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Blood transfusion therapyinvolves transfusing whole blood or blood components (specific portior fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected int60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not providtherapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors(factors V and VIII).

Blood components include:

1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present inone unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimexpansion of blood.

2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile nohemolytic reactions.

3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.4. Granulocytes ( basophils, eosinophils, and neutrophils )5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile

factors).6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and

VIII; the preferred product for reversal of Coumadin-induced anticoagulation.7. Albumin, a plasma protein.8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.

9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and

freeze-drying large volumes of plasma.10.Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, andfreeze-drying large volumes of plasma.

11.Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components.2. Provides optimal therapeutic benefit while reducing risk of volume overload.3. Increases availability of needed blood products to larger population.

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Principles of blood transfusion therapy

1. Whole blood transfusiono Generally indicated only for patients who need both increased oxygen-carrying capacity a

restoration of blood volume when there is no time to prepare or obtain the specific bloodcomponents needed.

2.

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

of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes,providing proper refrigeration of remaining blood until needed. One unit of packed red celshould raise hemoglobin approximately 1%, hemactocrit 3%.

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

platelets should raise the recipients platelet count by 6000 to 10,000/mm3: however, po

incremental increases occur with alloimmunization from previous transfusions, bleeding,fever, infection, autoimmune destruction, and hypertension.

4. Granulocyteso May be beneficial in selected population of infected, severely granulocytopenic patients (le

than 500/mm3) not responding to antibiotic therapy and who are expected to experienceprolonged suppressed granulocyte production.

5. Plasmao Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume

expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringerslactate) are preferred. Fresh frozen plasma should be administered as rapidly as toleratedbecause coagulation factors become unstable after thawing.

6. Albumino Indicated to expand to blood volume of patients in hypovolemic shock and to elevate leve

of circulating albumin in patients with hypoalbuminemia. The large protein molecule is amajor contributor to plasma oncotic pressure.

7. Cryoprecipitateo Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated

intravascular coagulation (DIC), and uremic bleeding.8. Factor IX concentrate

o Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requirepooling from many donors.

9. Factor VIII concentrateo Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepat

and HIV transmission.10.Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Objectives

1. To increase circulating blood volume after surgery, trauma, or hemorrhage2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets,

albumin)

Nursing Interventions

1. Verify doctors order. Inform the client and explain the purpose of the procedure.2. Check for cross matching and typing. To ensure compatibility3. Obtain and record baseline vital signs

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4. Practice strict Asepsis5. At least 2 licensed nurse check the label of the blood transfusion

o Check the following: Serial number Blood component Blood type Rh factor Expiration date Screening test (VDRL, HBsAg, malarial smear) - *this is to ensure that the blood is

free from blood-carried diseases and therefore, safe from transfusion.6. Warm blood at room temperature before transfusion to prevent chills.7. Identify client properly. Two Nurses check the clients identification.8. Use needle gauge 18 to 19. This allows easy flow of blood.9. Use BT set with special micron mesh filter. To prevent administration of blood clots and particles10.Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction

usually occurs during the first 15 to 20 minutes.11.Monitor vital signs. Altered vital signs indicate adverse reaction.12.Do not mix medications with blood transfusion. To prevent adverse effects

o Do not incorporate medication into the blood transfusiono Do not use blood transfusion lines for IV push of medication.

13.Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose.

Dextrose causes hemolysis.14.Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate,

transfuse quickly (20 minutes) clotting factor can easily be destroyed.15.Observe for potential complications. Notify physician.

Complications of Blood Transfusion

1. Allergic Reactionit is caused by sensitivity to plasma protein of donor antibody, which reactswith recipient antigen.

o Assessments: Flushing

Rush, hives Pruritus Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasproteins. This is the most symptomatic complication of blood transfusion

o Assessments: Sudden chills and fever Flushing Headache Anxiety

3. Septic Reactionit is caused by the transfusion of blood or components contaminated withbacteria.

o

Assessment: Rapid onset of chills Vomiting Marked Hypotension High fever

4. Circulatory Overloadit is caused by administration of blood volume at a rate greater than thcirculatory system can accommodate.

o Assessment: Rise in venous pressure Dyspnea Crackles or rales Distended neck vein

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Cough Elevated BP

5. Hemolytic reaction. It is caused by infusion of incompatible blood products.o Assessment:

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

Chills Feeling of fullness Tachycardia

Flushing Tachypnea Hypotension Bleeding Vascular collapse Acute renal failure

Assessment findings

1.

Clinical manifestations of transfusions complications vary depending on the precipitating factor.2. Signs and symptoms of hemolytic transfusion reaction include:o Fevero Chillso low back paino flank paino headacheo nauseao flushingo tachycardiao tachypneao hypotensiono hemoglobinuria (cola-colored urine)

3.

Clinical signs and laboratory findings in delayed hemolytic reaction include:o fevero mild jaundiceo gradual fall of hemoglobino positive Coombs test

4. Febrile non-hemolytic reaction is marked by:o Temperature rise during or shortly after transfusiono Chillso headacheo flushingo anxiety

5. Signs and symptoms of septic reaction include;o

Rapid onset of high fever and chillso vomitingo diarrheao marked hypotension

6. Allergic reactions may produce:o hiveso generalized prurituso wheezing or anaphylaxis (rarely)

7. Signs and symptoms of circulatory overload include:o Dyspneao cougho rales

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o jugular vein distention8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or

insidiously, depending on the disease.9. Characteristics of GVH disease include:

o skin changes (e.g. erythema, ulcerations, scaling)o edemao hair losso hemolytic anemia

10.Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis

1. Ineffective breathing pattern2. Decreased Cardiac Output3. Fluid Volume Deficit4. Fluid Volume Excess5. Impaired Gas Exchange6. Hyperthermia

7.

Hypothermia8. High Risk for Infection9. High Risk for Injury10.Pain11.Impaired Skin Integrity12.Altered Tissue Perfusion

Planning and Implementation

1. Help prevent transfusion reaction by:

o

Meticulously verifying patient identification beginning with type and cross match samplecollection and labeling to double check blood product and patient identification prior totransfusion.

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

o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particuladuring the first 15 minutes (severe reactions usually manifest within 15 minutes after thestart of transfusion).

o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize thrisk of bacterial growth at warm room temperatures.

o Preventing infectious disease transmission through careful donor screening or performingpretest available to identify selected infectious agents.

o

Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs(i.e., whole blood, platelets, packed RBCs and granulocytes) before transfusion; irradiatioalters ability of donor lymphocytes to engraft and divide.

o Preventing hypothermia by warming blood unit to 37 C before transfusion.o Removing leukocytes and platelets aggregates from donor blood by installing a

microaggregate filter (20-40-um size) in the blood line to remove these aggregates durintransfusion.

2. On detecting any signs or symptoms of reaction:o Stop the transfusion immediately, and notify the physician.o Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide acce

for possible IV drug infusion.o Send the blood bag and tubing to the blood bank for repeat typing and culture.

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o Draw another blood sample for plasma hemoglobin, culture, and retyping.o Collect a urine sample as soon as possible for hemoglobin determination.

3. Intervene as appropriate to address symptoms of the specific reaction:o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal

failure associated with RBC hemolysis and hemoglobinuria.o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics;

leukocyte-poor blood products may be recommended for subsequent transfusions.o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and

vasopressors as prescribed.o

Intervene for allergic reaction by administering antihistamines, steroids and epinephrine aindicated by the severity of the reaction. (If hives are the only manifestation, transfusioncan sometimes continue but at a slower rate.)

o For circulatory overload, immediate treatment includes positioning the patient upright witfeet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions when complications occurs in Blood transfusion

1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.

2.

Start IV line (0.9% Na Cl)3. Place the client in fowlers position if with SOB and administer O2 therapy.4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as

often as every 5 minutes.5. Notify the physician immediately.6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids,

and steroids as per physicians order or protocol.7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a

result of RBC hemolysis.8. Blood container, tubing, attached label, and transfusion record are saved and returned to the

laboratory for analysis.

