HEALTH AND ILLNESSES Health is an ongoing process

HEALTH - a way of life through which a person develops and

- Presence or absence of disease (traditional encourages every aspect of the body, mind, and
definition). feelings to interrelate harmoniously as much as
- State of being well and using every power the possible
individual possess to the fullest extent (Nightingale, WELLNESS
1860/1969). - Wellness is a state of well-being.
- A state of complete physical, mental, and social - Basic Aspects of Wellness include:
well-being, and not merely the absence of disease of a. Self-responsibility
infirmity (WHO,1948); a more holistic view of health. b. Ultimate goal
- Role and Performance: The ability to maintain c. Dynamic, growing process
normal roles (American Sociologist, Talcot Parsons, d. Daily decision making in the areas of Nutrition
1951) e. Physical fitness
- Health is not a condition; it is an adjustment. It is f. Preventive health care g. Emotional health
not a state but a process. The process adapts the h. Whole being of the individual (most important)
individual not only to our physical but also our social 7 Components of Wellness
environments (US President's Commission on 1.) Physical
Health Needs of the Nation, 1953) 2.) Social
- Health is a dynamic state of being which in which 3.) Emotional
the developmental and behavioral potential on an 4.) Intellectual
individual is realized to the fullest extent possible 5.) Spiritual
(ANA, 1980) 6.) Occupational
- ANA defines health is more than a state or the 7.) Environmental
absence of disease. It includes striving toward
optimal functioning 7 Components of Wellness
- ANA also stated "Health was an experience that is 1.) Physical
often expressed in terms of wellness and illness." - The ability to carry out daily tasks
(ANA, 2004) - Achieve fitness
- ANA also stated "Health may occur in the presence (pulmonary, cardiovascular, gastrointestinal)
or absence of disease or injury." (ANA, 2004) -Maintain adequate nutrition and proper body fat
PERSONAL DEFINITION OF HEALTH - Avoid abusing drugs, alcohol, and/or using
- Health is highly individual perception. tobacco products
- The following are examples of individuals who - Generally practice positive lifestyle habits
would probably say they are healthy even though 2.) Social
they have physical impairments that some would - The ability to interact successfully with people and
consider an illness: within the environment of which each person is a
• A 15-year-old with diabetes, takes injectable insulin part
each morning. He plays on the school soccer team - To develop and maintain intimacy with S.O.
and is editor of the high school newspaper (Health in - To develop respect and tolerance for those with
terms of roles and performance based from different opinions and beliefs
American Sociologist, Talcot Parsons, 1951) 3.) Emotional
- The ability to maintain stress
• A 32-year-old is paralyzed from the waist fown and - Express emotions appropriately
needs a wheelchair for mobility. He is taking - Involves the ability to recognize, accept, express
accounting at the nearby commege and uses a feelings, and to accept one's limitations
specially designed automobile for transportation. 4.) Intellectual
• A 72-year-old takes anti-hypertensive medications - The ability to learn and use information effectively
to treat high BP. She bowls once a week, makes for personal, family, and career development
handicrafts for a local charity, and travels 2 months - Involves striving for continued growth and learning
each year. to deal with new challenges effectively
- Many people define and describe Health as the 5.) Spiritual
following: - The belief in some force (nature, science, religion,
1. Being free from symptoms of disease and pain as or a higher power) that serves to unite human
much as possible. beings and provide meaning and purpose to life.
2. Being able to be active and to do what they want - Includes a person's morals, values, and ethics
or must. 6.) Occupational
3. Being in good spirits most of the time. & these - The ability to achieve a balance between work and
characteristics indicate that health is not something leisure time
that a person achieves suddenly at a - Person's beliefs about education, employment, and
specific time
home influence personal satisfaction and 3.) Adaptive Model
relationship with others Health is a creative process.
7.) Environmental Disease is a failure in adaptation/
- The ability to promotes health measures that maladaptation.
improve: Aim of treatment: To restore the ability of the
a. The standard of living person to adapt, that is, to cope.
b. The quality of life in the community Extreme good health is flexible adaptation and
- Includes influences: food, air, water interaction to the environment to maximum
• The 7 components overlap to some extent. advantage.
• The factors in one component often directly affects Focus: Stability; Although there is also an
the other. element of growth and change.
• Wellness involves working on "ALL" aspects of the
model. 4.) Eudemonistic Model
Example: Comprehensive view of health.
A person who learns to comtrol daily stress levels Health is seen as a condition of actualization/
from a physiologic perspective is also helping to realization of person's potential.
maintain the emotional stamina needed to cope with Actualization = the apex of fully developed
the crisis. personality (described by Abraham Maslow).
WELL-BEING Fulfillment & Complete development = said to be
is a subjective perception of vitality and feeling the highest aspiration of people.
well Illness = condition preventing self-actualization
can be described objectively, experienced,
measured, and can be plotted on a continuum. 5.) Agent-Host-Environment Model
(Hood & Leddy, 2003) Called "Ecological Model"; originated in the
a component of health community health work of Leavell and Clark
(1965), has been expanded into a general theory
MODELS OF HEALTH AND WELLNESS of diseases' multiple causes.
• Models can be helpful in assisting health Primarily used in predicting illness rather than in
professionals to meet the health and wellness needs promoting wellness.
of individuals. Identifying risk factors result in interactions of
• Models of Health include: agent, host, environment are helpful in promoting
1.) Clinical Model and maintaining health.
2.) Role Performance Model Has 3 Dynamic interactive elements: Agent,
3.) Adaptive Model Host, Environment
4.) Eudemonistic Model Health is an ever-changing state.
5.) Agent-Host-Environment Model When variables are in balance = health is
6.) Health-Illness Continua maintained
1.) Clinical Model
Narrowest interpretation of health 3 Dynamic interactive elements:
People are viewed as physiologic systems with a. Agent
related functions - any environmental factor/ stressor (biologic,
Health is identified by the absence of signs and chemical, mechanical, physical, or psychological)
symptoms of disease or injury that it's presence or absence
State of not "being sick" - (eg: lack of essential nutrients=may lead to
The opposite of health = disease/injury - illness/disease)
Used by medical practitioner b. Host
Absence of s/s = Health is restored - person who may or may not be at risk of
caquiring disease - family history, age, lifestyle,
2.) Role Performance Model habits = influence the host's reaction
Health is defined in terms of the individual's c. Environment
ability to fulfill societal roles (perform his/her - all factors external to the host that may or may
work) not predispose the person to the development of
Sickness = inability to perform one's work/role disease.
People who can fulfill their roles are healthy - Physical environment includes: climate, living
even if they have clinical illness. [People usually conditions, sound (noise) levels, economic level.
fulfill several roles: Mother, Daughter, Friend] - Social environment includes interactions with
Example: others and life events. (Eg: Death of spouse)
A man who works all day at his job is expected
is healthy even though an x-ray of his lung
indicates a tumor.
6.) Health-Illness Continua As nurses, it is our job to help our patients
 Grid/granulated scales can be used to find their inspiration and what their driving factor will
measure a person's perceived level of be to put them on the path to better health.
wellness.
 Health and Illness/Disease can be viewed as
the "opposite ends" of Health Continuum.
 People move back and forth with this
continuum daily.

One tool that nurses can use to help guide

their patients in the right direction is the health
Dunn's High-Level Wellness Grid continuum, also called the illness-wellness
✓ Dunn (1959) is known as the "Father of continuum.
movement".  The illness-wellness continuum is an illustration
✓ He distinguished between: that draws a connection between the treatment
Good Health–Not being ill—and what he termed paradigm and the wellness paradigm.
"High-Level Wellness".  Where they meet in the middle is considered the
✓ “High-Level Wellness" -- which he defined as "a neutral point.
condition of change in which the individual moves  Some examples of the continuum include the 6
forward, climbing toward a higher potential of components of personal health.
functioning".  These are categories within each of our daily lives
 A Health Grid in which a health axis and an that must be balanced in order to attain optimal
environmental axis intersect. health.
 Health axis = extends from peak wellness to  This is a great tool that nurses can use to help
death. their patients visualize, plan and achieve their
 Environmental axis = extends from very goals for a healthier lifestyle.
unfavorable to very favorable  Consider the farther down the continuum your
 Intersection forms 4 Quadrants of Health and patient: go towards illness the closer they are to
Illness death; rather, the farther up the continuum your
patients go towards wellness the closer they are
TERM: High-Level Wellness in a favorable to optimal health.
environment  Nurses are not only responsible for treating their
Example is a person who implements healthy patients but educating them on how prevention
lifestyle behaviors (this occurs when both the and lifestyle choices can help them move towards
environment and health are favorable) health and wellness.
TERM: Emergent High-Level Wellness in an  The continuum can be visualized many different
unfavorable environment ways, but here are a few examples:
Example is a person who knows healthy lifestyle but  The illness-wellness continuum was first imagined
cannot due to responsibilities (this occurs when the by Dr. John W. Travis in 1972.
environment is not favorable but health is favorable)  The wellness paradigm spans the entire length of
TERM: Protected poor health in a favorable the continuum, since this is the direction our
environment patients must be facing in order to achieve high-
Example: An ill person who needs are met by the level wellness. The treatment paradigm, however,
healthcare system and has access to medication only leads patients to the neutral point or, in other
(this occurs when the environment is favorable but words, a non-illness state.
health is not.)  Our goal as nurses should be to move our
TERM: Poor health in an unfavorable patients beyond that to a more optimal level of
environment health.
Example: Young child starving in drought-stricken  As you can see from the illustration, the way to
country (this occurs when both health and achieve this is through awareness, education and
environment are not favorable) individual growth
Illness-Wellness Continuum
 In this illustration you can see that not only is the ILLNESS AND DISEASE
health continuum moving from optimum wellness ILLNESS
to premature death with the various stages in  Highly personal state in which the persons
between, but the 6 components of personal physical, emotional, intellectual, social,
health are surrounding the continuum as well. developmental, or spiritual functioning is thought
 The components are revolving around the to be diminished.
continuum and contingent upon each other in a  Not synonymous with disease and may or may
continuous state. not be related to disease.
 Client could have a disease and not feel ill
Eg: a growth in the stomach
 Highly subjective
 Only the client can say and feel that she/he is ill
Eg: Client can feel ill and uncomfortable yet have
no discernible disease.

DISEASE
 The alteration in body functions resulting in a
reduction of capacities or a shortening of the
normal life span.
HEALTH PROMOTION MODEL
✓ The initial version of the Health Promotion Model ETIOLOGY
(HPM) appeared in the nursing literature in the early  Causation of a disease
1980's.  Includes identification of all causal factors that act
✓ Focused more on the health-promoting behaviors together to bring about the particular disease
rather than health protection or illness prevention Eg: Tubercle bacilli -designated biologic agent for
behaviors. Tuberculosis (TB)
✓The 1980 HPM was revised.  However, etiologic factors: age, nutritional status,
✓ Now a "competence or approached-oriented" occupation, are involved in the TB development
based on the individual's subjective value of the and influence course of infection.
change -- how the client perceives the benefit of Illness and Disease Classification
changing health behavior (Pender, 2006). 1.) ACUTE ILLNESS
-typically characterized by severe symptoms of
relatively short duration
-symptoms appear abruptly and subside quickly,
depending on cause
-may or may not require health care professionals
interventions
-some are serious (eg: appendicitis requiring
surgical intervention)
-Most people return to their normal level of wellness
after the acute illness (eg: colds)
2.) CHRONIC ILLNESS
-one that last for an extended period (6 months or
longer), and often for the person's life
-usually have a slow onset
-often have periods of remission, when the
symptoms disappear, and exacerbation, when the
symptoms reappear
Eg: Arthritis, Heart and Lung Diseases, Diabetes
Mellitus
-Care needs to focus on the highest level possible of
independence, sense of control and wellness
ILLNESS BEHAVIORS ✓ Client must also adjust to the disruption of a daily
 Coping mechanism where ill individual behaves schedule.
in a certain way. Stage 5: Recovery and Rehabilitation
 Involves ways individuals describe, monitor, and ✓ This stage can arrive suddenly, such as when
interpret their symptoms, take remedial actions, symptoms appeared.
and use the health care system.
✓ For Chronic illness, the final stage may involve in
 How people behave when they are ill are highly
an adjustment to a prolong reduction in health and
subjective; affected by many variables:
functioning.
- age
- sex
PREVENTION
- occupation
Prevention includes a wide range of activities -
- socioeconomic status
known as “interventions" — aimed at reducing risks
- religion
or threats to health.
- ethnic origin
You may have heard researchers and health experts
- psychological stability
talk about three categories of prevention: primary,
- personality education
secondary and tertiary. What do they mean by these
- modes of coping
terms?
3 Levels of Prevention:
4 Aspects of the Sick Role:
I-Primary Prevention
1. Clients are not held responsible for their
 Primary prevention aims to prevent disease or
condition.
injury before it ever occurs.
2. Clients are excused from certain social roles
 This is done by preventing exposures to
and tasks.
hazards that cause disease or injury, altering
3. Clients are obliged to try to get well as quickly
unhealthy or unsafe behaviours that can lead to
as possible.
disease or injury, and increasing resistance to
4. Clients or their families are obliged to seek
disease or injury should exposure occur.
competent help.
-Suchman (1979) described 5 Stages of Illness.
Examples include:
-NOT ALL clients progress through each stage.
a.) Legislation and enforcement to ban or control the
5 STAGES OF ILLNESS
use of hazardous products (e.g. asbestos) or to
Stage 1: Symptoms Experiences
mandate safe and healthy practices (e.g. use of
✓ The person is aware that something is wrong. seatbelts and bike helmets
✓ A person usually recognizes a physical sensation b.) Education about healthy and safe habits (e.g.
or a limitation in functioning but does not suspect a eating well, exercising regularly, not smoking)
specific diagnosis. c.) Immunization against infectious diseases.
Stage 2: Assumption of the Sick Role II - Secondary Prevention
✓ If symptoms persist and become severe, clients  Secondary prevention aims to reduce the impact
assume the sick role. of a disease or injury that has already occurred.
✓ The illness becomes a social phenomenon.  This is done by:
✓ Sick people seek confirmation from their families
and social groups that they are indeed ill and that *detecting and treating disease or injury as soon
they be excused from normal duties and role as possible to halt or slow its progress
expectations *encouraging personal strategies to prevent
Stage 3: Medical Care Contract reinjury or recurrence, and *implementing
programs to return people to their original
✓ If symptoms persist despite the home remedies,
health and function to prevent long-term
become severe or require emergency care, the
problems.
person is motivated to seek professional health
services.
Examples include:
✓ In this stage, the client seeks expert a.) regular exams and screening tests to detect
acknowledgement of the illness as well as the disease in its earliest stages (e.g. mammograms to
treatment. detect breast cancer)
Stage 4: Dependent Client Role b.) daily, low-dose aspirins and/or diet and exercise
✓ Client depends on health care professionals for programs to prevent further heart attacks or strokes
the relief of symptoms. c.) suitably modified work so injured or ill workers
✓ The client accepts care, sympathy and protection can return safely to their jobs.
from the demands and stresses of life. I - Tertiary Prevention
✓ Client can adopt the dependent role in a health  Tertiary prevention aims to soften the impact of
care institution, home, or in community setting. an ongoing illness or injury that has lasting
effects.
 This is done by helping people manage long- assure optimal physical, mental, and emotional
term, often-complex health problems and injuries health throughout the natural life cycle.
(e.g. chronic diseases, permanent impairments) • Examples:
in order to improve as much as possible their - removing financial, physical, and psychological
ability to function, their quality of life and their life barriers to obtaining health promotion and disease
expectancy. prevention services in clinical settings;
- use of media to deliver health education messages
Examples include: - screening or surveillance
a.) cardiac or stroke rehabilitation programs, chronic - providing immunizations to prevent illnesses
disease management programs (e.g. for diabetes, - health education
arthritis, depression, etc.) - advocacy of health policies that reduce the risk of
b.) support groups that allow members to share injury; that reduce exposure to toxins in the water,
strategies for living well air, and workplace; and that ensure the availability of
c.) vocational rehabilitation programs to retrain recreational facilities.
workers for new jobs when they have recovered as Curative
much as possible. • Curative care is to cure a disease or promote
LEVELS OF CARE recovery from an illness, injury or impairment.
Health Promotion • Can be provided in a hospital or at home.
• Health promotion programs aim to engage and • Services include physician and nursing care,
empower individuals and communities to choose surgery, medications and therapies.
healthy behaviors. • Examples:
• Make changes that reduce the risk of developing - chemotherapy for cancer
chronic diseases and other morbidities. - physical therapy after joint replacement surgery.
• Health promotion enables people to increase Palliative
control over their own health. It covers a wide range • Palliative care is to bring comfort and relief from a
social and environmental of interventions that are serious, progressive illness that may or may not be
designed to benefit and protect individual people's life-limiting.
health and quality of life by addressing and • It can be provided at home and in long-term care
preventing the root causes of ill health, not just facilities and hospitals.
focusing on treatment and cure (WHO) • It is available immediately after diagnosis and can
• Nurses are knowledgeable regarding the be given alongside curative care.
importance of health-promoting activities: • Services may include medical care (physician and
- healthy eating nursing care, medications) and non-medical care
- physical activity (care coordination and social work).
- stress management • Examples:
- sleep hygiene - a personalized care plan might include, for
Disease Prevention example
• Disease prevention is a procedure through which - pain relief medication
individuals, particularly those with risk factors for a - care coordination services
disease, are treated in order to prevent a disease - assistance with preparation of an advance
from occurring. directive form.
• Treatment normally begins either before signs and
symptoms of the disease occur, or shortly thereafter.
• Examples:
- regular physical exams
- screening tests to detect disease in its earliest
stages (Mammograms to detect breast cancer)
- daily, low-dose aspirins and/or diet and
exercise programs to prevent further heart
attacks or strokes.
Health Maintenance
• A guiding principle in health care that emphasizes
health promotion and disease prevention rather than
the management of symptoms and illness.
• Activities that preserves an individual's present
state of health and that prevent occurrence of
disease or injury
• It includes the full array of counseling, screening,
and other preventive services designed to minimize
the risk of premature sickness and death and to
VITAL SIGNS 2.) Surface Temperature
WHAT ARE "VITAL SIGNS"? - temperature of the skin, subcutaneous tissue, and
 Vital signs are measurements of the body's fat.
most basic functions. -- rises and falls in response to environment
Estimated Body Temperature Ranges in a Normal
The four (4) main vital signs routinely monitored by Person
medical professionals and health care providers
include the following:
1.) Body Temperature
2.) Pulse Rate
3.) Respiratory Rate (rate of breathing)
4.) Blood Pressure
 PAIN
= as the 5th vital sign (designated by the Veterans
Association).
= to be assessed together with the other 4 vital Factors
signs. affecting the
Body Heat
 These signs are checked to monitor body Production:
functions.
 Reflects changes in function that otherwise
might not be observed. HEAT PRODUCTION:
 Should be evaluated with reference to the 1. Basal Metabolism
client's present and prior health status; then 2. Muscular activity (shivering)
compare to her/his usual (if known) and 3. Thyroxine and Epinephrine
accepted normal standards. (stimulating effects of metabolic rate)
 Vital signs are useful in detecting or 4. Temperature effect on cells
monitoring medical problems.
HEAT LOSS:
>Vital signs can be measured in a medical setting, at 1. Radiation
home, at the site of a medical emergency, or 2. Conduction/ Convection
elsewhere. 3. Evaporation (Vaporization)

WHEN TO ASSESS VITAL SIGNS: 1.) Basal Metabolic Rate(BMR)

1.) On admission to a health care agency, to obtain --- rate of energy utilization in the body required to
baseline data. maintain essential activities, such as breathing.
2.) When client has a change in health status or --- decreases with age; the younger the person, the
reports symptoms. higher the BMR.
Examples: chest pains, fever, faint 2. Muscle activity --- including shivering, increases
3.) Before or after surgery or an invasive procedure. the metabolic rate.
4.) Before and/or after medicine administration that 3. Thyroxine output --- increased thyroxine output
could affect respiratory, cardiovascular systems. increases the rate of cellular metabolism
Example: Before giving Digitalis preparation throughout the body.
5.) Before and after any nursing interventions that Chemical Thermogenesis = the stimulation of body
could affect the vital signs, heat production through increased cellular
Example Ambulating a client who has been on bed metabolism.
rest 4. Epinephrine, Norepinephrine, and
Sympathetic Stimulations/
BODY TEMPERATURE: Stress Responses --these hormones immediately
 Reflects the balance between the heat increases the rate of cellular metabolism in many
produced and the heat lost from the body body tissues.
 Measured in heat units called "degrees". Epinephrine, Norepinephrine = directly affect
2 Kinds of Body Temperature: liver and muscle cells, increasing cellular
1.) Core Temperature metabolism
- temperature of the deep body tissues 5. Fever --- increases cellular
-- relatively constant metabolism rate and increases body's
Example: temperature further
abdominal cavity
pelvic cavity
BODY HEAT ARE LOST FROM THE BODY - when COLD SENSORS are stimulated = = signals
THROUGH: are sent (that is to increase heat production and
decrease heat loss)
1. RADIATION - the transfer of heat from the
surface of an object to the surface of another FACTORS AFFECTING BODY TEMPERATURE:
without contact between the two objects. 1) Age
- mostly in the form of infrared rays 2) Diurnal variations (Circadian Rhythm)
2. CONDUCTION- the transfer of heat from one 3) Exercise
molecule to another molecule of lower 4) Hormones
temperature. 5) Stress
Example: 6) Environment search
Body immersed in a cold water.
- the amount of heat transferred depends on the ALTERATIONS IN BODY TEMPERATURE:
temperature difference, amount and duration of 1.) PYREXIA
the contact. - Body temperature above normal range
CONVECTION- dispersion of heat by air currents. - Hyperthermia
- body usually has small amount of warm air - Fever (Lay term)
adjacent to it. The warm air rises and replaced by - Hyperpyrexia = very high fever (41°C/ 105.8°F)
cooler air (people always lose amount of heat - Febrile = client with fever
through convection). - Afebrile = client with no fever
3.) VAPORIZATION - continuous evaporation of Alterations in Body Temperature:
moisture from the respiratory tract and from the
mucosa of the mouth and from the skin. 4 Common Types of Fever
1) Intermittent – body temperature alternates at
INSENSIBLE WATER LOSS regular intervals between periods of fever and
= continued and unnoticed water loss periods of normal/subnormal temperatures. (Eg:
INSENSIBLE HEAT LOSS Malaria)
= accounts 10% of basal heat loss 2) Remittent - wide range of temperature
(body temperature increases = greater heat loss) fluctuations more than 2°C (3.6°F) occurs over the
24-hour period; All are above normal. (Eg: Cold/
REGULATION OF BODY TEMPERATURE: Influenza)
The system that regulates body temperature has 3 3) Relapsing Fever - short febrile period of few
major parts: days are interspersed with periods of 1 or 2 days of
1) Sensors in the shell and in the core normal temperature
2) Integrator of the Hypothalamus 4) Constant Fever - body temperature fluctuates
3) Effector System (adjusts heat production and heat minimally, but always remains above normal. (Eg:
loss) Typhoid Fever)

SKIN *** FEVER SPIKE = temperature rises to fever =

= most sensors and sensory receptors are found. level rapidly following normal temp, then returns to
Skin has more receptors for COLD than WARMTH. normal within few hours (Eg: Bacterial blood
Skin receptors detect COLD more efficiently than infection)
WARMTH.
When the skin becomes chilled over the entire body In some conditions, elevated temperature is not a
TRUE FEVER. (Eg: Heat Exhaustion & Heat Stroke)
When the skin becomes chilled over the entire body,
these "physiologic processes" to increase the body A) Heat Exhaustion = result of excessive heat and
temperature take place: dehydration. (Signs: paleness, dizziness, nausea,
1.) Shivering increases heat production vomiting, fainting, moderate increased temperature
2.) Sweating is inhibited to decrease heat loss. of 38.3°C/101°F-38.9°C/102°F)
3.) Vasoconstriction decreases heat loss.
B) Heat Stroke = generally have been exercising in
HYPOTHALAMIC INTEGRATOR the hot weather; have warm flushed skin, often no
- center that controls the core temperature sweat. May have 41°C/106°F or higher, delirious,
- located at the preoptic area of the hypothalamus unconscious, having seizures.
- when hypothalamic sensors detects heat = send
out signals intended to reduce the temperature (that
is to decrease heat production and increase heat
loss)
CLINICAL MANIFESTATIONS OF FEVER: Nursing Interventions for Clients with Fever:
I- Onset (Cold/ Chill Phase) -Monitor vital signs (especially body temperature).
Increased HR -Assess skin color.
Complaints of feeling cold -Monitor WBC count, HCT value, and other pertinent
Increase RR and depth lab reports (indications of infection/ dehydration).
Cyanotic nailbeds -Remove excess blankets when the client feels
Shivering warm;
"Gooseflesh" appearance of skin -Provide warmth when client feels chilled.
Pallid, cold skin Measure intake and output.
Cessation of sweating -Reduce physical activity to limit heat production
II- Course (Plateau Phase) (especially during flush stage).
Absence of chills -Administer antipyretics (drugs that reduce fever
Warm skin level) as ordered
Photosensitivity -Provide oral hygiene to keep the mucus
Glassy-eyed appearance membranes moist.
Increased PR and RR -Provide adequate nutrition and fluids (2,500-3,000
Increased thirst mL/day) to meet the metabolic demands and
Mild to severe dehydration prevent dehydration.
Drowsiness, Restlessness, Delirium, Convulsions -Provide Tepid Sponge Bath to increase heat loss
Herpetic Lesions of the mouth through conduction.
Loss of appetite (for prolonged fever) -Provide oral hygiene to keep the mucus
Malaise, Weakness, Aching Muscles membranes moist.
III – Defervescence (Fever Abatement/ Flush -Provide clean and dry clothing and bed linens.
Phase) -Provide a warm environment.
Flushed skin -Provide dry clothing.
Warm skin -Apply warm blankets.
Sweating -Keep limbs closet to body.
Possible Dehydration -Cover the client's scalp with a clean cap or turban
Decreased shivering -Supply warm oral or intravenous fluid.
-Apply warming pads.
Hypothermia
>Core body temperature below the normal limit of ASSESSING BODY TEMPERATURE:
normal. Common Sites:
2 Types: ✓ Oral
1.) Induced - deliberate ✓ Rectal
lowering of body temp to decrease the need for ✓ Axillary
oxygen by the body tissues (Eg: During surgery)
2.) Accidental - occur as a result of: ✓ Tympanic Membrane
a. Cold environment exposure ✓ Skin/ Temporal Artery
b. Cold water immersion
c. Lack of adequate clothing, shelter, heat ORAL SITE:
*Elders, decreased metabolic rate and use of The nurse should wait for 30 minutes before taking
sedatives temperature if the client is:
✓ Taking hot/cold food or fluid
3 PHYSIOLOGIC MECHANISM: ✓ Smoking
1) Excessive heat loss Rationale: To ensure temperature is not affected by
2) Inadequate heat production to counteract heat the temperature of food, fluid or warm smoke.
loss RECTAL SITE:
3) Impaired hypothalamic thermoregulation ✓ Considered very accurate
Clinical Manifestations: ✓ Stimulate Vagal Stimulation (cause abnormal
1) Decreased body temp, PR, RR heart rhythms)
2) Severe shivering (initially)
✓ Contraindications:
3) Feelings of cold & chills
4) Pale, cool, waxy skin *Myocardial Infarction patients
5) Frostbite (nose, fingers, toes) *Rectal surgeries
6) Hypotension *Diarrhea
*Rectum Diseases
7) Decreased Urinary Output
8) Lack of muscle coordination *Immunosuppressed
9) Disorientation *Clotting Disorder
10.) Drowsiness progressing to coma *Significant Hemorrhoids
AXILLARY SITE: 5.) TEMPORAL ARTERY
✓ Common for all ages ADVANTAGES
✓ Accessible and safe  Safe
 Non-invasive
✓ Preferred site for Newborns (check hospital
 Very fast
protocols
DISADVANTAGES
✓ Said to be inaccurate (Bindler & Ball, 2003)  Requires electronic equipment that may be
TYMPANIC MEMBRANE SITE: expensive or unavailable
✓ Nearby tissue in the ear canal  Variation in technique needed (if client has
✓ Frequent site for estimating body core perspiration on the forehead)
✓ Abundant arterial blood supply (same as the SL
oral site; primarily from branches of the external TYPES OF THERMOMETERS:
carotid artery)
✓ Uncomfortable No matter which type you choose, read the
✓ Risk of membrane injury/ perforation manufacturer's instructions carefully. No
thermometer will provide accurate results if it's used
✓ ELECTRONIC TYPANIC THERMOMETERS
incorrectly.
=non-invasive; used in in-patient and ambulatory Never use a thermometer on a person that is meant
care setting for another purpose, such as a laboratory or meat
TEMPORAL ARTERY SITE:
thermometer. These won't provide accurate
✓ Measured on the Forehead using CHEMICAL readings.
THERMOMETER/TEMPORAL ARTERY If you're a parent, you may be wondering why we're
THERMOMETER. omitting forehead strip thermometers from this
✓ Most useful for infants and children roundup. Strip thermometers are inexpensive and
✓ Non-invasive quick to use. However, since they measure skin
temperature rather than body temperature, they're
Advantages and Disadvantages of Body significantly less accurate and should be avoided.
Temperature Measurement Sites:
1.) Mercury Thermometer
1) ORAL  Were once the only option available for
ADVANTAGES taking temperature.
> Accessible and convenient  Due to safety concerns, they're no longer
DISADVANTAGES widely available and may even be illegal
> May break if bitten. where you live.
> Inaccurate if client ingested hot/cold fluids or food Benefits
or smoked. • Mercury thermometers provide accurate
> Could injure the mouth following oral surgery temperature readings and can be used orally,
2.) RECTAL rectally, or under the arm.
ADVANTAGES •They don’t require batteries.
>Reliable measurement Drawbacks
DISADVANTAGES • Since they're made from glass, mercury
>Inconvenient, unpleasant to clients thermometers may break easily, allowing toxic
>Difficult for client who cannot turn to sides mercury to escape.
>Could injure the rectum following rectal surgery • They may also cause cuts or glass splinters if they
>Presence of stool may interfere thermometer break.
placement • Since they contain a hazardous substance,
>May embed in stool rather than rectum mercury thermometers must be disposed of properly
4.) TYMPANIC MEMBRANE and can't be thrown into the trash.
ADVANTAGES • They can be hard to read and must stay in place
>Readily accessible for 3 minutes.
> Reflects the core temperature 2.) Digital Thermometer
> Very fast Digital thermometers work by using heat sensors
DISADVANTAGES that determine body temperature.
> May be uncomfortable They can be used to take temperature readings in
> Involves risk of injuring the membrane if probe is the mouth, rectum, or armpit.
inserted too far When assessing digital thermometer readings, keep
> Repeated measurements man vary in mind that armpit (axillary) temperature runs about
> Right and left measurements may differ ½ to 1°F (0.6°C) cooler than oral readings. Rectal
> Presence of cerumen can affect reading thermometers run 12 to 1°F (0.6°C) warmer than
oral readings.
Benefits • They may not fit properly in a small or curved ear
Digital thermometers provide accurate readings in canal.
about 1 minute or less. 5.) Temporal Thermometer
Drawbacks Forehead thermometers use infrared sensors to
• In order to get an accurate reading from oral use, measure the temperature of the superficial temporal
the tip of the device must be placed under the artery, which is a branch of the carotid artery.
tongue with the mouth completely closed. For this Some are known as non-contact infrared
reason, rectal readings are considered the most thermometers.
accurate for infants and small children. Additionally: Benefits
• Oral readings won't be accurate if they are taken • Temporal thermometers provide quick readings,
too close to eating or drinking, because results may within several seconds.
be skewed by your food or drink's temperature. Wait • They are easily administered and can be used on
at least 15 minutes. infants, children, and adults.
• Rectal readings may be uncomfortable to get for • Some research indicates that temporal
infants and small children. thermometers may be as accurate as rectal
• You shouldn't use the same thermometer for both thermometers in children and provide better
rectal and oral readings. This may require the readings than ear or armpit thermometers can.
purchase of two thermometers, which should be However, these findings aren't conclusive and have
labeled. been disputed in other studies.
• Batteries in thermometers should be replaced Drawbacks
periodically. Make sure you have the right type of • Forehead thermometers must be positioned
batteries on hand for your device and that you accurately and according to the manufacturer's
understand how to change them, so you're not left instructions, or they will not provide the right reading.
scrambling in an emergency. • Readings can be affected by external factors,
3.) Oral Thermometer including drafts, wind, indoor heating, and direct
• Oral temperature can be taken by either a digital or sunlight.
mercury thermometer. We'll go over the benefits and • Wearing certain clothing, such as hats or heavy
drawbacks of mercury thermometers below. coats, can skew the results.
• The average oral temperature reading is 98.6°F 6.) App-Based Thermometer
(37°C). However, any oral temperature from 97°F Most free phone apps designed to take temperature
(36.1°C) to 99°F (37.2°C) is considered typical. readings are meant for recording the temperature of
Some people run naturally cool, and others slightly environments, not people.
warmer. It's a good idea to know what your Phone apps that help with taking people's
temperature typically is so you can assess whether temperatures rely on digital thermometers that link
you're running a fever when you feel sick. back to the app via Bluetooth connection.
Benefits Benefits
• Oral thermometers are most accurate in children • Temperatures can be taken orally, rectally, or
over 3 and in adults. under the arm.
Drawbacks • They provide readings within 8 to 10 seconds.
• Small children and people with breathing issues • Some apps let you upload your anonymous
may not be able to keep their mouths closed long temperature readings to a health and weather map,
enough to acquire an accurate reading. which can help make local authorities aware of
4.) Digital Tympanic Thermometer illness spikes in your geographic area.
Tympanic thermometers measure the temperature • Some apps provide suggestions for medical next
inside the ear canal through infrared ray technology. steps, based on the reading.
Tympanic readings are 0.5°F (0.3°C) to 1°F (0.6°C) • Most apps provide you with the ability to keep a log
higher than oral temperature readings. of multiple people's temperatures.
Benefits Drawbacks
Tympanic thermometers provide fast and accurate • Not every app or thermometer that connects to an
readings and may be preferable to oral or rectal app is reliable. Some manufacturers have better
thermometers, especially in children. track records than others.
Drawbacks • App-based thermometers may be significantly
• Due to the size of the ear canal, tympanic more expensive than digital thermometers without
thermometers aren't recommended for infants under Bluetooth connectivity.
6 months old. 7.) Pacifier Thermometer
If your baby uses a pacifier, this may be an easy
• They must be positioned properly in order to get way for you to record their approximate temperature.
accurate results.
• Obstructions like earwax may skew results.
Benefits PULSE
Ease of use is the biggest benefit of pacifier  Wave of blood created by the contraction of the
thermometers. heart's LEFT Ventricle
Drawbacks  The "PULSE WAVE' = represents the stroke
Pacifier thermometers must remain in the mouth, volume output/ amount of blood that enters the
without moving, for up to 6 minutes. Additionally, arteries with each ventricular contraction
they provide an approximation of temperature rather  COMPLIANCE of the arteries = ability to contract
than an exact reading. and expand
 Greater pressure is required to pump blood into
ASSESSING BODY TEMPERATURE arteries = when persons arteries lose their
PURPOSES: distensibility (old age)
1. To establish baseline data for evaluation.  CARDIAC OUTPUT = blood volume pumped
2.To identify whether the core temperature is wihtin into the arteries by the heart and equals the
normal range result of the stroke volume (SV) times the
3.To determine changes in the core temperature in HR/min
response to specific therapies (medication, Eg: 65mL x 70bpm = 4.55L/min
immuosuppressant therapy, invasive procedure)  When an adult is resting, the heart pumps about
4. To monitor clients at risk for imbalanced body 5L blood/min
temperature (risk and diagnosed with infection;  HEALTHY PERSON: Pulse reflects the
exposed to temperature extremes). heartbeat
 PR = same rate of the heart's ventricular
ASSESSMENT: contraction
1. Clinical signs of fever  In some types of CVD, PR and HR can differ
2. Clinical signs of hypothermia Eg: Client's heart may produce weak or small
3. Appropriate site for body temperature waves that are not detectable in peripheral pulse
measurement  PERIPHERAL PULSE = pulse located away
4. Factors that alter the body core from the heart (Eg: foot, wrist)
 APICAL PULSE
SIGNS & SYMPTOMS OF FEVER: = central pulse; located at apex of heart
When someone has a fever, they may also: = referred to as "point of maximal impulse" (PMI)
• Above normal temperature (36.5-37.5°C)
• Shiver and feel cold when nobody else does FACTORS AFFECTING THE PULSE:
• Sweat Age
• Have a low appetite Age increases = PR decrease
• Show signs of dehydration Gender
• Have increased sensitivity to pain After puberty, average male's PR is slightly lower
• Lack energy and feel sleepy that the female's PR
• Have difficulty concentrating Exercise
When a baby has a fever, they may: Normally increases with activity
• feel hot to the touch Professional athlete, rate of increase is often less
• have flushed cheeks due to greater cardiac size, strength, and efficiency
• be sweaty or clammy Fever
With a high fever, there may also be irritability, PR increases in (a) response to low BP resulting
confusion, delirium, and seizures. from peripheral vasodilation associated with
elevated body temperature, and (b) increased
EQUIPMENT: metabolic rate.
• Thermometer Medications
• Thermometer sheath/ probe Depends on drug action
• Water-soluble lubricant for rectal temperature Eg: Cardiotonics (Digitalis preparation) decreases
• Disposable gloves HR Epinephrine increases HR
• Towel for axillary temperature Hypovolemia
• Clean tissue/ wet wipes Loss of blood from the vascular system normally
• Clean cottonballs increase PR (body's compensation to increase blood
• 70% isoprophyl alcohol pressure due to blood volume loss) 10% blood loss
of the normal circulating volume causes no adverse
effects
Stress
Sympathetic nervous stimulation increase the heart's
overall activity: increases rate and force of heartbeat
(fear, anxiety, severe pain)
Position Changes RESPIRATION
When a person is sitting/standing, blood is pooling in  The respiration rate is the number of breaths
dependent vessels of the venous system: decrease a person takes per minute.
venous blood return, BP reduced, increase HR  The rate is usually measured when a person
Pathology is at rest and simply involves counting the
Certain disease such as heart condition/ impaired number of breaths for one minute by
oxygenation may alter the resting PR counting how many times the chest rises.
 Respiration rates may increase with fever,
Variations in Pulse and Respirations by Age illness, and other medical conditions.
 When checking respiration, it is important to
also note whether a person has any difficulty
breathing.
• Normal respiration rates for an adult person at rest
range from 12 to 16 breaths per minute.

Reasons for Using Specific Pulse Site

 EUPNEA - normal breathing in rate and

depth
 BRADYPNEA = abnormally slow respirations
 APNEA - absence of breathing
 TACHYPNEA/ POLYPNEA = abnormally fast
Considerations: respirations
• Normally the heart beats 60 to 100 bpm.
• The rate may drop below 60 beats per minute in FACTORS AFFECTING RATE OF
people who exercise routinely or take medicines that RESPIRATIONS:
slow the heart. *INCREASE IN RATE:
• If your heart rate is fast (over 100 bpm) = - Exercise (increase metabolism)
Tachycardia. - Stress (readies the body for "fight and flight")
• A heart rate slower than 60 bpm Bradycardia. - Increased environmental temperature
• An occasional extra heartbeat out of rhythm is - Lowered O2 concentration at increased altitudes
known as Extrasystole. *DECREASE IN RATE:
• Palpitations are not serious most of the time. - Decreased environmental temperature
Sensations representing an abnormal heart rhythm, - Certain medications (Narcotics)
irregular heartbeats (arrhythmia) may be more - Increased Intracranial Pressure (ICP)
serious.
• Pulse volume DEPTH OF PERSON'S RESPIRATIONS:
= "Pulse strength"/ "Amplitude" *RESPIRATORY DEPTH = normal, deep, shallow
= force of blood with eat beat *DEEP RESPIRATIONS - large volume of air is
• Normal Pulse can be felt by moderate pressure inhaled and exhaled inflating most of the lungs
*SHALLOW RESPIRATIONS = involve the
Assessing Peripheral Pulses: exchange of small volume of air and often the
EQUIPMENT: minimal us of lung tissue
1. Watch with second hand *** During normal inspiration and expiration, an adult
2. Stethoscope takes in about 500 mL of air.
3. Clean gloves TIDAL VOLUME = volume of air
4. Clean tissues/ wipes *HYPERVENTILATION = very deep, rapid
respiration
*HYPOVENTILATION = very shallow respiration
*RESPIRATORY RHYTHM = regularity of inspiration Technique of BP measurement
and expiration Listen for auditory vibrations from artery "bump,
*RESPIRATORY QUALITY/ CHARACTER = bump, bump" (Korotkoff)
aspects of breathing that are different from normal, In order to measure the BP
effortless breathing Systolic blood pressure is the pressure at which you
can first hear the pulse.
BLOOD PRESSURE - Diastolic blood pressure is the last pressure at
 Measure of the pressure exerted by the which you can still hear the pulse
blood as it flows through the arteries - Avoid moving your hands or the head of the
 Because the blood moves in waves, there stethescope while you are taking readings as this
are 2 blood pressure measurements: may produce noise that can obscure the Sounds of
1.) Systolic Pressure Koratkoff.
- contraction of the ventricle, that is the pressure of
the height of the blood wave Remember the following for accuracy of your
2.) Diastolic Pressure readings:
- when the ventricles are at rest If the BP is surprisingly high or low, repeat the
- lower pressure measurement towards the end of your exam
- present at all times within the arteries (Repeated blood pressure measurement can be
uncomfortable).
PULSE PRESSURE = difference between the
diastolic and the systolic pressure The minimal SBP required to maintain perfusion
varies with the individual. Interpretation of low values
Remember the following for accuracy of your must take into account the clinical situation.
readings: SYSTOLIC: 140 or below is a normal systolic
Instruct your patients to avoid coffee, smoking or reading
any other unprescribed drug with sympathomimetic DIASTOLIC: 90 or below is a normal diastolic
activity on the day of the measurement reading

Position of the Patient Blood pressure for adult

-Sitting position · Physician will want to see multiple blood pressure
-Arm and back are supported. measurements over several days or weeks before
- Feet should be resting firmly on the floor making a diagnosis of hypertension and initiating
- Feet not dangling. treatment.

Position of the arm What Abnormal Results Mean?

Raise patient arm so that the brachial artery is • Pre-high Blood Pressure:
roughly at the same height as the heart. If the arm is Systolic pressure consistently 120 to 139, or
held too high, the reading will be artifactually diastolic 80 to 89
lowered, and vice versa. • Stage 1 High Blood Pressure:
Systolic pressure consistently 140 to 159, or
Blood Pressure diastolic 90 to 99
- The pressure exerted by the circulating volume of • Stage 2 high blood pressure:
blood on the arterial walls, veins, and chambers of systolic pressure consistently 160 or over, or
the heart diastolic 100 or over
Systolic
The higher number; represents the ventricles HYPERTENSION
contracting High blood pressure greater than 139-89.
Diastolic HYPOTENSION
The second number, represents the pressure within (blood pressure below normal): may be indicated by
the artery between beats a systolic pressure lower than 90, or a pressure 25
Pulse Pressure mmHg lower than usual
Difference between the systolic and diastolic
Blood pressure (mm Hg)
Blood Pressure - Normal blood pressure 100/60 and 139/89.
If it is too small, the readings will be artificially -Prehypertension 120,139-80,89.
elevated. Blood pressure may be affected by many different
The opposite occurs if the cuff is too large. conditions
-Cardiovascular disorders
-Neurological conditions
-Kidney and urological disorders
-Pre eclampsia in pregnant women HYPOXIA & BRAIN FUNCTION
-Psychological factors such as stress, anger, or fear

Remember the following for accuracy of your

readings:
- Orthostatic (postural) measurements of pulse
and blood pressure are part of the assessment for
hypovolemia.
- First measuring BP when the patient is supine and
then repeating them after they have stood for 2
minutes, which allows for equilibration.

OXYGEN SATURATION
Oxygen saturation is the fraction of oxygen
saturated hemoglobin relative to total hemoglobin in
the blood.
- The human body requires and regulates a very
precise and specific balance of oxygen in the blood,
Normal arterial blood oxygen saturation levels in
humans are 95-100 percent.
-Over the past decade, Oxygen Saturation
measurement of gas exchange and red blood cell
oxygen carrying capacity has become available in all
hospitals and many clinics.
-Oxygen Saturation provide important information
about cardio-pulmonary dysfunction and is
considered by many to be a fifth vital sign.

How Does Blood Oximeter Work?

A pulse oximeter, usually attached to the finger,
shines two separate light beams into the blood
circulating in the small vessels, i.e., capillaries.
These light beams reflect the amount of oxygen in
the blood, expressed as a percentage, along with
the pulse rate. Oxygen saturation (SpO2) measures
how much oxygen the blood is carrying.

What your blood oxygen level shows?

