SCIENTIFIC KNOWLEDGE BASE FACTORS AFFECTING OXYGENATION

- Oxygen is needed to sustain life. PHYSIOLOGICAL FACTORS

- Blood is oxygenated through the mechanisms of ventilation, diffusion - Decreased Oxygen-Carrying Capacity
and perfusion. - Hemoglobin carries the majority of oxygen to the tissues. Anemia
- Neural and chemical regulators control the rate and depth of and inhalation of toxic substances decrease the oxygen-carrying
respiration in response to changing tissue oxygen demands. capacity of blood by reducing the amount of available hemoglobin to
- Cardiovascular systems provide the transport mechanisms to transport oxygen. The physiological response to chronic hypoxemia is
distribute oxygen to cells and tissues of the body. the development of increased red blood cells (polycythemia). This is
the adaptive response of the body to increase the amount of
PROCESS OF OXYGENATION hemoglobin and the available oxygen-binding sites
- Carbon monoxide is a colorless, odorless gas that causes decreased
- Ventilation – process of moving gasses into and out of the lungs
oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly
(oxygen and carbon dioxide).
binds with CO, creating functional anemia. Because of the strength
- Diffusion – exchange of respiratory gasses in the alveoli and
of the bond, CO does not easily dissociate from hemoglobin, making
capillaries.
hemoglobin unavailable for oxygen support
- Perfusion – ability of the cardiovascular system to pump oxygenated
blood to the tissues and return deoxygenated blood to the lungs - Hypovolemia
- Conditions such as shock and severe dehydration cause extracellular
STRUCTURE OF RESPIRATORY SYSTEM fluid loss and reduced circulating blood volume, or hypovolemia.
Decreased circulating blood volume results in hypoxia to body
tissues. With significant fluid loss, the body tries to adapt by
peripheral vasoconstriction and by increasing the heart rate to
increase the blood volume returned to the heart, thus increasing the
cardiac output.
- Decreased Inspired Oxygen Concentration
- Decreases in the fraction of inspired oxygen concentration (FiO2) are
caused by upper or lower airway obstruction which limits delivery of
inspired oxygen to alveoli; decreased environmental oxygen (at high
altitudes); or hypoventilation (occurs in opiate overdoses)
- Increased Metabolic Rate
- Increased metabolic activity increases oxygen demand. An increased
metabolic rate is normal in pregnancy, wound healing, and exercise
because the body is using energy for building tissue. The level of
RESPIRATORY PHYSIOLOGY oxygenation declines when cardiopulmonary systems are unable to
- The exchange of respiratory gasses occurs between the environment meet this demand
and the blood. CONDITIONS AFFECTING CHEST WALL
- Respiration is the exchange of oxygen and carbon dioxide during
- Pregnancy
cellular metabolism.
- Airways of the lung transfer oxygen from the atmosphere to the alveoli, - As the fetus grows during pregnancy, the enlarging uterus pushes
where the oxygen is exchanged for carbon dioxide. abdominal contents upward against the diaphragm. In the last
- Through the alveolar capillary membrane, oxygen transfers to the trimester of pregnancy, the inspiratory capacity declined, resulting in
blood and carbon dioxide transfers from the blood to the alveoli. dyspnea on exertion and increased fatigue
- Obesity
ALTERATIONS IN RESPIRATORY FUNCTIONING - Patients who are morbidly obese have reduced lung volumes from
- Hypoventilation- occurs when alveolar ventilation is inadequate to the heavy lower thorax and abdomen, particularly when in recumbent
meet oxygen demand of the body or eliminate sufficient carbon and supine positions; this often causes obstructive sleep apnea.
dioxide. Morbid obesity creates a reduction in a patient’s lung and chest wall
- Hyperventilation- state of ventilation in which lungs remove carbon compliance as a result of encroachment of the abdomen into the
dioxide faster than its produced cellular metabolism. chest, increased WOB, and decreased lung volumes.
- Hypoxia- inadequate tissue oxygenation at the cellular level. - Musculoskeletal Abnormalities
- Symptoms of hypoxia: - Musculoskeletal impairments in the thoracic region reduce
- Restlessness oxygenation. Such impairments result from abnormal structural
- Anxiety configurations, the trauma, muscular diseases, and diseases of the
- Tachycardia central nervous system. Abnormal structural configurations
- Bradycardia impairing oxygenation include those affecting the rib cage, such as
- Extreme restlessness pectus excavatum, and the vertebral column such as kyphosis,
- Dyspnea lordosis, or scoliosis
- In pediatrics: - Trauma
- Feeding difficulties - Any rib fracture or bruising causes pain and resultant reduced
- Inspiratory stridor ventilation. Flail chest is a condition in which multiple rib fractures
- Nares flare cause chest wall instability. This instability causes the lung under
- Respiratory grunting the injured area to contract on inspiration and bulge on expiration,
- Sternal retractions resulting in hypoxia. Patients with thoracic or upper abdominal
surgical incisions use shallow respirations to avoid pain, which
decreases chest wall movement. Opioids for pain depress the
respiratory center, further decreasing the respiratory rate and chest
wall expansion.
- Neuromuscular Diseases. pressure, decreased cholesterol level, increased blood flow, and
greater oxygen extraction by working muscles.
- Neuromuscular diseases affect tissue oxygenation by decreasing a
patient's ability to expand and contract the chest wall. Ventilation is - Smoking
impaired, resulting in atelectasis, hypercapnia, and hypoxemia - Cigarette smoking worsens peripheral vascular and coronary artery
- Central Nervous System Alterations diseases. Inhaled nicotine causes vasoconstriction of peripheral and
coronary blood vessels, increasing blood pressure and decreasing
- Diseases or trauma of the medulla oblongata and/or spinal cord
blood flow to peripheral vessels.
result in impaired ventilation. When the medulla is affected, neural
regulation of ventilation is impaired, and abnormal breathing - Substance abuse
patterns develop. Cervical trauma at C3 and C5 usually results in - Excessive use of alcohol and other illicit drugs impairs tissue
paralysis of the phrenic nerve. When the phrenic nerve is damaged, oxygenation in two ways. First, the person who chronically abuses
the diaphragm does not descend properly, thus reducing inspiratory substances often has a poor nutritional intake substance abuse by
lung volumes and causing hypoxemia. Spiral cord trauma below the either smoking or inhaling substances such as crack cocaine or
C5 vertebra usually leaves the phrenic nerve intact but damages fumes from paint or glue cans causes direct injury to lung tissue
nerves that innervate the intercostal muscles, preventing that leads to permanent lung damage
anteroposterior chest expansion.
- Stress
- Influences of Chronic Disease
- Stress is a perceived threat that results in sympathetic stimulation.
- Oxygenation decreases as a direct consequence of chronic lung Continuous stress adversely affects a patient’s health and
disease due to alveolar and/or airway alterations. Changes in the well-being. A continuous state of stress increases the metabolic rate
anteroposterior diameter of the chest wall (barrel chest) occur and oxygen demand of the body. Stress causes an increased release
because of overuse of accessory muscles and air trapping in COPD or of cortisol, which affects the metabolism of fat and creates a risk for
cystic fibrosis. Chronic lung disease results in varying degrees of CAD and hypertension.
dyspnea, tachypnea, hypoxemia, and/or hypercapnia
DEVELOPMENTAL FACTORS
ASSESSMENT
- Infants and toddlers
- Nursing history:
- Healthy full-term infants younger than 3 months of age are
- Health Risk
presumed to have a lower infection rate because of the protective
function of maternal antibodies. The infection rate increases in - Determine familial risk factors such as a family history of lung
infants from to 6 months of age. Infants and toddlers are at risk for cancer or cardiovascular disease. Documentation includes blood
upper respiratory tract infections, especially when they are exposed relatives who had cardiopulmonary disease and their present level
to secondhand smoke or other children. Upper respiratory tract of health or age at time of death. Assess for an exposure to
infections are usually not dangerous, and infants and toddlers infectious organisms, such as tuberculosis (TB). also assess for
recover with little difficulty. Infants and toddlers are also at risk for occupational and environmental risk factors (e.g., asbestos
airway obstruction because of their anatomically smaller airways exposure)
and their tendency to place foreign objects in their mouths - Pain
- School-age children and adolescents - The presence of chest pain requires an immediate thorough
- School-age children and adolescents are exposed to respiratory risk assessment, including location, duration, radiation, and frequency.
factors such as cigarette smoking or secondhand smoke. This In addition, it is important to note any other symptoms associated
age-group is also at risk for experimenting with cigarette smoking with chest pain, such as nausea, diaphoresis, extreme fatigue, or
and other recreational inhalants. School-age children and weakness.
adolescents possess other cardiopulmonary disease risk factors - Chest pain in men is most often on the left side of the chest and
such as obesity, inactive lifestyles, unhealthy diets, and excessive radiates to the left arm. Chest pain in women is much less
use of caffeinated beverages or other energy drinks. definitive and often manifests itself as a sensation of
breathlessness, jaw or back pain, nausea, and/or fatigue.
- Young and middle-age adults
- Pleuritic chest pain results from inflammation of the pleural space
- Young and middle-age adults are exposed to multiple of the lungs; the pain is peripheral and radiated to the scapular
cardiopulmonary risk factors: an unhealthy diet, lack of exercise, regions. Inspiratory maneuvers such as coughing, yawning, and
stress, over-the-counter and prescription drugs not used as sighing worsen pleuritic chest pain. Patients usually describe it as
intended, illegal substances, and smoking. Reducing these knifelike, lasting from a minute to hours and always in association
modifiable factors decreases the patient’s risk for cardiopulmonary with inspiration.
diseases. This is also the time when individuals establish lifelong
- Fatigue
habits and lifestyles.
- Fatigue is a subjective sensation in which a patient reports a loss of
- Older adults
endurance. Fatigue in the patient with cardiopulmonary alterations
- The cardiac and respiratory systems undergo changes throughout is often an early sign of a worsening of the chronic underlying
the aging process. The changes are associated with calcification of process. To provide an objective measure of fatigue, ask the patient
the heart valves, vascular stiffening and increased left ventricular to rate it on a scale of 1 to 10.
wall thickness, impaired SA node function, and costal cartilage
- Dyspnea
thickening.
- Dyspnea is associated with hypoxia. It is the subjective sensation or
LIFESTYLE FACTORS
uncomfortable breathing or observed labored breathing with
- Nutrition shortness of breath. Dyspnea is usually associated with exercise or
- Good nutrition affects cardiopulmonary function by supporting excitement, but in some patients it is present without any relation
metabolic functions. A poor diet leads to risk factors affecting the to activity or exercise.
lungs and heart. - Cough
- Hydration - Cough is a protective reflex to clear the trachea, bronchi, and lungs
- Fluid intake is essential for cellular health. Fluid volume overload of irritants and secretions. Patients with a chronic cough tend to
may lead to vascular congestion in patients with heart, kidney, or deny, underestimate, or minimize their coughing, often because
lung diseases that impair the body’s ability to deliver oxygen to the they are so accustomed to it that they are unaware of its frequency.
tissues. Dehydration or fluid volume deficit may result in dizziness, - Allergies
fainting, hypotension, or a thickening of respiratory secretions, which
makes it difficult for a patient to expectorate secretions - Typical allergy symptoms include watery eyes, sneezing, runny nose,
or respiratory symptoms such as coughing or wheezing. Safe
- Exercise nursing practice also includes obtaining information about food,
- Exercise increases the metabolic activity and oxygen demand of the drug, or insect sting allergies on the initial history and physical.
body. The rate and depth of respiration increase, enabling the person - Medications
to inhale more oxygen and exhale excess carbon dioxide. People who
exercise for 30 to 60 minutes daily have a lower pulse and blood - These include prescribed medications, over-the-counter
 medications, folk medicine, herbal medicines, alternative long recovery with complications. Nursing interventions promoting
therapies, and illicit drugs and substances. removal of pulmonary secretions such as repositioning and
- Smoking suctioning assist in achieving and maintaining a clear airway and
help to promote lung expansion and gas exchange.
- Ask about any history of smoking; include the number of years
smoked and the number of packages smoked per day. Determine - Hydration
the exposure to secondhand smoke, because any form of tobacco - The best way to maintain thin secretions is to provide a fluid intake
exposure increases the risk for cardiopulmonary diseases. of 1500 to 2500 mL/day unless contraindicated or renal status. The
- Respiratory Infections color, consistency, and ease of mucus expectoration determines
adequacy of hydration
- Determine if the patient has had a pneumococcal or influenza (flu)
vaccine - Humidification
- Humidification is the process of adding water to gas to keep airways
NURSING DIAGNOSIS moist. Oxygen humidification by a nasal cannula or face mask is
achieved by bubbling oxygen onto sterile water. Sterile water should
- Nursing diagnosis examples appropriate for the patient with
be used to decrease the risk of hospital acquired infection; follow
alterations in oxygenation:
agency protocols to change the solution
- Activity Intolerance
- Nebulization
- Decreased Cardiac Output
- Fatigue - Nebulization adds moisture to inspired air by mixing particles of
- Impaired Gas Exchange varying sizes with the water. Aerosolization suspends the maximum
- Ineffective Airway Clearance number of water drops or particles of the desired size in inspired air.
- Ineffective Breathing Pattern Humidification through nebulization enhances mucociliary
- Risk for Aspiration clearance, the natural mechanism of the body for removing mucus
and cellular debris from the respiratory tract; this in turn improves
the clearance of pulmonary secretions. Nebulization is also a method
PLANNING of administration for certain medication such as bronchodilators
- Goals and Outcomes and mucolytic agents
- Example: for the goal of maintaining a patent airway, select specific - Coughing and Deep-Breathing Techniques
expected outcomes for the patient, such as the following: - Coughing is an effective technique for maintaining a patent airway.
- Patient’s lungs are clear to auscultation. deep breathing exercise with coughing is an airway clearance
- Patient achieves bilateral lung expansion. maneuver that is effective when spontaneous coughing is
- Patient coughs productively. inadequate
- Pulse oximetry (SpO2) is maintained or improved - Huff cough: Stimulates a natural cough reflex that is generally used
to help move secretions to a larger airway. The patient inhales deeply
and then holds the breath for 2 to 3 seconds while forcefully exhaling
IMPLEMENTATION
the patient opens the glottis by saying the word huff.
HEALTH PROMOTION - Quad cough, or manually assisted cough technique: Used in patients
- Vaccinations without abdominal muscle control such as those with spinal cord
- Patients with chronic illnesses (heart, lung, kidney, or injuries. While the patient breathes out to the maximum expiratory
immunocompromised), infants, older adults, and pregnant women effort the patient or nurse pushes inward and upward on the
can get very sick; thus they should be immunized. Vaccines are also abdominal muscles toward the diaphragm causing the cough
recommended for people in close or frequent contact with anyone in - Chest Physiotherapy
the high-risk groups, including infants and healthcare workers. - Chest physiotherapy is external chest wall manipulation using
- Healthy Lifestyle percussion, vibration, and high-frequency chest wall compression. It
- The risk factors for cardiac disease are lower when the total is often used in conjunction with postural drainage and can help
cholesterol levels are less than 200 mg/dL, high-density lipoprotein mobilize pulmonary secretions and the select group of patients.
(HDL) levels are greater than 40 mg/dL in men and 50 mg/dL in - Postural drainage is a component of pulmonary hygiene. It consists
women, and low-density lipoprotein (LDL) levels are less than 160 of the drainage, positioning and turning, and is sometimes
mg/dL. accompanied by chest percussion and vibration. It aids in improving
- Exercise is a key factor in promoting and maintaining a healthy heart secretion clearance and oxygenation
and lungs. Encourage patients to have at least 150 minutes a week of
moderate intensity exercise and at least 2 days a week of OXYGEN THERAPY
muscle-strengthening exercise.
- Also called as Supplemental Oxygen – treatment that provides extra
- Environmental Pollutants oxygen to breathe.
- Avoiding exposure to secondhand smoke is essential to maintaining
optimal cardiopulmonary function. Help patients develop a plan to
avoid environmental hazards in their home or work environments OXYGEN DELIVERY SYSTEMS
when possible.
ACUTE CARE Delivery FiO2 Advantages Disadvantages
- Dyspnea Management System Delivered
- pharmacological measures: bronchodilators, inhaled steroids,
mucolytics, and low-dose antianxiety medications Nasal Cannula 1-6 L/min: Safe and simple Drying to
- oxygen therapy: reduces dyspnea associated with exercise and (prongs) 24%-44% mucous
hypoxemia. membranes
- physical techniques
- psychosocial techniques
- Airway Maintenance
- Requires adequate hydration to prevent thick, tenacious secretions.
Proper coughing techniques remove secretions and keep the airways Simple Face 6-12 L/min: Useful for short Contraindicated
open. A variety of interventions such as suctioning, chest mask 35%-50% periods such as for patients who
physiotherapy, and nebulizer therapy assist in managing alterations patient retain CO2. May
in airway clearance. transportation. induce feelings
of
- Mobilization of Pulmonary Secretions
claustrophobia.
- The ability of a patient to mobilize pulmonary secretions makes the Therapy
difference between a short-term illness and an illness involving a interrupted with
 eating and
drinking.
Increased risk of
aspiration.