Evaluation

1. The patient maintains normal breathing pattern.2. The patient demonstrates adequate cardiac output.3. The patient reports minimal or no discomfort.4. The patient maintains good fluid balance.5. The patient remains normothermic.6. The patient remains free of infection.7. The patient maintains good skin integrity, with no lesions or pruritus.8. The patient maintains or returns to normal electrolyte and blood chemistry values.

References:J.Q. Udan, RN, MAN 2004. Mastering Fundamentals of Nursing 2nd ed. Educational Publishing House

Image courtesy of : http://www.beltina.org/pics/blood_transfusion.jpg

The Large Intestine

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Primary organ of bowel elimination Extends from the ileocecal valve to the anus

Functions

Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L) Manufacture of some vitamins Formation of feces Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis

Peristalsis is under control of nervous system Contractions occur every 3 to 12 minutes Mass peristalsis sweeps occur 1 to 4 times each 24-hour period One-third to one-half of food waste is excreted in stool within 24 hours

Peristalic Movements in the IntestineColonic peristalsis is slow. Mass peristalsis is strong, fewwaves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination

1. Age2. Diet3. Position4. Pregnancy5. Fluid Intake6. Activity

7.

Psychological8. Personal Habits9. Pain10.Medications11.Surgery/Anesthesia

Developmental Considerations

Infantscharacteristics of stool and frequency depend on formula or breast feedings Toddler physiologic maturity is first priority for bowel training (1 2 yrs) Child, adolescent, adultdefecation patterns vary in quantity, frequency, and rhythmicity

Older adultconstipation is often a chronic problem

Foods Affecting Bowel Elimination

Constipating foods cheese, lean meat, eggs, & pasta Foods with laxative effectfruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foodsonions, cabbage, beans, cauliflower

Effect of Medications on Stool

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Aspirin, anticoagulants pink, red, or black stool Iron saltsblack stool Antacids white discoloration or speckling in stool Antibioticsgreen-gray color

Physical Assessment of the Abdomen

Inspectionobserve contour, any masses, scars, or distension Auscultationlisten for bowel sounds in all quadrants Note frequency and character, audible clicks, and flatus Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussionexpect

resonant sound or tympany Areas of increased dullness may be caused by fluid, a mass, or tumor Palpationnote any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

Inspection and palpation

Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection

Medical aseptic technique is imperative Wear disposable gloves Wash hands before and after glove use Do not contaminate outside of container with stool Obtain stool and package, label, and transport according to agency policy

http://www.rnpedia.com/home/notes/fundamentals-of-nursing-notes/bowel-elimination

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Patient Guidelines for Stool Collection

Void first so urine is not in stool sample Defecate into the container rather than toilet bowl Do not place toilet tissue in bedpan or specimen container Notify nurse when specimen is available get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

Esophagogastroduodenoscopy (EGD) Colonoscopy Sigmoidoscopy Wireless capsule endoscopy

Indirect Visualization Studies

Upper gastrointestinal (UGI) Small bowel series Barium enema

Scheduling Diagnostic Tests

1 fecal occult blood test 2 barium studies (should precede UGI) make sure ALL barium is removed* 3 endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

Patient has a soft-formed bowel movement every 1-3 days without discomfort The relationship between bowel elimination and diet, fluid, and exercise is explained Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

Timing -attend to urges promptly Positioning have pt. sit up, gravity aids in BM Privacy close door & pull curtain Nutrition Exercise abdominal muscles & thighs Abdominal settings Thigh strengthening

Individuals at High Risk for Constipation

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Patients on bed rest taking constipating medications Patients with reduced fluids or bulk in their diet Patients who are depressed Patients with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) intrathoracic / intracranial pressure possible braininjury

Nursing Measures for the Patient With Diarrhea

Answer call lights immediately Remove the cause of diarrhea whenever possible (e.g., medication) If there is impaction, obtain physician order for rectal examination Give special care to the region around the anus After diarrhea stops, suggest the intake of fermented dairy products Fecal seepage may indicate impaction

Preventing Food Poisoning

Never buy food with damaged packaging Never use raw eggs in any form Do not eat ground meat uncooked Never cut meat on a wooden surface Do not eat seafood that is raw or has unpleasant odor Clean all vegetables and fruits before eating Refrigerate leftovers within 2 hours of eating them Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

Enemas Rectal suppositories Rectal catheters Digital removal of stool

Types of Enemas

Cleansing high volume Retention - oil Return-flow bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

Oil-retentionlubricate the stool and intestinal mucosa easing defecation Carminativehelp expel flatus from rectum Medicatedprovide medications absorbed through rectal mucosa Anthelminticdestroy intestinal parasites Nutritiveadminister fluids and nutrition rectally

Bowel Training Programs

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Manipulate factors within the patient's control Food and fluid intake, exercise, time for defecation Eliminate a soft, formed stool at regular intervals without laxatives When achieved, discontinue use of suppository if one was used

Types of Colostomieseach has different stool consistency

Sigmoid colostomy Descending colostomy Transverse colostomy Ascending colostomy Ileostomy

Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy

Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy

Location of an Ileostomy

Colostomy Care

Keep patient as free of odors as possible; empty appliance frequently Inspect the patient's stoma regularly Note the size, which should stabilize within 6 to 8 weeks Keep the skin around the stoma site clean and dry Measure the patient's fluid intake & output Explain each aspect of care to the patient and self-care role Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies

Community resources are available for assistance Initially encourage patients to avoid foods high in fiber Avoid foods that cause diarrhea or flatus Drink two quarts of water daily Teach about medications Teach about odor control (intake of dark green vegetables helps control odor) Resume normal activity including work and sexual relations

Comfort Measures

Encourage recommended diet and exercise Use medications only as needed Apply ointments or astringent (witch hazel) Use suppositories that contain anesthetics

Characteristics of Normal Stool

1. Color varies from light to dark brown foods & medications may affect color2. Odor aromatic, affected by ingested food and persons bacterial flora3. Consistencyformed, soft, semi-solid; moist

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4. Frequencyvaries with diet (about 100 to 400 g/day)5. Constituentssmall amount of undigested roughage, sloughed dead bacteria and epithelial cel

fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium,phosphates)

Common Bowel Elimination Problems

1.

Constipationabnormal frequency of defecation and abnormal hardening of stools2. Impactionaccumulated mass of dry feces that cannot be expelled3. Diarrhea increased frequency of bowel movements (more than 3 times a day) as well as liquid

consistency and increased amount; accompanied by urgency, discomfort and possibly incontinen4. Incontinenceinvoluntary elimination of feces5. Flatulence expulsion of gas from the rectum6. Hemorrhoidsdilated portions of veins in the anal canal causing itching and pain and bright re

bleeding upon defecation.

Cleansing Enemas

Stimulate peristalsis through irrigation of colon and rectum and by distention

1. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soain 1000 ml of water

2. Tap water: Give caution o infants or to adults with altered cardiac and renal reserve3. Saline: For normal saline enemas, use smaller volume of solution4. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not

require further preparation

Oil-Retention Enemas

Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass

Carminative Enema

Provides relief from gaseous distention

Astringent Enema

Contracts tissue to control bleeding

Key Points: Administering Enema

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1. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 ccor less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, orsolutions that are instilled too quickly, can cause cramping and damage to rectal tissues

2. Allow solution to run through the tubing so that air is removed3. Place client on left side in Sims position4. Lubricate the tip of the tubing with water-soluble lubricant5. Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches

children), past the external and internal sphincters6. Raise the water container no more than 12 to 18 inches above the client

7.

Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The cliewill also be able to tolerate and retain a greater volume of solution

8. After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes9. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 1

minutes.

