- Pat dry the axilla before placing thermometer. Do not rub.

- Place arm tightly for 9 minutes

TYMPANIC
- Reflects core temp

ARTERIAL WALL ELASTICITY- artery feels straight, smooth, soft & pliable
PRESENCE/ABSENCE OF BILATERAL EQUALITY- absence indicates CV disorder
Temporal pulse perfusion f face
Carotid pulse pulse during cardiac arrest; circulation in the brain
o Carotid massage stimulates vagal nerve decrease HR
Brachial pulse assess BP; cardiac arrest in infants; ABG specimen
Radial pulse normal routine; assessment pulse for adults; used in
checking pulse deficit; ABG specimen
Apical pulse children </= 3 yrs. Old and older adults; checking for pulse
deficit; cardio medicine drugs
Femoral pulse perfusion in the lower extremities; ABG specimen
Popliteal pulse perfusion of the lower leg; alternative site for BP taking
Posterior Tibial and Dorsalis Pedis perfusion of the foot

RESPIRATORY RATE
- Act of breathing

Pulse Rate
- represent stroke volume

PROCESSES:
1. Ventilation
- Inhalation/ inspiration 1.5 secs
- Exhalation 3 secs
2. Diffusion
3. Perfusion
Costal thoraxic muscle 7 years old
Diaphragmatic abdominal muscle
CHEST MOVEMENTS
1. INTERCOSTAL RETRACTION outline of the ribs; pneumonia
2. SUBSTERNAL RETRACTION under breast bone
3. SUPRASTERNAL RETRACTION above clavicle; ASTHMA

Tachycardia- above 100 bpm (adult)

Bradycardia below 60 bpm (adult)
RHYTHM pattern & intervals of beat
VOLUME strength of pulse
Normal felt with moderate pressure
Full / Bounding obliterated with great pressure
Thready easily obliterated

RESPIRATORY CENTERS
1. Medulla Oblongata primary
2. Pons contains:
- Pneumotaxic Center-responsible for rhythmic quality
- Apneustic Center- responsible for deep, prolonged inspiration
3. Carotid & Aortic bodies-contains peripheral chemoreceptors
4. Muscle & joints contains proprioreceptors
ASSESSMENT OF THE RESPIRATORY RATE

RATE Normal is 12-20 in adult

DEPTH may be normal, deep or shallow
RHYTHM observe for regularity of exhalations and inhalations
QUALITY / CHARACTER respiratory effort & sound of breathing

BLOOD PRESSURE

- Measure of pressure exerted by blood as it pulsates through arteries

Systolic Pressure- pressure of blood due to contraction of ventricles
Diastolic Pressure pressure when ventricles are at rest
Pulse Pressure difference bet. Systolic & diastolic pressures
Hypertension abnormally high BP over 140 systolic or over 90 diastolic for at
least 2 consecutive readings
Hypotension abnormally low BP, below 100/60

ASSESSMENT OF BLOOD PRESSURE

1. Ensure client is rested
2. Allow 30 mins after exercise, smoking,caffeine intake before taking BP
3. Use appropriate size of BP cuff
4. Position in supine or sitting
5. Arm must be at the level of the heart
6. Apply cuff 1 inch above antecubital space snugly and smoothly
7. Use bell of the stethoscope
8. The sound during BP taking is called KOROTKOFF sound
9. Read lower meniscus of mercury level of sphygmomanometer at eye
level to prevent Error of Parallax
10. ERROR OF PARALLAX if eye level is higher than level of lower
meniscus of mercury, it may cause false low reading

Medication Administration
Medications substance administered for diagnosis, cure, treatment, relief or
prevention of disease. AKA as drug
Prescription Name name given to a drug before it becomes official
Official Name name after which the drug is listed in one of the official
publications
Chemical Name- name that describes precisely the constituents of drugs
Brand name- name given to a drug by the manufacturer. AKA trademark.
Pharmacology study of effects of drugs on living organisms
Posology study of dosage or amount of drugs given in the treatment of
diseases
Types of Doctors Orders
Standing Order carried out until the specified period of time or until
discontinued by an order
Single Order carried out for only once
STAT Order carried out at once