Partial and 10-15 Useful for short Hot and

non-rebreather L/min: periods. Delivers confining; may
mask 60%-90% increased FiO2. irritate skin;
Easily humidifies tight seal
O2. Does not dry necessary
mucous Interferes with
membranes eating and
talking Bag may
twist or kink;
should not
totally deflate - Non-Invasive Ventilation
- Prevents or treats atelectasis by inflating the alveoli, reducing
Venturi Mask 24%-50% Provides a Mask and added pulmonary edema by forcing fluid out of the lungs back into
specific amount humidity may circulation, and improving oxygenation in those with sleep apnea.
of oxygen with irritate skin. - CPAP (Continuous Positive Airway Pressure) – fixed pressure during
humidity added. Therapy ventilation
Administers low, interrupted with - BiPAP (Bilevel Positive Airway Pressure) – used to facilitate
constant O2. eating and breathing, one level of air pressure during inhalation and
drinking. Specific exhalation, delivers higher pressure during breathing
flow rate must be
followed ARTIFICIAL AIRWAY
- Oral airways
- The oral airway, the simplest type of artificial airway, prevents
- Tracheostomy Collar: Collar attaches to the neck with an elastic strap
obstruction of the trachea by displacement of the tongue into the
and can deliver high humidity and O2 via tracheostomy.
oropharynx. The oral airway extends from the teeth to the oropharynx,
maintaining the tongue in the normal position
OXYGEN SAFETY - Nasal airways
- Never use oxygen near an open flame - Nasopharyngeal airways
- Never use oxygen near cigarettes
- inserted through the nares, terminating in the oropharynx
- Never use grease or oil with oxygen equipment
- Oxygen promotes combustion - Endotracheal airways
- Do not tamper with oxygen equipment - An endotracheal tube is a short term artificial airway used to
- Store in a cool place administer invasive mechanical ventilation, relieve upper area
- Store oxygen bottles lying flat, or securely fastened if upright obstruction, protect against aspiration or clear secretions
- Use only medical oxygen
- Do not use when delivering a shock via a defibrillator

AIRWAY MAINTENANCE
- Suctioning
- Chest physiotherapy
- Chest percussion (cup-shaped hand)
- Vibration
- Nebulizer therapy
- Adds moisture or medications to inspired air.
- Delivers bronchodilators and mucolytic agents. - Tracheal airways
- Hydration - Tracheostomy:
- Humidification - surgically created stoma (opening) in the trachea to establish an
- Coughing Exercises airway.
- Huff Cough – stimulates a natural cough reflex. Effective for clearing - It is used to :
central airways - Bypass an upper airway obstruction,
- Quad Cough Technique - For patients without abdominal muscle - Facilitate removal of secretions.
control such as those with spinal cord injuries. Similar to abdominal - Permit long-term mechanical ventilation.
thrust
- Maintenance and promotion of lung expansion
- Ambulation
- Positioning (Tripod position)
- Incentive Spirometry
- Incentive Spirometry encourages voluntary deep breathing by
providing visual feedback to patients about inspiratory volume. It is
commonly used intervention that promotes deep breathing and is
thought to prevent or treat atelectasis in the postoperative patient
- Sustained Maximal Inspiration Device (SMIs)
- Measure the flow of air inhaled through the mouthpiece are used to:
- improve pulmonary ventilation
- counteract the effects of anesthesia or hypoventilation
CHEST TUBE AND DRAINAGE SYSTEMS
- loosen respiratory secretions
- facilitate respiratory gaseous exchange -expand collapsed alveoli - Pneumothorax
- air collects in the pleural space.
- The loss of negative intrapleural pressure causes the lungs to
 collapse IMPLEMENTATION
- Pneumothorax can occur as a result of chest trauma (eg stabbing 1. Performs hand hygiene. Applying a mask, gown, goggles or face
gunshot wound or rib fracture) shield, splashing is likely to happen.
- Hemothorax 2. Connect one end of the tubing to the suction machine and place the
other end in a convenient location near the patient.
- accumulation of blood in the pleural space.
3. Turns suction device on and set vacuum regulator to appropriate
- It produces a counter pressure and prevents the lung from full
negative pressure:
expansion a rupture of small blood vessels from inflammatory
processes such as pneumonia or tb can cause a hemothorax, as ● 120 to 150 mmHg for adults
cantrauma ● 60 to 100 mmHg for children
- Pleural effusion - excessive fluid in the pleural space. ● 40 to 60 mmHg for infants
4. If indicated, increase supplemental Oxygen therapy to 100%.
Encourage patient to deep breathe
CHEST TUBE PLACEMENT 5. Opens appropriate suction catheter using aseptic technique and
- A catheter inserted through the thorax to remove air and fluids from leaving catheter in sterile wrapper. Do not allow suction catheter to
the pleural space, to prevent air or fluid from reentering the pleural touch any non-sterile surfaces
space, or to re-establish normal intrapleural and intrapulmonary 6. Fill the rinsing glass with approximately 100 ml of sterile water or
pressures NSS.
7. Wear gloves
EVALUATION a. Apply a clean glove to each hand or dominant hand for
- Ask the patient about the degree of breathlessness. Observe oropharyngeal suctioning.
respiratory rate before, during and after any activity or procedure. b. Apply sterile glove to each hand or non-sterile gloves to non
- Ask the patient if the distance ambulated without fatigue has dominant hand and sterile glove to dominant hand for
increased. nasopharyngeal, nasotracheal artificial airway (Endotracheal
- Ask the patient to rate breathlessness on a scale of 0 to 10, with 0 tube – ET tube,tracheostomy tube)
being no shortness of breath and 10 being severe shortness of breath. 8. Picks up suction catheter with dominant hand without touching non
- Ask the patient which interventions help reduce dyspnea. sterile surface. Picks up connecting tubing with a non-dominant
hand. Secure catheter to tubing.
9. Moisten catheter tip by dipping tip of the catheter into the sterile
SUCTIONING
NSS.
10.Suction airway
a. Oropharyngeal Suctioning
- Insert Yankauer catheter into patient’s mouth.
- Apply suction once the catheter is in the patient's mouth, move
the catheter around the mouth along the gum line to pharynx.
- Then apply suction and move catheter around mouth until
secretions are cleared
b. Artificial airway (tracheostomy or endotracheal tube [ET])
suctioning
- Check if equipment is functioning properly by placing the tip
of the catheter into the basin and suctioning a small amount
of saline by occluding suction vent.
11. Hyper oxygenate patient before suctioning using manual
resuscitation bag and increasing FiO2 for several minutes.
12.If a patient is receiving invasive mechanical ventilation, open a
ASSESSMENT swivel adapter or, if necessary, remove oxygen - or humidity - delivery
1. Identify patient using two identifiers device with a non-dominant hand.
2. Assesses for signs and symptoms of upper and lower airway 13. Advise patient that you are about to begin suctioning and without
obstruction requiring suctioning: applying suction, gently but quickly insert catheter using dominant
thumb and forefinger into artificial airway
● abnormal respiratory rate 14. Apply intermittent suction no longer than 10 seconds
● adventitious sounds on inspiration or expiration 15.Apply intermittent suction by placing and releasing non dominant
● drooling in my mouth and coughing without clearing secretions thumb over vent of catheter; slowly withdraw catheter while rotating
from the airway. it back and forth between dominant thumb and forefinger.
3. Assesses Signs and symptoms associated with hypoxia and 16.. If a patient is receiving invasive mechanical ventilation, close swivel
hypercapnia adapter or replace oxygen - delivery device.
● decreased SpO2 17. Encourage patients to deep breathe if able. Some patients respond
● increased pulse and BP well to several manual breaths from the mechanical ventilator or
● decreased level of consciousness and cyanosis bag-valve mask.
18.Perform Nasopharyngeal and oropharyngeal suctioning if necessary.
4. Assess the patient's understanding of the procedure. 19.Assess cardiopulmonary status of patient for secretion clearance
and complications. Allow adequate time (at least 1 full minute)
PLANNING between suction passesfor ventilation and hyperoxygenation
1. Explains to the patient how the procedure will help clear airway and 20. Perform Nasopharyngeal and oropharyngeal suctioning if necessary.
relieve breathing problems and that temporary coughing, sneezing, After performing nasopharyngeal and oropharyngeal suctioning,
gagging or shortness of breath is normal. Encourages patients to catheter is contaminated; do not reinsert into ET or tracheostomy
cough out secretions. tube
2. Explains importance and encourage coughing when catheter is 21. Complete procedure.
introduced a. Place Yankauer catheter in a clean, dry area for reuse with suction
3. Assists patients with assuming comfortable position (usually semi- turned off or within patients reach with suction on if patient is
fowlers or sitting upright with head hyperextended, unless capable of suctioning self.
contraindicated). Stand on patient’s right if you are right-handed or b. Disconnect nasal and artificial airway catheters from connecting
on patient’s left if you are left-handed tubing. Roll catheter around fingers of dominant hand. Pull the
4. If not in place, apply pulse oximeter on patient’s finger. Take and glove off inside out so the catheter remains in the glove. Pull off
monitor reading and ensure pulse oximeters are in place. the other glove over the first glove in the same way to contain
5. Place the towel across the patient's chest. contaminants. Discard into appropriate receptacles. Turn off the
suction device.
 c. Remove towel and place in laundry or remove drape and discard
in appropriate receptacle. Reposition patient as indicated by
condition. Reapply clean gloves for patient’s personal care (e.g.,
oral hygiene).
d. If indicated, readjust oxygen to original level
e. Discard remainder of normal saline into appropriate receptacle. If
the basin is disposable, discard into the appropriate receptacle. If
the basin is reusable, rinse and place it in the soiled utility room.
f. Remove and discard goggles, mask, or face shield and perform
hand hygiene.
g. Place an unopened suction kit on the suction machine table or
at the head of the bed according to institution preference.

EVALUATION
1. Compare vital signs and SpO2 saturation of patients before and
after suctioning.
2. Ask the patient if breathing is easier and congestion is decreased.
3. Auscultate lungs and compare patient’s respiratory assessment
before and after suctioning.
4. Observe airway secretions.
5. Observe patients perform oropharyngeal suctioning.

RECORDING AND REPORTING

1. Record amount, consistency, color, and odor of secretions and
response of patient to procedure in the chart.
2. Record and report cardiopulmonary status of patient pre suctioning
and post suctioning
3. Document evaluation of patient learning
 DEFINITION OF HEALTH such as smoking, drug or alcohol abuse, risky sexual behaviors, poor
- World Health Organization - “Health is a state of complete physical diet, and refusing to take necessary medications
mental and social well-being not merely the absence of disease or
infirmity” HEALTH BELIEF MODEL
- Health is a state of being that people define in relation to their own
values personality and lifestyle
- Health is the actualization of inherent and acquired human potential
through goal directed behavior competence self care and satisfy
relationships with others
- Health is influenced by a person's culture and lifestyle
- Cultural influences are values how we define health, what we believe
about illness, where we seek health care, and the treatments we
prefer
- Culture also influences the type of health promotion activities people
practice
- Life conditions include socioeconomic variables such as
environment, diet, lifestyle, practices or choices, and many other
physiological and psychological variables.
- Individual perceptions of definitions of health change with age and
are affected by a person's health beliefs
- FLORENCE NIGHTINGALE:state of well being and using every power the
individual possesses to the fullest extent.
- TALCOTT PARSONS (1951): Health is defined in terms of roles and - The health belief model addresses the relationship between a person's
performance. Conceptualized health as the ability to maintain normal beliefs and behaviors
roles - Individual Perception: The first component of the health belief model
- US President’s Commission on Health and Needs of the NAtion (1953): which includes the individual's perception of susceptibility to an
health is not a condition; it is an adjustment illness
- American Nurses Association (2010): health and illness are human - Modifying Factors: An individual's perception of the seriousness of
experiences the illness. This perception is influenced and modified by
- Being free from symptoms of disease and pain as much as possible demographic and social psychological variables, perceived threats of
- Being able to be active and to do what they want or must the illness, and cues to action
- Being in good spirits most of the time - Likelihood of Action: The likelihood that a person will take preventive
WELLNESS AND WELL-BEING measures. This component results from a person's perception of the
benefits and barriers to taking action. Preventive actions in good
- Wellness is a state of well-being lifestyle changes increase adherence to medical therapy or a search
- Well-being is a perception of vitality and feeling well for medical advice or treatment. A patient's perception of
- Basic aspect of wellness: susceptibility to disease and perception of the seriousness of an
- -Self Responsibility illness help to determine the likelihood of the patient will adopt
- Ultimate goal healthy behaviors
- Dynamic
- Growing process
HEALTH PROMOTION MODEL
- Daily decision-making
- Stress management
- Physical fitness
- Preventive health care
- Emotional health
- Whole being of the individual
- Components of wellness

-
MODELS OF HEALTH AND ILLNESS
- Health beliefs are a person's idea, convictions, and attitudes, about
health and illness.
- Common positive health behaviors include immunizations scheduled - Health Promotion Model defines health as a positive dynamic state,
screenings properly patterns adequate exercise stress management not merely the absence of disease
and nutrition - The health promotion model describes the multidimensional nature of
- Negative health behavior include practices that are harmful to health people as they interact within their environment to pursue health
- The variables for behavioral-specific cognitions and affect influence a disparities.
patient's motivation to change or adapt healthy behaviors - Five categories of SDOH: economic stability, education access and
quality, health care access and quality, social community context,
MASLOW’S HIERARCHY OF NEEDS and neighborhood and built environment
CULTURE
- Culture, a social and community context, influences a patient;’s
beliefs, values, and customs. It influences the approach to the health
care systems, personal health practices, and the nurse-patient
relationship.
- Cultural background also influences an individual’s beliefs about
causes of illness and remedies or practices to restore health.