References:

FEU In House Review Handout PPD test

1. Read result 48 72 hours after injection.2. For HIV positive clients, in duration of 5 mm is considered positive

Bronchography

1. Secure consent2. Check for allergies to seafood or iodine or anesthesia3. NPO 6-8 hours before the test4. NPO until gag reflex return to prevent aspiration

Thoracentesis (Aspiration of fluid in the pleural space.)

1. Secure consent, take V/S2. Position upright leaning on over bed table3. Avoid cough during insertion to prevent pleural perforation4. Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity5. Check for expectoration of blood. This indicate trauma and should be reported to MD immediatel

Holter Monitor

1. It is continuous ECG monitoring, over 24 hours period2. The portable monitoring is called telemetry unit

Echocardiogram

1. Ultrasound to assess cardiac structure and mobility

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2. Client should remain still, in supine position slightly turned to the left side, with HOB elevated 1520 degrees

Electrocardiography

1. If the patients skin is oily, scaly, or diaphoretic, rub the electrode with a dry 4x4 gauze to enhan

electrode contact.2. If the area is excessively hairy, clip it3. Remove client`s jewelry, coins, belt or any metal4. Tell client to remain still during the procedure

Cardiac Catheterization

1. Secure consent2. Assess allergy to iodine, shellfish3. V/S, weight for baseline information

4.

Have client void before the procedure5. Monitor PT, PTT, and ECG prior to test6. NPO for 4-6 hours before the test7. Shave the groin or brachial area8. After the procedure : bed rest to prevent bleeding on the site, do not flex extremity9. Elevate the affected extremities on extended position to promote blood supply back to the heart

and prevent thrombophlebitis10.Monitor V/S especially peripheral pulses11.Apply pressure dressing over the puncture site12.Monitor extremity for color, temperature, tingling to assess for impaired circulation.

MRI

1. Secure consent,2. The procedure will last 45-60 minute3. Assess client for claustrophobia4. Remove all metal items5. Client should remain still6. Tell client that he will feel nothing but may hear noises7. Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI.8. Client with cardiac and respiratory complication may be excluded9. Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the

procedure

UGIS Barium Swallow

1. Instruct client on low-residue diet 1-3 days before the procedure2. Administer laxative evening before the procedure3. NPO after midnight4. Instruct client to drink a cup of flavored barium5. X-rays are taken every 30 minutes until barium advances through the small bowel

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6. Film can be taken as long as 24 hours later7. Force fluid after the test to prevent constipation/barium impaction

LGIS Barium Enema

1. Instruct client on low-residue diet 1-3 days before the procedure

2.

Administer laxative evening before the procedure3. NPO after midnight4. Administer suppository in AM5. Enema until clear6. Force fluid after the test to prevent constipation/barium impaction

Liver Biopsy

1. Secure consent,2. NPO 2-4 hrs before the test

3.

Monitor PT, Vitamin K at bedside4. Place the client in supine at the right side of the bed5. Instruct client to inhale and exhale deeply for several times and then exhale and hold breath whi

the MD insert the needle6. Right lateral post procedure for 4 hours to apply pressure and prevent bleeding7. Bed rest for 24 hours8. Observe for S/S of peritonitis

Paracentesis

1.

Secure consent, check V/S2. Let the patient void before the procedure to prevent puncture of the bladder3. Check for serum protein. Excessive loss of plasma protein may lead to hypovolemic shock.

Lumbar Puncture

1. Obtain consent2. Instruct client to empty the bladder and bowel3. Position the client in lateral recumbent with back at the edge of the examining table

4.

Instruct client to remain still5. Obtain specimen per MDs order

References:

J.Q. Udan, RN, MAN 2004. Mastering Fundamentals of Nursing 2nd ed. Educational Publishing House

Ethos- comes from Greek work w/c means character/culture- Branch of Philosophy w/c determines right and wrong

Moral- personal/private interpretation from what is good and bad.

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Ethical Principles:

1. Autonomy the right/freedom to decide (the patient has the right to refuse despite the explanatof the nurse) Example: surgery, or any procedure

2. Nonmaleficence the duty not to harm/cause harm or inflict harm to others (harm maybe physicfinancial or social)

3. Beneficence- for the goodness and welfare of the clients4. Justice equality/fairness in terms of resources/personnel5. Veracity - the act of truthfulness6. Fidelity faithfulness/loyalty to clients

Moral Principles:

1. Golden Rule2. The principle of Totality The whole is greater than its parts3. Epikia There is always an exemption to the rule4. One who acts through as agent is herself responsible (instrument to the crime)5. No one is obliged to betray herself You cannot betray yourself

6.

The end does not justify the means7. Defects of nature maybe corrected8. If one is willing to cooperate in the act, no justice is done to him9. A little more or a little less does not change the substance of an act.10.No one is held to impossible

Law - Rule of conduct commanding what is right and what is wrong. Derived from an Anglo-Saxon termthat meansthat which is laid down or fixed

Court - Body/agency in government wherein the administration of justice is delegated.

Plaintiff- Complainant or person who files the case (accuser)

Defendant- Accused/respondent or person who is the subject of complaint

Witness- Individual held upon to testify in reference to a case either for the accused or against theaccused.

Written orders of court

Writ legal notes from the court

1. Subpoena

a. Subpoena Testificandum a writ/notice to an individual/ordering him to appear in court at aspecific time and date as witness.

b. Subpoena Duces Tecum- notice given to a witness to appear in court to testify including allimportant documents

Summonnotice to a defendant/accused ordering him to appear in court to answer the complaintagainst him

Warrant of Arrest- court order to arrest or detain a person

Search warrant- court order to search for properties.

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Private/Civil Law - body of law that deals with relationships among private individuals

Public law- body of law that deals with relationship between individuals and the State/government angovernment agencies. Laws for the welfare of the general public.

Private/Civil Law :

1. Contract law involves the enforcement of agreements among private individuals or the paymenof compensation for failure to fulfill the agreements

o Ex. Nurse and client nurse and insuranceo Nurse and employer client and health agency

An agreement between 2 or more competent person to do or not to do some lawfuact.

It maybe written or oral= both equally binding

Types of Contract:

1. Expressed when 2 parties discuss and agree orally or in writing the terms and conditions during thecreation of the contract.

Example: nurse will work at a hospital for only a stated length of time (6 months),under statedconditions (as volunteer, straight AM shift, with food/transportation allowance)

2. Implied one that has not been explicitly agreed to by the parties, but that the law considers to exis

Example: Nurse newly employed in a hospital is expected to be competent and to follow hospitalpolicies and procedures even though these expectations were not written or discussed.

Likewise: the hospital is expected to provide the necessary supplies, equipment needed to providcompetent, quality nursing care.

Feature/Characteristics/Elements of a lawful contract:

1. Promise or agreement between 2 or more persons for the performance of an action or restraint fromcertain actions.2. Mutual understanding of the terms and meaning of the contract by all.3. A lawful purpose activity must be legal4. Compensation in the form of something of value-monetary

Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

Tort law

Is a civil wrong committed against a person or a persons property. Person/persons responsible for the tort are sued for damages Is based on:

o ACT OF COMMISSION something that was done incorrectlyo ACT OF OMMISION something that should have been done but was not.

Classification of Tort

Unintentional Tort

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1. Negligence

Misconduct or practice that is below the standard expected of ordinary, reasonable and prudentperson

Failure to do something due to lack of foresight or prudence Failure of an individual to provide care that a reasonable person would ordinarily use in a similar

circumstance. An act of omission or commission wherein a nurse fails to act in accordance with the standard of

care.