PRN Order only as patient requires or needed

Parts of A Legal Doctors Order
1. Name of Patient
2. Date and Time
3. Name of Drug
4. Dose of Drug
5. Route of Administration
6. Time or Frequency
7. Signature of Physician
Effects of Drug
Therapeutic Effect intended primary effect. AKA desired effect.
Side Effect Unintended effect of the drug. AKA secondary effect.
Drug Allergy immunologic reaction to the drug
Anaphylactic Reaction severe allergic reaction
Drug Tolerance decreased physiologic response to repeated administration of
a drug
Cumulative Effect increased response to repeated doses of drug that occurs
when the rate of administration exceeds the rate of metabolism or excretion
Idiosyncratic Effect- unexpected peculiar response to the drug
Drug Abuse inappropriate intake of a substance, either continually or
periodically
Drug Dependence persons reliance to take a drug/substance which will
produce an intense reaction upon withdrawal
Addiction due to biochemical changes in body tissues esp. of the nervous
system. Tissues come to require the substance to function normally. AKA physical
dependence.
Habituation emotional reliance on a drug to maintain sense of well being. AKA
psychological dependence.
Drug Interaction effects of one drug are modified by the prior or concurrent
administration of another drug, thereby increasing or decreasing the
pharmacological action
Drug Antagonism conjoint effect of two drugs is less that the drugs acting
separately
Summation combined effect of two drugs produces result that equals the sum
of the individual effects of each agent
Synergism combined effects of drugs is greater than the sum of each
individual agent acting independently
Potentiation concurrent administration of two drugs in which one drug
increases the effect of the other drug
Therapeutic Actions of Drugs

Palliative relieves symptoms of disease but does not affect the disease itself
Curative treats the disease condition
Supportive sustains body functions until other treatment of the bodys
response can take over
Substitutive replaces body fluids / substances
Chemotherapeutic destroys malignant cells
Restorative returns/repairs body to health
Principles of Drug Administration
1. Observe the 7 Rights of drug administration.
-RIGHT drug,dose,time,route,patient, recording, approach
2. Practice asepsis.
3. Nurses administering medications are responsible for their own actions.
4. Be knowledgeable about the meds you administer.
5. Keep narcotics locked.
6. Use only medications that are clearly labeled.
7. Return liquid that are cloudy in color.
8. Identify patient correctly before administering medications.
9. Do not leave medications at the bedside.
10. The nurse who prepares the drug must be the one to administer it.
11. If patient vomits, report to nurse in charge or physician.
12. Preoperative meds are usually discontinued during postop unless ordered to
be continued.
13. When meds is omitted for any reason, record the fact & the reason.
14. When med error is made, report ASAP.
Routes of Drug Administration
I. ORAL
ADVANTAGES: most convenient, less expensive, safe & does not break the skin
barrier
DISADVANTAGES: inappropriate for those with nausea & vomiting, dysphagia,
reduced GIT motility, seriously ill
May give unpleasant odor/taste, discolor teeth, irritate gastric mucosa
Oral Drug Forms
1. SOLID tablet, capsule, pill, powder
2. LIQUID syrup, suspension, emulsion, elixir, milk, other alkaline substance
SYRUP-sugar-based
SUSPENSION-water-based
EMULSION- oil-based
ELIXIR- alcohol-based
- Never crush enteric-coated or sustained-release medication
II. SUBLINGUAL
- Drugs placed under the tongue

ADVANTAGES: for local effect, rapid absorption in the bloodstream

DISADVANTAGES: if swallowed, may be inactivated by gastric juices, must
remain under the tongue until dissolved/absorbed
III. BUCCAL
-held in the mouth against mucous membranes of the cheek. Should not be
chewed, swallowed or placed under the tongue
ADVANTAGES: local effect, greater potency because drug directly enters blood &
bypass the liver
DISADVANTAGES: if swallowed, may be inactivated by gastric juices
IV. TOPICAL
-application of medications to a circumscribed area of the body
1. Dermatologic-lotions, liniments, ointment
Pat dry area, use surgical asepsis, thin layer needed, use gloves over large areas
2. Ophthalmic instillations, irrigations
- Instillations-provides meds, Irrigations-flush eye of noxious/foreign material
3. Otic instillations, irrigations
Instillations-softens earwax, reduce inflammation & treat infection, relieve pain
Irrigations- remove cerumen, apply heat, remove foreign body
4. Nasal for astringent effect, loosen secretions, facilitate drainage, treat
infections
- Parkinsons position-frontal/maxillary
- Proetz position-ethmoid/sphenoid
5. Inhalation- nebulizers, MDI
6. Vaginal local therapeutic effect but has limited use
FORMS: tablet, liquid, cream, jelly, foam & suppository
Vaginal Irrigation washing of vagina by liquid at low pressure. AKA douche.
Empty bladder first, position
Irrigating can shld be 12 in higher
Remain in bed for 5-10 mins after
V. RECTAL
ADVANTAGE: Used when odor/taste is not favorable
DISADVANTAGE: absorption is unpredictable
REMINDERS: needs refrigeration, use gloves for insertion, position- lie on left &
breathe thru mouth, must remain on the side for 20 minutes for absorption
VI. PARENTERAL
- Administration by needle
1. INTRADERMAL thru the dermis beneath epidermis

