- Physical discomfort will
usually elevate the blood pressure.
Emotional Status- Fear, worry, or
excitement can elevate the
blood pressure.
Disease States and Medication -Some
disease conditions and/or the
medications influence the blood
pressure.
 
 
Points to remember when Assessing
Blood Pressure:
Equipment:
Sphygmomanometer with proper size
cuff
Stethoscope
Alcohol swabs
 
1. Select a cuff size that completely encircles
upper arm without overlapping
2. Wrap the blood pressure cuff on the arm 1
inch above client’s brachial pulsation, with
bladder centered over brachial artery
3. Position arm at heart level, extend elbow
with palm turned upward.
4. Palpate brachial artery, turn valve clockwise
to close and compress bulb to inflate cuff to
30 mm Hg above point where palpated
pulse disappears, then slowly release valve
(deflating cuff), noting reading when pulse is
felt again.
5. Place bell piece over brachial artery below
the level of the chest
6. With dominant hand, turn valve clockwise to
close. Compress pump to inflate cuff until
manometer registers 30 mm Hg above
diminished pulse point identified 
7. Slowly turn valve counterclockwise so that
mercury falls at a rate of 2–3 mm Hg per
second. Listen for five phases of Korotkoff’s
sounds while noting manometer reading:
8. A faint, clear tapping sound appears and
increases in intensity (phase I). – systolic
pressure
9. Swishing sound (phase II).
10. Intense sound (phase III).
11. Abrupt, distinctive muffled sounds (phase
IV).
12. Sound disappears (phase V) – Diastolic
Pressure
a. Deflate cuff and wait for 2 mins if
reasessement is needed
13. Document
Conditions related to Blood Pressure:
 
Hypotension refers to a systolic blood
pressure less than 90 mm Hg or 20 to
30 mm Hg below the client’s normal
systolic pressure. Hypotension is
caused by a disruption in
hemodynamic regulation, such as:
Decreased blood volume (e.g.,
hemorrhage)
 Decreased cardiac output (e.g., Alert
myocardial infarction [heart attack]) Drowsy
Decreased peripheral vascular resistance Very Drowsy
(vascular dilation) (e.g., shock) Unconscious Localizing
Orthostatic hypotension (postural Unconscious Withdrawing
hypotension) refers to a sudden drop of Decorticating
25 mm Hg in systolic pressure and 10 Decerebrating
mm Hg in diastolic pressure when the  
client moves from a lying to a sitting or a Glasgow Coma scale is a tool used to
sitting to a standing position. Orthostatic measure the levels of consciousness and
hypotension usually occurs with aging the degree of impairment. Included in the
and is a common antiadrenergic side GCS are: assessment of eye opening,
effect of several medications, such as best verbal response, and best motor
chlorpromazine hydrochloride. response.( Refer to table below)
  The score in each category is added in
Hypertension refers to a persistent systolic order to get the overall scale. The highest
pressure greater than 135 to 140 mm possible score is 15. If a score falls below
Hg and a diastolic pressure greater 7, the patient is considered I comatose
than 90 mm Hg. Diagnosis of status.
hypertension is based on the average  
of two or more readings taken at each
of two or more visits after an initial
screening.
 
Faulty techniques that constrict
blood flow will produce a
false high pressure reading:
A cuff too narrow for the GLASGOW COMA SCALE (GCS) TABLE: Score
extremity
Eye Spontaneous ( open with blinking at baseline) 4
A cuff that does not fit snugly
Opening Opens to verbal command, speech, or shout 3
around the extremity
Response Opens to pain, not applied to face 2
A cuff that is deflated too slowly
  None 1
Best Verbal Oriented 5
Response Confused conversation, but able to answer 4
questions
NEUROLOGICAL ASSESSMENT Inappropriate responses, words discernible 3
Incomprehensible speech 2
NEUROLOGICAL ASSESSMENT None 1
Levels of Consciousness - Can be Motor Obeys commands for movement 6
measured by RLS (Reactive Level Score) Response Purposeful movement to painful stimulus 5
and Glasgow Coma Scale Withdraws from pain 4
REACTIVE LEVEL SCORE (RLS) Abnormal (spastic) flexion, decorticate posture 3
Extensor (rigid) response, decerebrate posture 2
None 1
Total   15
Appearance: Neat, clean; clothes appropriate to
occasion, season, and sex
Affect: Attentive, cooperative, pleasant
Speech : Articulate, fluent, readily answers questions
Memory: Responds appropriately to questions:
Immediate: “Why are you here?”
Recent: “What did you eat for breakfast?”
Remote: “Where were you born?”
 
Orientation :
Person (self, others)
Place
Time
 
 
CRANIAL NERVES ASSESSMENT TOOL
 

I Olfactory Cribiform Plate Special Sensory: Smell Smell

II Optic Optic Canal Special Sensory: Sight Vision
III Oculomotor Superior Orbital Somatic Motor: Superior, Medial, Inferior Rectus, Inferior Oblique  ;
Fissure Visceral Motor: Sphincter Pupillae  Pupil Constriction, elevation of
upper lid
IV Trochlear Superior Orbital Somatic Motor: Superior Oblique Eye movement,
Fissure
V Trigeminal V1: Sup Orb Fissure Somatic Sensory: Face 
V2: Foramen Somatic Motor: Mastication, Tensor Tympani, Tensor Palati Controls
Rotundum muscle of chewing
V3: Foramen Ovale
VI Abducens Superior Orbital Somatic Motor: Lateral Rectus Eye movement,
Fissure
VII Facial Internal Auditory Somatic sensory: Posterior External Ear Canal 
Canal Special Sensory: Taste (Anterior 2/3 of Tongue) 
Somatic Motor: Muscles Of Facial Expression
Visceral Motor: Salivary Glands, Lacrimal Glands Controls muscle
for facial expression
VIII Internal Auditory Special Sensory: Auditory/Balance Maintain equilibrium; hearing
Acoustic
Canal
IX Glossophar- Jugular Foramen Somatic Sensory: Posterior 1/3 Tongue, Middle Ear 
yngeal Visceral Sensory: Carotid Body/Sinus 
Special Sensory: Taste
Somatic Motor: Stylopharyngeus  Visceral Motor: Parotid Controls
muscle of throat
X Vagus Jugular Foramen Somatic Sensory: External Ear  ; Visceral Sensory: Aortic
Arch/Body  ; Special sensory: Taste Over Epiglottis 
Somatic Motor: Soft Palate, Pharynx, Larynx (Vocalization and
Swallowing) 
Visceral Motor: Bronchoconstriction, Peristalsis, Bradycardia,
Vomitting Controls muscle of throat, thoracic and abdominal organs
XI Spinal Jugular Foramen Somatic Motor: Trapezius, Sternocleidomastoid Controls
Accessory neckmuscles
XI Hypoglossal Hypoglossal Canal Somatic Motor: Tongue Tongue movement
 Neurologic Assessment Normal Findings Significant Findings
Assessment Tool
Motor Function Muscle strength. · Equal ize on both ides of body NOTE: Tics, tremors, fasciculations may suggest neurologic
assessment of the Flexion and extension. · Usually firm involvement.
motor system Muscle tone · Equal strength on both sides of  
involves testing for   the body
muscle size, tone,   · Smooth , coordinated
and strength   movements
under voluntary
movements
Reflexes Scale Response Blink reflex NOTE: Diminished or absent reflexes may suggest upper or lower
  0 Absent Gag and swallow reflex motor neuron disease; however, this may also be found in normal
+ Present but Plantar response (Babinski reflex) people. (Reinforcement by isometric contraction such as asking
diminished Deep tendon reflex patient to push his or her hands together while knee reflex is
++ Normal Biceps - checked may increase reflex activity.)
+++ Mildly increased Triceps – A positive Babinski’s reflex may be seen in pyramidal tract disease or in
but not pathologic Brachioradialis the unconscious patient
++++ Markedly Patellar – NORMAL: extension of  
hyperactive; leg below the knee  
clonus may be Achilles – Normal: plantar flexion
present of feet
  Plantar (babinski) – Normal:
bending of toes downward 
Sensory Function Asses for: (done after NOTE: Inappropriate response indicates neurologic disorder.
  symmetric testing  
of the arms, legs,
and trunk)
Pain: “Sharp or dull?”
Temperature: “Hot or
cold?”
Light touch: “Feel
touch?”
Vibration: “Feel tuning
fork vibrating
against joint?”
Position sense
(proprioception):
“Am I moving your
toe up or down?”
 
 Cerebellar Function Perform . Note the client’s ability to NOTE: Loss of balance is termed “positive Romberg test” (indicates
  Romberg’s test: maintain balance with eyes sensory ataxia).
ask the client to open and closed for 20 Uncoordinated gait may suggest cerebral palsy, parkinsonism, or drug
stand erect, feet seconds with minimum side effect. Inappropriate movements suggest cerebellar disease
together and arms swaying  
at side, first with  
eyes open, then  
closed. The nurse
should stand close
to the client to
catch the client in
the event of a fall
 

HEAD ASSESSMENT
 

Assessment Assessmen Normal Significant Findings

t Tool Findings

Head Inspection : Normocephalic Hydrocephalic

Size or contour Micrpcephalic
Asymmetric

Scalp inspection Smooth, NOTE: Scaling, masses,

nontender tenderness

Head Measuring Tape : Between 5th Exceeds chest

circumference (measured at and 95th circumference by 1–2 cm
largest point percentile on until 18 mo.
above eyebrow standardized  
and behind growth chart.
occiput)
Anterior fontanel   3–4 cm in NOTE: Unusually large
  length and fontanel may indicate
2–3 cm in hydrocephaly (faulty
width until circulation or absorption of
9–12 mo CSF).
of age.  
  Unusually small fontanel
Soft, flat; may indicate
bulges craniosynostosis(prematur
while e closure of sutures).
crying.  
Closes  
between 9
and 18
mo.
 

Posterior fontanel   0.5–1 cm Delayed closure may indicate

  across. hydrocephaly.
May be  
closed at
birth or by
3 mo of
age.
FACE ASSESSMENT
 

Assessment Assessment Normal Significant

Tool Findings Findings
Face: Inspection Symmetric, Asymmetric,
  with relaxed weak; involuntary
  facial movements;tense
  expressions or expressionless
    facies

Sinuses   Frontal and Tenderness

maxillary
sinuses
nontender

Cranial nerve:   Able to smile, Unable to

(CN)VII: facial, puff cheeks, purposely and
motor frown, raise symmetrically
  eyebrows, with use facial
symmetry noted muscles

CN V: trigeminal:   Bilateral Weak or

Motor contractions of asymmetric
  temporal and contraction of
  masseter muscles
muscles when
teeth are
clenched
CN V: trigeminal:   Able to Unable to
sensory distinguish distinguish type
touch on both and location of
sides of face touch
 Eye Assessment symmetrical convergence of eyes.

Pupil Size:
Visual acuity  
assessment of visual acuity is a
simple, noninvasive procedure
that is performed with the use of
a Snellen chart(a chart that
contains various-sized letters
with standardized numbers at
the end of each line of letters)
standardized numbers or Common Refractory Error:
denominators indicates the Myopia (nearsightedness) elongation of the
degree of visual acuity from a eyeball or an error of refraction that causes
distance of 20 feet the parallel rays to focus in front of the retina
External lesions. Hyperopia ( farsightedness) rays of light
Equality of eyelid movement entering the eye are brought into focus
Test extraocular muscle function: behind the retina
Record results. Eye Presbyopia ( far sightedness) results from loss
movements should be of elasticity of the lens of the eye
symmetrical as both Astigmatism – unequal spherical curve of the
eyes follow the direction cornea that prevents the light from being
of the gaze. The upper focused directly in a point on the retina
eyelids cover only the  
uppermost part of the
iris and are free from
nystagmus (involuntary,
rhythmical oscillation of
the eyes).
Presence of discharge.
Internal lesions.
Differences between pupil size
and reaction.
Record results PERRLA (pupils equal, round,
reactive to light and accommodation). Pupil should
constrict quickly in direct response to light and the
opposite pupil should also constrict.Pupils should be
equal in size.
 
Pupillary accommodation causes constriction in
response to objects that are near, and dilation
occurs to accommodate distant vision, with
Ear Assessment
The nurse should observe the client for
signs of hearing difficulty during the
physical examination, such as turning
the head, lipreading, and speaking in
a loud voice.
Auditory acuity
Whispered voice test:
Nurse stands 1–2 feet away from client, out
of view to avoid client lipreading, and
softly whispers numbers on side of
open ear. Increase voice volume until
client identifies words correctly.
Inability to hear words may indicate a high-
frequency hearing loss (e.g., resulting
from excessive exposure to loud
noises).
 
Weber test:  
Hold the base of the vibrating fork with your
thumb and index finger and place
the base of the fork on center of top
of client’s head
Sound perceived equally in both ears; results
indicate a “negative” Weber test.
Positive : conductive hearing loss ( impacted
cerumen, perforated tympanic
membrane, cerum or pus in the
middle ear, fusion of the ossicles
Sensorinueral hearing loss : auditory nerve
damage , prolonged loud noise,
effect of ototoxic agent
Rinne test:
Vibrate prongs of tuning fork and place base of
fork on mastoid process of ear being
tested and note the time on your
watch until the client no longer
hears sound
Sound heard longer in front of the right auditory
meatus than on the mastoid process
because air conduction is twice as
long as bone.
Bone conduction is equal to or greater than air
conduction. Occurs with conductive
hearing loss resulting from diseases,
obstruction, or damage to outer or
middle ear.
 
Note Presence of external
lesions.
Note Presence of discharge.
Mouth and Lip Assessment
Mouth:
Stand 12–18 inches in front of client and
smell the breath. Breath should smell
fresh.
Halitosis (foul-smelling breath) occurs
with tooth decay or disease of gums,
tonsils, or sinuses or with poor oral
hygiene
Acetone breath (“fruity” smell) is
common in malnourished or diabetic
clients with ketoacidosis.
 Musty smell is caused by the
breakdown of nitrogen and presence of
liver disease.
Ammonia smell occurs during the end
stage of renal failure from a buildup of
urea.
Lip
Lip lesion:
Herpes simplex (cold sores or fever
blisters) are painful vesicular lesions
that rupture and crust over.
Chancre (primary lesion of syphilis)
is a reddish round, painless lesion
with a depressed center and raised
edges that appears on the lower lip.
Squamous cell carcinoma (most
common form of oral cancer) usually
involves the lower lip and may  
appear as a thickened plaque, ulcer,
or warty growth.
Lips and mucosa should be pink,
firm, and moist without inflammation
or lesions
Pale or cyanotic lips may indicate
systemic hypoxemia. Dry, cracked
lips occur with dehydration or
exposure to weather. Swollen lips
(angioneurotic edema) result from
allergic reactions
Gums are pink, smooth,moist and
firm
Pale gums that bleed easily may
indicate periodontal disease or  
vitamin C deficiency.
Inspect teeth: note tarter, cavities,
extraction and color.
Note position and alignment
 
Tongue:
tongue lies midline,medium red or
pink in color, moist and
smooth along lateral
margins, with free mobility.
Ventral surface is slightly
rough (taste buds), and
dorsum is highly vascular.
NOTE:Enlarged tongue may indicate
glossitis or stomatitis or
may occur with myxedema,
acromegaly, or
amyloidosis.
Inspect the hard and soft palate with
penlight.
Palates are concave and pink. Hard
palate has ridges; soft
palate is smooth
pharynx using a tongue depressor
and penlight
Instruct client to say “ah.” Note the
position, size, and
appearance of tonsils and
uvula
With phonation, the soft palate and
uvula rise
symmetrically.The pharynx
is pink, vascular, lesion-
free.
NOTE: Reddened, edematous uvula
and tonsillar pillars with
yellow exudate indicate
pharyngitis.
Neck Assessment
Inspect Neck:
Test sternocleidomastoid muscle
Muscles are symmetrical with head in
central position. Movement
through full range of motion
without complaint of discomfort
or limitation.
 NOTE: Prominent lateral deviation of
sternocleidomastoid muscles
(torticollis) is commonly
associated with inflammation of
viral myositis or trauma
Lymph Nodes
Palpate anterior and cervical lymph
nodes (with gentle pressure)
Note size, shape, mobility,
consistency, and tenderness.
Lymph nodes should not be
palpable. Small, movable
nodes are insignificant.
NOTE: palpable lymph nodes
indicates infectious process or
malignancy
THYROID Gland
Position: Stand behind patient and
gently push trachea to one
side. Palpate extended side as
patient swallows
There should be no enlargement,
masses, or tenderness. (Gland
is normally slightly enlarged
during pregnancy and puberty.
Right lobe may be slightly
larger.)
Auscultate over gland
NOTE: Enlargement (goiter), nodules,
tenderness
 
Assessment of the Skin
Part of Integumentary system which
includes: skin scalp,nails)
Color- inspect under natural
sunlight for accuracy
note color, size, and
anatomic location and
distribution ,mobility,
contour and consistency
presence of lesion:
 
primary lesion
macule - localized changes in skin color < 1
cm in diameter like freckles
papule – solid elevated lesion < 0.5cm in
diameter like elevated nevi
vesicle – elevated mass containing serous
fluid accumulation between
the upper layers of the skin
example: 2 degree burns,
nd
chicken pox
patch – localized changes in skin
pigmentation of <1cm in
diameter ; ex. Vitiligo,
pressure ulcer stage 1
plaque – solid elevated lesion > 0.5cm in
diameter; ex psoriasis
bullae – like vesicle but > 0.5cm in diameter
nodule – solid and elevated; extends deeper
than the papule into the
dermis or subcutaneous
tissues; 0.5 to 2 cm
ex.lipoma, erythema
pustule – pus filled vesicles or bullae, <0.5
cm in diameter. Ex. Impetigo,
acne
cyst – subcutaneous or dermis mass ex:
sebaceous cyst
 
secondary lesion
 scales – flaking of the skin’s surface
ex. Dandruff , psoriasis
 erosion – loss of epidermis ex.ruptured
chicken pox
 scar – fibrous tissue that replaces dermal
tissue after injury ex. Surgical incision
 crust – dried serum, blood or pus on skin
surface
 fissure – linear crack in the epidermis that
can extend to the dermis ex. Chapped
hands or lips
  keloid – enlarging of a scar past wound
edges due to excess collagen formation
( more prevalent in dark skinned person
 atrophy – thinning of the skin surface and
loss of markings ex. Striae
 ulcer – depressed lesion of the epidermis
and upper papillary layer of the dermis ex.
Stage 2 pressure ulcer 2
 excoriation – loss of epidermal layers
exposing the dermis ex. Abrasion
 vascular and purpuric lesion
 cherry angioma - ruby red – 1-3 mm, round
lesion
 spider angioma – fiery red lesion up to 2 cm
with central body surrounded by erythema
and radiating legs ( in liver disease,
pregnancy)
 venous star – bluish , varying in size from
small to 1 – 2inches, may resemble a spider
or be linear. Indicates an increased pressure
in superficial veins ; Ex varicose veins
 petechia – reddish purple, flat round lesion ,
1 – 3mm in size
 ecchymosis ( bruise ) purplish blue, fading to
green, yellow and brown usually results from
blood vessel trauma may indicate vit C
deficiency, blood clotting disorders,liver
disease or drug interactions
 
 
Turgor and mobility
Measures the elasticity of skin -determines degree of
hydration
For Mobility, palpate dependent areas such as
sacrum,feet,ankles by applying pressure with
fingers, noting the degree of indention.
Pitting edema scale:
1+ indentation of 1 cm or less
2+ indentation of 2cm
3+ indentation of 3cm
4+ indentation of 4cm
5+ indentation of 5cm
Moistness and temperature.
Moisture: wetness and oiliness
Excessive moisture or perspiration
(hyperhidrosis) caused
by hyperthermia,
infection,
hyperthyroidism, strong
emotion
Dryness usually occurs in dehydration
Bromhidrosis ( body odor) caused by
perspiration or bacterial
decomposition
Temperature:
Sensation/ texture
quality, thickness, suppleness
generalized roughness is seen in
hypothyroidism
Common skin alterations:
Melanin – naturally occurring brown pigment
( ex decreased in albinism)
Cyanosis - bluish discoloration in the lips,
mucous membranes, and nails
results from an increased amount
of reduced hemoglobin in the
blood caused by a cold
environment or heart or lung
disease.
Jaundice (yellowish discoloration) results from
increased bilirubin levels caused
by red blood cell hemolysis in
liver disease as observed first in
the sclera and mucous
membranes and then
generalized.
Carotenemia (yellowish discoloration) is
described as normal as a result
of increased levels of carotenoid
pigments in the palms, soles, and
face from a diet high in carotene.
  Hair
Hair is distributed over the body
except for the palmar and
plantar surfaces, lips,
nipples, and the glans
penis.
Vellus – fine, unpigmented
hair that covers most of
he body parts
Terminal Hair - coarser,
darker hair of scalp,
eyebrows and
eyelashes; axillary and
pubic hair becomes
terminal with the onset
of puberty
Nails
 The nail plate (translucent tissue
that covers the distal portion of the
digits and provides protection)
changes with many disease
processes
 Normal nail : angle of approximately
160 degrees between the fingernail
and the nail base ; feels firm when
palpated
 Clubbing : indicates hypoxia; angle
greater than 180 degrees ; feels
springy when palpated
 Koilonychia (spoon nail) concave
curves associated with iron
deficiency anemia
 Beau’s line : transverse depression
in the nails often associated with
injury and severe systemic
infections
 Paronychia: inflammation in the nail
base associated with trauma and
local infection
Thorax Assessment
 
Inspect for Thoracic contour
: shape, symmetry , and
developmental:
▪ Pigeon chest
▪ Funnel chest
▪ Spinal Deformities
▪ Kyphosis
▪ AP to Lateral diameter
▪ till age 6 - 1:1 (equal)
▪ 1:2 in normal adult
▪ barrel chest - 1:1 in adult
▪ presence of chronic pulmonary disease
▪ Ribs and interspaces
▪ retraction of interspaces indicative of
obstruction
bulging during exhalation result of air
outflow obstruction: tumor, aneurysm,
cardiac enlargement slope of ribs, costal
angle
 
Thoracic Expansion:
▪ Posteriorly- level of 10th rib
▪ Thumbs should separate 3 - 5 cm
▪ Feel during quiet I & E
▪ Palpate during deep inspiration
▪ Should be symmetrical
▪ Tactile Fremitus
▪ palpable vibrations of chest wall over lung
fields from speech or sounds- Use palmar
or ulnar surface
Tactile Fremitus
Increased- conditions
 that increase density of effortless
thoracic tissue quiet
consolidation of symmetrical
pneumonia  Respiratory Auscultation: During
some lung tumor auscultation, the client should be instructed
Tactile Fremitus to breathe only through the mouth because
Decreased - mouth breathing decreases air turbulence
obstruction of that could interfere with an accurate
assessment Note quality and location of
transmission of lung sounds
vibrations-  Vesicular breath sounds soft, breezy, and
pleural effusion low-pitched sounds heard longer on
pleural thickening inspiration than expiration that result from air
(fibrosis) moving through the smaller airways over the
lung’s periphery,
pnemothorax
 Bronchovesicular breath sounds
bronchial  medium-pitched and blowing sounds heard
obstruction equally on inspiration and expiration from air
COPD/emphysema moving through the large airways,
 Lung Assessment posteriorly between the scapula and
Respiratory Pattern anteriorly over bronchioles lateral to the
Rate sternum at the first and second intercostal
adult NL: 12 - 20 resting spaces
tachypnea = > 20
bradypnea= <10  Bronchial breath sounds loud and high-
Rhythm pitched sounds with a hollow quality heard
Depth : shallow, deep longer on expiration than inspiration from air
Hyperventilation :Hypoventilation moving through the trachea
Effort/Quality  Adventiitous Breath Sounds
unlabored  Abnormal breath sounds are characterized
labored- dyspnea, orthopnea by decreased or absent sounds.
shallow  Crackles: heard predominantly on inspiration
grunting over the base of the lungs as an interrupted
Respiratory movement fine crackle (dry, high-pitched crackling,
thoracic or abdominal popping sound of short duration) that
Men & children - abdominal sounds like a piece of hair being rolled
breathers between the fingers in front of the ear or a
Women- thoracic coarse crackle (moist, low-pitched crackling,
Normal rate, rhythm, quality termed gurgling sound of long duration) that sounds
eupnea like water going down the drain after the
rhythmic plug has been pulled on a full tub of water
  Rhonchi: heard predominantly on expiration
over the trachea and bronchi as a
continuous, low pitched musical sound. Also
called gurgle
 Wheezes: heard predominantly on
expiration all over the lungs as a continuous
sonorous wheeze (low-pitched snoring) or
sibilant wheeze (high pitched musical
sound)
 Pleural friction rub: heard on either
inspiration or expiration over the anterior
lateral lungs as a continuous creaking,
grating sound
 Stridor: heard predominantly on inspiration
as a continuous crowing sound
 
Breast and Axillae Assessment
Position: sitting position on the edge of examining
table or bed facing you
For Female Breasts:
Symmetric (Normal for dominant side to be slightly
larger.)
Significant differences in size or symmetry of
breasts, axillae, areolar areas, or nipples may be
indicative of a tumor
Skin: intact, no edema, color consistent with rest of
body, smooth, convex contour
Consistency: varies widely (Firm, transverse
inframammary ridge along lower breast edge should
not be mistaken as abnormal mass
NOTE: Reddened areas of breasts, areolar areas,
nipples, or axillae may be an indication of
inflammation, infection, or inflammatory carcinoma
Thickening or edema of breast tissue or nipple
causes enlarged skin pores that give the
appearance of an orange rind (peau d’orange),
which may be indicative of obstructed lymphatic
drainage
Signs of breast cancer: peau d’orange skin
(edema/thickened skin with enlarged pores),
retractions, dimpling. Hard, irregular, fixed,
noncircumscribed masses
Areola
Small elevations around the nipple (Montgomery’s
glands) are normal.
NOTE: Rashes or ulcerations may suggest cancer of
mammary ducts (Paget’s disease).
Nipples
Nipples should point upward and laterally or outward
and downward. Nipples may be inverted from
puberty, making breastfeeding difficult.
Usually elastic, everted ( in geriatric patients:
Nipples become smaller and flatter) Intact skin, no
discharge
Occasional hair around nipple
NOTE: Asymmetrical nipple direction or recent
nipple inversion, flattening, or depression is
indicative of nipple retraction. Thickening of a
previously inverted nipple may indicate a tumor
Nipple discharge in nonpregnant or nonlactating
woman may be caused by tranquilizers, oral
contraceptives, manual stimulation, infection, or
malignant or benign breast disease.
For Male breasts:
Flat or muscular appearance without masses
NOTE for Gynecomastia: a firm disk-shaped
glandular enlargement on one or both sides resulting
from imbalance in estrogen/androgen ratio,
sometimes drug-related (spironolactone, cimetidine,
digitalis preparations, estrogens, phenothiazines,
methyldopa, reserpine, marijuana, or tricyclic
antidepressants)

Axillae:
Rash (may be caused by deodorant). Velvety,
smooth deeply pigmented skin should be further
evaluated.