SpO2, also known as oxygen saturation, is a
measure of the amount of oxygen carrying
hemoglobin in the blood relative to the amount of
hemoglobin not carrying oxygen.
ASEPSIS ● FUNGI
● The freedom from disease-causing microorganism  Include yeast and molds
INFECTION  Example: Candida Albicans (Normal
● Opposite of Asepsis floor of the vaginal canal) becomes less,
● Growth of microorganisms in the body tissue where tendency it spreads (i.e. due to strong antibiotics)
they are not usually found ● PARASITES
● ASYMPTOMATIC OR SUBCLINICAL
 Microorganism produces no clinical
evidence of disease
● DISEASE
 A detectable alteration in normal  Live on other living organisms
tissue function  Include protozoa (i.e. malaria) and arthropods
● VIRULENCE (mites, fleas & ticks)
 Example of Protozoa: Entamoeba Histolitica
 Severity or harmfulness
 Example: UK Variant of COVID-19 (Very (causes amoebiasis)
communicable, causes less symptoms or effect of
the body compared to the African Variant) TYPES OF INFECTION
● COMMUNICABLE DISEASE ● LOCAL VS SYSTEMIC
 A condition resulting from transmission of an  LOCAL – Limited to a specific part of the body
infectious agent from one individual to another where the microorganisms remain
● PATHOGENICITY  SYSTEMIC – Microorganisms spread and damage
 Ability to produce disease different parts of the body
 BACEREMIA
 “pathogen” – a microorganism that causes disease
 Culture of the person’s blood reveals microorganisms
● OPPURTUNISTIC PATHOGEN
 SEPTICEMIA
 Causes disease only in a susceptible individual
 When bacteremia results in systemic infection
ASEPTIC TECHNIQUE
 The bacteria found in the blood could easily be
● The way to decrease the possibility of transferring transported all over the body that would cause a
microorganisms from one place to another systemic infection

TYPES OF ASEPSIS ● ACUTE VS. CHRONIC

● MEDICAL ASEPSIS  ACUTE – appear suddenly or last a short time
 Includes all practices intended to confine a specific  CHRONIC
microorganism to a specific area, limiting the  Occur slowly, over a long period, and may last
number, growth and transmission of months or years
microorganisms  Example: Tuberculosis (patients don’t realize they
 CLEAN – absence of almost all microorganisms have it until their cough worsens or has blood);
 DIRTY – means likely to have microorganisms medication could last for 3 months, if client is poor
● SURGICAL ASEPSIS and needs to start all over again, it will take 6 months
 Also known as “sterile technique”
 Refers to activities that keep area or NOSOCOMIAL INFECTIONS
object free of all microorganisms ● Infections that originate in the hospital
● Develop during a client’s stay in a facility or manifest
TYPES OF MICROOGANISMS THAT CAUSE after discharge
INFECTION ● May also be acquired by a personnel working in the
● BACTERIA facility
 Most common ● A sub-group of Health Care-Associated Infections
 Live and can be transported (HAIs)
through air, water, food soil, body  Infections that originate in any health care setting
tissues and fluids and inanimate  Secondary infections (usually caused by
things microorganisms found in the hospital
● VIRUSES  Example of HIAs: Nursing Homes/ Hospice
 Consist primarily of nucleic acid Homes
 Needs to enter living cells to ● ENDOGENOUS SOURCE
reproduce  May originate from the client themselves
● EXOGENOUS SOURCE
 From the client’s environment and hospital
personnel
● POSSIBLE FACTORS: METHOD OF TRANSMISSION
 LATROGENIC INFECTIONS - direct result of ● Means of transmission to reach another host
diagnostic or therapeutic procedures ● 3 Mechanisms:
 Example: Staphylococcus Aureus  DIRECT TRANSMISSION
– microorganism normally found in the skin, if patient  Involves immediate and direct transfer of
is injected/ skin is opened, there is a tendency if the microorganisms from person to person
epidermis is not cleansed properly, this can enter  E.g. Touching, biting, kissing or sexual intercourse
causing an infection  DROPLET SPREAD
 COMPROMISED HOST – normal defenses have  Occurs if source and host are within 3 feet of each
been lowered by treatment or illness other
 Immune system of pt is so poor, that it can be  Sneezing, coughing, spitting, singing, and talking
infected by microorganisms that could cause  INDIRECT TRANSMISSION
infection  VEHICLE-BORNE
 Caused by underlying conditions or therapies that TRANSMISSION
causes the immune system to function very poorly  Vehicle – any substance that serve as an
immediate means to transport and introduce an
infectious agent into a susceptible host through a
suitable portal of entry
 Ex: Fomites, water, food, blood, and plasma
 VECTOR-BORNE
TRANSMISSION
 Vector – an animal or insect that serves as an
intermediate means of transporting the infectious
agent
 Example: Mosquito (Dengue Virus); Dogs that
ETIOLOGIC AGENT are unvaccinated (Rabis)
● Any microorganism capable of producing infection  AIRBORNE TRANSMISSION
● Will depend on the following:  Transmitted by air currents
 Number (of microorganisms) present  May involve droplets or dust
 Virulence (ability to produce disease) and potency  DROPLET NUCLEI
 Ability to enter the body  Residue of evaporated droplets emitted by an
 Susceptibility of the host
infected host
 Ability to live in the host’s body
 Can remain in the air for long periods
 DUST
RESERVOIR
 May contain infectious agents such as spores of
● Sources of microorganisms
C. difficile
● Common examples:
 C. difficile – bacteria that causes inflammation of
 Other humans
your intestines (pseudo membranous colitis)
 Client’s own microorganisms
 Have spores, meaning it protects itself with an
 Plants
exogenous shell wherein it is able to survive for
 Animals
months or years and only activates when it is
 General environment
swallowed and can go fly back to air
● CARRIER
 A reservoir of a specific infectious agent that usually
STAGES OF INFECTIOUS DROPLETS AND DROPLET
does not manifest any clinical signs of disease
NUCLEI
1.) LARGE INFECTIOUS DROPLETS
PORTAL OF EXIT
● Mucus/ water encased
● Where the microorganisms leave the reservoir
● Viruses are aerosolized by
infector or by toilet water
● Quickly fall to the ground after
traveling up to 1 – 3 ft.
2.) SMALL INFECTIOUS DROPLETS
● Mucus/ water coating starts to
evaporate
● Fall to ground after traveling 3 –
5 ft.
● Can become droplet nuclei
3.) INFECTIOUS DROPLET IMPLEMENTATION: PREVENTING NOSOCOMIAL
● Droplet size has decreased to INFECTIONS (or HAIs)
<5 microns ● HAND HYGIENE
● Can float in the air for  Considered one of the most effective infection
prolonged periods due to prevention measures
microscopic size  Hands need to be cleaned at the following times:
 Before eating
PORTAL OF ENTRY  After using the bedpan or toilet
● Where microorganisms enter a body  After the hands have come in contact with any body
substances
● Often, the microorganisms enter the body of the
 Before and after giving care of any kind
host by the same route they used to leave the source
 For routine client care, vigorous hand washing under
a stream of water for 15 to 20 seconds using
SUSCEPTIBLE HOST
granular soap, soap-filled sheets or liquid soap
● Any person who is at risk for infection
 Should be done: (WHO, 2009)
 Beginning of the nurses’ shift
COMPROMISED HOST  When the hands are visibly soiled
 A person at increased risk, an individual who for one or  After using the toilet
more reasons is more likely than others to acquire an  ANTIMICROBIAL SOAPS are usually provided in
infection high-risk areas
 Very poor immune system  Utilized in the following situations, as recommended
 Example: A patient who undergoes chemotherapy by the CDC:
 When there are known multiple
FACTORS INCREASING SUSCPETIBILITY resistant bacteria
● Age  Before invasive procedures
● Hereditary  In special care units, such as
 When patient has low antibodies (has a disease nurseries and ICUs
 Before caring for severely
that has abnormal production of certain cells)
immunocompromised clients
● Level of stress
● Soap should at least be 5 ml or 1 teaspoon in amount
 Increased production of cortisone (produced by
● Wipe our hands with a clean towel
adrenals), a hormone when it is too much, makes
● Get another dry paper towel to close if elbow is not
immune system weak (immunocompromised)
available
● Nutritional status
● To further understand how hand hygiene is done with
 Nutrients needed for the development of good cells
the use of soap and water, view this video:
are lacking/ deficient
https://ww.youtube.com/watch?v=suUFO7FgKEw
● Current medical therapy
 Tends to affect the function of immune system due
to the purpose of killing normal cells (like WBCs)
● Preexisting disease
 COPD (Chronic Obstructive Pulmonary Disease),
affects the ciliary movement (a respiratory function),
making microorganisms be stagnant and be capable of
reproducing in your system
 Diabetes mellitus and Leukemia

NANDA NURSING DIAGNOSTIC PROBLEM

● RISK FOR INFECTION

 The state in which an individual is at increased risk for
being invaded by pathogenic microorganisms
 Risk factors:
 Inadequate primary defenses
 Inadequate secondary defenses
● HAND HYGEINE USING ALCOHOL-BASED HAND DISINFECTING AND STERILIZING
RUB ● The etiologic and the reservoir are interrupted by the
 Used before and after each direct client contact following:
 Not sufficient in the following situations:  ANTISEPTICS
 Hands have visible dirt or matter  Agents that inhibit the growth of
 C. difficile may be present the microorganisms
 C. difficile can only be get rid of with vigorous hand  DISINFECTANTS
washing
 Agents that destroy pathogens
 The CDC promotes the use of alcohol-based hand
other than spores
rubs because:  STERILIZATION
 They kill bacteria more effectively and more quickly
than hand washing with soap and water
 They are less damaging to skin than soap and water,
DISINFECTING
resulting in less dryness and irritation ● ANTISEPTICS AND DISINFECTANTS
 They require less time than hand washing with soap  Often have similar chemical components, but the
and water disinfectant is a more concentrated solution
 Bottles/ dispensers can be placed at the point of care so  Have bactericidal or bacteriostatic properties
they are more accessible
COMMONLY USED ANTISEPTICS AND
DISINFECTANTS AND THEIR EFFECTIVENESS AND
USE

B
A S
V
C P
I
T O
AGENT TB FUNGI R USE ON
E R
U
R E
S
I S
A

Hands, vial
ALCOHOL X X X X
stoppers
CHLORINE X X X X X Blood spills
H2O2 X X X X X Surfaces
Equipment,
intact skin &
IODOPHORS X X X X X
tissues (if
diluted)
Surfaces
PHENOL X X X X

Hands
CHLORHEXID
INE X X
GLUCONATE

Hands &
TRICLOSAN X
● Only needs 15 to 30 seconds of application intact skin

● To further understand how hand hygiene is done with

the use of alcohol-based hand rub, you may view this WHEN DISINFECTING ARTICLES, NURSES NEEDS
video: https://youtube.com/watch?v=GWx0jZYapm0 TO FOLLOW AGENCY PROTOCOL AND CONSIDER
THE FOLLOWING:
SUPPORTING DEFENSES OF A SUSCEPTABLE ● Type and number of infectious organisms
HOST ● Recommend concetration of the disinfectant and
● SUSCEPTIBILITY duration of contact
 The degree to which an individual can be affected ● Presence of soap
 The following measures can reduce a person’s  Certain ingredients in the soap that makes
susceptibility: germicidal effects of certain disinfectants become
 Hygiene inactivated when exposed to it
 Nutrition  A study “Effects of pure soaps on the bactericidal
 Fluid properties of phenolic germicides” states that
 Sleep certain ingredients of soap could actually inactivate
 Immunizations germicidal effects of phenol (Hampel)
● Presence of organic materials ASEPSIS PART 2
 Organic materials like blood, pus, or feces which IMPLEMENTATION: INFECTION CONTROL AND
have effect on certain disinfectants and can PREVENTION
become physical barriers (like an armor) for ● CDC has 2-tiered approach
microorganisms not to be killed by a disinfectant  Standard precautions
 Example, fecal matter, it tends to inactivate or slows  Transmission-based precautions
the germicidal effects of chlorine and iodophors/
iodine STANDARD PRECAUTIONS
● Surface areas to be treated ● Also termed as “Universal Precautions”
● Used in the care of all hospitalized individuals
STERILIZATION regardless of their diagnosis or possible infection status
● Process that destroys all microorganisms, including ● Used in any situations involving blood, all body fluids,
spores and viruses excretions, and secretions except sweat, nonintact skin
● 4 commonly used methods: and mucous membranes
● Include:
 MOIST HEAT  Hand hygiene
 Steam under pressure is used because it attains  Use of Personal Protective Equipment (PPE)
temperatures higher than the boiling point  Safe Injection Practices
 GAS  Safe Handling of Potentially Contaminated Equipment
 Ethylene Oxide or Surfaces in the Client Environment
 Tends to be effective in all microorganisms  Respiratory Hygiene/ Cough Etiquette
including spores but it is a gas that needs to be
carefully handled since it is PERSONAL PROTECTIVE EQUIPMENT (PPE)
known to be carcinogenic and teratogenic ● Include:
(affects health of a fetus of a pregnant mother)  Gloves (Clean or Sterile)
 BOILING  Gowns
 Minimum of 15 minutes  Masks
 Most common sterilization at home (minimum of 15  Protective Eyewear
minutes once it boils)
 RADIATION GLOVES
 Uses ionizing and non-ionizing radiation ● Worn for 3 reasons:
 Ionizing – sterilization  They protect the hands when the nurse
 Uses alpha and beta rays, it could kill spores is likely to handle any body substances
other than bacteria and viruses  Reduce the likelihood of nurses transmitting their
 Non-ionizing – disinfection own endogenous microorganisms to individuals
 Recommended for disinfection since it does receiving care
not kill spores, like UV light  Gloves reduce the chance that nurses’ hands will
transmit microorganisms form one client or an
object to another client
● Changed between client contacts
● Hands are cleansed each time gloves are removed for
2 reasons:
 They may have imperfections or be damaged
during wearing so that they could allow
microorganism entry
 The hands may be contaminated during glove
removal
● Wear clean gloves when touching blood, body fluids,
secretions, excretions, and contaminated items
 Clean gloves can be unsterile unless their use is
intended to prevent the entrance of microorganisms
into the body
 Remove gloves before touching noncontaminated
items and surfaces
 Perform proper hygiene immediately after removing
gloves
● View following videos to know the procedure in donning
clean gloves and removing them:
https://www.youtube.com/watch?v=DzgmgUfEVoM  Goggles
https://www/youtube.com/watch?v=pbnHIp5vesQ

GOWNS
 Masks w/ Face shield
● Clean or disposable impervious gowns or
plastic aprons are worn during procedures
when the nurse’s uniform is likely to
become soiled  Goggles with Prescription
● Sterile gowns may be indicated when the nurse Glasses
changes the dressings of a clien with extensive wounds
● SINGLE-USE GOWN TECHNIQUE
 Usual practice in the hospital  Face Shield
 If paper, gown is discarded
 Or places it in a laundry hamper DONNING AND DOFFING PPE:
● Remove a soiled gown carefully to avoid transfer of ●https://www.youtube.com/watch?v=H4jQUBAIBrl
microorganisms to others ●https://www.youtube.com/watch?v=PQxOc13DxvQ
● Cleanse hands after removing gown
TRANSMISSION-BASED PRECAUTIONS
FACE MASK ● Used in addition to standard precautions for clients with
● Worn to reduce the risk of transmission of organisms by known or suspected infections that are spread in one of
the droplet and airborne routes and by splatters of body the 3 ways:
substances  AIRBORNE
● The CDC recommends that mask be worn:  DROPLET
 By those close to the client if the infection is  CONTACT
transmitted by large-particle aerosols (droplets)
 By all individuals entering the room if the infection is ● AIRBORNE PRECAUTION
transmitted by small particle aerosols (droplet nuclei)  Used for clients with suspected illnesses transmitted
● TYPES OF FACE MASK by airborne droplet nuclei (smaller than 5 microns)
 SINGLE-USE DISPOSABLE  Examples:
SURGICAL MASKS  Measles (Rubeola)
 Effective for use while the nurses  Varicella (Chicken Pocks)
provide care to most clients bit  Tuberculosis
should be changed if they  Clients are placed in an airborne infection
become wet or soiled isolation room (AIIR)
 DISPOSABLE PARTICULATE RESPIRATORS  Private room that has negative air pressure, 6 to
12 air changes/ hour
 Effective for droplet transmission,  A filtration system for the room air
splatters and airborne organisms  if unavailable, client is place with another client
 Example: N95 Mask infected with the same microorganism
 Wear N95 Respirator Mask when entering the room
● During certain techniques requiring surgical asepsis,  Susceptible persons should not enter the room of the
masks are worn: client with such infections. If unavoidable, should
 To prevent droplet contact transmission of exhaled wear respirator mask
microorganisms to the sterile field or to client’s open  Limit movement of client outside the room
wound
 To protect the nurse from splashes of body ● DROPLET PRECAUTION
substances from the client  Used for clients known to have or suspected of
having serious illnesses transmitted by particle
EYEWEAR droplets larger than 5 microns
● Indicated in situations where body substances may  Examples:
splatter the face  Mumps
● May include goggles, glasses or face shields  Rubella (German Measles)
● If nurse is wearing prescription glasses, goggles should  Pharyngeal diphtheria
be worn over the glasses because the protection must  Mycoplasma pneumonia
extend around the sides of the glasses  use standard precaution as well as the following:
 Place client in a private room
 If a private room is unavailable, place the client PRINCIPLES AND PRACTICES OF SURGICAL
with another client infected with the same ASEPSIS
microorganisms ● All objects used in a sterile field must be sterile
 Wear mask if working within 1 meter (3 feet) of ● Sterile objects become unsterile when touched by
the client unsterile objects
 Limit the movement of client outside the room ● Sterile objects that are out of sight or below the waist or
table level are considered UNSTERILE
● CONTACT PRECAUTIONS ● Sterile objects can become unsterile by prolonged
 Used for clients known to have or suspected of exposure to airborne microorganisms
having serious illnesses easily transmitted by direct ● Fluids flow in the direction of gravity
client contact or by contact with the client’s items in ● Moisture that passes through a sterile object draws
the client’s environment microorganisms from unsterile surfaces above or below to
 Examples: the sterile surface by capillary action
 C. difficile ● The edges of the sterile field are considered unsterile
 E.coli ● The skin cannot be sterilized and is unsterile
 Shigella ● Consciousness, alertness and honesty are essential
 Hepatitis A qualities in maintaining surgical asepsis
 MRSA
 VRE STERILE FIELD
 Use standard precautions as well as the following: ● A microorganism-free area
 Place client in a private ● Established by using the innermost side of a sterile
 If unavailable, place client with another client wrapper or by using a sterile drape
infected with the same microorganism ● When established, sterile supplies, and sterile solutions
 Wear gloves as described in standard precautions can be placed on it
 Change gloves after contact with infectious material ● Sterile forceps are used in many instances to handle
 Remove gloves before leaving the client’s room and transfer sterile supplies
 Cleanse immediately after removing gloves. use an
antimicrobial agent ESTABLISHING A STERILE FIELD
 After hand hygiene, do not touch possibly ●https://www.youtube.com/watch?v=_aCf0HBVO_g
contaminated surfaces or items in the room
 Wear gown when entering a room if there is a STERILE GLOVES
possibility of contact with infected surfaces or items, if
client is incontinent, or has diarrhea, colostomy or wound
drainage not contained by a dressing
 Remove gown in the client’s room
 Make sure uniform does not contact possible
contaminated surfaces ● Worn during many procedures to enable the nurse to
 Limit movement of client outside the room handle sterile items freely
 Dedicate the use of noncritical client care equipment to ● Prevent clients at risk from becoming infected by
a single client or to clients with the same infecting microorganisms on unsterile gloves or the nurses’ hands
microorganisms
● Some diseases require a combination of transmission- TYPES OF STERILE GLOVES
based precautions ● LATEX AND NITRILE GLOVES are more flexible than
● When certain conditions exist, transmission-based VINYL
precautions are indicated until the presence or absence  First 2 mold to the wearer’s hands and allow
the suspected agent has been confirmed freedom of movement
 Over latex, nitrile gloves should be used in
STERILE TECHNIQUE performing tasks:
 That demand flexibility
 That place stress on the material
 That involve a high risk for exposure to
pathogens

● A set of specific practices and procedures performed to

 LATEX  NITRILE:
make equipment and areas free from all microorganisms
to maintain sterility
● VINYL GLOVES should be chosen for MEDICATIONS PART 1
tasks unlikely to stress the glove MEDICATION
material, requiring minimal precision ● A substance administered for:
and with minimal risk of exposure to  Diagnosis
pathogens Cure
 Treatment
● STERILE GLOVES may be applied by the OPEN  Relief of Symptom
METHOD or the CLOSED METHOD  Prevention of Disease
 OPEN METHOD – most frequently used outside the ● Used interchangeably with “DRUG”
operating room
 CLOSED METHOD – requires the nurse to wear a DRUG
sterile gown
● Also has a connotation of an illicitly
obtained substance
● Example:
OPEN METHOD GLOVING
 Heroin
 Cocaine
 Amphetamines
 Methamphetamine (“Shabu” or
“Crystal Meth”

●https://www.youtube.com/watch?v=lumZOF-METc PRESCRIPTION
●https://www.youtube.com/v=cl7u3kJHYHY ● The written direction for the preparation
and administration of a drug
CLOSED METHOD GLOVING

STERILE GOWNS

 Specific Medication accompanied by the

Doctor’s signature as validation
 Handwritten and Printed / Computer
Generated Prescriptions

● Sterile gowning and closed gloving are chiefly carried MEDICATION

out in the operating or delivery rooms ● Has 4 kinds of names:
● Before these procedures, the nurse applies a hair  GENERIC NAME
cover and a mask, and performs a surgical hand wash  Given before a drug becomes
officially an approved medication
DONNING OF STERILE GLOVES (CLOSED METHOD)  Used throughout the drug use
AND GOWN  OFFICIAL NAME
●https://www.youtube.com/watch?v=hTBR3yJ5IEs  Name under which it is listed in 1 of
the official publications
ROLE OF INFECTION PERVENTION NURSE  CHEMICAL NAME
● A nurse specially trained to be knowledgeable about the  Name by which a chemist knows it
latest research and practices in preventing, detecting and  Describes the constituents of the drug
treating infections  TRADE NAME
● All infections are reported to the nurse to allow  Name given by the drug manufacturer
recording and analyzing statistics that can assist in
● Example: PARACETAMOL
 Generic Name:
improving infection prevention practices
 PARACETAMOL
● May be involved in employee education
 Official Name:
 ACETAMINOPHEN (USP)
 PARACETAMOL (BP)
 Chemical Name: ● Number of actual available medication should be
 N-(4-hydroxyphenyl) compared with the number on the inventory
acetamide record. Investigation should be initiated if
 Trade Names: discrepancy is present.
 BIOGESIC ● Wasted drugs during preparation should also be
 TEMPRA recorded
 USP (US Pharmacopeia)
 BP (British Pharmacopeia)
 Philippine National Drug Formulary

PHARMACOLOGY
● Study of the effects of drugs on living organisms

PHARMACY
● Art of preparing, compounding, and
dispensing drugs  Computerized Controlled Dispensing System
● May also refer to the place where drugs  Record also the drugs left/ not utilized
are prepared and dispensed
Special inventory forms include:
LICENSED PHARMACIST ● Name of client
● Prepares, makes, and dispenses drugs as ● Date and time of administration
ordered by a physician, dentist, nurse ● Name of the drug
practitioner or physician assistant ● Dosage
● Signature of the person who prepared and
CLINICAL PHARMACIST gave the drug
● Specialist that guides physicians in prescribing ● Name of the physician
drugs ● For verification, may include another
nurse’s signature
PHARMACY TECHNICIAN
● A member of a health team that administers drugs EFFECTS OF DRUGS
to clients (applicable in some states in the US) THERAPEUTIC EFFECT
● Referred as desired effect
LEGAL ASPECTS OF DRUG ADMINISTRATION ● Primary effect intended
NURSES ● May either be:
● Need to know how nursing practice acts in their  PALLIATIVE
areas define and limit their functions  Relieves only the symptoms of a
● Should be able to recognize the limits of their diseases
knowledge and skill  CURATIVE
● Nurses are known to administer medications  Cures a disease or condition
prescribed by a physician  SUPPORTIVE
● Development and administration of any drugs is  Supports body function until other
always regulated by the law treatments or body’s response
● Need to know the laws can take over
● Responsibility to know more about the drug and  SUBSTITUTIVE
have the skills especially in health teachings and  Replaces body fluids or
administration substances
 Under the law, nurses are responsible for their  CHEMOTHERAPEUTIC
own actions regardless of whether there is a written  Destroys malignant cells
order  RESTORATIVE
 Therefore, nurses should question any order  Returns the body to health
that appears unreasonable and refuse to give the
medication until the order is clarified SIDE EFFECT
● Also known as “secondary effect”
USE OF CONTROLLED SUBSTANCES ● Unintended effect
● Kept in locked drawers, medication carts or ● Example: Allergy – take antihistamine medication;
computerized-controlled dispensing system side effect is sleepiness or drowsiness (secondary
● Have special inventory forms for recording their effect)
use
● Requires verification (i.e. 2 nurses) ADVERSE EFFECTS
● More severe side effects
● Justifies discontinuation of a drug
DRUG TOXICITY DRUG INTERACTION
● Harmful effects of a drug on an organisms or ● Occurs when the administration of one drug
tissue before, at the same time as, or after another drug
● Results from: alters the effect of one or both drugs
 Overdosage ● Effect may either be
 Ingestion of a drug intended for  INCREASED (POTENTIATING
external use EFFECT)
 Buildup of a drug in the blood because  DECREASED (INHIBITING EFFECT)
of impaired metabolism or excretion

DRUG ALLERGY  INCREASED (Potentiating Effect)

● An immunologic reaction to a drug  ADDITIVE
● Body may react by producing antibodies against it  Increase the action of each other
● May either be mild or severe  Example: Aspirin + Codeine
 MILD  SYNERGISTIC
 Rash or Diarrhea  Action of one or another drug is
 May occur minutes after or 2 increased
weeks after taking the medication  Example: Penicillin + Clavulanic
 SEVERE Acid
Occur immediately after  The bacteria used to be killed by penicillin
administration (anaphylactic produces penicillinase which prohibit the
reaction) penicillin to work effectively
 May be fatal if not treated
immediately IATROGENIC DISEASE
 Airway becomes so edematous ● Disease caused unintentionally by medical therapy
(swelling) making patient having ● Example: Isotretinoin effects on first trimester of
difficulty in breathing pregnancy
 Cleft palates
DRUG TOLERANCE  Heart defects
● Exist in a person who has unusually low  Hydrocephalus
physiologic response to a drug and who requires ● Isotretinoin (usually contained in cosmetic
increases in the dosage to maintain a given products) – reduce signs of aging
therapeutic effect
● E.g. DRUG MISUSE
 Opiates (heroin, morphine, ● The improper use of common medications in ways
fentanyl) that lead to acute and chronic toxicity
 Barbiturates DRUG ABUSE
 Ethyl alcohol ● inappropriate intake of a substance, either
continually or periodically
CUMULATIVE EFFECT ● 2 main facets
● Increasing response to repeated doses of a drug  DRUG DEPENDENCE
that occurs when the rate of administration  DRUG HABITUATION
exceeds the rate of metabolism or excretion  DRUG DEPENDENCE
● As a result, the drug accumulates in the body  Person’s reliance on or need to
unless the dosage is adjusted take a drug or substance
● Concentration of medication in the blood increases  2 types:
 PHYSIOLOGICAL DEPENDENCE
IDIOSYNCRATIC EFFECT  Tissues come to require the substance for
● One that is unexpected and may be individual to a normal functioning
client  Stopping could case WITHDRAWAL
● May either be underresponse or overresponse SYMPTOMS
● May also have a different effect from the normal  PSYCHOLOGICAL DEPENDCE
one  Emotional reliance on a drug to maintain a
● May cause unpredictable or unexplainable sense of well-being
symptoms  Accompanied by feelings of need or cravings
● Not very common for that drug
● Example: Ampicillin (some patients tend to  Example: Methamphetamine (Shabu),
develop rashes) withdrawal symptoms include having mild
depression/ severe depression and psychosis,
craving of the drug
 DRUG HABITUATION ● Highest plasma level achieved by a single dose
A mild form of psychological dependence until the elimination rate equals the rate of
 Individual develops the habit of taking the absorption
substance and feels better after taking ● Highest concentration a body has during intake of
 Continues taking even when injurious to health a certain medication
 Client does not care anymore if it causes harm ● Concentration when a medication has not been
to the body excreted by the body

ILLICIT DRUGS ONSET OF ACTION

● Also known as “street drugs” ● The time after administration when the body
● Drugs sold illegally initially responds to the drug
● May either be
 Drugs unavailable for purchase under any PLATEAU
circumstances ● A maintained concentration of a drug in the
 Drugs normally available with a prescription plasma during a series of scheduled doses
that are being obtained through illegal channels
● Taken for their mood-altering effect PHARMACODYNAMICS
● Mechanism of drug action and the relationships
ACTIONS OF DRUGS IN THE BODY between drug concentration and responses in the
body
● RECEPTORS
 Usually a protein found on the surface of a cell
membrane or within a cell
 Where drugs chemically bind to exert their
effects

● AGONIST
 A drug that produces the same type of
HALF LIFE response as the physiologic or endogenous
● Time interval required for the body’s elimination substance
processes to reduce the concentration of the drug  Example: Some chemicals in the body help in
in the body by one-half bronchodilation, when a person has asthma, the
● E.g. a drug’s half-life is 8 hours chemical mediator will act to have
 Initially 100 % bronchodilation to help the patient breath/
 After 8 hours: 50 % increase airway
 After 16 hours: 25 %  NATURAL AGONISTS
 After 24 hours: 12.5% ● Are substances within the body that have
evolved to produce a response when they
● To maintain a constant drug level in the body, bind to and “switch on” a receptor
repeated doses are required to maintain the level  AGONIS DRUGS
● Mimic natural agonists within the body,
PEAK PLASMA LEVEL binding to receptors to create the same effect
but often with a much more significant
physiological response

● ANTAGONIST
 A drug that inhibits cell function by occupying
receptor sites
 Work by binding to a cell’s receptor and blocking
access to the receptor from agonists in the body
 Sometimes called “blockers”
 Example: Antihistamines blocks the histamine
receptors, not causing i.e. an acid production in
the gastric area
PHARMACOKINETICS EXCRETION
● Study of the absorption, distribution, ● Process by which metabolites and drugs are
biotransformation, and excretion of drugs eliminated from the body
● Eliminated through”
ABSORPTION  Urine
● Process by which a drug passes into the  Feces
bloodstream  Breath
● To occur, correct form of the drug must be given  Perspiration
by the route intended  Saliva
● Stomach may be affected by:  Breast Milk
 Food
 Acid medium in the stomach FACTORS AFFECTING MEDICATION ACTION
 Drugs may also be absorbed in
the tissues DEVELOPMENTAL FACTORS
● FIRST-PASS EFFECT  FIRST TRIMESTER FETUS
 Oral drugs first pass through the liver and are  Affect formation of vital organs
partially metabolized before reaching the target  INFANTS
organ  Small dosages
● INTRAVENOUS  OLDER ADULTS
 Route of choice for rapid action  Decreased function of liver and kidney should
● INTRAMUSCULAR be considered
 Next most rapid due to the highly vascular  Consider also decreased gastric motility and
nature of the muscle tissue acidity and decreased blood flow
● SUBCUTANEOUS
 Slow due to poor blood supply GENDER
 May be applied heat to increase absorption or ● Related to the distribution of fat and fluid and
cold to slow it down hormonal differences
● RECTAL ● Example: Women tend to have more fat; fat
 Absorption tend to be unpredictable soluble vitamins can easily be absorbed than in
 Used only when other routes are unavailable men
 When intended action is localized to the rectum
or sigmoid colon CULTURAL, ETHNIC, AND GENETIC FACTORS
 PHARMACOGENECTICS
DISTRIBUTION  Study of the genetic ability to produce
● Transportation of a drug from the site of enzymes that affect the drug metabolism
absorption to its site of action  Drug response is influenced by genetic
● When in blood stream, goes to the highly variation including size and bodhy composition
vascularized organs  ETHNOPHARMACOLOGY
 LIVER, BRAIN AND KIDNEY  Study of the effect of racial and ethnic
 SKIN AND MUSCLE differences/ responses to prescribed
– receive drug later medications
● Liver, brain and kidney – highly vascularized  Research has shown that certain medications
(many blood flow) are safe at usual therapeutic dosages for
certain ethnic groups but may be toxic to
BIOTRANSFORMATION others
● A process by which a drug is converted to a less  CULTURAL FACTORS
active form  Example: Herbal medication utilized in certain
● Also called detoxification or metabolism groups may hasten or slow down the
● Most take place at the LIVER metabolism of some drugs
● METABOLITES
 Products of metabolism DIET
 May be active or inactive ● Nutrients can affect the action of a medication
 ACTIVE ● Example: Vitamin K in foods can counteract with
 Has pharmacologic effect anticoagulants such as warfarin
● Morphine – active metabolite that also causes
analgesia ENVIRONMENT
● Metabolite of codeine has a pharmacologic ● Temperature of environment may affect drug
effect activity
● High temperature enhance vasodilators
 Hydralazine – medication that can be used for ▪ Intravenous: into a vein
decreasing the BP of the patient, its effect can be
enhanced if patient is exposed in high temperature
● Cold temperatures enhance vasoconstrictors
 Dopamine – has increased effect in cold
temperature

PSYCHOLOGIC FACTORS
● A client’s expectation about what a drug can do
can affect the response to the medication

ILLNESS AND DISEASE

● Drug action is altered in clients with circulatory,
liver or kidney dysfunction

TIME OF ADMINISTRATION
● Most oral medications are absorbed more quickly ▪ Less commonly used parenteral routes
if the stomach is empty • Intra-arterial
● Some, though, need to be taken with meals • Intracardiac: into the heart muscle
● Most antibiotics are effective in an empty stomach • Intraosseous: into the bone
• Intrathecal or intraspinal:
MEDICATIONS PART 2 into the spinal canal
• Intrapleural
ROUTE ADMINISTRATION • Epidural: into the epidural space
ORAL • Intraarticular: into joint
o Drug is swallowed
o Most common, least expensive and TOPICAL
most convenient route o Applied to a circumscribed surface area of the
o Safe method body
o Disadvantages include o Affect only the area to which they are applied
▪ Unpleasant taste o Includes
▪ Irregular absorption from the GIT ▪ Dermatologic preparations:
▪ Slow absorption applied to the skin
▪ Sometimes, harmful for the client’s ▪ Instillation or irrigation:
teeth into body cavities or orifices
▪ Inhalations
SUBLINGUAL : to respiratory tract through a
o Administration of drug is placed under nebulizer or a positive pressure
the tongue where it dissolves breathing apparatus
o Should not be swallowed : air, oxygen and vapor are used to
o Example is nitroglycerin which carry the drugs to the lungs
decreases blood pressure

BUCCAL
o Medication is held in the mouth against
the mucous membranes of the cheek
until the drug dissolves
o Drug may act locally on the mucous
membranes of the mouth or systemically
once swallowed

PARENTERAL
o Involves the use of needle
o Includes
▪ Subcutaneous (hypodermic):
into the subcutaneous tissue, below
the skin
▪ Intramuscular: into a muscle
▪ Intradermal: under the epidermis
MEDICATION ORDERS 󠆻 If the primary care provider cannot be reached,
TYPES OF MEDICATION ORDERS document all attempts to contact him and the
reason for withholding the medication
STAT ORDER 󠆻 If someone else gives the medication, document
o Medication is to be given immediately and only data about the client’s condition before and after
once the administration
o Immediate 󠆻 If an incident report is indicated clearly document
SINGLE ORDER factual information
o One-time order
o Medication to be given once at a specified time SYSTEMS OF MEASUREMENTS
STANDING ORDER METRIC SYSTEM
o May or may not have a termination date o Liter and milliliter (volume)
o May be carried out indefinitely until an order is o Kilogram, grams and micrograms (weight)
written to cancel it or may be carried out at a APOTHECARIES SYSTEM
specified number of days o Grain (weight)
PRN ORDER o Minim (volume)
o As needed order HOUSEHOLD SYSTEM
o Permits the nurse to give a medication when, in o Drops, teaspoons, tablespoons, cups and
the nurse’s judgement, the client requires it glasses
o Examples are pain medications

ESSENTIAL PARTS OF A DRUG ORDER

󠆻 Client’s full name
o Includes first and last names including the
middle names to avoid confusion between 2
clients who have the same last name
o May also include client’s identification number
and physician’s name
󠆻 Date and time the order was written
󠆻 Name of the drug to be administered
󠆻 Dosage of the drug
o Dosages may be written in apothecary or metric
system (however, metric system is
recommended due to unfamiliarity to the
apothecary system)
󠆻 Frequency of administration;
may also include strength
󠆻 Route of administration
󠆻 Signature of the person writing the order
o Unsigned orders have no validity

COMMUNICATING A MEDICATION ORDER

󠆻 A drug order is written on the client’s chart by a
primary care giver or by a nurse receiving a
telephone or verbal order from the primary care (mg) (present in order)
giver
󠆻 Telephone or verbal orders are the consigned by
(mL)
the primary care provider
󠆻 The medication order is then copied to a Kardex
or to a medication administration (MAR)
󠆻 When in doubt about the medication order, do the
following:
o Contact the primary care provider and discuss
the rationale for believing the medication or
dosage to be inappropriate
o Document in notes the following
▪ When: primary care provider was notified
▪ What: was conveyed
▪ How: he responded
CALCULATING DOSAGES MEDICATION ADMINISTRATION ERRORS
󠆻 Dosages for children 󠆻 Any preventable event that may cause or lead to
o Use kilograms of body weight and per kilogram inappropriate medication use or patient harm
medication recommendation while the medication is in the control of a health
󠆻 Paracetamol used in children care professional, patient or consumer.
o The correct dose of paracetamol on children (NCCP MERP, 2013)
based on following three things
1) Child’s age 󠆻 4 MAIN TYPES OF MEDICATION ERRORS
2) Child’s weight 1) Prescription errors (wrong drug or dose)
3) Strength of Paracetamol in Medicine 2) Transcription/interpretation error
o Recommend dose for children is 10-15 mg per 3) Preparation errors
kg of body weight. For example: If weight of 4) Administration errors: most medication errors
children is 10 kgs, dose should be within 100 to 󠆻 CAUSES
150mg (10 X 10 to 15X 10 mg), this dose can be o Individual
given for every 4-6 hours and maximum 4 times ▪ Fatigue and stress
a day. o System
▪ Interruptions and distractions during medication
BODY SURFACE AREA administrations
o Uses a nomogram and the child’s height and • Overhead pages, telephone calls, family
weight queries, questions from other health care team
o Child’s dose members
Nomogram • May be solved by pitting a “no interruption
zone/quiet zones. Do not disturb sash”

MEDICATION RECONCILIATION
󠆻 Process of creating the most accurate list possible
of all medication a patient is taking
o On admission
o During transfer between units o In shift
reports
o In new MARs
o At discharge
PROCESS OF ADMINISTERING MEDICATION
󠆻 Identify the client - Inform the client
󠆻 Administer the drug
o Read the MAR carefully and perform 3
checks
o Refer to the 10 rights of medication
administration
󠆻 Provide adjunctive interventions as indicated
󠆻 Record the drug administers
󠆻 Evaluate the client’s response to the drug Verify:
ADMINISTERING MEDICATIONS SAFELY
󠆻 The nurse should always assess the client’s complete name and date of birth
10 RIGHTS OF MEDICATION ADMINISTRATION
health status and obtain a medication history prior
to administration of any medication. Includes
o Client’s illness or current condition
o Intended drug
o Route of administration
o Medication history
o Medications taken currently or has taken
recently
o Drug allergies
o Normal eating habits o Self-administration
o Socioeconomic factors
ORAL MEDICATION
󠆻 Oral route
o Most common route
o Route of choice as long as the client can
swallow and retain the drug in the stomach
󠆻 Special considerations
o Always perform hand hygiene and observe
appropriate infection prevention procedures
o Always do the “3 checks” when obtaining the
medication
o Calculate the medication accurately o Always
prepare the medication without contaminating it
o Tablets and capsules
▪ Place a packaged until-dose capsules/tablets
directly into the medicine cups. Do not
remove the medication from the package
until at the bedside
▪ If using a stock container, pour the required
number into the bottle cap and then transfer
the medication into the bottle cap, and then ORAL
transfer the medication to the disposable cup SYRINGE:
without touching the tablets Links
▪ Keep narcotics and medications that require https://www.youtube.com/watch?v=oylb_WQJU80
specific assessments separate from the (unavailable)
otters https://www.youtube.com/watch?v=fe7Yp3o-Xvg
▪ Break only scored tablets if necessary, to (how to deliver liquid medication)
obtain correct dosage. Use a cutting or
splitting device if needed. Always check if PARENTERAL MEDICATIONS
unused portions are to be discarded 󠆻 May be
Cutting Device Crushing Device o Intradermal
o Subcutaneous
o Intramuscular
o Intravenous
󠆻 Invasive
o Aseptic technique should be used
󠆻 Parenteral medications
o Liquid medication o Anatomy of a syringe
▪ Thoroughly mix the medication before pouring
▪ Discard medications that have changed color or
turned cloudy
▪ Remove the cap and place it upside down on the
countertop
▪ Hold the bottle so the label is next to your palm
and pour the medication away from the label
▪ Place the medication cup on flat surface at eye o Sterile parts of syringes
level ▪ Tip and inside of the barrel
▪ Fill the desired level, using the bottom of the ▪ Shaft of plunger
meniscus to align with the container scale ▪ Shaft of tip of needle
▪ Wipe the lip with a paper towel before capping 󠆻 Kinds of syringes
the bottle o Hypodermic syringe:
▪ Use a sterile syringe without the needle or come in 2,2.5,3 or 5 mL sizes
specially designed oral syringe for small
amounts of liquids. Label it with the name of med
and route (PO)
o Insulin syringe PREVENTING NEEDLESTICK INJURIES
- Use appropriate puncture-proof disposal containers
- Never bend or break needles
- Never recap needles
- When recapping
o Use safety mechanical device
o Tuberculin syringe
o Use a one-handed scoop Needle capper
- For tuberculosis: largest is 1 mL

o Insulin pen

PREPARING INJECTABLE MEDICATION

AMPULE
- Glass container
usually designed to
hold a single dose
drug
NEEDLES
Preparation of a medication from an ampule:
https://www.youtube.com/watch?v=mFKj3_Wk8m8

VIAL
- Small glass bottle with a sealed rubber cap
- Reconstitution: technique of adding a diluent to a
powdered drug

Proper way in preparing a medication from a viral:

https://www.youtube.com/watch?v=gyHhpPeioes
(302 preparing medications from vial)
Bevel: hole
3 variable characteristics Proper way of mixing medications with one syringe:
- Slant or length of bevel https://www.youtube.com/watch?v=rM5G3R_GaNE
- Length of shaft (mixing vial insulin for injection)
- Gauge
o The smaller the gauge, the bigger the diameter TYPES OF INJECTIONS
of shaft 1) Intradermal (ID) Injections
- Administration of a drug into the demal layer of
the skin just beneath the epidermis
- Usually only a small amount of lipid is used (e.g.
0.1 mL)
- Frequently used for allergy testing and
tuberculosis (TB) screening
- Common sites
o Inner lower arm
o Upper chest
o Back beneath scapulae
- For skin testing
o Solution should consistent the following
▪ 0.9 of diluent
Subcutaneous injections ▪ 0.1 of the medication
- G24 to G26’ 3/8 to 5/8 inch long o The borders are encircled using any color of
- Obese: 1-inch needle pen, except red-ink pen
- IM: 1 to 1 ½ inches long; G20 to G22 o Results are read 30 minutes thereafter by
physcicians
o Positive results include redness with - For insulin o #30-gauge and short needle
projections, itchiness and increase in o The risk for injecting into a muscle is lessened
diameter - Sites should be rotated to minimize tissue damage,
aid absorption and avoid discomfort
Proper way of doing intradermal injections: - Insulin sites should be rotated weekly, to avoid
https://www.youtube.com/watch?v=7i6YNqizxwk lipoatrophy and lipohypertrophy
- Routine aspiration is no longer recommended with
insulin administration
Proper way of doing subcutaneous injections:
https://www.youtube.com/watch?v=wXjQHAxopzk

3) Intramuscular (IM) injection

- Medications are absorbed more quickly than SC
injection due to greater blood supply
- Muscles can also take larger volume of
medications can tolerate up to 3 mL, specifically at
the gluteus medius and gluteus maximus
- Deltoid muscle: 0.5 to 1 mL
2) Subcutaneous injections - Standard needle: 1 ½ inches; #21 or #22 gauge
- Common drugs administered subcutaneously - Deltoid: 1 inch; #23 to #25-gauge
o Vaccines, insulin and heparin - Viscous solution: #20-gauge
- Common sites - Considerations o Away from large blood vessels,
o Outer aspect of upper arms nerves and bone
o Anterior aspect of thighs - Contraindications
- Other areas o Tissue injury
o Abdomen o Presence of nodules, lumps, abscesses,
o Scapular areas of the upper back tenderness and other pathology
o Upper ventrogluteal and dorsogluteal areas - Ventrogluteal site
- Only small amount (0.5 to 1 mL) of medication are o Safest site for more than 1 mL in clients aged
usually injected more than 7 months
o Preferred site
▪ Contains no large nerves or blood vessels
▪ Provides the greatest thickness of gluteal
muscle
▪ Is sealed off by bone
▪ Less fat than the buttock area
o Client positions
▪ Back
▪ Prone
▪ Side-lying
• Location of site is easier
o Location
▪ Place heel of hand on the client’s greater
trochanter, with fingers facing the client’s head
▪ With the index finger on the client’s anterior
superior iliac spine, the nurse stretches the
middle finger dorsally, palpating the crest of the
ilium and then pressing below it
▪ The triangle formed by the index finger, the third
finger and the crest of the ilium is the injection
site
- Type of syringe depends on the medication being ▪ Right side: left hand
given ▪ Left side: right hand
- Generally, #25-gauge, 5/8 inch is used for adults -
Needle is inserted at 45 degrees (5/8 inch); 90
degrees (3/8 inch)
- To determine the length of needle
o Half of the width of the pinched site
- To determine the angle of insertion
o 45 degrees: 1 inch of grasped tissue
o 90 degrees: 2 inches of grasped tissue
o Top of axilla is the line the marks the lower
border
o A triangle within these boundaries indicated the
deltoid muscle, about 5 cm below acromion
process

Vastus lateralis
- Recommended for infants and
Proper way of doing intramuscular injections:
young children https://www.youtube.com/watch?v=XsoVSDpD_7o
- Situated on the anterior lateral
aspects of the infant’s thigh Z-track method of IM injection
- In adults, site is established - When the skin returns to its normal position after
by dividing the area between the needle is withdrawn, a seal is formed over the
the greater trochanter of the intramuscular site.
femur and lateral femoral - Decreases leakage of irritating and
condyle into thirds and discoloring medications
selecting the middle third

Dorsogluteal site
- Should be avoided due to the adjacent sciatic
nerve, superior gluteal nerve and artery
- Upper left quadrant

Proper way do doing Z track method of injections:

https://www.youtube.com/watch?v=1ILZBduQh44
(not available)
Rectus femoris site
- Situated at the anterior aspect of thigh CVGH Medication System
- Clients who administer their own medications can
reach the site easily
- Main disadvantages: discomfort for some people

Deltoid site
- Not often used: relatively small and close to the
radial nerve and radial artery
- No more than 1 mL can be administered
- To locate: Medication
o Place 4 fingers across the deltoid muscle with Ticket
the first finger on the acromion process
NURSING INTERVENTIONS TO
PROMOTE HEALTHY PHYSIOLOGIC
RESPONSE
HYGIENE
Science of health and maintenance

PERSONAL HYGIENE
Self-care by which people attend to such function
as: bathing, toileting, generak body type, and
grooming

TYPES OF HYGIENE CARE FACTORS AFFECTING THE SKIN

1. Early Morning Care INTERNAL FACTORS:
● provided as the client wakes up 1. Genetics
● consists of providing urinal/bedpan to client ● A person’s genetics determine their skin type
confined to bed, washing face and hands, and (normal, dry, oily or combination) and affect their
giving oral care overall skin condition.
2. Morning Care 2. Hormones
● often provided after client’s breakfast ● Hormonal Changes can trigger acne and
● includes providing for elimination needs, a bath hyperpigmentation especially during pregnancy
shower, perineal care, back massages, and 3. Lifestyle
oral, nail, and hair care ● stress, amount of sleep, exercise, nutrition
3. Hours of Sleep or PM Care
● provided before they retire/sleep for the night EXTERNAL FACTORS:
● involves elimination needs, washing face and 1. UV Rays
hands, giving oral care, and giving a back ● Sustained exposure to the sun triggers the
massage formation of free radicals, which can weaken
4. As-needed (PRN) Care skin’s protective mechanisms
● provided as required by clent 7-8AM: sunlight is beneficial to skin
2. Temperature
SKIN ● Extreme temperatures, and the speed of change
● largest organ of the body between the, impact on skin
● Functions: Hot Temp: sunburns
1. Protects underlying tissues from injury by Cold Temp: cold sores near mouth/nose
preventing the passage of microorganisms: skin
and mucous membranes as body’s first line of CHEMICAL INFLUENCES:
defense 1. Aggressive Products
2. Regulates body temperature ● usage of overly acidic and alkaline products can
3. Secretes sebum impair epidermis
4. Transmits sensations through nerve receptors  pH: 4.7-5.75 (mildly acidic)
(sensitive to pain, temperature, touch and 2. Washing too frequently
pressure) ● strip off natural oils
5. Produces and absorbs Vitamin D in conjunction 3. Nutrition
with ultraviolet rays of the sun ● follow balanced diet, drink enough water, vit. C,
 has transient and resident microorganisms that antioxidants
may not be harmful to self; therefore, it cannot 4. Therapeutic Measures (Medications)
be sterile ● some causes dryness or rashes
● know the drug interactions bet. medications and
supplements

GENERAL GUIDELINES FOR SKIN CARE

1. Intact, healthy skin is the body’s first line of
defense
● Nurses need to ensure that all skin care
measures prevent injury and irritation
 Scratching with jewelry, nails
 Harsh rubbing of towels/cloths- linens should be
wrinkle free to avoid bed sores
2. The degree to which the skin protects the ● used to absorb water and prevent friction; some
underlying tissues from an injury depends on the have antibacterial properties
general health of the cells, the amount of 6. DEODORANT
subcutaneous tissue and the dryness of skin ● masks or diminishes body odor
● Skin that is poorly nourished and dry is less 7. ANTIPERSPIRANT
easily protected and more vulnerable to injury ● reduces amount of perspiration
Applying lotions to dry skin
Elderly patients are advised not to take a bath BATHING
every day. ● removed accumulated oil, perspiration, dead skin
3. Moisture in contact with the skin for more than cells and some bacteria
a short time can result in increased bacterial ● can stimulate circulation, especially warm/hot
growth and irritation baths
● Skin must be dried carefully and thoroughly
● Must pay attention to these locations (potential TWO CATEGORIES OF BATHS:
locations for irritation and fungal infections) CLEANING: for hygiene purposes and has different
O Axilla types
O Groin ● Complete Bed Bath: nurse washes entire body
O Beneath the breasts (boob sweat) ● Self-Help Bed Bath: able to bathe himself with
O Between toes the help from the nurse
Putting non-irritating dusting powder to reduce ● Partial Bath (Abbreviated Bath): only the parts of
moisture applied after drying patient the body that might cause discomfort or odor
Provide immediate skin care to patients who ● Bag Bath: commercially prepared product that
lack of control over defecation/ urination, or who contains 10-12 presoaked disposable washcloths
sweat profusely that contain no-rinse cleanser solution
4. Body odor are caused by resident skin ● Tub Bath: Sponge bath for newborns
bacteria acting on the body ● Shower
● Commercial deodorants and antiperspirants
can be applied only after the skin is cleaned
● Deodorant “diminish odor”
● Antiperspirant “reduces amount of perspiration”
 Do not apply deodorant/antiperspirant after
shaving, may cause skin irritation
5. Skin sensitivity to irritation and injury among
individuals and in accordance with their health
bath bag shower chair
● Infants, very young children, and older people
have greater skin sensitivity
THERAPEUTIC:
● Nutrition also plays a role in skin sensitivity –
● for physical effects such as to soothe irritated skin
e.g. obesity
or treat an area.
6 AGENTS USED FOR SKIN CARE WITH
(e.g. perineum area)
SELECTIVE ACTIONS AND PURPOSES
● Medications may be placed in the water
1. SOAP
● client remains in the bath for a designated time,
● lowers surface tension and thus helps in
often 20-30 mins
cleaning; may have antibacterial agents (can
● bath temp: 37.7⁰C to 46⁰C (adults)
change normal flora of skin)
40.5⁰C (infants)
 Harsh soaps causes UTI when used in
perineal area
HAIR
2. CHLOROHEXIDINE GLUCONATE (CHG)
● appearance of the hair often reflects a person’s
● disposable cloth saturated with 25% CHG and
feelings of self-concept and sociocultural well-being
skin moisturizing substances
● may also reflect state of health
● Advantage: continued antimicrobial activity after
 should be washed often as needed to keep it
application; used often in critical-care settings
clean
and in delivery room
 Head bath: specially designed cap (looks like a
3. BATH OIL
shower cap) placed over the hair
● used in bath water; softens and prevents
 Water should be 40.5
chapping of skin
 Children: monitor for nits (pediculosis)
 prone to injury (slippery on bath floor)
 Older adults: ensure adequate
4. SKIN CREAM, LOTION
warm
● provides fill on skin that prevents evaporation
and therefore chapping
5. POWDER
DEVELOPMENTAL VARIATION → If client is unconscious or lacks blink reflex, drying
● Newborns: Lanugo and irritation of the cornea should be prevented.
-fine hair on the body (down or Lubricating drops may be ordered.
woolly hair) over the shoulder,
back, and sacrum)

● Puberty: Pubic Hair,

Axillary Hair

● Adolescence: Increased
sebaceous glands activity due to
increased hormone levels
● Older Adults:
thinner hair leading
to baldness
USING A SAFETY RAZOR TO SHAVE FACIAL
HAIR
● Wear gloves
● Apply shaving cream or soap and water EYEGLASS CARE
● Hold the skin taut, particularly around creases ● Glass lenses: clean with warm water and dried
● Hold razor so that the blade is at 45-degree angle with soft tissue
to the skin. Shave in the direction of hair growth ● Plastic lenses: easily scratched; may require
● Wipe with wet washcloth special cleaning solutions and drying tissues
● Dry and apply aftershave lotion or powder ● must be placed in an appropriate case and stored
● Pat on the lotion with fingers and avoid rubbing the bedside, if not used
face
 A beard or mustache should NOT BE SHAVED GENERAL EYE CARE
OFF without the client's consent ➤ Avoid home remedies for eye problems. Seek
medical help immediately.
EYES
➤ If dust or dirt get into the eyes, clean them
Normally does not require special hygiene
copiously with clean, tepid water as emergency
Lacrimal Fluid: continually washes the eyes
treatment
Lashes and eyelids: prevents entrance of foreign
objects ➤ to avoid eyestrain and protect vision, maintain
Special interventions for unconscious/ comatose adequate lighting for reading and obtaining
clients or those recovering from eye surgery, eye shatterproof lenses for glasses
injuries, irritations, or infections. ➤ Schedule regular eye examinations, particularly
after age 40, to detect problems e.g., cataracts,
glaucoma