SITES: inner lower arm, upper chest & back, beneath the scapulae
INDICATIONS: for allergy & tuberculin testing & vaccinations
Needle at 10-15 degrees angle, bevel up
Inject over 3-5 sec to form a wheal/bleb
Do not massage the site
2. SUBCUTANEOUS
SITES: outer aspects of UA, anterior aspect of thighs, abdomen, scapular area of
the back, ventrogluteal & dorsogluteal areas
INDICATIONS: vaccines, preoperative meds, narcotics, insulin, heparin
Small doses only 0.5-1 ml & rotate sites
Use 5/8 needle for adults when given at 45 degrees (thin pts.), for 90 degrees
(obese pts)
Insulin Injection- do not massage & give at 90
3. INTRAMUSCULAR use 1 2 needle to reach the muscle layer
SITES: ventrogluteal, dorsogluteal (<3 y/o), vastus lateralis, rectus femoris,
deltoid, Z-track
4. INTRAVENOUS direct IV, IV push or infusion
- Most rapid route, predictable
INDICATIONS: pts with compromised GI function, rapid introduction of medications
TYPES OF IV FLUIDS:
A. Isotonic Solution- same concentration as body fluids (D5W, NaCl 0.9%, plain LR,
plain NM)
B. Hypotonic has lower concentration than body fluids (NaCl 0.3%)
C. Hypertonic has higher concentration than body fluids (D10W, D50W, D5LR,
D5NM)
Nursing Interventions:
1. Know the type, amount, indications of IV.
2. Inform client & explain purpose of IV therapy.
3. Prime IV tubing to expel air.
4. Change IV tubing every 72 hours.
5. Change /alter IV needle insertion site every 72 hours.
6. Regulate every 15-20 minutes.
7. Observe for complications.
mL
Gauge

Intradermal
1 mL

Subcutaneous
1 or 2 mL

25 -27

25

Intramuscular
1,2,3 or 5 mL p to 10
mL
Deltoid
Non -

deltoid
21-22
1.5 inch

length

- 5/ 8

3/8 5/8

23 -25
1 in

degree

Almost parallel to the

skin
15 degress

Average = 45
degrees
Fat = 90 degress

Average = 90
degrees
Thin= 45 degrees

Complications of IV Infusion:
1. Infiltration needle out of vein, fluids accumulate in the subcutaneous tissues
S/S: pain, swelling, cold skin, pallor at site, IV rate decreases/stops, no backflow
NSG.INT: change IV site, apply warm compress
2. Circulatory Overload from administration of excessive volume of IV fluids
S/S: headache, flushed skin, increased PR,BP,RR, weight, SOB, syncope, cough,
increased venous pressure, pulmonary edema, shock
NSG. INT: slow IV infusion (KVO), high fowlers position, administer diuretic,
bronchodilator as ordered
3. Drug Overload excessive amount of drugs in the fluids
S/S: dizziness, fainting, shock
NSG. INT.: slow IV infusion (KVO), inform physician
4. Superficial Thrombophlebitis due to overuse of vein, irritating soln/drugs, clot
formation, large bore catheter
S/S: pain along the vein, vein feels hard & cordlike, edema & redness over site,
affected arm warmer than the other
NSG. INT: change IV site every 72H, use large veins for irritating fluids, stabilize
area, apply cold compress immediately then warm compress after
5. Air Embolism - air enters the system (at least 5 ml or more)
S/S: chest/shoulder/back pain, hypotension, dyspnea, tachycardia, cyanosis,
increases venous pressure, LOC
NSG.INT: do not allow bottle to run dry, prime tubings before starting IV, turn to
left side in Trendelenburg position
6. Nerve Damage due to overly tight tying of the splint
S/S: numbness of fingers/hands
NSG.INT: massage area & move shoulders thru ROM, open/close hands several
times each hour, PT if required
7. Speed Shock D/T rapid administration of IV fluids
NSG.INT: to avoid speed shock & cardiac arrest, give most IV push meds over 3-5
minutes