Palpate Lymph Nodes:

Position: place arms at side. Place client’s head in a
flexed position (relaxes sternocleidomastoid muscle)

NOTE: Enlarged, tender, hard nodes may be due to

hand or arm infection but may also be a sign of
breast cancer.
 
Heart Assessment
Cardiac Landmarks
1. Aortic area is the second intercostal
space (ICS) to the right of the sternum.
2. Pulmonic area is the second ICS to the
left of the sternum.
3. Erb’s point is located in the third ICS to
the left of the sternum.
4. Tricuspid area (right ventricular area or
septal area) is the fifth ICS to the left of
the sternum.
5. Mitral area (left ventricular or apical area)
is the fifth ICS at the left midcavicular line.
S1 heart sounds - Atrioventricular heart
sounds
S2 heart sounds - Semilunar heart
sounds
S3 heart sounds – (Ventricular gallop)
sound resembles the pronunciation of
the word “Kentucky” (lub-dub-by )
S3 can be a normal physiological sound
in children and young adults; in adults
it may be indicative of cardiac
dysfunction
S4 heart sounds (atrial gallop)
sound resembles the pronunciation of
the word “Tennessee” (le-lub-dub).
Heart murmurs:
Grades and Characteristics of Murmurs:
Grade I: Barely audible
Grade II: Audible immediately
Grade III: Moderate intensity
Grade IV: Loud, may be associated with a
thrill
Grade V: Loud, with palpable thrill, audible
with stethoscope in contact with chest wall
Grade VI: Louder, heard without
stethoscope, palpable thrill
Distinct abnormal findings on palpation and
auscultation
 thrills (vibrations that feel similar to what one
feels when a hand is placed on a purring
cat)
 heaves (lifting of the cardiac area secondary
to an increased workload and force of left
ventricular contraction).
 stenosis or regurgitation sounds:
1. click (a high-pitched systolic sound
created by the opening of the valve) or
2. a murmur (swishing or blowing sounds of
long duration heard during the systolic
and diastolic phases created by turbulent
blood flow through a valve
3. bruits (blowing sounds that are heard
when the blood flow becomes turbulent
as it rushes past an obstruction
 
ASSESSMENT OF THE ABDOMEN
Place client in a supine position with knees flexed
over a pillow, hands at sides or across chest.
Order of assessment: Inspection, Auscultation,
Percussion and Palpation ( “ IAPP” )
Assessment should always begin in the right
lower quadrant (RLQ).
Inspect: Inspect abdomen from rib margin to
pubic area
Contour is flat or rounded and bilaterally
symmetrical
A convex symmetrical profile reveals either a
protuberant abdomen (results of poor
muscle tone from inadequate exercise or
obesity) or distension (taut stretching of skin
across abdominal wall
Asymmetry may indicate a mass, bowel
obstruction, enlargement of abdominal
organs, or scoliosis
Umbilicus is depressed and beneath the
abdominal surface.
Umbilicus bulging may indicate a hernia
Engorged or dilated veins around the umbilicus
are associated with circulatory obstruction of
superior or inferior vena cava
Abdomen rises with inspirations and falls with
expirations, free from respiratory retractions.
Uneven respiratory movement with retractions
may indicate appendicitis.
Visible peristalsis slowly traverses the abdomen
in a slanting downward movement as
observed in thin clients. Pulsations of the
abdominal aorta are visible in the epigastric
area in thin clients
Strong peristaltic movement may indicate
intestinal obstruction. Marked pulsations in
epigastric area may indicate an aortic
aneurysm
Auscultation:
Order: RLQ, RUQ, LLQ, LUQ
 High-pitched sounds, heard every 5 to 15
seconds as intermittent gurgling sounds in
all four quadrants as a result of air and fluid
movement in the gastrointestinal tract
 Hypoactive sounds may indicate decreased
motility of the bowel, such as occurs with
peritoneal irritation or paralytic ileus
 Absent bowels sounds (none heard for 3–5
minutes) may signal paralytic ileus,
peritonitis, or an obstruction
 Hyperactive (loud, audible, gurgling sounds
similar to stomach growling; sounds also
called borborygmi) may occur with diarrhea
or hunger
 A bruit over an abdominal vessel reveals
turbulent blood flow suggestive of an aortic
aneurysm or partial obstruction (e.g.,renal or
femoral stenosis).
Percussion: (deleted landmarks)
Note when tympany changes to dullness. Tympany
is heard because of air in the stomach and
intestines.Dullness is heard over organs (e.g., the
liver).
Dullness over the stomach or intestines may indicate
a mass or tumor; ascites (excessive fluid
accumulation in the abdominal cavity) or full
intestines
Palpation:
Never palpate over areas where bruits are
auscultated.
Order of palpation: RLQ, RUQ, LLQ, LUQ
Should feel smooth with consistent softness.
Tenderness and increased skin temperature may
indicate inflammation. Large masses may be due to
tumors, feces, or enlarged organs.
 
Genitourinary Assessment
The male genitalia may be examined with the patient
either standing or supine. However, the patient
should stand as you check for hernias or
varicoceles. Examine the female genitalia with the
patient in a dorsal recumbent position.
Check for urine frequency and urgency; dysuria;
nocturia; polyuria or oliguria; hematuria;
incontinence.
 
1. When assessing the urinary system, check for
and evaluate edema.
2. Palpate the bladder for distention and tenderness.
Press deeply in the midline about 1 to 2 inches
above the symphysis pubis. During deep palpation,
the patient may feel the need to urinate; this is a
normal response.
3. Ask the patient about urinary patterns such as
retention, urgency and frequency. Ask the patient if
he has noticed blood in his urine or if he has pain
when urinating. Ask the patient to urinate into a
specimen cup. Assess the sample for color, odor, close and ready to help if he should stumble or start
and clarity. to fall. Observe and evaluate his posture, pace and
4. Provide the patient with a gown. and drape length of stride, foot position, coordination, and
appropriately. Be sure to wear gloves. balance. Normal findings include smooth,
5. Inspect the inguinal and femoral areas carefully coordinated movements, erect posture, and 2 to 4
for bulges. A bulge that appears on straining inches between the feet. Abnormal findings include a
suggests a hernia. wide support base, arms held out to the side or in
6. Look for nits or lice at the bases of the pubic hairs. front, jerky or shuffling motions, toeing in or out, and
7. Have the male patient assume a supine position. the ball of the foot, rather than the heel, striking the
Begin assessment of the male genital system by floor first.
inspecting the penis. Look for ulcers, scars, nodules, 4. To assess gross motor skills, have the patient
or signs of inflammation. Compress the glans gently perform range-of-motion (ROM) exercises (see
between your index finger and thumb to open the Nursing Fundamentals I, To assess fine motor
urethral meatus and inspect it for discharge. coordination, have the patient pick up a small object
8. Inspect the scrotum. Note any swelling, lumps, or from a flat surface.
veins. Palpate each testis and epididymis. Note their 5. Assess muscle tone.
size, shape, consistency, and tenderness. Assess muscle mass. decreased muscle size
9. Ask. Explain in advance what you are about to do. (atrophy), excessive muscle size
10. Assess the perineal area for character of skin (hypertrophy) without a history of muscle
and abnormal masses or discharge. Spread her building exercises, flaccidity (atony),
labia with a gloved hand and inspect the urethral weakness (hypotonicity), spasticity
meatus; it should appear pink and free of swelling or (hypertonicity), and involuntary twitching of
discharge. In any patient, inflammation and muscle fibers (fasciculations).
discharge may signal urethral infection. Ulceration Assess muscle strength and joint ROM.
usually indicates a sexually transmitted disease.  
MUSCLE TONE AND STRENGTH
Musculoskeletal Assessment 0=COMPLETE PARALYSIS
Gait 1=10%-NO MOVEMENT CONTRACTION OF
Posture MUSCLE PALPABLE/VISIBLE
Muscular palpation 2=25% - FULL MOVEMENT AGAINST GRAVITY
Joint palpation WITH SUPPORT
Range of motion 3=50% - NORMAL MOVEMENT AGAINST
Muscle strength GRAVITY
  4= 75%- NORMAL MOVEMENT AGAINST
Procedure and Technique GRAVITY WITH MINIMAL RESISTANCE
5=100%-NORMAL FULL MOVEMENT WITH FULL
1. Inspect spinal curvature. RESISTANCE
2. Have the patient stand with his feet together. Note
the relation of one knee to the other. The knees
should be symmetrical and located at the same
height in a forward-facing position.
3. Ask the patient to walk away, turn around, and
walk back. If the patient is elderly or infirmed, remain
DIAGNOSTIC EXAMINATIONS Lower GI Endoscopy:
 
  Anoscopy
   Visualization of the anal canal
Diagnostic tests are either noninvasive or invasive.
Diagnostic testing is a critical element of Proctoscopy
assessment. Ongoing client assessment and  Visualization of the rectum
evaluation of the client’s expected outcomes
requires the incorporation of diagnostic findings Proctosigmoidoscopy
   Visualization of the rectum and sigmoid colon
 Invasive - means accessing the body’s tissue,  
organ, or cavity through some type of Position: knee chest or lateral
instrumentation procedure Cleansing enema is needed
 Non – invasive - means the body is not entered Pre Test: laxative
with any type of instrument Post test: position in a supine manner for a few
  minutes
  Monitor for bleeding and perforation
3 phases of Diagnostic Testing:
  Colonoscopy
Pretest  Needs to be sedated
Focus: Client Preparation  Position: sims/ left side, knees flexed
Consent is secured for every invasive procedure or  Post test: assess for bradycardia and hypotension
diagnostic test  Assess also for perforation
For radiologic studies: special precautions for  
pregnant clients Endoscopy ( UGI)
Know the supplies and equipment needed for a Pre test:
specific test  NPO
Know if the client needs to be on NPO prior to the  Needs sedation
test and if a dye is needed; if so, assess client for  Local spray anesthetic is administered
allergy Post Test:
  NPO until gag reflex returns
Intratest  
Focus: specimen collection and assisting or Gastric Analysis
performing the test ▪ Measures gastric pH and pepsin
Use or practice standard precaution and sterile ▪ Pre Test: NPO for 12 hours
techniques ▪ Requires NGT insertion that is connected to a
Provide emotional and physical support to the client suction
  Specimen is taken every 15 min to one hour
Post – Test
Focus: providing nursing care and follow – up  
  I. GIT- Indirect:
 
I. GIT- Direct visualizations ( invasive) Barium Swalllow ( upper GIT )
 
▪ To visulalize esophagus down to the jejunum ▪ Views cross sectional images of an organ using
▪ Needs to be on NPO for 6 – 8 hours magnetic field
▪ Barium Sulfate is taken by mouth prior to the ▪ CI: with pacemakers, Aneurysym clips, orthopedic
procedure screws
Post test: Pre Test:
 Laxative is given to wash off barium  NPO for 6 – 8 hours
 White stool is observed for about 72 hours Instruct client to remain still throughout the
  procedure
Barium Enema ( Lower GIT )  
▪ Visualize colon II. Respiratory System
Pretest:
 low residue/clear liquid diet for 2 days Invasive
 laxative
 cleansing enema is administered in the morning Mantoux Test
before the test ▪ Purified protein Derivative
 barium sulfate via rectal route ▪ Intradermal injection which will be read after 48
post test: hours and 72 hours
 laxative ▪ 10 mm induration is positive for Mycobacterium
 increase OFI tuberculosis
   ▪ 5 mm induration for an HIV positive patient is
Fecalysis already positive montoux test
Guaic Stool Exam  
 Used to assess Gastro intestinal Bleeding Bronchography
Pre Test: increase fiber diet 48 -72 hours prior Pre test:
▪ No red meat, iron and steroids, indomethacin and  A radioopaque medium is injected into the trachea
colchicine these can alter results and bronchial tree
▪ Taken in 3 consecutive days  Check for allergies to seafoods, iodine and
▪ Stool for Ova and Parasites lidocaine
 Specimen should be sent immediately ( warm and  Requires to be on NPO for 6 – 8 hours
fresh )  Meds prior to test:
   Atropine sulfate
Stool Culture  Valium
 Stool for Lipids Post:
 To assess stool for steatorrhea  Remain on NPO until gag reflex returns
   Position on side lying
Ultrasonography  
▪ Needs to be on NPO for 8 to 12 hours
▪ Laxative prior to test
 

Magnetic Resonance Imaging Bronchoscopy

▪ visual examination of the larynx, trachea & bronchi ▪ insertion of a flouroscopy via the antecubital or
with a fiber-optic bronchoscope femoral vein into the pulmonary artery
▪ it involves iodine or radiopaque or contrast material
Pre test: Pre Test:
 NPO 6 – 8 hours  Assess for allergies to iodine, seafood & dyes
 Needs to be sedated   NPO prior to procedure
Post Test:
Post Test:  No BP for 24 hrs in the affected extremity
 Remain on NPO until gag reflex returns   Monitor peripheral neurovascular status
 Monitor for complications: bronchospasm,   Assess for bleeding
bronchial perforation, crepitus, dysrhythmia, fever,   Monitor dye reaction
hemorrhage, hypoxemia, and pneumothorax  
Notify the MD if complications occur Ventilation Perfusion Scan
  ▪ determines the patency of the pulmonary airways
Lung Scan ▪ a radionuclide may be injected
▪ Used to detect pulmonary embolism Pre Test:
Pre test: radio isotope is injected  Assess for allergies to dye, iodine, or seafood
▪ Scans are taken with scintillation camera   Remove jewelry
    Review breathing methods
Thoracentesis   Administer sedation
▪ Aspiration of fluid / air from pleural space   Emergency resuscitation equipment
▪ Position : upright leaning on over bed table or  For 24 hrs following the procedure, handle body
 Side lying secretions carefully,
Post Test: Instruct the client to wash hands carefully with soap
 Position on the unaffected side to prevent leakage and H2O for 24 hrs following the procedure
   
Lung Biopsy Non – invasive
▪ To detect malignancy
Pre Test: Chest X – ray / fluoroscopy
 NPO prior ▪ Metal objects and other jewelries should be
  Local anesthetic removed prior to the test
  Pressure during insertion and aspiration  
  Administer analgesics & sedatives Sputum Examination
Post Test: ▪ obtained by expectoration or tracheal suctioning
 Pressure dressing ▪ identify organisms or abnormal cells
  Monitor for bleeding ▪ ideally taken early morning upon awakening
  Monitor for respiratory distress ▪ sterile specimen is needed
  Monitor for complications: pneumothorax and air ▪ only 15 ml of sputum
emboli ▪  Rinse the mouth with water prior to collection
  Prepare for Chest – X - ray for re evaluation ▪  Take several deep breaths and then cough
  forcefully
Collect the specimen before antibiotics
Pulmonary Angiography  III. Cardio Vascular System
 - catheter is inserted into the right or left side
Invasive Hemodynamic Monitoring of the heart to measure intracardiac
Central Venous Pressure pressures and oxygen levels in various parts
of the heart with injection of a dye, it allows
Obtained by inserting a catheter into the external visualization of the heart chambers, blood
jugular, antecubital, or femoral vein and threading it vessels and blood flow (angiography
into the vena cava. The catheter is attached to an IV Pre Test:
infusion and H2O manometer by a three way any allergies esp. to iodine
stopcock keep client on NPO for 8-12 hrs
Assess pressure of the right atrium, blood volume,  
pumping function of the right side of the heart Non Invasive:
Normal range is SV : 0 -12 cm H20
RA : 4-10 cmH20; Electrocardiogram (ECG)
elevation indicates hypervolemia, Monitors the electrical activity of the heart
decreased level indicates hypovolemia strip: small square: 0.04secs. and large square:
Maintain zero point of manometer always at level of 0.2secs
right atrium (midaxillary line)
Stop ventilatory assistance during measurement of P wave: produced by atrial depolarization; indicates
CVP SA node function
Practice Strict Aseptic Technique P-R interval (N˚= 0.12 - 0.20 secs.)
  a. indicates AV conduction time or the time it
Pulmonary Artery Pressure and Pulmonary takes an impulse to travel from
Capillary Wedge Pressure the atria down and through the
Uses Swanz – Ganz Catheter AV node
A multi lumen catheter with a balloon tip that is b. measured from beginning of P wave to
advanced through the superior vena cava into beginning of QRS complex
the RA, RV, and PA. When it is wedged it is in QRS complex (N˚= 0.06-0.10 secs.)
the distal arterial branch of the pulmonary artery. a. indicates ventricular depolarization
Purpose: b. measured from onset of Q wave to end of S
Proximal port: measures RA pressure wave
Distal port: measures Pulmonary Artery pressure  
and Pulmonary Capillary Wedge Pressure ST segment
Normal Range: PAP : 4 – 12mmHg a. indicates time interval between complete
PCWP : 4 – 12 mmH depolarization of ventricles and
Ensure that balloon is deflated with a syringe repolarization of ventricles
attached except when PCWP is read b. measured after QRS complex to beginning
Irrigate line before each reading of PCWP of T wave
Maintain client in same position for each reading T wave
Record PA systolic and diastolic readings at least a. represents ventricular repolarization
every hour and PCWP as ordered. b. follows ST segment
   

Cardiac catheterization ECG in MI:

 Elevated ST segment
Inverted T wave
Q wave
 
Echocardiography
noninvasive recording of the cardiac structures using
ultrasound
Portable recorder (Holter monitor)
provides continuous recording of ECG for up to 24
hrs
assess activities of the heart which precipitate
dysrythmias and time it occurred
Exercise ECG (stress test)
the ECG is recorded during prescribed exercise;
may show heart disease when resting ECG does not
Cardiac enzymes: in MI
a. Troponin T: detected 3-12 hours after chest
pain
b. Troponin I: detected 3-12 hrs
c. creatine phosphokinase (CPK – MB): 6-12Hrs
d. Aspartate aminotransferase (AST) (SGOT): 24
Hrs after chest pain
e. Lactic dehydrogenase (LDH): 36 Hrs
 
IV. Endocrine System
 
Radioactive iodine reuptake
 A thyroid function test that measures the
absorption of the iodine isotope to determine how
the thyroid gland is functioning.
 Administration of I123 or I131 orally followed in 24
hrs. by a scan of the thyroid for the amount of
radioactivity emitted.
 Normal value is 5-35% in 24 hours
 Increased: hyperthyroidism , thyrotoxicosis
 Decreased: hypothyroidism, thyroiditis
 
T3 and T4 resin
 Blood test for diagnosis of thyroid disorders
Normal Value : T3: 80-230 ng/dL
T4: 5-12 ng/dL
 increase in hyperthyroidism & decreased in
hypothyroidism
 Thyroid Stimulating Hormone Test:
 Blood test used to differentiate the diagnosis of
primary hypothyroidism from secondary
hypothyroidism
  Normal value is 0.2 to 5.4 uU/ml
 Elevated in primary hypothyroidism & decreased
in hyperthyroidism or secondary hypothyroidism
 
Thyroid Scan
Performed to identify nodules or growths in the
thyroid glands Discontinue medications containing
iodine 14 days prior to test and discontinue thyroid
meds 4-6 weeks prior to test.
NPO post MN;
 if iodine is used client will fast an additional 45
minutes after ingestion of radioactive isotope & scan
is done after 24 hours.
 A radio isotope of iodine or technetium is
administered prior to the scanning of the thyroid
gland.
 
NEEDLE ASPIRATION OF THYROID TISSUE
 Aspiration of thyroid tissue for cytological exam,
 No preparation needed
 Light pressure applied to aspiration site after the
procedure
 
Eight-hour intravenous ACTH Test
 Used to determine function of adrenal cortex
 Administration of 25 units of ACTH in 500 ml of
saline over an 8-hr period
 24-hr urine specimens are collected, before &
after administration, for measurement of 17-
ketosteroids and 17-hydrocorticosteroids
▪ In Addison’s disease, urinary output of steroids
does not increase following administration of ACTH;
normally steroid excretion increases threefold to
fivefold ff. ACTH administration
▪ In Cushing’s syndrome, hyperactivity of the adrenal
cortex increases the urine output of steroids in the
second urine specimen tenfold
 
Glucose Tolerance Test:
 Pre test:
▪ eat a high-carbohydrate (200 to 300 g) diet for 3
days before the test
▪ avoid alcohol, coffee & smoking 36 hours before
testing
▪ fast midnight before test
 fasting blood glucose & urine glucose specimens
obtained.
1. avoid strenuous exercise 8 hours before &
after test
2. client ingests 100g glucose; blood sugar
drawn at 30 & 60 mins, then hourly for 3-5
hrs
3. urine specimens may also be collected
Glycosylated Hemoglobin :
 Is a reflection of how well blood glucose levels
have been controlled for up to the prior 4 months
  Fasting is not needed
Values:
Diabetics with good control: 7.5% or less
Diabetics with fair control: 7.6% to 8.9%
Diabetics with poor control: 9% or greater
 
 
V. Peripheral Vascular Disorders
Non – invasive
Doppler Ultrasonography
Non-invasive diagnostic procedure that changes
sound waves into an image that can be viewed on a
monitor.
It is frequently used to detect problems with heart
valves or to measure blood flow through the arteries.
There is no special preparation needed for this test.
The ultrasound technician may apply a clear gel to
the skin in order to help the transducer more freely
over the body.
NOTE: Disrupted or obstructed blood flow through
the neck arteries may indicate the person is a risk of
having a stroke
 
Computed Tomography ( CT – SCAN )
CT imaging uses special x-ray equipment to produce
multiple images and a computer to join them
together in cross-sectional views.
Pretest Reminders:
1. Metal objects including jewelry, eyeglasses,
dentures and hairpins may affect the CT
images and should be left at home or
removed. You may also be asked to remove
hearing aids and removable dental work.
2. If contrast medium will be used, patient
needs to be on NPO. And assess for
seafood and iodine allergy.
3. Pregnant women may not be allowed to
undergo this test.
4. if an intravenous contrast material is used,
you will feel a slight pin prick when the
needle is inserted into your vein. You may
have a warm, flushed sensation during the
injection of the contrast materials and a
metallic taste in your mouth that lasts for a
few minutes
5. You will be alone in the exam room during
the CT scan, however, the technologist will
be able to see, hear and speak with you at
all times.
6. After a CT scan, you can return to your
normal activities. If you received a contrast
material, you may be given special
instructions.
 
Magnetic Resonance Imaging ( MRI )
noninvasive, usually painless medical test
Useful in detecting Abdominal Aortic Anuersyms and
deep vein thrombosis
Some MRI examinations may require the patient to
swallow contrast material or receive an injection of
contrast into the bloodstream.
the contrast material used for an MRI exam, called
gadolinium, does not contain iodine and is less likely
to cause an allergic reaction.
metal and electronic objects are not allowed in the
exam room. These items include: ( because this will
interfere with the magnetic field)
1.Jewelry, watches, credit cards and hearing aids,
all of which can be damaged.
2.Pins, hairpins, metal zippers and similar metallic
items, which can distort MRI images.
3.Removable dental work.
4.Pens, pocketknives and eyeglasses.
5.internal (implanted) defibrillator
6.cochlear (ear) implant
7.clips used on brain aneurysms
You may request earplugs to reduce the noise of the
MRI scanner, which produces loud thumping and
humming noises during imaging.
 