Doctrines of Negligence:

a. Res ipsa loquitor the thing speaks for itself the injury is enough proof of negligenceb. Respondeat Superior let the master answer command responsibilityc. Force majuere unforeseen event, irresistible force

2. Malpractice

stepping beyond ones authority

6 elements of nursing malpractice:

a. Duty the nurse must have a relationship with the client that involves providing care and followingan acceptable standard of care.

b. Breach of duty

the standard of care expected in a situation was not observed by the nurse is the failure to act as a reasonable, prudent nurse under the circumstances something was done that should not have been done or nothing was done when it should have

been done

c. Foreseeability a link must exist between the nurses act and the injury suffered

d. Causation it must be proved that the harm occurred as a direct result of the nurses failure tofollow the standard of care and the nurse should or could have known that the failure tofollow the standard of care could result in such harm.

e. harm/injury physical, financial, emotional as a result of the breach of duty to the client Example:physical injury, medical cost/expenses, loss of wages, pain and suffering

f. damages amount of money in payment of damage/harm/injury

Intentional Tort

Unintentional tort do not require intent bur do require the element of HARM Intentional tort the act was done on PURPOSE or with INTENT

o No harm/injury/damage is needed to be liableo No expert witnesses are needed

Assault

An attempt or threat to touch another person unjustifiably Example:

o A person who threatens someone with a club or closed fist.

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o Nurse threatens a client with an injection after refusing to take the meds orally.

Battery

Willful touching of a person, persons clothes or something the person is carrying that may or ma

not cause harm but the touching was done without permission, without consent, is embarrassingcauses injury.

Example:o A nurse threatens the patient with injection if the patient refuses his meds orally. If the

nurse gave the injection without clients consent, the nurse would be committing battery

even if the client benefits from the nurses action.

False Imprisonment

Unjustifiable detention of a person without legal warrant to confine the person Occurs when clients are made to wrongful believe that they cannot leave the place Example:

o Telling a client no to leave the hospital until bill is paido Use of physical or chemical restraintso False Imprisonment Forceful Restraint=Battery

Invasion of Privacy

intrusion into the clients private domain right to be left alone

Types of Invasion the client must be protected from:

1. use of clients name for profit without consent using ones name, photograph for advertisementsHC agency or provider without clients permission

2. Unreasonable intrusion observation or taking of photograph of the client for whatever purposewithout clients consent.

3.

Public disclosure of private facts private information is given to others who have no legitimateneed for that.

4. Putting a person in a false/bad light publishing information that is normally considered offensivebut which is not true.

Defamation

communication that is false or made with a careless disregard for the truth and results in injury tthe reputation of a person

Types:

1.

Libel defamation by means of print, writing or pictureo Example:

1. o writing in the chart/nurses notes that doctor A is incompetent because he didntrespond immediately to a call

2. Slander defamation by the spoken word stating unprivileged (not legally protected) or false woby which a reputation is damaged

o Example: Nurse A telling a client that nurse B is incompetent Person defamed may bring the lawsuit The material (nurses notes) must be communicated to a 3rd party in order that th

persons reputation maybe harmed

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Public Law:

Criminal Lawdeals with actions or offenses against the safety and welfare of the public.

1. homicide self-defense2. arson- burning or property3. theft stealing4. sexual harassment5. active euthanasia6.

illegal possession of controlled drugs

Homicidekilling of any person without criminal intent may be done as self-defense

Arson willful burning of property

Theft act of stealing

Early Beliefs, Practices and Care of the sick

Early Filipinos subscribed to superstitious belief and practices in relation to health and sickness Diseases, their causes and treatment were associated with mysticism and superstitions Cause of disease was caused by another person (an enemy of witch) or evil spirits Persons suffering from diseases without any identified cause were believed bewitched by

mangkukulam Difficult childbirth were attributed to nonos Evil spirits could be driven away by persons with powers to expel demons Belief in special Gods of healing: priest-physician, word doctors, herbolarios/herb doctors

Early Hospitals during the Spanish Regime

Religious orders exerted efforts to care for the sick by building hospitals in different parts of thePhilippines:

1. Hospital Real de Manila San Juan de Dios Hospital2. San Lazaro Hospital Hospital de Aguas Santas3. Hospital de Indios

Prominent personages involved during the Philippine Revolution

1.

Josephine Bracken wife of Jose Rizal installed a field hospital in an estate in Tejeros thatprovided nursing care to the wounded night and day.

2. Rose Sevilla de Alvaro converted their house into quarters for Filipino soldiers during the PhiAmerican War in 1899.

3. Hilaria de Aguinaldo wife of Emlio Aginaldo organized the Filipino Red Cross.4. Melchora Aquino (Tandang Sora) nursed the wounded Filipino soldiers, gave them shelter an

food.5. Captain Salomen a revolutionary leader in Nueva Ecija provided nursing care to the wounded

when not in combat.6. Agueda Kahabagan revolutionary leader in Laguna also provided nursing services to her troo7. Trinidad Tecson (Ina ng Biak na Bato) stayed in the hospital at Biac na Bato to care for the

wounded soldiers.

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School Of Nursing

1. St. Pauls Hospital School of Nursing, Intramuros Manila 19002. Iloilo Mission Hospital Training School of Nursing 1906

o 1909 Distinction of graduating the 1st trained nurses in the Phils. With no standardrequirements for admission of applicants except their willingness to work

o

April 1946 a board exam was held outside of Manila. It was held in the Iloilo MissionHospital thru the request of Ms. Loreto Tupas, principal of the school.3. St. Lukes Hospital School of Nursing 1907; opened after four years as a dispensary clinic.4. Mary Johnston Hospital School of Nursing 19075. Philippines General Hospital school of Nursing 1910

College of Nursing

1. UST College of Nursing 1st College of Nursing in the Phils: 18772. MCU College of Nursing June 1947 (1st College who offered BSN 4 year program)

3.

UP College of Nursing June 19484. FEU Institute of Nursing June 19555. UE College of Nursing Oct 1958

1909

3 female graduated as qualified medical-surgical nurses

1919

The 1st Nurses Law (Act#2808) was enacted regulating the practice of the nursing profession inthe Philippines Islands. It also provided the holding of exam for the practice of nursing on the 2nMonday of June and December of each year.

1920

1st board examination for nurses was conducted by the Board of Examiners, 93 candidates tookthe exam, 68 passed with the highest rating of 93.5%-Anna Dahlgren

Theoretical exam was held at the UP Amphitheater of the College of Medicine and Surgery.Practical exam at the PGH Library.

1921

Filipino Nurses Association was established (now PNA) as the National Organization Of FilipinoNurses

PNA: 1st President Rosario Delgado Founder Anastacia Giron-Tupas

1953

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Republic Act 877, known as the Nursing Practice Law was approved.

IV Fluid/Solution Quick Reference Guide

Intravenous Solutions are used in fluid replacement therapy by changing the composit

Listed below is a table which may serve as your quick reference guide on the

Type Description Osmolality Use Miscellaneous

NormalSaline(NS)

0.9% NaCl inWaterCrystalloidSolution

Isotonic

(308 mOsm)

Increasescirculating plasmavolume when redcells areadequate

Replaces losseswithout alteringfluid concentratio

Helpful for Na+replacement

1/2

NormalSaline

(1/2 NS)

0.45% NaCl inWaterCrystalloidSolution

Hypotonic

(154 mOsm)

Raises total fluidvolume

Useful for dailymaintenance ofbody fluid, but is less value forreplacementof NaCldeficit.

Helpful forestablishing renalfunction.

Fluid replacementfor clients who doneed extra glucos

(diabetics)

Lactated

Ringers

(LR)

Normal salinewith electrolytesand buffer

Isotonic

(275 mOsm)

Replaces fluidand buffers pH

Normal saline witK+, Ca++, andlactate (buffer)

Often seen withsurgery

D5W Dextrose 5% inwater

Crystalloidsolution

Isotonic (in thebag)

*Physiologicallyhypotonic

(260 mOsm)

Raises total fluidvolume.Helpful in

rehydrating andexcretorypurposes.