Blood Transfusion
4 objectives / Purpose
1) To replace circulating blood volume

2) To increase oxygen carrying capacity of the blood

3) Combat infection if decrease WBC
4) Prevent bleeding if decrease platelet
NURSING MANAGEMENT
1.Proper Refrigeration
- 250 cc packed of RBC, refrigerate 3-5 days
- 1 platelet bag refrigerate 5-6 days
2. Proper blood typing & cross matching
- Type O universal donor
- AB- universal recipient
- 85% of people is RH RH (+)
3. Aseptical assemble all materials needed for BT
4. With filter (BT set)
5. Gauge 18 of needle
6. Check for name of the client
7. Check for expiration date
8. Check for serial number
9. Use RED ballpen when charting
10. Check blood unit for presence of bubbles, cloudiness, and dark color
11. Never warm the BLOOD
- It may destroy vital product of the blood
- Let the room temperature warm the blood @ 30minutes
12. Avoid mixing the drugs at BT line
13. Regulate @ KVO or 100 cc/hr to prevent circulatory overload for first 30
minutes
- Start at slow rate (10 gtts/min)& remain at bedside for 15-30 mins
14. BT should be done less than 4hrs for WB & PRBC and 20 minutes for plasma,
platelets, cryoprecipitate
15. Monitor VS before. During & after BT 10 especially q15minns. For 1 st hour
- Majority of BT reaction occurs within 1hr.
16. Administer 0.9% NaCl before, during or after BT. Never administer IV with
dextrose
17. Observe for Complication

BT REACTION
H- emolytic
A- llergic

P- yrogenic
C- irculatory overload
A- ir embolism
T- hrombo cytophenia
C- itrate intoxication
H- yperkalemia

Asepsis and Infection Control

INFECTION invasion of body tissue by microorganismsASEPSIS absence of
disease-producing microorganisms; being free from infection
MEDICAL ASEPSIS practices designed to reduce number & transfer of
microorganisms
SURGICAL ASEPSIS practices that render & keep objects/areas free from
microorganisms; sterile technique
SEPSIS presence of infection
SEPTICEMIA transport of infection throughout the body or blood
CARRIER person / animal, with or without signs of illness but who harbors
pathogens within his body that can be transferred to another
CONTACT person / animal known or believed to have been exposed to a disease
RESERVOIR natural habitat for growth & multiplication of microorganisms
TRANSIENT FLORA microorganisms picked up as a result of normal activities &
can be removed easily.
RESIDENT FLORA microorganisms that normally live on a persons skin
STERILIZATION process by which all microorganisms including spores are
destroyed
DISINFECTANT substance that destroys pathogens but generally not including
spores
ANTISEPTIC substance that inhibits growth of pathogens but does not
necessarily destroy them
BACTERICIDAL chemical that kills microorganisms
BACTERIOSTATIC agent that prevents bacterial multiplication but does not kill all
forms of organisms
CONTAMINATION process by which something is rendered unclean / unsterile
DISINFECTION process by which pathogens but not their spores are destroyed
COMMUNICABLE DISEASE results if infectious agent can be transmitted to
another by direct/indirect contact thru vector/vehicle
INFECTIOUS DISEASE results from invasion & multiplication of microorganisms in
a host
PATHOGEN disease-producing microorganism
PATHOGENICITY ability to produce a disease
VIRULENCE vigor with which the organism can grow & multiply
SPECIFICITY organisms attraction to a specific host
OPPORTUNISTIC PATHOGEN causes disease only in susceptible individuals
NOSOCOMIAL INFECTION hospital-acquired infection
ISOLATION separation of persons with communicable disease from another so
that transmission is prevented
ISOLATION TECHNIQUES practices designed to prevent transfer of specific
microorganisms
ETIOLOGY study of causes

STAGES OF INFECTIOUS PROCESS

Incubation Period from entry of microorganism to the body to onset of S/S
Prodromal Period from onset of non-specific S/S to appearance of specific S/S
Illness Period specific S/S develop & become evident
Convalescent Period S/S start to abate until client returns to normal state of
health
ETIOLOGIC AGENT may be bacteria, virus, fungi or parasites
RESERVOIR humans, animals, plants, environment
PORTAL OF EXIT (from reservoir)
- Respiratory Tract- droplet,sputum
- GIT-vomitus, feces, saliva, drainage tubes
- Urinary Tract urine, urethral catheter
- Reproductive Tract- semen, vaginal discharge
- Blood needle puncture, open wound