MOUTH
DEVELOPMENTAL VARIATIONS
➤ Birth: Teeth appears 5 to 8 months
➤ Baby-bottle syndrome: may cause dental
caries; if child wants a bottle, should only contain
water
➤ 2 years old: usually have all 20 temporary teeth
➤ 6 to 7 years old: starts losing deciduous teeth
and gradually replace with 33 permanent teeth
EYE CARE
→ Accumulated dried secretions on the lashes must ➤ 25 years old: most people have all permanent
be softened and wiped away teeth
• Moisten cotton ball with sterile water or normal ➤ Pregnant women: high incidence of periodontal
saline and place over the lid margins. disease due to rise of female hormones and
• Wipe the loosened secretions from the inner increases reaction to bacterial plaque
canthus of the eye to the outer canthus – to ➤ Teeth turn to yellowish in color;
prevent the particles of fluid from draining into Normal: off-white
the lacrimal sac and the nasolacrimal duct ➤ Lack of fluoridated water and preventive dentistry
during developmental years can cause tooth and
gum problems in older adults
➤ Losing of few permanent teeth and use of Caring for Artificial Dentures
dentures ➤ must be cleaned regularly, at least once a day
➤ Aging: dryness of gums due to decrease saliva ➤ remove from mouth, scrub with a toothbrush,
production; brown pigmentation on gums rinse and can be used after
➤ dentrifice or toothpaste is used for cleaning
ORAL HYGIENE ➤ Most people prefer to privacy when cleaning
Infants and Toddlers dentures
• @ 18 months: brush child's teeth with soft ASSISTING CLIENTS WITH ORAL CARE
toothbrush; moisten with water at first (introduce For partially or totally dependent clients:
toothpaste later)
➤ nurse must wear gloves (clean)
• Give fluoride supplement daily or as
recommended, unless drinking water is fluoridated ➤ use a curved basin to receive the rinse water
• Schedule initial dental visit at 2-3 years old, as ➤ towel to protect patient and bedclothes
soon as all 20 primary teeth has erupted • Foam swabs are often used to clean mouths
• Seek professional dental attention for any of dependent clients
problems e.g., discoloring of teeth, chipping, signs Assisting Clients with Special Oral Hygiene
of infection Needs
Preschoolers and School-Age Children ➤ For debilitated or unconscious or who has
➤ Dental care is essential since deciduous teeth excessive dryness (xerostomia), sores c irritations
erupts and guide entrance of permanent teeth; of the mouth
fluoride to prevent dental caries • necessary to clean oral mucosa, tongue and
➤ Abnormal placed or lost deciduous cause teeth
misalignment of permanent teeth • oral care may be done every 2 to 8 hours
• must focus on removal of plaque and
➤ Must be taught to brush teeth after eating and
microorganisms as well as client comfort
limit intake of refined sugars
• use soft-bristled toothbrush for plaque removal;
➤ Parental supervision is important to ensure tooth sodium bicarbonate toothpaste/diluted sodium
brushing is done bicarbonate for viscous oral debris
➤ Regular dental checkups are required • oral swab or gauze, if cannot tolerate
Adolescent and Adults FEET
➤ Proper diet and tooth and mouth care should be FEET: DEVELOPMENTAL VARIATIONS
reinforced At birth, foot is relatively unformed; arches
Older Adults supported with fatty pads and do not take full
➤ rate of edentulism (lack of teeth) continues shape until 5 to 6 years
➤ At risk for dental cavities and periodontal disease Childhood: bones and small muscles of feet are
especially those with self-care deficits and in easily damaged by tight binding stockings and ill-
nursing homes with dementia fitting shoes
Aging: wider and longer feet, mild settling of the
arches, loss of natural padding on the bottom of
heels, cartilages around joints deteriorates, loss
of normal range of motion of the foot and ankle
FOOT CARE
● Wash the client's foot with warm water (40°C to
43°C) to promote circulation and comfort.
● Soak foot of the client and wash using a washcloth
with soap. Soap must be completely removed
during rinsing.
● Dry the foot thoroughly and apply lotion or foot
powder.
● Trim nails with the permission of the client or by
Brushing and Flossing Teeth institution's policy
➤ removes food particles that can harbor and
incubate bacteria SUPPORTING HYGIENIC ENVIRONMENT
Environment
➤stimulates circulation in gums
• Room temperature (between 20°C to 23°C)
➤ SULCULAR TECHNIQUE: • Ventilation - use of room deodorizers,
technique for brushing teeth, removes plaque and eliminating body odor
cleans under gingival margins • Noise - clients are hypersensitive to noise due
➤ Fluoride toothpaste is recommended due to its to illness (pain, stress); can cx delay in recovery
antibacterial protection Hospital Bed
MOBILITY AND ACTIVITY MOBILITY
Mattresses ● the ability to move freely, easily, rhythmically, and
- Covered with water-repellent material; can be purposefully in the environment; an essential part
cleaned easily of living.
- Egg-crate mattresses: to relieve pressure on ● vital to independence; a fully mobilized person is
bony prominences as vulnerable and dependent as an infant.
Side Rails  People must move to protect themselves from
Footboard trauma and to meet their basic needs.
Intravenous Rods The ability to move without pain also influences
self-esteem and body image.
MAKING BEDS For most people, self-esteem depends on a sense
Occupied and Unoccupied Bed: of independence and a feeling of usefulness or
• Unoccupied bed can either be closed or open being needed.
• Open: the top covers are folded back to make it People with mobility impairments may feel
easier for the client to get in helpless and burdensome to others. Their ability
to work and earn a living may be compromised.
Painful mobility makes coping even more difficult.
Body image can be altered by paralysis,
amputations, or any motor impairment.
The reaction of others to impaired mobility can
also alter self-esteem and body image
significantly.
• Closed: top covers are drawn up to the top of the  For those with impaired mobility, movements
bed and under the pillow must be fostered to the full extent of their
capability to facilitate a satisfying life.
Example:
1.) Many people who have impairments of use
wheelchairs participate in athletics to
experience the joys of competition and fitness.
2.) Many individuals with paralysis can
use a hand control to enter and drive adapted
vans or use their mouth to manipulate a paint
BEDMAKING OF AN OCCUPIED BED brush and create art.
● One of the most important nursing techniques  People with immobility should be encouraged to:
● Purpose: to prevent complications by ensuring
✔ breathe fully,
comfort and security of the patient
Materials used: ✔ engage their abdominal muscles, move as much
1. Gloves (Client) as possible to prevent physical and
2. Bath blanket psychoemotional hazards of immobility.
3. Bottom sheet
4. Draw sheet NORMAL MOVEMENTS
5. Top sheet NORMAL MOVEMENT and STABILITY are the
6. Pillowcase result of an intact musculoskeletal system, intact
THINGS TO REMEMBER: nervous system and intact inner ear structures
1. Wear gloves while handling the client’s used bed responsible for Equilibrium.
linens ▪ Body movement requires coordinated muscle
2. Hold soiled linen away from uniform activity and neurologic integration.
3. Linen for one client is never placed on another It involves 4 Basic Elements:
client’s bed 1.) Body alignment (Posture)
4. Place soiled linen directly to hamper or tucked in 2.) Joint mobility
pillowcase at the end of the bed before it is 3.) Balance
gathered up for disposal 4.) Coordinated movement
5. DO NOT SHAKE SOILED LINENS IN THE AIR
6. When stripping and making bed, conserve time 1.) BODY ALIGNMENT (Posture)
and energy by stripping and making up one side - bring body parts into positioning a manner that
as much as possible before working on the other promotes optimal balance and maximal body
side function whether the client is standing, sitting, or
7. To avoid necessary trips to linen supply area, lying down.
gather all linen before stripping the bed - A person maintains balance as long as the line of
gravity (an imaginary vertical line drawn through
the body's center of gravity) passes through the
center of gravity (the point at which all of the
body's mass is centered) and the base of
support (the foundation on which the body rests)
-In humans, the usual line of gravity begins at the
top of the head and falls between the shoulders,
through the trunk, slightly anterior to the sacrum,
and between the weight bearing joints and base
of support.

-When the body is aligned, strain on the joints,

muscles, tendons or ligaments is minimized and
internal structures and organs are supported.
-Proper body alignment enhances lung expansion
and promotes efficient circulatory, renal and
gastrointestinal functions.
-A person's posture is one criterion for assessing
general health, physical fitness and attractiveness.
-Posture reflects the mood, self-esteem, and
personality of the individual and vice versa. RANGE OF MOTION (ROM)
-These muscles are characterized according to the ➤ Range of Motion (ROM) of a joint is the maximum
type of joint movement they produce on contraction. movement that is possible for that joint.
-Muscles are therefor called flexors, extensors, ➤ Joint ROM varies from each individual and
internal rotators, and the like. is determined:
a.) genetic makeup
2.) JOINT MOBILITY b.) developmental patterns
-Joints are the functional units of the c.) presence or absence of disease,
musculoskeletal system. d.) the amount of physical activity in which the
-The bones of the skeleton articulate at the joints, person normally engages|
and most of the skeletal muscles attach to the two 4 Basic Elements of Normal Body Movement
bones at the joint. (cont’n):
-These muscles are characterized according to the 3.) BALANCE
type of joint movement they produce on
➤ The mechanisms involved in maintaining balance
contraction.
and posture are complex and involved
-Muscles are therefor called flexors, extensors,
informational inputs from the labyrinth (inner
internal rotators, and the like.
ear), from vision (vestibulo-ocular input), and
a. FLEXOR MUSCLES
from stretch receptors of muscles and
= are stronger than the extensor muscles.
tendons (vestibulospinal input).
= When a person is inactive, the joints are pulled
in to a flexed (bent) position. If this tendency is ➤ Mechanisms of Equilibrium (sense of balance)
not counteracted with exercise and position respond, frequently without our awareness,, to
changes, the muscles permanently shorten, and various head movements.
the joint becomes fixed in a flexed position ➤ The Labyrinth consists of the:
(contracture) are characterized according to the cochlea
type of joint movement they produce on = concerned with hearing
contraction. vestibule & semicircular canals
= with equilibrium
➤ Under normal conditions, the equilibrium
receptors in the semicircular canals and
vestibule, collectively called the "Vestibular
appratus” = send signals to the brain that
initiate reflexes needed to make required Activity Intolerance
changes in position. = the type and amount of exercise of daily living
➤ The receptors (hair-like cells) = respond to activities an individual is able to perform without
displacement of the head in any direction. experiencing adverse effects.
➤ When the head moves -- the fluid flow within the Functional strength
vestibule and semicircular canals -- stimulates = defined as the ability of the body to perform
sensory hair cells. work.
= is another goal of exercise
➤ Information from these balance receptors goes
directly to reflex centers in the brain stem EXERCISE
rather than to the cerebral cortex as with the TYPES OF EXERCISE:
other special senses Classified according to:
--> enables fast reflexive responses to body 1.) Type of muscle contraction
imbalance. a. isotonic
➤ PROPRIOCEPTION = term used to describe b. isometric
awareness of posture, movement, and changes in c. isokinetic
equilibrium and the knowledge of position, weight, 2.) The source of energy
and resistance of objects in relation to the body. a. aerobic
b. anaerobic
4.) COORDINATED MOVEMENT
► Balanced, smooth, purposeful movement is the 1.) Isotonic (Dynamic) Exercise
result of proper functioning of the cerebral ➤ are those in which the muscles shortens to
cortex, cerebellum, and basal ganglia. produce muscle contraction and active
a.) Cerebral cortex movement.
= initiates voluntary motor activity ➤ most physical conditioning exercises.
= operates movement; not muscles
Eg: May direct an arm to pick up a cup of Examples:
coffee
✓ running, walking, swimming, cycling, and other
b.) Cerebellum
such activities
= coordinates the motor activities; operates
below the level of consciousness; blends and ✓ ADLs and active ROM exercises (initiated by
coordinates the muscles involved in voluntary the client)
movement.
= doesn't direct the movement but translates the Isotonic bed exercises:
"instructions" from the cerebral cortex into ● pushing or pulling against a stationary object
detailed actions by the many different ● using a trapeze to lift the body off the bed
muscles in the hand, arm, and shoulder. ● lifting the buttocks off the bed by pushing with
When a client's cerebellum is injured, the hands against the mattress
movements become clumsy, unsure, and ● pushing the body to a sitting position
uncoordinated.
 Isotonic exercises increase muscle tone, mass
c.) Basal ganglia = maintain posture and strength and maintain joint flexibility and
circulation.
The U.S. Department of Health and Human Services Benefit: During isotonic exercise, both heart rate
defines exercise and physical activity as follows and cardiac output quicken to increase blood
(Edelman & Mandle, 2006): flow to all parts of the body.

2.) Isometric (Static/Setting) Exercise

✓ Physical Activity = is bodily movement produced
by skeletal muscle contraction that increases ➤ These are exercises in which there is muscle
energy expenditure. contraction without moving the joint (muscle
length does not change).
✓ Exercise = is a type of physical activity defined as
a planned, structured, adn repetitive bodily ➤ These exercises involve exerting pressure
movement performed by improve or maintain one against a solid object and are useful for:
or more components of physical fitness. 1. strengthening abdominal, gluteal, and
quadriceps muscles used in ambulation.
People participate in 2. for maintaining strength in immobilized
exercise programs to: muscles in casts or traction.
a.) decrease risk factors for cardiovascular 3. for endurance training
disease, and
b.) to increase their health and well-being.
Isometric bed exercise: 3) Borg scale of perceived exertion (Borg, 1998) =
"QUAD SQUATS" or squeezing a towel or pillow this measures how "difficult" the exercise feels to
between the knees while at the same time the person in terms of heart and lung exertion.
tightening the muscles in the fronts of the thighs ●"very, very hard" = corresponds closely to
by pressing the knees backwards, holding for 100% max HRT
several seconds. ●"very light" = close to 40%
 Most people need to strive for the "somewhat
Benefits: hard" level (13/20), which corresponds to 75%
> produce a mild increase in heart rate and cardiac of max HR.
output 5.) Anaerobic Exercise
> but no appreciate increase in blood flow to other ➤Involves activity in which the muscles cannot
parts of the body draw out enough oxygen from the bloodstream,
and anaerobic pathways are used to provide
3.) Isokinetic (Resistive) Exercise additional energy for a short time.
➤Involves muscle contraction or tension against
resistance; can either be isotonic or isometric. Benefit:
➤ During the isokinetic exercises, the person  This type of exercise is used in endurance
moves (isotonic) or tenses (isometric) against training for athletes such as weight lifting and
resistance. sprinting.
➤ Special machines or devices provide the
resistance to the movement. BENEFITS OF EXERCISE
In general, regular exercise is essential for
➤ Used in physical conditioning and are often
maintaining mental and physical health.
done to build up certain muscle groups.
1.) Musculoskeletal System
Eg: Pectoralis (chest muscles) may increase in size
- the muscle's size, shape, tone and strength
and strength by lifting weights.
(including heart muscles) are maintained with
mild exercise and increased with strenuous
Benefits:
exercise.
> an increase in blood pressure and blood flow to
- Strenuous exercise: muscles hypertrophy
muscles occur with resistance training.
(enlarge), and efficiency of muscular
contraction increases.
4.) Aerobic Exercise
➤ Activity during which the amount of oxygen HYPERTROPHY = commonly seen in the arm
taken in the body is greater than that used to muscles of tennis player, leg muscles of skater, arm
perform the activity. and hand of a carpenter
➤ Use large muscle groups that moves
repetitively. Joints lack a discrete blood supply. Joints receive
nourishment through exercise increasing
Benefits: flexibility, stability and ROM.
> improve cardiovascular conditioning and physical Controlled clinical trials have shown that exercise
fitness interventions significantly reduce weakness,
frailty, depression, and risk and incidence of
3 Ways to Measure Intensity of Exercise: falling in elderly people
1) Target heart rate = goal is to work up and sustain Bone density and strength is maintained through
a target heart rate during exercise; based on the weight bearing. The stress of weight bearing and
person's age. high-impact movement maintains a balance
● How to determine target heart rate? between osteoblasts (bone-building cells) and
a. Calculate the person's maximum HR by osteoclasts (bone-resorption and breakdown
subtracting her/his current age years from cells).
220.
b. Obtain the target HR by taking 60% to 85% Eg: swimming and bicycling
of the maximum. 2) Cardiovascular System
 Because HR varies among clients, - Adequate-moderate intensity exercise (40%-
the test that follows are replacing this measure. 60% max capacity such as walking a mile in 15-
20 minutes) increases the HR, strength of heart
2) Talk Test = easier to implement; keeps people at muscle contraction, and the blood supply to the
60% of max HR or more; person must experience heart and muscles through increased cardiac
labored breathing yet still be able to carry on output.
conversation
3) Respiratory System 8.) Psychoneurologic System
- Ventilation (air circulating into and out of the - Elevating mood
lungs) and oxygen intake increase during - Relieving stress and anxiety across the life span
exercise; thereby improving gas exchange. - Increases level of metabolites for
- More toxins are eliminated with deeper neurotransmitters such as norepinephrine and
breathing; problem solving and emotional serotonin; releases endogenous opioids,
stability are enhanced due to increased oxygen increasing endophine levels- increasing oxygen
in the brain. levels to the brain and body systems-- inducing
euphoria-- the body release stored stress
Benefits of Exercise: associated with accumulated emotional
> Prevents pooling of secretions in the bronchi and demands.
bronchioles, decreasing breathing effort and risk
for infection. 9) Cognitive Function
> Exercising muscles of respiration (deep - Physical exertion induces cells in the brain to
breathing exercises) enhances oxygenation strengthen and build neuronal connections.
(improving stamina) - Improving mood, learning, problem solving, and
performance
4) Gastrointestinal System
- Exercise improves appetite and increase 10) Spiritual Health
gastrointestinal tract tone, facilitating peristalsis. - The emphasis on breathing in Pilates and Yoga
- Rowing, swimming, walking, sit-ups work the is thought to soothe the nervous and
abdominal muscles = helps relieve constipation cardiorespiratory systems, promoting relaxation
- Abdominal compressive exercise, twisting and and preparedness for contemplative
forward bending yoga postures, has been experiences.
shown to improve symptoms of irritable bowel - Recitation of a word/ phrase (mantra) and rosary
syndrome. prayer were both found to powerfully enhance
and synchronize cardiovascular rhythm
5) Metabolic/ Endocrine System resulting decrease RR.
- Exercise elevates the metabolic rate,
increasing the production of body heat and FACTORS AFFECTING BODY ALIGNMENTAND
waste products and calorie use. ACTIVITY
- On strenuous exercise, metabolic rate can A number of factors affect an individual's
increase to as much as 20 times the normal body alignment, mobility and daily activity level.
rate These include:
- growth and development,
- Exercise increases the use of triglycerides and - nutrition,
fatty acids resulting in a decreased level of serum - personal values and attitudes,
triglycerides and cholesterol. - certain external factors, and
- Weight loss and exercise stabilize blood sugar and - prescribed limitations.
make cells more responsive to insulin.
1.) Growth and Development
6) Urinary System - a person's age, musculoskeletal, and nervous
- As adequate exercise promotes efficient blood system development affect posture, body
flow, the body excretes wastes more effectively. proportions, body mass, body movements, and
In addition, stasis (stangnation) of urine in the reflexes.
bladder is usually prevented. - as age advances, muscle tone and bone density
decrease, joint lose flexibility, reaction time
7) Immune System slows, bone mass decrease
- As respiratory and musculoskeletal effort
increase with exercise and as gravity is enlisted Osteoporosis = a condition in which the bones
with postural changes, lymph fluid is more becomes brittle and fragile due to calcium depletion
efficiently pumped from tissues into lymph (common in older women); primarily affects weight-
capillaries and vessels throughout the body. bearing joints of the lower extremities and the
- While moderate exercise seems to enhance anterior of spinal bones causing compression
immunity, strenuous exercise may reduce fractures of the vertebrae and hip fractures.
immune function, leaving a window of 2.) Nutrition
opportunity for infection during the recovery - Both undernutrition and overnutrition ca
phase. Adequate rest is important after vigorous influence body alignment and mobility. Poorly
training to allow the body to recover. nourished may have muscle weakness and
fatigue. Vitamin D growth deficiency causes - Head and spinal cord injuries can leave muscle
bone deformity during growth groups weakened, paralyzed (paresis), spastic
- Inadequate calcium intake and Vitamin D (with too much muscle tone), or flaccid (without
synthesis and intake increase the risk of muscle tone).
osteoporosis.
- Obesity can distort movement and stress joints, Musculoskeletal disorders affecting
adversely affecting posture, balance and joint mobility include:
health. - strains
- sprains
3.) Personal Values and Attitudes - fractures
- People who value a muscular build or physical - joint dislocations
attractiveness may participate regular exercise - amputations, and
program to produce the appearance they - joint replacement
desire.
- Thinking exercise as more "recreation EFFECTS OF IMMOBILITY: MUSCULOSKELETAL
movement", "enhancement of well-be and SYSTEM
a.) Disuse osteoporosis
"essential part of daily self-care" help overcome
perceptions that exercise is drudgery. - the bones may become spongy and may
gradually deform and fracture easily
4.) External Factors - depletion of calcium = gives bones strength
- Thinking exercise as more "recreational and density
movement", "enhancement of well-being" and b.) Disuse atrophy
"essential part of daily self-care" may help - unused muscles atrophy =decrease in size
overcome perceptions that exercise drudgery. - losing most of it's strength and normal function
c.) Contractures
5.) Prescribed Limitations - means permanent shortening of the muscle
- Limitations to movement may be medically - when the muscle fibers are not able to shorten
prescribed for some health promotions. To and lengthen, eventually a contracture forms,
promote healing, devices such as casts, braces, limiting joint mobility
splints, and traction are often used to - eventually involves tendons, ligaments a joint
immobilize body parts. capsules
- Bed rest may be the therapeutic choice for - irreversible except for surgical interventions.
certain clients - joint deformities such as "foot drop", wrist drop,
Eg: external hip rotation occur when a stronger
-to relieve edema muscle dominates the opposite muscle.
-to reduce metabolic and oxygen d.) Stiffness and joint pains
needs - without movement, the collagen (connective)
-to promote tissue repair tissues at the joint b ankylosed (permanently
-to decrease pain immobile addition, as the bones demineralize
excess calcium may deposit in the contributing
- Bed rest varies in meaning to some extent. In to stiffness and pain.
some, agencies bed rest means strict confinement
to bed or "complete" bed res Others allow bedside CARDIOVASCULAR SYSTEM
commode, or have bathroom privileges. a.) Diminished cardiac reserve
- decreased mobility creates imbalance in the
IMMOBILITY autonomic nervous system resulting increase
HR.
✔ Immobility is the state of not being able to move - rapid HR reduce diastolic pressure, coronary
around. blood flow, and capacity of heart to respond to
✔ incapable of being moved or fixed. any metabolic demands above basal levels
- because of diminished cardiac reserve, the
✔ If you fall out of a tree and break your arms and
immobilized person may experience
legs, then you will have to put up with months of
tachycardia with even minimal exertion.
immobility while your bones heal. b.) Increased use of the Valsalva Maneuver
Valsalva Maneuver = refers to the holding breath
Effects of Immobility:
and straining against a closed glottis.
- Bed rest varies in meaning to some extent. In Eg: Client tends to hold their breath while attempting
some, agencies bed rest means strict confinement to move up in a bed or sit on a bedpan
to bed or "complete" bed rest. Others allow
bedside commode, or have bathroom privileges.
- This builds up sufficient pressure on to thorax's Decreased surfactant
large veins to interfere with the return blood flow to +
the heart and coronal arteries. When the client Blockage of the bronchioles with mucus
exhales, the glottis opens again, pressure is =
sudden released, and a surge of blood flows to causes atelectasis
heart. (the collapse of a lobe or of an entire lung) distal to
-Cardiac arrhythmias can result if client has cardiac the mucous blockage.
disease Patients at greater risk for Atelectasis
> immobile elderly
c.) Orthostatic Postural Hypotension > postoperative clients
- common result of immobilization - Orthostatic d.) Hypostatic Pneumonia = pneumonia that
hypotension—also called postural usually results from the collection of fluid in the
hypotension—is a form of low blood pressure dorsal region of the lungs an occurs especially in
that happens when you stand up from sitting or those (as the bedridden or elderly) confined to a
lying down. Orthostatic hypotension can make sup position for extended periods
you feel dizzy or lightheaded, and maybe even
cause you to faint. METABOLIC SYSTEM
d.) Venous vasodilation and stasis a.) Decreased metabolic rate
- Congestion and slowing of circulation in veins Metabolism
due to blockage by either obstruction or high = the sum of all physical and chemical
pressure in the venous system, usually best processes by which living substance is formed
seen in the feet and legs. and maintained and by which energy is made
e.) Dependent edema available for body use
- is a term use to describe gravity-related swelling Basal Metabolic Rate (BMR)
in the lower body, Gravity has the eff. of pulling = minimal energy expended for the
fluid down toward the earth, causing too pool in maintenance of these processes.
the lowest parts of your body, such as your feet, b.) Negative Nitrogen Balance
legs, or hands. - A condition in which protein catabolism
- Dependent edema may happen to people with (breakdown) exceeds protein anabolism
limited mobility due to paralysis, stroke, ALS, (synthesis) resulting in tissues losing protein
another condition. If you're bedridden, you faster than it can be replaced.
might have dependent edema in your buttocks. - In an active person, a balance exists between
f.) Thrombus formation protein synthesis (anabolism) and protein
3 factors collective loosely predispose to breakdown (catabolism)
formation of thrombophlebitis (clot the loosely c.) Anorexia
attached to an inflamed vein wall): = loss of appetite occurs because of the
1. impaired venous return to the heart, decreased metabolic rate and the increased
2. hypercoagulability of blood (sometime catabolism that accompany immobility.
caused by meds such as oral d.) Negative Calcium Balance
contraceptives), and - occurs as direct result of immobility
3. injury to blood vessel wall. - greater amounts of calcium are extracted from
bone than can be replaced.
RESPIRATORY System
a.) decreased respiratory movement URINARY System
b.) pooling of respiratory secretions a.) Urinary Stasis
c.) atelectasis = is a complete or partial collapse of - (also known as urinary retention) is a condition
the entire lung or area (lobe) of the lung. It in which the bladder is not able to completely
occurs when the tiny air sacs (alveoli) within the empty.
lung become deflated or possibly filled with b.) Renal Calculi
alveolar fluid; one of the most common breathing - Kidney stones (also called renal calcu
(respiratory) complications after surgery. nephrolithiasis or urolithiasis) are hard deposits
made of minerals and salts the form inside
Atelectasis: your kidneys. Diet, excess body weight, some
When ventilation is decreased, pooled secretions medical conditions, and certain supplements
may accumulate the deeper area of the and medication are among the many causes of
bronchiole and effectively it. kidney stones.
Due to changes of regional blood flow rest c.) Urinary Retention
decreases the amount of surface produced. - a condition in which you cannot empty a the
(Surfactant enable the alveoli to remain open). urine from your bladder. Urinary retention can
be acute—a sudden inability to urinate, or
chronic—a gradual inability to completely • In addition, the loss of control over event can
empty the bladder of urine. cause anxiety.
d.) Urinary Infection
- A urinary tract infection (UTI) is an infection in MASSAGE
any part of your urinary system—your kidneys, 1. Preparation
ureters, bladder and urethra. Most infections Determine:
involve the lower urinary tract—the bladder (a) previous assessments of skin,
and urethra. Women are at greater risk of (b) special lotions to be used, and
developing a UTI than are men. (c) positions contraindicated for the client.
Arrange for a quiet environment with no
GASTROINTESTINAL SYSTEM interruptions to promote maximum effect of the
a.) Constipation back massage.
- generally described as having fewer than three 2. Performance
bowel movements a week. Though occasional Prior to performing procedure, introduce self and
constipation is very common, some people verify client’s identity using agency protocol.
experience chronic constipation that can Explain to client what you are going to do, what it
interfere with their ability to go about their daily is necessary, and how he or she can participate.
tasks. Encourage the client to give you feedback as to
the amount of pressure you're using during the
INTEGUMENTARY SYSTEM back rub
a.) Reduced Skin Turgor 3. Perform hand hygiene and observe other
- indicated when the skin (on the back of the appropriate infection control procedures.
hand for an adult or on the abdomen for a 4. Provide client privacy.
child) is pulled up for a few seconds and does 5. Prepare the client.
not return to its original state. • Assist client to move to the near side of the bed
- decrease in skin turgor is a late sign of within your reach and adjust the bed to a
dehydration comfortable working height.
b.) Skin Breakdown • Establish which position client [refers. The prone
- pressure sore (also called pressure ulcer position is recommended for a back rub. The
decubitus ulcer, bedsore, or skin breakdown) is side-lying can be used if the client cannot
an area of the skin or underlying tissue assume the prone position.
(muscle, bone) that is damaged due to loss of • Expose the back from the shoulders to the
blood flow to the area. inferior sacral area. Cover the remainder of the
- blood flow to the skin keeps it alive and body.
healthy. 6. Massage the back.
• Pour a small amount of lotion onto the palms of
PSYCHONEUROLOGIC SYSTEM your hands and hold it for a minute. The lotion
Due to low production of mood-elevating substances bottle can be placed in a bath basin filled with
in the body such as "endorphins", people experience warm water.
negative effects on mood when unable to engage in • Using your palm, begin on the sacral area using
physical activity. smooth circular strokes.
• Move your hands up the center of the back and
Eg: People who are unable to carry out their usual then cover both scapulae.
activities related to their roles. • Massage in a circular motion over the scapulae.
- as breadwinner • Move your hands down the sides of the back.
- as athlete • Massage the areas over the right and left iliac
- as top-performing student crests.
• Massage the back in an orderly pattern using a
variety of strokes and appropriate pressure.
• Apply firm, continuous pressure without
breaking contact with the client’s skin.
• Repeat above for the 3-5 minutes, obtaining
more lotion as necessary.
• While massaging the back, assess for skin
redness and areas of decreased circulation.
• Pat dry any excess lotion with a towel.
7. Document that a back massage was performed
• Problem solving and decision-making abilities may and the client’s response. Record any unusual
deteriorate as a result of lack of intellectual findings.
stimulation and the stress of the illness and
immobility.
Massage Strokes and Patterns: POSITIONS:
1. Effleurage - involving a circular stroking 1. Fowler’s Position - or a semi-sitting position, is a
movement made with the palm of the hand bed position in which the head of bed and trunk
2. Effleurage Variations: are raised to 45-60 degrees relative to the bed.
a) Knuckling 2. Orthopedic Position - in the Orthopneic position,
b) Bilateral tree the client sits either in bed or on the side of the
c) Shingles bed with an over bed table across the tap.
d) Fulling 3. Dorsal Recumbent Position - or Back-Lying
3. Petrissage – kneading the body Position; the client’s head and shoulders are
4. Friction slightly elevated on a small pillow.
5. Tapotement - rapid and repeated striking of 4. Prone Position - the client lies on the abdomen
the body with the head turned to one side. The hips are not
a) Cupping flexed.
b) Hacking 5. Lateral Position - or Side-Lying Position; the
c) Pinching client lies on one side of the body. Flexing the top
6. Vibration hip and knee and placing his leg in front of the
body creates a wider, triangular base of support
POSITIONING and achieves greater stability. The greater flexion
of the top hip and knee, the greater the stability
Support Devices: and balance on this position. This flexion reduces
▪ Pillow – different sizes are available. Used for lordosis and promotes good back alignment. For
support or elevation of an arm or leg. Specially this reason, the lateral position is good for resting
designed dense pillows can be used to elevate the and sleeping clients.
upper body. Pillows can be used as trochanter roll 6. Sim’s Position - or Semi-prone position; client
by placing the pillow from the client’s iliac crest to assumes a posture halfway between the lateral
mid-thigh. This prevents external rotation of the leg and the prone positions. The lower arm is
when the client is in a supine position. positioned behind the client, and the upper arm is
▪ Mattresses –There are 2 types: (a) standard flexed at the shoulder and the elbow. Both legs are
mattress = one that fit on the bed frame and flexed in front of the client. The upper leg is more
mattresses that fit on the standard bed mattress acutely flexed at both the hip and the knees that is
(egg crate mattress). Mattresses should be the lower one. Sim’s position may be used for
evenly supportive. unconscious clients because it facilitates drainage
▪ Suspension/ Heel Guard Boot – these are made from the mouth and prevents aspiration or fluids. It
of a variety of substances. They usually have a is also for paralyzed clients because it reduces
firm, exterior and padding of foam to protect the pressure over the sacrum and greater trochanter
skin. They prevent foot drop and relieve pressure of the hip.
on heels. 7. Lithotomy
▪ Footboard – a flat panel often made of plastic or 8. Trendelenburg
wood. It keeps the feet in dorsiflexion to prevent
planta flexion.
▪ Hand Roll – can be made by rolling a washcloth.
Purpose is to keep hand a functional position and
prevent finger contractures.
▪ Abduction pillow - a triangular-shaped foam
pillow that maintains hip abduction to prevent hip
dislocation following hip replacement.
COMFORT AND PAIN MANAGEMENT Types of Pain: Duration
Definition of Pain: ▪ Acute Pain = last only through the expected
• Pain is an unpleasant sensory and emotional recovery period; has a sudden or slow onset and
experience associated with actual or potential tissue regardless of the intensity
damage ▪ Chronic Pain = prolonged, usually recurring or
• Pain is highly personal experience that may be persisting over 6 months or longer, and interferes
imperceptible to others, while consuming all parts of with functioning
the person's life.

3 Important Implications of Pain:

1) Pain is a physical and emotional experience, not
all in the body or all in the mind.
2) It is in response to actual or potential
tissue damage, so there may not be abnormal lab or
radiographic reports despite real pain.
3) Pain is described in terms of such damage.

"Pain is whatever the experiencing person says it is,

existing whenever he says it does."
(McCaffert & Pasero, 1999)

➤ Pain is more than a symptom of a problem; it is a

high-priority problem in itself.
➤ Pain presents both physiologic and psychologic
dangers to health and recovery. ■ Cancer Pain may result from the direct effects of
➤ Severe pain is viewed as an emergency situation the disease and its treatment, it
deserving attention and prompt has been unrelated to the disease and its treatment
professional treatment. in individuals with cancer
Cancer Pain: may be categorized under "Malignant
Nature of Pain: Pain" and "Nonmalignant Pain".
➤ Although pain is a universal experience, the Other diagnosis were categorized under the
nature of the experience is unique to the individual "Malignant Pain": HIV/AIDS
based, in part, on the type of pain experienced, the = treated more aggressively than “Nonmalignant
psychosocial context and meaning, and the Pain"
response needed.
Types of pain: Intensity
Types of Pain: Classification of Pain by Intensity using a standard
Pain may be described in terms of: 0-10 Pain Scale:
1. Location 0 = no pain, to
2. Duration 10 = worst possible pain
3. Intensity Linking the rate to health and functioning scores
4. Etiology according to range:
1-3 = Mild Pain
Types of Pain: Location 4-6 = Moderate Pain
➤Classify pain based on where it is felt in the body. 7-10 = Severe Pain
➤ Some pain radiate (spread or extend) to other (associated with worst outcomes)
areas: low back to legs
➤ Pain may be referred (appear to arise in different
areas) to other parts of the body: cardiac pain may
be felt in the shoulder of
left arm, with or without chest pain
➤ Visceral pain (arising from organs or hollow
viscera) often presents this way, being perceived in
an area remote from
the organ causing the pain;
➤ Pain in the trunk area of the body that includes
the heart, lungs, abdominal and pelvic organs:
appendicitis, gallstones, chronic chest pain
diverticulitis and pelvic pain.
PHYSIOLOGY OF THE PAIN GATE CONTROL A specialized system of large-diameter fibers that
THEORY activate selective cognitive processes via the
The Gate Control Theory of Pain modulating properties of the spinal gate.
• Gate control theory was described by Melzack and • The way in which we experience pain is very
Wall in 1965. complex. All sorts of factors influence our
• This theory explains about a pain modulating experience, including our thoughts and feelings.
system in which a neural gate present in the spinal • For example, you will probably be aware that there
cord can open and close thereby modulating the are times when, even though you have pain, you
perception of pain. are only dimly aware of it. This can happen, for
• The gate control theory suggested that example, when you are really engrossed in doing
psychological factors play a role in the perception of something interesting or having to face a situation
pain. which demands all your attention. A very good
example of this are the stories you might have
TERMS heard about wounded soldiers, who despite being
Pain - an unpleasant sensory and emotional seriously injured will continue in battle and not
experience associated with actual or potential tissue really be aware of much pain until after the danger
damage. has passed.
Analgesia - the selective suppression of pain • These gates can sometimes be much more open
without effects on consciousness or other than at other times. This is important because it is
sensations. through these gates that messages from your
Nociceptors - sensory receptor whose stimulation body pass towards your brain. If the gates are
causes pain. more open, then a lot of pain messages pass
Pain threshold: the point at which a stimulus is through to the brain and you are likely to
perceived as painful. experience a high level of pain. If the gates are
Phantom limb pain - feelings of pain in a limb that more closed, then fewer messages get through
is no longer there and has no functioning nerves. and you are likely to experience less pain.
Sensation - the process of receiving, converting,
and transmitting information from the external and So, what are the factors that make a difference to
internal world to the brain. how open or closed the gates are?
 There are three main ways in which the gates to
 The 3 systems located in the spinal cord act to pain can be made more open, so that the pain
influence perception of pain, viz; the substantia feels worse.
gelatinosa in the dorsal horn, the dorsal column  These are to do with how we feel about things,
fibers, and the central transmission cells. how we think about things, and what we are
 The noxious impulses are influenced by a doing.
"gating mechanism." 1. Stress and Tension
 Stimulation of the large-diameter fibers inhibits 2. Mental Factors
the transmission of pain, thus "closing the gate." 3. Lack of Activity
Whereas, when smaller fibers are stimulated, the
gate is opened. 1. Stress and Tension
 When the gate is closed signals from small All sorts of emotional states can lead to the gates to
diameter pain fibres do not excite the dorsal horn pain being more open. These include being anxious,
transmission neurons. worried, angry, and depressed. Having a lot of
 When the gate is open pain signals excite dorsal tension in the body is a common way of opening the
horn transmission cells. pain gates.
 The gating mechanism is influenced by nerve 2. Mental Factors
impulses that descend from the brain. One of the most effective ways of opening the gates
and increasing your pain is to focus all your attention
Factors which influence opening and closing on it. Boredom can also lead to the pain gates
the gate are: opening.
1.) The amount of activity in the pain fibers. 3. Lack of Activity
2.) The amount of activity in other peripheral fibers Another factor that seems to open the gates to pain
3.) Messages that descend from the brain. is to not move around, to have stiff joints and to lack
fitness.
Factors that Close the Pain Gate In the same way Severe pain:
as above, the way we feel, the way we think and a) development of physical and emotional disorders
what we do can all have a part to play in helping to b) development of incurable chronic pain
close the gates to pain. syndromes

1. Relaxation and Contentment Factors affecting pain experience:

Feeling generally happy and optimistic has been
found to help to close the gates to pain. Also, feeling 1. Ethnic and Cultural Values
relaxed in yourself seems to be a particularly useful ➤ behaviors to pain is part of the socialization
way of closing the gates. process
2. Mental Factors ➤ Middle Eastern & African cultures: self
Being involved and taking an interest in life helps to inflicting is a sign of mourning or grief
close the gates: Also if you concentrate intensely on
➤ pain may be anticipated as part of ritualistic
something other than the pain (Eg: work, TV, book),
practices; pain tolerance signifies strength and
then this can distract you from any pain, helping to
endurance
close the gates.
2. Developmental Stage
3. Activity
Taking the right amount of exercise, so that you ➤ Children are less articulate and can't
develop your fitness, can help to close the gates. verbally express pain (undertreated pain)
4. Other Physical Factors ➤ Women: large number of painful disorders from
You may also find that for you certain types of puberty (headaches, fibromyalgia, PMS, lupus,
medication can help to close the gates, as might pregnancy-related)
certain types of counter stimulation (e.g. heat, ➤ Men: occupational and risk-taking patterns
massage, acupuncture). (burn pain, post-trauma, HIV/AIDS)
➤ Elders: constitute large group of individuals
RESPONSES TO PAIN seeking medical help
 Body's response to pain is a complex process ➤ Pain threshold does not appear to changne with
rather than a specfic action. aging althought the effe analgesics may increase
 It has both physiologic and psychosocial due to physiologic changes related to drug
aspects. metabolism and excretions.
 Initially the sympathetic nervous system 3. Environment and Support People
responds resulting in the fight-or-flight response, ➤ Strange environment such as hospitals, with its
with: noises, lights and activity can compound pain.
a) a noticeable increase in PR and BP
➤ Lonely places without support network may
b) hold his/her breath
perceive pain as severe.
c) short, shallow breathing
d) reflexive movements (as the person withdraws ➤ Person with supportive people may perceive less
from the painful stimuli) pain.
➤ Family caregivers can be a significant support for
Unrelieved pain has been noted to have a a person with pain.
potentially harmful effect on the person’s ➤ Expectations of SO can affect a person'
well-being. perception of and responses to pain
a) pain interfered with sleep 4. Past Pain Experiences
b) affects appetite ➤ Previous pain experiences alter a client's
c) lowers quality of life of clients/ family members sensitivity to pain.
Uncontrolled pain: ➤ People who have personally experiences or who
a) impairs immunce functions been exposed to the suffering are often more
b) slows healing = susceptible to infection/ threatened by anticipating pain than people without
dermal ulcers a pain experience.
c) short, shallow breathing -- atelectasis-- lowers 5. Meaning of Pain
circulating O2 levels-- increase cardiac
➤ A client who associates the pain with a positive
workload
outcome may withstand the pain amazingly well.
Undertreated pain:
Eg:
a) increases morbidity and mortality of a wide variety
- Woman givng birth to a child
of conditions
- Athlete undergoing knee surgery to prolong his
b) speeding metastasis of cancer
career.
c) extending cardiac damage during heart attack
*** May tolerate pain because of the benefit
Mneumonic for Pain Assessment: A. Cutaneous Stimulation
COLDERR - provide effective temporary pain relief
C-Character: - distracts client and focuses attention on tactile
describe the sensation (sharp, aching, burning) stimuli, away from painful sensation
O-Onset: - believe to interfere with transmission and pain
when is started? how it has changed? perception by stimulating large-diameter A-beta
L- Location: sensory nerve fibers that activate descending
where it hurts (all location)? mechanisms that can reduce pain intensity--activate
D - Duration: endorphin system of pain control--diminish
constant vs. intermittent in nature conscious awareness of pain.
E- Exacerbation: - Techniques:
factors that make it worse? a. Massage
R-Relief: b. Application or Heat or Cold
factors that make it better (medications and other c. Acupressure
factors)? d. Contralateral stimulation
R-Radiation: - Can be applied directly to painful area, proximal/
pattern of shooting/ spreading/ pain location away distal to pain (along nerve path or dermatome), and
from its origin? contralateral (exact location, opposite side of body)
to pain.
KEY STRATEGIES IN PAIN MANAGEMENT - Contraindicated: skin breakdown, impaired
1.) Acknowledging and accepting client's pain. neurologic functioning
- Nurses should assess client's pain and believe a.) Massage
their reports of discomfort. - a comfort measure that can aid relaxation,
2.) Assisting support persons. decrease muscle tension, an may ease anxiety
- Teach support person's about the disease and because the physical contact communicates caring
medications (including warning signs) and non drug - can decrease pain intensity by increasing
pain-relieveing techniques, may diminish client's superficial circulation to the area
feeling of helpness and strengthen their relationship. - Can involve back and neck, hands and arms, feet.
3.) Reducing misconceptions about pain. - Contraindication: skin breakdown, suspected clots,
- Nurse should explain to the client that pain is highly infections
individual experience and that it is only the client b.) Heat and Cold Application
who really experiencese the pain, although others - warm bath
can understand and empathize. - heating pads
- When clients have no opportunity to talk about thie - ice bags
pain and associated fears, their perceptions and - ice massage
reactions to pain can be intensified. - hot/ cold compresses
- The nurse should provide accurate education and - warm/ cold sitz bath
information to client. **General relief of pain and promote healing of
4.) Preventing pain injured
- A preventative to pain management involves the c.) Accupressure
provision of measures to treat the pain before it - developed from the ancient Chinese healing
occurs or before it becomes severe. system of Acupunture.
- Therapist applies finger pressure to points that
Preemptive analgesia = the administration of correspond to many of the points used in
analgesics prior to an invasive or operative acupunture.
procedure inorder to treat pain before it occurs. d.) Contralateral Stimulation
- can be accomplished by stimulating the skin in an
NON-PHARMACOLOGIC PAIN MANAGEMENT area opposite to the painful area (stimulating left
Consist of a variety of physical, cognitive behavioral, knee if right knee is painful).
and lifestyle pain management strategies that target - may be scratch from itching, massaged for cramps,
the body, mind, spirit, social interactions. treated with cold packs or analgesic ointments.
- useful when the area cannot be touched because it
1. PHYSICAL INTERVENTIONS is hypersensitive; when it is inaccessible by cast/
Goals: bandages; when pai is felt in a missing part
a. Provide comfort (phantom pain).
b. alter physiologic responses to reduce pain
perception
c. optimizing functioning
B. Immobilization/ Bracing C. REPATTERNING UNHELPFUL THINKING
- immobilizing/stricting the movement of painful body - Nurses can help by challenging the truthfulness
part (arthritic joint, traumatized limb) may help and helpfulness of these thoughts, replacing them
manage episodes of acute pain with realistic an confidence building ones that are
- splints, support devices particularly powerful predictors of more effective
- prolonged immobilization may result in: coping, better clinical outcomes and improved
* joint contracture wuality of life.
* muscle atrophy D. FACILITATING COPING
* cardiovascular problems - Strategies that enhance coping:
C. Transcutaneous Electrical Nerve Stimulation * therapeutic Communication with emphasis on
(TENS) listening
- method of applying low-voltage electricity * providing encouragement
stimulation directly over identified pain areas, at an * teaching self-management skills
acupressure point, along peripheral nerve areas that * sharing vicarious experiences, and
innervate the pain area, along with the spinal * persuading them to act on their own behalf
column. E. SELECTED SPIRITUAL INTERVENTIONS
- a portable, battery-operated device with head wire - The spiritual dimension encompasses a person's
and electronic pads that are applied to the chosen innermost concerns and values, including ascribed
area of skin activating large-diameter fibers that purpose, meaning, and driving force in her/his life.
modulate transmission of nociceptive impulse in Eg: offer prayer, intercessory prayer, and meditation
peripheral and CNS (closing pain gate), resulting
pain relief; releasing endorphins from CNS centers.

Contraindications:
- clients with pacemakers/ arrhythmias
- skin breakdown
-not use on the head or over chest

2. COGNITIVE-BEHAVIORAL INTERVENTIONS
A. DISTRACTION
- draw person's attention away from the pain and
lessens perception of pain
- makes person completely unaware of pain only for
amount of time and to the extent that the distracting
activity holds her/his undivided attention.
- Eg: Client recovering from surgery may feel no
pain while watching football game on TV, yet feel
pain during commercials or when game is over.