Invasive
Plethysmography
Plethysmography is a test used to measure changes
in blood flow or air volume in different parts of the
body. Limb plethysmography is a test that compares
blood pressure in the legs and arms. It is usually
done to check for blood flow blockages in the legs.
Position: supine with the involved extremity elevated
above the level of the heart
Three blood pressure cuffs are wrapped snugly
around your arm and leg. The cuff will be inflated
and a machine called a plethysmograph measures
the pulses from each cuff. The test records the
maximum pressure produced when the heart
contracts (systolic blood pressure)
If there is a decrease in the pulse between the arm
and leg, it may indicate a blockage.
Pre test preparation:
Do not smoke for at least 30 minutes before the test.
clothing from the arm and leg being tested should be
removed.
Venography
Phlebogram - leg; Venography - leg
 test used to see the veins in the leg.
Veins are not normally seen in an x-ray, so a special
dye (called contrast) is used to highlight them
X-rays are taken as the dye flows through the leg.
Assess for iodine allergies and for any history of
allergic reactions
Angiography
Arteriography or angiography is test that uses x-
rays and a special dye to see inside the arteries.
a dye, called contrast material, is injected into the
blood stream. X-rays will be taken to see how the
dye flows through the arteries. The test can be used
to determine if there are any blocked or damaged
arteries.
Pre Test:
Assess for allergies ( esp. to seafoods and iodine)
NPO for 2 to 6 hours
Post Test:
Monitor peripheral pulses on punctured extremity
Pressure dressing and ice packs at the puncture site
 
VI. Hepato – Biliary System
 
Liver Function Test:
Serum blood test:
Albumin
The normal range is 3.4 - 5.4 g/dL.
Because albumin is made by the liver,:
decreased serum albumin may result from liver
disease(for example hepatitis, cirrhosis, or
hepatocellular necrosis). It can also result from
kidney disease, which allows albumin to escape into
the urine.
Decreased albumin may also be explained by
malnutrition or a low protein diet.
Pre TesT: Drugs that can increase albumin
measurements include anabolic steroids, androgens,
growth hormone, and insulin. They are asked to
withheld prior to testing.
A1AT (Alpha-1 antitrypsin )
Alpha-1 antitrypsin is ordered to help diagnose the
cause of persistent jaundice and other signs of liver
dysfunction
ALP (Alkaline phosphatase )
a protein found in all body tissues. Tissues with
particularly high amounts of ALP include the liver,
bile ducts, and bones
increased: hepatocellular damage
decreased: Hypothyroidism, malnutrition, pernicious
anemia, placental insufficiency
Normal range: Adult: 20–90 U/L ; Child: 60–270
U/L
ALT
SGPT; Serum glutamate pyruvate transaminase;
Alanine transaminase
Most accurate indicator of liver function
4–36 U/L (varies by method)0.07–0.6 _kat/L
Increased: Liver disorders, muscular dystrophy,
muscular trauma, MI, CHF, renal failure, mono,
burns, shock, alcohol, numerous meds
Decreased: Exercise, salicylates
 
AST/SGOT
Male: 8–46 U/L
Female : 7–34 U/L
NB: 16–72 U/L
Increased: Liver or biliary disorder, MI (between 6 hr
and 3–4 days), shock, infectious mono, CHF, CVA,
infection or inflammation of muscle tissue
Decreased: Pregnancy, DKA, salicylates
 
GGT ( Gamma-glutamyltranspeptidase)
Male: 6–37 U/L
Female: < 45 yr old 5–27 U/L ; > 45 yrs old 6–37 U/L
Child : 3–30 U/L
Increased: Liver disease, biliary obstruction, CHF,
MI, epilepsy, cancer, mono, diabetes mellitus,
alcohol, numerous meds
Decreased: Late pregnancy, oral contraceptives
 
Partial thromboplastin time activated (PTT)
28–40 sec or within 5 sec of control
Increased: Heparin, vit K deficiency, hemophilia, liver
disease, DIC, polycythemia, leukemia
Decreased: Extensive cancer
 
Serum bilirubin :
indirect: up to 0.8mg/dL
increased: Sickle cell anemia, pernicious anemia,
hemolytic anemia, septicemia, Rh or ABO
incompatibility in newborn, numerous meds
Direct: up to 0.4mg/dL
Increased: Liver disorders, obstructive jaundice
Decreased: Barbiturates, salicylates, penicillin,
caffeine (These can affect all types of bilirubin.)
 
Total up up 1.0mg/dL
Urine urobilinogen
Bilirubin, a physiological product of RBC, is
metabolized in the liver and excreted into bile ducts,
therefore an appearance of jaundice means that
there is a breakdown of balance of bilirubin
metabolism and the patient may have a problem of Post test:
liver or RBC production and destruction Lie down on the right side for 4 hours with pressure
NV : 0.2 – 1.2 Units or 0 - 8 mg/dl / less than 17 dressing or apply pressure on the incision site to
umol/l (< 1mg/dl) prevent bleeding
Bed rest for 24 hours
Increased values:
overburdening of the liver Paracentesis:
excessive RBC breakdown a procedure to aspirate fluid that has collected in
increased urobilinogen production the peritoneum
re-absorption - a large hematoma The fluid is taken out using a long, thin needle put
restricted liver function through the belly. The fluid is sent to a lab and
hepatic infection studied to find the cause of the fluid buildup.
poisoning Paracentesis also may be done to take the fluid out
liver cirrhosis to relieve abdominal pressure or pain in people with
cancer or cirrhosis.
Low values: failure of bile production and
obstruction of bile passage Pre Test:
  Empty bladder prior to test to prevent puncturing the
Ultrasound of the Liver bladder
Pre Test: Check serum protein studies
Needs to be on NPO 8 – 23 hours
Increase fluid intake Intra Test:
Laxative is administered a night prior the test Position client: sitting or upright position
 
Liver biopsy Post Test:
examines a small piece of tissue from the liver for Monitor client’s vital signs and rigidity of abdomen/
signs of damage or disease. A special needle is signs of peritonitis
used to remove the tissue from the liver
pre test:
the physician will take blood samples to make sure VII. Neurologic System
blood clots properly.  
One week before the procedure, the patient will have CT SCAN
to stop taking aspirin, ibuprofen, and anticoagulant A cranial CT scan is computed tomography of the
NPO 2 – 4 hours head, including the skull, brain, orbits (eye sockets),
Vit K is injected and sinuses.
Instruct to hold breath for 5 – 10 seconds during the A type of brain scanning that may or may not require
insertion of needle to prevent trauma to the an injection of a dye
diaphragm Used to detect intracranial bleeding, space-
occupying lesions, cerebral edema, infarctions,
Intratest : position: left side or supine position with hydrocephalus, cerebral atrophy, and shifts of brain
pillow under the right structures

Pre Test:
 1.Assess allergies if dye is used
2.Instruct the client to lie still and flat during test
3.Remove objects from the head
4.Inform the client of possible mechanical noises
during the test
5.When dye is injected – there may be a hot,
flushed sensation and metallic taste
Post Test:
1.Provide replacement fluids because diuresis is
expected if dye is used
2.Monitor allergic reaction from the dye
3.Assess dye injection site for bleeding and
monitor extremity for color, warmth, and the
presence of distal pulses
 
MRI ( magnetic resonance imaging )
Non-invasive procedure that identifies types of
tissues, tumors, and vascular abnormalities
Provides more details than CT scan
metal and electronic objects are not allowed in the
exam room. These items include: ( because this will
interfere with the magnetic field)
- jewelry, watches, credit cards and hearing
aids, all of which can be damaged.
- pins, hairpins, metal zippers and similar
metallic items, which can distort MRI
images.
- removable dental work.
- pens, pocketknives and eyeglasses.
- internal (implanted) defibrillator
- cochlear (ear) implant
- clips used on brain aneurysms
Remove IV pumps during test
If patient have pulse oximeter – extra precaution is
done
Assess for claustrophobia
EEG (electroencephalogram )
a test that measures and records the electrical
activity of the brain.
Special sensors / electrodes are attached to the
head and hooked by wires to a computer.
Any conditions, such as seizures, can be seen by
the changes in the normal pattern of the brain's
electrical activity.
Pretest:
certain medicines (such as sedatives and
tranquilizers, muscle relaxants, sleeping aids, or
medicines used to treat seizures) should be WITH
HELD before the test.
Do not eat or drink foods that have caffeine (such as
coffee, tea, cola, and chocolate) for 8 hours before
the test.
it is important that the hair be clean and free of
sprays, oils, creams, and lotions.
Shampoo the hair and rinse with clear water the
evening before or the morning of the test. Do not put
any hair conditioner or oil on after shampooing.
The client may be asked not to sleep at all the night
before the test or to sleep less (about 4 or 5 hours)
by going to bed later and getting up earlier than
usual
If a child is going to be tested, try to keep him or her
from taking naps just before the test
Intra test:
The client may be asked to go to sleep. If he cannot
fall asleep, he may be given a sedative to help fall
asleep. If an EEG is being done to check a sleep
problem, an all-night recording of the brain's
electrical activity may be done.
 
Invasive
Lumbar Puncture
Insertion of a spinal needle through L3-L4 interspace
into the lumbar subarachnoid space to obtain CSF,
measure CSF pressure, or instill air, dye or
medications
Contraindicated in clients with increased ICP
Pre Test: Have the client empty the bladder
Intra Test:
1. Position the client in lateral recumbent
position and have the client draw knees up
to abdomen and chin unto the chest
2. Maintain strict asepsis
Post Test:
1. Flat on bed for 8 hours
2. Observe for bleeding at puncture site’
3. Observe for changes in vital signs
 
Myelogram
Injection of dye or air into the subarachnoid space to
detect abnormalities of the spinal cord and vertebrae
Pre Test:
1. Provide hydration for at least 12 hours
before the test
2. Assess for allergies
3. If taking Phenothiazine – hold the
medication
4. Needs sedation
Post Test:
1. Assess vital signs and neurologic condition
2. Elevate head 15 – 30 degrees for 6-8 hours
if water –based dye is used
3. Place flat on bed for 6-8 hours if oil-based
dye is used
 
Cerebral Angiography
Injection of contrast through the femoral artery into
the carotid arteries to visualize the cerebral arteries
and assess for lesions
 a contrast dye is injected into one or more arteries
to make them visible.
the contrast dye is injected into one or both of the
carotid arteries in the neck.
The test is most frequently used to confirm cases of
stroke , tumor , bulging of the artery walls, a clot , or
a narrowing of the arteries
Pre Test:
1. Assess for allergies
2. Hydration 2 days before
3. NPO 4-6 hrs prior the test
4. Remove metals
 
PET SCAN (positron emission tomography )
A PET scan can measure such vital functions as
blood flow, oxygen use, and glucose metabolism,
which helps doctors identify abnormal from normal
functioning of organs and tissues.
The test involves injecting a very small dose of a
radioactive chemical, called a radiotracer, into the
vein of the arm. The tracer travels through the body
and is absorbed by the organs and tissues being
studied.
Pretest:
1. Generally, most patients are told not to eat
anything for a minimum of 6 hours before
the scan.
2. Heart patients are also told to not take any
product with caffeine for at least 24 hours
intratest:
1. The client will be asked to lie down on a flat
examination table that is moved into the
center of a PET scanner—a doughnut-like
shaped machine.
VIII. Musculoskeletal System
Invasive:
 
Blood Test:
ESR (Erythrocyte sedimentation rate)
Male : Up to 15 mm/h Female: Up to 20 mm/h Child:
Up to 10 mm/h
Increased: Inflammation, infection, pregnancy, acute
MI, cancer
Decreased: Polycythemia vera, CHF, sickle cell
anemia
Rheumatoid Factor ( RF )
<1 : 20 or negative
Increased: Rheumatoid arthritis, SLE, scleroderma,
dermatomyositis
Antinuclear antibodies (ANA)
Neg at 1 : 10 dilution ; SI units Negative
Present / positive:
SLE, Sjögren’s syndrome, scleroderma, hepatitis,
rheumatoid arthritis, cirrhosis, ulcerative colitis,
leukemia, infectious mononucleosis
Anti – DNA
Anti-DNA or Anti-DNP
Normal: Negative ; SI Units <2.0 kU/L
Positive: SLE or lupus nephritis
 
C – reactive Protein
C-reactive protein measures general levels of
inflammation in your body.
High levels of CRP are caused by infections and
many long-term diseases
Normal range: 0–1.0 mg/dL or less than 10 mg/L (SI
units)
X – rays ( Bones )
Used to asses fractures of the bones
 
Bone Scan
 A bone scan is a nuclear scanning test that
identifies new areas of bone growth or breakdown
A bone scan can often detect a problem days to
months earlier than a regular X-ray test.
For a bone scan, a radioactive tracer substance is
injected into a vein in the arm. The tracer then
travels through the bloodstream and into the bones
Pretest:
1. limit fluids for up to 4 hours before the test
because you will be asked to drink extra
fluids after the radioactive tracer is injected.
2. The client should empty your bladder right
before the scan.
3. He usually has to wait 1 to 3 hours after the
radioactive tracer is injected before the bone
scan is done.
4. Remove any jewelry that might interfere with
the scan
5. Take off all or most of the clothes,
depending on which area is being examined
(the client may be allowed to keep on his
underwear if it does not interfere with the
test).
Intra test:
1. The client will lie on his back on a table and
a large scanning camera will be positioned
closely above him
2. The client may be asked to move into
different positions so the area of interest can
be viewed from other angles. He needs to lie
very still during each scan to avoid blurring
the pictures.
Post Test:
1. Increase fluid intake to wash off radioactive
tracer
 
Arthroscopy
 Arthroscopy is a type of joint surgery in which a thin
tube with a light source (called an arthroscope) is
inserted into the joint through a small incision (cut) in
the skin, allowing the doctor to see the inside of the
joint
Surgery will not cure rheumatoid arthritis or stop the
disease's progress, but it may improve function and
provide some pain relief.
Post Test:
1. the joint should be used as infrequently as
possible for several days.
2. Crutches may be needed if the foot or knee
joint was examined, depending on the extent
of the procedure and the doctor's
preference.
 
Arthrocentesis
a joint fluid aspiration
 
Myelogram
A myelogram uses a special dye (contrast material)
and X-rays (fluoroscopy) to make pictures of the
bones and the fluid-filled space (subarachnoid
space) between the bones in the spine (spinal
canal).
A myelogram may be done to find a tumor, an
infection, problems with the spine such as a
herniated disc, or narrowing of the spinal canal
caused by arthritis.
Pretest:
1. NPO 8 hours prior to the test
2. The client may need to take a laxative or
have an enema before the test to empty the
bowels.
3. Assess if the client:
- Has epilepsy or a seizure problem.
- Is or might be pregnant.
- Is allergic to any medicines, contrast
material, or iodine dye.
- Has bleeding problems or take blood-
thinning medicines, such as aspirin, heparin,
or warfarin (Coumadin).
- Has asthma.
- Has ever had a severe allergic reaction
(anaphylaxis).
- Has had kidney problems.
- Has diabetes, especially if you take
metformin (Glucophage).
- take off jewelry that might be in the way of
the X-ray picture.
Post test:
1. Elevate head 15 – 30 degrees for 6-8 hours
if water –based dye is used
2. Place flat on bed for 6-8 hours if oil-based
dye is used
 
EMG ( electromyogram)
An electromyogram (EMG) measures the electrical
activity of muscles at rest and during contraction and
electrical activity in response to stress
Measuring the electrical activity in muscles and
nerves can help find diseases that damage muscle
tissue (such as muscular dystrophy) or nerves (such
as amyotrophic lateral sclerosis or peripheral
neuropathies)
 
IX. Eyes and Ears
Eyes
Snellen’s Chart
Non invasive procedure to test visual acuity
standardized numbers or denominators indicates the
degree of visual acuity from a distance of 20 feet
  
Tonometry
A tonometry test measures the pressure inside your
eye, which is called intraocular pressure (IOP)
This test is used to check for glaucoma, an eye
disease that can cause blindness by damaging the
nerve in the back of the eye (optic nerve)
Tonometry measures IOP by recording the
resistance of the cornea to pressure (indentation
 
Pre test instruction:
1. Do not drink more than 2cups of fluid 4
hours before the test.
 2. Do not drink alcohol for 12 hours before the
test.
3. Do not smoke marijuana for 24 hours before
the test.
Intratest: Numbing eyedrops are used.
 
Gonioscopy
Gonioscopy is an eye examination to look at the
front part of the eye (anterior chamber) between the
cornea and the iris.
Gonioscopy is a painless examination to see
whether the area where fluid drains out of the eye
(called the drainage angle) is open or closed.
Pretest:
1. remove contact lenses before this test and
do not put them back in for one hour after
the test or until the medicine used to numb
the eye wears off.
2. Gonioscopy does not usually cause any
discomfort. The eyedrops used to numb
your eye may burn a little.
Ears
Tuning Fork
Rinne test
Vibrate prongs of tuning fork and place base of fork
on mastoid process of ear being tested and note the
time on your watch until the client no longer hears
sound
Sound heard longer in front of the right auditory
meatus than on the mastoid process because air
conduction is twice as long as bone.
If bone conduction, time is equal to or greater than
air conduction. This indicates conductive hearing
loss resulting from diseases, obstruction, or damage
to outer or middle ear.
 
Weber Test
Hold the base of the vibrating fork with your thumb
and index finger and place the base of the fork on
center of top of client’s head
If sound is perceived equally in both ears,indicate a
“negative” Weber test.
Positive : conductive hearing loss ( impacted
cerumen, perforated tympanic membrane, cerum or
pus in the middle ear, fusion of the ossicles
Sensorinueral hearing loss : auditory nerve
damage , prolonged loud noise, effect of ototoxic
agent
 
Whisper Voice Test
▪ Nurse stands 1–2 feet away from client, out of view
to avoid client lipreading, and softly whispers
numbers on side of open ear. Increase voice volume
until client identifies words correctly.
▪ Inability to hear words may indicate a high-
frequency hearing loss (e.g., resulting from
excessive exposure to loud noises).
Audiometry
evaluates a person's ability to hear by measuring the
ability of sound to reach the brain.
helps determine what kind of hearing loss the client
has by measuring your ability to hear sounds that
reach the inner ear through the ear canal (air-
conducted sounds) and sounds transmitted through
bones (bone-conducted sounds).
X. Genito – Urinary System
Non invasive
U/A– see opposite page
KUB
X – ray of the kidneys, bladder and bladder
Pretest:
1. Enema/ clean colon preparation prior to test
  Description Normal Value Clinical Significance
pH Evaluate the client’s acid – base status 4.6 – 8.0 (adults) Increased: alkaline
     
Urine ph is normally acidic with an average of 6 5.0 – 7.0 (newborns) Decreased : acidosis
Specific Gravity Indicator of urine concentration or the amount of 1.010 – 1.025 Increased: fluid deficit , dehydration, excess
solutes (wastes) present in the urine solutes such as glucose / ketones
   
Method: Decreased:
Urinometer/hydrometer in a cylinder of urine Excess fluid intake, disease in the kidney
Spectrometer / refractometer
Glucose This is an inadequate measure of blood glucose None Positive ; DM
 
Used to screen clients for DM and assess abnormal
glucose tolerance during pregnancy
Ketones Product of breakdown of fatty acids None Positive in poorly controlled or uncontrolled DM
 
Blood   0 – 2 RBCs Positive: bleeding
Protein   Qualitative: none Presnt if glomerular membrane has been damaged
Quantitative:
10 – 100 mg / 24 h
Osmolality Measures the solute concentration of urine 500 – 800 OsM/Kg Increased:
  Fluid volume deficit
Monitors Fluid and Electrolyte imbalances  
Decreased:
Fluid volume excess
Invasive :
Blood Studies:
BUN
5–25 mg/dL ( SI UNIT: 1.8–7.1 mmol/L)
Child: 5–20 mg/dL /2.5–6.4 mmol/L
Infant: 4–18 mg/dL / 1.4–6.4 mmol/L
Increased: Dehydration, renal disorders (cause
usually not renal if serum creatinine normal), tissue
necrosis, CHF, shock, MI
Decreased: Inadequate protein intake, liver disease,
water overload, nephrotic syndrome
Serum Creatinine
0.6–1.5 mg/dL/ 53–133 µmol/L
Child: 0.3–0.7 mg/dL
Newborn: 0.3–1.0 mg/dL
Increased: Impaired renal function, massive muscle
damage
Decreased: Muscular dystrophy, pregnancy,
eclampsia
Uric Acid
Male: 4.0–8.5 mg/dL / 0.24–0.51mmol/L
Female: 2.7–7.3 mg/dL / 0.16–0.43 mmol/L
Child: 2.5–5.5 mg/dL / 0.15–0.33 mmol/L
Increased: Gout, excessive purine intake, psoriasis,
sickle cell anemia, chemotherapy, tissue destruction,
eclampsia, alcohol, numerous meds
Decreased: Fanconi’s syndrome, numerous meds
Albumin
3.5–5.0 g/dL or 52–68% of total protein
Child: 4.0–5.8 g/dL
Increased: Dehydration, exercise, meds, prolonged
application of tourniquet prior to venipuncture
Decreased: Malnutrition, chronic diseases, liver
disorders, SLE, scleroderma, ascites, burns,
nephritic syndrome, chronic renal failure, Hodgkin’s
disease, meds
Cystoscopy
 Cystoscopy, also called a cystourethroscopy or,
more simply, a bladder scope, is a test to measure
the health of the urethra and bladder.
Direct visualization of the urinary tract
Position: lithotomy
Post – test:
1. Pink tinged urine (24 – 48 hours) , dysuria,
hematuria will be observed
2. Observe for signs of infection
3. Increase fluid intake
4. Hot sitz bath to relieve pain
IVP
An intravenous pyelogram (IVP) is an X-ray test that
provides pictures of the kidneys, the bladder, the
ureters, and the urethra
During IVP, a dye called contrast material is injected
into a vein in the arm. A series of X-ray pictures is
then taken at timed intervals.
Pretest:
1. Needs to be on NPO for 6 – 8 hours
2. Assess for allergy to seafoods and iodine or
any history of allergic reaction
Post test:
1. Increase fluid intake to excrete dye
2. Bed rest
3. Asses for any delayed allergic reaction
Renal Biopsy
Renal tissue sample is taken and sent to a lab to
detect any malignancy
pre test:
1. sedation is done
2. done with local anesthesia
3. needs to be on NPO for 6 – 8 hours
intra test:
1. position client to PRONE
2. hold breath and remain still during needle
insertion
3. post test: bed rest for 24 hours
4. increase fluids up to 3000ml per day
5. observe for bleeding tendencies and
infections

LABORATORY DATA
 
Laboratory studies are usually simple
measurements to determine how much or how
many analytes, (a substance dissolved in a
solution, also called a solute) are present in a
specimen.
Laboratory tests are ordered to:
 Detect and quantify the risk of future disease
 Establish and exclude diagnoses
 Assess the severity of the disease process and
determine the prognosis
 Guide the selection of interventions
 Monitor the progress of the disorder
 Monitor the effectiveness of the treatment
 Laboratory Values:
Hematologic System: types of blood Cells
Cell Origin Range ( in Major Function
SI Units)
Erythrocytes Bone Marrow F: 4.0 – 5.2 x Transport hemoglobin
10 12 / L Transporting carbon
M: 4.5 – 5.9 dioxide in the form of
x 1012 /L sodium
bicarbonate
Being an acid-base buffer
for whole blood
Leukocytes Granulocytes 4.5 – 11.0 x The protective system
10 9 /L
Monocytes  
Bone Marrow
Lymphocytes
Plasma Cells
Lymph Tissue
Platelets Bone Marrow 150 – 300 x 10 9 / L Vascular Repair
from
megakaryocytes
 Analyte SI Range Increased Decreased
Red Blood Cell F: 4.0 – 5.2 x 10 12 /L Dehydration Anemias
Count M: 4.5 – 5.9 x 1012 / L Induced hypoxia Hypothyroidism
Polycythemia leukemias
Hemoglobin F: 120 – 150 g/L Obstructive lung disease Anemia
M: 139 – 163 g/L Polycythemia Severe hemorrhage
High altitude burns
Shock

Hematocrit F: 0.36 – 0.46 Dehydration Luekemia

M: 0.41 – 0.53 Polycythemia Hemorrhage
Mean Red Cell 26 – 34 pg/RBC Macrocytosis Microcytic hypochromic anemia

Mean Red Cell 310 – 370 g/L Spherocytosis Chronic IDA

Concentration
Mean Red Cell 80 -100 fl Aplastic anemia IDA, Thalassemias, Chron.
Volume Folic and Vit B12 Anemia

White Blood Cells 4.5–11.0 109/L Acute leukemia, Acute chronic leukemias, aplastic
infections, surgery, anemia, agranulocytosis
trauma
WBC Differential % of total WBC      
Band Neutrophils 0–0.06% Severe bacterial disease  - INC.

Segmented 0.31–0.76% Diabetic acidosis, infarctions,

neutrophils inflammatory diseases,
malignancies  - INC.

Lymphocytes 0.14–0.44% Chronic Lupus erythematosus,

lymphocytic Hodgkin’s disease
leukemia

Monocytes 0.02–0.11% Chronic inflammatory diseases –INC.

Eosinophils 0–0.04% Allergies, parasites  - INC.

Basophils 0–0.02% Myelofibrosis  - INC.