HEALTH PROMOTION, WELLNESS, AND ILLNESS PREVENTION

- Health promotion helps individuals maintain or enhance their
present health. It motivates people to engage in healthy activities.
- Health promotion is a process of helping people gain control of and
improve their health and focuses on a wide range of socioeconomic
and environmental interventions.
- Health Education includes providing information on topics such as
physical awareness, stress management, and self-responsibility to
enable individuals to improve their health. Health education helps
- Basic human needs (e.g., food, water, safety, and love) are necessary people develop a greater understanding of their health and how to
for human survival and health better manage their health risks.
- According to this model certain human needs are more basic than - Illness prevention activities such as immunization programs and
others and some needs must be met before the others blood pressure screenings protect people from actual or potential
- Self actualization is the highest expression of one's individual risks to health.
potential and allows for continuous self discovery - Individuals gain from passive strategies (the activities of others)
without acting themselves. Ex: fluoridation of municipal drinking
HOLISTIC HEALTH MODEL water
- The Holistic Health Model of nursing promotes a patient’s optimal - Individuals become personally involved with active strategies or
level of health by considering the dynamic interactions among the health promotion. Ex: weight-reduction and smoking-cessation
emotional, spiritual, social, cultural, and physical aspects of an programs.
individual’s wellness
- The holistic health model supports how our choices powerfully affect THREE LEVELS OF PREVENTION
our health PRIMARY PREVENTION
- Some of the most widely used holistic interventions include
- Primary prevention is true prevention
meditation music therapy reminiscence, relaxation therapy,
- Goal: reduce the incidence of disease
therapeutic touch, and guided imagery
- Primary prevention includes health education programs, nutritional
VARIABLES INFLUENCING HEALTH AND HEALTH BELIEFS AND programs,
PRACTICES - It includes all health promotion efforts and wellness education
INTERNAL VARIABLES activities that focus on maintaining or improving the general health
DEVELOPMENTAL STAGE of individuals, families, and communities.
- Considering a patient’s growth and developmental stage helps you SECONDARY PREVENTION
predict a patient;s response to an actual illness or the threat of a - Focuses on preventing the spread of disease, illness, or infection once
future illness. it occurs
- Emotional development may also influence personal beliefs about - Activities are directed at diagnosis and prompt intervention, thereby
health-related matters. reducing severity and enabling the patient to return to a normal level
INTELLECTUAL BACKGROUND of health
- A person’s belief about health are shaped in part by educational - It includes screening techniques and treating early stages of disease
background, traditions, and past experiences, all of which influence to limit disability by averting or delaying the consequences of
knowledge or misinformation about body functions and illness advanced disease
- Cognitive abilities shape the way a person thinks, including the ability TERTIARY PREVENTION
to understand factors involved in illness and apply knowledge of - Tertiary prevention occurs when a defect or disability is permanent
health and illness to personal practices. and irreversible
PERCEPTION OF FUNCTIONING - It involves minimizing the effects of long-term disease and disability
- Perceptions of physical functioning affect people’s health beliefs and by interventions directed at preventing complications and
practices. deterioration
- Gather objective and subjective data - Activities are directed at rehabilitation rather than diagnosis and
SPIRITUAL FACTORS treatment.
- Care at this level helps patients achieve as high a level of functioning
- Spirituality is reflected in how people live their lives. It affects an as possible, despite the limitations caused by illness or impairment.
individual’s values and beliefs, the relationships established with
family and friends, and the ability to find hope and meaning in lids
- Religious practices are one way that people exercise spirituality.

EXTERNAL VARIABLES
FAMILY ROLE AND PRACTICES
- Families’ perception of the seriousness of diseases and their history
of preventive care behaviors influence how people think about them.
SOCIAL DETERMINANTS OF HEALTH
- External factors such as where a person lives, the quality of the
environment, income, educational level, and relationships with others RISK FACTORS
have a considerable impact on a patient’s health - Risk factor is any attribute, quality, environmental situation, or trait
- Social determinants of health include a variety of social, commercial, that increases the vulnerability of an individual or group to an illness
cultural, economic, environmental, and political factors that affect or accident.
- Risk factors do not cause diseases or accidents. Instead, they increase EXTERNAL VARIABLES
the chances that the individual, community, or population will - External variables influencing a patient's illness behavior include the
experience a disease or dysfunction. visibility of symptoms, social group, cultural background,
- Risk factors play a major role in how you identify a patient’s health socioeconomic variables, accessibility of the healthcare system, and
status social support
NONMODIFIABLE RISK FACTORS IMPACT OF ILLNESS ON THE PATIENT AND FAMILY
- Nonmodifiable risk factors include age, gender, genetics, and family BEHAVIORAL AND EMOTIONAL CHANGES
history. These factors cannot be changed - Short-term, non-life-threatening diseases usually require few changes
MODIFIABLE RISK FACTORS in the functioning of a patient or family
- Modifiable behavioral risk factors include smoking, drinking alcohol, - Diseases that are life-threatening or chronic lead to a more extensive
unhealthy diet, obesity, physical inactivity, and insufficient rest and sense of illness such as the emotional and behavioral changes of
sleep. anxiety, shock, denial, anger, and withdrawal.
- These risk factors put people at risk for certain chronic illnesses, IMPACT ON BODY IMAGE
such as diabetes and heart disease. - Body image is the subjective concept of physical appearance.
- Lifestyle behavioral choices are also modifiable. Lifestyle choices can - Some diseases and illnesses result in changes in physical
lead to health problems that cause a significant impact on our health appearance. Patient and family reactions differ and usually depend on
care system, our economy, and our communities. the type of changes, their adaptive capacity, the rate at which changes
take place, and the support services available
- Stress is a lifestyle risk factor if it is severe or prolonged or if the
person is unable to cope with life events inadequately. IMPACT ON SELF-CONCEPT
- Stress also threatens physical well-being and is associated with - Self-concept is a mental self image of all aspects of your personality
illnesses such as heart diseases, cancer, and gastrointestinal - Self-concept depends in part on body image and rules but also
disorders. includes other aspects of psychology and spirituality
ENVIRONMENT IMPACT ON FAMILY ROLES
- The physical environment in which a person works or lives can - Rule reversal is common when a family member is diagnosed with the
increase the likelihood that certain illnesses will occur disease or becomes ill
- Environmental exposure rarely occurs at one time, in one location, and - An individual and family generally adjust more easily to subtle short
from one source because of our constant interaction with the term changes. In most cases they know that the role change is
environment. temporary and will not require a prolonged adjustment
PATIENT TEACHING: LIFESTYLE CHANGES IMPACT ON FAMILY DYNAMICS
- Objective - Family dynamics is the process by which a family functions, makes
decisions, gives support to individual members, and copes with
- Patients will reduce health risks related to poor lifestyle habits
everyday changes and challenges.
through behavior change.
- family dynamics often change because of the effects of diseases and
- Teaching strategies illness
- Provide active listening, ask about perceived barriers, assist the
patient in establishing goals, and reinforce the process of change.
CARING FOR ONESELF
- Evaluation - Using personal and professional strategies that focus on caring for
- Have the patient track adherence, and provide positive oneself can help to decrease or prevent compassion fatigue
reinforcement. - Eat a nutritious diet
- - Get adequate sleep
- Engage in exercise and relaxation activities
- Establish a good work-family balance
ILLNESS - Engage in regular nonwork activities.
- Disease: a medical condition that causes distress for a person in the - Develop coping skills
form of its symptoms - Allowing personal time for grieving
- Disease is a generic term that includes all disorders, infections, - Focus on spiritual health
disabilities, and deformities that can afflict human beings - Find a mentor
HEALTH CARE SYSTEM
- Illness is a state in which a person's physical, emotional, intellectual,
social, developmental, or spiritual functioning is diminished or - The totality of services offered by all health disciplines.
impaired HEALTH CARE AGENCIES
- Government agencies
ACUTE AND CHRONIC DISEASES - Public health services
- Acute disease is usually reversible and has a short duration. The - Physicians’ offices
symptoms appear abruptly or intense and subside over a relatively - Primary care
short period - Routine health screening
- Chronic disease usually lasts more than 6 months, is irreversible, and - Diagnosis and treatment
effects functioning in one or more systems
- The nature of the disease either acute or chronic also affects a - Ambulatory care centers
patient's illness behavior - Diagnostic treatment facilities
ILLNESS BEHAVIOR - Minor surgery
- People who are a disease generally act in a way that medical - Occupational health clinics
sociologists call illness behavior - Run by companies for employees
- Illness behaviors affect how people monitor their bodies, define and - Health promotion activities
interpret their symptoms, take remedial actions, and use health care
resources - Hospitals
- If people perceive themselves to be ill illness behaviors become - Acute inpatient services
coping mechanisms - Outpatient and ambulatory care
VARIABLES INFLUENCING ILLNESS AND ILLNESS BEHAVIOR - Emergency department
INTERNAL VARIABLES - Hospice care
- Internal variables are a patient's perceptions of symptoms and the - Subacute care
nature of a disease - Variation of inpatient care
- Patient’s copy mechanism skills and locus of control (the degree to - Technically complex treatments
which people believe they control what happens to them) are other
- Extended care facilities (formerly called nursing homes)
internal variables that affect the way a patient behaves when ill
 - Independent living
- Assisted, skilled, extended care facilities
- Rehabilitation
- Custodial care
- Retirement and assisted-living centers
- For clients unable to stay at home, but do not require hospital or
nursing
- Home health care agencies
- Education to clients and families
- Care to acute, chronic, or terminally ill
- Rural care hospitals
- Federal funding
- Services for rural residents
- Day-care centers
- Infants or children
- Adults that cannot be left at home
- Hospice services
- Care for dying in home or facility
- Improve or maintain quality of life until death
FACTORS THAT AFFECT HEALTH CARE DELIVERY
- Increasing number of elderly
- Advances in technology
- Economics
- Women’s health issues
- Uneven distribution of services
- Access to health insurance
- Homeless and the poor
- HIPAA- Health Insurance Portability and Accountability Act
- Demographic changes
 LOSS, DEATH, AND GRIEF NURSING ASSESSMENT
- Everyone experiences loss, grieving and death during his or her life. NURSING ASSESSMENT
- In a clinical setting, nurses encounter clients who may experience - Nursing History
grief related situations. - Assessment of personal coping resources
- May interact with dying clients and their families or caregivers in a - Physical assessment
variety settings NURSING DIAGNOSIS
- The nurse should understand the significance of loss and develop the - Grieving
ability to assist clients - Complicated Grieving / Risk for Complicated Grieving
LOSS - Interrupted Family Processes
- An actual or potential situation in which something that is valued is - Risk-Prone Health Behavior
changed or no longer available - Risk for Loneliness
TYPES OF LOSS PLANNING
- ACTUAL Loss – recognized by others - Loss of body parts/function – goal is to adjust to the changed ability
- PERCEIVED Loss – experienced by a person but cannot verified by - Grieving of loved ones – to redirect emotional energy
others - Sustained/anticipate loss – require ongoing care to assist them in
- ANTICIPATORY LOSS adapting to the loss
- SITUATIONAL Loss – unexpected loss IMPLEMENTATION
- DEVELOPMENTAL Loss – expected loss - Facilitating grief work
SOURCES OF LOSS - Providing emotional support
- ASPECT OF SELF – physical changes and physiological function loss EVALUATION
- EXTERNAL OBJECTS – inanimate and animate loss - Client goals and related desired outcomes for grieving client will
- FAMILIAR ENVIRONMENT – separation of environment or people who depend on the characteristics of the loss and the client
provide security and care for one person
- LOSS OF LIFE – Losing loved/valued person
- LOVED ONES – Death of Family, friends DEATH
GRIEF - Universal experience
- The absence of life
- The total response to the emotional experience related to loss
- Permits to cope with the loss and accept it as a part of reality DYING
- Social Process; best shared with assistance of others - A process
- BEREAVEMENT - subjective response experienced by the surviving - Involves cessation of physical, psychological, social and spiritual life
loved ones RESPONSES TO DYING AND DEATH
- MOURNING - behavioral process through which grief is eventually
- Reaction of any person to another person’s impending or real death,
resolved or altered
depends on all the factors regarding loss and the development of the
TYPES OF GRIEF RESPONSES concept of death
- ABBREVIATED GRIEF – brief but genuinely felt, normal SIGNS OF IMPENDING CLINICAL DEATH
- ANTICIPATORY GRIEF – experience in advance of the event
- DISENFRANCHISED GRIEF – unable to acknowledge the loss to other - Loss of muscle tone
people. - Slow of the circulation
- COMPLICATED/UNHEALTHY GRIEF – maladaptive coping to loss - Changes in respiration
- Sensory impairment
- Unresolved or chronic grief
DYING PERSON’S BILL OF RIGHTS
- Inhibited grief or masked grief
- Delayed grief - I have the right to be treated as a living human until I die.
- Exaggerated grief - I have the right to maintain a sense of hopefulness, however changing
KUBLER-ROSS’ STAGES OF DYING its focus may be.
- I have the right to express my feelings and emotions about my
approaching death in my own way.
- I have the right to participate in decisions concerning my care.
- I have the right to expect continuing medical and nursing attention
even though “cure” goals must be changed to “comfort” goals.
- I have the right to not die alone.
- I have the right to be free of pain.
- I have the right to have my questions answered honestly.
- I have the right not to be deceived
- I have the right to have help from and for my family in accepting death
- I have the right to die in peace and with dignity
- I have the right to retain my individuality and not be judged for my
decisions, which may be contrary to the belief of others.
FACTORS INFLUENCING THE LOSS AND GRIEF RESPONSES - I have the right to be cared for by caring, sensitive, knowledgeable
- Human development people who will attempt to understand my needs and will be able to
- Personal relationships gain some satisfaction in helping me face my death.
- Nature of the loss NURSING ASSESSMENT
- Coping strategies NURSING ASSESSMENT
- Socioeconomic status
- Closed awareness
- Culture
- Mutual pretense
- Spiritual and religious beliefs
- Open awareness
NURSING DIAGNOSIS
- Fear
- Hopelessness
- Powerlessness
- Risk for caregiver role strain
- Interrupted family processes
PLANNING
- Maintain physiological and psychological comfort
- Achieving a dignified and peaceful death
- Maintaining personal control and accepting declining health status
IMPLEMENTATION
- Helping clients die with dignity
- Hospice and palliative care
- Meeting the physiological needs of the dying client
- Providing spiritual support
- Supporting the family
EVALUATION
- Listening to client’s feelings and thoughts
- Observing client’s relationship with significant others
-
 CLINICAL JUDGMENT IN NURSING PRACTICE symptoms), whether the patient’s condition is urgent, and the time
- accurate and appropriate clinical decisions or judgments. you have to gather data.
- learn to question, wonder, and explore different perspectives and SCIENTIFIC DATA AND THEORY
interpretations - Knowledge drives your assessment. When you know the scientific
CRITICAL THINKING nature of a disease condition, you become aware of the patient
- think in a systematic and logical manner behaviors and body systems to assess
- A continuous process PATIENT DATA
- open-mindedness, continual inquiry, and perseverance, combined - A patient is a nurses primary and best source of information
with a willingness to look at each unique patient situation and - Patients were conscious, alert, and able to answer questions
determine which identified assumptions are true and relevant appropriately provide the most accurate information
- Recognizing that an issue exists, analyzing information, evaluating TYPES OF PATIENT DATA
information, and drawing conclusions - Subjective data are the patients verbal descriptions of their health
REFLECTION problems gathered during interviews
- The ability to act on the basis of critical thinking comes with - Subjective data include patient feelings, perceptions, and self
experience. reported symptoms
- Turning over a subject in the mind and thinking about it seriously is - Objective data are the findings resulting from observation of patient
reflection. behavior and chemical science as well as direct measurement
- Reflection is not intuitive. including what you hear, see, and touch
LEVELS OF CRITICAL THINKING FAMILY CAREGIVERS AND SIGNIFICANT OTHERS
- Family caregivers, other family members, and significant others are
primary sources of information for infants or children, critically ill
adults, and patients who have intellectual disabilities or cognitive
impairments
- Family and significant others are also important secondary sources of
information for alert and responsive patients
TYPES OF ASSESSMENT
PATIENT-CENTERED INTERVIEW
- Use a patient centered interview when you conduct a comprehensive
nursing history
- Usually include categories of information and efficient history that
follow a structured database format based on an accepted framework
or practice standard
CRITICAL THINKING COMPETENCIES PERIODIC PROBLEM-FOCUSED ASSESSMENT
- General critical thinking - Periodic problem focus assessments collected during rounding or
- Scientific method while you administer patient care include quick screenings to rule out
- Problem solving or follow up on patient problems
- Decision making - Exposure (ABCDE) approach in all clinical emergencies for immediate
- Specific critical thinking assessment and treatment of patients who are injured or critically ill
- Another type of problem focus approach begins with the patient's
- Diagnostic reasoning and inference presenting situation and specific problematic areas such as
- Clinical decision making incisional pain, or limited understanding of postoperative recovery.
CRITICAL THINKING SYNTHESIS MEDICAL RECORDS
- Critical thinking and the nursing process go hand-in-hand in making - The medical record is a valuable resource for your patient assessment
quality decisions about patient care. - Medical records contains a patient's medical history, summaries of
DEVELOPING CRITICAL THINKING SKILLS ongoing assessments and care activities, laboratory and diagnostic
- Reflective journaling: Define and express clinical experiences in your test results, current physical findings, and a healthcare provider
own words statement plan
- Meeting with colleagues: Discuss and examine work experiences and - The record is available tool to check the consistency and similarities
validate decisions of your own observations and measurements
- Concept mapping: Visual representation of patient problems and - Patients medical records are confidential
interventions that shows their relationships to one another DIAGNOSTIC DATA
- Examples of diagnostic data are serum blood testing, radiological
ASSESSMENT examinations, endoscopic procedures, and specimen analysis
- Involves the collection of as much information as possible about the - This data are valuable in confirming observational findings
patient family or community COMPONENTS OF THE NURSING HEALTH HISTORY
- A thorough and comprehensive assessment allows you to sort the
data recognize patterns and make judgements that allow you to
identify the type of health problems your patient is experiencing
- The initial assessment of a patient is critical to identify or confirm as
quickly as possible a patient's health problems but nursing
assessment is ongoing
CRITICAL THINKING IN ASSESSMENT
- Application of critical thinking enables you to be deliberate and
systematic in collecting data about your patients
- The extent of any assessment is based on the nurse’s judgment,
triggered by how a patient is respondings (present signs and
 what a patient says, are interested in hearing
Diagnostic and Results provide further explanation of the full story, and are encouraging the patient
laboratory data alterations or problems identified during the to give more details
health history and physical examination
PROBING As patients tell their stories encourage a food
Interpreting and Ensures collection of complete database description without trying to control a stories
validating direction
assessment data Leads to second step of nursing process