B. ELICITING THE RELAXATION RESPONSE

- decreases and counteracts harmful effects of
stress
- involves structured techniques design to focus the
mind and relax muscle groups
Eg: breath-focus relaxation imagery meditation
NUTRITION ● STORAGE AND CONVERSION
DEFINITION OF TERMS  Stored as either glycogen (large polymer or
● NUTRITION – sum of all interactions between an compound molecule of glucose) or as fat
organism and the food it consumes  Stored in the liver and skeletal muscles where it is
● NUTRIENTS - organic and inorganic substances available for conversion back to glucose
in foods that are required for body functioning  Glucose that cannot be stored as glycogen
● NUTRITIVE VALUE – nutrient content of a converted into fat
specified amount of food
 PROTEINS
ESSENTIAL NUTRIENTS ● Amino acids
● WATER – most basic nutrient need of the body ● Organic molecules made up of carbon, hydrogen,
● NUTRIENTS – provide fuel or energy oxygen, and nitrogen
● ¾ of body solids
ENERGY PROVIDING NUTRIENTS ● Category:
1. Carbohydrates 1.) Essential Amino Acids
2. Protein  Cannot be made in the body
3. Fats  Supplied as part of protein ingested in diet
4. Minerals 2.) Nonessential Amino Acids
5. Vitamins  Manufactured by the body
6. Water  Takes a.a. derived from diet and construct new
ones
 MACRONUTRIENTS
● Needed in large amounts (e.g. hundreds of grams) ● May be complete or incomplete:
to provide energy 1.) Complete Proteins
1. Carbohydrates  Contain all essential amino acids +
2. Proteins many nonessential (animal proteins)
3. Fats 2.) Incomplete Proteins
 MICRONUTRIENTS  Lack one or more essential amino acids, usually
● Required in small amounts (e.g., mg) to from vegetables
metabolize energy-providing nutrients
1. Vitamins (Water-soluble, Fat-soluble) ● PROTIEN DIGESTION
2. Minerals  Begins in stomach, pepsin (enzyme) breaks down
protein into smaller units, mostly digested in the
MACRONUTRIENTS small intestine
 CARBOHYDRATES ● STORAGE
● Composed of carbon, hydrogen, and oxygen  Absorbed through small intestine into portal blood
(CHO) circulation
● Two basic types:  Plasma protein (in the liver)
1. SIMPLE CARBOHYDRATES (Sugars)  Stored as body tissue
 Water-soluble and produced naturally by plants ● PROTEIN METABOLISM
and animals 1.) Anabolism (Building Tissue) – synthesizes
2. COMPLEX CARBOHYDRATES (Starches and proteins from amino acids
Fiber) 2.) Catabolism (Breaking Down Tissue) – excess
 Starch – insoluble, nonsweet, exists naturally in amino acids are degraded for energy or converted to
plants (grains, legumes, potatoes) fat; occurs in the liver
 Fiber – complex carbo derivative from plants; 3.) Nitrogen Balance – measure of the degree of
supplies roughage, or bulk, to diet (cannot be protein anabolism and catabolism; net result of
digested) intake and loss of nitrogen
(Nitro IN = Nitro OUT)
● CARBOHYDRATE DIGESTION  FATS
 Carbohydrate (disaccharides) + enzymes = ● Organic substances that are greasy and insoluble
monosaccharides (absorbed by small intestine) in water but soluble in alcohol or ether
 Enzymes – biologic catalysts that speed up ● FATS - Lipids that are solid in room temperature
chemical reactions ● OILS – Lipids that are liquid at room temperature
● CARBOHYDRATE METABOLISM  FATTY ACIDS
 Major source of body energy ● Basic structural units of most lipids, saturated or
 Carbohydrates  glucose  some circulates in unsaturated
the blood and some are stored ● SATURATED – i.e., butter
● UNSATURATED – i.e., vegetable oil
 GLYCERIDES  MINERALS
● Simple lipids ● Found in organic compounds, as inorganic
● Most common form of lipids compounds and as free ions
 TRIGLYCERIDES ● Category:
● 3 fatty acids 1.) MACROMINERALS – people require daily in
● May be saturated or unsaturated amounts over 100 mg, e.g., calcium, phosphorous,
● SATURATED – animal products; magnesium
butter 2.) MICROMINERALS – people require daily in
● UNSATURATED – plant products; amounts less than 100 mg, e.g., zinc, iron, iodine,
olive oil and corn oil selenium
 CHOLESTEROL
● Fatlike substance found in the body FACTORS AFFECTING NUTRITION
and in foods from animals  DEVELOPMENT
● Synthesized in the liver, some ● People in rapid periods of growth (i.e., infancy and
absorbed from diet i.e., milk, egg yolk adolescence) = increased needs for nutrients
● Needed to create bile acids and ● Older adults: need fewer calories and need some
synthesize steroid hormones dietary changes
● Present in cell membranes  SEX
● LIPID DIGESTION ● Men: need more calories and proteins
 Begins in the stomach and is digested mainly in ● Women: need more iron; pregnant and lactating
the small intestine by bile, pancreatic lipase, and women (increased caloric and fluid needs for
enteric lipase (intestinal enzyme) nutrients)
 End products: glycerol, fatty acids, and  ETHNICITY AND CULTURE
cholesterol ● Nurse should not use a ‘good food, bad food’
 BUT, reassembled immediately in intestinal cells approach; variations of intake are acceptable under
into TRIGLYCERIDES AND CHOLESTEROL different circumstances
ESTERS (not water soluble) ● Guidelines:
 Liver and small intestine converts trigly to 1.) Eat a whole variety of foods to furnish adequate
lipoproteins (water soluble) nutrients
● LIPID METABOLISM 2.) To eat moderately to maintain body weight
 Enzyme hormone-sensitive lipase breaks down  BELIEFS ABOUT FOOD’
trigly in adipose cells, releasing glycerol and fatty ● Fad Diets: widespread but short-lived interests.
acids into blood Very appealing to someone looking for a miracle
 Glycerol molecules in fat can be converted to cure for a disease, desires superior health delay
glucose aging
 VITAMIN  PERSONAL PREFERENCES
● Organic compound that cannot be made by the  RELIGIOUS PRACTICES
body and needed in small quantities to catalyze ● Catholics: avoid meat during Lent
metabolic processes ● Protestants: prohibit meat, tea, coffee, or alcohol
● Fat soluble or water soluble ● Jews: observe Kosher customs
1. FAT SOLUBLE – ADEK, daily supply  LIFESTYLE
not necessary  ECONOMICS
2. WATER SOLUBLE – includes C and B-complex;  MEDICATIONS AND THERAPY
body cannot store these; need daily supply of these ● Alteration of appetite, disturbed taste perceptions
vitamins or interfere with nutrient absorption
 B-COMPLEX VITAMINS  HEALTH
1.) B1 – thiamine ● Missing teeth, ill-fitting dentures, sore mouth,
2.) B2 – riboflavin dysphagia (difficulty swallowing)
3.) B3 – niacin or nicotinic acid  ALCOHOL CONSUMPTION
4.) B6 – pyridoxine ● Lead to weight gain or can depress appetite
5.) B9 – folic acid ● Excessive alcohol has toxic effect on intestinal
6.) B12 – cobalamin mucosa, decreasing absorption of nutrients
7.) Pantothenic acid  ADVERTISING
8.) Biotin  PSYCHOLOGICAL FACTORS
● Depression, anorexia, bulimia
NUTRITIONAL VARIATIONS THROUGHOUT THE SCHOOL-AGED CHILD
LIFE CYCLE ● Require balanced diet of 1600 to 2200 kcal/day
NEONATE ● Three meals a day with two nutritious snacks in
● Neonate – newborn child between (balanced diet)
● Fluid and nutritional needs = breast milk or formula ● Protein rich foods for breakfast to sustain
● Fluid needs is greater than those of adults prolonged physical and mental effort required at
 Total daily nutritional requirement of newborn: 80 school
to 100 mL of breastmilk or formula per kilogram of ● Meal time should be a social time for the family:
body weight must practice good eating habits
 Stomach capacity: 90 mL; feeding is every 2 ½ to ● Eats lunch at school – parents should discuss with
4 hours child the proper foods to eat
● Regurgitation “spitting up” – common occurrence;
not a result of nutritional deficiency ADOLESCENT
 After Burping – “Duay”/ Spitting up of milk ● Needs for nutrients and calories increases,
(Normal for babies) especially during growth spurt such as protein,
● Adding solid food (pureed or strained) = between 4 calcium, Vitamin D, iron, and B vitamins
to 6 months of age ● Adequate diet: 1 quart or approximately 1L of milk
● Order of introduction = cereals (rice before oats per day and balanced diet
and wheat), fruits, vegetables (yellow before green), ● Ca intake during adolescent may reduce risk of
strained meat osteoporosis in the future
● 7 to 9 mos. = ready to chew and can experience ● Have irregular eating patterns: diet or snack
different textures of food (finger foods) frequently, eating high calorie foods (i.e. soft drinks,
● 6 mos. = need iron supplements to prevent iron ice cream and fast food)
deficiency anemia ● Should be provided with healthy snacks
● Weaning from breast or bottle = 12 to 24 months ● Problems: obesity, anorexia nervosa, bulimia
● Bottle Mouth Syndrome – decay of teeth caused  ANOREXIA NERVOSA
by constant contact with sweet liquid from bottle  Prolonged inability or refusal to eat, rapid weight
● Give water if baby is almost 1 year old loss, and emaciation of individuals who believe they
● Before 1 year old, milk should only be given are fat
 BULIMIA
TODDLER  Uncontrollable compulsion to consume enormous
● Can eat most foods and adjust to three meals a amounts of food (binge) and then expel it by self-
day induced vomiting or by taking laxatives (purge)
● 3 years old – most deciduous teeth emerges, can ● Must be treated in the early stages by
bite and chew adult food psychotherapy
● Developing of independence in eating, short meal
time due to brief attention span, has rituals during YOUNG ADULTS
eating ● Aware of food groups but may not be
● Caloric requirement – 100 to 1400 kcal/ day knowledgeable about how many servings of each
● Parents should make meal time a pleasant time group they need
● Offer variety of simple, attractive food in small ● Young adult females need to maintain adequate
portions iron intake (supplements, food)
● Do not use food as reward or punish a child who ● Must have adequate calcium intake and exposure
doesn’t eat to the sun (preferably early morning)
● Schedule meals, sleep and snack times ● Obesity may occur during this time (from active
● Avoid routine use of sweets lifestyle to sedentary)
● Low fat and or low cholesterol diets for prevention
PRESCHOOLER of cardiovascular disease
● Can eat adult foods
● Parents should be informed of the diet of children MIDDLE-AGED ADULT
● Children are very active, require snacks between ● Continue to eat a healthy diet (especially protein
meals (Cheese, fruit, yogurt, raw vegetables, milk) and calcium intake, less cholesterol and caloric
● Teach how to use utensils properly intake)
● Encourage children to help prepare food in the ● 2 to 3L of fluid should be included in diet
kitchen ● Postmenopausal women = Vitamin D
supplementation (osteoporosis) and antioxidant
(A,C,E) to prevent or reduce risk of heart disease
● Weight gain due to decreased metabolic activity
and physical activity means decrease in caloric need
● Heartburn and increase in belching = decrease 8.) Use iodized salt, but avoid excessive intake of
gastric juice secretions and free acid salty foods. The regular use of iodized salt in the
● Must have sensible eating habits and avoid fried, table and in cooking in addition to taking iodine-rich
fatty foods foods, will greatly help in eradicating goiter and
Iodine Deficiency Disorders. Avoiding too much
OLDER ADULTS table table salt and overly salty foods may help in
● Requires some basic nutrition as the younger the prevention and control of hypertension and
adult but less in calories due to lower metabolic rate hence of heart disease.
and decrease in activity 9.) Eat clean and safe food. It is important to buy
● May need more carbohydrates for fiber and bulk foods that are safe. Purchase food only from reliable
● Physical changes (missing teeth, dentures, sources. In addition, care must be taken when
impaired taste, decreased saliva and gastric juice preparing and seving meals to prevent food-borne
secretion) may affect eating habits diseases.
● Psychosocial factors: depression, anxiety, loss of 10.) For a healthy lifestyle and good nutrition,
spouse, dependence on others, low income exercise regularly, do not smoke and aboud drinking
alcoholic beverages.
STANDARDS FOR A HEALTHY DIET
NUTRITIONAL GUIDELINES FOR FILIPINOS PINGGANG PINOY
● 10 KUMAINMENTS
1.) Eat a variety of foods every day. Eat a variety of
foods, to provide all the nutrients required in the
proper amount and balance as the human body
needs more than 40 different nutrients for good
health.
2.) Breast-feed infants exclusively from birth to 4-6
months and then give appropriate foods while
continuing breast-feeding for up to 2 years of age or
longer.
3.) Maintain children’s normal growth through proper
diet and monitor their growth regularly. A well-
nourished child is healthy, strong, and alert, has
good disposition, and grows at a normal rate.
4.) Consume fish, lean meat, poultry or dried beans.
Including them in the daily meals will not only
enhance the protein quality of the diet but also
supply highly absorbable iron, preformed vitamin A
and zinc. They are low in saturated fats, which are
linked to heart disease.
5.) Eat more vegetables, fruits, and root crops. The
consumption of more vegetables, fruits, and root
crops is encouraged to help correct the micronutrient
deficiencies consistently noted in national nutrition
surveys. Eating root crops will add dietary energy to
the meal
6.) Eat foods cooked in edible/ cooking oil daily. In
general, the total fat and oil consumption in a Filipino
diet is low. Fats and oils are concentrated sources of
energy which are also essential for absorption and
utilization of fat-soluble vitamins, such as Vitamin A.
To ensure adequate fat intake, Filipinos should be
encouraged to stir-fry foods in vegetable oil or to add
fats and oils whenever possible in food preparation.
This will guard against chronic energy deficiency
and help to lower the risk of vitamin A deficiency.
7.) Consume milk, milk products and other calcium-
rich foods such as small fish, and dark green leafy
vegetables every day. An adequate amount of
calcium in the diet starting from childhood all through
adulthood will help prevent osteoporosis in later life.
PHYSIOLOGY OF URINARY ELIMINATION  MUSCLE TONE
● Kidney (formation of urine)  ureters  bladder ● Good muscle tone is able to maintain the
 urethra  urinary meatus (elimination of urine) stretching and contractility of the muscle so that
bladder can be filled adequately
 PATHOLOGIC CONDITIONS
● Renal failure, kidney stones, hypertrophy of the
prostate gland
 SURGICAL AND DIAGNOSTIC PROCEDURES
● Spinal anesthesia, cystoscopy

ALTERED URINE PRODUCTION

1. POLYURIA (Diuresis)
● Productions of abnormally large amounts of urine
by the kidneys
● May be due to polydipsia (excessive fluid intake)
or diseases i.e., diabetes mellitus, diabetes
insipidus, chronic nephritis
2. OLIGURIA AND ANURIA
● OLIGURIA – low urine output (less than 500
mL/day or 30 mL/hour for adult)
● ANURIA – lack of urine output; may need dialysis
FACTORS AFFECTING VOIDING to filter blood
 DEVELOPMENTAL FACTORS 3. URINARY FREQUENCY
 Infants ● Voiding at frequent intervals (more than 6x per
● Urine is colorless and odorless, specific gravity of day)
1.008 (not concentrated) 4. NOCTURIA
● Urine output varies but increases to 250 to 500 ● Voiding two or more times at night
mL/ day; may urinate 20 times a day 5. URGENCY
● No urinary control develops between 2 to 5 y/o ● Sudden, strong urge to void
 Preschoolers 6. DYSURIA
● Independent toileting ● Voiding that is either painful or difficult
● Parents need to realize that accidents occur and ● URINARY HESITANCY – delay or difficulty in
there’s no need for punishment initating voiding, associated with dysuria
● Must be reminded to wash their hands after 7. ENURESIS
toileting ● Involuntary urination (children 4 to 5 years)
● Girls should be taught on how to wipe from ● DIURNAL ENURESIS (day time) – affects girls
FRONT TO BACK and women frequently
 School-Age Children ● NOCTURNAL ENURESIS (nighttime) – affects
● Elimination system reaches maturity boys more
● Urinates 6 to 8 times a day 8. URINARY INCONTINENCE (UI)
● ENURESIS – involuntary passing of urine (may be ● Involuntary leakage of urine or loss of bladder
a problem) control
● NOCTURNAL ENURESIS – bedwetting (primary) ● STRESS UI – dues to weak pelvic floors and/
 Older Adults urethral hypermobility (laughing, coughing,
● Excretory function of kidney diminishes but not sneezing)
significantly ● URGE UI – urgent need to void and inability to
● Impaired filtering capabilities due to age, renal stop passage of urine (symptom of overactive
blood flow declines bladder)
● Ability to concentrate urine declines ● MIZED UI – both stress and urge UI is present
● Nocturnal Frequency – frequent urinations at ● OVERFLOW INCONTINENCE – continuous
night due to weakness of urethral sphincter involuntary leakage or dribbling of urine that occurs
 PSYCHOSOCIAL FACTORS with incomplete emptying of blaffer (enlarged
● Anxiety, being pressured with time prostate or neurologic disorder)
 FLUID AND FOOD INTAKE 9. URINARY RETENTION
● Foods rich in carotene can make urine yellowish to ● Impaired bladder emptying cause distention of
orangish, Beets can make urine reddish bladder
● Causes: prostatic hypertrophy, surgery, and
medications
 MEDICATIONS
● Antidepressants, anticholinergic, antihypertensives
MAINTAINING NORMAL URINARY ELIMINATION
 PROMOTING FLUID INTAKE
● Normal daily intake: 1,500 mL/day
● For clients who sweat profusely or experiences
fluid losses (diarrhea): must require enough fluid to
replace the loss in addtion to normal intake
● UTI or renal calculi (kidney stones): 2,00 to 3,000
mL
 MAINTANING NORMAL VOIDING
● Medical therapies (Bladder retraining, habit
training, Pelvic floor exercises)
● Kegel exercises to reduce or eliminate episodes of
incontinence
 ASSISTING IN TOILETING
● Assistance during trips to bathroom
● May give bed pa/ urinal or bedside commode if
unable to walk to bathroom or contraindicated  URINARY CATHETERIZATION
● Must have call signal to summon help when ● Introduction of catheter into the urinary bladder;
needed performed only when necessary
 PREVENTION OF UTI ● CAUTI (Catheter-Associated UTI): UTI occurs
● Eight 8-ounce glasses per day to wash out while indwelling catheter is in place or within 48
bacteria houts of removal
● Practice frequent voiding every 2-4 hours; void
immediately after intercourse
● Avoid harsh soaps, poweder, sprays, or buble
bath in perineal area
● Avoid fitting pants
● Wear cotton underwear to enhance ventilation of
perineal area
● Women: wipe perineum from front to back
(prevent introduction of GI bacteria to urethre)
 MAINTAINING SKIN INTEGRITY
● Wash perineum of client with mild soap and water
or no rinse cleaser after episodes of incontinence,
making sure to rinse and dry area thoroughly and
gently
 APPLYING EXTERNAL URINARY DRAINING
DEVICE
● Application of condom or external catheter

 MANAGING URINARY RETENTION

● For flaccid baldders: manual pressure on the
bladder to promote emptying (Crede’s Maneuver)
BOWEL ELIMINATION DEFECATION
PHYSIOLOGY OF DEFECATION ● Expulsion of feces from the anus and rectum
● Elimination of the waste products from the body is ● “Bowel movement”
essential to health. The excreted waste products ● Frequency and amount during bowel movement
referred to as “FECES” or “STOOL” vary from person to person
● Large Intestine  Rectum and Anal Canal  ● Assisted by contraction of the abdominal muscles
Defecation and the diaphragm (increases abdominal pressure)
and by the contraction of the muscles of the pelvic
LARGE INTESTINE floor, moves feces through anal canal
● Extends from ileocecal (ileocolic) valve, which lies ● Normal defecation
between the small and large intestines to the anus ● Facilitated by:
● Seven parts: a.) Thigh flexion (increases pressure on abdomen
 Cecum b.) Sitting position (increases downward pressure on
 Ascending Colon rectum)
 Transverse Colon
 Descending Colon FECES
 Sigmoid Colon ● Made of about 75% water and 25% solid material,
 Rectum normally soft but formed
 Rectum ● If propelled to quickly in large intestine, no time for
● Functions: the water to be reabsorbed resulting to loose stools
 Absorption of water and nutrients (95% water)
 Mucoid protection of intestinal wall ● Normally brown (due to stercobilin and urobilin
 Fecal elimination and action of bacteria E.coli or staphylococci)
● Acts to transport along its lumen the products of ● Amount of gas varies per person, 13 to 21 times of
digestion which are eventually eliminated through passing gas is normal
anal canal (flatus and feces) ● Gas composed of carbon dioxide, methane,
 Flatus – air or byproducts of hydrogen, oxygen, nitrogen
Carbohydrate digestion
● Three types of movement:
1.) HAUSTRAL CHURNING
 Movement of chyme back and forth within the
haustra
 Haustra – pouches of large intestine
2.) PERISTALSIS
 Wavelike movement produced by circular and
longitudinal muscle fibers of intestinal walls; propels
intestinal contents forward
 Movement of peristalsis is very sluggish, moves
chyme very little along the intestine
3.) MASS PERISTALSIS
 Involves wave of powerful muscular contraction
that moves over large areas of colon
 Occurs after eating

RECTUM AND ANAL CANAL FACTORS AFFECTING DEFECATION

● RECTUM ● Development
 Has folds that extends vertically, each fold I. NEWBORN AND INFANTS
contains a vein and an artery  Meconium – first fecal matter passed, black,
 Believed to help retain feces within the rectum tarry, odorless and sticky
 If distended, especially with repeated pressure,  Normally up to 24 hours after birth
hemorrhoids occur  Transitional stool: greenish yellow, contain mucus
● ANAL CANAL and are loose
 Bounded by internal and external sphincter  Infants pass stool frequently, often after each
muscle feeding (soft, liquid and frequent)
 Internal: involuntary control, innervated by  After introduction of solid foods, stool becomes
autonomic nervous system less frequent and firmer
 External: voluntary control, innervated by somatic  Breastfed infants: light yellow to golden feces
nervous system  Infants on formula: dark yellow or tan stool,
more formed
II. TODDLER ● Defecation Habits
 1 ½ to 2 years old – control of defecation start  Early bowel training may establish the habit of
 Desire to control daytime bowel movements and defecating at a regular time
to use the toilet starts when the child becomes  When normal defecation reflexes are inhibited or
a.) Discomfort caused by soiled diaper ignored, these conditioned reflexes tend to be
b.) Sensation that indicates the need for a bowel progressively weakened
movement  Most adults ignore these reflexes due to
 Daytime control usually achieved by age 2 ½ y/o pressures of time or work
after toilet training  Hospitalized clients: suppress the urge due to
III. SCHOOL-AGE CHILDREN AND ADOLESCENT embarrassment
 Similar bowel habits with adults ● Medications
 Some school-age may delay defecation due to  Some medications can cause diarrhea
activity such as play (tranquilizers)
● Diet  Repeated administration of morphine and codeine
 Sufficient bulk 9cellulose, fiber) is necessary in cause constipation
diet provide fecal volume  Iron supplements: constipation or diarrhea
 Two categories of fiber: 9cause black stool)
 INSOLUBLE  Laxatives: stimulate bowel movement
 Promotes movement of materials through GI  Some can cause GI bleeding (aspirin products)
 Increases stool bulk  Antibiotics: grey-greenish discoloration
 Example: Whole wheat flour, wheat bran, nuts  Antacid: whitish discoloration or white specks
and vegetables ● Diagnostic Procedure
 SOLUBLE  Restrictions of ingesting food or fluids before
 Dissolves in water certain diagnostic procedures (colonoscopy or
 Can help lower blood cholesterol and glucose sigmoidoscopy)
levels  Cleaning enema prior examination
 Examples: Oats, peas, beans, apples, carrots, ● Anesthesia and Surgery
citrus fruits, barley and psyllium (form of fiber made  General anesthesia: slowing down of normal
from the husks of the Plantago ovata plant's seeds) colonic movements by blocking parasympathetic
 Spicy foods, excessive sugar: produce diarrhea stimulation to muscles of the colon
and flatus  Regional/ Spinal block: less likely
 Gas producing foods: cabbage, onion,  Surgery involving intestines can cause temporary
cauliflower, bananas, apples cessation of intestinal movement (ileus): lasts 24 to
 Laxative producing foods: bran, prunes, figs, 48 hours
chocolate, and alcohol  Normal defecation will not occur until patient eats
 Constipation producing foods: cheese, pasta, again
eggs, and lean meat  Nurses should assess their patient’s bowel sound
● Fluid Intake and Output for intestinal mobility
 Healthy fecal elimination ● Pathologic Conditions
– 2,000 to 3,000 mL  Spinal cord injuries/ head injuries: decrease
 If fluid intake is inadequate or output is excessive, sensory stimulation for defecation
body continues to reabsorb fluid from the chyme as  Impaired Mobility: limit client’s ability to respond
it passes along colon the urge to defecate and may experience
 Less fluid intake = hard feces constipation
 If chyme abnormally passes quickly in colon, less  Fecal Incontinence: poorly functioning anal
water is absorbed = soft, watery feces sphincters
● Activity ● Pain
 Can stimulate peristalsis, facilitates movement of
chyme along the colon FECAL ELIMINATION PROBLEMS
 Weak abdominal and pelvic muscles are often 1. CONSTIPATION
ineffective in increasing the intra-abdominal ● Fewer than three bowel movements per week
pressure during defecation or in controlling ● Passage of hard, dry stool or the passage of no
defecation stool
● Psychological Factors ● FECAL IMPACTION
 People who are anxious or angry experience  Mass or collection of hardened feces in folds of
peristaltic activity and subsequent nausea or rectum
diarrhea ● Causes and Factors:
 People with depression may experience slow  Insufficient fiber/ fluid intake
intestinal mobility  Insufficient activity or immobility
 Irregular defecation habits
 Chronic use of laxatives or enemas PROMOTING REGULAR DEFECATION
 Irritable bowel syndrome  PRIVACY
 Pelvic floor dysfunction ● Provide much privacy as possible for such clients
 Neurologic conditions (Parkinson’s but may need to stay with those who are too weak to
Disease) be left alone
 Emotional disturbances  TIMING
 Medications (opioids, iron ● Client should be encouraged to defecate when the
supplements, antihistamines, etc.) urge is recognized
 Habitual denial and ignoring urge  NUTRITION AND FLUIDS
to defecate ● For constipation: increase fluid intake, include
2. DIARRHEA fiber in diet
● Passage of liquid feces and an increased ● For diarrhea: encourage oral intake and bland
frequency of defecation food, small frequent feedings, avoid excessively hot
● Opposite of constipation or cold drinks, spicy food, and high fiber
● Spasmodic cramps occur ● For flatulence: limit carbonated drinks, use of
● Irritation of anal region (persistent diarrhea) drinking straws, and chewing gum; gas forming
● Fatigue, weakness, malaise, emaciation foods should be avoided
● Cause: irritants of intestinal tract  EXERCISE
● “Protective Flushing Mechanism” ● In supine position, tighten abdominal muscle as
 Body is trying to flush out the though pulling them inward, hold for about 10 secs
bacteria or cause of diarrhea and then relax them. Repeat for 5 – 10 times, four
 Advisable not to drink any medication that would times a day, depending on client’s health
suppress the defecation like loperamide ● In supine position, contract thigh muscles and hold
● Skin breakdown near anal region them contracted for about 10 secs. Repeat 5 – 10
3. BOWEL INCONTINENCE times, four times a day
● Fecal incontinence  POSITIONING
● Loss of voluntary ability to control fecal and ● Elevated Toilet Seats – for clients who have
gaseous discharges through anal sphincter difficulty sitting down and getting up from toilet
● Two types: ● Bedside Commode – used for the adult client
 PARTIAL – inability to control flatus or to prevent who can get out of bed but unable to walk to
minor soiling bathroom
 MAJOR – inability to control feces of normal ● Bedpan – for clients restricted to bed
consistency  Women – bedpan for urine and f
● May be associated with impaired functioning of the feces
anal sphincter or its nerve supply such as  Male – bedpan for feces, urinal for
neuromuscular diseases, spinal trauma and tumors urine
of external anal sphincter muscle
4. FLATULENCE
● Presence of excessive flatus in the intestines and
leads to stretching and inflation of the intestines
(intestinal distention)
● Expelled through anus
● Occurs due to:
 Food (cabbage, onions)
 Abdominal surgery
 Narcotics
● Primary sources of Flatus:
1.) Action of bacteria on the chyme in the large
intestine
2.) Swallowed air
3.) Gas that diffuses between bloodstream and
intestine
FLUID, ELECTROLYTE AND ACID-BASE ֍ Composition of Body Fluids
BALANCE → Electrolytes
BODY FLUIDS AND ELECTROLYTES ▪ Products of salts after dissociating with water
֍ WATER = 60% of average adult’s body charged particles capable of conducting electricity
֍ Function of water → Cations- positive charge
→ Medium for metabolic reactions within cells ▪ Na+
→ Transport for nutrients, waste products and other ▪ K+
substances ▪ Ca2+
→ Lubricant ▪ Mg2+
→ Insulator and shock absorber → Anions
→ Means of regulating and maintaining body ▪ Negative charge
temperature ▪ Cl-
֍ Age, sex and body fat affect total body ▪ HCO3-
water ֍ Principal Electrolytes
→ Infants = highest proportion of water (70% to 80% → ECF- sodium, chloride and bicarbonate
of body weight) ▪ Others: K, Ca, Mg (in smaller quantities)
→ People > 60 years = 50% of total body weight → ICF – potassium, magnesium (cations)
→ Women- lower body water than men (due to low ▪ Anions
muscle mass and greater percentage • Phosphate
of fat tissue) • Sulfate
→ Water makes up a greater percentage of muscle ▪ Others- present but in smaller quantities→ Body
mass (fat= free water) fluids like gastrointestinal and gastric secretions
֍ Distribution of Body Fluids contain electrolytes
1) Intracellular Fluid (ICF): found within cells of ▪ Vomiting or diarrhea
body (2/3) • Excessive loss in GI routes
→ Vital for normal cell functioning • Cause severe fluid electrolyte imbalance
→ Solutes, electrolytes, glucose
→ Medium in which metabolic processes occur
2) Extracellular fluid (ECF): found outside of cells
(1/3)
→ Divided into components
→ Transport system that carries oxygen and nutrient
to the cell
→ Carry waste product outside the cell
i. Intravascular fluid (plasma)
→ Accounts approximately 20% of ECF ֍ Movement of Body Fluids and Electrolytes
→ Found within the vascular system ▪ The body fluid compartments are separated from
ii. Interstitial fluid one another by cell
→ Accounting approximately 75% of extracellular membranes and the capillary membrane
fluid ▪ Although completely permeable to water, they are
→ Surrounding the cells considered to be selectively permeable to solutes
iii. Lymph ▪ Solutes: substances dissolved in a liquid: may be
→ In lymph nodes crystalloids (dissolved readily into true solutions) or
iv. Transcellular fluid colloids (does not readily dissolves)
→ Cerebrospinal fluid, pleural, pericardial, ▪ Solvent: component of a solution that can dissolve
intraocular etc. a solute
▪ Glucose and protein: have a carrier since they
have a hard time passing through
۩ Osmosis o Filtration pressure
o Concentration of solutes in body fluids ▪ Pressure that results in movement of fluid and
o Determined by the total solute concentration within solutes out of a compartment
a fluid compartment, measured as parts of solute o Hydrostatic pressure
per kg of H20 (mOsm/Kg) ▪ Pressure exerted by a fluid within a closed system
o Sodium: greatest determinant of osmolality of on walls of container in which it is contained
plasma (serum osmolality) ▪ Force exerted against blood vessel walls
o ICF: K, glucose and urea (primary determinant) ▪ Oppose the osmotic pressure
۩ Tonicity: ▪ If over push -> leak -> diffusion -> cause edema
o may be used to refer to osmolality of one solution
in relation to another
solution
1) Isotonic solution
o Same osmolality as extracellular fluid
o Normal saline, 0.9 sodium chloride
2) Hypertonic solution
o High osmolality than extracellular fluid
o 3% NaCl
3) Hypotonic solution
o Lower osmolality than extracellular fluid
o 0.45% NaCl
o Osmotic pressure
- Power of a solution to pull water across a ۩ Active Transport
semipermeable membrane to equalize the o Movement of solutes across cell membranes from
concentration of the solutions a less concentrated solution to a more concentrated
one
o Differs with diffusion and osmosis (passive
processes)
o A substance combines with a carrier on outside
and moves to inside of surface of a cell membrane
o Once inside, they separate and substance is
released to the inside of the cell
o Example
o Colloid osmotic pressure or ▪ Sodium-potassium pump
oncotic pressure
- Plasma proteins exerting osmotic pressure by ֍ Regulating Body Fluids
holding water in plasma and when necessary, ۩ Fluid Intake
pulling water from the interstitial space into the o Average adult: 1,200-1,500 mL/day
vascular compartment o Fluids needed for normal functioning: 2,500
- Flow from lower to greater concentration mL/day
- Solve hypovolemia o Remaining 1,000 mL: acquired from foods and
۩ Diffusion from oxidation of foods during metabolic processes;
o Movement of molecules through a semi-permeable by-product of food metabolism
Source Amount (mL)
membrane from an area of higher concentration to
Oral fluids 1200-1500
an area of lower concentration Water in foods 1000
Water as by product
of food metabolism 200
TOTAL 2400-2700
۩ Osmosis ۩ Fluid Output
o Movement of water molecules from a less o Routes of fluid output urine, feces & insensible
concentrated area to a more concentrated in an losses (through skin as perspiration and lungs as
attempt to equalize the concentration of two water vapor of expired air)
solutions on two sides of a membrane 1) Urine
۩ Filtration - Formed in kidneys
o Process whereby fluids and solutes move together - Major route of fluid output
across a membrane from a higher concentration to a - Normal urine output:
lower concentration 1400-1500 mL per 24 hours or 0.5 mL per kg per
o Example: movement of fluid and nutrients from hour
capillaries of arterioles to the interstitial fluid around
cells
2) Feces b) Renin-Angiotensin-Aldosterone
- Chyme that passes from the small intestine into System
large intestine - Specialized receptors in the kidneys
- Normal chyme entering large intestine: to changes in renal perfusion
1,500ml/day - Blood flow or blood pressure
- All but about 100mL is reabsorbed in proximal half decreases  renin is released
of large intestine  renin causes conversion of
Route Amount (mL) angiotensinogen to angiotensin I
Urine 1400-1500  then converted to angiotensin II by
Insensible losses angiotensin
> Lungs 350-400  converting enzyme
> Skin 350-400
 sodium and water retention
Sweat 100
Feces 100-200  aldosterone is also released by
TOTAL 2300-2600 adrenal cortex to promote sodium
3) Insensible losses retention is distal nephron
- Through skin and lungs, occurs through diffusion - Goal: increase blood volume (and
and renal perfusion) by Na and water
perspiration retention
i. Diffusion: not noticeable but accounts for 300 to c) Atrial Natriuretic Hormone
400mL/day - Released from cells in atrium in
: can happen due to burns or large abrasions response to excess blood volume and
ii. Perspiration: varies on some factors stretching of atrial walls
(environmental, - Promote sodium wasting
activities, metabolic activity) - Acts on nephrons
iii. Water in exhaled air: usually 300-400mL/day, - Acts as potent diuretic thus
happens decreasing blood volume
when respiratory rate accelerates - Inhibits thirst, reducing fluid intake
۩ Maintaining Homeostasis
1) Kidneys ֍ Regulating electrolytes
- Primary regulator of body fluids and electrolyte
balances o Electrolytes
- Regulate volume and osmolality of ECF by ▪ Charged ions capable of conducting
regulating water and electrolyte excretion electricity
- Control reabsorption of water from plasma filtrate ▪ Important for
and ultimately the amount excreted as urine • Maintaining fluid balance
- 135-180 L filtered; only 1.5L of urine is excreted • Contributing to acid-base regulation
- Has significant role in acid-base balance (excretes • Facilitating neuromuscular reactions
H+ ions and retain bicarbonate) ▪ Mostly enters the body through dietary intake and
2) Hormones excreted in urine
a) Antidiuretic Hormone (ADH) I. Sodium (Na+)
- Regulates water excretion from kidneys - Normal level = 135 to 140 mEq/L
- When serum osmolality arise, - Most abundant cation in extracellular fluid; major
 ADH is produced contributor to serum osmolality
 increased permeability of - Controls and regulates water balance; maintaining
collecting ducts of nephrons extracellular fluid volume
 more water reabsorbed - Found in many foods; high levels in bacon, ham,
 urine falls processed cheese and table salt
 serum osmolality - Where sodium goes water follows
decreased (water dilutes II. Potassium (K+)
body fluids) - Normal levels - 125-140 mEq/L (in intracellular
fluid), 3.5 to 5.0 mEq/L (in blood)
- When serum osmolality decreases, - Major cation in intracellu.ar fluid with only a small
 ADH is suppressed amount in extracellular fluid
 collecting ducts become - Ration of intracellular to extracellular potassium
less permeable to water must be maintained for neuromuscular response to
 urine output increases stimuli
 serum osmolality returns - Viral electrolyte for skeletal, cardiac and smooth
to normal muscle activity
- Maintains acid-base balance and contributes to
intracellular enzyme reactions
- MUST BE INGESTED DAILY
- Foods containing Potassium VI. Phosphate (PO43-)
- Major anion of intracellular fluid; also found in
extracellular fluid; bones, skeletal muscle and nerve
tissue
- Normal levels: 2.5 to 4.5 mg/dL
- Essential for functioning of muscles, nerves and
RBCs
- Involved in metabolism of protein, fat and
III. Calcium (Ca+)
carbohydrate
- Majority of Ca (99%) in skeletal system
- Absorbed in intestine and found in many foods
- Small amount in extracellular fluid
such as meat, fish, poultry, milk products and
- Also vital in regulating neuromuscular function
legumes
(muscle contraction and
- Children have a higher phosphate level than adults
relaxation as well as cardiac function)
- Newborns
- Calcium in extracellular fluid is regulated by
- Twice more
interaction of parathyroid hormone, calcitonin
- Due to higher level of growth hormones and growth
(hormone produced by thyroid) and calcitriol (a
spurts
metabolite of vitamin D)
- Bone growth
- Lower calcium levels in extracellular fluid 
- Kuyog pirme: calcium, phosphate and magnesium
parathyroid hormone (PTH) and calcitriol causes
VII. Bicarbonate (HCO3)
Calcium to be released from bones into extracellular
- Present in both intracellular fluid and extracellular
fluid
fluid
 increase absorption of calcium in intestines
- Primary function
 increase serum calcium levels
- Regulation of acid base balance as essential
- Calcitonin stimulates deposition of calcium in bone,
component of body’s suffering system
reducing calcium in serum levels
- If too much, it is excreted by the kidneys
- Normal levels
- If needed, kidneys both regenerate and reabsorb
- Total serum calcium level: 8.5 to 10.5 mg/dL
bicarbonate ions
- Grounded into plasma proteins
- Unlike others, adequate amounts of bicarbonate
- Ionized serum calcium: 4.0 to 5.0 mg/dL
are produced through metabolic process
- 50% circulating freely in ungrounded form without
- Not needed in diet
bounding to ions
֍ Regulation of Acid-base balance
- Found in milk and milk products, dark green leafy
→ Acid-base balance
vegetables and canned salmon
▪ Acid
- Calcium supplements are also beneficial
• Substance that releases hydrogen (H+) ions in a
IV. Magnesium (Mg+)
solution
- Normal levels: 1.5 to 2.5 mEq/L
▪ Base
- Found primarily in the skeleton and intracellular
• Or alkalis
fluid; second most abundant intracellular cation
• Low hydrogen concentration and can accept
- Important for metabolism particularly in production
hydrogen ions in a
and use of ATP
solution
- Necessary for protein and DNA synthesis
▪ pH
- Only 1% of body’s Mg is in extracellular fluid;
• the relative acidity and alkalinity of a solution
important in regulating neuromuscular and cardiac
▪ the higher the H+ ion concentration, the lower the
function
pH (lower than 7)
- Found in cereal grains, nuts, dried fruit, legumes
▪ the lower the H+ ion concentration, the higher the
and green leafy vegetables also dairy product, meat
pH (higher than 7)
and fish
▪ neutral: 7
V. Chloride (Cl-)
- Normal levels = 95 to 108 mEq/L
- Major anion of extracellular fluid
- Functions with sodium to regulate serum osmolality
and blood volume
- Where Na goes, chloride passively follows
- Major component of gastric juice hydrochloric acid
(HCl) regulates acid-base balance
- Founds in the same foods as sodium
۩ Regulation ▪ Decrease thirst sensation, ability to kidneys to
o Body fluids should be maintained as slightly concentrate urine, intracellular fluid and total body
alkaline water, response to body hormones that help
o Normal pH of arterial blood: between 7.35 to 7.45 regulate fluid and electrolyte
1) Buffers ▪ Not tolerate laxatives
- Prevent excessive changes in pH by binding with ▪ use of diuretics
or releasing hydrogen ions ▪ decreased intake of food and water
- If body fluids become acidic: buffers bind with ▪ preparations for diagnostic tests
hydrogen ions ▪ impaired renal functions
- If body fluids become too alkaline: buffers release ۩ Sex and Body Size
hydrogen ions ▪ People with higher percentage of body fat has less
- Action is immediate but limited to its capacity body water than that of higher percentage of lean
- Major buffer in extracellular fluid: bicarbonate muscle
(HCO3) and carbonic acid ▪ Women have more body fat than lean muscle
- Acids are continually produced in metabolism ۩ Environmental Temperature
- Acidosis: too much acid or H+ ions in blood ▪ People with illness and those participating in
- Alkalosis: too much base or very strenuous activities are at increase risk of fluid and
low H+ in blood electrolyte imbalance when in high temperatures
2) Respiratory Regulation ▪ If water is only replenished, electrolyte depletion is
- Lungs help regulate acid-base at risk
balance ۩ Lifestyle
- Eliminate or retain carbon dioxide ▪ Diet (purging, anorexia bulimia),
(CO2) ▪ Exercise
- Altering rate and depth of ▪ Stress (increase production of ADH and RA
respirations mechanisms  decrease urine output and increase
3) Renal regulation in cellular metabolism and concentration of glucose
- Ultimate long term regulator for in blood)
acid-base balance ▪ Alcohol Consumption (low in magnesium and
- Slower to respond (hours to days) but more phosphate; risk for acidosis) can affect fluid and
permanent response and selective than that of electrolyte and acid-base balance
others
- High hydrogen ion level and low pH: kidneys
reabsorb ang regenerate bicarbonate ions ֍ Disturbances in fluid volume, electrolyte and
 excrete hydrogen ions acid balances
- Low hydrogen ion level and high pH: kidneys
→ 4 categories of fluid imbalances:
excrete excess bicarbonate ions  retain hydrogen
1) Isotonic loss of water and electrolytes
ions
FLUID VOLUME DEFICIT (FVD)
- Normal serum bicarbonate level: 22 to 26 mEq/dL
▪ Occurs when body loses both water and
electrolytes from the extracellular fluid in similar
proportions
▪ Result of
• Abnormal losses through skin,
gastrointestinal tract or kidney
• Decreased intake of fluid
• Bleeding
• Movement of fluid into a third space
֍ Factors affecting Body, Fluid, Electrolytes and
▪ Hypovolemia
Acid-base Balance
• Fluid is initially lost from intravascular compartment
۩ Infants and children
▪ RISK FACTORS of FVD
▪ High metabolic rates increases fluid loss
• Loss of water and electrolytes from
▪ Immature kidneys cannot concentrate urine
o Vomiting
▪ rapid respiratory create and proportionately larger
o Diarrhea
body surface area than adult
o Excessive sweating
▪ cannot express thirst, nor actively seeks fluids
o Polyuria
▪ vomiting and diarrhea is rampant
o Fever
• can lead to electrolyte imbalance
o Nasogastric suction
• treat: oral rehydration therapy with electrolyte
o Abnormal drainage or wound losses
solution such as pedialite, vivalite or ORS
• Insufficient intake due to
۩ Older Adults
o Anorexia
o Nausea
o Inability to access fluids o Increased capillary hydrostatic pressure (edema of
o Impaired swallowing feet, ankles and sacrum)
o Confusion, depression o Decreased serum osmotic pressure (low levels of
▪ CLINICAL MANIFESTATIONS of FVD plasma protein due to malnutrition, liver or kidney
• Complaints of weakness and thirst disease)
• Weight loss o Increased capillary permeability
• 2% loss: mild FVD • Pitting edema
• 5% loss: moderate o Edema that leaves a small depression or pit after
• 8% loss: severe finger pressure is applied on swollen area
• Fluid intake less than output o Palpate over tibia and behind medial malleolus
• Decreased skin turgor and over the dorsum of each foot
• Dry mucous membranes, sunken eyeballs o Use watch to time the depression- Grading of
• Weak pulse; tachycardia edema
• Decreased blood pressure
• Postural hypotension
• Decreased capillary refill
• Decreased urine volume (<30mL/hr)
• Increased specific gravity of urine (>1.030)
• Increased hematocrit
• Increased blood urea nitrogen
▪ Third Space Syndrome
• Fluid shifts from vascular space into an area where
it is not readily accessible as extracellular fluid
• Research: assignment 3) Hyperosmolar loss of only water
DEHYDRATION
2) Isotonic gain of water and electrolytes o Hyperosmolar fluid imbalance
FLUID VOLUME EXCESS o Occurs when water is lost from the body
• Occurs when the body retains both water and o Leave client with excess sodium
sodium in similar proportions to normal extracellular o Serum osmolality and serum sodium increase
fluid o Water is drawn into vascular compartment from
• Hypervolemia: increased blood volume interstitial which shrink cell and cause cell
• Causes dehydration
o Excessive intake of sodium chloride ▪ At risk
o Administering sodium-containing infusions too - Older clients (decrease in thirst sensation)
rapidly - Hyperventilating clients
o Disease processes that alter regulatory - Those with fever
mechanisms - Diabetic ketoacidosis
▪ Heart failure - On enteral feedings (nasogastric tube, total
▪ Renal failure parenteral, IV) with insufficient water intake
▪ Liver cirrhosis 4) Hypo-osmolar gain of only water
▪ Cushing’s syndrome OVERHYDRATION
▪ Clinical manifestation of FVE o Hypo-osmolar fluid imbalance; occurs when water
• Weight gain is gained in excess of electrolytes, resulting to low
o 2% gain- mild fluid volume excess serum osmolality and low serum sodium levels
o 5% gain- moderate ▪ Can cause cerebral edema in the brain because
o 8% gain – severe water is drawn into the cell causing it to swell
• Fluid intake greater than output o Often called water intoxication
• Full, bounding pulse, tachycardia o Can also occur when both fluid and electrolytes
• Increased blood pressure are lost but only water is replaced
• Distended neck veins o Result from
• Moist crackles (rales) in lungs, dyspnea, shortness ▪ SIADH: syndrome of inappropriate antidiuretic
of breath hormone
• Mental confusion ▪ Aids
▪ Edema (hupong) ▪ Head injury
• Excess interstitial fluid ▪ Administration of certain drugs that perpetrates and
• Apparent in areas where tissue pressure is low (far anesthetics
from heart)
o Around eyes
o Dependent tissues
• Mechanisms of edema
ELECTROLYTE IMBALANCES 2) POTASSIUM
1) SODIUM a. Hypokalemia
a. Hyponatremia - Potassium deficit
- Sodium deficit; - Serum k level of less than 3.5 mEq/dL
serum Na level of - Common causes
less than 125 - Gastrointestinal losses of potassium through
mEq/L vomiting and gastric suction
- Common - Use of potassium-wasting diuretics
electrolyte - Thiazide or loop diuretics
imbalance; caused by low serum osmolality - Symptoms - usually mild until level drops below 3
- As sodium levels decrease, the brain and nervous mEq/L
system are affected by cellular edema - If decrease is gradual, body compensates by
- Severe hyponatremia shifting potassium from intracellular into the serum
- medical emergency - Symptoms
- can lead to increasing intracranial pressure and - Muscle weakness
coma - Fatigue
- water is drawn out into the interstitial tissues and - Leg cramps
cells - Lethargy
- no water in vascular compartments - Anorexia
- manifestations - Nausea and vomiting
- mainly neurological - Decreased bowel sounds
i. Lethargy - Decreased bowel motility
ii. Confusion - Cardiac dysrhythmia
iii. Apprehension - Depressed deep tendon reflexes (?)
iv. Muscle twitching - Irregular pulses
v. Abdominal cramps - ABG for hypokalemia
vi. Anorexia - Alkalosis and patient
vii. Nausea and vomiting - ECG
viii. Seizures - T wave flattening
ix. Coma - S-T segment depression
b. Hypernatremia b. Hyperkalemia
- Excess sodium in - Potassium excess
extracellular fluid - Serum potassium level greater than 5.0 mEq/L-
- Serum sodium of Less common than hypokalemia but more
greater than 145 mEq/dL dangerous than hypokalemia
- Increased osmotic pressure of extracellular fluid - Can lead to cardiac arrest
causes fluid to move out the cell into the - Lethal injection for death penalty: potassium
extracellular fluid chloride (intravenously or intramuscularly)
- Cells become dehydrated (cells shrink) - Symptoms are more severe
- Prevented by drinking water when feeling thirst - GI irritability (diarrhea)
- Manifestations are neurologic in nature - Apathy
- Thirst - Confusion
- Dry mucous membranes - Cardiac dysrhythmias or arrest
- Swollen and dry tongue - Muscle weakness (areflexia: diminished deep
- Weakness tendon reflexes)
- Severe - Decreased heart rate
- Fatigue - Irregular pulse
- Restlessness - Paresthesias and numbness in extremities
- Decreasing level of consciousness - Parasthesia (abnormal sensation of skin; hands,
- Disorientation feet mouth; tickling, prickling, chilling, ringing,
- Convulsions numbness in extremities)
- ECG
- Peak T waves
- Widen QRS
3) CALCIUM
a. Hypocalcemia
- Calcium deficit: total serum calcium level of less
than 8.5 mg/dL or ionized calcium of less than 4.5
mEq/L
- Severe depletion: tetany with muscle spasms and - Usual cause: Over supplementation
parasthesias which can lead to seizures - Manifestations: Neurological
- Chvostek’s sign 5) Chloride
- contraction of facial muscles when tapped on facial a. Hypochloremia
nerve in front of the ear - Chloride deficit, serum chloride
level below 95 mEq/L
- Excess loss of chloride through
gastrointestinal tract
- Clients are at risk of alkalosis
- May experience muscle twitching,
tremors or tetany
- Trousseau’s sign b. Hyperchloremia
- Carpal spams in response to inflating BP cuff on - Chloride excess, serum chloride above 108 mEq/L
the upper arm to 20mmHg greater than the systolic - Risk factor
pressure for 2 to 5 minutes- - Excess replacement of NaCl or potassium chloride
- AT RISK and can lead to hypernatremia
- Those who have their parathyroid glands removed - MANIFESTATIONS
- Low serum magnesium - Acidosis
- Chronic alcoholism - Weakness
- MANIFESTATIONS - Lethargy with risk of dysrhythmias or coma
- Numbness, tingling of extremities and around 6) PHOSPHATE
mouth a. Hypophosphatemia
- Muscle tremors, cramps - Phosphate deficit
- If severe: tetany and convulsions - Serum phosphate of less than 2.5 mg/dL
- Cardiac dysrhythmias, decreased cardiac output - Causes
- Positive Chvostek and Trousseau’s signs - Glucose and insulin administration (cause
- Confusion, anxiety psychosis phosphate to shift into the cells from the extracellular
- Hyperactive tendon reflexes fluid compartment)
b. Hypercalcemia - Total parenteral nutrition
- Calcium excess - Alcohol withdrawal
- Total calcium serum greater than 10.5 mg/dL - Acid-base imbalances
- Ionized calcium level greater than 5.5 mEq/L - Use of antacids with phosphate binders
- Occurs when calcium is released in excess from - MANIFESTATIONS
bony skeleton due to malignancy or prolonged - Parenthesias- Muscle weakness
immobilization (breakdown of bones) - Pain
- MANIFESTATION - Mental changes
- Lethargy, weakness - Possible seizures
- Depressed deep tendon reflexes (DTR) b. Hyperphosphatemia
- Bone pain due to bone breakdown - Phosphate excess
- Anorexia - Serum phosphate greater than 4.5 mg/dL
- Nausea and vomitus - Occurs when phosphate shifts out of the cells into
- Polyuria, hypercalciuria (calcium in urine) extracellular fluid
- Flank pain 2 urinary calculi (calcium oxalate kidney - Usually,
stones) - In renal failure
- Dysrhythmias, possible heart block - Excess administration of phosphate (injected or
- ECG ingested)
- Shorten QP intervals and ST segments - At risk
4) MAGNESIUM - Cow’s milk fed infants
a. Hypomagnesemia - Using phosphate containing enemas or laxatives
- Magnesium deficiency - MANIFESTATIONS
- Serum magnesium of less than 1.5 mEq/L - Numbness and tingling around mouth and
- Occurs more frequently than hypermagnesemia fingertips
- Common cause- Chronic alcoholism - Muscle spasm
- May aggravate manifestations of alcohol - Tetany
withdrawal such as delirium tremens
- Manifestations: same with hypocalcemia
b. Hypermagnesemia
- Magnesium excess
- Serum magnesium above 2.5 mEq/L
- Due to increased intake or decreased excretion
- Often iatrogenic (caused by medical treatment)
ACID-BASE IMBALANCES ▪ Catheter or tube irrigants: fluid used to irrigate
o May be classified as respiratory or metabolic by urinary catheter, nasogastric tubes and intestinal
the general or underlying cause of the disorder tubes must be recorded if not immediately withdrawn
o Compensation: healthy regulatory systems will as part of the irrigation
attempt to correct acid-base imbalances • Fluid output noting the amount and time
1) Respiratory acidosis o Urinary output
- Carbonic acid levels increase and pH falls below o Vomitus and liquid feces: describe
7.35 due to carbon dioxide retention o Tube drainage: gastric or intestinal drainage
- When this occurs, kidneys retain bicarbonate to o Wound and fistula drainage: type and number of
restore normal carbonic acid to bicarbonate ration saturated dressed or linen or measuring vacuum
2) Respiratory alkalosis drainage
- Carbonic acid fall and pH level rises to greater than
7.45
- More carbon dioxide is exhaled than normal due to
hyperventilation
- Common cause
o Psychogenic
o Anxiety-related hyperventilation
- Kidneys will excrete bicarbonate to return pH to
normal range
3) Metabolic acidosis Diagnostic labels that relate to fluid and acid-
- Develops when carbonate levels are low in relation base imbalances
to the amount of carbonic aid in the body and pH o Deficient fluid volume
falls- May be due to renal failure and inability of ▪ Decreased intravascular, interstitial and
kidneys to excrete hydrogen ions and produce intracellular fluid
bicarbonate ▪ Refers to dehydration, water loss alone without
4) Metabolic alkalosis change in sodium
- Too much bicarbonate in the body exceeding the o Excess fluid volume
normal ration ▪ Increased isotonic fluid retention
- Causes o Risk for imbalance fluid volume
o Ingestion of bicarbonate of soda as antacid ▪ Vulnerable to a decrease, increase or rapid shift
o Prolonged vomiting with loss of hydrochloric acid from one to the other of intravascular, interstitial or
from stomach intracellular fluid; compromise health
- Respiratory center is depressed and respirations ▪ Refers to body fluid loss, gain or both
are slow and shallower o Risk for deficient fluid volume
֍ Nursing Management ▪ Vulnerable to experiencing decreased
۩ Assessing intravascular, interstitial or intracellular fluid volumes
o Nursing history which may compromise health
o Physical assessment o Impaired gas exchange
o Review of laboratory test results ▪ Excess or deficit in oxygenation or carbon dioxide
o Clinical measurements elimination at the alveolar-capillary membrane
▪ Daily weights • Planning care for patient with fluid, electrolyte and
▪ Vital signs acid-base imbalances; nurse identifies nursing
▪ Fluid intake and output interventions that will assist the client to achieve
• Fluid intake recorded with time and type broad goals
o Oral fluids o Maintain or restore normal fluid balance
▪ Water, milk, juice, soft drinks, coffee, tea, cream, o Maintain or restore normal balance of electrolyte in
soup and other beverages including water taken with the intracellular and extracellular compartment
medications o Maintain or restore gas exchange and oxygenation
▪ Ice chips: approximately one half the volume of ice o Prevent associated risks (tissue breakdown,
chips decrease cardiac output, confusion other neurologic
▪ Foods that are or become liquid at room signs)
temperature: ice cream, sherbet, custard and gelatin ۩ Parenteral fluid and electrolyte replacement
▪ Tube feedings: include water for flushes and other o IV fluid therapy
water given ▪ Essential when clients are unable to take sufficient
▪ Parental fluids: IV fluids and blood transfusion and food and fluids orally
volume
▪ IV medications: intermittent and continuous
infusion (50 to 100 mL of solution)
▪ Intravenous solutions 3) Roller clamp
1) Isotonic - Regulates drops of IV solution
- Same concentration as blood plasma - May be used to close the line
- Used to restore vascular volume 4) Injection port
a. 0.9 % NaCl (normal saline) - Where you can administer IV medications or IV
b. Lactated Ringer’s flushing to patient
(a balanced electrolyte solution) - May be via IV bolus or piggy back system
c. 5% dextrose in water (D5w) 5) Auxiliary clamp
- Easier to close line (administer blood products)
- Tighter clamp
6) Needle end
- Connect IV
- Screw then connects to veins
o 2 sets
2) Hypotonic o Macro set: large drops
- Lesser concentration of solutes (no needle stuck in)
- Provide free water and treat cellular
dehydration
- Solutions promote waste elimination
by kidneys o Micro set: small drops
- DO NOT administer to clients at risk (needle delivers microdrips)
for third space fluid shift or increased
intracranial pressure (IICP)/ cerebral
edema
a. 0.45% NaCl (half normal saline)
b. 0.33% NaCl (one-third normal saline)
3) Hypertonic
- Greater concentration of solutes than o 2 ways in administering medication
plasma o IV bolus
- Draw fluid out of intracellular and
interstitial compartments
- Expand vascular volume
- DO NOT administer to clients with
kidney or heart disease or who are o piggy back set (usual for medication and blood
dehydrated products)
- Watch for signs of hypovolemia
a. 5% dextrose in normal saline (D5NS)
b. 5% dextrose in 0.45% NaCl (D51/2NS)
c. 5% dextrose in Lactated Ringer’s (D5LR)
4) Volume expanders
- Used to increase blood volume
following severe blood loss
(hemorrhage) or loss of plasma o Infusion pumps- help deliver exact or
(burns) accurate drops or volume; Regulator
- Examples: dextran, plasma, o CVGH (terumo infusion set)
albumin and Hespan o Braun infusion pump; type
name of medication infused; see
o Standard IV Administration Set how many mL per hour delivered;
time consumed

