FUNDAMENTALS OF NURSING a.

Organic – results from changes in the normal

Classification of Diseases structure, from recognizable anatomical changes in
1. According to Etiologic Factors an organ or tissue of the body.
a. Hereditary – due to defect in the genes of one b. Functional – no anatomical changes are
or other parent which is transmitted to the observed to account from the symptoms present,
offspring may result from abnormal response to stimuli.
b. Congenital – due to a defect in the c. Occupational – Results from factors associated
development, hereditary factors, or prenatal with the occupation engage in by the patient.
infection d. Venereal – usually acquired through sexual
c. Metabolic – due to disturbances or abnormality relation
in the intricate processes of metabolism. e. Familial – occurs in several individuals of the
d. Deficiency – results from inadequate intake or same family
absorption of essential dietary factor. f. Epidemic – attacks a large number of
e. Traumatic- due to injury individuals in the community at the same time.
f. Allergic – due to abnormal response of the body (e.g. SARS)
to chemical and protein substances or to physical g. Endemic – Presents more or less continuously
stimuli. or recurs in a community. (e.g. malaria, goiter)
g. Neoplastic – due to abnormal or uncontrolled h. Pandemic –An epidemic which is extremely
growth of cell. widespread involving an entire country or
h. Idiopathic –Cause is unknown; self-originated; continent.
of spontaneous origin i. Sporadic – a disease in which only occasional
i. Degenerative –Results from the degenerative cases occur. (e.g. dengue, leptospirosis)
changes that occur in the tissue and organs.
j. Iatrogenic – result from the treatment of the Leavell and Clark’s Three Levels of Prevention
disease a. Primary Prevention – seeks to prevent a
disease or condition at prepathologic state; to stop
2. According to Duration or Onset something from ever happening.
a. Acute Illness – An acute illness usually has a  Health Promotion
short duration and is severe. Signs and symptoms -health education
appear abruptly, intense and often subside after a -marriage counseling
relatively short period. -genetic screening
b. Chronic Illness – chronic illness usually longer -good standard of nutrition adjusted to
than 6 months, and can also affects functioning in developmental phase of life
any dimension. The client may fluctuate between  Specific Protection
maximal functioning and serious relapses and may -use of specific immunization
be life threatening. Is characterized by remission -attention to personal hygiene
and exacerbation. -use of environmental sanitation
 Remission- periods during which the -protection against occupational hazards
disease is controlled and symptoms are not -protection from accidents
obvious. -use of specific nutrients
 Exacerbations – The disease becomes -protections from carcinogens
more active given again at a future time, -avoidance to allergens
with recurrence of pronounced symptoms. b. Secondary Prevention – also known as
c. Sub-Acute – Symptoms are pronounced but “Health Maintenance”. Seeks to identify specific
more prolonged than the acute disease. illnesses or conditions at an early stage with
prompt intervention to prevent or limit disability;
3. Disease may also be Described as: to prevent catastrophic effects that could occur if
proper attention and treatment are not provided
 Early Diagnosis and Prompt Treatment
-case finding measures include appropriate noise, nutrition,
-individual and mass screening survey hygiene, socialization and hope.
-prevent spread of communicable disease
-prevent complication and sequelae B. PEPLAU, HILDEGARD (1951)
-shorten period of disability Defined nursing as a therapeutic, interpersonal
 Disability Limitations process which strives to develop a nurse- patient
- adequate treatment to arrest disease process and relationship in which the nurse serves as a
prevent further complication and sequelae. resource person,
-provision of facilities to limit disability and counselor and surrogate.
prevent death.
c. Tertiary Prevention – occurs after a disease or Introduced the Interpersonal Model. She
disability has occurred and the recovery process defined nursing as a interpersonal process of
has begun; Intent is to halt the disease or injury therapeutic between an individual who is sick or in
process and need of health services and a nurse especially
assist the person in obtaining an optimal health educated to recognize and respond to the need for
status.To establish a high-level wellness. help.