Data Use clear, concise appropriate terminology NURSING DIAGNOSIS

documentation - First introduced in 1950.
Becomes baseline for care - In 1953, Fry proposed the formulation of a nursing diagnosis.
- In 1973, the first national conference was held.
Concept mapping Visual representation that allows you to - In 1980 and 1995, the American Nurses Association (ANA) included
graphically show the connections among a diagnosis as a separate activity in its publication Nursing: a Social
patient’s many health problems Policy Statement.
- In 1982, North American Nursing Diagnosis Association (NANDA) was
founded.
PHASES OF THE ASSESSMENT INTERVIEW TYPES OF NURSING DIAGNOSES
ORIENTATION AND SETTING AN AGENDA - NANDA-I (2014) nursing diagnoses include:
- Introduce yourself, explain why you are collecting data and that you - Problem-focused
will keep all information confidential. - Risk
- Focus on the patient’s goals, preferences, and concerns - Health promotion
- Professionalism and competence strengthens nurse-patient FORMULATING A NURSING DIAGNOSIS
relationships.
- Identify the correct diagnostic label with associated defining
- It is important to build trust and rapport with your patient.
characteristics or risk factors and a related factor.
WORKING PHASE–COLLECTING ASSESSMENT DATA - A related factor allows you to individualize a nursing diagnosis for a
- The working phase involves gathering accurate, relevant, and specific patient.
complete information about the patient's condition - Most settings use a two-part format in labeling health promotion and
TERMINATION PHASE problem-focused nursing diagnoses.
- Summarize the discussion with the patient and check for accuracy of - Some agencies prefer a three-part nursing diagnostic label:
the information you collected during the termination phase of an - Problem
interview - Etiology
INTERVIEW TECHNIQUES - Symptoms
CULTURAL RELEVANCE OF NURSING DIAGNOSES
OBSERVATION Observe a patient’s verbal and non-verbal
behaviors, such as the use of eye contact, - Ask questions such as:
body language and positioning, or tone of - How has this health problem affected you and your family?
voice - What do you believe will help or fix the problem?
- What worries you most about the problem?
Observations will lead to pursue further - Which cultural practices are important to you?
objective information to form thorough and - Cultural awareness and sensitivity improve your accuracy in making
accurate conclusions. nursing diagnoses.
An important aspect of observation includes a SOURCES OF DIAGNOSTIC ERROR
patient's level of function: the physical - Errors occur during:
developmental particle and social aspects of - Data collection
everyday living - Interpretation and analysis of data
- Clustering
OPEN-ENDED Open ended questions elicit a patient's unique - Diagnostic statement
QUESTIONS story

An open ended question gives a patient the

ability to decide how much information to
disclose

The use of open ended question from patients

to describe a situation in more than just one
or two words allowing patients to actively
describe their health status

DIRECT Close ended questions are used to seek

CLOSED-ENDED specific information about a problem
QUESTIONS
Direct questions are not ideal when you wish a
patient to be thorough and describing a
health problem

LEADING The use of leading questions are risky

QUESTIONS because they can limit the information of a
patient

BACK CHANNELING Back channeling includes the use of active

listening prompts

This technique shows that you have heard

 APPLICATION TO CARE PLANNING interventions—for ease of use.
- By learning to make accurate nursing diagnoses, your care plan will - NIC interventions are linked with NANDA International nursing
help communicate the patient’s health care problems to other diagnoses.
professionals. SYSTEMS FOR PLANNING NURSING CARE
- A nursing diagnosis will ensure that you select relevant and - Nursing care plan = Nursing diagnoses, goals and expected outcomes,
appropriate nursing interventions. and nursing interventions, and a section for evaluation
- Reduces the risk for incomplete, incorrect, or inaccurate care
PLANNING - Changes as the patient’s problems and status change
ESTABLISHING PRIORITIES HAND-OFF REPORTING
- Classification of priorities: - Transferring essential information from one nurse to the next during
transitions in care
- High—Emergent
- Ask questions, clarify, and confirm important details about a patient’s
- Intermediate—non-life-threatening
progress and continuing care needs
- Low—Affect patient’s future well-being
STUDENT CARE PLANS
- changes as a patient’s condition changes.
- A student care plan helps you apply knowledge gained from the
- begins at a holistic
nursing and medical literature and the classroom to a practice
- patient’s preferences, values, and expressed needs.
situation
- Ethical care is a part of priority setting.
CRITICAL THINKING IN SETTING GOALS AND EXPECTED OUTCOMES - Is more elaborate than a care plan used in a hospital or community
agency because its purpose is to teach the process of planning care
- Goal: A broad statement that describes the desired change in a
patient’s condition, perceptions, or behavior; An aim, intent, or end - Planning care for patients in community-based settings
- Expected outcome: Measurable change that must be achieved to - Involves educating the patient/family about care and guiding them to
reach a goal; Many times, several must be met to meet a single goal assume more of the care over time
ROLE OF THE PATIENT IN GOAL/OUTCOME SETTING
- Always partner with patients when setting their individualized goals.
- Mutual goal setting includes the patient and family (when
appropriate) in prioritizing the goals of care and developing a plan of
action.
- Act as a patient advocate.
SETTING GOALS AND EXPECTED OUTCOMES
- Patient-centered goal: A patient’s highest possible level of wellness
and independence in function, based on patient needs, abilities, and
resources
- Nursing-sensitive patient outcome: A measurable patient, family, or CRITICAL PATHWAYS
community state, behavior, or perception largely influenced by and - provide the multidisciplinary health care team with activities and
sensitive to nursing interventions tasks to be put into practice sequentially.
- Nursing Outcomes Classification (NOC): Links outcomes to NANDA-I - deliver timely care
nursing diagnoses CONCEPT MAPS
WRITING GOALS AND EXPECTED OUTCOMES - Visual representation of all of a patient’s nursing diagnoses that
- Must be patient-centered allows you to diagram interventions for each
- Use SMART acronym - Group and categorize nursing concepts to give you a holistic view of
- Specific your patient’s health care needs and help you make better clinical
- Measureable decisions in planning care
- Attainable - Help you learn the interrelationships among nursing diagnoses to
- Realistic create a unique meaning and organization of information
- Timed SBAR METHOD
CRITICAL THINKING IN PLANNING NURSING CARE - S = Situation (a concise statement of the problem)
- Nursing interventions are treatments or actions based on clinical - B = Background (pertinent and brief information related to the
judgment and knowledge that nurses perform to enhance patient situation)
outcomes. - A = Assessment (analysis and considerations of options — what you
- Nurses need to: found/think)
- Know the scientific rationale for the intervention - R = Recommendation (action requested/recommended — what you
- Possess the necessary psychomotor and interpersonal skills want)
- Be able to function within a setting to use health care resources
effectively IMPLEMENTATION
TYPES OF INTERVENTIONS STANDARD NURSING INTERVENTIONS
- Nurse-initiated - clinical guidelines or protocols, preprinted (standing) orders, and
- Independent—Actions that a nurse initiates Nursing Interventions Classification (NIC) interventions
- American Nurses Association (ANA) standards
- Health care provider initiated
- Quality and Safety Education for Nurses (QSEN) skill competencies
- Dependent—Require an order from a physician or other health care IMPLEMENTATION PROCESS
professional
- Five preparatory activities
- Collaborative
1. reassessing the patient,
- Interdependent—Require combined knowledge, skill, and expertise of 2. reviewing and revising the existing nursing care plan,
multiple health care professionals 3. organizing resources and care delivery,
SELECTION OF INTERVENTIONS: FACTORS TO CONSIDER 4. anticipating and preventing complications,
- Desired patient outcomes 5. implementing nursing interventions.
- Characteristics of the nursing diagnosis - Preparing for implementation
- Research-based knowledge for the intervention
- Time management
- Feasibility of the interventions
- Equipment
- Acceptability to the patient
- Personnel
- Nurse’s competency
- Environment
NURSING INTERVENTIONS CLASSIFICATION (NIC) - Patient
- Iowa Intervention Project
- The NIC model includes three levels—domains, classes, and
 DIRECT CARE VS INDIRECT CARE - Interventions
STANDARDS OF EVALUATION
DIRECT CARE INDIRECT CARE
- Nursing care helps patients
● Treatments performed through ● Treatments performed away - Resolve actual health problems
interactions with patients from the patient but on behalf - Prevent potential problems
● Medication administration of the patient or group of - Maintain a healthy state
● Insertion of an intravenous (IV) patients - Collaborate and evaluate effectiveness of interventions with family
infusion ● Managing the patient’s and health care team
● Counseling during a time of environment (e.g., safety and - Document results
grief infection control) -
● Documentation
● Interdisciplinary collaboration
DIRECT CARE
- Activities of daily living (ADLs)
- Performed in the course of a day, including ambulation, eating,
dressing, bathing, and grooming
- Instrumental ADLs (IADLs)
- Skills such as shopping, preparing meals, house cleaning, writing
checks, and taking medications.
- Physical care techniques
- The safe and competent administration of nursing procedures
- Lifesaving measures
- Counseling
- Controlling for adverse reactions
- Preventive measures
INDIRECT CARE
- are nursing actions that manage the patient care environment and
interdisciplinary collaborative actions that support the effectiveness
of direct care interventions
- Communicating nursing interventions (written or oral)
- Delegating, supervising, and evaluating the work of other staff
members

EVALUATION
EXAMINE RESULTS
- Reflection-in-action
- Once you deliver an intervention, you continuously examine results
by gathering subjective and objective data from the patient, family,
and health care team members.
- At the same time you review knowledge regarding a patient’s current
condition, the treatment, and the resources available for recovery.
- By reflecting on previous experiences caring for similar patients, you
are in a better position to know how to evaluate your patient.
EVALUATIVE MEASURES
- Evaluative measures are assessment skills and techniques
- Evaluating behavior
- Self-management
- Nursing Outcomes Classification (NOC)
COMPARE ACHIEVED EFFECT WITH GOALS AND OUTCOMES
- Gather objective and subjective Data
- Reflect on previous clinical experience
- Apply critical thinking attitudes
- Apply intellectual standards
- Review expected outcomes/were outcomes met?
INTERPRETING AND SUMMARIZING FINDINGS
- When you evaluate the effect of interventions, you interpret or learn to
recognize relevant evidence about a patient’s condition
- Early detection is first line of defense
- Compare actual and expected findings
- Steps to objectively evaluate the degree of success in achieving
outcomes of care
RECOGNIZE ERRORS OR UNMET OUTCOMES
- Must have an open mind, actively pursue truth, be patient and
confident, and engage in self-reflection
- Systematic use of evaluation
- Self-reflection and correction of errors
CARE PLAN REVISION
- Discontinuing a care plan
- Modifying a care plan
- Reassessment
- Redefining diagnoses
- Redefining diagnoses
 PERIOPERATIVE NURSING Palliative Relieves or reduces intensity Colostomy,
- includes a registered nurse’s planned patient-centered approach in of disease symptoms; does debridement of
providing care to patients preoperatively, intraoperatively and nor produce cure necrotic tissue;
postoperatively. resection of nerve
NURSING GOALS roots
- Quality improvement
- Patient safety reconstructi Restores function and Internal fixation of
- Teamwork and collaboration ve/restorativ appearance to traumatized fractures; scare
- Effective communication e or malfunctioning tissues revision
- Timely assessment and deliver intervention
- Patient advocate Procurement Removal of organs and/or Kidney, heart, or liver
- Cost containment for tissues from a person transplant
SCIENTIFIC KNOWLEDGE BASE transplant pronounced as brain dead of
from living donors for
CLASSIFICATION OF SURGERY
transplantation into another
CLASSIFICAT DESCRIPTION EXAMPLE person
ION TYPE
Constructive Restores function lost or Repair of cleft palate;
SERIOUSNESS reduced as result of closure of atrial
congenital anomalies septal defect in heart
Major Involves extensive Coronary artery
reconstruction or alteration bypass, colon Cosmetic Performed to improve Blepharoplasty of
in body parts; poses great resection, removal of personal appearance eyelid deformities;
risks to well being larynx, resection of rhinoplasty to
lung lobe reshape nose