Blood Type and Cross Matching

a laboratory test that identifies the client’s blood type and determines the compatibility of blood between a potential donor and
 recipient
type O negative blood are often called universal donors
type AB positive blood are called universal recipients

Cell Type A B AB O
Antibodies Anti – B Anti – A None Anti – A and Anti – B
Antigens A antigen B Antigen A and B antigen None

Hematologic Function Studies

Test
Erythrocyte
sedimentation rate
(ESR or sed rate)
 
 
Haptoglobin
Glucose-6-phosphate
dehydrogenase (G6PD)
(red blood cell)
Normal Range Significance
Westergren: Alterations in the plasma proteins cause aggregation of the RBCs with an elevated ESR
F: < 50 yr 0–25 mm/h moderately, with inflammatory diseases
> 50 yr 0–30 mm/h high, with multiple myeloma, macroglobulinemias, hyperfibrinogenemias.
M: < 50 yr 0–15 mm/h
> 50 yr 0–20 mm/h
0.10–0.30 g/L The test measures
12–35 ìmol/L enzyme deficiencies that are hereditary, sex-linked conditions carried on the
female X chromosome, which causes hemolytic anemia. Clinical disease traits
are found in males
F: 7.4–9.4 IU/g hemoglobin Whites Increased in hereditary spherocytosis, spherocytosis resulting from autoimmune
6.5–9.3 IU/g hemoglobin African- hemolytic anemia, severe burns, chemical poisoning, erythroblastosis
Americans fetalis, transfusion reactions, prosthetic heart valve transplantation.
M: 7.4–9.4 IU/g hemoglobin Whites  
6.6–10.8IU/g hemoglobin African- Decreased in
Americans sickle cell and iron deficiency anemia, polycythemia vera, hemoglobin C disease,
thalassemia major, liver disease, obstructive jaundice, or splenectomy
 Test Normal Range Significance
Osmotic fragility 0.30%–0.45% saline Increased in
Test measures the < 0.30% saline hemolytic and sickle cell anemia; hereditary spherocytosis; treatment of anemias
fragility of RBCs to aid > 0.50% saline from iron, vitamin B12 , and folic acid deficiencies.
in the diagnosis of  
hereditary Decreased in aplastic,
spherocytosis. iron deficiency and untreated pernicious anemias; chronic infection; radiation
Therapy
Reticulocyte count Adults 0.5–2.0%  
Used to differentiate Children 0.5–2.0%
between Infants 0.5–3.5%
hypoproliferative and Newborns 2.5–6.0%
hyperproliferative
anemias;
to assess blood loss
and bone marrow
response to therapy.

Blood and urine specimens are obtained at 30

Blood Chemistry
Blood Glucose
▪ Glucose measurement is performed by either :
 Skin puncture or venipuncture
fasting blood sugar (FBS)
 normal fasting value is 70 to 115 mg/dl
 nonfasting (usually 2-hours postprandial)
 less than 120 mg/dl
 
2-hour postprandial - This test is used to screen for
diabetes mellitus; if the results are abnormal, the
practitioner may order a glucose tolerance test
 A glucose tolerance test is the most accurate test
for diagnosing hypoglycemia and hyperglycemia
(diabetes mellitus).
 Requires fasting
The test is conducted as follows:
Initial blood and urine specimens are obtained.
An oral loading dose of glucose is administered.
minutes, 1 hour, 2 hours, 3 hours, and sometimes 4
hours after loading dose.
Glycosylated Hemoglobin
 Reflects serum glucose for the past 2 – 4 months
Most accurate
Serum Electrolytes
▪ These tests measure the serum concentration of
sodium, potassium, calcium, chloride, magnesium,
and phosphate.
▪ An electrolyte is an element or compound that,
when dissolved in water or another solvent,
separates into ions and provides for cellular
reactions
 
Sodium - 135–148 mEq/L, adult 138–144 mEq/L,
children 133–144 mEq/L, newborns
▪ Clinical Significance :
 
Increased: excessive intake of sodium without
water; salt water drowning; high solute concentration
(tube feeding, IV, hyperalimentation) without fluid
correction; diarrhea; diabetes insipidus; primary Magnesium - 1.3–2.0 mEq/L, adult 1.6–2.6 mEq/L,
aldosteronism; renal failure children 1.4–2.9 mEq/L, newborn
▪ Clinical Significance :
 
Decreased: excessive intake of water without Increased: chronic renal failure, drugs (magnesium
sodium (oral, IV therapy, tap water enemas); heart sulfate, antacids, enemas containing magnesium,
failure, cirrhosis; nephrosis and massive diuretic sedatives); acute adrenalcortical insufficiency.
therapy Decreased: chronic diarrhea and alcoholism,
  nontropical sprue, steatorrhea, hereditary
Potassium (serum) - 3.5–5.0 mEq/L, adult, 3.4– alabsorption, starvation, bowel resection, diuretics
4.7 mEq/L, children, 3.7–5.9 mEq/L, newborns (mannitol,urea, glucose); hypoparathyroidism
Clinical Significance :  
Increased: high potassium intake (oral, IV therapy, Phosphate - 2.7–4.5 mg/dl, adult 4.5–5.5 mg/dl,
rapid infusion of aged blood); renal disease; drugs children 4.5–6.7 mg/dl, newborn
(adrenal steroids, potassium-conserving diuretics, ▪ Clinical Significance :
potassium penicillin, chemotherapeutic agents); increased: renal insufficiency; intake, IV solutions
Addison’s disease; burns and other massive tissue and enemas; blood transfusion; muscle necrosis;
trauma; metabolic and respiratory acidosis. hypoparathyroidism.
Decreased: drugs (diuretics, digitalis); metabolic Decreased: alcohol withdrawal;hyperventilation;
alkalosis; primary aldosteronism; Cushing’s diabetic ketoacidosis; phosphate-binding antacids
disease;vomiting and gastric suction
  Blood Enzymes
Calcium - Total 8.4–10.5 mg/dl Ionized 1.13–1.32
mmol/L
Isoenzyme Normal Clinical Significance
Clinical Significance :
Range
Increased: hyperparathyroidism; bone catabolism
CPK1 (BB) 0 IU/I Primarily in
(multiple myeloma, leukemia, bone tumors);
brain/indicative of cerebrovascular
immobility.
accident
Decreased: renal failure; sprue; pancreatitis;
Crohn’s disease; hyperphosphatemia; drugs CPK2 (MB) 0–7 IU/I Exclusively in
(aminoglycosides, antacids containing aluminum, myocardium/indicative
caffeine, cisplatin, corticosteriods, loop diuretics of myocardial infarction
  CPK3 5–70 Found in skeleton and
Chloride - 1.3–2.0 mEq/L, adult 1.6–2.6 mEq/L, IU/I myocardium/skeletal
children 1.4–2.9 mEq/L, newborn muscle disorders
Clinical Significance:
Increased : hyperparathyroidism; drugs (ammonium CPK Isoenzymes
chloride, ion exchange resin, phenylbutazone);  
metabolic acidosis; respiratory acidosis; dehydration. Enzymes are globular proteins produced in the body
Decreased: prolonged vomiting and gastric suction; that catalyze chemical reactions within the cells by
diarrhea; diuretics(ethacrynic acid and furosemide). promoting the oxidative reactions and synthesis of
  various chemicals, such as lipids, glycogen, and
adenosine triphosphate (ATP).
 5'- 0–17 U/L Biliary cirrhosis;
Nucleotida extrahepatic
se obstruction; hepatic
carcinoma
LDH Isoenzymes
Blood Lipids
Isoenzym Normal Clinical significance Cholesterol and other fats cannot dissolve in the
e Range blood; they have to be transported to and from the
LDH1 17–33 Primarily in heart, cells by special carries called lipoproteins (blood
kidneys, RBCs lipids bound to protein).
LDH2 27–37 Primarily in heart, The types of lipoproteins:
kidneys, RBCs 1. Chylomicrons—mainly ingested triglycerides
LDH3 18–25 Primarily in lungs, to a 2. Very low-density lipoproteins (VLDLs)—
lesser extent in pancreas, mainly endogenous triglycerides
thyroid, adrenal glands, 3. Low-density lipoproteins (LDLs)—moderate
lymph nodes amounts of phospholipids with 50%
cholesterol
LDH4 3–8 Liver and skeletal Tissue
4. High-density lipoproteins (HDLs)—50%
LDH5 0–5 Liver and skeletal tissue protein
5. LDL is the major cholesterol carrier in the
Digestive Enzymes  blood. When too much LDL circulates in the
Enzyme Normal Clinical Significance blood, it can slowly build up in the walls of
Range the arteries feeding the heart and brain
Alanine 0–30 IU/L Hepatocellular which will form atherosclerotic plaque, then
aminotran Damage will thrombus which will then cause CVA or
sferase MI
Aldolase 0–8 IU/L Anemia (hemolytic Lipid Normal Risk for CHD
and megaloblastic); Range/Border
granulocytic Line
leukemia; metastatic Cholesterol < 200 mg / dl > 250 mg/dl
carcinoma; skeletal 200 – 239
muscle tissue LDL < 130 mg/dl > 160 mg /dl
damage Cholesterol 130 – 159 mg/dl
Amylase Total: 40–220 Pancreatitis HDL > 40 mg /dl < 35 mg/dl
IU/L Cholesterol 35 -40 mg/dl
Aspartate 0–35 IU/L Hepatitis; infectious Triglyceride < 250 mg/dl > 500 mg /dl
aminotran mononucleosis; 250 – 500 mg/dl
sferase cirrhosis
Lipase 0–1 Cherry- Acute pancreatitis Arterial Blood Gas
Crandell U/L  Measures the acidity and the levels of oxygen and
carbon dioxide in the blood.
Normal Blood Gas Values
 Ph 7.35 – 7.45 ▪ Measures the amount of time it takes for a clot
Pco2 35 – 45 mmHg formation ; used to evaluate warfarin sodium
PO2 80 – 100 mmHg therapy.
▪ INR evaluates the effects of oral anticoagulants
HCO3 22 – 26 mmHg
▪ Antidote: Vit K
Thyroid Lab data:
Interpretation Used to evaluate thyroid disorders
▪ Key Points:  
 In acidosis, Ph is low: in alkalosis, Ph is high   Normal Range
 The respiratory function indicator is PCO2 and the
TSH (thyroid stimulating Hormone) / 0.2 – 5.4
metabolic function indicator is HCO3
thyrotropin microunits/mL
 
Steps: Thyroxine 5.0 – 12.- mcg/dl
1.assess Ph – low acidic; high alkalosis Triiodothyronine 80 – 230 ng/dl
2. assess PCO2 – if opposite to the response of Ph
then it is respiratory imbalance if not look at HCO3 Hepatitis Test:
concentration;  Serological tests ( detects specific virus )
3. assess HCO3 – if HCO3 concentration is  
proportionate with the Ph then it is a metabolic HIV/AIDS
imbalance  The following tests detects presence of antibodies
4. A COMPENSATION has occurred if the Ph is in ▪ Enzyme Linked immunosorbent assay ( ELISA)
normal range (7.35 - 7.45). if not assess the ▪ Western Blot - CONFIRMATORY TEST
respiratory and metabolic function indicator ▪ Immunofluorescence assay ( IFA)
 If respiratory imbalance: assess HCO3 ▪ CD4+ T cell counts:
concentration: ▪ Monitors / evaluates the progress of the virus
▪ If normal it is uncompensated Normal : 500 – 1600 cellµ/
▪ If abnormal, then it is partial compensation  
▪ If metabolic imbalance: assess PCO2
▪ If normal it is uncompensated Acetaminophen ( Tylenol) 10 – 20 mcg/mL
▪ If abnormal, then it is partial compensation
  Amikacin ( Amikin) 25 – 30 mcg/mL
 Coagulation Studies:
Amitriptyline ( Elavil ) 120 – 150 ng/mL
 aPTT ( activated partial Thromboplstin)
▪ normal value: 20 to 36 seconds Carbamazepine (tegretol) 5 – 12 mcg/ mL
▪ measures the time it takes for a citrated plasma to
clot,after a partial thromboplastin to clot Chloramphenicol 10 – 20 mcg/mL
▪ antidote: warfarin sodium/coumadin
▪ Prothrombin time and International Normalized Digoxin ( Lanoxin ) 0.5 – 2.0 ng/mL
Ration (INR) Imipramine(Tofranil) 150 – 300 ng/mL
 ▪ M: 9.6 to 11.8 seconds
▪ F: 9.5 – 11. 3 seconds Lidocaine 1.5 – 5.0 mcg/mL
▪ INR : 2 – 3 seconds for warfarin therapy
▪ INR : 3 – 4.5 seconds for high dose of warfarin Lithium 0.5 -1.3 mEq/L
therapy
 Phenobarbital 50 – 150 ng/mL
Phenytoin (dilantin) 10- 20 mcg/mL
SPECIMEN COLLECTION
Sputum Specimen:
Purpose:
For Culture and sensitivity test. To test for specific
microorganism
Cytology ( identify origin, structure, function and
pathology of cells)
For AFB to detect TB
Done in 3 consecutive days
Evaluate effectiveness of therapy
NOTE:
1. Best collected in the morning upon
awakening
2. If client cannot cough, do pharngeal
suctioning\
3. Mouth care should be done prior to
obtaining specimen ( water only)
4. 1 – 2 tablespoon or 15 – 30 ml (4 – 8 fluid
dram) of sputum is needed
 
Throat Culture:
Collected from the mucosa of the oropharynx and
tonsillar region with the use of culture swab
Purpose: detect specific microorganism
This is an invasive procedure
Position of patient: sitting position ( if tolerated )
Extension of tongue ( to expose the pharynx)
Let the patient say “ah” to relax the throat muscles
 
Blood collection
Laboratories employ a phlebotomist (an individual
who performs venipuncture) to collect blood
specimens; however, it is
 the responsibility of a nurse to know how to
perform a venipuncture
 Point of care testing (POCT) is a common practice
in critical care settings and is proving to be a cost-
effective. With advances in POCT technology over
the past two decades, critical care nurses can
perform a blood analysis and within seconds
to minutes have a measurement upon which to
change or implement an intervention
Venipuncture
▪ To assses Venous Blood
▪ Test tubes ( vacuum Tubes ) are used to collect
blood specimens.
 Vacuum Tube Color Coding:
 Red—no additive
  Lavender—EDTA (ethylenediaminotetraacetic
acid)
 Light blue—sodium citrate
 Green—sodium heparin
 Gray—potassium oxalate
Black—sodium oxalate
 
Arterial Puncture
▪ To assess Arterial Blood Gas ( ABG )
Blood gases are ordered to evaluate:
 Oxygenation
 Ventilation and the effectiveness of
respiratory therapy
 Acid-base level of the blood
▪ Arterial blood samples are drawn from a peripheral
artery (e.g., radial or femoral) or from an arterial line.
▪ Allen’s test is performed prior to drawing of arterial
blood. ( performed to measure the collateral
circulation to the radial artery)
▪  The arterial blood sample is collected in a 5-ml
heparinized syringe. The syringe is then rotated to
mix the blood with the heparin to prevent clotting
▪ Direct pressure must be applied to the puncture
site until all bleeding has stopped, a minimum of 5
minutes.
Arterial punctures should not be performed:
1. If the client is hyperthermic
2. Immediately after breathing and suctioning
treatments
3. If there have been changes on ventilator
settings
4. Anticoagulant therapy
5. Clotting disorders
6. Symptomatic peripheral vascular disease
7. Negative Allen test
 
Capillary Puncture
▪ Skin punctures are performed when small
quantities of capillary blood are needed for analysis
or when the client has poor veins.
▪ Ex. Drawing blood for Hgt monitoring
▪ The common sites for capillary punctures are the:
 Heel—most common site for neonates and infants
 Fingertip—the inner aspect of palmar fingertip
used
 most commonly in children and adults
  Earlobe—when the client is in shock or the
extremities are edematous
 
Central Lines
▪ A central line refers to a venous catheter inserted
into the superior vena cava through the subclavian,
internal, or external jugular vein
▪ A central line is inserted when a peripheral route
cannot be obtained, for treatment, and to withdraw
blood for analysis
▪ It is standard practice to mark each lumen of a
multilumen catheter with the name of the infusion
(e.g., fluid or medication)
▪ Implanted Port
▪ port-a-cath (a port that has been implanted under
the skin) over the third or fourth rib
▪ The port has a catheter that is inserted into the
superior vena cava or right atrium through the
subclavian or internal jugular vein.
Blood can be withdrawn for sampling by accessing
the port using strict sterile technique
Urine Collection
▪ The different methods of urine collection are:
  Random collection (routine analysis)
  It can be collected at any time using a clean cup
 The urine does not have to be collected in a sterile
container.
 
Timed collection
 done over a 24-hour period.
 The urine is collected in a plastic gallon container
that contains preservatives.
 discard the specimen at the beginning of the
collection and save all other voided specimens until
1000 hours the following day
 The collection container should be refrigerated or
kept on ice throughout the 24 hours. This retards
bacterial growth and stabilizes the analytes
 The last urine collection, 1000 hours, should be a
complete, forced voiding at the exact timed period.
 Collection from a closed urinary drainage system
 Urine collection from a client with an indwelling
Foley catheter with a closed drainage system
 The urine specimen should not be obtained
from the drainage bag. The analytes in the urine
drainage bag change; this will cause inaccurate
results.
 Collect urine from the aspiration port that is used
for sterile urine collection
 
Clean-voided specimen / Clean Catch Urine
 Clean-voided (clean-catch, or midstream)
specimen collection is done to secure a specimen
uncontaminated by skin flora.
 Obtained on first voiding in the morning
 
Stool Collection
 Stools can be collected for either a one-time
defecation or over 24, 48, or 72 hours
If a specimen is needed over a prolonged period of
time, all stools must be placed into a container and
refrigerated, otherwise, a clean container is enough.
 
Nutrition
NUTRITION
 
Vitamins and Minerals
 
Vitamin /Recommended Daily Uses Food Source
Mineral Allowance
 
Men Women
FAT SOLUBLE VITAMINS
A 1000 RE 800 RE Proper vision, growth Liver, milk, eggs, beta-carotene
found in dark-orange and darkgreen
fruits and vegetables (carrots,
pumpkins, broccoli, spinach)
D 5 µg 5 µg Proper bone formation, cell Function Fortified milk, liver, fish
E 10 mg 8 mg Immune system functioning, destruction of Vegetable oils, green leafy vegetables, whole grains
free radicals (by-products of metabolism that
can cause vascular damage)
K 80 µg 65 µg Blood clotting, bone formation Green leafy vegetables, dairy products

WATER SOLUBLE VITAMINS

C 60 µg 60 µg Collagen synthesis, destruction of free Fruits and vegetables (especially citrus fruits)
radicals, assistance n iron absorption,
nfection fighting, healing
Thiamine 1.5 mg 1.4 mg Converting carbohydrates and fats to energy Fortified and whole grains, lean cuts of pork, legumes (beans and peas),
(B1) seeds, nuts
Riboflavin 1.7 mg 1.3 mg Converting bodily fuels to Dairy products, meat, poultry,fish, whole-wheat and fortified grain products,
(B2) Energy green leafy vegetables
Niacin 19 mg 15 mg Converting carbohydrates, Meat, milk, eggs, poultry, fish, enriched breads and cereals
(B3) fats, and amino acids to
energy
B6 2 mg 1.6 mg Assistance in at least 50 Chicken, fish, liver, pork, eggs, whole-wheat products, peanuts, walnuts
enzyme reactions—the most
important regulate nervous
system activity
Folate 200 µg 180 µg Manufacturing of DNA and Liver, leafy vegetables, legumes, fruits
new body cells
B12 2 µg 2 µg Manufacturing of new body Meat, poultry, fish, dairy products
cells and mature new red
blood cells, maintenance of
nerve growth, protection of
nerve cells

MINERALS
Calcium 800 mg 800 mg Building bone, transmitting Dairy foods, canned sardines and salmon with the bones, fortified orange
nerve impulses, and aiding juice; smaller amounts in some fruits and vegetables (broccoli, tangerines,
muscle contractions pumpkins)
Phosphor 800 mg 800 mg Building bone, helping the In nearly all foods
us body utilize energy and
reproduce cells
Magnesiu 350 mg 280 mg Holding calcium in tooth Nuts, legumes, cereal grains,
m enamel, assistance in relaxing green vegetables, seafood
muscles after contractions
Iron 10 mg 15 mg Transporting oxygen in red Meat, poultry, fish, dried beans
blood cells and muscle and peas, fortified grain products
cells, DNA synthesis, formation
of major enzymes
Zinc 15 mg 12 mg Promotion of healing and Meats, oysters, milk, egg yolks
growth, maintaining
immune function, DNA synthesis,
and a normal sense
of taste
Iodine 150 µg 150 µg Helping the thyroid regulate Seafood, iodized table salt
Metabolism
Selenium 70 µg 55µ g Destruction of free radicals, Fish, meat, breads, cereals
formation of enzymes
Tips THERAPEUTIC DIETS
   
Fats, oils and Sweet Treats. Go easy.  
  Acid-ash diet
Milk, Yogurt and Cheese Retards the formation of alkalinic renal stones
▪ 2 to 3 servings a day. One serving (one and one- Indicated to patients with renal calculi (Alkaline
half ounces) of cheese is about the size of six dice stones)
or three dominoes. A serving of milk or yogurt is one E.g. cheese, cranberries, eggs, meat, plums,
cup (or one small container of yogurt). prunes, whole grains
▪  
Vegetables Alkaline ash diet
▪ 3 to 5 servings a day. If you're talking leafy-green Retards the formation of acid renal stones.
veggies like spinach, kale or collard greens, put a Indicated to patients with renal stones (Acidic
baseball-sized portion (one cup) on your plate. Half stones)
a baseball will do it for veggies like green beans, E.g. fruits (except cranberries, plums, prunes), milk,
carrots and Brussels sprouts. Since that equals vegetables
about eight green beans, 10 carrot slices or three
Brussels sprouts, it should be easy to get a few Bland diet
servings at a time. A small (6-ounce) glass of tomato Low fiber, mechanical irritants, chemical stimulants
or other vegetable juice works too. Indicated for patients with gastritis, diarrhea, biliary
  indigestion, and hiatal hernia
Meat, Poultry, Fish, Eggs and Nuts
▪ 2 to 3 servings a day. A deck of cards or a small BRAT Diet
fist describes what one serving (three ounces) of Banana, Rice, Apple. Toast
meat, fish or poultry looks like. A 1 1/2 cup portion of Indicated for patients with diarrhea
cooked beans make a great stand-in for three
ounces of meat. Two tablespoons of peanut butter— Butterball diet
about the size of a golf ball—are a third of a serving. Spare protein but high in carbohydrates
  Indicated for patients with liver disorders
Fruit
▪ 2 to 4 servings a day. Picture filling half a baseball Clear liquid Diet
with fruit. That's all it takes to get one half-cup To relieve thirst and help maintain fluid balance
serving. Whole fruits only need to be about the size Indicated for post-operative patients and following
of a tennis ball, and a small (6-ounce) glass of juice vomiting and gastroenteritis
counts as a serving too.
  Diabetic Diet/
Bread, Cereals, Rice and Pasta Well balance diet
6 to 11 servings a day. It's easier to eat your share The purpose is to maintain near to normal blood
than it sounds. Your bagel would only have to be the glucose level
size of a hockey puck to equal one serving (one Indicated to patients with diabetes mellitus
ounce) of bread.
Full liquid diet Low fat/cholesterol Diet
It serves to provide nutrition to patients who cannot It serve the purpose of reducing hyperlipedemia, and
chew or tolerate solid foods to patients with intolerance to fats
Indicated to patients with stomach upsets, post- Indicated to patients with cardiovascular diseases,
surgical patients, after progression from clear liquid patients who underwent resection of the small
diet intestines, hypertension cholecystitis and
cholelithiasis
Giordano Diet
Spare protein Low Residue diet
Indicated to patients who suffers from Chronic renal Reduces the bulk of stools
Failure Indicated to patients with ulcerative colitis,
diverticulitis, patients who will undergo surgery of the
Gluten free Diet GI tract
No to B R O W – Barley. Rye. Oat, Wheat
This is the diet of a patient who suffers from celiac’s Low Sodium Diet
Disease Indicated to patients with cardiovascular and renal
disorders
Halal Diet
No pork diet Purine restricted diet
Diet of the Muslims To reduce uric acid
Indicated to patients with gouty arthritis, renal calculi,
High Fiber Diet and hyperuricemia
Fruits and vegetable
It speeds up the passage of food to the digestive Sodium-restricted diet
tract, it Indicated to patients with heart failure, hypertension,
softens the stool,Indicated to patients who are renal diseases, PIH, and steroid therapy
constipated,
with diverticolosis, with hyperlipedemia Soft diet
  Used to provide nutrition for those patients who have
High Protein Diet problems in chewing
Lean-meat, cheese, eggs, For patients with ill-fitting dentures; transition from
Indicated to patients with nephrotic syndrome full-liquid to general diet, patients with
gastrointestinal disturbances such as gastric ulcers
Kosher Diet and cholelithiasis
Meat ad milk cannot be served simultaneously
Diet of the Orthodox Jews Tyramine-free Diet
Use to prevent hypertensive crisis for patients who
Low carbohydrate diet are taking-in MAOI antidepressant.
Indicated to patients with dumping syndrome No to ABC’s- Avocado, Banana, Canned and
Processed Foods, and also, no to fermented foods
Yin Diet
Cold deserts after a surgery. It is a Chinese belief. Vegan Diet
Diet of the Seventh Day Adventists
THERAPEUTIC NURSING 90 degrees
Semi-Fowler’s:
PROCEDURES head and torso
elevated 45 to
POSITIONING CLIENTS 60 degrees

BASIC PRINCIPLES IN POSITIONING OF 2. Low Fowler’s:

PATIENTS head and torso
1. Maintain good patient body alignment. Think elevated to 30
of the patient in bed as though he were degrees Knees
standing. slightly flexed
2. Maintain the patient's safety.
3. Reassure the patient to promote comfort
KNEE- prone with To prevent further cord
and cooperation. CHEST
4. Properly handle the patient's body to weight of prolapse. , Promotes
prevent pain or injury. upper body Maximum exposure of
5. Keep in mind proper body mechanics for the supported Rectum
practical nurse. on flat
6. Obtain assistance, if needed, to move heavy surface by
or helpless patients. chest
7. Follow specific physician's orders. • Hips and
knees flexed to
elevate buttocks
Position Description Therapeutic Use