o Starting an intravenous infusion

- Before starting an infusion, the nurse determines
the following:
1) Type and amount of solution to be infused
2) Exact amount (dose) of any medications to be
1) Bag spike added to a compatible solution
- Insert into IV bag or container 3) Rate of flow or the time over which the infusion is
- Sterile to be completed
2) Drip chamber o Regulating and Monitoring Intravenous
- Allows appropriate amount of fluid to be delivered Infusions
to patient
- Drop factor: number of drops delivered per
milliliter of solution
- Macrodrops: drop factors of 10, 12, 15 or 20
drops/mL
- Microdrops: 60 drops/mL
- Keep Vein Open (KVO) or To Keep Open (TKO):
less than 50 mL/hour (usually 5-15 drops)
- Calculate flow rates: volume of fluid to be infused
and the specific time for infusion
- Two commonly used methods of indicating flow
rates
- The number of milliliters to be administered in 1
hour (mL/hr)
- The number of drops to be given in 1 minute
(gtt/min)
- Milliliters per hour: hourly rates of infusion
- Divide total infusion volume by the total infusion
time in hours
- Example: 3,000 mL is infused in 24 hours
- Milliliters per hour is
3,000 mL (total infusion volume)
• = 125 mL/hr
24 hours (total infusion time)
- Drops per minute: to ensure that the prescribed
amount of solution will infuse
- Total infusion volume multiplied to drop factor then
dividing it to the total time of infusion in minutes
- Example: 1000 mL D5LR in 8 hours and the drop
factor is 20 drops
1000 mL (total infusion volume)x20(drop factor)
•
8ℎ𝑟𝑠 x 60 mins
= 41 drops/min
- Round off: final answer is absolute value
- Infusion time: to know when will the
intravenous fluid be due
- Total infusion volume divided by volume infused
per hour (mL./hr)
1000 mL
• = 8 hours
125mL/hr
OXYGEN AND PERFUSION FACTORS AFFECTING RESPIRATORY
FUNCTION
Respiration
1) Age
o Process of gas exchange between the individual
→ At birth; fluid-filled lungs drain, the PCO2
and the environment
rises and neonate takes the first breath
o Involves four (4) components
→ Lungs expand with each subsequent breath,
1) Ventilation or breathing, the movement of air
reaching full inflation by 2 weeks of age
in and out of the lungs as we inhale and
→ Older adults
exhale
→ Chest wall and airways become rigid and
2) Alveolar-capillary gas exchange, which
less elastic
involves the diffusion of oxygen and carbon
→ Amount of exchanged air is decreased
dioxide between the alveoli and the
→ Cough reflex and cilia action is decreased
pulmonary capillaries
→ Fragile mucous membranes, drier
3) Transport of oxygen and carbon dioxide
→ Decrease in muscle strength and
between the tissues and the lungs
endurance
4) Movement of oxygen and carbon dioxide
→ If osteoporosis is present, adequate lung
between the systemic capillaries and the
expansion is compromised
tissues
→ Decrease in efficiency of immune system
→ GERD (gastroesophageal reflux disease)
Structure of the Respiratory System
more common and increases risk of
aspiration
2) Environment
→ altitude, heat, cold and air pollution affects
oxygenation
→ higher altitude, the lower the PO2 a person
breathes (increases respiratory and cardiac
rates and increased respiratory depth)
→ air pollution: stinging of eyes, dizziness,
coughing
3) Lifestyle
→ exercise: increases rate and depth of
PROCESSES OF THE RESPIRATORY SYSTEM respiration and oxygen supply in the body
1) Pulmonary Ventilation → sedentary people: lack of alveolar expansion
→ Accomplished through act of breathing and deep breathing patterns
inspiration (inhalation)as air flows into the 4) Health status
lungs, and expiration (exhalation) as air moves → Good lungs
out of the lungs → Comorbidities: changes in respiratory function
2) Alveolar Gas Exchange 5) Medications
→ Diffusion of oxygen from the alveoli and into → Some can decrease the rate and depth of
the pulmonary blood vessels respirations (benzodiazepine sedative-
3) Transport of Oxygen and Carbon Dioxide hypnotics and antianxiety drugs, barbiturates,
→ Oxygen needs to be transported from the lungs opioids)
to the tissues, and carbon dioxide from the → Reduced doses in older adults
tissues back to the lungs → Monitor respiratory rate if giving medications
4) Systemic Diffusion 6) Stress
→ Diffusion between the capillaries and the → During stress, arterial PO2 and PCO2 falls due
tissues and cells down to a concentration to hyperventilation
gradient similar to diffusion at the alveolar- → Lightheadedness and numbness and tingling
capillary level of fingers and toes and around the mouth
→ diffusion: from greater concentration to lower occurs
concentration
ALTERATIONS IN RESPIRATORY FUNCTIONS ▪ K=ketones (diabetic ketoacidosis)
۩ Conditions Affecting the Airway ▪ U=Uremia
1) Upper Airway Obstruction ▪ S=Sepsis
→ Obstruction in the nose, pharynx or larynx ▪ S=Salicylates
→ Occurs when ▪ M=Methanol
a) A foreign object (food) is present ▪ A=Aldehydes
b) When the tongue falls back to the ▪ U
oropharynx when unconscious ▪ L=Lactic acid (lactic acidosis)
c) Secretions collect in the passageways o Cheyne-Stokes Respirations
2) Lower Airway Obstruction → Marked, rhythmic, waxing and waning of
→ Partial or complete occlusion of the respirations from very deep to very shallow
passageways in the bronchi and lungs with short periods of apnea
→ Often due to increased accumulated mucus or → Caused by chronic diseases, increased
inflammatory exudate intracranial pressure or drug overdose
۩ Assessment → Periodic breathing: gradual
o Maintaining patency of the airways is a nursing hyperpnoea/hypopnea and apnoea
responsibility and requires immediate action → Sleep/hypoxemia/drugs
o Partial obstruction of upper airway → Hypoperfusion of the brain (respiratory center)
→ Low-pitched snoring sound during inhalation o Biot’s (Cluster) Respirations
o Complete Obstruction → Shallow breaths interrupted by apnea; seen in
→ Extreme respiratory effort, no chest clients with central nervous system disorders
movement and inability to talk or speak, → “ataxic respiration”
exhibit marked sternal or intercostal → Periodic breathing: hyperpnoea (or
retractions normopnoea) and apnoea
o Lower airway obstruction → Poor prognosis & Neuron damage
→ Stridor heard during inspiration
۩ Conditions Affecting Movement of Air
o Breathing patterns- rate, volume, rhythm and
relative ease or effort of respiration
a) Normal respiration (eupnea)
→ Quiet, rhythmic and effortless
b) Tachypnea (rapid)
→ Seen in fevers, metabolic acidosis, pain and
hypoxemia
c) Bradypnea (abnormally slow)
→ Seen in clients who have taken drugs
→ Morphine or sedatives, metabolic alkalosis
or increased intracranial pressure
d) Apnea
→ Absence of any breathing
o Hypoventilation
→ Inadequate alveolar ventilation, slow or shallow
breathing or both
→ Occurs due to diseases or respiratory muscles,
drugs or anesthesia
→ May lead to increased levels of carbon dioxide
(hypercarbia or hypercapnia) or low levels of
oxygen (hypoxemia)
o Hyperventilation
→ Increased movement of air in and out of lungs
→ Kussmaul’s Breathing
o Body attempts to compensate by blowing
off carbon dioxide CO2
o Also occurs in response to anxiety or stress
o Metabolic acidosis (diabetes mellitus)
o Hyperpnoea
o Orthopnea NURSING MANAGEMENT
→ Inability to breathe easily unless sitting upright ۩ Diagnostic Labels
or standing o DIAGNOSTIC LABELS FOR CLIENTS WITH
o Dyspnea OXYGENATION PROBLEMS
→ Difficulty in breathing or feeling of being short 1) Ineffective Airway Clearance: inability to
of breath (SOB) clear secretions from the respiratory tract to
→ May happen while doing physical activities or maintain a clear airway
at rest 2) Ineffective Breathing Pattern: inspiration or
→ SIGNS expiration that does not provide adequate
o Flaring of nostrils ventilation
o Labored-appearing breathing 3) Impaired Gas Exchange: excess or deficit in
o Increased heart rate oxygenation and/or carbon dioxide elimination
o Cyanosis at the alveolar-capillary membrane
o Diaphoresis 4) Activity Intolerance: insufficient physiological
or psychological energy to endure or complete
۩ Conditions Affecting Diffusion required or desired daily activity
o Hypoxemia
→ Reduced oxygen levels in the blood o THE PRECEDING NURSING DIAGNOSES MAY
→ Caused by conditions that impair diffusion at ALSO BE THE ETIOLOGY OF SEVERAL OTHER
the alveolar-capillary level such as NURSING DIAGNOSIS SUCH AS:
pulmonary edema or atelectasis (collapsed 1) Anxiety related to ineffective airway clearance
alveoli) or by low hemoglobin levels and feeling of suffocation
o Hypoxia 2) Fatigue related to ineffective breathing pattern
→ Occurs when the body is unable to 3) Fear related to chronic disabling respiratory
compensate or hypoxemia is severe illness
→ Insufficient oxygen levels anywhere in the 4) Powerlessness related to inability to maintain
body causing cellular injury or death independence in self-care activities because of
→ 3 to 5 minutes of hypoxia: permanent damage ineffective breathing pattern
→ CLINICAL MANIFESTATIONS o THE PRECEDING NURSING DIAGNOSIS MAY
a) Rapid pulse ALSO BE THE ETIOLOGY OF SEVERAL OTHER
b) Rapid, shallow respirations and dyspnea NURSING DIAGNOSIS SUCH AS:
c) Increased restlessness or light- 1) Insomnia related to orthopnea and required
headedness oxygen therapy
d) Flaring of the nares 2) Social isolation related to activity intolerance
e) Substernal or intercostal retractions and inability to travel to usual social activities
f) Cyanosis ۩ Outcomes/Goals
o Acute Hypoxemia → The overall outcome/goals for a client with
→ Appears anxious, tired and drawn; assumes a oxygenation problems are to:
sitting position often leaning forward slightly to o Maintain a patient airway
permit greater expansion of thoracic cavity o Improve comfort and ease of breathing
o Chronic Hypoxemia o Maintain or improve pulmonary ventilation and
→ Appears fatigued, lethargic has clubbed oxygenation
fingers and toes o Improve ability to participate in physical
→ Clubbed: curved nailbeds: caused by long- activities
term lack of oxygen in arterial blood supply o Prevent risks associated with oxygenation
problems such as skin and tissue breakdown,
۩ Conditions Affecting Transport syncope, acid-base imbalances and feelings of
o Congestive heart failure or Hypovolemia hopelessness and social isolation
→ Affect tissue oxygenation and also the body’s ۩ Interventions
ability to compensate for hypoxemia → Nursing interventions should be directed toward
achieving optimal respiratory effort, gas,
exchange, self-care habits and wellness
o Always encourage wellness and prevention by
reinforcing the need for good nutrition, exercise
and immunizations
o Increase fluid intake
o In hospitalized and immobilized patients, 2) Counteract the effects of anesthesia or
encouraged ambulation and frequent changing hypoventilation
of positions 3) Loosen respiratory secretions
֍ Promoting Oxygenation 4) Facilitate respiratory gaseous exchange
o Nursing interventions should be directed to 5) Expand collapsed alveoli
achieving optimal respiratory effort, gas
exchange, self-care habits and wellness: o 2 TYPES OF SPIROMETER
1) Positioning the client to allow maximum chest 1) Flow oriented Spirometer
expansion (Semi- or High-Fowlers) → Consists of one or more
2) Encouraging or providing frequent changes in clear plastic chambers
position (side to side) containing freely movable
3) Encouraging ambulation colored balls or disks
4) Implementing measures that promote comfort → Balls or disks are elevated as the client inhales
such as giving pain medications → The longer the inspiratory flow is maintained,
5) Teach to use deep-breathing and coughing the larger the volume, so the client is
techniques encouraged to take slow deep breaths
6) Pace activities to conserve energy → Does not measure specific volume of air
7) Eat more frequent, smaller meals to decrease inhaled
gastric distention 2) Volume-oriented Spirometer
8) Avoid extreme hot or cold temperature → Measures of the inhalation volume maintained
9) Teach actions and side effects of drugs, by the client
inhalers and treatment → When the client inhales, a piston-like plate or
֍ Deep Breathing and Coughing accordion-pleated cylinder rises as the client
→ when coughing raises secretions high enough, inspires, and marking on the side indicate the
the client may either expectorate (spit it out) or volume of inspiration achieved by the client
swallow them
→ swallowing secretion is not harmful but does
not allow the nurse to view the secretions for
documentation purposes or to obtain specimen
for testing
o Pursed Lip Technique
→ Client is taught to breathe normally through the
nose and exhale through pursed lips as if
about to whistle and blow slowly and o CLIENT TEACHING: Using an Incentive
purposefully, tightening the abdominal muscles Spirometer
to assist with exhalation → Hold or place the spirometer in an upright
o Normal forceful coughing position. A titled flow-oriented device requires
→ Highly effective; some client lacks the strength less effort to raise the balls or disks; a volume-
or ability to cough normally oriented device will not function correctly
→ Client inhales deeply and then coughs twice upright
while exhaling → Exhale normally
o Alternative cough techniques → Seal the lips tightly around the mouthpiece
→ Forced expiratory technique or “huff coughing”: → Take in a slow, deep breath to elevate the balls
if unable to do normal forceful cough; inhale or cylinder, and then hold the breath for 2
through pursed lips and exhale with “huff” seconds initially, increasing to 6 seconds
sound in mid—exhalation (optimum), to keep the balls or cylinder
֍ Incentive Spirometry elevated if possible
→ Referred to as sustained maximal inspiration → For a flow-oriented device,
devices (SMIs) avoid brisk, low-volume
→ Measure the flow of air inhaled through the breaths that snap the balls to
mouthpiece the top of the chamber.
→ Client must be assisted into a position, Greater lung expansion is
preferably an upright sitting position in bed or a achieved with a very slow inspiration than with
chair, that facilitates maximum ventilation a brisk, shallow breath, even though it may not
→ Used to elevate the balls or keep them elevated while
1) Improve pulmonary ventilation you hold your breath. Sustained elevation of
the balls or cylinder ensures adequate o Vibration
ventilation of the alveoli (lung air sacs). → Series of vigorous quivering produced by hands
→ If you have difficulty breathing only through the that are placed flat against the client’s chest
mouth, a nose clip can be used wall
→ Remove the mouthpiece and exhale normally → Used after percussion to increase the
→ Cough after the incentive effort. Deep turbulence of the exhaled air and thus loosen
ventilation may loosen secretions and thick secretions
coughing can facilitate their removal → To perform vibration
→ Relax and take several normal breaths per ▪ Ask the patient to inhale deeply
before using the spirometer again ▪ Exhale slowly through pursed lips
→ Repeat the procedure several times and then ▪ During exhalation, firmly press your fingers
four or five times hourly. Practice increases and palms of your hands against the chest
inspiratory volume, maintains alveolar wall
ventilation and prevents atelectasis (collapse ▪ Tense the muscles of your arms and
of the air sacs) shoulders in an isometric contraction to send
→ Clean the mouthpiece with water and shake it the fine vibrations through the chest wall
dry ▪ Vibrate during five exhalations over each
o Using an incentive spirometer chest segment
→ Do it 5 or 10-15 minutes a day ▪ Encourage the patient to cough and
→ Not eat prior to incentive spirometer procedure expectorate into a sputum container after
֍ Percussion, Vibration and Postural Drainage each
→ Performed according to a primary care o Postural Drainage
provider’s order by nurses, respiratory → Drainage by gravity of secretions from various
therapists, physical therapists or an lung segments
interdisciplinary team of these healthcare → Wide variety of positions necessary to drain all
team members segments of the lungs but not all positions are
o Percussion required for ever patient
→ “Clapping” → Postural drainage treatments are scheduled
→ Forceful striking of the skin with cupped hands two or three times a day daily, depending on
→ Performing over congested lung areas can the degree of lung congestion
mechanically dislodged tenacious secretions → Best time:
from the bronchial walls o Before breakfast
→ To perform percussion o Before lunch
▪ Instruct the patient to breathe slowly and o In the late afternoon
deeply o Before bed time
▪ Using the diaphragm → AVOID hours shortly after meals
▪ To promote relaxation → Risk for Aspiration and Vomiting
▪ Hold your hands in a cupped shape with o Before procedure: bronchodilator or
fingers flexed and thumbs pressed tightly nebulization may be given to loosen
against your index finger secretions
▪ Percuss each segment for 1 to 2 minutes → Evaluate client’s tolerance to postural
by alternating your hands against the drainage by assessing stability of client’s vital
patient in a rhythmic manner signs (pulse, respiratory rate; RR) and signs
▪ Listen for a hollow sound on percussion to of intolerance (pallor, diaphoresis, dyspnea,
verify correct performance of the technique nausea and fatigue)
→ make adjustments when the client does not
react well with certain positions
→ SEQUENCE
o Positioning
o Percussion
o Vibration
o Removal of secretions (coughing or
suction)
→ Each position must be assumed for 10-15
minutes beginning sessions may start at
shorter time than gradually increases
→ MUST ASSESS o Affected Lung Segment
o Lung fields ▪ Upper Lobes- Anterior Segments
o Compare findings to baseline data
o Document amount
o Color and characteristics of
expectorated sections
o Affected Lung Segment
o Affected Lung Segment
▪ Lower Lobes – Posterior Basal Segments
▪ Upper Lobes- Apical Segments

o Affected Lung Segment

▪ Lower lobes – superior segments ֍ Oxygen Therapy
→ Prescribed by primary care provider who
specifies
o Concentration
o Method of delivery
o Liter flow per minute (L/min) depending on
method
→ Supplied in 2 ways in health care facilities
o Affected Lung Segment o Portable systems (cylinders or tanks)
▪ Lower lobes- lateral basal segments o Wall outlets

o Affected Lung Segment

▪ Right Middle Lobe- Medial & Lateral Segments

o Affected Lung Segment

▪ Upper Lobe- Posterior Segments
- Wall outlet
- Oxygen tank
- Oxygen converter
֍ OXYGEN DELIVERY SYSTEMS
→ Low flow and high flow systems
o Low flow
▪ Deliver oxygen via small bore tubing
o Affected Lung Segment ▪ Nasal cannulas, face masks, face tents and
▪ Left Upper Lobe- Superior & Inferior Segments transtracheal catheters
▪ Low flow oxygen delivery systems
1) Nasal Cannula (nasal prongs)
● Most common; easy to apply and does not
interfere with the client’s ability to eat or talk
● Concentration: 24% to 45% at flow rates of 2
to 6L/min
2) Face Mask o Green adapter: delivers 35% concentration of
● Cover the client’s nose and mouth: many oxygen at 8L/min
varieties ● Concentration: 24% to 40% or 50% at 4 to
o Simple face mask: oxygen concentration of 10L/min
40% to 60% at 5-8L/min
o Partial rebreather mask: oxygen
concentration of 60% to 90% at 6-10L/min
o Nonrebreather mask: oxygen concentration o Noninvasive Positive Pressure Ventilation
at 95% to 100% at 10-15L/min (NPPV)
3) Face Tent → The delivery of air or oxygen under pressure
● Can replace face masks when poorly tolerated without the need for an invasive tube such as
by clients an endotracheal tube or tracheostomy tube
● Provide varying concentration of oxygen → For clients who require mechanical assistance
o 30% to 50% at 4-8L/min to maintain adequate breathing
4) Transtracheal Catheter o Acute and chronic respiratory failure
● Placed through a surgically created in the o Pulmonary edema
lower neck directly to the trachea o COPD (chronic obstructive pulmonary
● Once the tract has matured (healed), the client disease)
removes and cleans the catheter two to four o Obstructive sleep apnea
times per day
● Oxygen delivered at greater than 1L/min must
be humidified; can deliver high flow rates as
much as 15 to 20 L/min

Left: noninvasive positive pressure ventilation

Right: CPAP (Continuous Positive Airway Pressure)
TIME TAPING IV FLUIDS
TIME TAPING
● The use of time taping an IV helps ensure that an
Nasal cannula, face mask, face tent IV solution is being infused at the prescribed rate.
● It also helps facilitate calculation of fluid intake

- Partial Rebreather Mask

- Non rebreather: valves
o High flow
▪ Supply all the oxygen required during ventilation
in precise amount
▪ Venturi mask with large-bore tubing
▪ High flow oxygen delivery systems
1) Venturi Mask  Has different uses
● Has wide-bore tubing and color-coded jet  IV Fluid – 1 Level (100 mL of total volume of fluid
adapters that correspond to a precise oxygen has been infused)
concentration and liter flow  IV Fluid – 2 Level (800)
● Example in some cases  IV Fluid – 3 Level (700)
 IV Fluid – 4 Level (600 mL)
o Blue adapter: delivers 24% concentration of
oxygen at 4L/min
CVGH IV FLUID TIME TAPE

 Venoclysis: specific fluid

or solution infused to the
client
 Additives: Medications,
Electrolytes, Fluid, Products
incorporated on IV
 After plotting, sign Family
Name, SN /
● Find the rate of flow in mL/hr.

SITUATION
● You are assigned to patient De la Cruz, Juan in
PPS 2nd, Room 203. You are going to make a time
tape for his IV fluid. He is being infused with 2 PNSS
1L @ 30 gtts/min. The endorsed level is 600 mL.
The drop factor is 15 gtts/mL. ● Plot the values on the IV Fluid Time Tape form.

HOW TO FILL UP THE TIME TAPE FORM?

● Fill up the necessary information such as the date,
patient’s name, floor and room number, Venoclysis,
additives, flow rate, etc.

 If there is an order, for example, “please infuse

bottle number 3…” Before IV fluid will be finished by
12 noon, change the IV bottle according to the
doctor’s order.

● Write the endorsed IV fluid level above the first

column
● FLUID LEVEL IS DIFFERENT THAN FLUID ● The endorsed IV fluid level is the level of the fluid
VOLUME BEING INFUSED by 7 AM. When plotting on the table, subtract 120
 Example: If 200 ml is infused to the patient, and mL or the mL/hr. from the endorsed level since the
1L is the endorsed IV, the fluid level is 800. table starts at 8 AM.
● Compute for the number of hours to consume the ● Before the IV fluid is consumed, check the doctor’s
IV fluid. Use the endorsed IV fluid as the value for order if there is a to-follow IV fluid to be infused. If
the total volume there is an order, change the IV bottle with a new
● Use the formula for the rate flow: one before it runs out
● Do not forget to put your signature on the last part
of the form (Last Name, SN/)
 Non vesicant: non-irritating
 Vesicant: chemotherapy drugs, antibiotics (at
maximum dosage), can cause blisters, and irritating
● How much of the IV solution was infused from 7 to blood vessels and tissues
AM to 10 AM?  Swelled hands on IV site
● Subtract the IV fluid level from 7 AM to the IV level
from 10 AM. 2.) EXTRAVASATION
 Answer: 600 – 240 = 360 ml is the IV  Similar to infiltration with difference of the solution
infused from 7 am to 10 am being infused, vesicant fluids unintendedly
administered to subcutaneous tissue
IMPORTANT TO KNOW (For actual) S/Sx:
● Change primary administration sets and any  Same as infiltration and can also include
piggyback (secondary) tubing that remains  Burning, stinging pain
continuously attached to them every 72-96 hours to  Redness followed by blistering, tissue necrosis
minimize breaks in the closed administration system and ulceration
● IV bags must be changed every 24 hours
regardless how much solution remains to minimize
contamination
● IV sites must be changed 48-72 hours to minimize
infections
● When plotting for the IV Fluid Time Tape,
3.) PHLEBITIS
 For AM shift, start at 8 AM to 3 PM
 Inflammation of the vein
 For PM shift, start at 4 PM to 11 PM
A.) MECHANICAL PHLEBITIS – cause: too large of
 For Night shift, start at 12 AM to 7 AM
a catheter in a small vein, causing irritation of the
vein
 Closed Administration System – Plastic without
B.) CHEMICAL PHLEBITIS – inflammation of vein
vents, reducing exposure to bacteria
due to vesicant or irritating solutions
 KSS Set-up – keep set sterile
C.) BACTERIAL PHLEBITIS – inflammation of vein
 Advisable not to remove IV bags
and bacterial infection, may be caused by poor
 Regardless if IV bag is still full, dispose it because
aseptic technique during insertion
it is already contaminated
S/Sx:
 Redness at site
● Common complications of Infusion
 Skin warm
Therapy
 Swelling
1.) INFILTRATION
 Palpable cord along the vein
 Unintended administration of a NONVESICANT
 Increase in temperature
drug or fluid into the subcutaneous tissue
S/Sx:
 Coolness of skin around site
 Skin blanching, tautness
 Edema at, above, or below insertion site
 Leakage of insertion site
 Absence of “pinkish” blood return PRACTICE EXERCISE
 Difference in size of opposite hand or arm ● Solve:
 You are assigned to patient J.J.K. in PPS 3rd,
Room 304. You are going to make a time tape for
his IV fluid. He is being infused with 4 PNSS 1L @
20 gtts/min. The endorsed level is 900 mL. The drop
factor is 15 gtts/mL.
STRESS AND COPING SITUATIONAL STRESSOR
STRESS ● Unpredictable and may occur at any time during
● A condition in which an individual experiences life
changes in the normal balanced state ● May be positive or negative
STRESSOR ● Example:
● Any event or stimulus that causes an individual to  Death of a family member
experience stress  Marriage or divorce
● When a person faces stressors, responses are  Birth of a child
referred to as COPING STRATEGIES, COPING  New job
RESPONSES, or COPING MECHANISMS  Illness
INTERNAL STRESSOR ● Effect of stressor may depend to some extent on
● Originate within a person i.e., infection or feeling of an individual’s developmental stage
depression
EXTERNAL STRESSOR EFFECTS OF STRESS
● Originate outside the individual i.e., death in the ● May have physical, emotional, intellectual, social,
family, moving to another place, peer pressure and spiritual consequences
DEVELOPMENTAL STRESSOR a.) Physical – can threaten a person’s
● Occurs at predictable time throughout an physiological homeostasis
individual’s life b.) Emotional – can produce negative or
nonconstructive feelings about the self
SOURCES OF STRESS c.) Intellectual – can influence a person’s
Selected Stressors Associated with Developmental perceptual and problem solving abilities
Stages d.) Social – can alter a person’s relationship with
Developmental others
Stressor
Stage e.) Spiritual – can challenge one’s beliefs and
Child ● Beginning school values
● Establishing peer ● Many health conditions have been linked to stress
● relationships i.e., metabolic disorders, cardiopulmonary
● Peer competition disorders etc.
Adolescent ● Changing physique
● Relationships involving MODELS OF STRESS
sexual attraction ● Stress is defined as a STIMULUS, a life event, or
● Exploring independence a set of circumstances that arouses physiological
● Choosing a career and/ or psychological reactions that may increase
Young Adult ● Marriage the individual’s vulnerability to illness
● Leaving home ● Holmes and Rahe (1967) assigned a numerical
● Managing a home value to 43 life changes or events. The most
● Getting started in an recent versions: 77 items (1977), a shortened
occupation version (54 items, full stress and coping inventory
● Continuing one’s education completed in 15 minutes) has been created
● Children
Middle Adult ● Physical changes of aging STIMULUS – BASED STRESS MODELS
● Maintaining social status and
standard of living ● The scale of stressful life events is used to
● Helping teenage children to document a person’s relatively recent experiences
become independent such as divorce, pregnancy, and retirement
● Aging parents ● Both POSITIVE and NEGATIVE events are
Older Adult ● Decreasing physical abilities stressful
and health
● Changes in residence
● Retirement and reduced
income
● Death of spouse and friends
RESPONSE – BASED MODELS  Increased fat mobilization to provide energy
● Stress may be considered as a response and to synthesize other compounds needed
● Defined as the nonspecific response of the body to by the body
any kind of demand made upon it (Selye, 1956, ● Norepinephrine – decreased blood to the kidneys
1976) and increased secretion of renin (enzyme that
hydrolyzes one of the blood proteins to produce
LOCAL ADAPTATION SYNDROME (LAS) angiotensin)
● The body reacts to the stressor locally: one organ ● Angiotensin increases the blood pressure by
or a part of the body reacts alone i.e. inflammation constricting arterioles
● All these adrenal effects permits the person to
GENERAL ADAPTATION SYNDROME (GAS) perform far more strenuous physical activity than
● Characterized stress response by a chain or would otherwise be possible
pattern of physiological events ● Ready for “fight or flight” response; lasts from 1
● STRESSOR – any factor that produces stress and minute to 24 hours
disturbs the body’s equilibrium
● Release of adaptive hormones as response to any 2. COUNTERSHOCK PHASE
kind of demand, there are subsequent changes in ● The changes produced in the body during the
the structural and chemical positions of the body shock phase is reversed
 GI tract, adrenal glands and lymphatic ● A person is best mobilized to react during the
structures are often affected by stress shock phase of the alarm reaction
 Prolonged stress appear on the lining of the
stomach B. STAGE OF RESISTANCE
 Adrenal glands are prone to atrophy (body/ ● When the body’s adaptation takes place, body
structure would degenerate or shrink) and attempts to cope with the stressor and to limit the
enlargement stressor to the smallest area of the body that can
deal with it
● Has 3 stages:
A. ALARM REACTION C. STAGE OF EXHAUSTION
● Initial reaction of the body divided into two parts: ● The adaptation made during the second stage
SHOCK PHASE & COUNTERSHOCK PHASE cannot be maintained
● If adaptation has not overcome the stressor, the
stress effects may spread to the entire body
● The body may either rest or return to normal, or
death may be the ultimate consequence
● At the end of this stage, it would depend largely on
the adaptive energy resources of the individual,
the severity of the stressor and the external
adaptive resources provided such as oxygen.

TRANSACTION – BASED MODELS

● Based on the work of Lazarus (1966):
 Stated that the stimulus theory and the
response theory do not consider individual
1. SHOCK PHASE differences
● Stressor is perceived consciously or  Recognizes that certain environment demands,
unconsciously by the person and pressures produce stress in substantial
● Stimulates the sympathetic nervous system which numbers of people
stimulates the hypothalamus  He emphasizes that people and groups differ in
● At times of stress, the adrenal medulla secretes their sensitivity and vulnerability to certain types
epinephrine and norepinephrine in response to of events, as well as in their interpretations and
sympathetic stimulation reactions
● Significant Body Responses to Epinephrine: ● Lazarus’ transaction stress theory encompasses a
 Increased myocardial contractility which set of cognitive, affective, and adaptive (coping)
increases cardiac output and blood flow to responses that arise out person – environment
active muscles transactions
 Bronchial dilation, which allows increased ● The person and the environment are inseparable,
oxygen intake each affects and is affected by the other
 Increased blood clotting ● According to Lazarus and Monat (1991), “Stress
 Increased cellular metabolism refers to any event in which environmental
demands, internal demands, or both tax or exceed
the adaptive resources of an individual, social 3. SEVERE ANXIETY
system or tissue system” ● Consumes most of the person’s energies and
INDICATORS OF STRESS requires intervention
PHYSIOLOGICAL INDICATORS ● Perception is further decreased
● Responses to stress vary depending on the ● Person is unable to focus on what is happening,
individual’s perception of events focuses only on one detail of the situation
● The physiological signs and symptoms of stress generating the anxiety
result from activation of the sympathetic and
neuroendocrine systems of the body 4. PANIC
CLINICAL MANIFESTATIONS (STRESS) ● Overpowering, frightening level of anxiety causing
● Pupils dilate to increase visual perception when the person to lose control
serious threats to the body arise ● Less frequently experienced than other levels of
● Sweat production (diaphoresis) increases to anxiety
control elevated body heat due to increased ● Perception of a panicked person can be affected
metabolism to the degree that the person distorts events
● Heart rate and cardiac output increase to
transport nutrients and by-products of PHYSICAL EFFECTS OF ANXIETY
metabolism more efficiently LEVEL OF ANXIETY
● Skin is pallid because of constriction of Category MILD MODERATE
peripheral blood vessels, an effect of Verbalization Increased Voice tremors
norepinephrine changes questioning and pitch
● Sodium and water retention increase due to changes
release of mineralocorticoids, which increases
blood volume Motor -Mild -Tremors, facial
● Rate and depth of respirations increase activity restlessness twitches, and
because of dilation of the bronchioles, changes -Sleeplessness shakiness
promoting hyperventilation -Increased
● Urinary output decreases muscle tension
● Mouth may be dry
● Peristalsis of the intestines decreases, resulting Perception -Feelings of -Narrowed
in possible constipation and flatus and increased focus of
● For serious threats, mental alertness improves attention arousal and attention
● Muscle tension increases to prepare for rapid changes alertness -Able to focus
motor activity or defense but selectively
● Blood sugar increases because of release of inattentive
glucocorticoids and gluconeogenesis -Learning
PSYCHOLOGICAL INDICATORS slightly
● Include anxiety, fear, anger, depression, and impaired
unconscious ego defense mechanisms\
1.) Anxiety and Fear Respiratory -None -Slightly
ANXIETY and increased RR
● A common reaction to stress Circulatory and HR
● A state of mental uneasiness, apprehension, changes
dread, or foreboding or a feeling of helplessness
related to an impending or anticipated unidentified Other -None -Mild gastric
threat to self or significant relationships changes symptoms (i.e.,
● There are coping patterns that can be helpful in “butterflies in
lessening the effects of psychological indicators the stomach”)
and some of them can be harmful
● May be manifested on four levels:
1. MILD ANXIETY
● Produces a slight arousal than enhances
perception, learning and productive abilities
2. MODERATE ANXIETY
● Increases arousal to a point where the person
expresses feeling of tension, nervousness, or
concern
● Perceptual abilities are narrowed
● Attention is focused more on a particular
aspect than on peripheral activities
Category SEVERE PANIC ● AGGRESSION
Verbalization Communication Communication  An unprovoked attack or a hostile, injurious, or
changes difficult to may not be destructive action or outlook
understand understandable ● VIOLENCE
 The exertion of physical force to injure or
Motor - Increased - Increased abuse
activity motor activity, motor activity, ● Verbally expressed anger differs from hostility,
changes inability to relax agitation aggression, and violence, but it can lead to
- Fearful facial - Unpredictable destructiveness and violence if the anger persists
expression responses unabated
Perception - Inability to - Trembling, ● A clearly expressed verbal communication of
and focus or poor motor, anger, when the angry person tells the other
attention concentrate coordination person about the anger and carefully identifies the
changes - Easily - Perception source, is constructive
distracted distorted or ● The clarity of communication gets the anger out
- Learning exaggerated into the open so the other person can deal with it
severely - Unable to and help to alleviate it. The angry person “gets it
impaired learn or off the chest” and prevents an emotional buildup
function
Respiratory - Tachycardia, - Dyspnea, 3. DEPRESSION
and hyperventilatio palpitations, ● A common reaction to events that seem
Circulatory n choking, chest overwhelming or negative
changes pain or ● An extreme feeling of sadness, despair, dejection,
pressure lack of worth or emptiness
Other - Headache, - Feeling of ● Emotional Symptoms:
changes nausea, impending  Feelings of tiredness, sadness, emptiness, or
dizziness doom numbness
paresthesia, ● Behavioral Signs:
sweating  Irritability, inability to concentrate, difficulty
making decisions, loss of sexual desire, crying,
FEAR sleep disturbance, and social withdrawal
● Emotion or feeling of apprehension aroused by ● Physical Signs:
impending or seeming danger, pain or another  Loss of appetite, weight loss, constipation,
perceived threat headache, and dizziness
● May be in response to something that has already
occurred, in response to an immediate or current ● People experience short depression in response
threat, or in response to something the person to overwhelming events such as job loss and loss
believes will happen of a loved one
● May or may not be based in reality ● Prolonged depression needs treatment as soon as
● Anxiety and fear differ in four ways: possible
ANXIETY FEAR
● Source may not be ● Source is identifiable 4. EGO DEFENSE MECHANISM
identifiable ● Related to the past, ● Unconscious psychological adaptive mechanisms
● Related to the future, present and future or, according to Anna Freud (1967), mental
that is, to an ● Definite mechanisms that develop as the personality
anticipated event ● Results from a attempts to defend itself, establish compromises
● Vague specific physical or among conflicting impulses, and calm inner
● Results from psychological event tensions
psychological conflict ● Defense Mechanism: unconscious mind working
to protect the person from anxiety
2. ANGER
● Emotional state consisting of a subjective feeling
of animosity or strong displeasure
● A verbal expression of anger can be a signal to
others of one’s internal psychological discomfort
and a call for assistance to deal with perceived
stress
● HOSTILITY
 Usually marked by overt antagonism and
harmful or destructive behavior
DEFENSE MECHANISMS COGNITIVE INDICATORS
NAME DEFINITION ● Cognitive indicators of stress are thinking
Denial Blocking out painful anxiety- responses that include problem solving,
inducing events or feelings structuring, self-control, or self-discipline
Displacement Discharging pent-up feelings
on people less dangerous 1. PROBLEM
than those who initially ● Involves thinking through the threatening situation,
aroused the emotion using specific steps to arrive at a solution
Dissociation Handling emotional conflicts, ● The person assesses the situation or problem,
or internal or external analyzes or defines it, chooses alternatives,
stressors, by a temporary carries out the selected alternative, and evaluates
alteration of consciousness whether the solutions succeeded
or identity
Fantasy Symbolic satisfaction of 2. STRUCTURING
wishes through nonrational ● The arrangement or manipulation of a situation so
thought threatening events do not occur
Identification Unconscious assumption of ● Can be productive in certain situations i.e., a
similarity between oneself person who schedules a dental examination
and another semiannually to prevent severe dental disease is
Intellectualization Separating an emotion from using productive structuring
an idea or thought because ● Close ended questions are done to be direct and
the emotional reaction is too avoid causing emotional triggers and stress by
painful to be acknowledged open ended questions
Introjection Acceptance of another’s
values and opinions as 3. SELF-CONTROL (DISCIPLINE)
one’s own ● Assuming a manner and facial expression that
Projection Attributing one’s own convey a sense of being in control or in charge
unacceptable feelings and ● When self-control prevents panic and harmful or
thoughts to others nonproductive actions in a threatening situation, it
Rationalization is a helpful response that conveys strength
Falsification of experience
through the construction of
4. SUPPRESSION
logical or socially approved
explanations of behavior ● Consciously or willfully putting a thought or feeling
out of mind
Reaction Unacceptable feeling
● “I won’t deal with that today; I’ll do it tomorrow”
Formation disguised by repression of
the real feeling and by
5. FANTASY OR DAYDREAMING
reinforcement of the
● Likened to make-believing
opposite feeling
● Unfulfilled wishes and desires are imagined as
Regression Reverting to an earlier stage
fulfilled, or a threatening experience is reworked or
of development (i.e. Adult
replayed so it ends differently from reality
tantrums)
● Fantasy responses can be helpful if they lead to
Repression Unconsciously keeping
problem-solving
unacceptable feelings out of
● Can be destructive and nonproductive if it is used
awareness
to excess and retreat from reality
Suppression Consciously keeping
unacceptable feelings and ENCOURAGING HEALTH PROMOTION
thoughts out of awareness STRATEGIES
Undoing Attempting to take back an EXERCISE
unconscious thought or ● Regular exercise promotes both physical and
behavior that is emotional health
unacceptable or hurtful ● Can improve muscle tone, increase
cardiopulmonary function, and weight control,
relief of tension, feeling of wellbeing and
NUTRITION d.) Recognize usual coping patterns and
● Essential for health and in increasing body’s differentiate positive from negative coping
resistance to stress mechanisms
● Avoid excesses of caffein, salt, sugar, and fat, and e.) Identify new strategies for managing stress
deficiencies in vitamins and minerals to prevent (i.e., exercise, massage, progressive
negative effects of stress relaxation)
f.) Identify available support systems
SLEEP ● Teach clients about:
● Restores body’s energy levels and is an essential a.) The importance of adequate exercise, a
aspect of stress management balanced diet, and rest and sleep to energize
● To ensure adequate sleep, clients may need to the body and enhance coping abilities
attain comfort (such as pain management) and to b.) Support groups available such as Alcoholics
learn techniques that promotes peace of mind and Anonymous, Weight Watchers or Overeaters
relaxation (relaxation techniques) Anonymous, and parenting and child abuse
support groups
TIME MANAGEMENT c.) Educational programs available such as time
● People who manage their time effectively usually management, assertiveness training, and
experience less stress because they feel more in meditation groups
control of their circumstances
● Controlling demands of others is also an important MEDIATING ANGER
aspect of effective time management because ● Often nurses find client’s anger difficult to handle
requests made by others cannot always be met due to two reasons:
1. Client seldom states “I feel angry or frustrated,”
DIFFERENT RELAXATION TECHNIQUES or indicate the reason for their anger. Instead they
● Breathing exercises may refuse treatment, become verbally abusive
● Massage or demanding, threaten violence, or become
● Progressive Relaxation overly critical. Their complaints rarely reflect the
● Imagery cause of their anger.
● Biofeedback 2. Anger from clients can elicit fear and anger in the
● Yoga nurse, who may respond in a manner that
● Meditation intensifies the client’s anger, even to the point of
● Therapeutic Touch violence. Nurses respond in a way that reduces
● Music Therapy their own tress rather than the client’s stress.
● Humor and Laughter ● Delaune (2013) recommends the following
strategies for dealing with client’s anger
MINIMIZING STRESS AND ANXIETY  Remember that there is a difference between
● Listen attentively; try to understand the client’s anger (a subjective feelings) and aggression (a
perspective on the situation harmful behavior)
● Provide an atmosphere of warmth and trust;  Approach each client with a calm, reassuring
convey a sense of caring and empathy manner. This will help the client feel less
● Determine if it is appropriate to encourage client’s threatened and more secure.
participation in the plan of care; give them choices  Involve clients in their own care as much as
about some aspects of care but do not overwhelm possible. This will increase their sense of
them with choices control, which helps decrease anger/
● Stay with the clients as needed to promote safety  When a client’s aggression is escalating, you
and feelings of security and to reduce fear must protect the safety of the client, other
● Control the environment to minimize additional clients, yourself, and the other staff
stressors such as reducing noise, limiting the  Call for help immediately if your interventions
number of individuals in the room, and providing have not de-escalate the client’s aggressive
care by the same nurse as much as possible behavior
● Implement suicide precautions if indicated
● Communicate in short, clear sentences CRISIS INTERVENTION
● Help clients to: CRISIS
a.) Determine situations that precipitate anxiety ● An acute, time-limited state of disequilibrium
and identify signs of anxiety resulting from situational, developmental, or
b.) Verbalize feelings, perceptions, and fears as societal sources of stress
appropriate. Some cultures discourage the ● A person in crisis temporarily unable to cope with
expression of feelings or adapt to the stressor by using previous methods
c.) Identify personal strengths of problem solving
COMMON CHARACTERISTICS OF CRISES ● Crisis Home Visits:
● Experienced as sudden  Made when telephone counseling does not
● Is often experienced as life threatening whether suffice or when the crisis worker need to obtain
this perception is realistic or not additional information by direct observation or
● Communication with significant others is often to reach a client who is unobtainable by
decreased or cut off telephone
● May have perceived or real displacement from  Appropriate when crisis workers need to initiate
familiar surroundings or loved ones contact rather than waiting for clients to come
i.e., caller is assessed as suicidal or when a
CRISIS INTERVENTION concerned person (neighbor, SO, doctor,
● Short-term helping process of assisting clients to: clergy member) informs the agency of clients
a.) Work through a crisis to it resolution with potential crisis
b.) Restore their precrisis level of functioning
 Also includes various members of the STRESS MANAGEMENT FOR NURSES
client’s support network ● Nurses, like clients, are susceptible to
 People who intervene come from the fields experiencing anxiety and stress.
of: Stressors of Nursing Practice:
 Nursing, medicine, psychology, social  Understaffing
work, theology  Increasing severity of client illnesses
 Police officers, teachers, guidance  Adjusting to various work shifts
counselors, and rescue workers, among  Being expected to assume responsibilities for
others, are often on the spot in moments of which one is not prepared for
crisis  Inadequate support from supervisors and peers
 Visiting homes that are depressing and caring
ASSESSMENT for dying clients, and so on
● Nurse or helper must focus on the person and the ● Nurses get overwhelmed and develop BURNOUT
problem  BURNOUT – complex syndrome of behaviors
● Collecting data about the client, client’s coping that can be likened to the exhaustion stage of
style, the precipitating event, situational supports, the general adaptation syndrome
client’s perception of the crisis and the client’s ● Nurses with burnout manifests physical and
ability to handle the problem emotional depletion, a negative attitude and self-
concept, and feelings of helplessness and
DIAGNOSIS hopelessness
● The client’s perception of the event and personal
response will determine nursing diagnoses HOW TO PREVENT BURNOUT:
● COMMON: ● Plan a daily relaxation program with meaningful
 Anxiety, Defensive Coping, Ineffective Coping, quiet time to reduce tension (e.g., read, listening to
Ineffective Denial, Post-Trauma Syndrome, music, soak in a tub or mediate)
Risk for Self-Directed Violence, Risk for Other ● Establish a regular exercise program to direct
Directed Violence, Rape-Trauma Syndrome, energy outward
Hopelessness ● Study assertiveness techniques to overcome
feelings of powerlessness in relationships with
PLANNING others. Learn to say NO
● Must be based on the careful assessment and ● Learn to accept failures – your own and others –
developed in active collaboration with the person and make it a constructive learning experience
in crisis and the significant people in that person’s ● Accept what cannot be changed
life ● Develop collegiate support groups to deal with
feelings and anxieties generated in the work
IMPLEMENTATION setting
● Crisis Counseling and Home Crisis Visits ● Participate in professional organizations to
● Crisis Counseling: address workplace issues
 Focuses on solving immediate problems and it ● Seek counseling if indicated to help clarify and
involves individuals, groups, or families cope with concerns
 Crisis intervention centers rely heavily on
telephone counseling by volunteers who have
professional consultation available to them
(aka hotlines)
 Goal: plan steps to provide immediately relief
and then long term follow-up if needed
Nursing Interventions to Promote Healthy ֍ Self-awareness
Psychosocial Responses  Relationship between one’s perception of
Self-Concept himself or herself and other’s perceptions of him
֍ One’s mental image of oneself and her
֍ An essential to a person’s mental and physical  A nurse who is very self-aware has perceptions
health that are very congruent
֍ Individual with a positive and strong self-concept  Requires time and energy and is never
are: complete
 Better able to develop and maintain  Introspection
interpersonal relationships and resist o Nurse reflecting on his/her own beliefs,
psychologic and physical illness attitudes, motivation, strengths and limitations
 Better able to accept of adapt to changes that  Also gains insight into the self through working
may occur over the life span with other nurses (mentors, had given
֍ How one views oneself affects one’s interaction feedback)
֍ Involves all self-perceptions (appearance, values
and beliefs) that influence behavior ֍ Once the nurse has developed a clear
֍ “I” and me” understanding and awareness of self, the nurse can
֍ Self-concept influences the ff: respect and avoid projecting his or her own beliefs
1) How one thinks, talks and acts onto others
2) How one sees and treats another person ֍ While in the caregiver role, the self-aware nurse is
3) Choices one makes able to suspend judgement and focus on the needs
4) Ability to give and receive love of the client, even if they differ from those of the
5) Ability to take action and to change things nurse
֍ When conflicts, arise, the nurse can analyze his or
֍ Four dimensions of self-concept her reactions through introspection and by asking
1) Self-knowledge: insight into one’s own these questions:
abilities, nature and limitation o “Why do I react this way (fear, anger, anxiety,
2) Self-expectation: what one expects of oneself; annoyance, worry)”
may be realistic or unrealistic o “Can I change the way I respond to this situation
3) Social self: how a person is perceived by to affect the client’s reaction in a helpful way?”
others and society
4) Social evaluation: appraisal of oneself in Formation of Self-concept
relationship to others, events or situations  A person is not born with a self-concept; rather
develops as a result of social interactions with
֍ “How I perceive me” vs “How others perceive others
me”  According to Erikson (1963)
 Me-centered: they try hard to live up to their o People face developmental tasks associated
own expectations and compete only with with eight psychosocial stages that provide a
themselves, not others theoretical framework
 Other-centered: high need for approval from  Stage 1 (Infancy 0-1 year): Trust vs. Mistrust.
others and try hard to live up to the  Stage 2 (Early Childhood 1-3 years):
expectations of others, comparing, competing Autonomy vs. Shame and Doubt.
and evaluating themselves in relation to others  Stage 3 (Play age 3-6 years): Initiative vs. Guilt.
 Stage 4 (School age 6-12 years):
֍ Positive Self-concept Industry vs. Inferiority.
 Me-centered and formed with limited  Stage 5 (Adolescence 12-19 years):
Identity vs. Confusion.
reference to other’s opinions
 Stage 6 (Early adulthood 20-25 years):
Intimacy vs. Isolation.
֍ Nurse’s own self-concept is important
 Stage 7 (Adulthood 26-64 years):
֍ Nurses who understand the different dimensions Generativity vs. Stagnation.
of themselves are better able to understand the  Stage 8 (Old age 65 years to death):
needs, desires, feelings and conflicts of their Integrity vs. Despair
clients o The success with which a person copes with
֍ Nurses who feel positive about themselves are these developmental tasks largely determines
more likely to help clients meet their needs the developmental tasks largely determines the
development of self-concept
o Difficulty coping can result in self-concept  how we should be or would prefer to be
problems at the time, and, often, later in life  may be realistic; may be not
֍ The development of one’s self-concept consists of  nurses, like other adults, view themselves based
three broad steps on both internal and external inputs acquired
1) The infant learns that the physical self is over many years
separate and different from the environment ֍ Influences on self-concept
2) The child internalizes other’s attitudes toward  Ability to appraise one’s own strength, the desire
self to follow in the steps of role models, and the
3) The child and adult internalize the standards of feedback received by colleagues and clients
society ֍ If perceived self is very close to ideal self
֍ Global self  Not wish to be more different
 Collective beliefs and images one holds about ֍ Difference between ideal self and perceived self
oneself  Incentive for self-improvement
 Most complete description that individual gives ֍ Discrepancy or great difference between perceived
himself self and ideal self
 Frame reference for experiencing and viewing  Too low self-esteem
the world
 Self as a whole, overall perception of self Components of self-concept
 Fact - 4 components (PBRS)
 Fat, short 1. Personal identity
 Non-tangible 2. Body image
 Strong, confident, shy 3. Role performance
֍ Core Self-concept 4. Self-esteem
 Beliefs and images that are most vital to a
person’s identity 1) PERSONAL IDENTITY
 Not equal of weight or importance  Conscious sense of individuality and
 Piece of art; center uniqueness that is continually evolving
֍ People base their self-concept on how they throughout life
perceive and evaluate themselves in these areas:  May view their identity in terms of
o Vocational performance  Tangible
o Intellectual functioning i. Name v. Ethnic origin or culture
o Personal appearance and physical ii. Gender vi. Occupation or roles
attractiveness iii. Age vii. Talents
o Sexual attractiveness and performance iv. Race viii. Other situational
o Being liked by others characteristics (marital
o Ability to cope with and resolve problems status and education)
o Independence  Intangible
o Particular talents o Beliefs and values
֍ Self-concept also extends to the choices that o Personality
people make and perceptions they have about their o Character
health  Distinguishes oneself to others
֍ Individuals with strong positive self-concept  Strong sense of identity, body image, good role
 likely value healthy behaviors and take action to performance and self-esteem that would
maintain health of their skin, hair and body tone complete self-concept
֍ With negative self-concept  Provides healing and continuity of the
 less proactive about health promotion and illness personality
prevention activities  How one person sees himself as a unique
֍ Maintaining and evaluating one’s self-concept is an person
ongoing process
2) BODY IMAGE
 Image of physical self; how a person
֍ Having basic self-concept perceives the size, appearance and
 Includes how we see ourselves and how we are functioning of the body and its parts
seen by others  Cognitive and affective aspects
֍ Ideal self o Cognitive: knowledge of material body
o Affective: sensations of the body (pain,  Role mastery: person’s behavior has met role
pleasure, fatigue and physical expectations
movement)  Standards or expectations of behavior of a role
 Sum of these attitudes, conscious and are set by society, a cultural group or a smaller
unconscious, that a person has towards his group to which a person belongs
or her body  Role development: involves socialization into a
 Clothing, makeup, hairstyle and jewelries particular role (e.g. nursing students)
 Intimately connected to the person  Role ambiguity: occurs when expectations are
 Body prosthesis unclear and people do not know what to do or
o Limbs how to do it and are unable to predict the
o Dentures reactions of others to their behavior
o Hairpiece (wigs)  Self-concept is affected by
 Devices for functioning i. Role strain: one is frustrated because they
o Eyeglasses feel or are made to feel inadequate or
o Canes unsuited for the role
o Wheelchairs  Women who have jobs of men
 Past and present perceptions and how body ii. Role conflicts: arise from incompatible
evolves overtime expectations
 A person’s body image develops from other’s  Due to different expectations
attitudes and responses to that person’s i) about a particular role (grandparents
body and partly from individual’s own on parenting)
exploration of the body ii) from different people or groups (work
o Infancy: parents smile and baby and marriage)
expresses during breastfeeding and iii) may violate the values and beliefs of
sulking role occupant (birth control)
 Cultural and societal values also influence a  cause
person’s body image 1) Tension
o Adolescence: highly conscious 2) Decrease of self-esteem
o Social media: unrealistic 3) Embarrassment to client
 If a person’s body image closely resembles 4) SELF-ESTEEM
one’s body ideal, the individual is more likely  One’s judgement of one’s own worth; how that
to think positively about the physical and person’s standards and performances compare to
nonphysical components of the self other’s standards and to one’s ideal self
 One must understand that different parts of  Types of self-esteem
the body has different values for different i. Global self-esteem: how much one likes
people oneself as a whole
 A person with a healthy body image will ii. Specific self-esteem: how much one
normally show concern for both health and approves of a certain part of oneself
appearance  GLOBAL SELF-ESTEEM IS INFLUENCED BY
 A person with an unhealthy body image is SPECIFIC SELF-ESTEEM
likely to be overly concerned about minor  Derived from self and others
illness and to neglect activities like sleep and o Infancy: self-esteem is related to evaluation
a healthy diet and acceptance of caregiver
 If with body image disturbance: may hid or o Later on, child’s self-esteem will be affected by
not look at or touch a body part that is competition (acceptance from others)
significantly changed in structure to illness or  As an adult, a person with high self-esteem has
trauma feeling of significance, of competence, of ability to
o Feel helpless cope with life and of control over one’s destiny
o Self-destructing behaviors  Foundation for self-esteem: established during
3) ROLE PERFORMANCE early life usually with the family
 Role: set of expectations about how the person  may change markedly from day to day and
occupying a particular position behaves moment to moment (severe stress from
 Role performance: how a person in a particular prolonged illness or unemployment)
role behaves in comparison to the behaviors
expected of that role
 in health care, individuals who believe that their 5) History of success and failure
condition is viewed negatively by society may  History of failures=see themselves as failures
have lower self-esteem  History of successes=more positive self-
 people frequently notice negative aspect concept (contented)
 important to identify strength and weaknesses 6) Illness
of client  People respond to stressors such as illnesses
and alteration in function related to aging in
variety of ways
 Common reactions
i. Acceptance
FACTORS THAT AFFECT SELF-CONCEPT ii. Denial
iii. Withdrawal
1) Stage of development iv. Depression
 As an individual develop, the conditions that affect
the self-concept change IDENTIFYING AREAS OF STRENGTH
2) Family and culture  When a client has difficulty identifying personality
 Child’s values are largely influenced by the family strengths and assets, the nurse provides the
and culture; peer influence later on client with a set of guidelines or framework for
 If confronted by differing expectations from family, identifying personality strengths
culture and peers; confused sense of self
3) Stressors
 Can strengthen self-concept as an individual cope
successfully with problems
 Overwhelming stressors can cause maladaptive
responses such as substance abuse, withdrawal
and anxiety
 Ability to handle stressors will largely depend on
personal resources