“To maximize use of remaining capacities”s
 Restoration and Rehabilitation She identified four phases of the nurse client
-work therapy in hospital relationship namely:
- use of shelter colony 1. Orientation: the nurse and the client initially
do not know each other’s goals and testing the
NURSING role each will assume. The client attempts to
As defined by the INTERNATIONAL identify difficulties and the amount of nursing help
COUNCIL OF NURSES as written by Virginia that is needed;
Henderson. 2. Identification: the client responds to help
 the unique function of the nurse is to assist professionals or the significant others who can
the individual, sick or well, in the meet the identified needs. Both the client and the
performance of those activities nurse plan together an appropriate program to
contributing to health, its recovery, or to a foster health;
peaceful death the client would perform 3. Exploitation: the clients utilize all available
unaided if he had the necessary strength, resources to move toward a goal of maximum
will or knowledge. health functionality;
 Help the client gain independence as 4. Resolution: refers to the termination phase of
rapidly as possible. the nurse-client relationship. it occurs when the
client’s needs are met and he/she can move
CONCEPTUAL AND THEORETICAL toward a new goal. Peplau further assumed that
MODELS OF NURSING PRACTICE nurse-client relationship fosters growth in both the
A. NIGHTANGLE’S THEORY ( mid-1800) client and the nurse.
 Focuses on the patient and his environment
. C. ABDELLAH, FAYE G. (1960)
 Developed the described the first theory of  Defined nursing as having a problem-
nursing. Notes on Nursing: What It Is, solving approach, with key nursing
What It Is Not. She focused on changing problems related to health needs of people;
and manipulating the environment in order developed list of 21
to put the patient in the best possible nursing-problem areas.
conditions for nature to act.  Introduced Patient – Centered
 She believed that in the nurturing Approaches to Nursing Model She
environment, the body could repair itself. defined nursing as service to individual
Client’s environment is manipulated to and families; therefore the society.
 Furthermore, she conceptualized nursing as F. JOHNSON, DOROTHY (1960, 1980)
an art and a science that molds the  Focuses on how the client adapts to illness;
attitudes, intellectual competencies and the goal of nursing is to reduce stress so
technical skills of the individual nurse into that the client can move more easily
the desire and ability to help people, sick through recovery.
or well, and cope with their health needs.  Viewed the patient’s behavior as a system,
which is a whole with interacting parts.
D. ORLANDO, IDA  The nursing process is viewed as a
 She conceptualized The Dynamic Nurse – major tool.
Patient Relationship Model. Conceptualized the Behavioral System Model
According to Johnson, each person as a behavioral
E. LEVINE, MYRA (1973) system is composed of seven subsystems namely:
 Believes nursing intervention is a 1. Ingestive. Taking in nourishment in socially
conservation activity, with conservation and culturally acceptable ways.
of energy as a primary concern, four 2. Eliminated. Riddling the body of waste in
conservation principles of nursing: socially and culturally acceptable ways.
conservation of client energy, conservation 3. Affiliative. Security seeking behavior.
of structured integrity, conservation of 4. Aggressive. Self – protective behavior.
personal integrity, conservation of social 5. Dependence. Nurturance – seeking behavior.
integrity. 6. Achievement. Master of oneself and one’s
 Described the Four Conversation environment according to internalized standards of
Principles. Sh Advocated that nursing is a excellence.
human interaction and proposed four 7. Sexual role identity behavior
conservation principles of nursing which
are concerned with the unity and integrity G. ROGERS, MARTHA
of the individual. The four conservation  Considers man as a unitary human being
principles are as follows: co-existing with in the universe, views
1. Conservation of energy . The human body nursing primarily as a science and is
functions by utilizing energy. The human body committed to nursing research.
needs energy producing input (food, oxygen,
fluids) to allow energy utilization output.