DORSAL Flat on back For perineal and

RECUMBE
with legs flexed rectal examination
NT
at hips and
knees

Feet flat on
mattress

FOWLER’S Head of bed up Promote maximum lung

30 to 90 expansion
degrees Relieve DOB/ SOB
1. High Fowler’s:  
sitting upright at  
LITHOTOM Flat on back For vaginal/ perieneal weight of body
Y
with legs flexed procedures and assesment on shoulder
90 degrees at SUPINE Flat on back
hips and with body in
knees anatomic
• Feet up in alignment
stirrups

PRONE • Flat on
abdomen with Common Positions after surgery / after a
knees slightly procedure:
flexed  
• Head turned to  Autograft:
side site is immobilized for 3 to 7 days
• Arms flexed at Burns of face and Head:
side elevate head of bed
SIMS • Halfway Circumferentiated burns of Extremities:
between side elevate extremities above the level of
lying and prone the heart
with bottom Skin graft:
knee slightly elevate and immobilize
flexed Mastectomy:
• Lower arm Semi fowler’s with affected arm elevated
behind back on a pillow
• Upper arm Perineal and Vaginal Procedures:
flexed, hand Lithothomy Positions
near head Hypiphysectomy:
TRENDELE • Head is low Elevate head of bead ( prevent ICP )
N-BURG’s Thyroidectomy:
with body and
legs elevated on Semi – fowlers position
an May use sand bags or pillows for the
inclined plane head and neck
Hemorrhoidectomy:
Lateral Side Lying Position
LATERAL • Side lying with GERD:
RECUMBE Reverse Trendelenburg’s
upper leg flexed
NT
at hip and knee Liver Biopsy:
• Lower arm During:
flexed with Supine with right side of upper
shoulder abdomen exposed
positioned to
avoid
 Right arm is raised and extended Prone Position for 10 – 30 mins
over the left shoulder behind the twice a day
head Arterial Vascular Grafting of an Extremity
After: Bed rest for 24 hours; affected extremity
Right Lateral side lying position is kept straight
Small pillow or folded towel under  Cardiac Catheterization:
the puncture site for 3 hours Affected extremity is kept straight and
NGT head is elevated to no greater than
Insertion: 30 °
High fowler’s position with head tilted forward
Irrigations and tube feedings
Semi fowlers ( 30 ° )
  Congestive Heart Failure and Pulmonary Edema:
Rectal Enemas/ Irrigations: Upright
Sim’s Position Preferably legs dangling to the side of
Sengstaken – Blakemore and Minnesota tubes: the bed to decrease venous return
Maintain elevation of head of the bed Varicose Vein:
COPD: Leg elevation above heart level
Sitting position, leaning forward Cataract Surgery:
Laryngectomy: After:
Semi fowler’s or fowler’s position Semi to fowler’s position and position
Bronchoscopy: patient on the back or non operative
Semi – fowler’s side
Postural Drainage: Retinal Detachment:
Lung segment to be drained should be If gas bubble is injected:
in the uppermost position Face down or toward the unoperative
Thoracentesis: side
During: Autonomic Dysreflexia:
Sitting on the edge of the bed and High Fowler’s Position
leaning over the bedside table Cerebral Anuerysm:
or Semi – fowler’s to fowler’s position
Lying in bed on the affected side CVA:
with head of bed elevated ( 45°) Hemorrhagic Strokes:
After: HOB is elevated to 30°
Position on the unaffected side Ischemic Strokes:
Abdominal Anuerysm Resection: Flat
After: Craniotomy:
Fowler’s Position Should NOT be positioned on the
Amputation of the Lower Extremities: operative site
1st 24 hours: Semi to fowler’s position
Elevate foot of the bed; stump Laminectomy:
supported with pillows but not Back is kept straight
elevated Logroll client
ICP:
Semi – Fowler’s to Fowler’s Position
LP:
During:
Lateral (side lying ) position; knees
flexed upto the abdomen and
head is bent so that chin is
resting on the chest
Fetal position
After:
Supine ( 4 to 12 hours )
SCI:
Immobilze on a spinal backboard
Myelogram:
After:
Water Soluble dye: HOB elevated
30 to 60 degrees
If Oil based : supine
Total Hip Replacement:
Avoid internal and external Rotation
Avoid adduction and side lying on the
operative side
Maintain abduction if on supine position
( pillows between legs)
Do not cross legs
To promote relaxation :
Obtain comfortable bedding. Allow some of
patient's own possessions (such as a
pillow or afghan) when possible.
Change the bed position (head and knee).
Reduce the noise and light in the patient's
room.
Check for mechanical reasons for
discomfort:
Bed linens which are gathered and
wrinkled under the patient.
Plastic mattress covers that wrinkle and
cause pressure.
Top covers which may be pulled too
tightly over the feet and legs.
The patient lying on tubes, drains,
syringe caps, or other equipment.
Soiled dressings, urine, and feces
causing the bed to be wet.
Nonfunctioning equipment, to include
alarms sounding without cause
 Log rolling
  Logrolling is a technique used to turn a patient
whose body must at all times be kept in a straight
alignment (like a log).
 This technique is used for the patient who has a
spinal injury.
 The bed should be in the flat position at a
comfortable working height.
 Lower the side rail on the side of the body at
which you are working.
 Position yourself with your feet apart and your
knees flexed close to the side of the bed
 Place your arms under the patient so that a major
portion of the patient's weight is centered between
your arms. The arm of one nurse should support the
patient's head and neck.
On the count of three, move the patient to the side of
the bed, rocking backward on your heels and
keeping the patient's body in correct alignment.
 
Place pillows in front of and behind the patient's
trunk to support his alignment in the lateral position.
 
 
PRINCIPLES OF ASSISTING PATIENTS
OUT OF BED
1. Reassure the patient of his personal safety
against injury and over-exertion.
2. If necessary, get additional help to assist you in
ambulating the patient.
3. Support the affected side or extremities of the
patient when ambulating or moving.
4. Do not overtire the patient; increase time up in the
chair and ambulation gradually.
5. Lock all wheelchair or litter wheels before
transferring the patient from the bed.
6. Stabilize the footstool, when it is utilized.
7. Place a signal cord or call-light button within easy
reach of the patient while he is up.
8. Check on the patient frequently.
 
ACTIVE AND PASSIVE RANGE OF MOTION
EXERCISE
PURPOSES OF EXERCISE FOR THE IMMOBILE
PATIENT
 To maintain joint mobility is done by putting
each of the patient's joints through all possible
movements to increase and/or maintain
movement in each joint.
 To prevent contracture, atony (insufficient
muscular tone), and atrophy of muscles.
 To stimulate circulation, preventing thrombus
and embolus formation.
 To improve coordination.
 To increase tolerance for more activity.
 To maintain and build muscle strength.
 
TYPES OF EXERCISES
Passive
These exercises are carried out by the
nurse, without assistance from the
patient. Passive exercises will not
preserve muscle mass or bone
mineralization because there is no
voluntary contraction, lengthening of
muscle, or tension on bones.
Active Assistive.
These exercises are performed by the
patient with assistance from the
nurse. Active assistive exercises
encourage normal muscle function
while the nurse supports the distal
joint.
Active.
Active exercises are performed by the
patient, without assistance, to
increase muscle strength.
Resistive.
These are active exercises performed
by the patient by pulling or pushing
against an opposing force.
Isometric
These exercises are performed by the
patient by contracting and relaxing
muscles while keeping the part in a
fixed position. Isometric exercises
are done to maintain muscle
strength when a joint is immobilized.
Full patient cooperation is required.
BODY MOVEMENT
 
Flexion -The state of being bent. The cervical spine
is flexed when the chin is moved toward the chest.
Extension -The state of being in a straight line. The
cervical spine is extended when the head is held
straight.
Hyperextension - The state of exaggerated
extension. The cervical spine is hyperextended
when the person looks overhead, toward the ceiling.
Abduction -Lateral movement of a body part away
from the midline of the body. The arm is abducted
when it is held away from the body.
Adduction - Lateral movement of a body part
toward the midline of the body. The arm is adducted
when it is moved from an outstretched position
toward the body.
Rotation -Turning of a body part around an axis.
The head is rotated when moved from side to side to
indicate "no."
Circumduction -Rotating an extremity in a complete
circle. Circumduction is a combination of abduction,
adduction, extension, and flexion.
Supination. - The palm or sole is rotated in an
upward
GUIDELINES FOR RANGE OF MOTION
EXERCISES
2. Plan when range of motion exercises should
be done
3. Plan whether exercises will be passive,
active-assistive, or active. Involve the
patient in planning the program of exercises
and other activities because he/she will be
more apt to do the exercises voluntarily.
4. Expect the patient's heart rate and
respiratory rate to increase during exercise.
5. Range-of-motion exercises should be done
at least twice a day. During the bath is one
appropriate time. The warm bath water
relaxes the muscles and decreases
spasticity of the joints. Also, during the bath,
areas are exposed so that the joints can be
both moved and observed. Another
appropriate time might be before bedtime.
The joints of helpless or immobile patients
should be exercised once every eight hours
to prevent contracture from occurring.
6. Joints are exercised sequentially, starting
with the neck and moving down. Put each
joint needing exercise through the range of
motion procedure a minimum of three times,
and preferably five times. Avoid overexerting
the patient; do not continue the exercises to
the point that the patient develops fatigue.
Some exercises may need to be delayed
until the patient's condition improves.
7. Start gradually and move slowly using
smooth and rhythmic movements
appropriate for the patient's condition.
8. Support the extremity when giving passive
exercise to the joints of the arm or leg.
9. Stretch the muscles and keep the joint
flexible.
10. Move each joint until there is resistance, but
never force a joint to the point of pain.
11. Keep friction at a minimum to avoid injuring
the skin.
12. Return the joint to its neutral position.
13. Use passive exercises as required, however,
encourage active exercises when the patient
is able to do so.
Gastric tube Insertion
Purpose:
 Administer tube feedings and medications to
clients who cannot take in food per orem
( Gavage )
 Prevent gastric distention, nausea and
vomotting
 To remove stomach contents for laboratory
analysis
 To lavage / wash stomach in case of
poisoning or over dose of medication
Procedure:
1. Gather the necessary equipment.
2. Explain procedure to the patient
3. Wash hands.
4. Position the patient in a sitting position
5. Check nostrils for patency by asking the
patient to breathe through one naris while
occluding the other.
6. Measure length of NG tubing to be inserted
by measuring the distance from tip of nose
to ear-lobe and from ear-lobe to about 1 inch
beyond base of xiphoid process. Use a
small strip of adhesive tape to mark the
measured distance on the tube.
7. Don gloves and lubricate tube in water or a
water soluble lubricant. (Never use mineral
oil or petroleum jelly.)
8. Ask the patient to tilt his or her head
backward, and gently advance the NG tube
into an unobstructed nostril; direct tube
 toward back of throat and down.
9. As the tube approaches the nasopharynx,
ask the patient to flex head toward chest (to
close the trachea) and allow him or her to
swallow sips of water or ice chips as the
tube is advanced into the esophagus (about
3 to 5 inches each time the patient
swallows).
NOTE: If the patient coughs or gags,
check the mouth and oropharynx. If the
tube is curled in the mouth or throat,
withdraw the tube to the pharynx and
repeat attempt to insert the tube.
10. Ask the patient to continue swallowing until
the tube reaches the premeasured mark.
11. Check for proper tube placement in the
stomach by aspirating with a syringe for
gastric drainage or by instilling about 20 mL
of air into the NG tube while listening with a
stethoscope for a gurgling sound over the
stomach.
12. Secure the tube after checking for proper
placement by cutting a 3-inch strip of 1-inch
tape and then splitting the tape lengthwise at
one
13. end, leaving 1 inch intact at the opposite end
14. Place the intact end of the tape on top of the
patient’s nose, and wrap one side of the split
tape end around the tube and secure on a
nostril. Repeat with the other split tape end.
15. Connect the NG tube to suction if ordered,
or clamp.
16. Wrap adhesive tape around the distal end of
the tubing and attach a safety pin through
the tape tab to the patient’s gown.
17. Document the size and type of tube
inserted. Note the nostril used and the
patient’s tolerance of the procedure.
Document how placement was validated
and whether tubing was left clamped or
attached to other equipment.
INTERMITTENT (BOLUS) TUBE FEEDING
 
1. Explain procedure to the patient.
2. Assist the patient to a normal position for eating; if
patient cannot tolerate this position or it is
contraindicated, raise head of bed at least 30
degrees.
3. Wash hands, don gloves, and organize supplies.
4. Verify gastric tube placement by aspirating gastric
contents and checking its pH level (this may be
difficult with small-bore duodenal tubes); or quickly
instill 20 ml air into the tube while auscultating for
gurgling sound over the gastric area.
5. Aspirate and measure gastric residual and re-
instill contents through tube; check physician’s
orders or follow unit policy regarding residual as the
determinant of whether to administer or avoid
feeding (commonly held if residual greater than 100
mL ); if feeding held due to excess gastric residual,
turn patient on right side and recheck residual in 30
to 60 minutes.
6. Prepare dietary formula; formula should be at
room temperature to prevent gastrointestinal muscle
cramping.
7. Place syringe barrel (with plunger removed) into
the end of the tube and slowly pour formula into the
barrel until it is almost full; regulate formula
administration rate by adjusting the height of the
syringe (typically held 6 to 8 inches above tube
insertion site). Allow formula to flow slowly by
gravity. Continue to add formula to the syringe barrel
until feeding is complete; to prevent entrance of air
into the stomach, do not allow the syringe to
completely empty.
8. Follow the feeding with water as ordered or 30 to
50 ml to flush the tube.
9. Clamp the tube and maintain elevation of the
head of the bed at least 30 degrees for 30 to 60
minutes following feeding to prevent aspiration.
10. Clean or dispose of equipment appropriately.
11. Wash hands.
12. After checking residual between bolus feedings, chance of organism growth and contamination
follow by using water to clear the tubing unless of feeding.
contraindicated
13. Monitor bowel sounds, bowel regularity, and
hydration on any patient receiving tube feedings. Colostomy Care
14.Document tube placement, gastric residual  
check, type and amount of feeding, and patient OSTOMIES – divert and drain fecal material/ bowel
tolerance resection
temporary ( trauma / inflammatory condition)
CONTINUOUS TUBE FEEDING permanent ( Cancer / congenital or Birth
  defects )
The feeding bag is hung on an IV pole about 12 Stoma – red, initial slight bleeding - normal, no
inches above the patient’s head if dietary formula is redness or irritation 2 to 5 inches surrounding the
delivered by gravity; the drop factor is regulated to area, no burning sensation
deliver the ordered rate of flow. If using a pump
designed for tube feedings, simply hang the bag Colostomy Ileostomy
above the pump. – can irrigate , can be – no irrigation , wet
1. For bolus feeding, follow steps 1 to 6 above. bowel trained , pouch fecal material ,
2. Pour no more than 1 can (240 mL) or may not be worn and appliance all the time ,
approximately 4 hours’ volume into the bag emptied after every meticulous skin care,
(bacterial growth is promoted when formula hangs defecation prevent skin
for prolonged periods at room temperature). Ascending colon breakdown, constant
3. Prime the tubing by allowing the formula to run colostomy: liquid stool flow not regulated, bag
through and expel air; clamp the tube and attach it to Transverse Colon emptied half full
the patient’s feeding tube. Colostomy: loose to semi  
4. Insert the bag’s tubing into the pump mechanism formed
and set pump to deliver appropriate volume; Descending Colon
unclamp the tubing and start the pump. Colostomy: close to
If using gravity delivery method, calculate the drip normal Stool
rate and regulate manually with the tubing clamp.  
5. Maintain elevation of head of bed at least 30
degrees while dietary formula infuses and for 30 to Monitor color changes in Healthy stoma is red: a
60 minutes thereafter, if feedings are stopped. the stoma: color change ( dark
6. Related care: Normal color : pink or red black to blue is
• Monitor bowel sounds, bowel regularity, and Pale pink : low hgb / hct notifeable)
hydration on any patient receiving tube feedings. Purple black: Stool is liquid
• Check tube placement at least once per shift. compromised circulation Post op drainage is
• Check gastric residuals every four hours during If pouch is not in place: dark green then yellow
continuous tube feedings; flush tube with water Place petroleum jelly as the client begins to
after checking residuals. gauze over the stoma to eat
• Replace bag and tubing every 24 hours or keep it moist followed by
according to agency policy to decrease a dry sterile dressing .
 Precautions  
 avoid gas forming foods and nuts , but can Types:
have any food at tolerated after 6 weeks… Cleansing Enema
yogurt recommended It irritates the colon producing peristalsis by
 dry skin before applying appliance distending the colon with volume fluid
 karaya – barrier to prevent contamination
with excreta High enema
 appliance can be up to 2 weeks ; 24-48 Target: colon
hours if eroded or ulcerated 1L of solution is introduced
with deodorant ( Charcoal filter Disk,
Bismuth ) Low enema
 refer to enterostomal therapy nurse for Target: rectum and sigmoid process
complications ½ L is administered
 
Carminative Enema
Enema Administration: Aims to expel flatus
  About 60mL to 180 mL of solution is administered
Enema is a solution introduced into the rectum and  
large intestines. Retention enema
Its aim is to distend the intestine and irritate the Uses oil based solution( which acts as stool
intestinal mucosa;stimulates peristalsis and softeners and facilitates passage of feces)
excretion of feces Administer oil into the rectum and sigmoid colon,
then the oil is retained for 1 – 3 hours
 
Non – retention Retention Enema: Return flow / colonic Irrigation
Enema: Aims to expel flatus
Fluids: Fluids: Uses an inflow – outflow process
tap water Carminative enema that is repeated 5 – 6 times
soap suds Oil (mineral , olive, Solution container is lowered so that
NSS cottonsee) the fluid backs out through the rectal tube
Hypertonic Fluids   into the container

Intravenous Therapy
Height of solution: Height of solution:  
18 inches above the 12 inches IV therapy is administering fluids / medications
rectum above the through a vein
rectum  
Purpose:
Position: Left Lateral ( adult) dorsal recumbent sustain clients who are unable to take foods/fluids
( child) via oral route
After administering the solutions, press buttocks used to replace fluids and electrolytes
together to prevent feces from expelling
For abdominal cramps: stop temporarily
provides vascular access for immediate or rapid
delivery of substances or medications especially in
emergency situation
 
Scope of Practice
Role Definition- the I.V nurses are registered nurse
committed to ensure the safety of all patients
receiving I.V Therapy

Ethico-legal Implications

The I.V nurse in compliance with PRC, Board of

Nursing Resolution No. 08 series of 1994 shall
uphold the Philippine Nursing Act of 1991, the
Nurse’s Code of Ethics and the established Nursing
Standards of Safe Nursing Practice

Basis of Practice
Legal therapeutic prescription of a licensed
physician. Thorough knowledge of the vascular
system, interrelatedness of the body system with
proficiency in the skill of the IV nurse.
Key points prior to initiation of I.V therapy

Physician’s prescribed treatment. The initiation of Patient assessment

intravenous therapy is upon the written prescription of a Factors to consider for IV Therapy
licensed physician which is checked for the following: duration of therapy
type and amount of solution cannula size
flow rate condition of the vein / skin
type, dose and frequency of medication to be type of solution
incorporated/push & others affecting the procedure (x- patient’s level of consciousness
ray,Tx of the extremities. patient’s activity
patient age
dominant arm
clinical status of patient
I.V set and equipment preparation
check for expiration date
check for clarity; any presence of holes on plaster cover (packaging); plastic container (bag) or presence of sediments or insect.
check labels against the physician’ order
label for any medication(s) that are added: date, time, medication and amount; compatibility of drug with the solution.
function ability of Infusion Pump,(Patient controlled analgesia )
▪ For Blood products, anesthetics : G 14,16,18 or 19 Drip Chambers
▪ For Standard IV fluid and clear liquid IV : G 22 or 24 Microdrip chambers
Type of Solution Fluid Uses
▪ For clients with small veins: G 24 - 25  Used if solution contains potent medication that needs to be titrated
   Used if fluidwill
Isotonic Solutions be saline
 0.9% infused( NS
at slow  
) rate ( about 50 mL per hour)
Filters Macrodrip Chambers
 5% dextrose in water  Supplies calories as
▪ Used to prevent particles from entering the client’s vein Drop factors varies from 10 – 20 drops/mL carbohydrates; prevents
( D5W)
▪ Needleless System  
   5% dextrose in 0.255% saline (5% D dehydration; maintains water
balance; promotes sodium diuresis
¼ NS)
 Lactated Ringers solution ( LR)
Hypotonic  0.45 Saline ( ½ NS)  Replaces fluid and electrolyte loss
Administration of Medications and IV solutions  0.25% Saline ( ¼ NS)
 0.33 % Saline (1/3 NS)
Types of IV solutions
Hypertonic  3% Saline ( 3% NS)  Replaces fluid and electrolyte loss
Isotonic  5% Saline ( 5% NS)
Isotonic fluids have an osmolality the same as that  10% Dextrose in water ( D10 W)
of blood; that is, about 310 mEq/L of total
electrolytes.  5% dextrose in 0.9% saline ( 5%
D/NS)
Hypotonic  5% Dextrose in 0.45% saline ( 5%
D/1/2 Solution
Colloid  Dextran  Maintains colloid osmotic
 Albumin pressure
Hypotonic fluids have an electrolyte content below
250 mEq/L. Lower osmalality than the body thus
causing movement of solutes into the cells by
osmosis
Used to prevent cellular edema

Hypertonic
Hypertonic fluids have an electrolyte content above
375 mEq/L. Higher osmolality than the body
Movement is from cell to extracellular compartment

Crytalloids
Used for fluid volume replacement
Contains mostly of electrolytes

Colloids
Or plasma expander Used in cases such as
severe hemorrhage and hypovolemia

 Flow rate: amount of fluid _ drop factor on tubing

box ÷ running time stated in total number of minutes
Infusion Sets / infusion pumps Bacteremic catheter related infection—is defined as
a positive blood culture with clinical or microbiologic
INFUSION TECHNIQUES evidence that strongly implicates the catheter as
source of infection.
CONTINUOUS;  
- Administration of a drug over a period of Cellulitis- Warm erythematous and often tender skin
several hours. surrounding the site of cannula insertion, pus is
rarely detectable.
INTERMITTENT:  
- Administration of medication in a relatively Purulent thrombophlebitis- warm, erythematous skin
short span. over an indurated or tender vein with purrulent
drainage from the cannula wound.Pus may drain
BOLUS: spontaneously or express by pressure.
- Medication given all at one time Through an  
existing port or lock. Infiltration – Edema, pain, and coolness at the site
  ( may not have back flow)
SECONDARY INFUSION:  
- Administration of a drug that has been Catheter Embolism – decrease in BP, pain along the
diluted in a small volume of IV solution, vein, weak and rapid pulse, cyanosis
usually over 30-60minutes. (Piggyback)  
Hang higher than Primary. Circulatory Overload – distented jugular vein, high
  Blood Pressure, dyspnea, moist cough and crackles
VOLUME CONTROL SET:  
- Chamber in IV tubing that holds a portion of Hematoma – ecchymosis, immediate swelling and
the solution from a larger container. Avoids leakage of blood at the site of insertion and painful
overloading Circulatory System. (Volutrol, lumps
Buretrol, Soluset.)
 
Air embolism – tachycardia, dyspnea, hypotension,
Selection of IV Site
cyanosis, decreased LOC
 Veins in the hands , forearm, antecubital ( most
suitable access)
 Veins in the lower extremities ( not suitable
because of high risk for embolism, pooling of
medication )
Veins in the scalps ( for infants)
 
Complications of IV Therapy
Local /Phlebitis- involves only the insertion site and
manifest as
pericatheter inflammation ; Warm erythematous skin
over an indurated or tender vein an often precedes
or is associated with more severe infections.
 
Administration of Blood and Blood 6. Check baseline vital signs (VS) and report any
Products abnormal findings to the physician before beginning
infusion of component.
Guidelines in Administering Blood and Blood 7. Warm blood in approved blood warmer for use in
Products: rapid transfusions or for neonatal exchange
  transfusions.
1. Verify physician’s order. 8. Ascertain that the IV line is present and not
2. Check expiration date on product. infiltrated before beginning infusion.
3. Verify accuracy of component with another 9. Flush any solution from present IV line with 0.9%
licensed nurse or physician. normal saline. (Flush again with saline after
completion of product.)
Types of Blood Products:
Contraindications :
Fresh Whole Blood—complete components
- Do not store blood products in nursing unit
Red Blood Cells
refrigerators. (Blood must be stored at a
Used to replace erythrocytes
temperature between 1° and 6°C.)
1 unit increases hgb by 1g/dl and hct by 2 – 3 %
- Do not use a blood filter for more than 6
after transfusion
hours nor administer more units than
White Blood Cells / Granulocyte Concentrate
recommended by the manufacturer.
Rarely used
- Do not heat blood products in a microwave
Platelets
oven. (Doing so could result in cellular
Used to treat thrombocytopenia
damage.)
Administered rapidly over 15 to 30 minutes
- Do not discontinue IV access if an
Fresh Frozen Plasma
undesirable reaction occurs.
Used to provide clotting factors or for volume
- Do not save blood administration tubing for
expanders
future use.
Albumin
10. Check manufacturer’s information before using
To maintain colloid osmotic pressure
any pump to administer product. (Some pumps may
4. Check patient’s ID band for proper identification. cause hemolysis of red cells.)
5. Explain procedure to patient and tell him or her to 11. Initiate infusion within 30 minutes from the time
report any unusual symptoms or sensations that the product is released from the blood bank.
may occur during infusion. 12. Remain with the patient for at least 5 minutes
after transfusion has begun.
Stop infusion of blood product, maintain IV access with 13. Check VS 15 minutes after product infusion has
0.9% normal saline, and notify the physician , send begun, then 15 minutes later, and at least every 30
blood and blood set to the lab and reasseintensive minutes until the infusion is completed.
monitoring if any of the following occurs: 14. Administer a maximum of 50 mL of product over
- Burning at injection site the first 15 minutes of transfusion.
15. Complete the infusion within a 4 hours..
- Pain in any area 16. Validate teaching, assessment (including VS),
- Flushing or rash product ID check, procedure (including time infusion
- Itching begun and completed), and reaction in the patient’s
- Fever record.
- Chills
TPN 6. Dressing changes are made on all
Total parenteral nutrition (TPN) is delivered via a catheters using sterile technique. (Both
central venous catheter to reverse starvation nurse and patient should wear a mask
and promote tissue synthesis, wound healing, during the procedure.)
and normal metabolic function.
TPN solutions are nutritionally complete, based on
ACCESS: the patient’s weight and caloric/nutrient needs.
peripheral< 2 weeks – phlebitis Content - mixture of:
PIC – Basilic / cephalic  dextrose (20 to 70 percent)
PCC – subclavian  amino acids
Triple Lumen- infuse and draw  multivitamins
blood;TPN;Medications  electrolytes, and trace elements.
Atrial- Hickman/Biovac and Groshong; Huber  Insulin is often added to the content as
needle port needed to control blood glucose.
   