Provides 170-200calories/1,000cc f

energy. Physiologically

hypotonic-thedextrose ismetabolized quickso that only wateremains ahypotonic fluid

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D5NS Dextrose 5% in0.9% saline

Hypertonic

(560 mOsm)

Replaces fluidsodium, chloride,and calories.

Watch for fluidvolume overload

D51/2 NSDextrose 5% in0.45% saline

Hypertonic

(406 mOsm)

Useful for dailymaintenance ofbody fluids andnutrition, and for

rehydration.

Most commonpostoperative flui

D5LR Dextrose 5% inLactatedRingers

Hypertonic

(575 mOsm)

Same as LR plusprovides about180 calories per1000ccs.

Watch for fluidvolume overload

Normosol-R

Normosol Isotonic

(295 mOsm)

Replaces fluidand buffers pH

pH 7.4 Contains sodium,

chloride,calcium, potaum and magnesiu

Common fluid forOR and PACU

Urine Specimen

1. Clean-Catch mid-streamurine specimen for routine urinalysis, culture and sensitivity test

a. Best time to collect is in the morning, first voided urineb. Provide sterile containerc. Do perineal care before collection of the urine

d. Discard the first flow of urinee. Label the specimen properlyf. Send the specimen immediately to the laboratoryg. Document the time of specimen collection and transport to the lab.h. Document the appearance, odor, and usual characteristics of the specimen.

2. 24-hour urine specimen

a. Discard the first voided urine.b. Collect all specimens thereafter until the following dayc. Soak the specimen in a container with iced. Add preservative as ordered according to hospital policy

3.Second-Voided urine required to assess glucose level and for the presence of albumen in the urin

a. Discard the first urineb. Give the patient a glass of water to drinkc. After few minutes, ask the patient to void

4. Catheterized urine specimen

a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequatespecimen can be collected.

b. Clamping the drainage tube and emptying the urine into a container are contraindicated after agenitourinary surgery.

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Stool Specimen

1. Fecalysisto assess gross appearance of stool and presence of ova or parasite

a. Secure a sterile specimen containerb. Ask the pt. to defecate into a clean, dry bed pan or a portable commode.c. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial

growth and paper towel contain bismuth which interfere with the test result.

2. Stool culture and sensitivity test

To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to variousantibiotics.

3. Fecal Occult blood test

Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer,detecting melena stool

a. Hematest- (an Orthotolidin reagent tablet)b. Hemoccult slide- (filter paper impregnated with guaiac)*Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.

c. Colocare a newer test, requires no smear

Instructions

1. Advise client to avoid ingestion of red meat for 3 days2. Patient is advice on a high residue diet3.

Avoid dark food and bismuth compound4. If client is on iron therapy, inform the MD5. Make sure the stool in not contaminated with urine, soap solution or toilet paper6. Test sample from several portion of the stool.

Venipuncture

Pointers

1.

Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy oblood administration because it mat affect the result.2. Never collect venous sample from an infectious site because it may introduce pathogens into the

vascular system3. Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular

injury.4. Dont wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine

iodine.5. If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy, maintain

pressure on the site for at least 5 min after withdrawing the needle.

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Arterial puncture for ABG test

1. Before arterial puncture, perform Allens test first.2. If the patient is receiving oxygen, make sure that the patients therapy has been underway for a

least 15 min before collecting arterial sample3. Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the

patient is having.4. If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting th

sample.

Blood specimen

1. No fasting for the following tests:o CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes

2. Fasting is required:o FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)

Sputum Specimen

1. Gross appearance of the sputum

a. Collect early in the morning

b. Use sterile container

c. Rinse the mount with plain water before collection of the specimen

d. Instruct the patient to hack-up sputum

2. Sputum culture and sensitivity test

a. Use sterile container

b. Collect specimen before the first dose of antibiotic

3. Acid-Fast Bacilli

a. To assess presence of active pulmonary tuberculosis

b. Collect sputum in three consecutive mornings

4. Cytologic sputum exam

a. To assess for presence of abnormal or cancer cells.

Leavell and Clarks Three Levels of Prevention

Primary Prevention

Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happenin

Health Promotion

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health education

marriage counseling

genetic screening

good standard of nutrition adjusted to developmental phase of life

Specific Protection

use of specific immunization attention to personal hygiene

use of environmental sanitation

protection against occupational hazards

protection from accidents

use of specific nutrients

protections from carcinogens

avoidance to allergens

Secondary Prevention

Also known as Health Maintenance. Seeks to identify specific illnesses or conditions at an early sta

catastrophic effects that could occur if proper attention and treatment are not provided

Early Diagnosis and Prompt Treatment

case finding measures

individual and mass screening survey

prevent spread of communicable disease

prevent complication and sequelae

shorten period of disability

Disability Limitations

Adequate treatment to arrest disease process and prevent further complication and sequelae.

Provision of facilities to limit disability and prevent death.

Tertiary Prevention

Occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt t

health status. To establish a high-level wellness. To maximize use of remaining capacities

Restoration and Rehabilitation

Work therapy in hospital

Use of shelter colony

Maslows Hierarchy of Basic Human Needs

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Definition

Each individual has unique characteristics, but certain needs are common to all people.

A need is something that is desirable, useful or necessary. Human needs are physiologic and psycho

health or well-being.

Physiologic

1. Oxygen

2.

Fluids3. Nutrition4. Body temperature

5. Elimination

6. Rest and sleep7. Sex

Safety and Security

1. Physical safety

2.

Psychological safety3. The need for shelter and freedom from harm and danger

Love and belonging

1. The need to love and be loved2. The need to care and to be cared for.

3. The need for affection: to associate or to belong

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4. The need to establish fruitful and meaningful relationships with people, institution, or organization

Self-Esteem Needs

1. Self-worth2. Self-identity

3.

Self-respect4. Body image

Self-Actualization Needs

1. The need to learn, create and understand or comprehend

2. The need for harmonious relationships3. The need for beauty or aesthetics

4. The need for spiritual fulfillment

Characteristics of Basic Human Needs

1. Needs are universal.

2. Needs may be met in different ways

3. Needs may be stimulated by external and internal factor4. Priorities may be deferred

5. Needs are interrelated

Maslows Characteristics of a Self-Actualized Person

1. Is realistic, sees life clearly and is objective about his or her observations

2. Judges people correctly

3. Has superior perception, is more decisive4. Has a clear notion of right or wrong

5. Is usually accurate in predicting future events

6. Understands art, music, politics and philosophy

7. Possesses humility, listens to others carefully8. Is dedicated to some work, task, duty or vocation

9. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes

10.Is open to new ideas

11.

Is self-confident and has self-respect12.Has low degree of self-conflict; personality is integrated

13.Respect self, does not need fame, and possesses a feeling of self-control

14.Is highly independent, desires privacy15.Can appear remote or detached

16.Is friendly, loving and governed more by inner directives than by society

17.Can make decisions contrary to popular opinion18.Is problem centered rather than self-centered

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19.Accepts the world for what it is

Metro Manila Development Screening Test (MMD

Definition

Simple and clinically useful tool

To determine early serious developmental delays

Dr. William K. Frankenburg

Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST

Developed for health professionals (MDs, RNs, etc) It is not an intelligence test

It is a screening instrument to determine if childs development is within normal

Children 6 years and below

Purposes

Measures developmental delays

Evaluates 4 aspects of development

Aspects of development

In the care of pediatric clients, growth and development are not in isolation. Nurses being competent in the

and milestones are in best position to counsel clients on these aspects. Having background knowledge on g

determine developmental delays through the aid of screening tests.