Minor Involves minimal alteration Cataract extraction,

n body parts; designed to facial plastic surgery, SURGICAL RISK FACTORS
correct deformities; involved tooth extraction SMOKING
minimal risks to well-being - Chronic smoking increases the amount of thickness of airway
secretions, thus increasing the risk for aspiration.
URGENCY - Smoking decreases the amount of oxygen the amount of oxygen that
the cells in the surgical wound
- Current studies suggests that surgical patients who use electronic
Elective Performed on a basis of Bunionectomy, facial
cigarettes are at risk for delayed wound healing
patient’s choice; is not plastic surgery ,
- Recent studies suggest the need for healthcare providers to
essential and is not always hernia repair, breast
implement systematic and planned measures targeted at educating
necessary for health reconstruction
preoperative patients on the surgical risks of smoking all forms of
cigarettes
Urgent Necessary for patient’s Excision of cancerous
health; often prevents tumor, removal of AGE
development of additional gallbladder stones, - Very young and older patients are at greater surgical risks.
problems (e.g., tissue vascular repair for - Infants have difficulty maintaining normal circulatory blood volume,
deconstruction or impaired obstructed artery causing risks for dehydration and overhydration
organ function); not (e.g., coronary artery - A healthy older adult has reduced physiological reserve, and organ
necessarily emergency bypass) systems may be compromised during illness and/or surgical stress,
creating a surgical risk.
Emergency Must be done immediately Repair or perforated NUTRITION
to save life or preserve the appendix or trauma - Surgery increases the the need for nutrients
function of body parts. amputation; control - After surgery, a patient requires at least 1500 kcal/day to maintain
of internal energy reserves.
hemorrhaging.
- This intake is difficult to attain when a patient’s food and/or fluid
intake is limited after surgery or if a patient develops postoperative
PURPOSE nausea and vomiting (PONV)
- Patients who enter surgery malnourished are more likely to have poor
Diagnostic Surgical exploration to Exploratory tolerance for anesthesia, negative nitrogen balance, delayed
confirm diagnosis; often laparotomy(incision postoperative recovery, induction, and delayed wound healing.
involves removal of tissue into peritoneal cavity
for further diagnostic testing to inspect abdominal OBESITY
organs); breast mass - As weight increases, a patient’s ventilatory and cardiac function
biopsy diminish, increasing the risk for postoperative atelectasis,
pneumonia, and death
Ablative Excision or removal of Amputation; removal - Patients who are obese often have difficulty resuming normal physical
diseased body part of appendix or an activity after surgery because of the pain and fatigue caused by
organ such as surgery in addition to preexisting impaired physical mobility.
gallbladder - Obesity also increases the risk of poor wound healing, wound
(cholecystectomy) infection, dehiscence, and evisceration because fatty tissue contains
a poor blood supply, slowing the delivery of essential nutrients and
antibodies needed for wound healing.
 OBSTRUCTIVE SLEEP APNEA - Determine the patient’s expectations of surgery and the road to
- Obstructive sleep apnea is a chronic sleep disorder characterized by recovery
periodic episodes of narrowing or collapse of the upper airway. It - Nursing history
occurs when muscles in the throat relax during sleep, causing soft
- Include information about advance directives
tissue in the back of the throat to collapse and block the upper airway.
- Patients with OSA who are to undergo surgery present a significant - Medical history
risk. Receiving sedatives, opioid analgesics, and general anesthesia - Screen for conditions that increase surgical risks
causes relaxation of the upper airway and may worsen OSA.
- Surgical history
IMMUNOSUPPRESSION
- Check for complications in prior surgeries
- Patients with conditions that alter immune function are at an - Maintain normal baseline function
increased risk for developing infection after surgery.
- Risk factors
FLUID AND ELECTROLYTE IMBALANCE
- Screen patients carefully
- Severe protein breakdown causes a negative nitrogen balance and
- Take necessary precautions
hyperglycemia. These effects decrease tissue healing and increase the
- Collaborate with health care provider
risk of infection.
- Obstructive sleep apnea, malnourishment, and smoking are all risk
- As a result of adrenocortical stress response, the body retains sodium
factors.
and water and loses potassium in the first 2-5 days after surgery.
- Medications
RISKS FOR POSTOPERATIVE NAUSEA AND VOMITING (PONV)
- PONV approximately affects 30% of patients in recovery rooms after - Inpatient vs. outpatient
surgery. - Hold WARFARIN
- PONV can lead to serious complications, including pulmonary - Allergies
aspiration, dehydration, and arrhythmias resulting from fluid and - Medications, topical agents, latex, food
electrolyte imbalance. - Inform OR
RISKS FOR POSTOPERATIVE URINARY RETENTION (POUR) - Smoking habits
- POUR is common following anesthesia, affecting up to 70% of patients. - Alcohol ingestion and substance abuse and use
- Common risk factors are: - Pregnancy
- Patient specific: older age, male gender, history of POUR, - Perceptions and knowledge regarding surgery
neurological disease, or prior pelvic surgery. - Support sources
- Procedure-specific: anorectal surgery, joint arthroplasty, hernia - Occupation
repair, or incontinence surgery. - Preoperative pain assessment
- Anesthesia-specific: excessive intraoperative fluid administration, - Review of emotional health
medication-related, prolonged anesthesia, or type of anesthesia - Self concept
RISKS FOR VENOUS THROMBOEMBOLISM (VTE) - Body image
- Some VTEs are subclinical (without symptoms), whereas others - Coping resources
present a sudden pulmonary embolus or symptomatic DVT - Physical Examination
- Patients most at risk for developing VTE are those who undergo - General survey
surgical procedures with a general anesthetic and under a surgical - Head and neck
time of more than 90 mins, or 60 mins if the surgery involves the - Integument
pelvis or lower limb. - Thorax and lungs
- Heart and vascular system
NURSING KNOWLEDGE BASE - Abdomen
PERIOPERATIVE COMMUNICATION - Neurological status
- Diagnostic screening.
- A smooth communication “hand-off” between caregivers is needed to
ensure continuity of care and reduce risk of medical errors.
GLYCEMIC CONTROL AND INFECTION PREVENTION DIAGNOSTIC AND LABORATORY
- Poor glucose control increases risk for wound infection and mortality - Hgb – Hemoglobin (Oxygen Level & Blood Replacement)
- Controlling blood sugars perioperatively reduces mortality in patients - Hct – Hematocrit (Wound Healing)
with or without diabetes who have general surgery and in patients who - Platelet Count – (Risk for Bleeding)
have cardiac surgery, - WBC count – (Infection level)
PRESSURE INJURY PREVENTION - PT – (Risk for bleeding / Clotting time)
- Specific OR risk factors: - PTT – (Risk for bleeding / Clotting time)
- Glucose – (Sugar level / Wound Healing)
- Intrinsic risks (patient’s tolerance to a pressure injury insult) –
altered nutrition (albumin levels <3 g/dl), decreased mobility, older
age, decreased mental status, infection, incontinence, impaired NURSING DIAGNOSIS
sensory perception, and co-morbidities such as diabetes, - Common nursing diagnoses relevant to the patient having surgery
malnutrition, and weight. include:
- Extrinsic risks (variables that increase tissue susceptibility to - Ineffective airway clearance
sustain external pressure) – temperature, friction and shearing - Anxiety
forces, and moisture. - Ineffective Coping
- OR risk factors – length and type of surgery, position on OR table, - Impaired skin integrity
positioning devices used, warming devices, anesthetic agents, - Risk for aspiration
intraoperative hemodynamics, and length of time on the OR bed. - Risk for perioperative positioning injury
- Registered nurses assist in preventing pressure injuries - Risk for infection
intraoperatively by carefully positioning patients and using - Deficient knowledge (specify)
pressure-relieving surfaces. - Impaired physical mobility
PREOPERATIVE EDUCATION - Ineffective thermoregulation
- Education allows for preoperative collaborative decision making that - Nausea
allows the patient to make better choices. - Acute pain
- Delayed surgical recovery

PHASES OF PERIOPERATIVE NURSING

PREOPERATIVE PHASE PLANNING
ASSESSMENT - Goals and outcomes
- Through the patient’s eyes - Review and modify the plan during the intraoperative and
 postoperative periods INTRAOPERATIVE SURGICAL PHASE
- Setting priorities - Nursing roles during surgery
- Patients requiring emergent surgery often experience changes in - Circulating nurse
their physiological status that require urgent reprioritizations. - Scrub nurse
- Registered nurse first assistant
- Teamwork and collaboration
PLANNING
- Preoperative instruction gives patients time to make necessary
preparations - Acute care
- Physical preparation
- Intraoperative warming
IMPLEMENTATION
- Latex sensitivity/allergy
- Informed consent
- Introduction of anesthesia
- Surgical procedures require documentation of consent
- General anesthesia
- Report any concerns about the patient’s understanding of the
- Regional anesthesia
surgery to the operating surgeon or anesthesia provider
- Moderate (conscious) sedation
- Privacy and social media
- Positioning the patient for surgery
- Do not discuss confidential patient information in public areas or - Documentation of intraoperative care
use social media to convey patient information; posting patient
EVALUATION
information and photos on websites is prohibited
- Through the patient’s eyes
- Acute care
- Keep the family informed
- Minimize risk for surgical wound infection - Ask family members if they have questions
- Antibiotics - Patient outcomes
- Skin antisepsis
- Clipping instead of shaving hair - Evaluate a patient’s ongoing clinical status during surgery
- Maintaining normal fluid and electrolyte balance
- Fasting before surgery
- IV fluid replacement
- Parenteral nutrition
- Preventing bowel incontinence and contamination
- Bowel preparations
- Preparation on the day of surgery
- Hygiene
- Preparation of hair and removal of cosmetics
- Removal of prostheses
- Safeguarding valuables
- Preparing the bowel and bladder
- Vital signs
- Prevention of DVT – Anti Embolism devices
- Administering preoperative medications
- Documentation and hand-off
- Eliminating wrong site and wrong procedure surgery OPERATING ROOM ATTIRE
- Purpose: provide barrier and protect personnel
POLICIES REGARDING OR ATTIRE
EVALUATION
- Personnel should wear street clothes when reporting to the OR
- Through the patient’s eyes - Upon arrival, the personnel should change to clean, fresh, basic OR
- Evaluate whether the patient’s expectations were met with respect to attire. Hanging of identification cards around the next is nor
surgical preparation recommended to avoid contamination of the sterile field. Names of
- Patient outcomes the personnel may be embroidered instead onto the OR suit for proper
identification.
- Deficient knowledge
- OR attire of the personnel should be laundered only in the hospital’s
- Anxiety
laundry facilities.
- OR attire should not be worn outside the OR suite or outdoors. On
TRANSPORT T THE OPERATING ROOM occasions such as lunch breaks or when fetching the patient, a smock
- Notification gown may be worn over the OR suit.
- Transportation PRINCIPLE OF STERILE TECHNIQUE
- Verify patient’s identity - All objects used in a sterile field must be sterile.
- Two identifiers - A sterile object becomes non-sterile when touched by a non-sterile
object.
- Family - Sterile items that are below the waist level, or items held below waist
- Allowed to visit before patient is transported to OR level, are considered to be non-sterile.
- Directed to waiting area - Sterile fields must always be kept in sight to be considered sterile
- Prepare room for patient’s return - When opening sterile equipment and adding supplies to a sterile field,
take care to avoid contamination.
- Any puncture, moisture, or tear that passes through a sterile barrier
PREANESTHESIA CARE UNIT must be considered contaminated.
- Preanesthesia care unit (PCU) or pre surgical care unit (PSCU) (holding - Once a sterile field is set up, the border of one inch at the edge of the
area) sterile drape is considered non-sterile.
- PCU nurse - If there is any doubt about the sterility of an object, it is considered
non-sterile.
- Inserts IV catheter (if not already present)
- Sterile persons or sterile objects may only contact sterile areas;
- Administers preoperative medications
non-sterile persons or items contact only non-sterile areas.
- *Instruct patient to call for assistance
- Movement around and in the sterile field must not compromise or
- Monitors vital signs
contaminate the sterile field.
- Anesthesia provider
- Performs patient assessment
 THREE AREAS IN OR - Informs the surgeon of the surgery
UNSTERILE/CLEAN AREA - If two scrub nurses are available, one may prepare and the other one
passes the instruments
- After the surgery
- Accounts for all instruments and supplies after procedure
- Cleans patient after the surgical procedure
- Assist in the transfer of the patient from OR theater to recovery
room
- Assist in the after-care of the theater
- Ensure all specimens are secured and properly labeled.
- Others:
- Second assistant surgeon
- Student nurse
- Surgical intern/resident
- Nurse trainee
UNSTERILE TEAM
SUB-STERILE AREA - Anesthesiologist
- Induces and maintains anesthesia
- Oversees the care of the patient in the recovery room
- Participates in cardiopulmonary resuscitation program
- Documents the induction of the anesthesia
- Circulating Nurse
- Before the surgery:
- Together with scrub nurse, identify the patient correctly
- Accompanies the patient in transferring to OR
- Identifies and reports potential danger
- Safe keep patient’s valuables
- Ensures the sterility of the field together with the scrub nurse
- Records all instruments and supplies
- Ensure the safety and comfort of the patient
- Assist the anesthesiologist
- Check and maintain the functionality of the equipment
STERILE AREA
- During the surgery:
- Provides promptly any supplies/instruments as needed
- Provides assistance to any member of the surgical team
- Acts as communication link
- Ensures everyone complies with the principle of asepsis
- Ensures patient safety throughout the procedure
- After the surgery
- Determines the outcomes of final counts as correct or incorrect
- Records any medication as the surgeon used in the procedure
- Make pathology request
- Give health teaching to patient’s relative
- Assist in transferring of the patient to recovery room
- Others:
- Nurse anesthetist (if needed)
- Nursing auxiliary
THE SURGICAL TEAM - Biomedical technician
STERILE TEAM - Laboratory or x-ray personnel
- The Surgeon
- “Captain of the ship” POSTOPERATIVE SURGICAL PHASE
- Provides three phases of perioperative care - Immediate postoperative recovery (Phase I)
- Assumes responsibility in medical and surgical care of the patient
- Notification and arrival
- Determines the site of operation and appropriate surgical position
- Hand-off: OR to PACU
- Assistant Surgeon - Patient monitoring and assessment
- Perfors skin preparation - Modified Aldrete score
- Position the client - Modified post anesthesia recovery score (PARS)
- Helps maintain the visibility of the surgical site - DASAIM discharge assessment tool
- Handles tissues and instruments
- Discharge and hand-off: PACU to Acute Care
- Documents the operating technique
- Recovery in ambulatory surgery (Phase II)
- Scrub Nurse
- Postanesthesia recovery score (PARS)
- Before the surgery:
- Together with circulating nurse, identify the patient correctly
- Validates surgeon’s preference to surgery POSTOPERATIVE CONVALESCENCE
- Prepares protective attire ASSESSMENT
- Accounts for the all instruments and supplies before and after - Neurological functions
procedure - Skin integrity and condition of the wound
- Check and labels the drugs and syringes - Metabolism
- During the surgery: - Genitourinary function
- Gastrointestinal function
- Prepares and arranges sterile instruments and supplies
- Established and maintains the sterile field - Paralytic ileus
- Anticipates the needs of the surgeon and other surgical team - Comfort
- *Untoward Incident like profuse bleeding, bring back the patient BASIC OPERATING ROOM INSTRUMENTS
immediately to the OR
FORCEPS
DIAGNOSIS
- Medical Forceps are grasping-type surgical instruments
- Nursing diagnosis for postoperative patients include: used during surgeries and other medical procedures.
- Ineffective airway clearance - Forceps are used for tweezing, clamping, and applying
- Anxiety pressure. They can be used as pincers or extractors. They are
- Risk for infection used in emergency rooms, exam rooms, operating rooms
- Deficient knowledge (specify) and to render first aid.
- Impaired physical mobility
- Impaired skin integrity THUMB FORCEP TISSUE FORCEP
- Nausea
- Acute pain
PLANNING
- Goals and outcomes
- Goals that continue into the home setting
- Goals established during the preoperative surgical phase that are
still relevant
- Setting priorities DEBAKEY FORCEP ADSON FORCEP
- Reestablish priorities as the status of the patient’s health problems
change
- Teamwork and collaboration
- Goal: help the patient return to the best possible level of functioning
with a smooth transition to home, rehabilitation, or long-term care
IMPLEMENTATION CLAMPS
- Acute care - Surgical instruments designed to hold materials together or
- Maintaining respiratory function back during medical procedures, commonly used for blood
- Preventing circulatory complications vessels, tissues, needles, towels, and drapes. Products
- Achieving rest and comfort include hemostats in straight and curved forms, forceps,
- Temperature regulation pliers, and more.
- Maintaining neurological function
- Provide leg exercises if necessary KELLY CURVE KELLY STRAIGHT
- Maintaining fluid and electrolyte balance
- Promoting normal gastrointestinal function and adequate nutrition
- Promoting urinary elimination
- Skin and wound care
- Maintaining/enhancing self-concept
- Restorative and continuing care
- Prepare for discharge
- Provide patient education
- Help patients adhere to exercise programs MOSQUITO CURVE MOSQUITO STRAIGHT
- Make referrals to home care as needed
EVALUATION
- Through the patient’s eyes
- Have the patient’s expectations been met?
- Patient outcomes
- Evaluate for pain relief using a pain scale
- Evaluate patient self-care measures
KOCHER CURVE KOCHER STRAIGHT
SAFETY GUIDELINES FOR NURSING SKILLS
- Coughing and deep breathing may be contraindicated after brain,
spinal, head, neck, or eye surgery. Provide pillow if necessary for
splinting
- Bariatric patients may have more improved lung function and vital
capacity in the reverse Trendelenburg or side-lying position.
- Report any signs of venous thromboembolism such as pain,
tenderness, redness, warmth, or swelling in the upper or lower BABCOCK CLAMP ALLIS CLAMP
extremities to the medical team immediately.