Guidelines: Five hundred milliliters of 10 or 20 percent fat
1. Monitor the patient for infection. emulsion (lipids) is also administered to meet the
2. Maintain patency by flushing catheter patient’s remaining nutritional needs.
according to agency policy. Usually he
catheter is flushed with twice the TPN-AMINO ACID- TNA-TOTAL NUTRIENT
catheter volume of heparinized DEXTROSE- 2-3 L ADMIXTURE AMINO ACID,
saline at specified intervals, and all /24H – FINE DEXTROSE AND LIPIDS-1
medication dosages and blood sample BACTERIAL FILTER LITER /24 HOURS – NO FILTER
withdrawals are followed by saline and USED
heparin flushes.
3. The Groshong catheter is not flushed
DIRECT COMPLICATIONS:
with heparin because it has a valve that
hyperglycemia- hyperosmolar(HA, Nausea and
restricts blood backflow. Clamps should
Vomiting, fever, chills, malaise)
not be used on the Groshong as they
Infection ( IV tubing and filter Q24 changed,
may damage the catheter. This catheter
solutions refrigerated and warmed just prior to
is flushed, according to agency policy,
administration )
with 0.9% normal saline after
Pneumothorax ( dyspnea , ecchymosis, diminished /
medication administration and after
absent lung sound )
withdrawal of blood samples.
 
4. Central Venous Tunneled Catheters
( CVT) are catheters with single, double,
or triple lumens and can be used for
administering drugs, blood products,
and total parenteral nutrition as well as
for obtaining blood samples for lab
tests.
5. CVTCs can be used for months or years
if infection does not occur
INDIRECT COMPLICATION Pulmonary Volumes and Capacities:
Hypoglycemia
  Description Normal
 
Value
Guidelines:
Tidal Volume (VT) Volume inhaled and exhaled during normal quiet 500
1. Verify central line placement after initial
breathing
insertion via chest (radiograph) prior to
 
beginning ( pneumothorax or hemothorax is a
risk with central line placement.) Inspiratory Reserve Maximum amount of air that can be inhaled over 3100
2. Check vital signs (including blood pressure) at Volume ( IRV ) and above a normal breath
least every 6 hours after initiating infusion. Expiratory Reserve Maximum amount of air that can be exhaled 1200
3. Check central line insertion site frequently for Volume (ERV) following a normal breathing
signs of infection ( which may lead to sepsis)
4. Follow agency policy regarding frequency of Total Lung Capacity Total volume of the lungs at maximum inflation 6000
dressing changes and procedure. ( TLC ) TLC = (VT) + ( IRV ) + (ERV) + ( RV )
5. Change IV line setup every 24 hours. Residual Volume The amount of air remaining in the lungs after 1200
(TPN fluidsare an excellent medium for (RV ) maximal inhalation
bacterial growth.) Vital Capacity Total amount of air that can be inhaled after a 4800
6. Do not administer IV piggyback or direct IV push maximal inspiration;
medications through or draw blood samples VC = (VT) + ( IRV ) + (ERV)
from the TPN line. Only lipids may be
Inspiratory The volume left in the lungs after normal quiet 3600
“piggybacked” carefully through the TPN line
Capacity ( IC ) exhalation
beyond the in-line filter.
IC = (VT) +( IRV )
7. Monitor blood glucose every 6 hours; administer
Functional The volume left in the lungs after a normal 2400
sliding scale insulin as ordered.
RESIDUAL exhalation
8. Weigh patient daily. (High glucose content of
Capacity ( FRC ) FRC = ( ERV ) + ( RV)
TPN can cause an osmotic diuresis and lead to
dehydration.)
9. Order TPN solutions from the pharmacy in a O2 Therapy safety precautions:
timely manner; remove the next container from 1. NO Smoking
the refrigerator an hour before needed to 2. Avoid use of volatile and flammable
prevent central infusion of cold solutions. materials such as alcohol, oils,
  greases, ether and acetone
Oxygen Therapy
Indicated to clients who need additional oxygen,
those clients who have reduced lung diffusion of
oxygen through the respiratory membrane, heart
failure leading to inadequate transport of oxygen.
Postural Drainage
Drainage by gravity
Pre therapy:
Administer bronchodilator or nebulization therapy
Frequency: 2 – 3 times a day
Best time:
 Before breakfast
 Before lunch
 Before bedtime
CI: spinal cord injury
Sequence: Positioning, Percussion, Vibration, cough
/ suctioning
To drain the middle and lower portions of your lungs:
Positions:
1. If a hospital bed is available, put in
Trendelenburg position (head lower than
feet)
2. Place 3-5 wood blocks, that are 2 inches by
4 inches, in a stack that is 5 inches high,
under the foot of a regular bed. Blocks
should have indentations or a 1 inch rim on
top so that the bed does not slip
3. Stack 18-20 inches of pillow under hips.
4. Place on a tilt table, with head lower than
feet.
5. Lower head and chest over the side of the
bed.
6. To drain the upper portions of your lungs,
you should be in a sitting position at about a
45 degree angle.
7. Remain in each position approximately five
to ten minutes. Use suction or assisted
cough before changing position to insure
removal of any secretions drained while in
that position.
Incentive Spirometry:
Sustained maximal inspiration device
Measures the flow of air inhaled through the
mouthpiece
Used to expand collapsed alveoli loosen secretions
and improved pulmonary ventilation
Artificial Airway
Orophharyngeal and Nasopharyngeal Airway
 Devices that keeps the airway open / patent
 Oropharynheal airways stimulates gag reflex
and SHOULD only be used with altered LOC
 When inserting, hold it by the outer flange,
with distal end pointing up
 Should be inserted along the top of the
tongue with the distal end pointing up
 When the distal end reached the back of the
mouth, rotate airway 180 degress
downward, and slip it to the uvula into the
oral pharynx
 Suction and mouth care as needed
 Never tape the airway in place
 
Nasopharyngeal Airway
From the nose to the oropharynx
Frequents oral and nasal care
 
 
Endotracheal Tube
 Suction as needed to prevent pooling of
secretions and keep the airway patent
 Monitor cuff pressure ( should be 20 – 25
mm Hg or as recommended) to prevent
tracheal tissue necrosis
 Mouth care as needed
 Provide humidified oxygen
 Communicate frequently using pad and pen.
 ▪ If with mechanical vent ensure alarms are
functioning
 Tracheostomy
Surgical incision of the trachea which is used as a
long term airway support
Tracheostomy tube components:
 Outer cannula with flange
 Inner cannula
 Obturator
 Inflatable cuff( secures the placement of the tube)
 Tracheostomy tubes have an outer cannula with a
flange ( which rests on the neck) this allows the
tube to be secured in place with a tie / tape
 The obturator is used to insert the outer cannula
and then removed. This should remain at the
bedside incase the tube will be dislodged and needs
reinsertion
 NOTE: children donot require cuffed tubes
because their tracheas are resilient enough to seal
the air space around the tube
 
 
Tracheostomy care:
▪ Air is not filtered and humidified therefore, a mist
collar or a 4 ix 4 guaze may be held in place with a
cotton tie over the stoma to filter the air as it enters.
▪ tie new tie before removing the old tie to prevent
accidental dislodgement
▪ use precut gauze and perform care once a day at
least.
▪ soak inner cannula in antiseptic soak with
hydrogen peroxide, rinse well
▪ suction as needed and do oral care frequently
 
Suctioning
Aspiration of secretions through a catheter that is
connected to a suction machine or wall suction outlet
Catheters:
1. Open tipped
- Most effective in aspirating secretions
2. Whistle tipped
- Less irritating
Oral suctioning: Yankauer device / oral suction tube
Catheter have a thumb port which serves as a
controller when suctioning
 
Notes:
▪ NEVER suction more 10 – 15 seconds
▪ Use aseptic technique when suctioning
▪ HYPEROXYGENATE prior to suctioning
▪ Do oral care after suctioning
▪ DO NOT suction while inserting the catheter
▪  When u close the thumb port with your finger the
suctioning is done
▪  Open thumb port ( no suction is done)
▪  Suction in a circular manner/ by rotating catheter
( ensures all surfaces are reached and prevents
trauma)
▪  Apply intermittent suction on withdrawal of the
catheter
Urinary Catheterization
Procedure
1. Explain procedure to the patient.
2. Provide privacy.
3. Prepare trash receptacle.
4. Wash hands.
5. Position the female patient supine with knees
flexed; male patient supine with legs slightly
spread.
6. Place waterproof pad under buttocks.
7. Drape patient, diamond fashion, with sheet.
8. Arrange for adequate lighting.
9. Wash perineum with soap and water if soiled.
 10. Open kit using sterile technique. 1. Gather equipment.
11. Don sterile gloves. 2. Explain procedure to the patient.
12. Set up sterile field (off bed if the patient may 3. Wash hands and don gloves.
contaminate). 4. Place waterproof pad beneath the patient’s hips.
13. Test balloon if catheter will be indwelling. 5. Pour sterile normal saline into a sterile basin and
14. With nondominant hand, spread labia (female) draw into sterile irrigation syringe.
or retract foreskin (male). 6. Using aseptic technique, disconnect drainage
This hand is no longer sterile. Using provided tubing. (Avoid contaminating end of catheter tube or
antiseptic solution and cotton balls or swabs, drainage system.)
cleanse perineum (female) from clitoris toward anus 7. Instill 30 mL of solution into bladder.
with top-to-bottom motion or retract foreskin (male) 8. Allow irrigation solution to return by gravity.
and use circular motion from meatus
outward.Repeat this step at least three times. Chest Tube:
 
NOTE: Each swab is used only once and Types of Chest Tube Drainage System:
discarded into the trash receptacle, away from  
the sterile field. Simple drainage system
  a simple drainage system that can be connected to
15. Lubricate catheter. suction or to a Heimlich valve. The fluid-collection
16. Slowly insert catheter until urine is noted (2 to 3 bottle would have measurement markings on it to
inches for female or 7to 8 inches for male)For male help clinicians track the amount of fluid collected.
patient, hold penis perpendicular to body and pull up
gently during insertion.
17. Collect specimen if needed. Water Seal Drainage System
 18. Remove catheter if it is not indwelling.  addition of a water-sealed bottle to the simple
drainage system. This helps to stop the problem of
IF INDWELLING air moving back into the chest, and it also provides
19. Inflate balloon. If patient has sudden pain, greater capacity for the collection of blood or body
deflate balloon, then advance catheter slightly fluids without any clogging of the suction
and reinflate. outlet/connection.
20. Pull catheter gently to check adequacy of
balloon. Three-bottle drainage system.
21. Attach catheter to collection tubing if not already the system has a fluid-collection bottle and a water-
connected by manufacturer. sealed bottle, along with a pressure-regulating
22. Tape catheter to patient’s inner thigh. Allow slack bottle. This bottle helps the system maintain a
for patient movement. measured, constant negative pressure and negative
23. Discard gloves and equipment. flow.
24. Wash hands.
25. Document size and type of catheter inserted,
amount and appearance of urine, and patient’s
tolerance of procedure.

Catheter Irrigation:
Chest Tube care
1. Gather equipment and unwrap Pleur-Evac or
other closed-chest drainage apparatus.
2. Fill the water-seal chamber to the 2-cm level
according to manufacturer’s instructions
regardless of whether suction is to be used.
3. If suction is ordered, fill chamber to the ordered
level; typically 20 cm H2O.
4. Hang drainage unit from the bed frame
5. After chest tube insertion (by the physician) and
before tube clamp removal, attach drainage
unit to the tube.
6. Attach long (drainage unit) tube to suction source,
if ordered, and advance suction until gentle bubbling
occurs in suction-control chamber. Amount of suction
applied to the pleural space is determined by the
height of fluid in the suction-control chamber and not
the wall suction source.
 
MAINTENANCE
1. Note accumulated drainage in the collection
chamber at the start of each shift or more
frequently if warranted by patient condition, and
mark the date and time of observation on the
collection chamber.
2. Check the water-seal and suction-control fluid
levels at the start of each shift and replace water
as necessary;water will evaporate from the suction-
control chamber, especially with vigorous
bubbling.To check fluid levels,temporarily turn off
the wall suction.
3. Observe the water-seal chamber for fluctuations
(tidaling) that occur with the patient’s ventilations;
unless the patient is on a ventilator, the column of
fluid rises with inhalation and falls with exhalation.
4. Observe the water-seal chamber for bubbling.
Bubbling is normal on exhalation when the patient
has a pneumothorax; continuous bubbling indicates
an (abnormal) air leak in the system.
5. Maintain extra lengths of tubing by coiling it on the
bed in order to prevent dependent loops that may
slow/stop drainage.
6. If drainage slows or stops, gently “milk” the chest
tube from proximity to the patient toward the
collection chamber: to milk the tube, grasp and
squeeze it between the fingers and palm of one
hand; release and repeat with the other hand on the
next lower portion of the tube; continue toward the
Collection chamber, squeezing the tube with only
one hand at a time.
 
Do NOT strip the tube; stripping involves both hands
with one holding the tube while the other squeezes
and pulls toward the drainage chamber. (Stripping
greatly increases the negative pressure applied to
the pleural space and can cause tissue damage,
bleeding, and pain.)
7. Document system function, including time
initiated/ discontinued, type and amount of drainage,
patient respiratory status, details related to chest
dressing, and appearance of the tube insertion site.
8. Notes for safety:
• Maintain all connections in the system to
prevent inadvertent entrance of air into the
patient’s pleural space.
• Keep drainage unit below chest level.
• If drainage system is turned over or water seal
disrupted: re-establish water seal, assess the
patient’s condition, and encourage coughing and
deep breathing. If secretions were present in the
disrupted system, obtain a new system.
• If the drainage system is broken and no new
drainage system is immediately available, place
the end of the chest tube in a bottle of saline or
water and place the bottle below chest level,
encourage the patient to cough and deep
breathe, obtain a new drainage system, and
attach it to the patient’s chest tube.
ASEPSIS AND PERIOPERATIVE
NURSING
“Universal Precautions takes us back to the area
where presence of mind matters most, the Operating
Room. One of the highlights of the licensure
examination is perioperative nursing. In this chapter,
let us take a closer look on the standards of
perioperative nursing from admission until
discharge.”
ASEPSIS -Is the freedom from disease – causing
microorganism
9. Sterile instruments should be stored well,
and checked regularly
10. When opening a pack, the outer flap should
be opened away from you first
11. The outer pack of a double – wrapped
instrument is considered unsterile
12. Honesty and presence of mind should be of
greater value when maintaining sterility.

Types :

Medical Asepsis
All practices intended to confine a specific
microorganism to a specific area, limiting the
number, growth, and transmission
Clean and dirty technique

Surgical Asepsis
Sterile technique
All practices intended to keep an area or objects free
of all microorganism, and destroy all microorganism
 
PRINCIPLES OF ASEPTIC TECHNIQUE
1. Only sterile objects should be on the sterile
field
2. Things below the waist, above the head, and
out of vision are considered unsterile
3. There is a 1 by 1 inch border that is
considered unsterile in every sterile pack
4. If in doubt, consider it unsterile
5. Overexposed pack is already unsterile
6. Gravity may contaminate the sterile field
therefore AVOID overreaching
7. Moisture is a good medium for
contamination
8. Do not pour fluids on the sterile field
Standard Precaution HEAT AND COLD THERAPY
Promote hand washing , use of gloves, masks, eye An intervention that reduces inflammation
protection, and gowns when in contact with clients
 APPLIES TO: blood, all body fluids, secretions, non Principles:
intact skin , mucous membrane 1. Cold application is generally safer than heat
  application.
2. Heat application usually requires a doctor’s
 Standard Disease Ways of Protection order
plus + + + 3. Cold application is done within 72 hours
Airborne Measles - Room: negative Pressure after an injury, while heat application is done
Precaution Chicken Pox - Negative Airflow Pressure after 72 hours.
Varicella Zoster Virus - Door must be kept closed 4. The application of heat and cold is done at a
Tuberculosis - Use of high – efficiency maximum of 30 minutes (an average of 15-
particulate air filter In the 20 minutes)
room 5. Check the area of applications are done
- Use of mask every 15 minutes.
- Must be in a single room  
- Mask client when in contact with Wound Dressings
others and when leaving the room Purpose:
Droplet Adenovirus Use of mask ( also by the  Protect from injury and bacterial
Precaution Diphtheria patient especially when contamination
Epiglottitis leaving the room )  Maintain humidity
Influenza Room: private room or can be  For thermal insulation
Meningitis cohorted or grouped  Absorb drainage and at the same time
Mumps   debride the wound
Pertusis  Prevent hemorrhage
Pnuemonia  To splint and immobilize wound
Sepsis  Provide comfort
Rubella  
Contact MDR (multi drug room: private room or can be Wound Healing
Precaution resistant ) cohorted or grouped
Enteric Infections together Inflammation Phase
(e.g. clostridium use of GLOVES and GOWNS HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----(3-
difficile) 4DAYS)
Respiratory Syncytial
virus Proliferative Phase
Wound Infections FIBROBLAST—COLLAGEN---CAPILLARIES----
Skin infestations: GRANULATION TISSUE---ESCHAR---(3 – 21
Impetigo DAYS)
Pediculosis
Scabies Maturation Phase (21 DAYS – 2 YEARS)
Eye infections
conjunctivitis
Types of dressing:
Dry to Dry
Trap necrotic debris and exudate
Wet to Dry
Uses saline and anti microbial solution
this softens debris as it dries and dilute exudate
Wet to damp
Wound debrided if gauze is removed
Variation at drying
WOUND DEBRIDED IF GAUZE REMOVED
( VARIATION at DRYING)
Wet to Wet
Keeps wound moist ( wound is bathed )
Moisture dilutes viscous exudate
Notes:
- Use sterile gloves or clean gloves
- Use gauze pads (which may be lifted with
sterile forceps) to cleanse the wound with
prescribed antiseptic solution.
- Cleanse the wound from the center outward,
using a new gauze pad for each outward
motion.
- NOTE: Iodine solutions may cause skin
irritation if they are left on the skin between
dressing changes
- NOTE: “Wet-to-dry dressing change”
describes the technique of applying several
layers (the number of layers depends on the
size of the wound area and the patient) of
saline-soaked dressings next to the wound
and covering these with dry dressings.
 
PERIOPERATIVE NURSING
Perioperative - refers to the total span of surgical
intervention. Surgical intervention is a common
treatment for injury, disease, or disorder and has
three phases: preoperative, intraoperative, and
postoperative
PERIOPERATIVE NURSE - is a nurse who provides
patient care, manages, teaches, and studies the
care of patients undergoing operative or other
invasive procedures.
- Provides specialized nursing care to patients
before, during, and after their
surgical and invasive procedures
- Helps plan, implement, and evaluate treatment of
the patient
- Acts as a patient advocate for patients undergoing
surgical and invasive
procedures
- Works closely with all members of the surgical
team
CLASSIFICATIONS OF SURGERY
Reason/Purpose
Diagnostic- removal and examination of tissue
(e.g., biopsy).
Curative/Ablative-removal of a diseased organ or
structure (e.g. appendectomy).
Restorative - repair a congenitally malformed organ
or tissue. (e.g., harelip; cleft palate repair).
Palliative- relief of pain (for example, rhizotomy--
interruption of the nerve root between the ganglion
and the spinal cord).
Reconstructive- repair or restoration of an organ or
structure (e.g., colostomy; rhinoplasty, cosmetic
improvement).
Degree of Urgency  prior surgical experiences
Urgent – needs immediate interventions (positive/negative)
Elective- surgery that can be delayed  type of surgery
Optional – Patient may opt to have or not to have  location site
surgery
Nursing History
Degree of Risk  past & present
Major- requires hospitalization, is usually prolonged,  meds
carries a higher degree of risk, involves major body  diet
organs or life-threatening situations, and has the
 allergies (latex)
potential of postoperative complications.
 personal habits
 Minor- brief, carries a low risk, and results in few
complications  occupation
 finances
COMMON PSYCHOLOGICAL DISTRESS PRIOR  family support
TO SURGERY  knowledge of surgery
 Anxiety  attitude
 Loss of a body part.
 Unconsciousness and not knowing or being Physical Exam
able to control what is happening.
 Pain. Diagnostic tests
 Fear of death.  CBC
 Separation from family and friends.  Electrolytes
 The effects of surgery on his lifestyle at  Creatinine
home and at work.  Urinalysis
 Exposure of his body to strangers.  x-ray exams
 Fear of the unknown (Most common fear)  EKG
 Blood Type
PREOPERATIVE PHASE  PTT and PT
Begins when a decision for surgery is made until the  Platelet
client is admitted at the operating room.  Blood donations

PREOPERATIVE ASSESSMENT: PREOPERATIVE CHECKLIST

Risk Factors  History and physical examination
 Age  Name of procedure on surgical consent
 Nutritional and health status  Signed surgical consent
 fluid & electrolytes imbalances  Laboratory results
 radiation  Client is wearing an identification bracelet
 cardiopulmonary  Allergies have been identified
 chemotherapy  NPO
 meds  Skin preparation completed
 family history  Vital signs assessed
  Jewelry removed  Topical
 Dentures removed Anesthetic agents
 Client is wearing a hospital gown and  Xylocaine, Novocain, carbocaine
hair cover Topical
 Client has urinated  Dermoplast (benzocaine)
 Location of IV site, type of intravenous
solution, rate of infusion is identified ADJUNCTIVE ANESTHESIA
 The prescribed preoperative medication  Opioid analgesic
has been given Alfenta
Demerol and Morphine
PREOPERATIVE HEALTH TEACHINGS  Benzodiazepine
 leg and deep breathing exercises; ROM Valium, Versed
exercises  Anticholinergic
 Moving patient ; coughing and splinting  Atropine, scopolamine
 Preoperative medications : when they  Sedative-hypnotic
are given & their effects Atarax, Vistaril, Seconal, Nembutal
 Postoperative pain control
 Explanation & description of post NURSING RESPONSIBILITIES
anesthesia care recovery room 1. Geriatric concerns
2. Address safety issues - sensory decline
 Discussion of the frequency I assessing
3. Hepatic, cardiac respiratory and renal
V/S & use of monitoring equipments
decline
4. Assess for preexisting problems such as
PREOPERATIVE - ANESTHESIA cardiac, renal, hepatic, or respiratory.
Types
1. General
INTRAOPERATIVE PHASE
 The intraoperative phase is the period during which
2. Regional
the patient is undergoing surgery in the operating
3. Local
room. It ends when the patient is transferred to the
post-anesthesia recovery room.
General Anesthetics
 Inhaled General Anesthetics THE SURGICAL TEAM
 Nitrous oxide, cyclopropane
 Inhaled liquid A. The Surgeon
 halothane, enflurane, isoflurane The surgeon is the leader of the surgical team. The
 Intravenous Anesthetic surgeon is ultimately responsible for performing the
 Pentothal (thiopental) surgery effectively and safely; however, he is
Local/Regional dependent upon other members of the team for the
 Epidural patient's emotional well being and physiologic
 Infiltration monitoring.
 Nerve Block
 Spinal