 Nurses can employ the following specific

strategies to reinforce strengths
o Stress positive thinking rather than self-
negation
o Notice and verbally reinforce client strengths
o Encourage the setting of attainable goals
o Acknowledge goals that have been attained
o Provide honest, positive feedback

4) Resources
 May be internal or external
 Internal: confidence, values
 External: support network, sufficient finances
and organizations
PROVIDING SELF-ESTEEM ENHANCING SELF-ESTEEM

֍ Children ֍ Key ingredients

 Can build strong self-esteem if they develop 5  Love
basic attitudes  Acceptance
1) Security and trust  Firmness
 Infants should learn that they can rely on their  Consistency
parents to meet their needs promptly and  Establishment of expectations
consistently
 Other children: strengthened when adults spend I. ADOLESCENTS
time with them (listening, playing, reading or just ۩ Provide increasing levels of responsibility; need
being there) to experience successes and failures and the
 Emotional and physical contact for children consequences of their own behavior
convey warmth and caring ۩ Encourage discussion about issues including a
2) Identity problems and mistakes
 Developed when children are allowed to explore ۩ Show appreciation for effort and contributions.
and experiment with the world around them and Emphasize the process and not the result
to express themselves as unique individuals in ۩ Ask for their opinion and suggestions
that world ۩ Encourage participation in decision making in
 Give them opportunities to practice who they are areas that affect the adolescent. Show
 Choose own outfit confidence in teen’s judgement
 Hairstyles and hair colors (crucial developmental ۩ Avoid comparison with or ridicule or punishment
stages) in front of others
3) Belonging  Lead to aggressiveness
 Essential for all humans ۩ Assist in the creation of realistic goals and
 Children: being included in activities; praised by standards
their efforts and achievements; being valued by ۩ Adolescents often engage in volunteer activities
parents, siblings, caregivers and other adults in their schools or communities, helping them to
 Parents: make an effort to catch their children identify their strengths and find meaning in their
doing well and praise them for it; valued for who activities
they are
II. ADULTS
4) Purpose
۩ Explore the meaning of self-esteem and how his or
 Children need opportunities to participate in the
her self-esteem has influenced past behaviors and
family and their community in order to discover
actions
what they can best contribute based on their
۩ It can also influence present and future plans and
strengths and skills
decisions
5) Personal competence
۩ Assist in assessing the internal and external forces
 Children develop competence as they confront
contributing to or retarding his or her self-esteem
and solve problems, face challenges, expand
۩ Act in ways that demonstrate belief that the person
their thinking and are asked to do more than they
can cope with realities and demands of life and is
think they can do
worthy of experiencing joy and happiness
 Must be provided with support guidance,
۩ Avoid comparisons with other people
appropriate assistance and constructive
۩ Discourage statements about the self that are
feedback (including praise) to prevent the child
negative
being overwhelmed
۩ Encourage the use of affirmations to enhance self-
 Helps children identify and refine their skill esteem like I like myself, I am valuable
 Develop competence and independence ۩ Encourage associations with positive, supportive
people
۩ Make positive statements about the person’s past
successes (major or minor)
۩ Assist the person to make a list of his or her
positive qualities and to review list often
۩ Suggest the person to do this for others
III. OLDER ADULTS  Loss of object external to oneself
۩ Encourage clients to participate in planning their Includes:
own care  Loss of inanimate objects that have
۩ Listen carefully to their concerns importance to a person
۩ Assist clients to identify and use their own  Loss of animate (live) objects
strength  Separation from accustomed environment
۩ Encourage them to participate in activities in  Separation from an environment and
which they can be successful people who provide security can cause a
sense of loss
۩ Communicate that the client is valued. Use the
 Loss of a loved one or valued person
client’s name and ask for advice
 Through illness, divorce, separation or
۩ Encourage older adults to stay connected with
death
their memories (reminiscing by writing or  In some illness such as Alzheimer’s
recording an autobiography or storytelling) dementia, a person may undergo
۩ Encourage creative activities to tap their personality changes that make friends
resources (music, art, storytelling, quilting or and family feel that they have lost that
knitting, photography) person
۩ For older adults who are in hospitals or nursing  Death = permanent and complete loss
homes, make sure that they are always shown BEREAVEMENT
respect and dignity and are provided privacy  Subjective response experienced by the surviving
۩ Work with clients to establish goals in small loved ones
steps that are achievable-this can bolster self- MOURNING
esteem  Behavioral process through which grief is
eventually resolved or altered
LOSS, GRIEF, AND DEATH  influenced by culture, spiritual beliefs, and custom
DEATH GRIEF
 loss both for the dying person and for those who  Total response to emotional experience related to
survive loss
 may be inevitable but can stimulate people to grow  Manifested in thoughts, feelings and behaviors
in their understanding of themselves and others associated with overwhelming distress or sorrow
LOSS  Types of Grief Response:
 actual or potential situation in which something  Abbreviated Grief
that is valued is changed or no longer available  Brief but genuinely felt
 Types:  Can occur if lost object is NOT significantly
 Actual loss – can be recognized by others important or may have been replaced
 Perceived Loss – experienced by one immediately by another equally esteemed
person but cannot be verified by others (e.g. object
psychological losses, not directly verifiable)  Anticipatory Grief
 Anticipatory Loss – experienced before the  Experienced in advance of the event
loss actually occurs  E.g. grieve before operation bec of scar
 Can be viewed as:  Disenfranchised Grief
 Situational – losing one’s job, death of a  When a person is unable to acknowledge
child, losing functional ability due to acute the loss of other people
illness or injury  Socially unacceptable loss
 Developmental – retirement of career,  E.g. suicide, abortion, homosexuality
departure of grown children from the home,  Unhealthy or Complicated Grief
death of aged parents  When strategies cope with the loss are
 Sources: maladaptive and out of proportion or
 Loss of an aspect of one’s self inconsistent with cultural, religious, or
(body part, physiological function or age-appropriate norms
psychological attribute)  Persistent Complex Bereavement
 Can change a person’s body image Disorder: if it exists for more than 6
seen though may not be obvious months and leads to reduced ability to
 E.g. Scarred face due to burns function formally
(obvious);  Different forms:
Loss part of the stomach or loss of  Unresolved/chronic grief
ability to feel emotion (not obvious) - Extended in length & sensitivity
 Inhibited grief
- Normal symptoms of grief are suppressed
 Delayed grief  Loss of appetite
- Occurs when the feelings are purposely  Difficulty concentrating
suppressed until a much later time
 Exaggerated grief FACTORS INFLUENCING THE LOSS AND GRIEF
- Use dangerous activities as a method to RESPONSES
lessen the pain of grieving 1. AGE
 Complicated grief after a death may be inferred  Childhood
from the following:  Losing a parent or other significant
 Failure to grief (e.g. avoids crying) person threatens the child’s ability to
 Avoids visiting the grave & refuses to develop, and regression sometimes
participate memorial services results
 Becomes recurrently symptomatic on  Early to Middle Adulthood
anniversary of loss or holidays  Loss becomes a part of normal
 Develops persistent guilt & lowered self- development
esteem  Late Adulthood
 Continues to search for lost person even after  Loss of health, mobility, independence,
a prolonged period; may also consider suicide and work role
to effect reunion 2. SIGNIFICANCE OF THE LOSS
 A relatively minor event triggers symptoms of  Factors affecting the significance of the loss:
grief  Importance of the lost person, object, or
 Unable to discuss the deceased with function
composure after a period of time  Degree of change required bec of the
 Experiences physical symptoms similar to loss
those of the person who died after normal  The person’s beliefs and values
period of grief 3. CULTURE
 Relationships with friends & relatives worsen  Some cultures believe that grief should be
following the death endured internally
 Factors that may contribute to unresolved grief  Some would expect you to show emotions
after a death: when mourning
 Ambivalence (intense feelings positive or  If a member of a nuclear family dies, there
negative) toward the lost person should be someone to replace his/her role
 A perceived need to be brave and in control 4. SPIRITUAL BELIEFS
 Endurance to multiple losses 5. GENDER
 Extremely high emotional value invested in the  Males are expected not to show their grief
dead person 6. SOCIOECONOMIC STATUS
 Uncertainty about the loss  The lost person is the breadwinner
 Lack of support systems 7. SUPPORTSYSTEM
 Close contacts of grieving individual will first
STAGES OF GRIEF (DABDA) by: Kubler-Ross recognize and provide support but will
1. DENIAL withdraw if refused
 Refuses to believe that loss is happening 8. CAUSE OF LOSS OR DEATH
 May assume artificial cheerfulness to prolong  Due to illness =
denial  Preventable Deaths = difficult to accept
2. ANGER e.g. Motor Vehicular Accidents, Honorable
 May direct anger at nurse or staff about Deaths
matters that normally would not bother
3. BARGAINING POSSIBLE NURSING DIAGNOSES
 Seeks to bargain to avoid loss  Grieving
(“It should have been me”)
 Complicated grieving (difficulty in coping)
4. DEPRESSION
 Risk for complicated grieving
 Grieves over what has happened and what
cannot be  Interrupted family processes
 Talks freely, reflect, or withdraw from support (affected family roles)
systems  Risk-prone health behavior (self-harm)
5. ACCEPTANCE - comes to terms with loss  Risk for loneliness
FACILITATING GRIEF WORK
MANIFESTATIONS OF GRIEF  Explore & respect ethnic, cultural, religious, &
 Verbalizations of loss personal values
 Crying  Teach what to expect in the grief process
 Sleep disturbance
 Encourage expressing and sharing with support  Isoelectric encephalogram for at least 30
people minutes in the absence of hypothermia &
 Teach family members to encourage expression poisoning CNS depressants
of grief
 Encourage the client to resume normal activities DEATH-RELATED RELIGIOUS & CULTURAL
on a schedule that promotes physical and PRACTICES
psychological health  Cultural and religious traditions and practices
associated with death, dying, and the grieving
PROVIDING EMOTIONAL SUPPORT process help people cope with these experiences
 Use silence and personal presence along with  Knowing these practices help nurses provide
techniques of therapeutic communication individualized care to the client and their families
 Acknowledge the grief  Some people prefer a peaceful death at home
 Offer choices that promote client autonomy rather than in the hospital
 Provide appropriate information regarding how to  Members of ethnic groups may request not to
access community resources reveal prognosis to dying clients (last days should
be free of worry)
 Suggest additional resources of information and
 Prefer that a family member (male) be told of the
help
diagnosis
DYING AND DEATH
 Beliefs and attitudes about death, its cause, and
RESPONSES TO DYING AND DEATH
the soul also vary among cultures
 Caregivers, both professionals and support
 Unnatural deaths or “bad deaths”, “good deaths”
persons, also respond to impeding death
 Death of a person who is well behaved in life is
 Risk for Caregiver Role Strain
less threatening based on the belief of
 Interrupted Family Processes
reincarnation
 Some will think of death as the worst occurrence  Beliefs about preparation of the body, autopsy,
in life and do their best to avoid thinking or talking organ donation, cremation, and prolonging life is
about death especially their own closely allied to the person’s religion
 Nurses who are uncomfortable with dying clients  Autopsy: prohibited, discouraged by Muslims,
tend to impede the client’s attempts to discuss Eastern Orthodox, religions, Jehovah’s Witness
dying and death in these ways and Orthodox Jews
 Change the subject  Some Hindus: oppose to autopsy based on not
 Offer false reassurance wanting non-Hindus touching the body
 Deny what is happening  Removal of body parts or indicate all body parts
 Be fatalistic (mangamatay ratang tanan) should be buried
 Block discussions and convey an attitude  Organ donation by Jehovah’s Witness and
that stops further discussion of the subject Muslims but Buddhists in America consider this
 Be aloof and distant or avoid the client as an act of mercy
 “Manage” the client’s care and make the  Hindus prefer cremation and cast the ashes in
client feel increasingly dependent and the holy river
powerless  Jewish opposes prolonging life after irreversible
brain damage
DEFINITIONS & SIGNS OF DEATH  In hopeless cases/illness, Buddhists may permit
 Heart-Lung death euthanasia
 Cessation of the apical pulse, respiration  Nurses also need to be knowledgeable about the
and blood pressure client’s death related rituals such as rites,
 World medical assembly guidelines chanting at the bedside, and other practices
 Total lack of response to external stimuli such as special procedures for washing, dressing,
 No muscular movement, esp breathing positioning shrouding, and attending the dead
 No reflexes HELPING CLIENTS DIE WITH DIGNITY
 Flat encephalogram  Treat with honor and respect
 In instances with of artificial support  Maintain their humanity, consistent with their
 Absence of brain waves for at least 24 hrs values, beliefs, and culture
is an indication of death  Help determine their physical, psychological and
 Cerebral death / higher brain death social priorities (self-fulfillment over self-
 Cerebral cortex is irreversibly destroyed preservation)
 Manifested by:  Discuss about death
 The absence of responsiveness to  Strategies to make discussion about death easier
external stimuli  Identify your personal feelings about death
 Absence of cephalic reflexes and how they may influence interactions
 Apnea with clients.
 Focus on the client’s needs. early identification and impeccable assessment
 Talk to the client or family members about and treatment of pain and other problems,
how the client usually copes with stress. physical, psychosocial and spiritual. (WHO)
 Establish a communication relationship
that shows concern for and commitment to MEETING THE PHYSIOLOGICAL NEEDS OF
the client. THE DYING CLIENT
- “You seem sad. Would you like to talk  Providing hygiene
about what’s happening to you?”  Controlling pain
- “I’d like to know better how you feel and  Relieving respiratory difficulties
how I may help you.”  Assisting with movement
- “It must be difficult to feel so  Nutrition
uncomfortable. I would like to help you be  Hydration
more comfortable.”  Elimination
- Provide a caring touch.  Providing measures related to sensory
 Determine what the client knows about the changes
illness and prognosis. PROVIDING SPIRITUAL SUPPORT
 Respond with honesty and directness to  Facilitating expressions of feeling
the client’s questions about death.  Prayer
 Make time to be available to the client to  Meditation
provide support, listen, and respond  Reading
 Discussion with appropriate clergy or
Hospice and Palliative Care spiritual adviser
HOSPICE
 focuses on support and care of the dying SUPPORTING THE FAMILY
person and family,  Therapeutic communication
PALLIATIVE CARE  Empathetic and caring presence
 an approach that improves the quality of life of  Encourage to participate physical care
clients and their families facing the problem  Encourage to view the body because
associated with life threatening illness, through this has shown to facilitate the grieving
the prevention and relief of suffering by means of Process
POST MORTEM CARE  Body position: supine, arms at sides with palms
RIGOR MORTIS down or across the abdomen
 stiffening of the body that  One pillow is placed under the head and
 occurs about 2 to 4 hours after death. shoulders
 starts in the involuntary muscles (heart, bladder)  Eyelids are closed and held in place to remain it
 progresses to the head, neck, and closed
trunk, and extremities  Dentures are inserted and mouth is closed
 leaves the body about 96 hours after death.  Soiled areas are washed; however complete
 Nursing responsibilities: bath is not necessary
 place the body in an anatomic position,  Absorbent pads are placed under the buttocks
 place dentures in the mouth  A clean gown is placed on the client
 close the eyes and mouth before rigor  Hair is brushed/combed
mortis sets in  Jewelry is removed, usually except the wedding
band, which is taped on the finger
ALGOR MORTIS  The top bed linen is adjusted neatly to cover the
 gradual decrease of the body’s temperature after client to the shoulders
death.  Soft lighting and chairs are provided for the
family
 blood circulation terminates and the hypothalamus
 After viewing, the deceased wrist identification
ceases to function
tag is left and additional identification tags are
 temperature falls about 1°C (1.8°F) per hour until it
applied
reaches room temperature.
 Body is wrapped in shroud, large piece of
 skin loses its elasticity and can easily be broken plastic or cotton material used to enclose the
when removing dressings and adhesive tape. body after death
 Additional identification tag is placed outside of
LIVOR MORTIS the shroud
 Discoloration of the tissues due to the release of  The body is then taken to the morgue
hemoglobin as a result of RBCs break down
 Appears in the lowermost or dependent areas of POST MORTEM
the body ֍ Post Mortem Care
 Caring for a deceased patient’s body with
sensitivity and in a manner that is constituent
with the patient’s religious or cultural beliefs
 PURPOSE
1) Preparing the patient for viewing by family
2) Ensuring proper identification of the patient
prior to transportation to the morgue or
funeral home
3) Providing appropriate disposition of
patient’s belongings
4) Maintaining vital organs, if donation is
planned
֍ Materials
 After death, tissues become soft and eventually
liquefy due to bacterial fermentation 1) Post mortem kit (shroud)
 The hotter the temperature, the more rapid the
change
 Embalming prevents the process through
injection of chemicals to destroy the bacteria
 Should be carried out according to the hospital 2) Gauze for tying the hands, feet and jaw (4x4
or agency policy gauze tied together)
 Check client’s religion and make every attempt
to comply
 If the family wants to view the client, make the
environment as clean as possible 3) Cotton balls
 Body should appear natural and comfortable 4) Clean gloves
 All equipment, soiled linen and supplies should
be removed from the bedside
 Tubes: will depend on the agency policy
5) Plaster (white)
6) 2” x 2” gauze (to cover eyes)

7) Identification tag (2 pieces) 11) Put the shroud under the patient’s body
12) After putting the shroud over the body without
covering the face
13) Position it like a diamond
1) Place body in anatomical position 14) Locate upper and lower edges
2) Remove all life-giving tubes 15) Fold it into half
a. Oxygen masks
b. IV

16) Fanfold

17) Make sure the edge of shroud points towards the

patient
3) Pull down blanket

18) Place the fanfolded shroud under the patient’s

body. Make sure there is enough to cover the
4) Lay shroud over patient w/o covering the face
head and feet
5) Open the shroud and position it like a diamond

19) Turn patient to the side, always ask permission

6) Locate the upper and lower edges of the shroud
from the patient before repositioning

7) Fold it into half 20) Straighten the unfanfolded side of the shroud

8) Make sure the edges of the shroud meet

21) Do not forget to raise the side rails up when

9) Get the other half of the shroud positioning the patient

10) Do the fanfolding like accordion plates 22) Side rails down and turn the patient to right side.
Ask permission
23) Open the fanfolded side and straighten shroud

36) Get cottonballs and carefully place in nostrils

24) Place patient back to anatomical side 37) Also the ears

38) Take out the last tie and close the jaw. Tie it
25) Get the gauze to tie hands and feet shut. Not too tight and not too loose. We don’t
26) Under patient’s ankle. Tie it however you want want to see a body with it’s mouth open in the
but not too tight coffin.

27) Hands 39) Cover head and face with shroud and tape
shroud where necessary. Tie it securely without
bulging and openings.

28) Get the morgue tag or identification tag and tie it

on the wrist. Make sure it is properly filled up
before putting it around the wrist

40) Put the last identification tag or morgue tag on

body
29) Cover patient’s body with the shroud and secure
it with plaster

41) After postpartum care, complete the death

certificate and secure the family’s consent if an
30) Cover patient in this manner autopsy is to be done
42) Do after care

31) Secure shroud and no holes

32) Leave head uncovered. You can call family for

final viewing of patient

33) After viewing, continue with remaining parts of

the post mortem process
34) Get 2x2 gauze
35) Fold one gauze to half and place over eyes.
Securing with palster. Close eyes before placing
gauze
REST AND SLEEP ● Reticular formation, where the collection of
REST stimulus happens, bind by the RAS and sending it to
● Is a condition in which the body is in a the Cerebral Cortex
decreased state of activity without physical
emotional stress and freedom from anxiety
SLEEP
● Is a state of rest accompanied by altered level
of consciousness and relative inactivity, and
perception to environment are decreased
● Basic human need
● Universal biological process common to all
people
● Enhances daytime functioning
● Vital not only for optimal psychological
functioning but also physiological functioning as
the rate of healing damaged muscles and
tissues is greater during sleep
● Humans spend 1/3 of their lives sleeping
● Reasons why we require sleep:
1. To cope with daily stresses
2. To prevent fatigue
3. To conserve energy
● RAS determines the level of alertness
4. To restore the mind and body
● Network in brain stem
5. To enjoy life more fully
● Arousal, sleep, pain, and muscle tone
PHYSIOLOGY OF SLEEP
● Ascending fiber sends signals upward
● Sleep was considered the state of
● Arouses and activates cerebral cortex
unconsciousness, historically
● Controls overall degree of cortical alertness or
● Recently, sleep is not considered an altered
level of consciousness:
state of consciousness in which the individual’s
○ Maximum alertness
perception of and reaction to the environment
○ Wakefulness
are decreased
○ Sleep
● Sleep is characterized by:
○ Coma
○ Minimal physical activity
● The RAS filters and prioritizes sensory
○ Variable levels of consciousness
information to let the mind be focused and alert
○ Changes in the body’s physiologic
processes RETICULAR ACTIVATING SYSTEM
○ Decreased responsiveness to external
stimuli Sleep-wake Provides an inhibitory
● An individual’s response to meaningful stimuli Transition influence (from external
while sleeping selectively disregard non- stimuli) - by reducing
meaningful stimuli afferent (sensory
● Example: neurons) activity during
○ A mother may respond to her own baby’s sleep
cry but not to another baby’s cry
○ A person wakes up to a smoke detector Neurons in the RAS have
alarm while sleeping a higher firing rate during
● Parts of the Brain mostly responsible of wakefulness
sleep are:
1. RAS - Reticular Activating System Medical Anesthetics - affect
2. Cerebral Cortex Procedures consciousness by turning
3. Pineal Gland off the RAS
RETICULAR ACTIVATING SYSTEM
Melatonin affects the RAS

Damage could Coma

result in Sleep disorders such as
narcolepsy, Chronic
fatigue, Attention deficit
disorder
CEREBRAL CORTEX PINEAL GLAND
● Cortex Cerebri ● “Seat of the Soul” by Renee Descartes
● Is the outer layer of our brain that has a ● Located in the center of the brain
wrinkled appearance ● Main function of the pineal gland is to receive
● It is divided into fields with specific functions information about the state of the light-dark
such as sight, hearing, smell, and cycle from the environment and convey this
sensation, and controls higher functions information to produce and secrete the
such as speech, thinking, and memory hormone “melatonin”
● Is responsible for many higher-order brain
functions such as sensation, perception, POS: SLEEP AND EXPOSURE TO DARKNESS
memory, association, thought, and voluntary ● Darkness and preparing for sleep causes a
physical action decrease in stimulation of the RAS
● The cerebrum is the large, main part of the ● During this time, Pineal Gland actively secretes
brain and serves as the thought and control “melatonin” and the person feels less alert
center ● During sleep → Secretes growth hormone →
inhibits cortisol

CORTISOL
● Nature’s built-in alarm system
● Body’s main stress hormone
● Works with certain parts of brain to control
mood, motivation, and fear
● Your adrenal glands (triangle shaped organs
at the top of your kidneys make cortisol
● It’s best known for helping fuel your body’s
“fight-or-flight” instinct in a crisis, but cortisol
plays an important role in a number of things in
your body
PHYSIOLOGY OF SLEEP ● Example:
THE RETICULAR ACTIVATING SYSTEM (RAS) 1. Manages how your body uses
● RAS may be best known for its role in carbohydrates, fats, and proteins
promoting arousal and consciousness 2. Keeps inflammation down
● RAS contains circuits that originate in several 3. Regulates your blood pressure
areas of the brainstem, including the 4. Increases your blood sugar (glucose)
midbrain reticular formation, and ascend to 5. Controls your sleep/ wake cycle
the cerebral cortex and thalamus 6. Boosts energy so you can handle stress
● The cyclic nature of sleep is controlled by and restores balance afterward
centers at the brain’s lower part ● In the beginning of daylight, melatonin is at its
● Neurons within the reticular formation lowest body level → cortisol (stimulating
(located in the brain stem) → Integrate hormone) at its highest
sensory info from the peripheral nervous ● Wakefulness associated with high levels of:
system (PNS) → Relay the info → Cerebral a. Acetylcholine - released in the reticular
cortex formation
● Upper part of the Reticular Formation b. Dopamine - released in the midbrain
consists of a network of ascending nerve c. Noradrenaline - released in the pons
fibers, RAS ● Neurotransmitters are localized within the
○ Involve in the “Sleep-Wake Cycle” reticular formation and influence cerebral
○ An intact Cerebral Cortex and cortical arousal
Reticular Formation are necessary for
the regulation of sleep and waking CIRCADIAN RHYTHMS
states ● Biological Rhythms exist in plants, animals and
● Neurotransmitters, located within brain humans
neurons, affect the Sleep-Wake Cycles ● In humans, these are controlled from within the
● Example: body and synchronized with environmental
○ Serotonin - lessens the response to factors: Light and Darkness
sensory stimulation ● Circadian is from the Latin word “circa dies”,
○ Gamma-aminobutyric Acid (GABA) meaning, “about a day”
- shut off the neuron’s activity in the
RAS
● Sleep and Waking Cycle is best known for 3. Body is getting ready for deep sleep
circadian rhythms, including: 4. Breathing and HR become more regular
○ Body temperature
○ BP NREM STAGE 3
○ Other physiologic functions also follow ● “Delta” Sleep
circadian pattern ● During stage 3 sleep:
● Sleep is a complex biological rhythm 1. Muscles relax
● When a person’s biological clock coincides with 2. BP and RR drop
the sleep-wake cycles, the person is said to be 3. Deepest sleep occurs. This is the deep
in circadian synchronization; that is, the person sleep stage. It is harder to rouse you during
is awake when the body temperature is highest, this stage, and if someone woke you up, you
and asleep when the body temperature is at its would feel disoriented for a few minutes
lowest ● During the deep stages of NREM sleep, the body
● Layman’s Term: Body Clock repairs and regrows tissues, builds bone and
● Circadian regularly begins to develop by the 6th muscle, and strengthens the immune system
week of life, and by 3-6 months most infants ● As you get older, you sleep more lightly and get
have regular sleep-wake cycle less deep sleep. Aging is also linked to shorter
time spans of sleep, although studies show you
TYPES OF SLEEP still need as much sleep as when you were
● Sleep Architecture refers to the basic younger
organization of normal sleep ● Body starts to heal or repair
● 2 Types of Sleep: ● Older studies suggested that bed-wetting was
1. NREM (Non-Rapid Eye Movement) - also most likely to occur during this stage of sleep,
known as quiet sleep but some more recent evidence suggests that
2. REM (Rapid Eye Movement) - also known such bed-wetting can also occur at other stages
as active sleep or paradoxical sleep ● Sleepwalking also tends to occur most often
● During sleep, NREM and REM sleep alternate during the deep sleep of this stage
in cycles
STAGE 4: REM (RAPID EYE MOVEMENT) SLEEP
NREM (NON-RAPID EYE MOVEMENT) SLEEP ● Usually, REM sleep happens 90 minutes after
● Occurs when activity in the RAS is inhibited you fall asleep
● About 75% - 80% sleep during the night is ● The first period of REM typically lasts 10 minutes
NREM sleep ● Each of your later REM stages gets longer, and
● Each stage can last from 5 to 15 minutes the final one may last up to an hour. Your heart
● You go through all 3 phases before reaching rate and breathing quickens
REM sleep ● You can have intense dreams during REM
sleep, since your brain is more active
NREM STAGE 1 ● REM is important because it stimulates the
● Beginning of the sleep cycle areas of the brain that help with learning and is
● Relatively light stage of sleep associated with increased production of proteins
● Transition period between wakefulness and ● Babies can spend up to 50% of their sleep in the
sleep REM stage, compared to only about 20% for
● Your eyes are closed, but it’s easy to wake you adults
up ● During REM sleep:
● May last for 5 - 10 minutes 1. The brain becomes more active
● In stage 1, the brain produces high amplitude 2. The body becomes relaxed and immobilized
Theta waves, which are very slow brain waves 3. Dreams occur
● This period of sleep lasts only a brief time 4. Eyes move rapidly
(around 5 to 10 minutes) ● More dreaming occurs during the fourth stage of
● If you awaken someone during this stage, they sleep, known as rapid eye movement (REM)
might report that they were not really asleep sleep
● REM sleep is characterized by eye movement,
NREM STAGE 2 increased respiration rate, and increased brain
● Lasts for approximately 10 - 25 minutes activity.
● You are in light sleep ● The American Sleep Foundation suggests that
● During Stage 2 sleep: people spend approximately 20% of their total
1. You become less aware of your sleep in this stage
surroundings ● REM sleep is also referred to as paradoxical
2. HR slows, body temperature drops sleep because while the brain and other body
systems become more active, muscles become Adolescents ✓ 9-10 hours of sleep
more relaxed (12 to 18 ✓ Sleepy at times on places where
● Dreaming occurs due to increased brain activity, years old) they should be fully awake (school,
but voluntary muscles become immobilized home, on the road)
FUNCTIONS OF SLEEP
✓ May result: lower grades, negative
1. Exerts physiologic effects on both the nervous moods (unhappy, sad, tense),
system and other body structures increase potential to car accidents
2. Restores normal levels of activity and normal ✓ Circadian rhythm began to shift
balance among parts of the nervous system which is a natural tendency for
3. Necessary for protein synthesis which allows teenagers to stay up late at night,
repair processes to occur wake up late in the morning
4. Psychological well-being best noticed by the ✓ Many school starts at 7AM,
deterioration in mental functioning related to conflicts with their sleep pattern and
sleep loss needs, contributes to their sleep
5. Persons with inadequate amounts of sleep tend deprivation
to become emotionally irritable, have poor ✓ Nocturnal Emissions (boys)
concentration, and experience difficulty making ● Orgasm and emission of
decisions semen during sleep; “wet
dreams”
NORMAL SLEEP PATTERNS ✓ Inform boys about this normal
development to prevent
Age Group Requirements embarrassment and fear
Newborns ✓ 16-18 hours/day Adults ✓ 7-9 hours of sleep
✓ 1-3 hours spent awake on irregular ✓ Signs of not getting enough sleep:
schedule ● Falling asleep/ drowsy
✓ Enter REM immediately during a task
● Not being able to
Infants ✓ Awakens every 3 or 4 hours at first concentrate/ remember info
✓ By 6 months, sleep most by the ● Being unreasonably irritable
night (from midnight to 5 AM) with others
✓ 14-15 hours/ 24 hours ✓ Ladies, pregnant women, and
✓ Self-Smoothers mothers tend to get less sleep due to
● Can put themselves back to responsibilities, menses, child-
sleep independently if they rearing
wake up at night
✓ Signalers
Elders (67-75 ✓ Early bedtimes and wake times;
years old) one hour early to bed; wakes up 3.5
● Cry for parent’s help to
return to sleep hours earlier in the morning than
their usual
Toddlers ✓ 12-14 hours sleep (for 1-3 years ✓ Better health of older adults (likely
old) to sleep well)
✓ Needs morning and afternoon ✓ May have major health conditions
naps complicating their sleep patterns
✓ Security Object ✓ Clients with Dementia /
● Blanket, stuffed toy “Sundown Syndrome”
● Pattern of symptoms that
Preschoolers ✓ Requires 11-13 hours of sleep/ occur during late afternoon
(3 to 5 years lasting through the night
night
(agitation, anxiety,
old) ✓ Maintain regular and consistent aggression, delusion
sleep pattern sometimes) further disrupting
✓ Limit/ eliminate TV exposure prior sleep
to sleeping time (prevent dark, night
terrors, and nightmares)