TOWEL CLAMP/CLIP ADAIRS CLAMP

 THYROID CLAMP NEEDLE HOLDER RAKE RETRACTOR MALLEABLE/RIBBON RETRACTOR

SCISSORS
- Surgical scissors are surgical instruments usually used for
cutting.

MAYO CURVE MAYO STRAIGHT

DEAVER RETRACTOR WEITLEINER RETRACTOR

BLADDER RETRACTOR SELF-RETAINING RETRACTOR

IRIS CURVE IRIS STRAIGHT

THOMPSON RETRACTOR

METZENBAUM BANDAGE SCISSORS

TENOTOMY SCISSORS POTTS SCISSORS

KIDNEY BASIN/EMESIS BASIN
- A kidney dish or emesis basin is a shallow basin with a
kidney-shaped base and sloping walls used in medical and
surgical wards to receive soiled dressings and other
medical waste.

RETRACTORS
- Surgical retractors help surgeons and operating room
professionals hold an incision or wound open during
surgical procedures.
- They aid in holding back underlying organs or tissues,
allowing doctors/nurses better visibility and access to the
exposed area.
CAUTERY PENCIL/TIP/PEN
SENN MILLER RETRACTOR MAYO COLLINS RETRACTOR - Cauterization is a medical practice or technique of burning
a part of a body to remove or close off a part of it.
- It destroys some tissue in an attempt to mitigate bleeding
and damage, remove an undesired growth, or minimize
other potential medical harm, such as infections when
antibiotics are unavailable

ARMY NAVY RETRACTOR RICHARDSON RETRACTOR

SUCTION TIP
- It is typically a firm plastic suction tip with a large opening
surrounded by a bulbous head and is designed to allow
effective suction without damaging surrounding tissue.
 - This tool is used to suction secretions in order to prevent SEDATION procedures like colonoscopies. The level of
aspiration. sedation ranges from minimal - drowsy
but able to talk - to deep

LOCAL ANESTHESIA Used for procedures such as getting

stitches or having a mole removed. It
SURGICAL KNIFE numbs a small area, and you are awake
- A scalpel is a small and extremely sharp bladed instrument and alert.
used for surgery, anatomical dissection, and incision

BLADE #10 BLADE #11

- A large curved cutting - A large curved blade commonly
edge,which represents a more used for cutting tissue and
traditional blade shape. It is other procedures that require a
used for cutting soft tissue, puncture or cut.
typically with large incisions.

BLADE #15 BLADE #11

- Ideal for making short, precise - A long, triangular blade with
incisions because of its small, the hypotenuse as its sharpest
curved cutting edge. edge. Because of its pointed
tip, it is typically used for
stabbing incisions and/or
short, precise cuts that are
shallow.

DIFFERENT ANESTHESIA

GENERAL ANESTHESIA Is used for major operations and causes

you to lose consciousness

REGIONAL ANESTHESIA Is often used during childbirth and

surgeries of the arm, leg, or abdomen. It
numbs a large part of the body but the
patient will remain awake

IV/ MONITORED Often used for minimally invasive

 PATIENT ADMISSION MEDICAL EQUIPMENT
- (def.) Admission is defined as allowing a patient to stay in hospital for HOSPITAL BED
observation, investigation, treatment and care.
- The initial introduction into the healthcare system, a key step in client
care.
- The first contact is usually the admitting receptionist and interviews
the client, a parent or guardian of a child. ID band is placed.
- Valuables are placed in a safe but preferably sent home with the
family.
- Home medications or herbal supplements placing in medication HOSPITAL ADMISSION KIT
drawer as per agency policy or as per order of the physician
- Prehospital laboratory and x-rays should be done before admission for
elective procedure
- Patient is directed to nursing unit or escorted by a healthcare provider
TYPES OF ADMISSION
EMERGENCY/UNPLANNED
- Emergency Medical Service (EMS) or Outpatient Department (OPD)
- Patients are admitted in acute conditions requiring immediate
treatment VITAL SIGNS MONITOR
- Examples: Patient with cardiac or respiratory emergency, burns,
trauma/accident.
ROUTINE ADMISSION
- Patients are admitted for investigation, diagnostic and medical or
surgical treatment.
- Treatment is given according to the patient's problem.
- Examples: Elective OR, Executive check-up, Chemotherapy
POINT OF ENTRY FOR ADMISSION
- Emergency Medical Service (EMS) / ER
- Operating Room/Theatre (OR/OT) / Delivery Room (DR)
- Outpatient Department (OPD) WEIGHING SCALE WITH HEIGHT
- Doctor’s clinic MEASUREMENT
- Pre-admission Unit (PAU) / Admission Office
- Receive report from admission point of entry
- Receive patient details including demographic profile, diagnosis,
preadmission report and other pertinent information.
- Verify if pt has signed hospital admission consent, patient bill of
rights.
- Ensuring Availability of Necessary Resources CARDIAC MONITOR
- (e.g., Linen, Bed, Equipment, Supplies)
- Prepare patient room, equipment needed and special needs
- (e.g. cardiac monitor, IV pump)
UNIT AND ITS PREPARATION
- It is a place where the patient is kept during hospital stay. The
admitting department notifies the unit prior to the patient's arrival so
that room/ bed can be prepared.
- Prepare the treatment table or bed
- Ensure all the equipment are completed
- Check ventilation IV POLE, IV PUMP (INFUSION
- Ensure patient privacy PUMP)
ARTICLES NEEDED
- Prepare bed
- Vital signs equipment
- Weighing scale
- Admission kit
- Patient gown, bath towel, washcloth
- Other equipment like cardiac monitor for ICU patients, IV pole,
infusion pump
- Forms like:
- Nurses’s Notes, PA sheet
- Doctor’s Progress Sheet SYRINGE PUMP
- Doctor’s order sheet
- Pre-op Sheet
- TPR Sheet
- Other sheets like I & O, Lab sheet, request forms, etc.
 ORIENTATION TO THE PATIENT AND RELATIVES
OXYGEN FLOW METER
- The equipment/ instruments
- Use of call system and telephone
- Treatment schedule
- Visiting hours
- Other health care team members
- Policy and rules and regulations
- Care of patients is valuable, etc.
PERFORM EXAMINATION AND EVALUATION PROCEDURE
- Perform examination and evaluation procedure establish base line
ELECTROCARDIOGRAM MACHINE values like vital signs. Do history taking, physical examination etc.
- Coordinate with the physician and carry out initial orders
- Give the treatment and instruction as needed

MEDICO-LEGAL ISSUES
- Medico-legal cases (MLC) are an integral part of medical practice that
is frequently encountered by Medical Officers
- Proper handling and accurate documentation of these cases is of
prime importance to avoid legal complications and to ensure that the
Next of kin (NOK) receive the entitled benefits.
ADMISSION TO THE NURSING UNIT - (def.) “any case of injury or ailment where, the attending doctor after
- Introduction – of self and other personnel, introduce other client if history taking and clinical examination, considers that investigations
present in the same room. by law enforcement agencies (and also superior military authorities)
- Verification of Patient Information (ID wrist band) are warranted to ascertain circumstances and fix responsibilities
- Completion of Admission Forms and Consent Documents regarding the said injury or ailment according to the law”
- Take patient height, weight and ask for allergies (food, medications) TYPES OF CLIENT TRANSFER
- Nursing Assessment (Head-to-foot), Nursing notes - Internal Transfer - moving a patient within the same hospital to a
- Patient orientation to the unit (mealtimes, visiting hours, use of different unit that provides special care or care suited to his needs,
phones recreational use, physician’s visits, other schedules) e.g. from general ward to ICU.
- Coordination with Support Services (e.g., Dietary, Laboratory,
Radiology) - Transfer from one unit to another
- Transfer within the same unit
ADMISSION PROTOCOL
- Advance directives are made available to clients. - External Transfer - moving a patient from one hospital to another
- The clients Bill of Rights is presented to each client hospital for the purpose of special care, e.g. from general hospital to
- The admission assessment is completed by a registered nurse (RN) specialized hospital – cancer centre.
within a specified time after admission - Transfer to another facility
- All clients must be clearly identified by a legible identification band.
- When consent forms are required (for surgical procedure, they must PATIENT DISCHARGE
be signed by an adult or guardian who is mentally competent. The
- “Discharge of patient from the hospital means, reliving a person from
patient must give voluntary consent and have the opportunity to ask
hospital setting, who admitted as an inpatient in that hospital”
questions.
TYPES OF DISCHARGE
ADVANCE DIRECTIVES (LIVING WILL)
- PLANNED DISCHARGE - Patient completes the initial, actual
- An advance directive or living will is a written document that tells your management in the hospital and now he or she need not to be under
healthcare providers who should speak for you and what medical direct supervision of that hospital
decisions they should make if you become unable to speak for
yourself. This information is important if you become unconscious or - Essentials of planned discharge:
otherwise too sick to make your wishes known. - Written order by doctor
PATIENT’S BILL OF RIGHTS - Discharge card/Discharge Summary
- Right to appropriate medical care and humane treatment - Informing other departments
- Right to informed consent - Check payment of the bills
- Right to privacy and confidentiality - Hospital glossaries taken back
- Right to information - Returning of personal belongings
- The right to choose healthcare provider and facility - Arrangement for transport
- Right to self determination - Documentation
- Right to religious belief - DAMA/LAMA: Discharge/Leave Against Medical Advice
- Right to medical records
- Right to leave
- Right to refuse participation in medical research
- Right to correspondence and to receive visitors
- Right to express grievances
- Right to be informed of his rights and obligations as a patient.
PATIENT’S RESPONSIBILITIES
- Know rights
- Provide accurate and complete information
- Report unexpected health changes
- Understand purpose and cost of treatment
- Accept consequences of own informed consent - TRANSFER: Transfer to other unit or hospital 4
- Settle financial obligations - ABSCOND: Abscond from Hospital
- Relation to others - REFERRAL: Referred for further management
- Exhaust grievance mechanism
NURSES RESPONSIBILITIES IN DISCHARGE
SPECIAL CONSIDERATION PREPARATION FOR DISCHARGE
- Admission cause undue stress (emotional factors as well as financial
- Planning in the beginning.
capability must given utmost importance)
- Plan for rehabilitation and follow - up need.
- Be observant consider the individual patient needs
- Teach nursing procedures to be continued at home, get it’s practice
- Provide an individual admission procedure
done.
- Show efficiency and concerns
- Arrangement for transport.
 DURING DISCHARGE PROCEDURE practice
- See doctor’s written order. - Informatics competencies for nursing graduates entering the
- Explanations. workforce
- Hand over personal belongings
- Check and receive any hospital property. COMMON MEDICAL DIAGNOSTIC EXAMINATIONS
- Confirm bill paid.
- Diagnostic examinations
- Inform other departments regarding discharge
- Arrange transport - Diagnostic examinations cover a wide range of medical specialties
- DAMA: - check consent and are essential for accurate diagnosis, treatment planning, and
ARTICLES NEEDED IN DISCHARGING PATIENT monitoring of various health conditions.
- Wheelchairs or stretchers – do not allow patients to ambulate upon BLOOD TEST
discharge for patient safety. (JCIA) - Blood tests can be used to help a doctor identify a variety of health
- Discharge booklet conditions, including infections, anemia, high cholesterol, vitamin
- Prescription order deficiencies, organ failure, HIV, cancer, diabetes, and more.
- Clinic appointment HEMATOLOGY
AFTER DISCHARGE - are tests on the blood, blood proteins and blood-producing organs.
- Documentation They can help diagnose and monitor a variety of blood conditions such
- Care of patient’s room and articles as anemia, infection, inflammation, hemophilia, blood-clotting
disorders, and leukemia.
- Example: CBC, Platelet count, PT, PTT.
INFORMATICS AND DOCUMENTATION
BLOOD CHEMISTRY
- Documentation is a vital aspect of nursing
- measure certain chemicals in your blood. Results of these tests give
- Nursing documentation systems
your health care provider important information about your general
- Should reflect current standards of nursing practice and minimize health, how well your organs (such as the liver and kidneys) are
the risk of errors working, and whether you may be experiencing side effects from HIV
- Need to be flexible enough to allow members of the health care team drugs.
to efficiently document and retrieve clinical data, track patient - Example: B. sugar, S-Elect, Liver function test (LFT) like alanine
outcomes, and facilitate continuity of care transaminase (ALT), aspartate transaminase (AST), and alkaline
- Must document all nursing care provided in the health record phosphatase (, Kidney function test like BUN, creatinine, Blood fat
PURPOSES OF THE HEALTHCARE RECORD (Lipids) like T. Chol, LDL, HDL, Triglycerides
- Facilitates interprofessional communication among health care SEROLOGICAL TESTS
providers - Blood tests that detect specific antibodies or antigens to diagnose
- Legal record of care provided infectious diseases such as HIV, hepatitis, syphilis, Lyme disease, or
- Justification for financial billing and reimbursement of care autoimmune disorders like rheumatoid arthritis or lupus.
- Auditing, monitoring, and evaluation of care provided BLOOD CULTURES
- Education and research
- Tests for the presence of bacteria or fungi in the blood, indicating
THE SHIFT TO ELECTRONIC DOCUMENTATION systemic infection.
- The use of health information technology (HIT) will result to improve - Example: Blood culture and sensitivity (Blood C/S).
the quality and value of health care IMAGING TEST
- Experts believe that implementing EHRs across the health care X-RAYS
delivery system will decrease costs and improve the quality of patient
care - Use electromagnetic radiation to create images of bones and some
- EHR attributes, components, and advantages soft tissues.
- Example: Detecting fractures or pneumonia.
MAINTAINING PRIVACY, CONFIDENTIALITY, AND SECURITY OF THE
HEALTHCARE RECORD COMPUTED TOMOGRAPHY (CT) SCANS
- Nurses are legally and ethically obligated to keep all patient - Combine X-rays and computer technology to produce detailed cross
information confidential. sectional images of the body.
- Only discuss the patient’s status with members of the health care - Example: Identifying tumors or assessing internal injuries after
team trauma.
- Protected health information MAGNETIC RESONANCE IMAGING (MRI)
- Can use data for research or continuing education, but need - Uses magnetic fields and radio waves to generate detailed images of
permission organs and tissues.
STANDARDS AND DOCUMENTATIONS FOR QUALITY NURSING - Example: Diagnosing brain tumors or spinal cord injuries.
DOCUMENTATION ULTRASOUND
- Know the standards of your organization. (SLMC-PDAR, DOH-FDAR)
- Uses sound waves to create images of internal organs and tissues.
(others – SOAPIE, ADPIE)
- Example: Monitoring fetal development during pregnancy or
- Documentation needs to conform to standards of the National
diagnosing gallstones.
Committee for Quality Assurance (NCQA) and TJC to maintain
institutional accreditation and minimize liability OTHERS
ECHOCARDIOGRAM
- Assessment
- Nursing process - Uses ultrasound waves to create images of the heart's structure and
function, helping diagnose conditions such as heart valve disorders,
- Medical record component – (Pt demographic profile, Doctor’s order heart failure, and congenital heart defects.
sheet, Progress Notes, Nurses Notes, etc.)
ELECTROCARDIOGRAM (ECG OR EKG)
METHODS DOCUMENTATION
- Records the electrical activity of the heart to diagnose heart
- Documentation of patient assessment data
conditions such as arrhythmias, heart attacks, and abnormal heart
- Flow sheets – includes VS, I&O, ventilator setting, ABG, nurses notes rhythms.
(3-folds) ELECTROENCEPHALOGRAM (EEG)
- Progress notes – multi-disciplinary
- Charting by exception – e.g. morse fall assessment tool, ICU bundles - Measures and records electrical activity in the brain, aiding in
(CAUTI & VAP bundles), integrated assessment data (MIAD) diagnosing epilepsy, sleep disorders, and brain conditions
NURSING INFORMATICS
- Integrates nursing science, computer science, and information COMMON MEDICALLY PRESCRIBED DIET
science to manage and communicate data, information, knowledge, - Diet as Tolerated – No food restriction
and wisdom in nursing and informatics practice - Soft Diet - foods that are easy to digest and are mild in seasoning.
- Nursing informatics is also recognized as a specialty area of nursing - Full Liquid Diet - full liquid diet is used when you have problems with
 chewing, swallowing or digesting solid food. This diet is often ordered
when you are going from a clear liquid diet to solid foods.
- Clear Liquid Diet - On this diet you will be given foods that are liquid
at room temperature. These foods will leave little or no residue after
digestion
- Regular Diet - For good health, it contains many types of foods with
moderate levels of salt, fat and sugar.
- Diabetic Diet (DM Diet) - It limits carbohydrates, protein and fat. Your
choices will vary depending on your calorie level. You will have no
concentrated sweets. Sugar substitutes are allowed.
- Renal Diet - The renal diet limits potassium, salt, phosphorus, protein
and sometimes fluid.
- Low Fat Low Cholesterol Diet - This diet lowers the total fat in the diet
to 50 grams per day. Eat less fat, oils, butter and margarine. Fried
foods are not allowed. Do not eat fatty meats
 URINARY ELIMINATION COMMON SYMPTOMS OF URINARY ALTERATIONS
DESCRIPTION COMMON CAUSES