The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for normalcy of the years old and below. Modified and standardized by Dr. Phoebe Williams from the original Denver Deve

MMDST evaluates 4 sectors of development:

Personal-Socialtasks which indicate the childs ability to get along with people and to take care o

F ine-Motor Adaptivetasks which indicate the childs ability to see and use his hands to pick up ob

Languagetasks which indicate the childs ability to hear, follow directions and to speak

Gross-Motortasks which indicate the childs ability to sit, walk and jump

MMDST KIT. Preparation for test administration involves the nurse ensuring the completeness of the test

followed as specified:

MMDST manual

test Form

bright red yarn pom-pom

rattle with narrow handle

eight 1-inch colored wooden blocks (red, yellow, blue green)

small clear glass/bottle with 5/8 inch opening

small bell with 2 inch-diameter mouth

rubber ball 12 inches in circumference

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cheese curls

pencil

EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the procedure to the

not a diagnostic test but rather a screening test only. When conducting the test, the parents or caregivers o

may be misinterpreted by them. The nurse should also establish rapport with the parent and the child to ens

AGE & THE AGE LINE.To proceed in the administration of the test, the nurse is to compute for the exacitself. The age is the most crucial component of the test because it determines the test items that will be app

subtracting the childs birth date with the test date. After computing, draw the age line in the test form.

TEST ITEMS.There are 105 test items in MMDST but not all are administered. The examiner prioritizes explain to the parent or caregiver that the child is not expected to perform all the tasks correctly. If the sequ

social then progressing to the other sectors. Items that are footnoted with R can be passed by report.

SCORING. The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor Opportunity (NO

considered a developmental delay. Whereas, failure of an item that is completely to the right of the childs a

CONSIDERATIONS:

Manner in which each test is administered must be exactly the same as stated in the manual, words o

If the child is premature, subtract the number of weeks of prematurity. But if the child is more than

If the child is shy or uncooperative, the caregiver may be asked to administer the test provided that t

in the manual

If the child is very shy or uncooperative, the test may be deferred

Moral Theories

Freud (1961)

Believed that the mechanism for right and wrong within the individual is the superego, or conscienstandards and character or character traits of the model parent through the process of identification

The strength of the superego depends on the intensity of the childsfeeling of aggression or attachmthe parent.

Erikson (1964)

Eriksons theory on the development of virtues or unifying strengths of the good man suggests ththe conflicts of each psychosocial developmental stages favorably resolved, then an egostrength

Kohlberg

Suggested three levels of moral development. He focused on the reason for the making of a decisio

1. At first level called the premolar or the preconventional level, children are responsive to cultural ru

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interpret these in terms of the physical consequences of the actions, i.e., punishment or reward.2. At the second level, the conventional level, the individual is concerned about maintaining the expe

3. At the third level, people make postconventional, autonomous, or principal level. At this level, peo

regard to outside authority or to the expectations of others. These involve respect for other human

Peter (1981)

Proposed a concept of rational morality based on principles. Moral development is usually considefeels), moral judgment (how one reason), and moral behavior (how one act).

In addition, Peters believed that the development of character traits or virtues is an essential aspect

learned from others and encouraged by the example of others.

Also, Peters believed that some can be described as habits because they are in some sense automat

tidiness, thrift and honesty.

Gilligan (1982)

Included the concepts of caring and responsibility. She described three stages in the process of dev

1. Caring for oneself.2. Caring for others.

3. Caring for self and others.

She believed the human see morality in the integrity of relationships and caring. For women, what

the other hand, men consider what is right to be what is just.

Spiritual Theories

Fowler (1979)

Described the development of faith. Hebelieved that faith, or the spiritual dimension is a force tha

He used the term faith as a form of knowing a way of being in relation to an ultimate environm

made-of-being-in-relation to others in which we invest commitment, belief, love, risk and hope.

Nasogastric and Intestinal Tubes

Nasogastric Tubes

1. Levin Tubesingle lumen

a. Suctioning gastric contentsb. Administering tube feedings

2. Salem Sump Tubedouble lumen (smaller blue lumen vents the tube & prevents suction on the gastri

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source)

a. Suctioning gastric contents

b. Maintaining gastric decompression

Key Points

1. Prior to insertion, position the client in High-Fowlers position if possible.

2. Use a water-soluble lubricant to facilitate insertion3. Measure the tube from the tip of the clients nose to the earlobe and from the nose to the xiphoid p

the stomach

4. Flex the clients head slightly forward; this will decrease the chance of entry into the trachea

5. Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the sthe esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress

6. Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of th

7. Validating placement of tube.o Aspirate gastric contents via a syringe to the end of the tube

o

Measure ph of aspirate fluido Place the stethoscope over the gastric area and inject a small amount of air through the NG

should be heard

8. Characteristics of nasogastric drainage:o Normally is greenish-yellowish, with strands of mucous

o Coffee-ground drainageold blood that has been broken down in the stomach

o Bright red bloodbleeding from the esophagus, the stomach or swallowed from the lungs

o Foul-smelling (fecal odor)occurs with reverse peristalsis in bowel obstruction; increase i

Intestinal Tubes

Provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distenormal peristalsis to propel tube through the stomach into the intestine to the point of obstruction w

1. Types of Intestinal Tubes

a. Cantor and Harris Tubes

i. Approximately 6-10 feet long

ii. Single lumen

iii. Mercury placed in rubber bag prior to tube insertion

b. Miller-Abbot Tubes

i. Approximately 10 feet long

ii. Double lumen

iii. One lumen utilized for aspiration of intestinal contents

iv. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into th

2.Nursing Implications

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a. Maintain client on strict NPO

b. Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray

c. After the tube has been placed in the stomach, position client on the right side to facilitae passage thro d. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician

e. Encourage activity, to facilitate movement of the tube through the intestine

f. Evaluate the type of gastric secretions being aspiratedg. Do not tape or secure the tube until it has reached the desired position

h. Tubes may attached to suction and left in place for several days

i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirstj. Removal of the tube depends on the relief of the intestinal obstruction

k. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or

l. May be allowed to progress through the intestines and expelled via the rectum.

How to Insert a Nasogastric (NG) Tube

Check physicians order.

Check clients identaband and if able have client state name.

Discuss procedure to client.

Provide privacy.

Gather equipment.

Position client at 45 degree angle or higher with head elevated.

Wash hands and don clean gloves.

Provide regular oral and nasal hygiene.

Remove gloves and wash hands.

Position client for comfort.

Document procedure.

Nasal GavageI. Definition:

In this method of feeding, liquid is introduced into the stomach through a rubber catheter which is

the esophagus. When forced feeding is necessary, this method is less exhausting as the mouth does

II. Therapeutic Uses:

1. When a patient is weakened and cannot swallow food.

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2. Sometimes in the operation of the mouth such as carcinoma of the tongue, a cleft palate or fracture

3. In the operation of the throat and sometimes after tracheotomy.

4.

In tetanus or meningitis with a locked jaw.5. In forced feeding for irrational and violet patients.

6. In very weak patient who cannot swallow food vary well.

III. Equipment:

Tray with:

Medium size rubber catheter

Sterile (No.2 French catheter for adult)

Sterile glass syringe or a small glass funnel attached O.S

Kidney basin

Dressing rubber

Draw sheet

Lubricant

A flask containing the nourishment ordered at temperature of 104 to 105F

IV. Procedure

Food consists of any liquid for which will readily pass through the tube. The temperature should be warm, not hot, as the lining of the nose is much sensitive than that of th

The danger of burning the patient is greater when feeding by this method

1. The position of the patient may be lying down with the head turned to one side or sitting up with thwith head turned away from the nurse.

2. Expel the air and lubricate the tube.

3. Insert the curve thru the nose and backward inward the septum. Instruct the patient to make motion4. Tell patient to open the mouth and look if the catheter has passed if patient coughs, wait before mo

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5. Introduce 6 to 8 inches. Wait until the patient is accustomed to the presence of the tube.6. Connect the funnel to the catheter; then pour the liquid slowly at the sides. Raise 3 to 4 inches abov

7. Wait for a few minutes then pinch the tube and withdraw. In some cases the tube is left and hold in

VI. Precautionary Measures While Doing the Nasal Gavage

The following precautions should be strictly observe during a nasal gavage:

1. The catheter should first be lubricated and in inserting it should be directed toward the septum of th

and inserted again in the other nostril.