B. Anesthesiologist/Anesthetist.
An anesthesiologist is a physician trained in the
administration of anesthetics. An anesthetist is a
registered professional nurse trained to administer
anesthetics. The responsibilities of the
anesthesiologist or anesthetist include:
(1) Providing a smooth induction of the patient's
anesthesia in order to prevent pain.
(2) Maintaining satisfactory degrees of relaxation
of the patient for the duration of the surgical
procedure.
(3) Continuous monitoring of the physiologic
status of the patient for the duration of the
surgical procedure.
(4) Continuous monitoring of the physiologic
status of the patient to include oxygen
exchange, systemic circulation, neurologic
status, and vital signs.
(5) Advising the surgeon of impending
complications and independently intervening as
necessary.
C. Scrub Nurse/Assistant.
The scrub nurse or scrub assistant is a nurse or
surgical technician who prepares the surgical set-up,
maintains surgical asepsis while draping and
handling instruments, and assists the surgeon by
passing instruments, sutures, and supplies. The
scrub nurse must have extensive knowledge of all
instruments and how they are used. The scrub nurse
or assistant wears sterile gown, cap, mask, and
gloves.
D. Circulating Nurse.
The circulating nurse is a professional registered
nurse who is liaison between scrubbed personnel
and those outside of the operating room. The
circulating nurse is free to respond to request from
the surgeon, anesthesiologist or anesthetist, obtain
supplies, deliver supplies to the sterile field, and
carry out the nursing care plan. The circulating nurse
does not scrub or wear sterile gloves or a sterile
gown. Other responsibilities include:
(1) Initial assessment of the patient on
admission to the operating room, helping
monitor the patient’s condition.
(2) Assisting the surgeon and scrub nurse to don
sterile gowns and gloves.
(3) Anticipating the need for equipment,
instruments, medications, and blood
components, opening packages so that the
scrub nurse can remove the sterile supplies,
preparing labels, and arranging for transfer of
specimens to the laboratory for analysis.
(4) Saving all used and discarded gauze
sponges, and at the end of the operation,
counting the number of sponges, instruments,
and needles used during the operation to
prevent the accidental loss of an item in the
wound.
MAJOR CLASSIFICATIONS OF ANESTHETIC
AGENTS
A. There are three major classifications of anesthetic
agents: general anesthetic, regional anesthetic, and
local anesthetic. A general anesthetic produces loss
of consciousness and thus affects the total person.
When the patient is given drugs to produce central
nervous system depression, it is termed general
anesthesia.
(A) General anesthesia is used for major head and
neck surgery, intracranial surgery, thoracic surgery,
upper abdominal surgery, and surgery of the upper
and lower extremities.
(1) There are three phases of general
anesthesia: induction, maintenance, and
emergence.
Induction, (rendering the patient
unconscious) begins with
administration of the anesthetic
agent and continues until the patient
is ready for the incision.
 Maintenance (surgical anesthesia)
begins with the initial incision and
 continues until near completion of
the procedure.
Emergence begins when the
patient starts to come out from
under the effects of the anesthesia
and usually ends when the patient
leaves the operating room. The
advantage of general anesthesia is
that it can be used for patients of
any age and for any surgical
procedure, and leave the patient
unaware of the physical trauma. The
disadvantage is that it carries major
risks of circulatory and respiratory
depression.
(2) Routes of administration of a general
anesthetic agent are:
rectal (which is not used much in
today's medical practices),
intravenous infusion, and
inhalation. No single anesthetic
meets the criteria for an ideal
general anesthetic. To obtain
optimal effects and decrease
likelihood of toxicity, administration
of a general anesthetic requires the
use of one or more agents. Often an
intravenous drug such as thiopental
sodium (Pentothal) is used for
induction and then supplemented
with other agents to produce
surgical anesthesia. Inhalation
anesthesia is often used because it
has the advantage of rapid excretion
and reversal of effects.
(3) Characteristics of the ideal general
anesthetic are:
(a) It produces analgesia.
(b) It produces complete loss of
consciousness.
(c) It provides a degree of muscle
relaxation.
(d) It dulls reflexes.
(e) It is safe and has minimal side
effects.
(B) A regional or block anesthetic agent causes
loss of sensation in a large region of the body. The
patient remains awake but loses sensation in the
specific region anesthetized. In some instances,
reflexes are lost also. When an anesthetic agent is
injected near a nerve or nerve pathway, it is termed
regional anesthesia.
(1) Regional anesthesia may be
accomplished by nerve blocks, or
subdural or epidural blocks
 
(a) Nerve blocks are done by
injecting a local anesthetic around a
nerve trunk supplying the area of
surgery such as the jaw, face, and
extremities.
(b) Subdural blocks are used to
provide spinal anesthesia. The
injection of an anesthetic, through a
lumbar puncture, into the
cerebrospinal fluid in the
subarachnoid space causes
sensory, motor and autonomic
blockage, and is used for surgery of
the lower abdomen, perineum, and
lower extremities. Side effects of
spinal anesthesia include headache,
hypotension, and urinary retention.
(c) Epidural block, the agent is
injected through the lumbar
interspace into the epidural space,
that is, outside the spinal canal.
 C)Local anesthesia is administration of an
anesthetic agent directly into the tissues. It may be
applied topically to skin surfaces and the mucous
membranes in the nasopharynx, mouth, vagina, or
rectum or injected intradermally.. Local infiltration is
used in suturing small wounds and in minor surgical
procedures such as skin biopsy. Topical anesthesia
is used on mucous membranes, open skin surfaces,
wounds, and burns. The advantage of local
anesthesia is that it acts quickly and has few side-
effects.
SELECTION OF AN ANESTHETIC AGENT
Depending on its classification, anesthesia produces
states such as narcosis (loss of consciousness),
analgesia (insensibility to pain), loss of reflexes, and
relaxation. General anesthesia produces all of these
responses. Regional anesthesia does not cause
narcosis, but does result in analgesia and reflex
loss. Local anesthesia results in loss of sensation in
a small area of tissue.
The choice of route and the type of anesthesia is
primarily made by the anesthetist or anesthesiologist
after discussion with the patient. Whether by
intravenous, inhalation, oral, or rectal route, many
factors effect the selection of an anesthetic agent:
 The type of surgery.
 The location and type of anesthetic agent
required.
 The anticipated length of the procedure.
 The patient's condition.
 The patient's age.
 The patient's previous experiences with
anesthesia.
 The available equipment.
 Preferences of the anesthesiologist or anesthetist
and the patient.
 The skill of the anesthesiologist or anesthetist.
Factors considered by the anesthetist or
anesthesiologist when selecting an agent are the
smoking and drinking habits of the patient, any
medications the patient is taking, and the presence
of disease. Of particular concern are pulmonary
function, hepatic function, renal function, and
cardiovascular function.
 Pulmonary function is adversely affected by upper
respiratory tract infections and chronic obstructive
lung diseases such as emphysema, especially when
intensified by the effects of general anesthesia.
These conditions also predispose the patient to
postoperative lung infections.
 
 Liver diseases such as cirrhosis impair the ability
of the liver to detoxify medications used during
surgery, to produce the prothrombin necessary for
blood clotting, and to metabolize nutrients essential
for healing following surgery.
 Renal insufficiency may alter the excretion of
drugs and influence the patient's response to the
anesthesia. Regulation of fluids and electrolytes, as
well as acid-base balance, may be impaired by renal
disease.
 Well-controlled cardiac conditions pose minimal
surgical risks. Severe hypertension, congestive heart
failure, or recent myocardial infarction drastically
increase the risks.
Medications, whether prescribed or over-the-counter,
can affect the patient's reaction to the anesthetic
agent, increase the effects of the anesthesia, and
increase the risk from the stress of surgery.
Medication is usually withheld when the patient goes
to surgery; but some specific medications are given
even then. For example, patients with cardiovascular
problems or diabetes mellitus may continue to
receive their prescribed medications.
(1) Because some medications interact adversely
with other medications and with anesthetic agents,
preoperative assessment should include a thorough
medication history. Patients may be taking
medication for conditions unrelated to the surgery,
and are unaware of the potential for adverse
reactions of these medications with anesthetic
agents.
(2) Drugs in the following categories increase
surgical risk.
(a) Adrenal steroids--abrupt withdrawal may
cause cardiovascular collapse in long-term
users.
(b) Antibiotics--may be incompatible with
anesthetic agent, resulting in untoward
reactions. Those in the mycin group may
cause respiratory paralysis when combined
with certain muscle relaxants used during
surgery.
 (c) Anticoagulants--may precipitate Anesthesia impairs the patient's ability to respond to
hemorrhage. environmental stimuli and to help himself. An
(d) Diuretics--may cause electrolyte artificial airway is usually maintained in place until
(especially potassium) imbalances, resulting reflexes for gagging and swallowing return. When
in respiratory depression from the the reflexes return, the patient usually spits out the
anesthesia. airway. Position the unconscious patient with his
(e) Tranquilizers--may increase the head to the side and slightly down. This position
hypotensive effect of the anesthetic agent, keeps the tongue forward, preventing it from
thus contributing to shock. blocking the throat and allows mucus or vomitus to
drain out of the mouth rather than down the
REASONS FOR SURGICAL INTERVENTION respiratory tree. Do not place a pillow under the
Descriptors used to classify surgical procedures head during the immediate postanesthetic stage.
include ablative, diagnostic, constructive, Patients who have had spinal anesthetics usually lie
reconstructive, palliative, and transplant. These flat for 8 to 12 hours. The return of reflexes indicates
descriptors are directly related to the reasons for that anesthesia is ending. Call the patient by name
surgical intervention: in a normal tone of voice and tell him repeatedly that
 To cure an illness or disease by removing the the surgery is over and that he is in the recovery
diseased tissue or organs. room.
 To visualize internal structures during diagnosis. (2) To relieve the patient's discomfort. Pain is usually
 To obtain tissue for examination. greatest for 12 to 36 hours after surgery, decreasing
 To prevent disease or injury. on the second and third post-op day. Analgesics are
 To improve appearance. usually administered every 4 hours the first day.
 To repair or remove traumatized tissue and Tension increases pain perception and responses,
structures. thus analgesics are most effective if given before the
 To relieve symptoms or pain. patient's pain becomes severe. Analgesics may be
Recovery Room Care administered in patient controlled infusions.
The postoperative phase lasts from the patient's (3) Early detection of complications. Most people
admission to the recovery room through the recover from surgery without incident. Complications
complete recovery from surgery. or problems are relatively rare, but the recovery
  room nurse must be aware of the possibility and
THE RECOVERY ROOM clinical signs of complications.
a. The recovery room is defined as a specific nursing (4) Prevention of complications. Complications that
unit, which accommodates patients who have should be prevented in the recovery room are
undergone major or minor surgery. Following the respiratory distress and hypovolemic shock.
operation, the patient is carefully moved from the
operating table to a wheeled stretcher or bed and The difference between the recovery room and
transferred to the recovery room. The patient usually surgical intensive care are:
remains in the recovery room until he begins to (1) The recovery room staff supports patients for a
respond to stimuli. General nursing goals of care for few hours until they have recovered from
a patient in the recovery room are: anesthesia.
(1) To support the patient through his state of (2) The surgical intensive care staff supports
dependence to independence. Surgery traumatizes patients for a prolonged stay, which may last 24
the body, decreasing its energy and resistance. hours or longer.

RESPIRATORY DISTRESS
Respiratory distress is the most common recovery
room emergency. It may be caused by
laryngospasm, aspiration of vomitus, or depressed
respirations resulting from medications.
(1) A laryngospasm is a sudden, violent contraction
of the vocal cords; a complication which may happen
after the patient’s endotracheal tube is removed.
During the surgical procedure with general
anesthesia, an endotracheal tube is inserted to
maintain patent air passages. The endotracheal tube
may be connected to a mechanical ventilator. Upon
completion of the operation, the endotracheal tube is
removed by the anesthesiologist or anesthetist and
replaced by an oropharyngeal airway (figure 8-4).
 
 
Oropharyngeal airway.
(2) Swallowing and cough reflexes are diminished by
the effects of anesthesia and when secretions are
retained. To prevent aspiration, vomitus or
secretions should be removed promptly by suction.
(3) Ineffective airway clearance may be related to
the effects of anesthesia and drugs that were
administered before and during surgery. If possible,
an unconscious or semiconscious patient should be
placed in a position that allows fluids to drain from
the mouth.
b. After removal of the endotracheal tube by the
anesthesiologist or anesthetist, an oropharyngeal
airway is inserted to prevent the tongue from
obstructing the passage of air during recovery from
anesthesia. The airway is left in place until the
patient is conscious.
 
POSTOPERATIVE PATIENT CARE ACCORDING
TO BODY SYSTEM
Respiratory System
The cough reflex is suppressed during surgery and
mucous accumulates in the trachea and bronchi.
After surgery, respiration is less effective because of
the anesthesia and pain medication, and because
deep respirations cause pain at the incision site. As
a result, the alveoli do not inflate and may collapse,
and retained secretions increase the potential for
respiratory infection and atelectasis.
 
Turn the patient as ordered.
Ambulate the patient as ordered.
If permitted, place the patient in a semi-Fowler's
position, with support for the neck and
shoulders, to aid lung expansion.
Reinforce the deep breathing exercises the patient
was taught preoperatively. Deep breathing
exercises hyperventilate the alveoli and prevent
their collapse, improve lung expansion and
volume, help to expel anesthetic gases and
mucus, and facilitate oxygenation of tissues. Ask
the patient to:
(a) Exhale gently and completely.
(b) Inhale through the nose gently and
completely.
(c) Hold his breath and mentally count to
three.
(d) Exhale as completely as possible
through pursed lips as if to whistle.
(e) Repeat these steps three times every
hour while awake.
Coughing, in conjunction with deep breathing, helps
to remove retained mucus from the respiratory
tract. Coughing is painful for the postoperative
patient. While in a semi-Fowler's position, the
patient should support the incision with a pillow
or folded bath blanket and follow these
guidelines for effective coughing:
 (a) Inhale and exhale deeply and slowly
through the nose three times.
(b) Take a deep breath and hold it for 3
seconds.
(c) Give two or three "hacking" coughs while
exhaling with the mouth open and the
tongue out.
(d) Take a deep breath with the mouth open.
(e) Cough deeply once or twice.
 (f) Take another deep breath.
(g) Repeat these steps every 2 hours while
awake.
An incentive spirometer may be ordered to help
increase lung volume, inflation of alveoli, and
facilitate venous return. Most patients learn to
use this device and can carry out the procedure
without a nurse in attendance. Monitor the
patient from time to time to motivate them to use
the spirometer and to be sure that they use it
correctly.
(a) While in an upright position, the patient
should take two or three normal breaths,
then insert the spirometer's mouthpiece into
his mouth.
(b) Inhale through the mouth and hold the
breath for 3 to 5 seconds.
(c) Exhale slowly and fully.
(d) Repeat this sequence 10 times during
each waking hour for the first 5 post-op
days. Do not use the spirometer immediately
before or after meals.
 
Cardiovascular System
Venous return from the legs slows during surgery
and may actually decrease in some surgical
positions. With circulatory stasis of the legs,
thrombophlebitis and emboli are potential
complications of surgery. Venous return is increased
by flexion and contraction of the leg muscles.
To prevent thrombophlebitis, instruct the patient to
exercise the legs while on bedrest. Leg exercises
are easier if the patient is in a supine position with
the head of the bed slightly raised to relax abdominal
muscles. Leg exercises (figure 8-8) should be
individualized using the following guidelines.
(a) Flex and extend the knees, pressing the
backs of the knees down toward the
mattress on extension.
(b) Alternately, point the toes toward the chin
(dorsiflex) and toward the foot of the bed
(plantar flex); then, make a circle with the
toes.
(c) Raise and lower each leg, keeping the
leg straight.
(d) Repeat leg exercises every 1 to 2 hours.
Ambulate the patient as ordered.
(a) Provide physical support for the first
attempts.
(b) Have the patient dangle the legs at the
bedside before ambulation.
(c) Monitor the patient's blood pressure
while he dangles.
 (d) If the patient is hypotensive or
experiences dizziness while dangling, do not
ambulate. Report this event to the
supervisor.
 
 
Urinary System
Patients who have had abdominal surgery,
particularly in the lower abdominal and pelvic
regions, often have difficulty urinating after surgery.
The sensation of needing to urinate may temporarily
decrease from operative trauma in the region near
the bladder. The fear of pain may cause the patient
to feel tense and have difficulty urinating.
1. If the patient does not have a catheter, and has
not voided within eight hours after return to the
nursing unit, report this event to the supervisor.
2. Palpate the patient's bladder for distention and
assess the patient's response. The area over the
bladder may feel rounder and slightly cooler than the
rest of the abdomen. The patient may tell you that he
feels a sense of fullness and urgency.
3. Assist the patient to void.
(a) Assist the patient to the bathroom or provide
privacy.
(b) Position the patient comfortably on the bedpan or
offer the urinal.
4. Measure and record urine output. If the first urine
voided following surgery is less than 30 cc, notify the
supervisor.
5. If there is blood or other abnormal content in the
urine, or the patient complains of pain when voiding,
report this to the supervisor.
6. Follow nursing unit standing operating procedures
(SOP) for infection control, when caring for the
patient with a Foley catheter.
 
Gastrointestinal System
Inactivity and altered fluid and food intake during the
perioperative period alter gastrointestinal activities.
Nausea and vomiting may result from an
accumulation of stomach contents before peristalsis
returns or from manipulation of organs during the
surgical procedure if the patient had abdominal
surgery.
1. Report to the supervisor if the patient complains of
abdominal distention.
2. Ask the patient if he has passed gas since
returning from surgery.
3. Auscultate for bowel sounds. Report your
assessment to the supervisor, and document in
nursing notes.
4. Assess abdominal distention, especially if bowel
sounds are not audible or are high-pitched,
indicating an absence of peristalsis.
5. Provide privacy so that the patient will feel
comfortable expelling gas.
6. Encourage food and fluid intake when the patient
in no longer NPO.
7. Ambulate the patient to assist peristalsis and help
relieve gas pain, which is a common postoperative
discomfort.
8. Instruct the patient to tell you of his first bowel
movement following surgery. Record the bowel
movement on the intake and output (I&O) sheet.
9. If nursing measures are not effective, the doctor
may order medication or an enema to facilitate
peristalsis and relieve distention. A last measure
may require the insertion of a nasogastric or rectal
tube.
10. Document nursing measures and the results in
the nursing notes.
 
Integumentary System
wound irrigations and cultures. In addition to
assessment of the surgical wound, you should
evaluate the patient's general condition and
laboratory test results.
complains of increased or constant pain from the
wound,
wound edges are swollen or purulent drainage, .
Generalized malaise, increased pain, anorexia, and
an elevated body temperature and pulse rate are
indicators of infection.
 
further assessment should be made and your
findings reported and documented.Important
laboratory data include an elevated white blood cell
count and the causative organism if a wound culture
is done.
Staples or sutures are usually removed by the doctor
using sterile technique. After the staples or sutures
are removed, the doctor may apply Steri-Strip® to
the wound to give support as it continues to heal.
 
There are two methods of caring for wounds: the
open method, in which no dressing is used to cover
the wound, and the closed method, in which a
dressing is applied.
The basic objective of wound care is to promote
tissue repair and regeneration, so that skin integrity
is restores.
(a) Advantages. Dressings absorb drainage, protect
the wound from injury and contamination, and
provide physical, psychological, and aesthetic
comfort for the patient.
(b) Disadvantages. Dressings can rub or stick to the
wound, causing superficial injury. Dressings create a
warm, damp, and dark environment conducive to the
growth of organisms and resultant infection.
 First, gather needed supplies. Items may be
packaged individually or all necessary items
may be in a sterile dressing tray.
 Next, prepare the patient for the dressing change
by explaining what will be done, providing
privacy for the procedure, and assisting the
patient to a position that is comfortable for him
and for you.
 Finally, use appropriate aseptic techniques when
changing the dressing and follow precautions for
contact with blood and body fluids. .
 It is especially important to wash hands thoroughly
before and after changing dressings and to
follow the Center for Disease Control (CDC)
guidelines.
 
Precautions for Contact with Blood and Body
Fluids
1. Wear gloves when touching blood, body
fluids containing visible blood, an open
wound, or non-intact skin of all clients and
when handling items or surfaces soiled with
blood or body fluids.
2. Wash hands thoroughly after removing
gloves and if contaminated with blood or
with body fluids that contain visible blood.
3. Take precautions to prevent injuries by
needles, sharp instruments, or sharp
devices.
4. Do not give direct client care if you have
open or weeping lesions or dermatitis.
5. If procedures commonly cause droplets or
splashing of blood or body fluids to which
universal precautions apply, wear gloves, a
surgical mask, and protective eyewear, as
appropriate.
GENERAL POSTOPERATIVE NURSING
IMPLICATIONS
1. Monitor vital signs as ordered.
2. Report elevated temperature and rapid/weak
pulse immediately to supervisor (infection).
3. Report lowered blood pressure and increased
pulse to supervisor (hypovolemic shock).
4. Administer analgesics as ordered.
Apply all nursing implications related to the patient
receiving analgesics whether narcotic or
nonnarcotic, to include the following.
 Check each medication order against the
doctor's order.
 Prepare the medications (check labels,
accurately calculate dosages, observe
proper asepsis techniques with needles and
syringes).
 Check the patient's identification wristband
to ensure positive identification before
administering medications.
 Administer the medications. Offer each drug
separately if administering more than one
drug at the same time.
 Remain with the patient and see that the
medication is taken. Never leave
medications at the bedside for the patient to
take later.
 Document the medications given as soon as
possible.
6. Administer IV fluids as ordered. Maintain and
monitor all IV sites. Follow SOP for infection control.
7. Participate with the health team in the patient's
nutrition therapy.
8. Apply all nursing implications related to the patient
diets (serving, recording intake, and food tolerance).
9. Coordinate with team leader for "take-home"
wound care supplies and prescriptions for self-
administration.
Prepare the patient and the family for disposition
(transfer, return to duty, discharge). Supply the
patient or family member with written instructions for:
10. Document the patient's disposition in the nurse's
notes in accordance with unit SOP.
PROVISION OF SAFETY
 
Safety in emergency
“Nurses are known to work best under pressure. In
this Chapter, Provisions of safety, and emergency
management of client’s in biologic crisis will be
comprehensively reviewed. A system not only
applicable in the examination, but also in the actual
clinical experience”
 
FIRE
 
Fire:
RACE:
R – Rescue ( remove clients from the utility )
A – Alarm ( Activate Fire alarm. Then report fire)
C – Confine ( close doors to confine fire )
E – Extinguish ( use extinguisher if available )
Extinguisher: PASS
P – Pull the pin while holding the extinguisher upright
A – Aim nozzle at the Base of the fire
S – Squeeze the handle firmly
S – sweep the fire
 Do not use elevator
 Turn of oxygen and appliances
 For patients with mechanical Ventilation , do
ambubagging
 Observe proper transfer techniques for non
ambulatory patients
Electrical
Safety:
avoid overloading any circuit
Read warning labels on all equipment
Radiation
Safety:
Label potentially radioactive material
Principle:
Distance: keep distance of at least 3 feet
Time: limit time when doing nursing procedures
and communicating with patient ( 5 minutes per
contact; total of 30 minute per shift)
Shield : use LEAD apron
Never touch radiation implants with bare hands ( use
forceps and put in a lead container)
Falls
To prevent falls:
1. Provide adequate lightning
2. Eliminate clutter and obstruction in the room
3. Personal items should be within reached
4. Lock all beds , wheelchairs and stretchers
5. Keep bed in low position with side rails up.
Restraints
 A protective device used to limit physical
activity of a client or a body part
 Used to immobilize an extremity or
extremities
Types:
Physical – involves manual or physical or
mechanical device, material or equipment
Chemical – use of medications ( e. g. Nueroleptics,
sedatives, anxiolytics )
Legal Implication:
2 standards for applying restraints:
1. Behavior management standard: if
client is a danger to self or others
2. Medical Surgical Care Standard: if it
is related to any procedure
The nurse will apply the restraints BUT the physician
must see the client WITHIN 1 HOUR for evaluation.
Or a written order must be obtained within 24 hours
The written order, after the evaluation is VALID for 4
HOURS
 Wrist or ankle restraint
Vest Restraint
Medical surgical Standard allows until 12 hours for
the physician to write the written order Category:
 
Key Points: 1. Emergent: Conditions that are life threatening and
 Orders must be renewed daily require immediate attention.
 Ensure that the restraints allow some Examples: Cardiopulmonary arrest, pulmonary
movement of the body part edema, chest pain of cardiac origin, and multisystem
 Nuerovascular and Circulatory assessment trauma. These patients frequently arrive by
should be checked every 30 minutes and ambulance.
restraints must be removed every 2 hours to Treatment must be immediate.
4 hours ( or according to hospital policy)  
  Permission of the client or the family Is 2. Urgent: Conditions that are significant medical
required problems and require treatment as soon as possible.
 A restraint must never be applied as a Vital signs are stable.
punishment for any behavior or merely for Examples: fever, simple lacerations, uncomplicated
the nurse’s convenience extremity fractures, significant pain, and chronic
 Pad bony prominence before applying illnesses such as cancer or sickle cell disease.
restraints Treatment may be delayed for several hours if
necessary.
 Never tie the ends to the side rails or to the
 
fixed frame of the bed
3. Nonurgent: Minor illnesses or injuries such as
 Never leave the patient unattended when
rashes, sore throat, or chronic low back pain. Waist Restraint
restraints are removed temporarily
Treatment can be delayed indefinitely
 
Kinds of Restraints
Adults:
 Jacket Restraints
 Belt Restraints
 Mitt or hand Restraints
 Limb Restraints
Infants and Children
 Mummy restraints and Crib Nets Restraints CPR Guidelines
 Elbow Restraints
  Age Cardiac Method Depth Compression Ventilation: Cycles /
Compression (rate / Compression minute
Location minute) Ratio
CLIENTS IN BIOLOGIC CRISIS Neonate Center 2 fingers 1/2–1 120    
sternum
AND FIRST AID Infant <1 Center 2 fingers 1/2–1 100 1:5 20
  yr sternum
Emergency Triage Child 1– Center 1 hand 1–1 ½ 100 1:5 20
The purpose of triage is to classify severity of illness 8 yr sternum (heel)
or injury and determine priority needs for efficient
Adult Lower half, 2 hands 1 1/2–2 100 2 : 30 5
use of health care providers and resources.
sternum
Trauma in Emergency Setting

PRIMARY SURVEY

1. Airway maintenance with cervical spine

immobilization:
Use jaw thrust, clear secretions, and insert artificial
airway as needed.
2. Breathing:
Intubate if needed. Administer high-flow oxygen.
3. Circulation with hemorrhage control:
Use pressure as needed, establish two large-bore
IVs, and draw blood for cross-match.
4. Neurologic status:
Assess and document LOC, assess pupil reaction to
light, and assess for head and neck injuries.
5. Injuries:
Expose patient to completely assess for injuries.
 