Urgency - immediate and - Full bladder

strong desire to urinate - Urinary tract infection
- Inflammation of the bladder
- Overactive bladder

Dysuria - pain or discomfort - Urinary Tract Infection

in voiding (urinating) - Inflammation of the prostate
- Urethritis
- Trauma to the lower urinary tract
- Urinary tract tumors
- The last step in the removal and elimination of excess water and
byproducts of body metabolism Frequency - voiding more - High volumes of fluid intake
- Kidneys: filter waste products of metabolism from the blood than 8 times during walking - Bladder irritants (caffeine)
- Ureters: transport urine from the kidney to the bladder hours or less than every 2 - Urinary tract infection
- Bladder: holds urine until the volume in the bladder triggers a hours - Increased pressure on bladder (ex:
sensation of urge indicating the need to pass urine pregnancy)
- Micturition occurs when the brain gives the bladder permission to
empty, the bladder contracts, the urinary sphincter relaxes, and urine Polyuria - voiding excessive - High volumes of fluid intake
leaves the body through the urethra. amounts of urine - Uncontrolled diabetes mellitus
NEPHRONS - Diabetes insipidus
- Functional unit of the kidney, remove waste products from the blood - Diuretic therapy
and play a major role in the regulation of fluid and electrolyte balance
- Normal range of urine production: 1 to 2 L/day Oliguria - diminished - Fluid and electrolyte imbalance (e.g.,
- Erythropoietin, produced by the kidneys stimulates red blood cell urinary output dehydration)
(RBC) production and maturation in bone marrow - Kidney dysfunction or failure
- Kidneys play a major role in blood pressure control via the - Increased secretion of antidiuretic
renin-angiotensin system, release of aldosterone and prostacyclin hormone (ADH)
- Urinary tract obstruction
ACT OF URINATION
Hesitancy - delay in start of - Anxiety (e.g., vpoiding in public
- urination , micturition, and voiding are all terms that describe the restroom)
voiding
process of bladder emptying. - Bladder outlet obstruction (e.g.,
FACTORS INFLUENCING URINATION prostate enlargement, urethral
- Growth and development structure)
- Sociocultural factors
- Psychological factors Nocturia - awakened from - Excess intake of fluids (especiallu
- Personal habits being asleep due to the urge coffee or alcohol before bedtime)
- Fluid intake - Bladder outlet bstruction (e.g.,
- Pathological conditions prostate enlargement)
- Surgical procedures - Overactive bladder
- Medications - Medications (e.g., diuretic taken in
- Diagnostic examinations the evening
- Cardiovascular disease (e.g.,
COMMON URINARY ELIMINATION PROBLEMS hypertension)
- Urinary tract infection
- Urinary retention
- Accumulation of urine due to the inability of the bladder due to
emptying Dribbling - leakage from - Bladder outlet obstruction (e.g.,
- Urinary tract infection being asleep due to the urge prostatic enlargement)
- Results from catheterization or procedure - Incomplete bladder emptying
- Symptoms of UTI - Stress incontinence
- Dysuria
- Fever Hematuria - blood in urine - Tumors (e.g., kidney, bladder)
- Chills - Infection (e.g., glomerular nephritis,
- Nausea cystitis)
- Vomiting and malaise - Urinary tract calculi
- Cystitis - Trauma to the urinary tract
- Hematuria
- WBC or bacteria in the urine Retention - unable to void - Bladder outlet obstruction (e.g.,
prostatic enlargement, urethral
- Urinary incontinence - involuntary leakage of urine
Acute retention: suddenly obstruction)
- Urinary diversion - diversion of urine to external source
unable to void when bladder - Absent or weak bladder contractility
- Nephrostomy tubes - small tubes tunneled through the skin into the
is adequately fill or overfull (e.g., neurological dysfunction such
pelvis
as caused by diabetes, multiple
- Placed to drain the renal pelvis when the ureter is obstructed. Chronic retention: bladder sclerosis, lower spinal cord injury)
 NURSING DIAGNOSIS
doesn't empty completely - Side effects of certain medications
- Nursing diagnoses common to patients with urinary elimination
during voiding, and urine is (e.g., anesthesia, anticholinergics,
problems:
retained in the bladder antispasmodics, antidepressants)
- Functional urinary incontinence
- Stress urinary incontinence
NURSING KNOWLEDGE BASE - Urge urinary incontinence
- Risk for infection
ASSESSMENT
- Toileting self-care deficit
- Through the patient’s eyes - Impaired skin integrity
- Self-care ability - Urinary retention
- Cultural considerations health literacy
- Nursing history
- Pattern of urination IMPLEMENTATION
- Symptoms of urinary alterations HEALTH PROMOTION
PHYSICAL ASSESSMENT - Patient education
- Kidneys and bladder - Promoting normal micturition
- External genitalia and urethral meatus - Maintaining elimination habits
- Perineal skin - Maintaining adequate fluid intake
- Promoting complete bladder emptying
ASSESSMENT OF
- Preventing infection
- Intake and output
ACUTE CARE
- Characteristics of urine
- Color - Types of Catheters
- Clarity
- Odor
- Urine has a characteristic ammonia odor. The more concentrated the
urine, the stronger the odor. As ursine remains standing (e.g., in a
collection device), more ammonia breakdown occurs, and the odor
becomes stronger. A foul odor may indicate UTI. some foods such as
asparagus and garlic can change the odor of urine.
LABORATORY DIAGNOSTIC AND TESTING

- Catheter sizes

- Nursing responsibilities before testing:

- Ensure a signed consent is completed
- Assess the patient for any allergies
- Administer bowel-cleansing agent or ordered
- Ensure that the patient adheres to the appropriate pretest diet or
nothing by mouth (NPO - nothing per orem)
- Responsibilities after testing include:
- Assessing I&O
- Assessing voiding and urine
- Encouraging fluid intake IMPLEMENTATION
SHADE OF URINE - Catheterization
- Catheter drainage systems
- Routine catheter care
- Preventing catheter associated infection
- Catheter irrigations and instillations
- Removal of indwelling catheters
- Alternatives to catheterization
- Suprapubic catheters
- External catheters
CONTINUING AND RESTORATIVE CARE
- Lifestyle changs
- Pelvic floor muscle training
- Bladder retraining
- Toileting schedules
- Intermittent catheterization
- Skin care
EVALUATION
- Through the patient’s eyes
- Assess the patient’s self-image, social interactions, sexuality, and
 emotional status
- Patient outcomes
- Use the expected outcomes developed during planning to determine
whether interventions were effective
- Evaluate for changes in the patient’s voiding pattern and/or
presence of symptoms
- Evaluate patient/caregiver compliance with the plan
SAFETY GUIDELINES FOR NURSING SKILLS
- Follow principles of surgical and medical asepsis as indicated
- Identify patients at risk for latex surgeries
- Identify patients at risk for latex allergies
- Identify patients with allergies to povidone-iodine (betadine). Provide
alternatives such as chlorhexidine
 SCIENTIFIC KNOWLEDGE BASE - The reason the drug is prescribed
- To safely and accurately administer medications, you need knowledge - Side effect/secondary effect
related to: - Effect that is unintended
- Legal aspects of health care - These are usually predictable (harmless or potentially harmful)
- Pharmacology - Adverse effect/reactions
- Pharmacokinetics
- Life sciences - More severe side effects
- Pathophysiology - May justify the discontinuance of a drug
- Human anatomy - Drug allergy
- Mathematics - An immunologic reaction to a drug (mild or severe)
- Anaphylactic reactions
MEDICATION - a severe allergic reactions usually occurs after drug is administered.
- also known as Drugs PHARMACOLOGICAL CONCEPTS
- a substance administered for the diagnosis, cure, treatment, or relief
- Medication names:
of a symptom or for prevention of disease.
PRESCRIPTION - Chemical—provides the exact description of medication’s
composition.
- the written direction for the preparation and administration of a drug
- Generic—the manufacturer who first develops the drug assigns the
NAME OF DRUGS name, and it is then listed in the U.S. Pharmacopeia.
- Generic Name – a name given before a drug becomes officially - Trade—also known as brand or proprietary name. This is the name
approved. under which a manufacturer markets the medication.
- Official Name – The name under which is listed in one of the oficial
- Classification
publications
- Effect of medication on body system
- USP (United States Pharmacopeia)
- Symptoms the medication relieves
- Chemical Name – the name by which a chemists knows - Medication’s desired effect
- It describes the constituents of the drug precisely - Medication forms
- e.g. N-acetyl-para-aminophenol
- Solid, liquid, other oral forms; topical, parenteral; forms for
- Trade Name – Also known as brand name instillation into body cavities
- The name given by the drug manufacturer PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTIONS
TERMINOLOGIES - The study of how medications:
- Pharmacology - The study of the effect of drugs on living organisms - Enter the body
- Pharmacy – The art of preparing, compounding and dispensing drugs - Are absorbed and distributed into cells, tissues, or organs
- It also refers to the place where drugs are prepared and dispensed - Reach their site of action
- Alter physiological functions
- Pharmacist – A person licensed to prepare and dispense drugs and to
- Are metabolized
make up prescription
- Exit the body
- Pharmacopeia – A book containing a list of products used in
medicine, with descriptions of the product, chemical tests for ABSORPTION
determining identity and purity, formulas and prescriptions - Passage of medication molecules into the blood from the site of
TERMINOLOGIES administration
- Factors that influence absorption:
- Drugs - may have natural (plant, minerals and animal) sources
- Route of administration
- vary in strength and activity
- Ability of a medication to dissolve
LEGAL ASPECTS OF DRIG ADMINISTRATION - Blood flow to the site of administration
- Under the law, nurses are responsible for their own actions regardless - Body surface area
of whether there is a written order. - Lipid solubility
- Demerol 500 mg instead of Demerol 50 mg DISTRIBUTION
- Therefore, nurses should question any order that appears - After absorption, distribution occurs within the body to tissues,
unreasonable and refuse to give the medication until the order is organs, and specific sites of action.
clarified - Distribution depends on:
- A list of High-alert Medications (HAM), including controlled - Physical and chemical properties of the medication
substances requires the verification of two RN’s. - Physiology of the person taking it
- Before removing a controlled substance, the nurse verifies the number
- Circulation
actually available with the number indicated on the narcotic or
- Membrane permeability
controlled substance inventory record.
- Protein binding
MEDICATION LEGISLATION AND STANDARDS
METABOLISM
- Federal regulations
- Medications are metabolized into a lesspotent or an inactive form.
- Pure Food and Drug Act - Biotransformation occurs under the influence of enzymes that
- Food and Drug Administration (FDA) detoxify, break down, and remove active chemicals.
- MedWatch program - Most biotransformation occurs in the liver.
- State and local regulation of medication - Kidneys, blood, intestines, and lungs play a role.
- Health care institutions and medication laws EXCRETION
- Medication regulations and nursing practice (Nurse Practice Acts) - Medications exit the body through the:
EFFECTS OF DRUGS - Kidney
- Therapeutic/Desired effect - Liver
- Primary effect intended - Bowel
 - Lungs NURSING KNOWLEDGE BASE
- Exocrine glands - Safe administration is imperative.
- Chemical makeup of medication determines the organ of excretion. - Nursing process provides a framework for medication administration.
TYPES OF MEDICATION ACTION - Clinical calculations
- Therapeutic effect: Expected or predicted physiological response • - Conversions within one system
- Adverse effect: Unintended, undesirable, often unpredictable - Conversions between systems
- Side effect: Predictable, unavoidable secondary effect - Dose calculations
- Toxic effect: Accumulation of medication in the bloodstream - Pediatric doses
- Idiosyncratic reaction: Overreaction or underreaction or different - Calculations require special caution.
reaction from normal DOSE CALCULATION METHODS
- Allergic reaction: unpredictable response to a medication - Verify medication calculations with another nurse to ensure accuracy.
- Medication interactions: when one medication modifies the action of - The ratio and proportion method
another - Example: 1:2 = 4:8
TIMING OF MEDICATION DOSE RESPONSES
- Formula Method:
- Therapeutic range
- Peak
- Trough
- Biological half-life
- Plateau
- Time-critical medications - Dimensional analysis
- Patient teaching
- Factor-label or unit factor method
ROUTES OF ADMINISTRATION
HEALTHCARE PROVIDER’S ROLE
- Oral routes
- Prescriber can be physician, nurse practitioner, or physician’s
- Sublingual administration assistant.
- Orders can be written (hand or electronic), verbal, or given by
telephone.
- The use of abbreviations can cause errors; use caution.