2. As the catheter is small, there is considerable danger of its passing into the larynx therefore the patin the solution which if the tube should be in the larynx would down the patient.

3. Even a small amount of food in the lungs would cause a severe irritation, and dyspnea and if, allow

lead to a lung abscess or septic pneumonia, if the tube is in the trachea a whistling sound will be he

a gurgling sound will be heard.4. As the tube is soft it may become coiled upon itself in the mouth or in the throat. If the fluid, is pou

checking and gasping. And will almost certainly enter the larynx causing dyspnea, cyanosis and lapass the finger to the back of the throat to sea the tube is in position.5. Before pouring in the solution, wait until the patient is at rest, until all distress has subsided and no

esophagus.

6. Pour in only few drops at first, then pour the balance in very slowly, if there are not symptoms of c7. After all the fluid has left the funnel, pinch the catheter and quickly withdraw.

Nursing Jurisprudence

Jurisprudence

It embraces:

1. All laws enacted by the legislative body.2. All regulations promulgated by those in authority.

3. Court decisions.4.

Formal principles upon which laws are based.

Nursing Jurisprudence

Defined as the department of law that comprises all the legal rules and principles affecting the pracinterpretation of all these rules and principles and their application in the regulation of the practice

It deals with:

1. All laws, rules and regulations.

2. Legal principles and doctrines governing and regulating the practice of nursing.

3. Legal opinions and decisions of competent authority in cases involving nursing practice.

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Sources of Nursing Jurisprudence in the Philippines

The sources are the following:

1. The Constitution of the Republic of the Philippines, particularly the Bill of Rights.

2.

Republic Act No. 7164 otherwise known as the Philippine Nursing Law of 1991.3. Rules and regulations promulgated by the Board of Nursing and/or Professional Regulation Comm

4. Decisions of the Board of Nursing and/or Professional Regulation Commission on nursing cases.5. Decisions of the Supreme Court on matters relevant to nursing.

6. Opinions of the Secretary of Justice in like cases.

7. The Revised Penal Code.

8. The New Civil Code of the Philippines.9. The Revised Rule of Courts.

10.The National Internal Revenue Code as amended

Nursing TheoristNursing

As defined by the INTERNATIONAL COUNCIL OF NURSESas written by Virginia Henderson.

The unique function of the nurse is to assist the individual, sick or well, in the performance of thos

the client would perform unaided if he had the necessary strength, will or knowledge.

Help the client gain independence as rapidly as possible.

Nursing Theory

Over the years, nursing has incorporated theories from non-nursing sources, including theories of systems

Barnum defines theory as a construct that accounts for or organizes some phenomenon. A nursing theory

With the formulation of different theories, concepts, and ideas in nursing it:

It guides nurses in their practice knowing what is nursing and what is not nursing.

It helps in the formulations of standards, policies and laws.

It will help the people to understand the competencies and professional accountability of nurses.

It will help define the role of the nurse in the multidisciplinary health care team.

Four Major Concepts

Nurses have developed various theories that provide different explanations of the nursing discipline. All thhuman beings. People are the recipients of nursing care; they include individuals, families, communities, a

internally and externally. It means not only in the everyday surroundings but all setting where nursing care

being. The concept of Nursingis central to all nursing theories. Definitions of nursing describe what nurs

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nursing theories address each of the four central concepts implicitly or explicitly.

Betty Neuman

(1972, 1982, 1989, 1992)

Health Care System Model

The Neuman System Model or Health Care System Model

Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, seco

To address the effects of stress and reactions to it on the development and maintenance of health. T

clients basic structure and to obtain or maintain a maximum level of wellness. The nurse helps theadjust to environmental stressors and maintain client stability.

Metaparadigm

Person

A client system that is composed of physiologic, psychological, sociocultural, and environmental v

Environment

Internal and external forces surrounding humans at any time.

Health

Health or wellness exists if all parts and subparts are in harmony with the whole person.

Nursing

Nursing is a unique profession in that it is concerned with all the variables affecting an individual

Dorothea Orem

(1970, 1985)Self-Care Deficit Theory

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Self-Care Deficit Theory

Defined Nursing: The act of assisting others in the provision and management of self-care to

effectiveness. Focuses on activities that adult individuals perform on their own behalf to maintain life, health and

Has a strong health promotion and maintenance focus.

Identified 3 related concepts:

1. Self-care - activities an Individual performs independently throughout life to promote and m

2. Health- results when self-care agency (Individuals ability) is not adequate to meet the kno3. Nursing System- nursing interventions needed when Individual is unable to perform the n

Wholly compensatory - nurse provides entire self-care for the client.

Example: care of a new born, care of client recovering from surgery in a pos

Partial compensatory - nurse and client perform care; client can perform selected

the client cannot meet independently.

Example: Nurse can assist post operative client to ambulate, Nurse can bring

Supportive-educative - nurses actions are to help the client develop/learn their ow

Example: Nurse guides a mother how to breastfeed her baby, Counseling a p

Dorothy E. Johnson

(1980)Behavioral System Model

Behavioral System Model

Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client

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Viewed the patients behavior as a system, which is a whole with interacting parts.

The nursing process is viewed as a major tool.

To reduce stress so the client can recover as quickly as possible. According to Johnson, each perso

1. Ingestive. Taking in nourishment in socially and culturally acceptable ways.2. Eliminated.Riddling the body of waste in socially and culturally acceptable ways.

3. Affiliative.Security seeking behavior.

4.

Aggressive.Selfprotective behavior.5. Dependence.Nurturanceseeking behavior.

6. Achievement.Master of oneself and ones environment according to internalized standard

7. Sexual role identity behavior

In addition, she viewed that each person strives to achieve balance and stability both internally and

environmental forces through learned pattern of response. Furthermore, She believed that the patie

social demands; who is able to modify his behavior in ways that support biologic imperatives; who

care professionals knowledge and skills; and whose behavior does not give evidence of unnecessa

Metaparadigm

Person

A system of interdependent parts with patterned, repetitive, and purposeful ways of behaving.

Environment

All forces that affect the person and that influence the behavioral system

Health

Focus on person, not illness. Health is a dynamic state influenced by biologic, psychological, and s

Nursing

Promotion of behavioral system, balance and stability. An art and a science providing external assi

Ernestine Wiedenbach

(1964)

The Helping Art of Clinical Nursing

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The Helping Art of Clinical Nursing

Developed the Clinical NursingA Helping Art Model.

She advocated that the nurses individual philosophy or central purpose lends credence to nursing

She believed that nurses meet the individuals need for help through the identification of the needs

Components of clinical practice: Philosophy, purpose, practice and an art.

Metaparadigm

Person

Any individual who is receiving help from a member of the health profession or from a worker in t

Environment

Not specifically addressed

Health

Concepts of nursing, client, and need for help and their relationships imply health-related concerns

Nursing

The nurse is a functional human being who acts, thinks, and feels. All actions, thoughts, and feelin

Faye Glenn Abdellah

(1960)Twenty One Nursing Problems

Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing jud

Introduced PatientCentered Approachesto Nursing Model She defined nursing as service to conceptualized nursing as an art and a science that molds the attitudes, intellectual competencies an

help people, sick or well, and cope with their health needs.

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21 Nursing Problems

1. To maintain good hygiene.2. To promote optimal activity; exercise, rest and sleep.

3. To promote safety.

4. To maintain good body mechanics

5.

To facilitate the maintenance of a supply of oxygen6. To facilitate maintenance of nutrition

7. To facilitate maintenance of elimination8. To facilitate the maintenance of fluid and electrolyte balance

9. To recognize the physiologic response of the body to disease conditions

10.To facilitate the maintenance of regulatory mechanisms and functions

11.To facilitate the maintenance of sensory functions12.To identify and accept positive and negative expressions, feelings and reactions

13.To identify and accept the interrelatedness of emotions and illness.