MODES OF TRANSMISSION
- CONTACT TRANSMISSION direct/indirect
- DROPLET TRANSMISSION when MM are exposed to secretions of an infected
personwho is coughing, sneezing, laughing within 3 feet
- VEHICLE TRANSMISSION transfer by way of vehicles or contaminated items
(food, water, milk, utensils, pillows, mattress)
- AIRBORNE TRANSMISSION when fine particles are suspended in the air for a
long time & dispersed by air current then inhaled/deposited to a host
VECTOBORNE TRANSMISSION
- vectors can be biologic or mechanical
- Biologic animals (rats, snails, mosquitoes)
- Mechanical infected inanimate objects (contaminated needles/syringes)
PORTAL OF ENTRY
- permits organism to enter host
- Through body orifice such as mouth, nose, vagina, rectum OR breaks in the skin
or MM
SUSCEPTIBLE HOST
host is a person who is at risk for infection, whose body defense mechanism are
unable to withstand the invasion of the pathogen

TYPES OF IMMUNIZATION

ACTIVE IMMUNIZATION- antibodies are produced by the body in response to

infection
NATURAL antibodies formed in presence of active infection in the body. It is
lifelong.
ARTIFICIAL antigens (vaccines/toxoid) are administered to stimulate Ab
production

PASSIVE IMMUNIZATION antibodies are produced by another source

(animal/human)
NATURAL Ab from mother to baby
ARTIFICIAL Immune serum (antibody) from an animal or another human is
injected

ASEPTIC PRACTICES
1. HANDWASHING
Handwashing is the single most important infection control practice.
Handwashing for medical asepsis is done by holding hands lower than the
elbows
Use running water, soap & friction for 15-30 seconds each hand
Wash hands before and after client contact
2. CLEANING, DISINFECTION & STERILIZATION
Cleaning physical removal of dirt & debris by washing, dusting or mopping
Disinfection chemical or physical process to reduce number of potential
pathogens on a surface but not necessarily the spores
Sterilization complete destruction of all microorganisms including spores

METHODS OF STERILIZATION
STEAM STERILIZATION autoclaving uses supersaturated steam under
pressure
- non-toxic , inexpensive, sporicidal & penetrates fabric
- Color indicator strips change color to indicate sterilization
GAS STERILIZATION
ethylene oxide is colorless gas that can penetrate plastic, rubber, cotton or
other subs. Used for oxygen, suction gauges, BP apparatus, stethoscope, catheter
- Expensive & requires 2-5 hours
- Ethylene oxide is toxic to humans
RADIATION
- ionizing radiation penetrates deeply to objects
- Used for drugs, food & other heat-sensitive items
CHEMICALS are effective disinfectants
- Attacks all types of microorganisms rapidly, inexpensive & stable in light & heat.
Chlorine is used.
BOILING WATER least expensive, at least 15 minutes
3. USE OF BARRIERS
a. Masks
b. Gowns

c. Caps & shoe covers

d. Gloves
e. Private rooms
f. Equipment & refuse handling
4. ISOLATION SYSTEMS

CLASSIFICATIONS:
A. Standard Precautions
- Universal Precaution & Body-Substance Isolation
- Prevent transmission of bloodborne & moist body substance pathogens
1. Wear clean gloves
2. Perform handwashing
3. Wear masks, goggles, face shield if sprays/splashes are expected
4. Wear gown if soiling & splashes are expected
5. Remove soiled protective items immediately
6. Clean & reprocess all equipment
7. Discard all single-used items
8. Prevent injuries
9. Use private room or consult with Infection Control Department
B. Transmission-Based Precautions
1. AIRBORNE PRECAUTION
- for small-particle droplet that may remain suspended in the air & dispersed by
air current (varicella, TB, measles
-Private room, negative airflow, wear masks
2. DROPLET PRECAUTION
- for large-particle droplet & dispersed by air current (H. influenza, diphtheria,
rubella, mycoplasma pneumoniae)
- Private room, wear masks within 3 ft.
3. CONTACT PRECAUTION
- for those transferred by hand-or skin-to-skin contact (clostridium difficile,
shigella, impetigo)
- Private room, use gloves, gowns & other protective barriers when exposure to
infected material is likely
C. Protective Isolation
- prevent infection for people with compromised resistance (leukopenia,
undergoing chemoRx, extensive burns)
- Private room, restrict visitors, no fresh fruits/flowers, raw foods, potted plants
allowed, only cooked/canned foods allowed
5. SURGICAL ASEPSIS
PRINCIPLES:
a. Moisture causes contamination.