TYPES OF ORDERS IN ACUTE CARE AGENCIES

Standing or routine: prn: Given when the patient
Administered until the dosage is requires it
changed or another medication
is prescribed
- Buccal administration
Single (one-time): Given one STAT: Given immediately in an
time only for a specific reason emergency

Now: When a medication is Prescriptions: Medication to be

needed right away, but not STAT taken outside of the hospital

- Parenteral routes
- Four major sites of injection
- Intradermal
- Subcutaneous
- Intramuscular
- Intravenous
- Other routes
- Epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, and
intra arterial
- Routes usually limited to physicians
- Intracardiac and intraarticular MEDICATION ADMINISTRATION
- Pharmacist’s role
- Topical administration
- Prepares and distributes medication
- Skin
- Mucous membranes - Nurse’s role
- Inhalation route - Determining medications ordered are correct, assessing patient’s
- Intraocular route ability to self-administer, determining whether patient should
receive medications at a given time, administering medications
correctly, and closely monitoring effects.
SYSTEMS OF MEDICATION MEASUREMENT - Cannot be delegated
- Require the ability to compute medication doses accurately and - Includes patient teaching
measure medications correctly
- Distribution systems
- Metric system (0 before the decimal only)
- Unit dose systems
- Most logically organized
- Automatic medication dispensing system [AMDS)
- Meter, liter, gram
MEDICATION ERRORS
- Household system
- Report all medication errors.
- Most familiar to individuals - Patient safety is top priority when an error occurs.
- Disadvantage: inaccuracy - Documentation is required.
- Solution - The nurse is responsible for preparing a written occurrence or incident
 report: an accurate, factual description of what occurred and what was - Older adults
done. - Polypharmacy
- Nurses play an essential role in medication reconciliation.
EVALUATION
CRITICAL THINKING - Through the patient’s eyes
- Knowledge - Partner with your patients.
- Experience
- Patient outcomes
- Psychomotor skills
- Use knowledge of the desired effect and common side effects of each
- Attitudes medication to compare expected outcomes with actual findings.
- Be disciplined; take your time.
- Be responsible and accountable.
MEDICATION ADMINISTRATION
- Standards ORAL ADMINISTRATION
- Ensure safe nursing practice. - Easiest and most desirable route.
- Six rights: - Food sometimes affects absorption.
- Aspiration precautions.
1. Right medication
- Enteral or small-bore feedings:
2. Right dose
3. Right patient - Verify that the tube location is compatible with medication
4. Right route absorption. – Use liquids when possible.
5. Right time - If medication is to be given on an empty stomach, allow at least 30
6. Right documentation minutes before or after feeding.
- Risk of drug-drug interactions is higher.
MAINTAINING PATIENTS’ RIGHTS - Advantages:
- A patient has the right: - It is the most common route
- To be informed about a medication - Least expensive
- To refuse a medication - Most convenient route
- To have a medication history - A safe method
- To be properly advised about experimental nature of medication - Disadvantages:
- To receive labeled medications safely
- Unpleasant taste of the drug
- To receive appropriate supportive therapy
- Irritation of the gastric mucosa
- To not receive unnecessary medications
- Irregular absorption from the GIT
- To be informed if medications are part of a research study
- Slow absorption
- Harmful to teeth
NURSING PROCESS: ASSESSMENT - Iron liquid preparation – stains the teeth
- Through the patient’s eyes SUBLINGUAL MEDICATION ADMINISTRATION
- History: Allergies, medications, diet history, patient’s perceptual or - Place the pill or direct spray between the underside of the tongue and
coordination problems the floor of the oral cavity
- Patient’s current condition
TOPICAL MEDICATION ADMINISTRATION
- Patient’s attitude about medication use
- Factors affecting adherence to medication therapy - Skin applications
- Patient’s learning needs - Use gloves and applicators; clean skin first.
- Use sterile technique if the patient has an open wound.
- Follow directions for each type of medication.
NURSING DIAGNOSIS - Transdermal patches:
- Anxiety
- Remove old patches before applying new.
- Ineffective Health Maintenance
- Document the location of the new patch.
- Deficient Knowledge (Medication SelfAdministration)
- Ask about patches during the medication history.
- Noncompliance (Medications)
- Apply a label to the patch if it is difficult to see.
- Impaired Swallowing
- Document removal of the patch as well.
- Impaired Memory
- Caregiver Role Strain (Caregiving Activities) NASAL INSTILLATION

PLANNING
- Always organize your care activities to ensure the safe administration
of medications.
- Goals and outcomes
- Setting goals and related outcomes contributes to patient safety and
allows for wise use of time during medication administration.
- Setting priorities
- Provide the most important information about the medications first.
- Teamwork and collaboration

IMPLEMENTATION
- Health promotion
- Patient and family teaching - Spray
- Acute care - Drops
- Tampons
- Receiving, transcribing, and communicating medication orders.
- Accurate dose calculation and measurement EYE INSTILLATION
- Correct administration – Recording medication administration - Instillation
- Restorative care - Avoid the cornea.
- Special considerations - Avoid the eyelids with droppers or tubes to decrease the risk of
infection.
- Infants and children
 - Use only on the affected eye. - Use clean technique when the cavity to be irrigated is not sterile, as in
- Never share medications. the case of the ear canal or vagina.
- Intraocular instillation VAGINAL INSTILLATION
- Disk resembles a contact lens.
- Teach patients how to insert and remove the disk.
- Teach about adverse effects.
EYE DROPS AND OINTMENT
- Dosage Form
- meds for use in the eye should be labeled OPHTHALMIC.
- ocular solutions are sterile, easily administered and do not interfere
with vision.
- ocular ointments do not cause alterations in visual acuity but have
no longer duration of action than solutions.
- Eye drop administration
GASTRIC TUBE ADMINISTRATION
- Use a medication dropper to place the prescribed dosage on the - Gastric tubes provide access directly to the GI system
conjunctival sac
- Dosage form
- always use a separate bottle or tube of eye medication for each Confirm proper tube placement.
patient.
- Eye Drops - conjunctival sac from inner to outer canthus.
- Eye Ointments - strip ointment to conjunctival sac.
EAR INSTILLATION
- Instill ear drops at room temperature.
- Use sterile solutions.
- Check for eardrum rupture if the patient has ear drainage.
- Never occlude the ear canal.
- Administration for children 3 years of age and older and adults
-straightening ear canal by pulling auricle upward and outward.
ADMINISTERING MEDICATIONS BY INHALATION Withdraw the plunger while
- Pressurized metered-dose inhalers (pMDIs) observing for the presence of
gastric fluid or contents.
- Need sufficient hand strength for use
- May be used with a spacer
- Breath-actuated metered-dose inhalers (BAIs)
- Release depends on strength of patient’s breath
- Dry powder inhalers (DPIs)
- Activated by patient’s breath
INHALATION
- Via respiratory tract
- Deeper passage of the respiratory tract provides a large surface area PARENTERAL ROUTE
for medication absorption. - Is defined as other than the alimentary or respiratory tract, that is, by
- Meds can be administered through the nasal passages, oral passages, needle
or tubes that have been placed into the client’s mouth to the trachea. - Main Advantage – fast absorption
- May have local or systemic effect - Types:
RECTAL INSTILLATION - Subcutaneous (hypodermic) – into the subcutaneous tissue, just
- Advantages below the skin
- Can be used when drug has objectionable taste or odor - Intramuscular – into a muscle
- Drug released at slow, steady rate - Intradermal – under the epidermis (into the dermis)
- Provides a local therapeutic effect - Intravenous – into a vein
- Intra-arterial – into an artery
- Disadvantages
- Intracardiac – into the heart muscle
- May be perceived as unpleasant by the client - Intrathecal or Intraspinal – into the spinal canal
- Drug can enter body through abrasions and cause systemic effects - Intrapleural – into the pleural space
- Inserting a rectal suppository beyond the internal sphincter and along - Epidural – into the epidural space
the rectal wall. - Intra-articular – into a joint
PARENTERAL ADMINISTRATION OF MEDICATIONS
- Equipment
- Syringes
- Luer-Lok
- Non–Luer-Lok
- Needles
- Hub
- Shaft
- Bevel
- Preparing an injection from an ampule
- Snap off ampule neck
ADMINISTERING MEDICATIONS BY IRRIGATION - Aspirate medication into syringe using filter needle
- Irrigations cleanse an area, instill a medication, or apply hot or cold to - Replace filter needle with an appropriate size needle or needless
injured tissue. device
- Irrigations most commonly use sterile water, saline, or antiseptic - Administer injection
solutions on the eye, ear, throat, vagina, and urinary tract. - Preparing an injection from a vial
- Use aseptic technique if there is a break in the skin or mucosa. - If dry, use solvent or diluent as needed
 - Inject air into vial
- Label multi dose vials after mixing Use an ampule opener or place
- Refrigerate remaining doses if needed piece of sterile gauze or alcohol
swipe between thumb and the
- Mixing medications ampule neck
- Mixing medications from a vial and an ampule
- Prepare medication from the vial first.
- Use the same syringe and filter needle to withdraw medication from
the ampule.
- Mixing medications from two vials
- Do not contaminate one medication with another.
- Ensure that the final dose is accurate.
- Maintain aseptic technique.
- Insulin preparation
- Insulin is the hormone used to treat diabetes.
- It is administered by injection because the GI tract breaks down
and destroys an oral form of insulin.
- Use the correct syringe:
- 100-Unit insulin syringe or an insulin pen to prepare U-100 insulin
- Insulin is classified by rate of action:
- Rapid, short, intermediate, and long-acting Draw up the medication.
- Know the onset, peak, and duration for each of your patients’ ordered
insulin doses.
- Mixing Insulins
- Patients whose blood glucose levels are well controlled on a mixed
insulin dose need to maintain their individual routine when
preparing and administering their insulin.
- Do not mix insulin with any other medications or diluents unless
approved by the health care provider.
- Never mix insulin glargine (Lantus) or insulin detemir (Levemir)
with other types of insulin.
- Inject rapid-acting insulins mixed with NPH (neutral protamine Dispose needle by placing in a
Hagedorn) insulin within 15 minutes before a meal. Sharp collector
- Verify insulin doses with another nurse while preparing the
injection.
- Administering Injections
- Each injection route differs based on the types of tissues the
medication enters.
- Before injecting, know:
- The volume of medication to administer
- The characteristics and viscosity of the medication
- The location of anatomical structures underlying the injection site
OBTAINING MEDICATION FROM A VIAL
- If a nurse does not administer injections correctly, negative patient
outcomes may result. Confirm the vial label. Remove
the protective cap of the vial
- Minimizing Patient Discomfort
- Use a sharp-beveled needle in the smallest suitable length and
gauge; position the patient comfortably.
- Select the proper injection site.
- Apply a vapocoolant spray or topical anesthetic.
- Divert the patient’s attention from the injection.
- Insert the needle quickly and smoothly.
- Hold the syringe steady while the needle remains in tissues.
- Inject the medication slowly and steadily

Prepare the syringe and

PREPARING MEDICATION FROM AMPULES
hypodermic needle.
Hold the ampule upright and tap
its top to dislodge any trapped
solution.

Wipe by rubbing in a circular

motion
Insert the hypodermic needle Withdraw the appropriate
into the rubber top and inject the volume of medication.
air from the syringe into the vial.

Remove all solutions from the

vial containing the mixing PARENTERAL ADMINISTRATION OF MEDICATIONS (CONT.)
solution.

Cleanse the top of the vial

containing the powdered drug
and inject the solution.
- Subcutaneous injections
- Medications placed into loose connective tissue under dermis
- Intramuscular Injections
- Faster absorption than subcutaneous route
- Many risks, so verify the injection is justified
- Angle of administration: 90 degrees
Agitate or shake the vial to - Body mass index (BMI) and adipose tissue influence needle size
ensure complete mixture. selection
- Amounts:
- Adults: 2 to 5 mL (4 to 5 mL unlikely to be absorbed properly)
- Children, older adults, thin patients: up to 2 mL
- Small children and older infants: up to 1 mL
- Smaller infants: up to 0.5 mL
- Ventrogluteal

Prepare a new syringe and

hypodermic needle.

Withdraw the appropriate

volume of medication.

- Gluteus medius
- Deep and away from major nerves and blood vessels
- Preferred and safest site for all adults, children, and infants
- Recommended for volumes greater than 2 mL
- Index finger, the middle finger, and the iliac crest form a V-shaped
In the Mix-O-Vial system, the triangle
vials are joined at the neck. - Injection site is the center of the triangle
Confirm the labels.
- Vastus Lateralis

Squeeze the vials together to

break the seal. Agitate or shake
to mix completely.
 - Used for adults and children restricted.
- Use middle third of muscle for injection - The most dangerous method for medication administration because
- Often used for infants, toddlers, and children there is no time to correct errors.
- Deltoid - Confirm placement of the IV line in a healthy site.
- Determine the rate of administration by the amount of medication
that can be given each minute.
- Volume-Controlled Infusions
- Uses small amounts (50 to 100 mL) of compatible fluids.
- Three types of containers: volume-control administration sets,
piggyback sets, and syringe pumps.
- Advantages of volume-controlled infusion:
- Reduces the risk of rapid-dose infusion by IV push
- Allows for administration of medications that are stable for a
limited time in solution
- Allows control of IV fluid intake
- Use of the Z-track method in intramuscular injections - Piggyback
- A small (25 to 250 mL) IV bag or bottle connected to a short tubing
line that connects to the upper Y-port of a primary infusion line or
to an intermittent venous access
- Volume-control administration
- Small (150-mL) containers that attach just below the primary
infusion bag or bottle
- Syringe pump
- Battery operated
- Allows medications to be given in very small amounts of fluid (5 to
60 mL) within controlled infusion times using standard syringes
- Intermittent venous access (saline lock)
- Advantages:
- Cost savings resulting from the omission of continuous IV
- Zigzag path seals needle track therapy
- Medication cannot escape from the muscle tissue - Effectiveness of nurse’s time enhanced by eliminating constant
monitoring of flow rates
- Intradermal injections
- Increased mobility, safety, and comfort for the patient
- Used for skin testing (tuberculosis [TB], allergies)
- Before administration:
- Slow absorption from dermis
- Skin testing requires the nurse to be able to clearly see the injection - Assess the patency and placement of the IV site
site for changes - After administration:
- Use a tuberculin or small hypodermic syringe for skin testing
- Access must be flushed with a solution to keep it patent
- Angle of insertion is 5 to 15 degrees with bevel up
- A small bleb will form - Administration of IV therapy in the home
- Needleless devices - Usually patients have a central venous catheter.
- Home care nurses assist with monitoring.
- Most needlestick injuries are preventable
- Carefully assess patients and their families to determine their ability
- Needlestick Safety and Prevention Act
to manage this therapy at home.
- Safety syringes
- Begin instruction on IV care management while the patient is still in
- Dispose of sharps in marked containers the hospital. Teach family and patient:
- Use puncture- and leakproof containers - To recognize signs of infection and complications
- Never force needles into receptacle - When to notify the home care nurse or health care provider
- Never place used needles into wastebaskets, your pockets, or - How to maintain IV administration equipment
patient’s tray or bedside
- Intravenous Administration
- Three methods:
- As mixtures within large volumes of IV fluids
- By injection of a bolus or small volume of medication through an
existing IV infusion line or intermittent venous access (heparin or
saline lock)
- By “piggyback” infusion of a solution containing the prescribed
medication and a small volume of IV fluid through an existing IV
line
- Large-Volume Infusions
- Safest and easiest method of IV administration.
- Large volumes (500 or 1000 mL) are used.
- If infused too rapidly, patient is at risk for overdose and fluid
overload.
- Best practices:
- Standardized concentrations and dosages
- Standardized procedures for ordering, preparing, and administering
IV medications
- Ready-to-administer doses when possible
- Intravenous bolus
- Introduces a concentrated dose of medication directly into the
systemic circulation.
- Advantageous when the amount of fluid that a patient can take is