School-Age ✓ 10-11 hours of sleep

Children (5 to ✓ Most receive less sleep because
12 years old) of increasing demands (homework,
sports, social activities), drinking
caffeinated drinks
FACTORS AFFECTING SLEEP ● Drugs that disrupt sleep (these drugs may
● Both quality and quantity of sleep are disrupt REM sleep, delay onset, decrease
affected by a number of factors sleeping time)
● Sleep Quality - subjective characteristics 1) alcohol
and is often determined by whether a person 2) amphetamines
wakes up feeling energetic or not 3) antidepressants
● Quantity of Sleep - total time the person 4) beta-blockers
sleeps 5) bronchodilators
6) caffeine
1. Illness 7) decongestants
● Arthritis, back pain, physical distress 8) narcotics
2. Environment 9) steroids
● Noise, lack of ventilation, too hot, too cold, COMMON SLEEP DISORDERS
comfort and size of bed - nurses can assess the sleep complaints of
3. Lifestyle clients, when appropriate, make a referral to
● Night-shift workers, ability to relax a specialist in sleep disorders medicine
4. Emotional Stress - clinicians focus more one the client’s
● Stress, sleeping difficulties, personal symptoms (excessive sleepiness, insomnia,
problems, job-related issues, family/ abnormal events) occurring during sleep
marriage problems (parasomnias)
5. Stimulants and Alcohol 1) INSOMNIA
● Caffeine-containing beverages act as ● described as the inability to fall asleep or
stimulants of the CNS, may interfere sleep remain asleep
● People often experience nightmares after the ● persons with insomnia awaken, not feeling
effects of alcohol has worn off rested
● The alcohol-tolerant person may be unable ● most common sleep complaint
to sleep well and become irritable as a result a) acute insomnia: last one to several nights
6. Diet often caused by personal stressor and/or
● Weight gain is associated with worry
○ reduced total sleep time b) chronic insomnia: insomnia persisting
○ broken sleep more than a month
○ early awakening c) chronic-intermittent insomnia: difficulty
● dietary L-tryptophan mostly found in cheese sleeping for a few nights, followed by a
and milk may induce sleep few nights of adequate sleep before the
● warm milk helps people get to sleep problem returns
7. Smoking ● clinical manifestations of insomnia
● nicotine are stimulants: difficulty falling ○ difficulty falling asleep
asleep, aroused easily -> light-sleepers ○ waking up frequently during the night
● refrain from smoking during dinner and ○ difficulty returning to sleep
onwards to have good sleep (for smokers) ○ waking up too early in the morning
8. Motivation ○ unrefreshing sleep
● can increase alertness in some situations ○ daytime sleepiness
● example: a tired person can probably stay ○ difficulty concentrating
awake all night and alert while attending an ○ irritability
interesting concert; surfing the web late at ● 2 MAIN RISK FACTORS OF INSOMNIA
night; watching your favorite movies 1) Age: increase = thought to be caused by
● insufficient sleep plus (+) boredom = sleep some medical conditions
may occur 2) Gender: Female = suffer sleep loss in
9. Medications connection with hormonal changes
● some medicines affect the quality of sleep: e.g. menstruation, pregnancy and
a) Hypnotics: interferes deep sleep and menopause
suppress REM sleep ● Treatment for Insomnia
b) Beta-blocker: insomnia and nightmares ○ frequently requires the client to develop
c) Narcotics: suppress REM sleep, frequent new behavior patterns that induce and
awakening and drowsiness (Meperidine maintain sleep
HCL (Demerol), Morphine) ■ stimulus control = creating a sleep
d) Tranquilizers: interferes w/ REM environment that promotes a sleep
e) Anti-depressants: interferes REM but as ■ cognitive therapy = learning to
“therapeutic action” > mood improvement develop positive thoughts and beliefs
about sleep
■ sleep restriction = following a - prolonged sleep apnea can cause a sharp rise
program that limits time in bed in in blood pressure and may lead to cardiac
order to get to sleep and stay asleep arrest
throughout the night - overtime, apneic episodes can cause
2) EXCESSIVE DAYTIME SLEEPINESS a) Cardiac arrhythmias
● clients may experience excessive daytime b) Hypertension
sleepiness as a result of c) Subsequent left-sided heart failure
1) Hypersomnia - treatments for obstructive sleep apnea are
- conditions where the affected individual available. one treatment involves using a
obtains sufficient sleep at night but still device that uses positive pressure to keep
cannot stay awake during the day your airway open while you sleep. Another
- caused by medical conditions option is a mouthpiece to thrust your lower
- CNS damage jaw forward during sleep. In some cases,
- Kidney and liver disorders surgery may be an option too.
- Metabolic disorders (diabetic - what triggers sleep apnea
acidosis, hyperthyroidism) - In adults, the most common cause of
- rarely on psychological origin obstructive sleep apnea is excess weight
2) Narcolepsy and obesity which is associated with soft
- caused by lack of chemical tissue of the mouth and throat.
“HYPOCRETIN” in the CNS that regulates - during sleep, when throat and tongue
sleep muscles are more relaxed, this soft tissue
- clients with narcolepsy have sleep attacks can cause the airway to become blocked
or excessive daytime sleepiness; their
night sleep usually begins with a sleep
onset REM period (dreaming sleep occurs
within the first 15 minutes of falling asleep)
- Onset: may start 15 to 30 years old
- a chronic sleep disorder characterized by
overwhelming daytime drowsiness and
sudden attacks of sleep. people with
narcolepsy often find it difficult to stay
awake for long periods of time, regardless
of the circumstances. Narcolepsy can - normal breathing during sleep: tongue,
cause serious disruptions in your daily soft palate, uvula
routine - obstructive sleep apnea: blocked airway
- 5 Main Symptoms of Narcolepsy (referred
to by the acronym CHESS)
a) cataplexy
b) hallucinations
c) excessive daytime sleepiness
d) sleep paralysis
e) sleep disruption
- while all patients with narcolepsy
experience excessive daytime
sleepiness, they may not
experience all 5 symptoms
3) Sleep Apnea
- Obstructive sleep apnea is a potentially serious - snoring: partial obstruction of the airway
sleep disorder. It causes breathing to - OSA: complete obstruction of the airway
repeatedly stop and start during sleep - 3 COMMON TYPES OF SLEEP APNEA
- There are several types of sleep apnea, but a) Obstructive apnea
the most common is obstructive sleep apnea. - occurs when the structures of the pharynx or
This type of apnea occurs when your throat oral cavity block the flow of air. The person
muscles intermittently relax and block your continues to try to breathe: that is chest and
airway during sleep. A noticeable sign of abdominal muscle move
obstructive sleep apnea is snoring - movements of the diaphragm becomes
- sleep apnea profoundly affects the person’s stronger and stronger until the obstruction is
work or school performance removed
- predisposing apnea
- enlarged tonsils and adenoids
- deviated nasal septum
- nasal polyps - IDEAL: children 3 to 5 years of age should sleep
- obesity 10 to 13 hours/ 24 hours (including naps) on a
- an episode usually begins with snoring regular basis to promote optimal health
- thereafter, breathing ceases - children 6 to 12 years of age should sleep 9 to
- followed by marked snorting as breathing 12 hours/ 24 hours on a regular basis to promote
ceases optimal health
- followed by marked snorting as breathing - children 6 to 12 years of age should sleep 9 to
resumes 12 hours/ 24 hours on a regular basis to promote
- towards the end of each apneic episode, optimal health
increased carbon dioxide levels in the blood - although effects of obtaining less than optimal
cause the client to wake up amount of recommended sleeping hours are
b) Central apnea generally considered benign, there is a growing
- thought to involve a defect in the respiratory evidence that insufficient sleep can have
center of the brain significant delirious effects
- all actions involved in breathing, such as - staying awake 19 consecutive hours produces
chest movement and airflow, stops the SAME impairments in reaction times and
- common to client’s with cognitive function as a blood alcohol level of
=> brain stem injuries 0.05.
=> muscular dystrophy - staying awake for 24 consecutive hours
c) Mixed Apnea produces the SAME effects on reaction times
- combination of obstructive and central apnea and cognitive function as being legally drunk with
blood alcohol concentration of 0.1
- TREATMENT OF SLEEP APNEA BAC (% by mg/dL Behavior Impairment
a) no available treatment volume)
b) directed towards the main cause
- enlarged tonsils will be removed 0.001-0.029 1-29 may appear subtle effects
c) other surgical procedures normal detected with
- laser removal of excess tissue in the special tests
pharynx, reduce or eliminate snoring
and may be effective in relieving the
0.030-0.059 30-59 decreased decreased
apnea
social attentional
d) use of Nasal Continuous Positive Airway inhibition; control
Pressure (CPAP) especially at night time joyousness;
is effective in maintaining open airways mild euphoria;
e) weight loss may also help decrease the relaxation;
severity symptoms increased
verbosity
4) Insufficient Sleep
- healthy individuals who obtain less sleep
than they need will experience sleepiness 0.060-0.099 60-99 alcohol flush depth
reaction; perception;
and fatigue during the daytime hours
reduced affect glare
- depending on the severity and chronicity of this display; recovery;
voluntary, unintentional sleep deprivation, disinhibition; peripheral
individuals may develop: euphoria; vision;
a) attention and concentration deficits extraversion; reasoning
b) reduced vigilance increased pain
c) distractibility tolerance
d) reduced motivation
e) fatigue
0.100-0.199 100- analgesia; gross motor
f) malaise
199 ataxia; skill; motor
g) occasionally diplopia boisterousnes planning;
h) dry mouth s; over- reflexxes;
- cause of these symptoms may or may not be expressed slurred
attributed to insufficient sleep emotions; speech;
- it is believed that 6.8 hours sleep on the possibility of staggering;
weekdays and 7.4 hours on weekends nausea and temporary
- even 4 to 5 year old children now average less vomiting; spins erectile
than 9.5 hours of sleep, approximately 1.5 to 2.5 dysfunction
hours less than recommended.
0.200-0.299 200- anger or amnesia
- clenching and grinding of the teeth can
299 sadness; (memory eventually erode the dental crowns, cause teeth
anterograde blackout); to come loose, and lead to deterioration of the
amnesia; unconsciousn temporomandibular joint and TMJ syndrome
impaired ess; severe - usually occurring during Stage 2d NREM sleep
sensations; physical - clenching grinding of the teeth can eventually
inhibited disabilities erode the dental crowns, cause teeth to come
sexual desire loose and lead to to deterioration of the
(ISD); mood temporomandibular joint and TMJ syndrome
swings;
ENURESIS
nausea; partial
loss of - bed-wetting during sleep can occur in children
understanding; over 3 years old
possibility of - more males than females are affected
stupor; - occurs 1-2 hours after falling asleep, when
vomiting rousing from NREM stages 3 and 4
PLMs DISORDER (PERIODIC LIMP
0.300-0.399 300- central dysequilibriu MOVEMENTS)
399 nervous m; breathing; - legs jerk 2x or 3x per minute during sleep
system resting heart - most common among elders
depression; rate; urinary
- kicking motion can wake the client and result in
lapses in and incontinence
out of poor sleep
consciousness - may be treated with medications (used for
; loss of Parkinson’s Disease)
understanding; - PLMs differ from Restless Leg Syndrome (RLS),
low possibility which occurs when the person is at rest, not just
of death; at night when sleeping
pulmonary - RLS may occur during pregnancy, or be due to
aspiration; other medical problems that can be treated
stupor SLEEP TALKING
0.400-0.500 400- coma; respiratory
- talking during sleep occurs during NREM sleep
500 possibility of failure; heart before REM sleep
death; severe rate; - rarely presents a problem to the person unless it
central positional becomes troublesome to other
nervous alcohol SOMNAMBULISM
system nystagmus - sleepwalking
depression - occurs during NREM Sleep’s Stages 3 and 4
- episodic usually occurs 1-2 hours after falling
>0.50 >500 high possibility asleep
of death
- sleepwalkers tend not to notice dangers
(stairs), and often need to be protected from
- nurses who report reduced hours of sleep are injury
more likely to SLEEP HYGIENE
a) make an error - term referring to interventions used to
b) have difficulty staying awake on duty promote sleep
c) have difficulty staying awake while driving - nursing interventions to enhance the quantity
home from work, than those who obtained and quality of client’s sleep involve largely
more sleep non-pharmacologic measures
PARASOMNIAS - involve health teachings about
- behavior that may interfere with sleep and may a) health habits
even occur during sleep b) support of bedtime rituals
- the international classification of sleep disorders c) the provision of a restful environment
(American Sleep Disorders Association, 2005) d) specific measures to promote comfort
1) Arousal Disorder; Sleep Walking; Sleep and relaxation and
Terror e) appropriate use of hypnotic
2) Sleep-Wake Transition Disorders Sleep medications
Talking - for hospitalized clients, sleep problems are
3) Parasomnias associated with REM Sleep often related to hospital environment and
Nightmares; Bruxism their illness
- usually occurring during Stage 2 NREM Sleep Challenges include
a) assisting client to sleep
b) scheduling activities c) Diet
c) administering analgesics - avoid alcohol and caffeine-containing foods
d) provide a supportive environment and beverages (coffee, tea, chocolate) at
- for fearful and anxious clients, nurses need least 4 hours before bedtime
to provide explanations and build a - caffeine can interfere with sleep
supportive relationship - both caffeine and alcohol act as diuretics,
creating the need to void during sleep time
CLIENT TEACHING ON PROMOTING SLEEP - if a bedtime snack is necessary, consume
a) sleep pattern only light carbohydrates or a milk drink.
- establish a regular bedtime and wake-up heavy or spicy food can cause
time for all days of the week to enhance your gastrointestinal upsets that disturb sleep
biological/circadian rhythm (if you have
difficulty sleeping or staying asleep) d) Medications
- a short daytime nap (15-30 mins), esp - use sleeping medications only as a last
elders, can be restorative and not interfere resort. use over-the-counter medications that
with nighttime sleep cause daytime drowsiness
- younger person with insomnia should not - take analgesics before bedtime to relieve
take naps aches and pains
- establish a regular, relaxing bedtime routine - consult with you healthcare provider about
before sleep such as: adjusting other medications that may cause
- reading insomnia
- listening to soft music
- taking warm bath, or
- doing some other quiet activity you
enjoy
- avoid dealing with office work or family
problems before bedtime
- get adequate exercise during the day to
reduce stress, but avoid excessive physical
exertion at least 3 hours before bedtime
- use the bed for sleep activity, so that you
associate it with sleep
- take work material, computers, and TVs out
of the bedroom
- lying awake, tossing and turning will
strengthen the association between
wakefulness and lying in bed (many people
with insomnia report falling asleep in a chair
or in front of the TV but having trouble falling
asleep in bed)
- Make sure that bed is free from working
materials
- when you are unable to sleep, get out of bed,
go into another room and pursue some
relaxing activity until you feel drowsy
b) Environment
- create a sleep-conducive environment that is
dark, quiet, comfortable and cool
- keep noise to a minimum, block out
extraneous noise as necessary with white
noise from a fan, air conditioner or white
noise machine
- music is not recommended as studies shown
that music will promote wakefulness (it is
interesting and people will pay attention to it)
SENSORY FUNCTIONING → Auditory impulses travel along the 8th cranial
Components of Sensory Experience nerve to the brain’s temporal lobe
→ An individual's senses are essential for growth, → Cranial nerve VIII
development and survival o Vestibulocochlear nerve
→ Sensory stimuli give meaning to events in our o Referred to as “auditory vestibular nerve”
environment o Known as the 8th cranial nerve
→ Any alteration in people’s sensory functions can o Transmits sound and equilibrium (balance)
affect our ability to function within an environment informationfrom the inner ear to the brain
o Many clients have impaired sensory functions o Brings sound and information about one’s
that puts them at risk in healthcare settings position and movement in space into the
o Nurses can help them find place to function brain
safely in this environment o Auditory and vestibular systems subserve
several functions basic to clinical medicine
1) Sensory Reception and to psychiatry
→ Process of receiving stimuli or data 4. Perception
→ Stimulus or stimuli are either internal or → Awareness and interpretation stimuli
external to the body → Takes place in the brain
a. External stimuli → Specialized brain cells interpret the nature and
▪ Visual (sight) quality of sensorystimuli
▪ Auditory (hearing) → Level of consciousness affects the perception
▪ Olfactory (smell) of the stimuli
▪ Tactile (touch)
▪ Gustatory (taste): can be internal ֍ Arousal mechanism
b. Internal stimuli → Brain must be alert to be able to receive and
i. Kinesthetic interpret data
→ Refers to awareness to position and → RAS (resticular activating system)
movement of body parts o Thought to mediate the arousal mechanism
→ a person walking is aware of which foot is o Responsible for wakefulness or being active
forward → 2 components of RAS
→ Stereognosis: ability to perceive and 1) REA (reticular excitatory area)
understand an object through touch by its → Responsible for stimulus arousal and
size, shape and texture wakefulness
o a person holding a tennis ball is aware 2) RIA (reticular inhibitory area)
of its size, round shape, soft surface → Sensoristasis
without seeing it o Describe when a person is in optimal arousal
ii. Visceral o Beyond this comfort zone, people must adapt
→ Refers to any large organ within the body to the increased/decreased sensory stimuli
→ May produce stimuli that make a person → Brain has the capacity to adapt to sensory
aware of them (full stomach) stimuli
2) Sensory Perception o Person living in the city may not notice traffic
→ Involves the conscious organization and noise that someone from the rural area finds
translation of the data or stimuli into loud and disturbing
meaningful information o Not all sensory stimuli are acted upon
→ Components o Some are stored by the memory to be used at
o For an individual to be aware of the a later
surrounding → Cognition is cerebral functioning
o 4 aspects of the sensory process must be ▪ Involves processes such as:
present • Conscious thought
1. Stimulus • Reality orientation
→ an agent or act that stimulates a nerve • Problem solving
receptor • Judgment
2. Receptor • Comprehension
→ Nerve cell acts as receptor by converting the → Awareness
stimulus to a nerveimpulse ▪ Ability to perceive environmental stimuli and
→ Most receptors are specific; sensitive to only body reactions to respondappropriately
one type of stimulus (visual, auditory, touch) through thought and action
3. Impulse conduction → Sensory alterations
→ Impulse travels all along nerve pathways to o People become accustomed to certain
the spinal cord/directly to the brain sensory stimuli
o may feel uncomfortable for some changes
State of Awareness o Abnormal flexion -> 3
State Description o Extension -> 2
Full • Alert o None -> 1
Consciousness • Oriented to time, • Mild: 13-15
place, person • Moderate: 9-12
• Understands verbal • Severe: 3-8
and written words
Disoriented • Not oriented to time, ֍ Factors Contributing to Behavior Alterations
place and person 1) Sensory Deprivation
Confused • Reduced awareness → Decrease in or lack or meaningful stimuli
• Easily bewildered → RAS balance is disturbed
• Poor memory (orient → RAS unable to maintain normal stimulation to the
client: asa ka right cerebral cortex
now) → Person becomes more accurately aware of the
• Misinterprets stimuli remaining stimuli and often perceives these in a
• Impaired judgment distorted manner
Somnolent • Extreme drowsiness → Person often experiences perception, cognition
but will respond to and emotional alterations
stimuli → Clinical Manifestations of Sensory Deprivation
Semi-comatose • Can be aroused by • Excessive yawning, drowsiness, sleepiness
extreme or repeated • Decreased attention span, difficulty
stimuli concentrating, decreased problem solving
Coma (please see • Will not respond to • Impaired memory
GCS) verbal stimuli • Periodic disorientation, general confusion or
nocturnal confusion
Glasgow Coma Scale Assessment • Hallucination or delusions
- check every 15 minutes • Preoccupation with somatic complaints
- check also vital signs, palpating and input and (palpitations)
output • Crying, annoyance over small matters
• Depression
• Apathy
• Emotional lability
2) Sensory Overload
→ Generally, occurs when a person is unable to
process or manage the amount or intensity of
sensory stimuli
→ Factors contributing to Sensory Overload
• Increased quantity/quality of internal stimuli
(pain, dyspnea, anxiety)
• Increased quantity/quality of external stimuli
(noisy health care setting, intrusive diagnostic
studies, contacts with many strangers)
• Inability to disregard stimuli selectively, perhaps
as a result of the nervous system disturbances
or medications that stimulate the arousal
• Eye opening mechanism
o Spontaneous -> 4 → Clinical manifestation of sensory overload
o To sound -> 3 • Complaints of fatigue, sleeplessness
o To pressure -> 2 • Irritability, anxiety, restlessness
o None -> 1 • Periodic or general disorientation
• Verbal response • Reduced problem-solving ability and task
o Oriented -> 5 performance
o Confused -> 4 • Increased muscle tension
o Words -> 3 • Scattered attention and racing thought
o Sounds -> 2 3) Sensory Deficits
o None -> 1 → Impaired reception, perception or both
• Motor response → Of one or more of the scenes
o Obey commands -> 6 → Blindness and deafness = sensory deficits
o Localising -> 5
o Normal flexion -> 4
→ When only one sense is affected, the other ✓ Some special senses also are present at birth
senses may become more acute to compensate but functions change during growth process
for the loss ✓ Child’s visual acuity develops during early
→ Factors affecting amount and quality of childhood
sensory stimulation
✓ Children often have 20/20 vision by 6 years of
a) Developmental stage
age
o Young child: respond to music by singing or
dancing, interacting with their peers
o Adult: have many learned responses to
1) Early screening is essential
sensory cues
→ to detect visual and hearing problems
o Late adult: chronic disease or aging
→ center of disease control and prevention, 2004
b) Culture
o by 1 month of age: all infants should be
o The normal amount of stimulation associated
screened for hearing and vision loss, preferably
with ethnic origin, income level, religious
before hospital discharge
affiliation and income level
o before 3 months: infants with hearing loss
o Resulting to sensory and income level
should get follow-up evaluation
o Culture deprivation/ cultural care deprivation
o before 6 months: deaf infants or those with
▪ Lack of culturally insistive, supportive and
difficulty hearing should be enrolled in an
facilitate acts
intervention program
▪ Nursing responsibilities:
→ routine auditory testing: children with chronic ear
• Be sensitive to the stimulation
infections and/or people who live/work in an
• Encourage clients to follow practices with
environment with high noise level
which they are comfortable, provided that
2) Women
these practices do not endanger health
→ who are considering pregnancy should be
c) Stress
advised on the importance of syphilis and
o People may find their sense overloaded thus
rubella testing
seek decrease sensory stimulation
→ These diseases may cause hearing impairments
o Client with physical illness may which to have
in newborns
visits only from close support
3) Periodic vision screening
people. Nurse must help decrease unnecessary
→ of all newborns and children is recommended to
stimuli (noise)
detect congenital blindness, strabismus and
d) Medication and Illness
refractive errors
o Narcotics and sedatives decrease stimuli
→ Strabismus (crossed eyes)
awareness
o condition in which the eyes do not line up with
o Anti-depressants alter stimuli perceptions
one another
o Long term medication may cause ototoxicity
o In other words, one eye is turned in a direction
injures auditory nerve causing irreversible
that is difficult that is different form the other
hearing loss
eye. They do not look at the same object at the
o Elders at risk need to be monitored carefully
same time
o Medications: aspirin, furosemide (Lasix),
o Under normal condition, the six muscles that
aminoglycosides, chemotherapy drugs
control eye movement work together and point
o Certain diseases
both eyes at the same direction
▪ Atherosclerosis -> restrict blood flow to the
→ Refractive error
receptor organs and the brain, decreasing
o Shape of eye does not bend light correctly,
awareness, slowing responses
resulting in a blurred image
e) Lifestyle and personality
o Type of refractive errors
o Client employed in a bog company may be
a. Myopia (nearsightedness)
accustomed to diverse stimuli, whereas a self-
b. Hyperopia (farsightedness)
employed client working at home is exposed to
c. Presbyopia (loss of near vision w/ age)
fewer, less diverse stimuli
d. Astigmatism
o Personality: some are happy on constantly
4) Healthy sensory function
changing stimuli while others prefer a more
→ can be promoted with environment stimuli that
structured life with changes
provide appropriate sensory input
→ Many senses should be stimulated
֍ Promoting Health Sensory Function
→ Various colors, sounds, textures, smells and body
✓ Detecting sensory problems early is one step positions can provide various sensations
toward preventing serious problems 5) Teach parents to stimulate infant’s and
✓ The arousal mechanism for sensation is children with sensory deficits
normally present at birth, but is undifferentiated → Social activities often help stimulate the mind and
the senses
6) Teach clients at risk of sensory low how to 4) Bright contrasting colors in the environment
prevent and reduce loss and general health 5) Magnifying glass
measures 6) Phone dialer with large numbers
→ Regular eye exam 7) Color code/texture code on stoves, washer,
→ Controlling chronic disease such as diabetes medicine containers and so on
7) Ensuring client safety 8) Colored or raised rims on dishes
→ Nurses must implement safety precautions in 9) Reading material with large print
healthcare settings for clients with sensory 10) Braille or recorded books
deficits 11) Seeing-eye dog
→ Keeping the bed in lowest position
→ Placing call light/ call buzzer within reach (in case ֍ Sensory aids for hearing deficits
of emergency or assistance) 1) hearing aid in good order
2) lip reading
֍ Preventing Sensory Disturbances 3) sign language
a) Have regular health examinations 4) amplified telephones
b) Have regular eye exams 5) telecommunication device for the deaf (TDD)
c) Seek medical attention 6) amplified telephone
i. Signs of visual impairment 7) telecommunication device for the deaf (TDD)
• Failure to react to light 8) amplified telephone ringers and doorbells
• Reduced eye contact (infant) 9) flashing alarm clocks
ii. Child complains of earache/ear infection 10) flashing smoke detectors
iii. Persistent eye redness, discharge or
increasing tearing, growths on/near the eye, ֍ Impaired Vision
pupil asymmetry/irregularity, any → Vision loss lead to increase disability which may
pain/discomfort lead to depression
d) Obtain regular immunizations of children against → Loss of vision causes fear – fear of losing one’s
diseases capable of causing hearing loss autonomy and becoming dependent on
(Rubella, Mumps, Measles) another/others
e) Avoid giving infants/toddlers toys with long, → Affects how a person obtains information
pointed handles and keep pointed instruments → Reading is a leisure activity; it’s loss can affect a
(scissors, screwdrivers) out of reach. Supervise person’s quality of life
preschoolers when they’re using scissors
f) Make sure toddlers do not walk/run with a pointed ֍ Clients with Impaired Hearing
object in hand; teach preschoolers to walk 1) orient client to the arrangement of room
carefully when carrying such objects (sticks, toy furnishings and maintain an uncluttered
weapons) environment
g) Teach school-age children and adolescents the 2) keep pathways clear and do not rearrange
proper use of sports equipment (hockey sticks) furniture without orienting the client. Ensure
and power tools housekeeping personnel are informed about this
h) Wear protective eye goggles when using power 3) organize self-care articles within easy reach and
tools, riding motorcycles, spraying chemicals so place the bed in the low position
on 4) assist with ambulation by standing at client’s side,
i) Wear eye protectors when working in an walking about one foot ahead, allow person to
environment with high noise levels or brief loud grasp your arm
impulse noises (blasting)
֍ Clients with Impaired Hearing
֍ Managing Sensory Disturbances 1) Taught to use their visual sense to identify what
→ When assisting clients who have a sensory the client see in the environment
deficit, the nurse needs to o IV tubing kinks
a) Encourage the use of sensory aids to support o Loose ECG lead
b) Promote use of other sense 2) For home safety, clients near to have devices that
c) Communicate effectively amplify sounds/respond to flashing lights/burglar
d) Ensure client safety alarm
o The sound of doorbells and alarm clocks may
֍ Sensory aids for visual deficits be amplified or changed to a lower frequency
1) Eyeglasses of the correct prescription, clean and or buzzerlike sound
in good repair o These devices can be obtained from hearing
2) Adequate room lighting, including night lights aid dealers, telephone companies and
3) Sunglasses or shades on windows to reduce appliance stores
glare
→ An important consequence of a decline in hearing DIFFERENTIATING DELIRIUM AND DEMENTIA
= difficulty understanding speech Characteristic Delirium Dementia
→ Factors affecting the difficulty Distinguishing Acute; Memory
o Environment feature fluctuating impairments
o Rate of speech change in
o Presence of accent mental status
→ Environments that are noisy and reverberant Onset Sudden acute Slow,
(echoing, hollow sounds) cause difficult for elderly onset insidious
listeners Duration Temporary; may Chronic,
→ Elderly adults with hearing loss have difficulty last hours to gradual,
understanding fast speech days irreversible
Time of day Worsens at No changes
֍ Clients with Impaired Olfactory Sense night with time of
→ Teach them about the dangers of cleaning day
chemicals (ammonia) Sleep-Wake Disturbed; Disturbed;
→ Clients need to keep gas stoves and heaters in cycle cycles often fragmented;
good working order (gas leak can go undetected) reversed awakens
→ Strong chemicals (ammonia) used in confined often during
spaces (bathroom) may affect the client before the
they are smelled night
→ Food poisoning is a concern with clients who Alertness Fluctuates; may Generally
have difficulty detecting spoiled meat or dairy be alerts and normal
products oriented during
→ Clients must carefully inspect food freshness the day but
(check color and texture) and check expiration become
dates confused and
disoriented at
֍ Clients with Impaired Tactile Sense night
→ Clients may not be aware of hot temperatures Thinking Memory Impaired
(may cause burns), or pressure on bony alterations judgment;
prominences which can produce ulcers difficulty with
→ Clients with decreased sensation to temperatures abstraction
should have the temperature adjusted on their hot and word
heater; test water with water thermometer before finding
bathing Delusions/ Have visual, Delusions;
Hallucinations auditory, tactile usually no
֍ The Confused Client hallucinations; hallucinations
→ Confusion can occur in client of all ages, but it is misinterpretation
most commonly seen in older people of real sensory
o Acute confusion (delirium) experiences
o Chronic confusion (dementia) Causative/ Cerebral and Alzheimer’s
risk factors cardiovascular Disease;
diseases; multiple
infections; infarct
reduced dementia
hearing and
vision;
environment
changes; stress;
sleep
deprivation;
polypharmacy;
dehydration
֍ Promoting a therapeutic environment for a ֍ Promoting Sensory Stimulation for the
client with acute confusion/delirium Unconscious Client
✓ Wear a readable name tag a) Auditory
✓ Address the person by name and introduce → Introduce yourself to client
yourself frequently → Orient client to time, month, year, location and
happenings
✓ Identify time and place as indicated
→ Inform client beforehand the care to be provided
✓ Ask the client “where are you?” and orient to place → Read literature aloud to client
if indicated. (nursing home) → Play tape recording of a familiar voice
✓ Place a calendar and clock in the client’s room. → Converse directly to the client
Mark holidays with ribbons, pins b) Visual
✓ Speak clearly and calmly to the client, allowing → Sit client upright in a chair or bed (provides
time for your words to be processed and for the normal visual orientation)
client to give a response c) Olfactory
✓ Encourage family to visit frequently except if this → Provide aromatic stimuli that may include client’s
activity causes the client to become hyperactive favorites (coffee, lemon, cologne, perfume)
✓ Provide clear, concise explanations of each d) Gustatory
treatment procedure or task → Provide mouth care using mint-flavored cleaning
✓ Eliminate unnecessary noise agent
→ Place different tastes on tongue
✓ Reinforce reality by interpreting unfamiliar sounds,
e) Tactile
sights, and smell; correct any misconceptions of → Incorporate during bath activities (temperature
events, situations and texture of washcloth, back massage,
✓ Schedule activities (meals, bath, activity, rest brushing hair, rubbing lotion on extremities)
periods, treatments) at the same day each day to f) Kinesthetic
provide a sense of security if possible, assign the → Perform range of motion exercises
same caregivers → Change of client’s position
✓ Provide adequate sleep
✓ Keep glasses and hearing aid within reach
✓ Ensure adequate pain management
✓ Keep familiar items in the client’s environment
(photograph), keep the environment uncluttered.
A disorganized, cluttered environment increases
confusion
✓ Keep room well lit during waking hours

֍ Promoting a therapeutic environment for a

client with acute confusion/delirium
→ COMA is a sleep state of unconsciousness that
last for a period more than 2-4 weeks following a
traumatic brain injury
→ Previously, the client would be medically
stabilized and approximately 6 months later
transferred to a rehabilitation setting for coma
stimulation
→ Coma stimulation
▪ Consists of providing sensory stimulation to
promote brain recovery by waking up the RAS
▪ Delivered in a quiet environment, to prevent
sensory overload
▪ Done slowly to allow time for response to occur
SPIRITUALITY SPIRITUAL HEALTH/ SPIRITUAL WELL-BEING
● Nurses provide holistic care, not only the physical ● Manifested by a feeling of “being alive, purposeful,
body and mind, but also the client’s spirit. and fulfilled” (Ellison, 1983, pp 332)
● Meeting the client’s spiritual needs can decrease ● A way of living, lifestyle that views and lives life as
suffering and aid in physical and mental healing. purposeful and pleasurable, that seeks out life-
● To implement nursing care, nurses need to be sustaining and life-enriching options to be chosen
skilled in establishing trusting nurse-client freely at every opportunity, and that sinks its roots
relationship. deeply into spiritual values and/ or specific religious
● This Spiritual Caregiving Skill requires the nurse to beliefs (Pilch, 1998)
possess a healthy spiritual self-awareness. ● The connectedness with self, others, higher
● This Spiritual Self-Awareness will help the nurse to power, all life, nature, and the universe that
identify and be empathic toward the spiritual transcends and empowers the self.
concerns of the client.
● Nurses need some awareness of the diverse ● People nurture or enhance their spirituality in
spiritual beliefs and practices (coping resources for many ways:
persons) that their clients may possess, it is vital to 1.) Focus on development of inner self
understand how such beliefs help or hinder a  Example:
client’s health.  Conducting inner dialogue with a higher power
● Nurses need to relieve spiritual distress or to or with oneself through prayer or meditation,
enhance spiritual health to implement spiritual care analyzing dreams, communing with nature, or
therapeutics that promote spiritual and emotional art inspiration (drama, music, dance, paintings)
health, help with coping and adjustment, or assist 2. Focus on expression of their spiritual energy
one face a more peaceful death. with others or the outer world.
 Example:
SPIRITUAL  Loving relationships with service to others, joy
● Spiritus (Latin Word) and laughter
● “To Blow”, “To Breathe”  Religious services participation, associated
● Gives life/ essence to being human fellowship gatherings and activities
 Expression of compassion, empathy,
SPIRITUALITY forgiveness, and hope
● Refers to that part of being human that seeks
meaningfulness through intra-, inter-, ● Nurses who attend to their own spirituality can
transpersonal connections. work better with clients who have spiritual needs
● Generally involves a belief in a relationship with ● Therefore, it is important to be comfortable with
some higher power, creative force, divine being, or one’s own spirituality
infinite source of energy/
● Example: EXAMPLES OF SPIRITUAL NEEDS
 God ● Needs related to the Self:
 Allah  Need for meaning and purpose
 Great Spirit  Need for hope
 High Power  Need to transcend life challenges
● Includes the following aspects:  Need for personal dignity
1. MEANING  Need for gratitude
 Having purpose, making sense of life  Need for vision
2. VALUE  Need to prepare for and accept death
 Having cherished beliefs and standards ● Needs related to Others:
3. CONNECTING  Need to forgive others
 Relating to others, nature, Ultimate Other  Need o cope with loss of loved ones
4. BECOMING ● Needs related to the Ultimate Other:
 Which involves reflection, allowing life to  Need to be certain there is a God or
unfold, and knowing who one is Ultimate Power in the universe
 Need to believe that God is loving, and
● Spirituality can be described by measuring it, personally present
“Spirit Titer” (Jourard, 1971)  Need to worship

SPIRIT TITER ● Needs among and within Groups:

● Influenced by numerous factors: life experiences,  Need to contribute or improve one’s community
coping skills, social supports, and individual belief  Need to be respected and valued
system  Need to know what and when to give and take
INDICATORS OF SPIRITUAL HEALTH ● Refuses interaction with friends, family
● Uncompromised ● Sudden changes in spiritual practices
 Faith ● Requests to see a religious leader
 Hope ● No interest in nature, reading spiritual literature
 Meaning and purpose of life
 Achievement of spiritual world SPIRITUALITIY’S RELATED CONCEPTS
 Feelings of peacefulness ● RELIGION
 Ability to love ● FAITH
 Ability to forgive ● HOPE
 Ability to pray ● TRANSCENDENCE
 Ability to worship ● FORGIVENESS
 Spiritual experiences
 Participation in spiritual rites and passages RELIGION
 Participation in meditation ● Is an organized system of beliefs and practices
 Participation in spiritual reading ● Offers a way of spiritual expression that provides
 Interaction with spiritual leaders guidance for believers in responding to life’s
 Expression through song/ music questions and challenges
 Expression through art ● The Organized Religion offers:
 Expression through writing a. Sense of community bound by common beliefs
 Connectedness with inner self b. Collective study in scripture (Torah, Bible,
 Connectedness with others Koran, others)
 Interaction with others to share thoughts, c. The performance of ritual
feelings, beliefs d. The use of disciplines and practices
SPIRITUAL DISTRESS e. Ways of taking care of person’s spirit (fasting,
● Refers to a challenge to the spiritual well-being or prayer, meditation)
to the belief system that provides strength, hope, AGNOSTIC
and meaning to life ● A person who doubts the existence of God or a
● Contributing factors supreme being or believes the existence of God
A. Physiologic problems has not been proved
B. Treatment related concerns ATHEIST
C. Spiritual concerns ● Is one without belief in a God
SPIRITUAL DISTRESS’ CONTRIBUTING MONOTHEISM
FACTORS ● Is the belief in the existence of one God
A. Physiologic Problems POLYTHEISM
● Examples: ● Is the belief of more than one God
 Medical diagnosis of a terminal or
debilitating disease FAITH
 Experiencing pain ● Is to believe in or be committed to something or
 Experiencing loss of body part/ function someone
 Experiencing miscarriage/ stillbirth ● Being present in both religious and nonreligious
B. Treatment-related Concerns people (Fowler 1981)
● Examples: ● Gives life meaning, providing the individual with
 Recommendation for blood transfusions strength in difficult times
 Abortion ● For the client who is ill, faith whether in a higher
 Surgery authority (God, Allah, Jehovah) in oneself, in the
 Dietary restrictions health care team, or in a combination of all –
 Amputation of a body part provides strength and hope
 Isolation
C. Situational Concerns HOPE
● Examples: ● A concept that incorporates spirituality
 Death/ illness of a significant other ● Process of anticipation of thinking, acting, feeling,
 Inability to practice one’s spiritual rituals and relating, and is directed toward a future
 Feelings of embarrassment when fulfillment that is personally meaningful
practicing them (Stephenson, 1991)
NANDA INTERNATIONA’S DEFINING ● The absence of hope may make the client give up,
CHARACTERISTICS OF SPIRITUAL DISTRESS losing spirit, and illness is likely to progress more
● Expresses lack of hope, meaning and purpose in rapidly
life, forgiveness of self
● Expresses being abandoned by or having anger
toward God
TRANSCENDENCE Adolescence ● Experience of the world now
● Often used interchangeably with self- beyond the family unit and
transcendence; capacity to reach out beyond spiritual beliefs can aid
oneself, to extend oneself beyond personal understanding of extended
concerns and to take on broader life perspectives, environment
activities and purposes (Coward, 1990) ● Generally conform to the
● Thought to involve a person’s recognition that beliefs of those around them;
there is something other or greater than the self begin to examine beliefs
and a seeking and valuing of that greater other, objectively, especially in late
whether it is an ultimate being, force, or value adolescence
FORGIVENESS Young ● Development of a self-identity
● Receiving increased attention among health care Adulthood and a worldview differentiated
professionals from those of others
● Health problem is interpreted as a punishment for ● The individual forms
past sins independent commitments,
● Client facing imminent death may seek lifestyle, beliefs, and attitudes
forgiveness from others as well as from God ● Begins to develop personal
● Research suggested that nurses can play a pivotal meaning for symbols of
role in assisting clients to understand the process religion and faith
of forgiveness and to persevere through it Middle ● Newfound appreciation for the
Adulthood past; increased respect for
STAGES OF SPIRITUAL DEVELOPMENT inner voice; more awareness
Developmental of myths, prejudices, and
Characteristics
Stage images that exist because of
0-3 years ● Neonates and Toddlers are social background
acquiring fundamental spiritual ● Attempts to reconcile
qualities of trust, mutuality, contradictions in mind and
courage, hope and love experience and to remain open
● Transition to next stage of to other’s truths
faith begins when child’s Mid-to-Late ● Able to believe in, and live
language and thought begin to Adulthood with a sense of participation in,
allow use of “Symbolism” a nonexclusive community
● May work to resolve social,
3-7 years ● Fantasy-filled, imitative phase political, economic, or
when child can be influenced ideological problems in society
by examples, moods, actions ● Able to embrace life, yet hold
● Child relates intuitively to it loosely, (Martin Luther King
ultimate conditions of Jr, Mahatma Gandhi, Mother
existence through stories and Teresa illustrate this stage)
images, the fusion of facts and
feelings SPIRITUAL PRACTICES AFFECTING NURSING
● Make-believe is experienced CARE
as reality (Santa Clause, God ● Clients frequently identify religious practices, such
as grandfather in the sky) as prayer, as important strategies for coping with
illness
7-12 years, ● Child attempting to sort ● Most common practices affecting client’s nursing
even into fantasy from fact by care include:
adulthood demanding proofs or  Holy days
demonstrations of reality  Sacred writings
● Stories are important for  Prayer
finding meaning and  Meditation
organizing experience  Those associated with diet
● Child accepts stories and  Nutrition, healing, dress, birth, death
beliefs literally
● Ability to learn the beliefs and
practices of the culture,
religion
COMMON PRACTICES AFFECTING CLIENT’S ● Medical professionals should respect such objects
NURSING CARE because they usually have great significance for
1. HOLY DAYS clients
● A day set aside for special religions observance, ● Nurses should instruct patients to remove these
and all the world religions observe certain holy jewelries while receiving care (let SO keep them)
days
● Examples: 4. PRAYER AND MEDITATION
 Christians: Easter, Christmas MEDITATION
 Jews: ● Is the act of focusing one’s thoughts or engaging
 Yom Kippur in self-reflection or contemplation
● Day of Atonement ● Some people believed that through deep
● The day is set aside to “afflict the soul”, to atone meditation, one can influence or control physical
for the sins over the past year; purpose is to and psychological functioning and the course of
atone against Him, according to Judaism 101 illness
 Passover
● One of the most important religious festivals in PRAYER
the Jewish calendar, Pesach in Hebrew, to ● Some argue that because prayer requires a belief
commemorate the liberation of the Children of in a divine or spiritual entity, not all people pray,
Israel who were led out of Egypt by Moses while others consider prayer a universal
 Buddhism: phenomenon that doesn’t require such belief
 Vesak’s Day ● People pray whether or not they call it prayer. We
● Buddha’s birthday pray every time we as ask for help, understanding
● Time to reflect on his teachings and what it or strength, in and out of religion, who and what
means to be Buddhist we speak out of us, to pray is to listen to and hear
 Muslims: this self who is speaking (Ulanov, 1983)
 Ramadan ● Prayer is intention plus love, often communicated
● Observe the month-long holy period with “the Absolute” according to Dossey (1999)
 Hindu: ● Prayer is a loving wish or thought for oneself or
 Mahashivarathri another, and not an invocation of positive or
● Celebration of Lord Shiva, known as ‘The negative forms of magic
Destroyer,’ within the Trimurti/ Hindu trinity that
includes Brahma and Vishnu. In the Shaivite 5. BELIEFS AFFECTING DIET AND NUTRITION
tradition, Shiva is the Supreme Lord who ● Orthodox Jews
creates, protects, and transforms the universe  Do not eat shellfish or pork
● Many religions require fasting, extended prayer, ● Muslims
and reflection or ritual observances on sacred  Not allowed to drink alcoholic beverages, or
(or high holy) days. eat pork
● Believers who are seriously ill are often ● Mormons
exempted from such religious requirements  Not allowed to drink caffeinated or alcoholic
beverages
2. SACRED WRITINGS ● Catholics
● Scriptures generally set forth religious law in the  May choose not to eat meat on Fridays as
form of admonitions and rules for living prescribed in the past years
● Example: ● Buddhist and Hindus
 Ten Commandments  Generally vegetarian, not wanting to take life
● May affect a client’s willingness to accept needed to support life
treatment suggestions ● Jews
● Example:  Kosher food (prepared according to Jewish
 Blood transfusions in conflict to Jehovah’s law)
Witnesses; religious admonitions (Needs a  Kosher meat comes from animals that have
waiver) split hooves – like cows, sheep, and goats –
and chew their cud. When these types of
3. SACRED SYMBOLS animals eat, partially digested food (cud)
● May include jewelry, medals, amulets, icons, returns from the stomach for them to chew
totems, or body ornamentation (tattoo) that carry again. Pigs, for example have hooves, but
religious/ spiritual significance they don’t chew their cud. So pork isn’t
● Worn to pronounce one’s faith kosher.
● Clients may bring their religious objects to the
hospital to use in prayer or their other religious
rituals
6. BELIFES REATED TO HEALING  A layer of fat maintains warmth, protecting the
● Illness is cause by a spiritual disruption body’s vital energy
● Healing for such clients may appear to be  Imbalance from worry and overwork create
unrelated to current treatment practices stress and illness
● Nurse must assess client’s beliefs, and include  Emotional restraint is a key element in
aspects of healing when providing health restoring balance
teachings  A sense of balance imparts increased body
● Orthodox and Conservative Jewish awareness
 Men wear “yalmulkes” ● MYSTICAL CAUSES
 Women cover their hair with wigs/ scarf as a  Mystical causes are often attributed to
sign of respect to God experiences or behaviors such as ancestral
● Muslim retribution for unfinished tasks or obligations
 Cover their hair in accordance with their  Some believe that the soul goes out from the
particular ethnic or national background body and wanders, a phenomenon known as
● Mormons “Bangungot,” or that having nightmares after a
 Wear temple undergarments in compliance to heavy meal may result in death
religious law
● PERSONALISTIC CAUSES
GUIDLENES FOR ETHICAL CONDUCT IN  Personalistic causes are associated with social
SPIRITUAL CAREGIVING punishment or retribution from supernatural
● First, seek a basic understanding of client’s forces such as evil spirit, witch, (Manga ga mud)
spiritual needs, resources, and preferences or sorcerer (Mangkukulam)
(assess)  The forces cast these spells on people if they are
● Follow the client’s expressed wishes regarding jealous or feel disliked
spiritual care  Witch doctors (Herbularyo) or priests are asked to
● Follow the client’s expressed wishes regarding counteract and cast out these evil forces through
spiritual care the use of prayers, incantations, medicinal herbs,
● Do not prescribe or urge clients to adopt certain and plants
spiritual beliefs or practices, and do not pressure  For protection, the healer may recommend using
them to relinquish such beliefs or practices holy oils, or wearing religious objects, amulets or
● Strive to understand personal spirituality and how talismans (anting anting)
it influences caregiving
● Provide spiritual care in a way that is consonant ● NATURALISTIC CAUSES
with personal beliefs  Naturalistic causes include a host of factors
ranging from natural forces (thunder, lightning,
FILIPINO CULTURE, VALUES, AND PRACTICES drafts, etc.) to excessive stress, food and drug,
IN RELATION TO HEALTH CARE incompatibility, infection, or familial susceptibility
HEALTH BELIFS AND BEHAVIORS:
INDIGENOUS HEALTH BELIEFS HEALTH BELIEFS AND BEHAVIORS: BASIC
● CONCEPT OF BALANCE (TIMBANG) LOGIC OF HEALTH AND ILLNESS
 This concept is central to Filipino self-care ● The basic logic of health and illness consists of
practices and is applied to all social relationships prevention (avoiding inappropriate behavior that
and encounters leads to imbalance) and curing (restoring
 According to this principle, health is thought to be balance); It is a system oriented to moderation
a result of balance, while illness due to humoral ● Parallel to this holistic belief system is the
pathology and stress is usually the result of some understanding of modern medicine with its own
imbalance basic logic and principles for treating certain types
 Rapid shifts from “hot” to “cold” cause illness and of diseases. These two systems co-exist, and
disorder Filipino older adults use a dual system of health
 Range of humoral balances that influence care (Anderson, 1983)
Filipino health perceptions:
 Rapid shifts from “hot” to “cold” can lead to
illness
 “Warm” environment is essential for
maintaining optimal health
 Cold drinks or cooling foods should be avoided
in the morning
 An overheated body is vulnerable to disease; a
heated body can get “shocked”
 When cooled quickly, it can cause illness
HEALTH BELIEFS AND BEHAVIORS: HEALTH which the patient, family members, and even
PROMOTION/ TREATMENT CONCEPTS the physician should not interfere
● Health beliefs and practices are oriented towards ● Conceding to the wishes of the collective
protection of the body (Pakikisama)
FLUSHING  To maintain group harmony
● The body is thought to be a vessel or container
that collects and eliminates impurities through HEALTH BELIEFS AND BEHAVIORS:
physiolohical processes such as sweating, RESPONSES TO MENTAL HEALTH
vomiting, expelling gas, or having an appropriate Indigenous traits common among elderly Filipino
volume of menstrual bleeding when faced with illness related to mental conditions:
HEATING ● Devastating shame (Hiya)
● Adapts the concept of balanced between “hot” and ● Sensitivity to criticism (Amor Propio)
“cold” to prevent occurrence of illness and ● Unwillingness to accept having mental illness,
disorders which leads to the avoidance of needed mental
PROTECTION health services due to fear of being ridiculed
● Safeguards the body’s boundariies from outside ● Involvement of other coping resources such as
influences such as supernatural and naturral reliance on family and friends or indigenous
forces healers, and dependence on religion which can
RESPONSE TO ILLNESS diminish the need for mental health services
● Filipino older adults tend to cope with illness with ● Prioritizing of financial and environmental needs
the help of family and friends, and by faith in God. which preclude the need for mental health services
Complete cure or even the slightest improvement ● Limited awareness of mental health services
in malady or illness is viewed as a miracle. Filipino resulting in limiting access
families greatly influence patients’ decisions about ● Difficulty in utlizing mental health services during
health care usual hours because of the unavailablity of
● Patients subjugate personal needs and tend to go working adult family members
along with the demands of a more authoritative
family figure in order to maintian group harmony HEALTH BELIEFS AND BEHAVIORS: COMMON
● Before seeking professional help, Filipino older PERCEPTIONS OF FILIPINOS ABOUT MENTAL
adults tend to manage their illnesses by self ILLNESS
monitoring of symptoms, ascertaining possible ● Mental illness connotes a weak spiritu, and may
causes, determining the severity and threat to be attributed to divine retribution as a conseqence
functional capacity, and considering the financial of personal and ancestral transgression
and emotional burden to the family ● Lack of culturally oriented mental health services
● They may even resort to utilizing traditional home ● Through such coping mechanisms, perceptions
remedies such as alternatuve or complimentary and traits may help elderly Filipino adjust initially to
means of treatment. They may discuss their their illnesses, these tactics also pose barriers and
concern with a trusted family member, friend, impede implementation of necessary treatment
spiritual counselor, or healer intervention in a timely fashion
● Seeking medical advice from family members or
friends who are health professionals is also a COMMON FILIPINO SUPERSTITIONS
common practice among Filipino older adults and ● The present-day Filipino culture still embraces
their family members, especially if severe somatic superstitions that cling to ancient beliefs and
symptoms arise practices
● Some may be quite amusing, such as serving
HEALTH BELIEFS AND BEHAVIORS: COPING noodle dishes like pancit during birthday
STYLES celebrations as it is believed to represent long life,
Coping styles common among elderly Filipino in while some sound more serious, like thinking that
times of illness or crisis include: faith-healers can heal certain ailments
● Patience and Endurance (Tiyaga)
 The ability to tolerate unceratain situations WHERE DID THESE SUPERSTITIONS COME
● Flexibility (Lakas ng Loob) FROM?
 Being respectful and honest with oneself ● Most early Filipinos believed in worshipping
● Humor (Tatawanan ang Problema) different gods, creatures, and spirits. They
 The capacity to laugh at oneself in times of appease them through various practices,
adversity sacrifices, and rituals
● Fatalistic Resignation (Bahala Na) ● However, due to colonization, religious beliefs and
 The view that illness and suffering are the traditions have changed from animism to
unavoidable and predestined will of God, in Christianity
● In marrying animism and Christianity, the impact of ● Rubbing wet hair against your pillow can cause
Filipino superstitions remains to affect everyday hair dfamage and breakage
life, spanning from fortune, love, and marriage to ● The friction will also lead to you having to deal with
family, illness, and death. a bad hair day the next morning
● If you notice alarming symptioms of vision loss or
WHAT ARE THE MOST COMMON FILIPINO a mental health issue, it’s best to visit an eye
HEALTH SUPERSTITIONS? doctor or a trusted outpatient care facility and let a
1. Get rid of a hiccup by placing a short thread medical professional handle it
wet with saliva on the forehead 4. Washing sweaty hands can lead to spasmodic
● According to a survey by Smart Parenting, 5 out hands or “pasma”
of 10 parents continue to cure their kid’s ● It’s a common Filipino advice not to wash your
hiccups by practicing this superstition or hands right after finishing labor-intesnive chores to
“pamahiin”. However, there is no scientific avoid pasma – the reason for shaky hands,
evidence that supports this. sweaty palsm, and numbness or pain in the hands
● Several factors can cause hiccups, include ● Often right after ironing a handful of clothes, you’ll
swallowing air and eating or drinking too much be discouraged by your mom or grandmother to
or too fast wet your hands
● Instead of using a thread, you can try the ● Similarly, it is believed that taking a bath after a
following remedies: workout can lead to illnesses
1. Bite on a slice of lemon ● The truth is, hand tremors, sweaty hands,
2. Slowly sip ice-cold water while placing gentle numbness, and pain in the nads are symptoms
pressure on your nose as you swallow that are often related to diabietes mellitus,
3. Hold your breath for a short time thyroid dysfuncion, and nervous system
4. Avoid it altogether by staying away from dysfunction
carbonated drinks, eating slower, and ● If you regularly experience such symptoms, rule
consuming smaller meals out any underlying conditions by paying a quick
2. By showing fondness or affection when visit to a trusted health professional
meeting a baby for the first time, you may cause 5. Not patting your sweat dry with a towel can
the baby to feel uneasy or make the baby cry cause you to get Pneumonia
non-stop which is commonly referred to as “na- ● Many Filipinos believe this superstition in fear of
usog” suffering from this serious lung diease. Although
● This belief in usog can cause an infant to feel like most pamahiins, there is no scientific basis
unwell either by greeting the baby or simply being for this particular belief
overly fond of him or her when meeting the child ● According to MedicineNet, the inflammation of the
for the first time airspaces in the lungs is often caused by fungi,
● To avoid passing the negative energy and cure the viruses, and bacteria – not sweat left to dry
infant of usog, superstitionn practice says you 6. Stepping over a child will stunt his or her
must dab your saliva on the baby’s forehead or growth
abdomen ● This superstition is common to older generations,
● Often, most people would also greet the child by but no evidence confirms this specific pamahiin to
saying “pwera usog” (pwera buyag) meaning for be true
protection from the hex. ● As we all know, the growth of a child depends on
● Some even make it a point to by their child a various factors that influence development,
bracelet made from black and red coral beads to including nutrition, genese, sex hormones, and
fight usog socioeconomic status
● While Filipinos believe in usog, the most logical 7. Frog urine causes warts
explanation for babies feeling unwell after meeting ● This belief is often used by Filipino parents to stop
strangers is that the infant reacts to a stress their kids from going near frogs
trigger of seeing unfamiliar faces or people – ● The myth is rooted infrogs having bumps on their
resulting in anxiety to the baby skin that look like warts.
3. Hitting the sack right after a shower is ● While some may believe this superstition, warts
believed to cause blindness and insanity are actually brought about by viruses that cause
● This superstiion suggests that if you go straight to an overproduction of keratin
bed with wet hair, you might wake up blind or 8. Showering salt over the threshold of the front
insane door of your new house can help you and your
● However, there is no firm correlation between family ward off sickness
wet hair, loss of eyesight, and insanity, so avoiding ● Some Filipinos still practice this pamahiin because
sleeping with wet hair is mostly for cosmetic they believe “it’s better to be safe than sorry”
reasons
● Unfortunately, spreading salt can’t protect you 3. VERBALIZATION (V)
from getting sick, but having a healthy diet and  Does the client mention God or a higher power,
taking multivitamins to boost immunity will prayer, faith, the church, the synagogue, temple,
spiritual or religious leader, or religious topics?
THE IMPACT OF SUPERSTITIONS ON HEALTH 4. AFFECT/ ATTITIUDE
AND WELL-BEING  Does the client appear lonely, depressed, angry,
● Many irrational beliefs from the pre-colonial past anxious, agitated, apathetic, or preoccupied?
still exist and continue to shape the opinions, 5. INTERPERSONAL RELATIONSHIPS
decisions, values, and actions of Filipinos in modern  How does the client respond to visitors?
times.  Does a minister or priest come?
● While it seem harmless at first glance, pamahiins  How does the client relate to other clients and
often interfere with how Filipinos cope with illnesses nursing personnel?
and respond to mental health issues
● Don’t allow superstitions to cloud your judgement. DIAGNOSING
Make your physical health a priority by regularly ● The nurse may find that spiritual problems provide
visiting a medical professional and undergoing the diagnostic level, or that spiritual diagnoses
health checkups as needed related to spirituality
● Spiritual Issues as the Diagnostic Label:
NURSING ASSESSMENT (NANDA 20017) recognizes 3 Diagnoses
● Data about a client’s spiritual beliefs are obtained 1. Spiritual Distress
from: 2. Readiness for Enhanced Spiritual Well-being
1. The client’s general history (religious 3. Risk for Spiritual Distress
preferences and orientation) ● Religious Issues as the Diagnostic Label:
2. Through nurisng history 1. Impaired Religiosity
3. By clinical observations of the client’s behavior  Impaired ability to exercise a reliance on
4. Verbalizations religious beliefs and/ or participate in rituals of
5. Mood a particular faith tradition
6. Significant others 2. Risk for Impaired Religiosity
7. Proof/ evidences  At risk for an impaired ability to exercise
● Nurses should never assume that a client follows reliance on religious beliefs and/ or participate
all the practices of the client’s stated religion in a ritual of particular faith tradition
3. Readiness for Enhanced Religiosity
SPIRITUAL HEALTH OF THE NURSING  Ability to increase reliance on religious beliefs
PROCESS and/ or participate in rituals of a particular faith
NURSING HISTORY tradition
● Ask the appropriate questions: ● Spiritual or Religious Distress as the Diagnostic
FAITH/ BELIEFS (F) Label
● What spiritual beliefs are most important to you?  Spiritual Distress many affect other areas of
IMPLICATIONS/ INFLUENCE (I) functioning and indicate other diagnoses
● How is your faith affecting the way you cope up  In this instances, spiritual distress becomes the
now? etiology
COMMUNITY (C) 1. Fear related to apprehension about soul’s future
● Is there a group or like-minded believers with after death and unpreparedness for death
which you regularly meet? 2. Chronic Situational Low Self-Esteem related to
ADDRESS (A) failure to live within the precepts of one’s faith
● How would you like your health care team to 3. Disturbed Sleep Pattern related to spiritual
support you spritually? distress
4. Decisional Conflict related to between treatment
CLINICAL ASSESSMENT plan and religious beliefs
● Cues to spiritual and religious preferences,
strengths, concerns, or distress may be revealed by PLANNING
one or more of the following: ● Help the client fulfill religious obligations
1. ENVIRONMENT (E) ● Help the client draw on and use inner resources
 Does the client have sacred books, devotional more effectively to meet the present situation
literature, religious medals, rosary, cross in her ● Provide sense of hope
room? ● Provide spiritual resources otherwise unavailable
2. BEHAVIOR (B)
 Does the client appear to pray before meals or at
other times or read religious literatures?
IMPLEMENTING
● Providing Presence
 PRESENCING
 Being present, just being with a client
 4 Distinguishing Features of Presencing:
1. Giving of self in the present moment
2. Being available with all of the self
3. Listening, with full awareness of the privilege of
doing so
4. Being there in a way that is meaningful to another
person