14.To facilitate the maintenance of effective verbal and non-verbal communication

15.To promote the development of productive interpersonal relationship

16.

To facilitate progress toward achievement of personal spiritual goals17.To create and maintain a therapeutic environment

18.To facilitate awareness of self as an individual with varying needs.19.To accept the optimum possible goals

20.To use community resources as an aid in resolving problems arising from illness.

21.To understand the role of social problems as influencing factors

Metaparadigm

Person

The recipients of nursing care having physical, emotional, and sociologic needs that may be overt

Environment

Not clearly defined. Some discussion indicates that clients interact with their environment, of whic

Health

A state when the individual has no unmet needs and no anticipated or actual impairment.

Nursing

Broadly grouped in 21 nursing problems, which center aroundneeds for hygiene, comfort, activiand emotional health promotion, interpersonal relationships, and development of self-awareness. N

Florence Nightingale

(1860)

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Environmental Theory

Environmental Theory

Defined Nursing: The act of utilizing the environment of the patient to assist him in his recov

Focuses on changing and manipulating the environment in order to put the patient in the best possi Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation a

Considered a clean, well-ventilated, quiet environment essential for recovery.

Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, Developed the described the first theory of nursing. Notes on Nursing: What It Is What It Is No

order to put the patient in the best possible conditions for nature to act.

Metaparadigm

Person

An individual with vital reparative processes to deal with disease.

Environment

External conditions that affect life and individuals development.

Health

Focus is on the reparative process of getting well

Nursing

Goal is to place the individual in the best condition for good healthcare

Evelyn Tomlin, Helen Erickson, and Mary A

(1983)Modeling and Role Modeling Theory

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Modeling and Role Modeling Theory

Developed Modeling and Role Modeling Theory. The focus of this theory is on the person. The n

interpersonal and interactive theory.

They asserted that each individual unique, has some self-care knowledge, needs simultaneously to

Nurses in this theory, facilitate, nurture and accept the person unconditionally.

Metaparadigm

Person

A differentiation is made between patients and clients in this theory. A patient is given treatment an

is for nurses to work with clients. A client is one who is considered to be a legitimate member ofplanned regimen, and who is incorporated into the planning and implementation of his or her own

Environment

Environment is not identified in the theory as an entity of its own. The theorist see environment incultural and individual. Biophysical stressors are seen as part of the environment.

Health

Health is a state of physical, mental and social well-being, not merely the absence of disease or invarious subsystems [of a holistic person].

Nursing

The nurse is a facilitator, not an effector. Our nurse-client relationship is an interactive, interpers

his or her own strengths.

Hildegard Peplau

(1951)Interpersonal Relations Theory

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Interpersonal Relations Theory

DefinedNursing: An interpersonal process of therapeutic interactions between an Individual who

to recognize, respond to the need for help.

Nursing is a maturing force and an educative instrument

Identified 4 phases of the Nurse - Patient relationship:

1.

Orientation - individual/family has a felt need and seeks professional assistance from a nurse (wh2. Identification- where the patient begins to have feelings of belongingness and a capacity for dealin

strength ensues. Here happens the selection of appropriate professional assistance.3. Exploitation- the nurse uses communication tools to offer services to the patient, who is expected t

4. Resolution - where patients needs have already been met by the collaborative efforts between the p

links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Metaparadigm

Person

An organism striving to reduce tension generated by needs

Environment

The interpersonal process is always included, andpsychodynamic milieu receives attention, with e

Health

Ongoing human process that implies forward movement of personality and other ongoing human p

personal, and community living.

Nursing

Interpersonal therapeutic process that functions cooperatively with others human processes that meducative instrument, a maturing force that aims to promote forward movement of personality.

Ida Jean Orlando

(1961)

The Dynamic Nurse-Patient Relationsh

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The Dynamic Nurse-Patient Relationship

Conceptualized The Dynamic NursePatient Relationship Model.

She believed that the nurse helps patients meet a perceived need that the patient cannot meet for th

to meet an immediate need for help in order to avoid or to alleviate distress or helplessness.

She emphasized the importance of validating the need and evaluating care based on observable out

To interact with clients to meet immediate needs by identifying client behaviors, nurses reactions,

Metaparadigm

Person

Unique individual behaving verbally nonverbally. Assumption is that individuals are at times able

Environment

Not defined

Health

Not defined. Assumption is that being without emotional or physical discomfort and having a sens

Nursing

Professional nursing is conceptualized as finding out and meeting the clients immediate need for h

Imogene King

(1971, 1981)Goal Attainment Theory

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Goal Attainment Theory

Nursing process is defined as dynamic interpersonal process between nurse, client and health care

Postulated the Goal Attainment Theory. She described nursing as a helping profession that assis

health. If is this not possible, nurses help individuals die with dignity.

In addition, King viewed nursing as an interaction process between client and nurse whereby durin

and goals are achieved.

Metaparadigm

Person

Biopsychosocial being

Environment

Internal and external environment continually interacts to assist in adjustments to change.

Health

A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing

Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situat

Jean Watson

(1979)

The Philosophy and Science of Caring

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The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring h

Nursing is a human science of persons and human health-illness experiences that are mediated by p

transactions

She defined caring as a nurturing way or responding to a valued client towards whom the nurse fee

demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts

Carative Factors:1. The formation of a humanistic-altruistic system of values

2. Instillation of faith-hope3. The cultivation of sensitivity to ones self and others

4. The development of a helping- trust relationship

5. The promotion and acceptance of the expression of positive and negative feelings.

6. The systemic use of the scientific problem-solving method for decision making7. The promotion of interpersonal teaching-learning

8. The provision for supportive, protective and corrective mental, physical, socio-cultural and

9.

Assistance with the gratification of human needs10.The allowance for existential phenomenological forces

Metaparadigm

Person

A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, int

Environment

Social environment, caring and the culture of caring affect health

Health

Physical, mental, and social wellness

Nursing

A human science of people and human health; illness experiences that are mediated by professiona

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Joyce Travelbee

(1966, 1971)

Interpersonal Aspects of Nursing

Interpersonal Aspects of Nursing

She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing

health finding meaning in illness, or maintaining maximal degree of health. She further viewed that interpersonal process is a human-to-human relationship formed during illn

She believed that a person is a unique, irreplaceable individual who is in a continuous process of b

Metaparadigm

Person

A unique, irreplaceable individual who is in a continuous process of becoming, evolving, and chan

Environment

Not defined

Health

Heath includes the individuals perceptions of health and the absence of disease.

Nursing

An interpersonal process whereby the professional nurse practitioner assists an individual, family,

suffering, and if necessary, to find meaning in these experiences.

Lydia Hall

(1964)Core, Care and Cure Model

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Core, Care and Cure Model

The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (c

Introduced the model of Nursing:What Is It? Focusing on the notion that centers around three com

Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self anthe physicians orders. Core and cure are shared with the other health care providers.

The major purpose of care is to achieve an interpersonal relationship with the individual that will f

Metaparadigm

Person

Client is composed of body, pathology, and person. People set their own goals and are capable of l

Environment

Should facilitate achievement of the clients personal goals.

Health

Development of a mature self-identity that assists in the conscious selection of actions that facilitat

Nursing

Caring is the nurses primary function. Professional nursing is most important during the recuperat

Madeleine Leininger

(1978, 1984)Transcultural Care Theory and Ethnonur

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Transcultural Care Theory and Ethnonursing

Developed the Transcultural Nursing Model.She advocated that nursing is a humanistic and scie

processes (cultural values, beliefs and practices) to improve or maintain a health condition.

Nursing is a learned humanistic and scientific profession and discipline which is focused on human

or enable individuals or groups to maintain or regain their well being (or health) in culturally mean

Transcultural nursing as a learned subfield or branch of nursing which focuses