As life-threatening problems are identified, each
must be dealt with immediately.
 
 
SECONDARY SURVEY Predictable Injury in a Trauma Patient:
The secondary survey consists of a history and a
complete head-to-toe assessment. The purpose Trauma Injuries
of the survey is to identify problems that may not Pedestrian hit by car Head, chest, abdominal injuries fractures of
have been identified as life threatening. If, at any femur, tibia, and
time during the secondary survey, the patient’s fibula on side of impact
condition worsens, return to the steps in the
primary survey. Pedestrian hit by large Pelvic fractures
1. Take history and complete head-to-toe vehicle or dragged under
assessment. vehicle
2. Splint fractures.
3. Insert urinary catheter unless there is gross blood Front seat occupant (lap Head, face, chest, ribs, aorta, pelvis, and lower
at meatus. and shoulder abdomen
4. Assess urinary output and check urine for blood. restraint worn)
Insert NG tube (OG if facial fractures are involved).
6. Obtain Chest X - ray Front seat occupant (lap Cervical or lumbar spine, laryngeal fracture,
7. Administer tetanus prophylaxis (see Tetanus restraint only) head, face,
Prophylaxis) and antibiotics (question regarding chest, ribs, aorta, pelvis, and lower abdomen
allergies first) if indicated.
8. Continue to monitor components under primary Unrestrained driver Head, chest, abd, pelvis
survey as well as adequacy of urine output, and
document findings.
 
Front seat passenger Fractures of femurs and/or patellas, posterior
(unrestrained, dislocation of acetabulum
head-on collision)

Back seat passenger Hyperextension of neck with associated high

(without head restraints, cervical
rear-end collision) fractures

Fall injuries with Compression fractures of lumbosacral spine and

landing on feet fractures of calcaneus (heel bone)
 
Medical Emergencies
Increased intracranial Pressure
Increased intracranial pressure (ICP) is defined as
intracranial pressure above 15 mm Hg. It can result
from head injury, brain tumor, hydrocephaly,
meningitis, encephalitis, or intracerebral
hemorrhage.
 
MANIFESTATIONS OF INCREASED ICP
• Headache
• Change in level of consciousness
• Irritability
• Increased systolic BP
• Decreased HR (early)
• Increased HR (late)
• Decreased RR
• Hemiparesis
• Loss of oculomotor control
• Photophobia (light sensitivity)
• Vomiting (with subsequent decreased
headache)
• Diplopia (double vision
• Papilledema (optic disk swelling)
• Behavior changes
• Seizures
· Bulging fontanel in infants
MANAGEMENT OF INCREASED ICP
Increased ICP should be treated as a medical
emergency
1. Elevate head of bed 15 to 30 degrees. Keep
head in neutral alignment. Do not flex or rotate
neck.
2. Establish IV access.
3. Insert Foley catheter. (Output may be
profound if diuretic is given.)
4. Meds that may be used include osmotic
diuretics, sedatives, neuromuscular blocking
agents, corticosteroids, and anticonvulsants.
5. Restrict fluids.
6. Closely monitor vital signs and perform neuro
checks. Monitor fluids and electrolytes (diuretic
administration can predispose the patient to
hypovolemic shock).
7. Schedule all procedures (including
bathing and especially suctioning) to
coincide with periods of sedation.
8. Discourage patient activities that result in
use of Valsalva’s maneuver.
9. Keep environment as quiet as possible.
10. Ventilator may be used to maintain
PaCO2 between 25–35.
11. Ventricular tap may be performed if
unresponsive to other measures.
12. ICP monitoring via a fiberoptic catheter
may be used to continuously assess
changes in ICP.
 
Rigid Postures (with Neurological Conditions):
Medical Emergency:
 
Decorticate rigidity
Decorticate rigidity: Flexion of the arm, wrist, and fingers, with
adduction of upper extremities. Extension, internal rotation, and
vigorous plantar flexion of lower extremities indicate lesion in
cerebral hemisphere, basal ganglia, and/or diencephalon or
metabolic depression of brain function.
Decerebrate rigidity
Decerebrate rigidity: Arms are stiffly extended, adducted,
and hyperpronated. Legs and feet are stiffly extended with
feet plantar flexed. Teeth may be clenched (may be seen
with opisthotonos). Indicates brain stem pathology and
poor prognosis.
Opisthotonos
Opisthotonos: Rigid hyperextension of the spine. The head and
heels are forced backward and the trunk is pushed forward.
Seen in meningitis, seizures, tetanus, and strychnine
poisoning.
SEIZURES: SHOCK
EMERGENCY CARE OF PATIENT DURING  
SEIZURE ACTIVITY Type Description Causes Signs and treatment
1. If the patient is standing or sitting when seizure Symptoms
begins, ease him or her to the floor to prevent fall. Anaphylactic Dilation of blood Allergic reaction Respiratory O2
2. Move furniture and other objects on which the shock vessels, fluid distress Epinephrine
patient may injure himself or herself during shifts, edema, Hypotension Corticosteroids
uncontrolled movements. and spasms of Edema Antihistamine
3. Do not put objects (e.g., tongue blades, respiratory Rash IV fluids
depressors) into the patient’s mouth. tract. Pale, cool Aminophylline
4. After the seizure, turn the patient to the side and skin
ascertain patency of airway. Convulsions
5. Allow the patient to rest or sleep without possible
disturbance
Cardiogenic Failure to Acute left or right Increased IV fluids
shock maintain ventricular failure pulse rate O2
What to document after seizure:
blood supply to Acute mitral Weak pulses Dopamine
 Presence of aura circulatory regurgitation Cardiac Norepinephrine
 Circumstances in which the seizure activity system and Acute ventricular dysrhythmias Nitroprusside if
occurred tissues because septal defect Prolonged BP
 Time of the onset of seizure activity of inadequate Acute pericardial capillary fill adequate
 Muscle groups involved (and whether cardiac output. tamponade time Dobutamine
unilateral or bilateral) Acute pulmonary Cool, clammy
 Total duration of seizure activity embolism skin
 VS Acute myocardial Cyanosis
 Behavior after seizure Infarction Altered
 Injury mental ability
 
 Type Description Causes Signs and Symptoms treatment
Hypovolemic Decrease in intravascular Hemorrhage Hypotension Control bleeding
shock volume relative to vascular capacity. Results from Vomiting Decreased pulse pressure IV fluids (Replace
blood volume deficit of at least 25% and larger Diarrhea Tachycardia type F&E lost if
interstitial fluid deficit. Any excess loss Rapid respiratory rate known.)
of body fluids Pale, cool skin O2
Anxiety Elevate legs
Volume expanders
Neurogenic Increase in vascular Anesthesia Hypotension Supine position
shock capacity and subsequent decrease in blood Spinal cord injury Bradycardia O2
volume: space ratio resulting from profound Bounding pulse IV fluids
vasodilation. Pale, warm, and dry skin Possibly
Vasopressors
Septic shock Circulatory failure and impaired cell metabolism Endotoxins released Elevated temperature O2
associated with most commonly by Flushed, warm skin IV fluids
septicemia. Divided into “early warm” (increased gram-negative Vasodilation (early) Culture, e.g., blood,
cardiac output) and “later cold” (decreased organism Vasoconstriction (late) urine, sputum,
cardiac output). Decreased WBC at first wounds.
Normal urinary output (early) Antibiotics
Decreased urinary output(late) Possibly
vasopressors

FRACTURES First Aid Management

  Assess and document:
Signs and Symptoms Alignment
 Obvious deformity (in alignment, contour, or Warmth
length) Tenderness
 Local and/or point tenderness that increases Sensation
in severity until splinting Motion
 Localized ecchymosis Circulatory status distal to injury
 Edema Intactness of skin
 Crepitus (grating sound) on palpation Cover open fractures with a sterile dressing.
 False movement (unnatural movement at Remove rings from fingers immediately if upper
fracture site) extremity is involved. (Progressive swelling may
make it impossible to remove rings without cutting).
 Loss of function related to pain
Splint injured extremity.
 
Never attempt to force bone or tissue back into
wound.
Elevate injured extremity and apply ice (do not
apply ice directly to skin).
 Assess for and document frequently the five BURNS
Ps:
 
Pain
Pulselessnes
Pallor
Paralysis
Paresthesia (e.g., numbness, burning,
tingling)
 
TYPES OF FRACTURES
 
 Classification Description
1st Degree Burn involves epidermis only
Erythematous and painful skin
Looks like sunburn
2nd Degree Burn Superficial partial thickness
Extends beyond epidermis superficially into dermis
Red and weepy appearance
Very painful
Formation of blisters
Deep partial thickness
Extends deep into dermis
May appear mottled
Dry and pale appearance
3rd Degree ( Full Extends through epidermis, dermis, and into
Thickness ) subcutaneous
tissues
• Dry, leathery appearance
• May be charred, mottled, or white
• If red, will not blanch with pressure
• Painless in the center of the burn

 American Burn Asso. Classification of Burns:

Minor Second-degree burns over _15% BSA (body
surface area) for adult or < 10% BSA for child
• Third-degree burns of 2%
Moderate Second-degree burns over 15 to 25% BSA for adult
or 10 to 20% BSA for child
• Third-degree burns of 2% to 5% BSA
• Burns not involving eyes, ears, face, hands, feet,
or perineum
Major Second-degree burns >25% BSA for adult or > 20%
BSA for child
• Third-degree burns ≥ 10% BSA
• All burns of hands, face, eyes, ears, feet, or
perineum
• All inhalation injuries
• Electric burns
• All burns with associated complications of
fractures or other trauma
• All high-risk patients (with such conditions as
diabetes, COPD, or heart disease)
First Aid Management of Burns
1. First, evaluate respiratory system for
distress or smoke inhalation (any abnormal
respiratory findings in rate, effort, noise, or
observations of smoky odor of breath or
soot in nose or mouth).
2. Assess cardiovascular status. (Look for
symptoms of shock.)
3. Assess percentage and depth of burns, as
well as presence of other injuries.
4. Flush chemical contact areas with sterile
water; 20 to 30 minutes of flushing may be
needed to remove chemical. Fifteen to 20
minutes of normal saline irrigation is
preferable for chemical burns to eyes.
Contact lens must be removed prior to eye
irrigation.
5. Insert IV line(s) for major and some
moderate burns. (Establish more than one
large-bore IV site if possible.) Attempt
to insert IV(s) in unburned area(s).
6. Weigh patient to establish baseline and
assist in determination of fluid needs.
7. Fluid resuscitation with Ringer’s lactate or
Hartmann’s solution for the first 24 hours as
follows:
4 mL fluid x kilograms of body weight x
percent of burned BSA.
 Administer 1/2 of fluid in first 8 hours.
Administer 1/4 of fluid in second 8 hours.
Administer 1/4 of fluid in third 8 hours.
NOTE: Time is calculated from time of
injury, not time of admission.
8. Administer analgesics as indicated.
9. Remove easily separated clothing. Soak any
adherent clothing to facilitate removal.
NOTE: Keep patient warm. Removal of
clothing may result in rapid and
dangerous drop in temperature.
10. Cover burn area with sterile dressing.
11. Put on Hold NPO until function of GI system
is evaluated.
12. Insert NG tube for gastric decompression if
indicated.
13. Insert Foley catheter (to monitor urine
output) for severe and some moderate
burns.
14. Assess need for and administer tetanus
prophylaxis
15. Frequently monitor vital signs (be aware that
patients who have inhaled smoke are
subject to progressive swelling of the airway
for several hours following injury), ABGs,
and serum electrolytes.
16. Monitor urine output and titrate fluids to
maintain: 30 to 50 mL urine/h in the
adult;0.5 to 2 mL urine/kg of body weight/h
in the child
 
Tetanus Prophylaxis
Td: Tetanus and diphtheria toxoids
adsorbed (for adult use).
TIG: Tetanus immune globulin (human).
For children younger than 7 years old,
diphtheria and tetanus toxoids and
pertussis vaccine adsorbed (or
diphtheria and tetanus toxoids
adsorbed, if pertussis vaccine is
contraindicated) is preferable to
tetanus toxoid alone.
For persons 7 years old and older, Td is
preferable to tetanus toxoid alone.
 
POISONING
Management: promote diuresis. Peritoneal dialysis or hemodialysis
1. Focus initially on the ABCs of life support: may be required.
A - Establish and maintain airway. 9. Continue ABCs of life support and monitor fluids,
B - Assess RR, and provide oxygen and electrolytes, and urine output.
respiratory support PRN.  
C - Assess HR and BP, establish IV access, Chemical Eye Contamination:
and keep warm (shock may occur). Flush eye with sterile water for 15 to 20 minutes,
2. Attempt to identify poison. allowing water to drain away from uncontaminated
3. Contact poison control center for directions eye.
4. Vomiting is to be induced only if the patient is
conscious and nonconvulsive and only if the Respiratory acidosis
ingested substance is noncorrosive (corrosives Treat underlying cause
will further damage esophagus if vomited and may IV fluids
also be aspirated into the lungs). Vomiting may be Bronchodilators
induced by tickling the back of the throat or Mechanical ventilation
administering ipecac syrup in the following dosages: O2
Ipecac syrup (PO) Metabolic acidosis
Child under 1 year: 5–10 mL followed by Correct underlying cause
100 to 200 mL water IV sodium bicarb
Child 1 year or older: 15 mL followed by 100 Seizure precautions
to 200 mL water Monitor and correct electrolyte imbalances
Adult: 15 mL followed by 100 to 200 mL Respiratory alkalosis
water Treat underlying cause
Dose may be repeated after 20 minutes if Breathe into paper bag to > PaCO2
patient does not vomit. Sedatives and calm environment
5. Gastric lavage with NG tube can be used to Metabolic alkalosis
remove poison but must not be attempted if Correct cause
corrosive has been ingested (corrosives severely IV normal saline
damage tissue and NG tube may cause perforation). IV potassium, as indicated
Corrosives include strong acids and alkalies such as Seizure precautions
drain cleaners, detergents, and many household Monitor and correct electrolyte imbalances
cleaners as well as strong antiseptics such as  
bichloride of mercury, phenol, Lysol, cresol
compounds, tincture of iodine, and arsenic
compounds.
6. Corrosives should be diluted with water and the
poison control center contacted immediately.
Activated charcoal may be given via NG tube. EMERGENCY MANAGEMENT
Destructionand/or swelling of esophageal and
airway tissue is likely with corrosive ingestion. OF OB PATIENTS
7. Monitor respiratory status closely.  
8. If several hours have passed since poison
ASK
ingestion, large quantities of IV fluids are given to
Due date?
 Contractions? Wait for the placenta to Do not put traction on the cord
Frequency? separate. or pull on the cord
Duration? Inspect the placenta for Do not hold the baby up by the
Ruptured BOW? completeness ankles.
Bleeding? Do not allow the baby to
Number of previous pregnancies (gravida)? become cold.
Number of births (pararity)? Do not hold the baby below the
Problems with past deliveries? mother’s perineum.
Problems with pregnancy? Do not “strip” or “milk” the
Has the baby moved today? umbilical cord.
OBSERVE Do not push on the uterus to try
Size of abdomen to deliver the placenta.
Fundal height Do not cut the cord unless you
Presentation (cephalic or breech) have sterile equipment.
Fetal heart tones (not assessed if birth is Do not allow the mother’s
imminent) bladder to become distended.
Signs of Imminent Birth
 Mother is experiencing tension, anxiety, Domestic Violence
diaphoresis, and intense contractions.
 With a contraction, the mother catches her Clues of abuse in patient history:
breath and grunts with involuntary pushing • frequent injuries reported as “accidental”
(with inability to respond to questions). • history of repeated miscarriages
 A blood “show” is caused by a rapid • vague or changing description of pain or
dilatation of the cervix. injury
 The anus is bulging, evidencing descent. • lack of patient cooperation during collection
 Bulging or fullness occurs at the perineum. of subjective and/or objective data
“Crowning” of the head at the introitus of a Common sites of injuries caused by physical
multiparous mother means that the birth is abuse:
very imminent. In nulliparous birth, it means • head and neck (most common)
that the birth may be up to 30 minutes • breasts
later. (Birth is near when the head stays • chest
visible between contractions.) · abdomen
   
What to do What NOT to do Signs of possible abuse:
Keep calm. Do not put your fingers into the • multiple injuries
Allow the baby to emerge birth canal. • bilateral distribution of injuries
slowly. Do not force rotation of the • injuries at different stages of healing
Clear the airway. baby’s head after the head • fingernail marks
Dry the baby off. emerges. • bruises shaped like a handprint or
Hold the baby at or slightly Do not try to pull out the baby’s instrument
above the level of introitus. arm. • rope burns
Put the baby next to the Do not overstimulate the baby • cigarette burns
mother’s skin and allow nursing. by slapping. • bites
 • spiral fractures
• burns
Appropriate nursing actions:
1. Question and examine the patient in privacy.
2. Assure confidentiality.
3. Examine entire body.
4. Ask specific questions related to suspected
abuse
5. Be aware that the perpetrator may retaliate if
exposed by the patient.
6. Encourage patient to seek shelter if abuse is
suspected.
7. Give patient contact information for
community resources.
8. Call law enforcement immediately if violence
is threatened (do not warn the perpetrator
of this action).
 
Defibrillation:
To terminate ventricular fibrillation by electric
countershock.
Synchronous contershock
Indications:
• Ventricular fibrillation
• Pulseless ventricular tachycardia
NOTE: CPR efforts should be enacted during
preparation for defibrillation.
METHOD
1. Place two gel pads on the patient’s bare
chest or apply gel to entire surface of
paddles. (To prevent burns and improper
conduction, remove gel from your hands and
the sides of the paddles, and remove any
gel that may have fallen on the patient’s
chest.)
2. Temporarily discontinue oxygen (if
applicable).
3. Apply one electrode below right clavicle just
to the side of the upper sternum.
4. Apply second electrode just below and
lateral to left nipple.
5. Set defibrillator at 200 joules (J)
6. Grasp paddles by insulated handles only.
7. Give “Stand Clear” command, and ascertain
that no one is touching patient or
bed.
8. Push discharge buttons in both paddles
simultaneously, using pressure to ensure
firm contact with the patient’s skin.
9. Remove paddles and assess patient and
ECG pattern.
10. Successive attempts at defibrillation may
deliver 200 to 300 J, then 360 J.
Energy levels for biphasic models
are 50 J, 100 J, 150 J.
AHA recommends that, if three rapidly administered
shocks fail to defibrillate, CPR should be continued,
IV access accomplished, epinephrine given, and
then shocks repeated.
Automatic External Defibrillator
Used in prehospital setting
Cardioversion
Treatment for arrhythmias
The procedure restores the normal heart rate and
rhythm, allowing the heart to pump more effectively.
Synchronized countershock
The defibrillator is synchronized to the client’s R
wave
Oxygen should be stopped during the procedure
Pacemakers
Temporary or permanent device that provides
electrical stimulation and maintains heart rate when
the intrinsic pacemaker fails
Types:
 1. Synchronous / demand Pacemaker
- Paces only if the client’s intrinsic rate
falls below the set pacemaker rate
2. Asynchronous or Fixed Rate
- Paces at preset rate regardless of
client’s intrinsic rhythm
 
GRIEF, LOSS, DEATH and DYING 3. Disenfranchised Grief
- Unable to acknowledge the loss to other people
 
- Examples are unacceptable loss that cannot be
spoken about like suicide, abortion
Loss
Actual or potential situation where in something
4. Dysfunctional Grief
valued is changed / lost / gone
- Pathologic grieving
That something can be: significant others, job, sense
of well being, security etc
5. Unresolved Grief
 
- Extended / lengthy and severe grieving
Types of Loss
- May deny loss or grieve beyond expected time
1. Actual
- Can be recognized by others
6. Inhibited Grief
- Suppressed grieving
2. Perceived
 
- Only the “ self ” can experience
Stages of Grieving
- Cannot be verified by others
 
KÜbler Ross Engel Sander
3. Anticipatory
- Experienced before the actual loss Denial Shock and Disbelief Shock
- Loss can be situational or developmental “ No! not me” (accepts situation but
  denies emotionally)
Sources of Loss
▪ Aspect of Self ( physiologic function / psychologic , Anger Awareness Awareness of Loss
body part) “why me?”    
▪ External to oneself Bargaining Restitution Conservation/Withdrawal
▪ Separation from accustomed environment “if only I could live a ( do rituals of (social withdrawal/ needs
▪ Loss of loved or Valued person little longer.” mourning) time to be alone)
 
Depression Resolving Loss Healing: The turning point
Grief silence   (acceptance)
- Response or reaction to loss
- Bereavement Acceptance Idealization Renewal
- Subjective Response “I’m ready” (new self – awareness;
- Mourning learning to live
- Behavioral Response independently without
Outcome
  loved ones)
Types of Grief Responses:
1. Abbreviated Grief
- Genuinely felt grief but brief

2. Anticipatory Grief Death and Dying

- Grieving in advance
Concept of Death
Infancy to 5 years - no concept of death
5 -9 years old – begins to understand death; death is
final
9-12 years old – death as inevitable and end of life
Heart – lung death
Indications of death:
- Total lack of response to external stimuli, no
muscular movement and reflexes, flat brain
waves and ECG (asystole)
- Cerebral death or higher brain death
- When cerebral cortex( this is the brain
center) is irreversibly damaged
Legal Aspects Related to Death
Advance Health Care Directives
Variety of legal and lay documents that allow
persons to specify aspects of care they wish to
receive should they become incapable of verbalizing
their care preference
2 types:
Living Will
- Provides specific instructions about what
medical treatments the client choose to
refuse in the event that the client is
incapable of making decisions
Health Car Proxy
- Durable Power of Attorney for Health Care
- Notarized / witnessed statement appointing
SOMEONE ELSE (relative or friend) to
manage health care treatment and decisions
when the client is incapable of doing so.
 
Euthanasia
Mercy killing
Act of painlessly putting to death persons suffering
from incurable / terminal/ distressing disease
Autopsy
Postmortem examination
Done in certain cases where death is sudden to
know the cause of death and in some legal cases
Do – Not – Resuscitate Orders
DNR / no Code
 Ordered by physician when the client /
health care proxy has verbalized the wish for
no resuscitation when the client will have
respiratory or cardiac arrest
 DNR indicates that the goal of treatment is a
comfortable dignified death and further life
sustaining interventions will not be done to
patients any longer.
Nursing Responsibility in Dying Patients
 
1. Assisting the client to a peaceful death.
Done by helping clients die with dignity
2. Maintaining humanity , consistent with the
client’s values, beliefs and culture
3. Suggesting/introducing options available like
location of care (at home or hospital)
4. Support client’s will and hope because dying
clients often strive for self fulfillment more
than for self preservation.
5. Meeting Physiologic Needs of the dying
client
 Airway clearance
 Hygiene / bathing
 Nutrition
 Urinary and fecal elimination
6. Providing spiritual support
7. Facilitating expressions of feelings and
emotions about death
8. Arranging an appointment with a clergy or a
spiritual adviser if the client wishes to.
9. Supporting Family
10. Use of therapeutic communication for the
family to be able to express feelings
Hospice Care
Current trend in nursing care
Common setting : home or in a nursing home
Goal: facilitates peaceful and dignified death
Eligible for hospice care are those diagnosed /  Acknowledge the client’s feelings and
predicted to die within 6 months struggles
   Be honest with the client especially on
  Intervention questions about death
Rigor Mortis Position the body naturally  Have an available time for the client to
(stiffening of the body; starts in (in natural / neutral manner) be able to listen, support and interact
the involuntary muscles like the Place dentures (if there is) with him / her.
heart etc.) Close eyes and mouth 9. Document intake and output measurements;
( 2 – 4 hours after death) color, appearance, and amount of urinary
Algor Mortis drainage; and patient’s response to
(gradual decrease of procedure.
temperature) 10. When a new container of TPN is needed,
Livor Mortis but is not available, follow agency policy to
( discoloration of the body) maintain the ordered fluid delivery rate with
D10W until the TPN is available. (High
glucose content of fluid stimulates release of
insulin, which may cause hypoglycemia if
Post Mortem Care fluids are discontinued abruptly.)
11. Do not attempt to “catch up” on fluids if rate
Stages of PMC inadvertently slows.
  12. Discontinue TPN solution gradually at the
1. Do post mortem care according to hospital end of therapy to prevent hypoglycemia.
policy 13. Monitor lab values. (Liver complications,
2. Identify religious belief of clients electrolyte imbalances, and pH changes are
3. All equipment, tubes, supplies must be possible.)
removed
4. A pillow is placed under the head and
shoulders to prevent discoloration in the
face
5. A complete bath is not necessary ( the
mortician will do the bathing
6. Identification band should be attached
before the body is taken to the morgue
7. A shroud is used to wrap the body
8. Must Know for Nurses in caring for dying
Clients:
 Identify personal feelings about death
and how they can affect when caring for
dying patients
 Focus on client’s needs
 Ask client and family support about the
client’s usual coping with stress
 Provide caring and genuine concern