● Supporting Religious practices

 Nurses will consider specific religious practices
that will affect nursing care

● Assisting Clients with Prayer

 Prayer involves in a sense of love and
connection, and reaching out has many health
benefits and healing properties
 Nurses’ major responsibility is to ensure a quiet
environment for the client to do her/ his
spirituality/ religious acts

● To ensure good health eat lightly, breathe deeply,

live moderately, cultivate cheerfulness, and
maintain an interest in life”
EVIDENCED BASED PRACTICE NURSING How does Evidence-based benefit nurses and
Evidence-based Practice Nursing patients?
 integration of research evidence, clinical
 by searching for documented interventions
expertise and a patient’s preferences
that fit the profiles of their patients, nurses can
 this problem-solving approach to clinical
increase their patient’s chances for recovery
practice encourages nurses to provide
 it enables nurses to evaluate research so they
individualized patient care.
understand the risks or effectiveness of a
 process of collecting, processing and
diagnostic test or treatments
implementing research findings to improve
 the application of evidence-based practice
clinical practice, the work environment or
enables nurses to include patients in their
patient outcomes
care plan
 utilizing the evidence-based practice (EBP)
 this allows patients to have a proactive role in
approach to nursing practice helps us provide
their own healthcare since they can voice
the highest quality and most cost-efficient
concerns, share their values and a
patient care possible.
preferences and make suggestions on how
Why is Evidence-Based Practice in nursing so
they want to proceed
important
 registered nurses (RN) deliver care to patients
by applying validated interventions What is the Advantage of Evidence-based
 in a Bachelor of Science in Nursing (BSN) Practice for Healthcare Organizations?
program, nurses learn about evidence-based  with the application of evidence-based
practice (EBP) which aids them in pinpointing practice comes better patient outcomes which
care strategies that can help their patients can decrease the demand for healthcare
 in recent decades, evidence-based practice resources
has become a key component of exceptional  thus, healthcare organizations can reduce
patient care expenses
EBP Incorporated in Nursing  example
 helps nurses determine an effective course of  outdated practices may have included
an action for care delivery. Evidence-based supplies, equipment or products that
practice involves the following five steps: are no longer necessary for for certain
 5 STEPS procedures or techniques
1. form a clinical question to identify a
problem
2. gather the best evidence What is the history of evidence-based practice?
3. analyze the evidence
4. apply the evidence to clinical practice  Florence Nightingale was credited with
5. assess the result improving patient care in the 1800s when she
What Kind of Research is used in evidence- noted that unsanitary conditions and restricted
based practice ventilation could adversely affect the health of
 research utilized in evidence-based practice patients. She went on to record medical
falls into statistics using patient demographics to
4 CATEGORIES ascertain number of deaths in hospitals and the
1. randomized controlled trials mortality rate connected to different illnesses and
2. evidence gathered from cohort, case-control injuries
analysis or observational studies  Archie Cochrane introduced the concept of
3. opinions from clinical experts that are applying Randomized Controlled Trials (RTC)
supported by experiences, studies or reports and other types of research to the nursing
from committees practice in 1972. Before Cochrane’s contribution
4. personal experience to healthcare, medical care centered on
How does Evidence-Based Practice (EBP) unfounded assumptions without consideration
benefit nurses and patients for the individual patient. Proposed that
healthcare systems have limited resources so
 the inclusion of evidenced-based practice in they should only use treatments that are proven
nursing provides nurses with the scientific to be effective. He believed that RTCs were the
research to make well-founded decisions most verified form of evidence and his assertion
 through evidence-based practice, nurses can created the foundation for the evidence-based
stay updated about new medical protocols for practice movement
patient care  David Sackett introduced the term evidence-
based medicine in 1996 along with a definition
that is still widely used today. Unlike Cochrane,
Sackett felt that EBP should not only focus on
research but should merge evidence, clinical Research-related Roles and Responsibilities
experience and patient values. As other
healthcare professions began adopting Sackett’s  Research is essential. It is the only evidence-
concept for patient care, it was renamed based method of deciding whether a new
evidence-based practice approach to treatment or care is better than
 Evidence-based practice is an essential the current standard, and is essential to
component of safe, quality patient care. Nurses diagnose, treat, prevent and cure disease.
must be aware of current practices in order to Research nurses play a vital role in delivering
provide care to patients with complicated and research and ultimately improving patient
debilitating conditions care
 Nursing students in an RN to BSN program learn  Research nurse: role is compex, exciting
the role of research in the nursing practice. and interesting.
These programs cover the design,  forefront of new developments in
methodologies, process and ethical principles of treatments for their patients
research  day to day, the role of a research
 Nursing students use critical thinking skills to nurse may vary, as they hold
evaluate and critique research studies in order to numerous responsibilities
apply the findings to their nursing practice Responsibilities
 Europe: written exam and practical exam  Identifying and screening potential patients
(licensure exam)  Making sure that patients have necessary
information to allow them to make a fully
informed decision about whether they want
Evidence-based practice is a TREND
to participate in a study
 involving all disciplines, evidence-based practice  Ensuring the patients give fully informed
is an approach to clinical practice that’s been consent before they are enrolled in a study
gaining ground since its formal introduction in  Support principal investigator (PI) by
1992. Starting in medicine, it then spread to coordinating the day to day management of
other fields such as nursing, psychology and research studies
education.  Providing ongoing support to patients
 Currently, 55% of all nursing practices are based throughout their time as a participant
on the research findings. The ANA predicts that
by 2020, 90% of all nursing practice will be based The Importance of Teamwork and Collaboration
on evidence-based practice research findings in Nursing
 When you incorporate up-to-date information
from new EBP research, you’ll be able to  patient care is the top priority in nursing
question current practices. You may ask  for patients to receive the best healthcare
questions such as “Are my current nursing possible, nurses must communicate with
interventions the most effective or safest for relevant professionals about their patients’
my patients?” or “Could we utilize these new treatment plan while also understanding the
EBP interventions in my work area?” role of each assigned team member
(Aspirin: anticoagulant (di magpilit ang blood);  In essence, nurses serve as a bridge
blood thinner(dali ra mabunog if maigo) between doctors, patients and the hospital.
: stop prescribing to fever  teamwork and collaboration are critical to
: increase injury to internal bleeding this role
Symptom: fever but comes along with internal  even the World Health Organization (WHO)
bleeding (dengue/ dengue hemorrhagic fever) in the Multiprofessional Patient Safety
Dengue: not eat chocolate colored food = give Curriculum Guide who acknowledges that
brown feces “effective teamwork in healthcare delivery
Internal bleeding: black or dark feces) can have an immediate and positive impact
 Nurses committed to EBP will compare current on patient safety”
professional and clinical practices with new  noticing that patients in modern-day
research facts and outcomes as they emerge healthcare rarely see just one medical
 to meet the 2020 goal, nurses must become professional, WHO adds that teamwork and
proficient in evaluating various types of EBP coordination help minimize the occurrence of
research because they provide effective, proven adverse events caused by errors in both
rationales for nursing actions communication and an understanding of
defined professional roles
A Blueprint for Success in Teamwork and b. during shift changes
Collaboration c. through poor transfer of information
d. when the patient changes nurses
 there is an important but subtle difference  on the other hand, team members whose input
between teamwork and collaboration in nursing and successes are verbally acknowledged to the
and both are essential to ensure patient safety greater team are more likely to contribute their
and care idea which builds team cohesion and efficiency
 collaboration refers to joint efforts between
various independent teams or groups
4) Promote Mutual Respect
 example: pregnant patient shows signs of a
 mutual respect is critical in health care settings,
heart issue, a cardiac surgery team will be called
not just within the team but across collaborative
to work together with those in the maternity ward
departments
 teamwork refers to the efforts within one team to
 team members who are not feeling respected can
produce the highest quality and most efficient
become defensive, foster hidden agendas,
results. Whether in a small, focused healthcare
demonstrate a lack of engagement and worse
organization or a large hospital with many
 building mutual respect comes through a
departments both teamwork and collaboration
common, focused goal; an understanding that
are central to healthcare
each individual’s work is valuable and an
 To provide patients with the best care, nurses in
acknowledgement of the efforts of others
leadership roles should maintain the following
teamwork and collaborative principles
5) Handle Conflict Proactively
1. Establish Team Goals
 effective teamwork and collaboration in nursing
 for example, if the goal is to reduce patient wait
exist with the understanding that some conflict is
times, but each each individual pursues a
inevitable
different method without speaking to their team,
 By allowing for open communication and
the likely outcome is confusion around the patient
listening to team member’s concerns, nurses
intake process
can encourage productive conflict resolution in its
 as a result, wait times may actually increase
early ages.
 Nursing 2019: while there are several
2. Assign Roles within a Team approaches to handling conflict - such as
 nurses interact with a large number of healthcare competition, accommodation and compromise -
professionals, both within their own team and collaboration is most effective.
across departments. It is crucial then, to have an  when all parties approach conflict by focusing on
understanding of key roles within individual teams the end goal, maintaining respect and listening
to achieve greater collaboration openly, most issues can be resolved effectively
 if clear roles are not assigned, team members
may duplicate efforts in some areas while leaving 6) Be an Effective Leader
gaps in others. This not only wastes time but  the field of healthcare is filled with leaders and
could cause patient harm nursing is no exception
 the publication Working Nurse notes that the  specialized nurse practitioners frequently assume
most effective collaboration is interdisciplinary - leadership roles, taking charge of teamwork and
where each individual brings their area of collaborative efforts
expertise to the team to provide the best possible  the best leaders can adapt to different
care circumstances based on the team, patient care
 each member must understand their role and goals and the needs of the healthcare
expectations to achieve the team goal organization. Quality leader must be flexible
while helping their team members and other
3. Allow for Open Communication departments in an open and respectful manner
 because nurses interact with many people, from
patients to practitioners, they must develop keen
listening skills.
 those working alongside nurses may have their
individual feedback, suggestions or questions;
making active listening an important aspect of
team operations
 Wolters Kluwer, professional solutions provider,
notes that breakdowns in healthcare
communication can happen for various reasons:
a. when team members are transferred to another
department
DEVELOPMENT OF TEAWORK AND  About 25% of the infants between 15 and 18
COLLABORATION months reached for their own noses while
Self-awareness about 70% of those between 21 and 24
 it matters, the most successful leaders have months did so
always been obsessed with knowing themselves  Lewis and Brooks-Gunn study only indicates
better children might actually possess other forms of
 involves being aware of different aspects of the self-awareness even at this early point in life
self including  For example, researchers Lewis, Sullivan,
a. traits Stanger and Weiss suggested that
b. behaviors expressing emotions involves self-
c. feelings awareness as well as an ability to think about
 essentially, it is a psychological state in which oneself in relation to other people
oneself becomes the focus of attention
 one of the first components of the self-concept to
emerge. While self-awareness is something that Self-awareness Development
is central to who you are, it is not something that  researchers have proposed that an area of the
you are acutely focused on at every moment of brain known as the anterior cingulate cortex
every day located in the frontal lobe region plays an
 instead, it self-awareness becomes woven into important role in developing self-awareness
the fabric of who you are and emerges at different  studies have also used brain imaging to
points depending on the situation and you show that this region becomes activated in
personality adults who are self-aware
 people are not born completely self-aware  The Lewis and Brooks-Gunn experiment
 research has also found that infants do have suggest that self-awareness begins to
rudimentary sense of self-awareness emerge in children around the age of 18
 infants possess the awareness that they are a months, an age that coincides with the rapid
separate being from others, which is evidenced growth of spindle cells in the anterior
by behaviors such as the rooting reflex (related cingulate cortex.
to breastfeeding) in which an infant searches for  however, one study found that a patient
a nipple when something brushes against his or retained self-awareness even with the
her face extensive damage to areas of the brain
 researchers: even newborns are able to including the insula and the anterior cingulate
differentiate between self- and non-self touch cortex
 these areas of the brain are not required for
Self-awareness Emergence most aspects of self-awareness and that
 studies have demonstrated that a more complex awareness may instead arise from
sense of the awareness of the self begins to interaction distributed among brain
emerge at around one year of age and becomes networks
much more developed by approximately 18
months of age TYPES OF SELF-AWARENESS
 researchers Lewis and Brooks-Gunn performed  psychologists often break self-awareness
studies looking at how self-awareness develops down into two different types: either public or
 the researchers applied a red dot to an infant’s private
nose and then held the child up to a mirror 1. Public Awareness
 children who recognized themselves in the mirror  emerges when people are aware of how they
would reach for their own noses rather than the appear to others.
reflection in the mirror, which indicated that they  emerges in situations when people are at the
had at least some level of self-awareness center of attention, such as when giving a
 Lewis and Brooks-Gunn found that almost NO presentation or talking to a group of friends
children under one year of age would reach for  this type of self-awareness often compels
their own nose rather than the reflection in the people to adhere to social norms
mirror  when we are AWARE that we are being
watched and evaluated, we often try to
 WHAT ARE THE STAGES OF LIFE behave in ways that are socially “acceptable”
Infant = 0-1 year and “desirable”
Toddler = 2-4 years  can also lead to evaluation anxiety in which
Teen = 13-19 years people become distressed, anxious or worried
Adult = 20-39 years about how they are perceived by others
Middle-Age Adult = 40-59 years
Senior Adult = 60+ years
2. Private Awareness  Here is why self-awareness dramatically
 happens when people become aware of affects how the team collaborates,
some aspects of themselves, but only in a communicates, and performs. And how the
private way organization can benefit from it:
 examples
 seeing your face in the mirror THE CASE FOR SELF-AWARENESS
 feeling your stomach lurch when you  “Your own Self-Realization is the greatest
realize you forgot to study for an service you can render the world. (Ramana
important test or feeling your heart Maharshi)
flutter when you see someone you  Research by Tasha Eurich, author of Insight,
are attracted to. shows that self-awareness is the meta-skill of
the 21st century -- self-aware people are
Self-awareness on Self-Consciousness more successful, more confident, build better
 sometimes, people can become overly self- relationships, and are more effective leaders
aware and veer into what is known as self-  Eurich spent several years studying how self-
consciousness awareness impacts organizational behavior.
 have you ever felt like everyone was watching  The most prominent problem organizations
you, judging your actions and waiting to see face is not knowing what they don’t know.
what you will do next? This heightened state Blind spots, assumptions, and
of self-awareness can leave you feeling overconfidence hinder the performance of
awkward and nervous in some instances both individuals and teams
 in a lot of cases, these feelings of self-
consciousness are only temporary and arise
in situations when we are “in the spotlight”
 for some people, however, excessive self-
consciousness can reflect a chronic
condition such as social anxiety disorder
 people who are privately self-
consciousness have a higher level of private
self-awareness, which can be both a good
and bad thing
 Iceberg of ignorance
 these people tend to be more aware of their
 Staff see 100% of problems
feelings and beliefs and therefore more
 Self-awareness is much more than a
likely to stick to their personal values
personality assessment -- it’s learning to
 however, they are also more likely to suffer
observe yourself through other people’s eyes
from negative health consequences such
and yours too. It requires developing a
as increased stress and anxiety
mindful mentality to avoid being the prey of
 people who are publicly self-conscious have a
overconfidence and ignorance
higher level of public self-awareness
 they tend to think more about how other
people view them and are often concerned HIGH SELF-AWARENESS LEADS TO BETTER
that other people might be judging them TEAM PERFORMANCE
based on their looks or their actions  A simulation shows that it affects decision-
 as a result, these individuals tend to stick to making, coordination, and conflict
group norms and try to avoid situations in management
which they might look bad or feel  Probability of Success:
embarrassed.
 self-awareness is not something new.
throughout history, the most successful
leaders have always been obsessed with
knowing themselves
 self-awareness is having an accurate view of
one’s skills, abilities and shortcomings

 Sun Tzu Said: “If you know the enemy and

know yourself, you need not fear the result of
a hundred battles.”
 Self-awareness clearly increases hindering, rather than enabling, growth. The
performance. Interesting to note more people know their team members, the
organizations are not as self-aware as they better they can interact among each other
believe they are, the study shows.  Self-aware teams are more self-resilient,
 The good news? Organizations can self-confident, and more adaptive - they
dramatically benefit from it if they start taking share a common purpose
it seriously  Clarity doesn’t just help current members
 Fortunately, self-awareness can be nurtured collaborate; self-aware teams make the
immersion of newcomers much easier/
SEVEN WAYS TO DEVELOP SELF-AWARE  Open dialogue and candid feedback require
TEAMS a self-space
 “No one is free who has not obtained the  Psychological Safety is crucial for people to
empire of himself. No man is free who cannot speak up without the fear of being ignored,
command himself” (Pythagoras) criticized, or punished

1. Being present increases productivity 4. Turn awareness into a team practice

 Distraction is our worst enemy. Having focus is  Having the entire team play by the same
a scarce currency - the cost of “not paying rules, levels the playing field, if some
attention” is costing organizations $ 588 billion members have high self-awareness and
per annum in the US alone others are clueless, the team will still suffer
 People attend meetings or video conferences,  Self-awareness is a collective journey - the
but their minds are somewhere else whole team experiences the
 Being present is the better gift you can give transformation together
to your productivity  Encourage your team to engage in self-
 Promoting self-awareness removes awareness rituals every day
distractions - it helps people stay focused.  Promote ongoing feedback, not just annual
 Checking-in people’s mindset before a meeting 360 reviews. Feedback is a gift for your
creates both individual and collective organization - it’s necessary fuel for
awareness. Letting everyone share “What has continuous improvement
got your attention” is a useful practice to  Self-awareness is a collective journey - the
focus on being present whole team experiences the
transformation together
2. Move from blind spots to bright spots  Assigning Accountability Partners is a simple
 What you don’t know can get you into trouble practice we facilitate to turn everyone into a
 What you don’t know, you don’t know, blinds mirror; they can reflect what others are
you missing
 How you can implement this method:
⇒ 4 COMMON TYPES OF BLIND SPOTS o Turn every team member into a coach
1. Knowledge
2. Beliefs 5. Self aware people don’t fight reality - they
3. Thoughts adapt and thrive
4. Emotional Blindness  Adaptability is a critical advantage to thrive in
 That’s why teams make wrong decisions. a fast-paced and unexpected world.
Inaccurate assessments or members that  The problem is that most people resist reality -
overrate their contributions, damage they fight what they don’t know, what makes
performance and collaboration them feel uncomfortable or what they can’t
 Self-awareness can turn blind spots into understand
bright spots  Self-awareness encourages curiosity - rather
 Our blind spots lie at the intersection of how than resisting change, people pay attention
we perceive ourselves and how others and ask questions
perceive us  Accepting reality is not passive - it doesn’t
 Self-awareness is not just a personal journey - mean giving up either
it requires feedback from others to see what  Teams have to have an objective and
you are missing unfiltered assessment of reality
(Acknowledge), so they can understand why
3. Nurture a culture of clarity and things are happening (Learn), and adjust their
transparency mindsets, strategies, and behaviors (Adapt)
 (Mis) Communication is the main reason  Helpy your team embrace unknown, instead
behind most team tensions. The inability to of resisting it
discuss things openly - people see conflict as
 Health systems and physician organizations
face many complex challenges. To respond
6. Go deep, but mind the gap and proactively plan for these challenges, an
 Self-awareness is not an X-ray of who you are. organization’s management structure must
I see many organizations that believe that support its culture, demonstrate financial
developmental assessment tools (DiSC, The stewardship and have strong leadership
Core Values Index, etc.) provide self-  Dyad leadership, in its simplest form, is a
awareness. Uncovering biases and blind spots partnership. It’s the union of an administrative
- same as becoming more aware of how our leader and a physician leader forming a best-
mindsets and emotions get in the way - of-both-worlds structure. While the term has
requires going deep reappeared over the last 5-10 years, the model
 However, too much introspection can kill is not new. Dyad leadership dates back to
people. It’s essential that everyone leaves the 1908 at the Mayo Clinic when Will Mayo, MD,
room in a great mood. That’s why we recruited Harry Harwick to help him manage
incorporate games, improvisations, and other their growing business and operations
tricks and team activities to balance the spirit  Often a health system executive will say “I
have had a physician leader before and it
7. Encourage self-development, not just didn’t work out well “In a way, they’re right.
awareness Simply designating a leader, regardless of
 Team development is an ongoing practice, not clinical or administrative roles does not
just a one-off. The same way that guarantee success. Likewise, simply having a
developmental assessment tools only provide dyad structure does not resolve leadership and
a snapshot, holding a self-awareness structural voids
workshop won’t change much  Recruiting your physician dyad counterparts
 We normally experience a dramatic should take as much time and effort as
transformation in just a few hours of coaching recruiting your administrative leaders
teams.  After all, these individuals will spearhead
 However, building a practice requires clinical strategy, act as change agents and
consistency and time advocate for initiatives to their physician peers
 Self-development is an ongoing practice -  There is a set of shared attributes for leaders
it’s a habit that takes a lifetime to master it that will increase the likelihood of success
 Whatever plans you have to increase your 1. Effective communication
team’s self-awareness, follow-up is critical. 2. Enjoy working as part of high-
Artists and athletes practice most of the time, performing team
and then play; in business is the other way 3. Able to solve complex problems
around. 4. Respected by their peers
 Developing self-awareness requires  Dyad leadership has proven to be an effective
preparation - set aside “practice time”. Equip and differentiating leadership model. Research
your team with tools and methods that they indicates that there are three critical success
can implement (and adapt) on their own factors for high-performing dyads
 Long-lasting change happens from within
 Prepare your team by showing them the 1. Role definition: Each leadership role has
benefits of self-awareness. Involve your people disciplined scoping and explicit delineating of
from the start - self-awareness can’t be responsibility
imposed, they need to own it  The most effective dyads delineate roles. They
 Making “self-awareness” a company priority is do not duplicate work; rather, they are
not enough - develop the right conditions. advocates and supporters of each other.
 Provide a safe space, proper tools, and  Communication is critical, and both parties must
coaching, Keep it simple. Start small understand their share of the common work
 Self-awareness doesn’t happen overnight - it’s
a lifetime journey. It’s time to take the first step 2. Accountability: Leaders are held
accountable for specific, measurable goals -
DYAD some shared, some separate, but always
 “Dyads are mini-teams of two people who work complementary
together as co-leaders of a specific system,  High-performing dyads are held accountable to
division, clinical service line or project” goals and performance toward these goals.
 Dyad leadership in Healthcare: When One This is standard practice for administrative
Plus One is Greater than Two leaders. Performance management goals for
 77% of healthcare leaders utilize a dyad clinician leaders are less common but
leadership model increasingly adopted. Within the dyad structure,
goals should be individual and shared and
always complementary

PRACTICAL APPLICATION
1. What does a dyad leadership model look like
in practice?
2. High-performing groups embed dyad
leadership throughout all levels of the
organization
 Work with an organization that established
dyad leaders at the executive level, at the  The leader has his own roles and
specialty administrator level and at individual responsibilities but the two should be
practice sites together in a dyadic relationship and should
 This deep dyad implementation established a come up with a common goal
consistent structure across the organization.  Dyadic leadership theories consider how and
It created opportunities for physician why a leader’s behavior may vary across
leadership and development, and it individuals (as followers)
positioned the physician enterprise to  In addition, both parties have considerable
succeed in a rapidly changing, complex influence on how their relationship gradually
environment. forms
 Most important, this structure exponentially  Leader-member exchange theory is the most
multiplied the number of clinical champions popular theory of this field
across the organization’s practice sites and
specialties and created leadership teams to DEFINING DYAD AND TRIAD LEADERSHIP
handle difficult conversations and obstacles
DYAD - a partnership where an Administrative or
Nurse Leader is paired with a Physician Leader,
bringing together complementary skills and expertise

TRIAD - bringing all three together as partners -

Nurse Leader, Physician Leaders, and Administrator
- for complementary skills and expertise

MODEL OF DYAD CARE

 Nurse-doctor dyadic relationship

LEADER MEMBER EXCHANGE

GROUP
 A group is a collection of individuals who 3. Managed Group
interact with each other such that one 4. Process Group
person’s actions have an impact on the 5. Semi-Formal Groups
others 6. Goal Group
 A group is defined as two or more 7. Learning Group
individuals, interacting and interdependent, 8. Problem-Solving Group
who have come together to achieve 9. Friendship Group
particular objectives 10. Interest Group
 In organizations, most work is done within
groups
 Groups where people get along, feel the 1. FORMAL GROUP
desire to contribute to the team, and are  Formal groups are created to achieve
capable of coordinating their efforts may specific organizational objectives. Usually,
have high-performance levels they are concerned with the coordination of
 The definition of a group can be given by work activities
some other simple ways like:  People are brought together based on
 Several people or things that are together or different roles within the structure of the
in the same place organization. The nature of the task to be
 Several people who are connected by some undertaken is a predominant feature of the
shared activity, interest or quality formal groups
 Several individuals assembled or having  Goals are identified by management and
some unifying relationship short and rules relationships and norms of
 A set of people who meet or do something behavior established. Formal groups chain to
together because they share the same be related to permanent although there may
purpose or ideas be changes in actual membership
 However temporary formal groups may be
FUNCTIONS OF A GROUP created by management, for example, the
 The organizational functions of groups help use of project teams inn a matrix
to realize an organization’s goals organization
 Such functions include the following:
1. Working on a complex and 2. INFORMAL GROUP
independent task that is too complex  Within the formal structure of the
for an individual to perform and that organization, there will always be an informal
cannot be easily broken down into structure
independent tasks  The formal structure of the organization and
2. Generating new ideas or creative system of role relationship, rule, and
solutions to solve problems that procedures, will be augmented by
require inputs forms several people interpretation and development at the
3. Serving liaison or coordinating informal level
functions among several workgroups  Informal groups are based more on personal
whose work is to some extent relationships and agreement of group’s
independent members than on defined role relationships.
4. Facilitating the implementation of They serve to satisfy psychological and
complex decisions. A group social needs not related necessarily to the
composed of representatives from tasks to be undertaken
various working groups can  Groups may devise ways of attempting to
coordinate the activities these satisfy member’s affiliations and other social
interrelated groups motivations that are lacking in the work
5. Serving as a vehicle for training new situation, especially in industrial
employees, groups teach new organizations
members methods of operations and
group norms 3. MANAGED GROUP
 Groups may be formed under a named
TYPES OF A GROUP manager, even though they may not
 Groups may be classified according to many necessarily work together with a great deal.
dimensions including function, the degree of The main thing they have in common, at
personal involvement, and degree of least the manager and perhaps a similar type
organization of work
1. Formal Group
2. Informal Group 4. PROCESSED GROUP
 The process group acts together to enact a similar age or ethnic heritage, support for
process, going through a relatively fixed set Kolkata Knight Riders cricket, or the holding
of instructions. The classic environment is a of similar political views, to name just a few
manufacturing production line, where every such characteristics
movement is prescribed
 There may either be little interaction within 10. INTEREST GROUP
process groups or else it is largely  People who may or may not be aligned into a
prescribed, for example where one person command or task groups may affiliate to
hands something over to another attain a specific objective with which each is
concerned. This is an interest group
5. SEMI-FORMAL GROUP  Employees who band together to have their
 Many groups act with less formality, in vacation schedules altered, to support a peer
particular where power is distributed across who has been fired, or too seek improved
the group, forcing a more collaborative working conditions represent the formation of
approach that includes- negotiation rather a united body to further their common
than command and control interest
 Families, communities, and tribal groups
often act as semi-formal ways as they both TEAM
have nominal leaders yet members can have  A team is a group of individuals (human or
a high degree of autonomy non-human) working together to achieve
their goal
6. GOAL GROUP  Team is a group of people who are
 The goal group acts together to achieve a interdependent with respect to information,
shared objective or desired outcome. Unlike resources, knowledge, and skills and who
the process groups, there is no clear seek to combine their efforts to achieve a
instruction on how they should achieve this, common goal
although they may use some processes and  A group does not necessarily constitute a
methods along the way team
 As there is no detailed instruction, the  Teams normally have members with
members of the goal group need to bring complementary skills generate synergy
more intelligence, knowledge, and through a coordinated effort which allows
experience to the task each member to maximize their strengths
and minimize their weaknesses
7. LEARNING GROUP  Naresh Jain (2009) claims: Team members
 The learning group comes together to need to learn how to help one another, help
increase their net knowledge. they may act other team members realize their true
collaboratively with discussion and potential and create an environment that
exploration, or they may be a taught class, allows everyone to go beyond their
with a teacher and a syllabus limitations

8. PROBLEM-SOLVING GROUP TEAM NURSING

 Problem-solving groups come together to  Team nursing is a system of integrated care
address issues that have arisen. They have that was developed in the 1950s directed by
a common purpose in understanding and Eleanor Lambertson at Teachers College,
resolving their issue, although their different Columbia University in New York, NY.
perspectives can lead to particular  Because the functional method received
disagreements criticism, a new system of nursing was
 Problem-solving may range along a devised to improve patient satisfaction
spectrum from highly logical and  Difficult problems require creative solutions.
deterministic to uncertain and dynamic None of us are strangers to the nursing
situations their creativity and instinct may be shortage affecting nurses and patients
better ways of resolving the situation everyday in the US
 Since this problem doesn’t look like it’s going
9. FRIENDSHIP GROUP away anytime soon, as nurse innovators,
 Groups may often develop because it’s time we put our thinking caps on.
individual members have one or more  A novel solution to staffing demands may be
common characteristics. We call these new formations of an old practice,
formations of friendship groups somethings called the Team Nursing Model
 Social alliances, which frequently extend
outside the work situation, can be based on THE CONCEPT OF TEAM NURSING
 The concept dates back to WWII when  general concept can be applied in various
nurses were pulled away from the bedside. care settings and situations. The key is to
Forced to come up with a way to still care for keep in mind the unique problems that the
patients, the use of nurse aides increased unit staffing has, and then cater this concept
drastically. Hospitals found that they could to those specific issues.
quickly train nurse aides to decrease the  Its flexibility is what allows it to shine in so
workload of hard-pressed nurses by allowing many different scenarios.
them to focus only on tasks that their
specialized training and education prepared
them to do
 What this typically looks like today is a HEALTH CARE TEAM
charge nurse (RN), and ancillary personal The healthcare team, regardless of whether you’re
(often a CNA or similar nursing aid) working treated at a large academic institution or a small,
together as team members to care for a rural private practice, is the group of professionals
group of patients who contribute to your care and treatment as a
 Though this is the most common format for patient.
Team Nursing today, variations of this Typical members of a healthcare team are a doctor
concept are endless and may prove to help and a registered nurse.
combat the nursing shortage. Who is the Healthcare Team?
 Staffing strategies can vary from facility to  Doctors
facility as we work to be open to ways in  Physician Assistants
which we can best work together to provide  Nurses
the highest quality of care for our patients  Pharmacists
 Dentists
Other Examples of Team Nursing  Technologists and technicians
 RN is more knowledgeable than the LPN.  Therapists and rehabilitation specialists
CNA is not allowed to give medications.  Emotional, social and spiritual support providers
 Using this model is actually more traditional  Administrative and support staff
to the way in which LPNs have worked in  Community health workers and patient
hospital settings. However, some hospitals navigators
are recently finding it to be especially
beneficial when they do not have enough Doctors
RNs to cover the patient care load.  Doctors, or physicians, are key members of the
 More ample staffed units will assign RNs an healthcare team.
additional RN to act as a partner that works  have years of education and training.
closely with them to cover lunches, pass out a. Primary Care Doctors
late medications, and provide support and  When patients need medical care, they
second opinions on cases that may require first go to primary care doctors.
more experience or expertise than one of  Primary care doctors focus on preventive
them has alone healthcare.
 In this case, the nurses will give/get handoff  This includes regular check-ups, disease
together on all their collective patients so screening tests, immunizations and
they are aware of the background for each health counseling.
patient  Primary care doctors may be family
 In this partnered form of nursing, patient practitioners, internal medicine or
ratios will likely stay the same as before the Osteopathic Doctors (OD's).
partnering since the partner is only meant to  Pediatricians also provide primary care
act as a resource to the primary RN. for babies, children and teenagers.
 Anecdotes have shown that partnering Primary care pediatricians treat day-to-
nurses together can be helpful in units with day illnesses and provide preventive
high number of novice nursing staff and new care such as minor injuries, viral
hires (looking at you, new grad nurses) infections, immunizations and check-
 Giving a novice nurse or new hire a more ups.
seasoned or senior nurse as a partner can  Cater to different simple cases
build relationships and take pressure off a b. Specialists
charge to act as the only resource  Specialists diagnose and treat conditions
 With fewer RNs available and more to get that require a special area of knowledge.
creative and build a team of competent  Patients may see a specialist to
caregivers to provide the best experience for diagnose or treat a specific short-term
patients condition or, if they have a chronic
disease, they may see a specialist on an blood), meningitis, and
ongoing basis. pneumonia.
 Examples of specialties include:
endocrinology, dermatology and Internal Medicine Internal organs and their
obstetrics. diseases

Neonatology Newborn baby conditions and

diseases

Nephrology Kidney disease

MEDICAL SPECIALISTS Neurology Nervous system: brain, spinal
cord, and nerves
Allergy and Allergic reactions to food,
Immunology medications, insect stings, and Obstetrics Care for women during and after
environment; asthma and other pregnancy
lung problems
Oncology Cancer; cancer treatment such
Anesthesiology Medication to help patients as surgery, chemotherapy,
manage pain or sedate them radiation, biotherapy, pain
during surgery management

Cardiology Heart, blood vessels, and the Ophthalmology Eye disease

circulatory system (blood
vessels) Optometry Eye exams and lenses (glasses
and contact lenses);
Chiropractic Adjusting areas of the body and Optometrists are not medical
Medicine spine to prevent or treat disease doctors
and improve nerve function
Orthopedics Bones, joints, muscles, tendons,
Critical Care Acute, life-threatening illness or ligaments and nerves
Medicine injury, usually in a hospital’s ICU
(Intensive Care Unit) or CCU Otolaryngology Ear, nose, sinuses, throat
(Critical Care Unit). (Ear, Nose, and (larynx) and upper airway
Throat)
Dentistry Diseases of the teeth and mouth
Pain Management Pain management through
Dermatology Skin, hair and nail disease medication, exercise, stress
reduction or relaxation
Emergency Life-threatening medical
Medicine conditions or injuries, usually in a Pathology Tissues, blood, urine and other
hospital emergency room body fluid to diagnose or treat
medical conditions
Endocrinology and Hormones and glands such as
Metabolism the thyroid, pituitary, adrenal, Pediatrics Newborn, infants, children and
pancreas, ovaries and testes; adolescent healthcare
also deals with diabetes
Physical Medicine Restoring function and
Gastroenterology Digestive system organs such as and Rehabilitation movement for people with
the esophagus, stomach, bowel disabilities or injuries
(large and small intestines), liver,
gall bladder and pancreas Plastic Surgery Reconstruct, restore function or
change the look of face or body
Geriatric Medicine Conditions and issues related to
older people Podiatry Foot and ankle treatment or
corrective devices
Gynecology Female reproductive system and
fertility disorders (also see Preventive Healthcare, education or
Obstetrics and Gynecology) Medicine counseling to help prevent or
delay disease
Hematology Blood and blood-producing
organs; disorders such as Psychiatry Brain or nervous system
anemia, leukemia and lymphoma disorders; treatment of drug or
chemical abuse; Psychiatrists
Infectious Disease Infections and diseases that can are medical doctors (MD)
be passed from person to person
such as bacterial infections, viral Psychology Mental health; treat patients
infections, parasites, sepsis through counseling or
(infection or bacteria in the psychotherapy (”talk” therapy);
Psychologists are not medical
doctors, but may have either a o advanced practice RN who earned a
Doctor of Psychology (PsyD) or master’s/doctor’s degree in nursing
a doctor of philosophy degree o assess, diagnose, treat patients, and
(PhD) extends to health care management and
research
Pulmonary Lung and respiratory (breathing)  Nurse Anesthetist
Medicine system
o administers anesthesia for cergy and
Radiology X-rays, ultrasound and imaging other medical procedures
techniques such as o varying levels of autonomy
Computerized Tomography (CT o provide pain medication care before,
Scan) and Magnetic Resonance during and after surgery
Imaging (MRI) o keep patients asleep/pain-free
Rheumatology Muscles, tendons or joint  Nurse Midwife
disease; inflammation and o both nurse and midwife
autoimmune diseases such as  Nurse Practitioner
arthritis, rheumatism, gout, o advanced practice RN and mid-level
lupus, scleroderma, and Lyme practitioner
disease o NPs are trained to assess px needs, order
and interpret diagnostic and lab tests,
Sports Medicine Sports-related injuries and
therapy
diagnose disease, formulate prescribed
treatment plans
Surgery Operations to remove, repair or
replace body parts Difference between an NP and a Doctor
 Amount of time spent on training. While NPs
Toxicology Detecting and treating poisons or
harmful substances have more training than a registered nurse, they
receive less training than a doctor.
Urology Urinary tract (male and female);  Licensed differently. In California, nurse
male reproductive organs practitioners are licensed by the Nursing Board
and MDs are licensed by the Medical Board.
Physician Assistants (PA's)  Ease of access. Patients can often get an
 Physician's Assistants are licensed to practice appointment to see an NP sooner than they can
medicine and are supervised by a doctor. get in to see a doctor.
 Their training is similar to a doctor's but they do Similarities between an NP and a Doctor
not complete an internship or residency.  Diagnose and treat acute conditions
 Like a medical doctor, a physician's assistant  Order diagnostic tests like X-rays or lab work
can perform physical exams, order tests,  Manage a patient's overall care
diagnose illnesses and prescribe medicine,  Serve as a primary care provider
assist in surgery, provide preventive Healthcare  Be board-certified in specialties like family
counseling. practice or women's health
 Education for PA's includes a 4-year degree plus  NPs can also write prescriptions. In California,
a 2-year Physician Assistant program. most NPs work under the supervision of a
cooperating physician to prescribe medication to
Nurses patients.
 Nurses work closely with patients.
 A nurse’s job duties depend on their education, Pharmacists
area of specialty and work setting. Types of  give patients medicines that are prescribed, or
nurses include: recommended, by a doctor.
a. Licensed Practical Nurses (LPN)  tell patients how to use medicines and answer
 aka Licensed Vocation Nurses questions about side effects.
 train for about one year at a community  Sometimes help doctors choose which
college or vocational school and are medicines to give patients and let doctors know
licensed by their state. if combinations of medicines may interact and
b. Registered Nurses (RN’s) harm patients.
 licensed by their state. T  have a PharmD degree and are licensed by the
 have associate’s (2-year) degree or a state.
bachelor’s (4-year) degree.  PharmD education may take five or six years
c. Advanced Practice Nurses and is a combination of college courses and
 have more education and experience than pharmacy school.
RN’s.
 Clinical Nurse Specialist (CNS)
 Pharmacists who work in a clinical setting, such  There are no standard training
as a hospital or long-term care facility, must also requirements for pharmacy technicians, but
complete 1-2 years of residency. some
 States require a high school diploma or its
Dentists equivalent. Some pharmacy technicians
 diagnose and treat problems with teeth and are trained on-the-job and others complete
mouth, along with giving advice and a certificate, which takes 6 months to 2
administering care to help prevent future years. Licensing is not required, but in
problems. most states, pharmacy technicians must
 teach patients about brushing, flossing, fluoride, register with the state board of pharmacy
and other aspects of dental care. They treat
tooth decay, fill cavities and replace missing
teeth. Some dentists are specialists.
 It takes six to eight years to become a dentist. Therapists and Rehabilitation Specialists
This includes 2-3 years of college or a 4-year  help people recover from physical changes
bachelor's degree and 4 years of dental school. caused by a medical condition, chronic
 A dental specialty takes another 2-4 years of disease or injury.
education or residency. Dentists are licensed by a. Occupational Therapists
passing a written and hands-on test  help patients perform tasks needed for every-
day living or working.
Technologists and Technicians  work with patients who have physical, mental or
 have a technical role in diagnosing or treating developmental disabilities. This includes stroke
disease patients who have lost function on one side of
 work in a variety of settings. Examples of their body, heart or lung disease patients with
technologists and technicians include: activity or breathing limitations, or diabetes
a. Laboratory Technologists patients who have had a limb amputated.
 aka medical technologists  help clients find new ways to dress, cook, eat or
 help providers diagnose and treat disease work.
by analyzing body fluids and cells.  May visit patients in their home or workplace to
 look for bacteria or parasites, analyze find adaptive equipment or teach patients new
chemicals, match blood for transfusions, or ways to do things.
test for drug levels in the blood to see how  May have a master's or doctoral degree and are
a patient is responding to treatment. licensed by their state
 Most lab tech positions require a 4-year b. Physical Therapists (PT's)
bachelors’ degree and some states require  help patients when they have an injury,
a license. disability or medical condition that limits their
b. Radiology Technologists ability to move or function.
 also called radiographers, help providers  Test a patient's strength and ability to move and
diagnose and treat disease by taking x- create a treatment plan.
rays.  goal of treatment: improve mobility, reduce
 For some procedures technologists make a pain, restore function prevent further disability.
solution that patients drink to help soft body  may treat patients who have had an
tissues can be seen. amputation, stroke, injury or chronic disease.
 can specialize in computed tomography  required to have a license and may have a 2-
(CT scans), Magnetic Resonance Imaging year master's or a 3-year doctoral degree.
(MRI’s) or mammography c. Respiratory Therapists
 Most radiology technologists complete a 2-  treat and care for patients with breathing
year an associate degree, but some have a problems.
4-year bachelor's degree or a certificate,  work with all types of patients including
which takes 21-24 months. Licensing premature babies, older people with lung
requirements vary by state. disease, or patients with asthma or
c. Pharmacy Technicians emphysema.
 help pharmacists prepare prescription  require an associate's degree, but many have a
medications. bachelor's degree. A license is required in most
 provide customer service and perform state
administrative duties such as take d. Speech Therapists
prescription requests, count pills, label  aka speech-language pathologists
bottles and prepare insurance forms.  work with patients who have problems related
to speech, communication or swallowing. These
problems may be caused by cancer, stroke or
brain injury. Speech therapists tailor care plans 
schedule appointments, answer phones, greet
to each patient's needs. patients, keep medical records, handle medical
 If a patient has a problem speaking, the billing, fill out insurance forms, arrange for
therapist may teach them to use communication laboratory or other diagnostic services, and
devices, sign language or alternative ways to handle financial records.
communicate.  Some job titles of administrative or clerical staff
 For problems swallowing, they may teach include:
patients to strengthen muscles or new ways to o Clinic Coordinator
swallow food and liquids without choking. o Administrative Medical Assistant
 Most states license speech-language o Medical Records Specialist
pathologists and require a master's degree o Medical Billing Specialist
o Financial Counselor
o Scheduler
Emotional, Social and Spiritual Support Volunteers
Mental Health Professionals  important part of the healthcare team.
help with the emotional aspect of living with a  The duties of volunteers can vary widely.
chronic disease. Volunteers may have administrative duties and
a. Psychiatrists work in reception areas or gift shops.
 medical doctors (MD's) who diagnose and treat  In a medical office they may file documents,
mental, emotional and behavioral disorders. answer phones, help with health screening or
This includes disorders of the brain, nervous deliver documents to various parts of the
system and drugs or chemical abuse. hospital.
b. Psychologists  "Advanced Volunteers" have special training
 deal with mental processes, especially during and may work closely patients under the
times of stress. They are not medical doctors, supervision of a nurse or doctor
but have a Doctor of Psychology (PsyD) or a
doctor of philosophy degree (PhD). Most Community Health Workers and Patient
psychologists do not prescribe medicine, but Navigators
treat patients with counseling and  Community Health Workers/Outreach Workers,
psychotherapy ("talk" therapy). work in community settings.
c. Social Workers  link patients to primary care providers, health
 help patients and families cope with emotional, information, health screening, financial
physical and financial issues related to an assistance or transportation.
illness. Patient navigators
 Depending on a patient's need a social worker  usually work in a clinic or a hospital. They work
may help coordinate services such as housing, closely with patients to reduce the barriers that
transportation, financial assistance, meals, keep them from getting Healthcare. Barriers
long-term care, or hospice care. may be related to low income, transportation,
 may also refer patients to mental health childcare, language or ability to read forms and
professionals for emotional or substance understand the healthcare system.
abuse support. Social workers have a master's a. Level 1 Patient Navigator
degree and are licensed by the state.  work with patients through the screening
d. Clergy and diagnosis phase. lay healthcare
 Religion or spirituality can be important for workers with some college
people coping with illness. b. Level 2 Patient Navigator
 Members: priests, ministers and rabbis provide
 may work with patients through the
patients with spiritual support.
 listen to patients, counsel them on religious or treatment phase, into survivorship or
spiritual philosophy. They may also perform health maintenance and end of life
religious sacraments or rites such as special Real Life: How does one patient navigator interact
with the healthcare team?
blessings, communion or last rights.
 When there is a cultural, language or other issue that
The Affect of Religion on Health
the doctor should know about, Veronica explains the
For nearly 90% of hospitalized, seriously ill patients in one
situation to the doctor. She also translates for
study indicated that religion helped them cope. Patients in
doctors and patients during medical appointments.
other studies indicated that religious belief and practice
helped prevent depression.  Veronica meets regularly with oncology nurses to
discuss specific patients. Nurses let her know when
test results come back so she can make a follow-up
Administrative and Support Staff visit with the patient.
facilitate patient care within the hospital system.  Veronica works with administrators to coordinate
Administrative and Clerical Staff patient appointments and make sure medical records
 Coordinate and facilitate patient care. are available. This helps patients go through the
process of diagnosis and treatment as quickly as the patient. Ideal MDT for the delivery of care
possible. consists of:
o General Practitioners
Chronic disease team o Practice Nurses
 Different chronic diseases require different o Community Health Nurses
healthcare team members. o Allied Health Professionals (mix of GO and
 eg. a patient with cancer may see a primary NGO health professionals)
care provider, a medical oncologist, oncology  PT/OT
nurse and radiologist.  Dieticians
 eg. Cancer Specialists, Diabetes Specialists,  Psychologists
Heart and Pulmonary Disease Specialists  Social workers
 Podiatrists
 Aboriginal Health Workers
IV-2 MULTIDISCIPLINARY TEAMS o Health Educators (eg. diabetes educator)
MDTs are the mechanism for organising and MDT requires:
coordinating health and care services to meet the  respect and trust between team members
needs of individuals with complex care needs.  the best use of the skill mix within the team
 bring together the expertise and skills of  agreed clinical governance structures
different professionals to assess, plan and  agreed systems and protocols for
manage care jointly. communication and interaction between team
 found in health care, education, business and members
community organizations
 broaden the conversation, solve problems and
realize faster outcomes; transformative in most
organizational applications
 Consists of:
a. psychiatrists
b. clinical nurse specialist/community mental
health nurses
c. psychologists
d. social workers
e. occupational therapists
f. medical secretaries
g. others (counsellors, drama therapists, art
therapists, advocacy workers, care workers)
Example:
 When a child is exhibiting extreme behavioral
issues in school, a MDT approach provides
comprehensive intervention. American
Academy of Special Education Professionals
explains that the team composition for this
situation would be as follows:
o School Psychologist
o School Nurse
o Classroom teacher
o Special Education Teacher
o Special Education Supervisor
o Behavioral consultant
o School social worker
o Educational diagnostician
o Physical therapist
o Speech/language
o Occupational therapist
o Parents
o Audiologist
o Guidance counselor
 As a patient's condition changes over time, the
composition of the team may change to reflect
the changing clinical and psychological needs of