b. Never assume that an object is sterile.

c. Always face the sterile field.
d. Sterile articles may touch only sterile surface/articles to maintain sterility.
e. Sterile equipment/areas must be kept above the waist & on top of the sterile
field.
f. Prevent unnecessary traffic & air currents around sterile area
g. open, unused sterile articles are no longer sterile after the procedure
h. A person who is considered sterile who becomes contaminated must
reestablish sterility
i. Surgical technique is team effort.

Wound Care
TYPES OF WOUNDS: According to contamination
1. Clean Wounds uninfected, minimal inflammation, closed
- respiratory, GIT & urinary tract are not entered
2. Clean-contaminated Wounds also surgical wounds, no infection
- respiratory, GIT & urinary tract entered
3. Contaminated Wounds- open, fresh, accidental wounds, with evidence of
inflammation
4. Dirty/Infected Wounds with dead tissue & evidence of infection
TYPES OF WOUND: According to cause
1. Incision
2. Contusion
3. Abrasion
4. Puncture
5. Laceration
6. Penetrating wound
TYPES OF WOUND HEALING
1. Primary Intention healing
2. Secondary Intention healing
PHASES OF WOUND HEALING
1. Inflammatory Phase immediate, 3-6 days
2. Proliferative Phase 3rd to 21 days
3. Maturation Phase 21 days to 2 years
STAGES OF PRESSURE ULCER FORMATION
Stage 1 non-blanchable erythema signaling potential ulceration
Stage 2 partial-thickness skin loss (abrasion, blister or shallow crater) involving
epidermis & dermis
Stage 3 full-thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down but not thru fascia. Deep crater.

Stage 4 full-thickness skin loss with necrosis or damage to muscle, bone,

structures, tendon, joints
KINDS OF WOUND DRAINAGE
EXUDATE material that escapes from blood vessels during the inflammatory
process
1. SEROUS EXUDATE blister from burns
2. PURULENT EXUDATE
3. SANGUINEOUS (Hemorrhagic) EXUDATE

Oxygenation

Kinds of Chest Physiotherapy

1. Percussion (clapping)
2. Vibration
3. Postural drainage
Bronchial Hygiene Measures
1. Steam Inhalation semifowlers position & position spout 12-18 inches away
from nose
2. Aerosol Inhalation
3. Medimist Inhalation

SUCTIONING
1. Assess indications for suctioning.
2. Position properly:
a. conscious: semi-fowlers
b. unconscious: lateral position
3. Apply proper pressure
4. Use appropriate size of catheter
Adult: Fr 12-18
Child: Fr 8-10
Infant: Fr 5-8
5. Don sterile gloves
6. Insert proper length of catheter
7. Lubricate catheter
8. Apply suction during withdrawal of catheter
9. Apply suction for 5-10 seconds (max 15)
10. Hyperventilate 100% before & after
11. Allow 20-30 sec interval between each suction
12. Provide oral & nasal hygiene
13. Dispose contaminated equipment/matls safely
14. Assess effectiveness / document

INCENTIVE SPIROMETRY
-Enhance deep inspiration
INTERMITTENT POSITIVE PRESSURE BREATHING
Administer oxygen at pressures higher than the atmospheric pressure
OXYGEN SYSTEMS
1. Low flow administration devices
2. High flow administration devices
ADMINISTRATION OF OXYGEN
Indications: hypoxemia
Signs of Hypoxemia:
- Restlessness
- Increased pulse rate
- Rapid, shallow breathing, DOB, nasal flaring
- Light headedness
- Substernal / intercostals retractions
- Cyanosis
ALTERATIONS IN RESPIRATORY FUNCTION
HYPOXIA
Insufficient oxygenation of tissues
CLINICAL SIGNS:

RHYTHM
CHEYNE-STOKES marked rhythmic waxing & waning of respirations from very
deep to very shallow and temporary apnea
KUSSMAULS (Hyperventilation) increased rate & depth of respiration
APNEUSTIC prolonged gasping inspiration followed by very short inefficient
expiration
BIOTS shallow breaths interrupted by apnea