2. Conservation of Structural Integrity . The H. OREM, DOROTHEA (1970, 1985)
human body has physical boundaries (skin and  Emphasizes the client’s self-care needs,
mucous membrane) that must be maintained to nursing care becomes necessary when
facilitate health and prevent harmful agents from client is unable to fulfill biological,
entering the body. psychological, developmental or social
3. Conservation of Personal Integrity. The needs.
nursing interventions are based on the  Developed the Self-Care Deficit Theory.
conservation of the individual client’s personality. She defined self-care as “the practice of
Every individual has sense of identity, self worth activities that individuals initiate to
and self esteem, which must be preserved and perform on their own behalf in maintaining
enhanced by nurses. life, health well-being.” She
4. Conservation of Social integrity. The social conceptualized three systems as follows:
integrity of the client reflects the family and the 1. Wholly Compensatory: when the nurse is
community in which the client functions. Health expected to accomplish the entire patient’s
care institutions may separate individuals from therapeutic self-care or to compensate for the
their family. It is important for nurses to consider patient’s inability to engage in self care or when
the individual in the context of the family. the patient needs continuous guidance in self care;
2. Partially Compensatory: when both nurse  The client is composed of the ff.
patient engage in meeting self care needs; overlapping parts: person (core),
3. Supportive-Educative: the system that requires pathologic state and treatment (cure) and
assistance decision making, behavior control and body (care).
acquisition knowledge and skills.  Introduced the model of Nursing: What Is
It?, focusing on the notion that centers
I. IMOGENE KING (1971, 1981) around three components of CARE,
 Nursing process is defined as dynamic CORE and CURE. Care represents
interpersonal process between nurse, client nurturance and is exclusive to nursing.
and health care system. Core involves the therapeutic use of self
 Postulated the Goal Attainment Theory . and emphasizes the use of reflection. Cure
She described nursing as a helping focuses on nursing related to the
profession that assists individuals and physician’s orders. Core and cure are
groups in society to attain, maintain, and shared with the other health care providers.
restore health. If is this not possible, nurses
help individuals die with dignity. M. Virginia Henderson (1955)
 In addition, King viewed nursing as an  Introduced The Nature of Nursing
interaction process between client and Model. She identified fourteen basic
nurse whereby during perceiving, setting needs.
goals, and acting on them transactions  She postulated that the unique function of
occurred and goals are achieved. the nurse is to assist the clients, sick or
well, in the performance of those activities
J. BETTY NEUMAN contributing to health or its recovery, the
 Stress reduction is a goal of system model clients would perform unaided if they had
of nursing practice. Nursing actions are in the necessary strength, will or knowledge.
primary, secondary or tertiary level of  She further believed that nursing involves
prevention. assisting the client in gaining independence
as rapidly as possible, or assisting him
K. SIS CALLISTA ROY (Adaptation Theory) achieves peaceful death if recovery is no
(1979, 1984) longer possible.
 Views the client as an adaptive system.
The goal of nursing is to help the person N. Madaleine Leininger (1978, 1984)
adapt to changes in physiological needs,  Developed the Transcultural Nursing
self-concept, role function and Model. She advocated that nursing is a
interdependent relations during health and humanistic and scientific mode of helping
illness. a client through specific cultural caring
 Presented the Adaptation Model. She processes (cultural values, beliefs and
viewed each person as a unified practices) to improve or maintain a health
biopsychosocial system in constant condition.
interaction with a changing environment.
She contented that the person as an O. Ida Jean Orlando (1961)
adaptive system, functions as a whole  Conceptualized The Dynamic Nurse –
through interdependence of its part. The Patient Relationship Model.
system consists of input, control processes,  She believed that the nurse helps patients
output feedback. meet a perceived need that the patient
cannot meet for themselves. Orlando
observed that the nurse provides direct
L.LYDIA HALL (1962) assistance to meet an immediate need for
 help in order to avoid or to alleviate belief that nursing is an existential
distress or helplessness. experience.
 She emphasized the importance of  Nursing is viewed as a lived dialogue that
validating the need and evaluating care involves the coming together of the nurse
based on observable outcomes. and the person to be nursed.
 The essential characteristic of nursing is
P. Ernestine Weidanbach (1964) nurturance. Humanistic care cannot take
 Developed the Clinical Nursing – A place without the authentic commitment of
Helping Art Model. the nurse to being with and the doing with
 She advocated that the nurse’s individual the client. Humanistic nursing also
philosophy or central purpose lends presupposes responsible choices.
credence to nursing care.
 She believed that nurses meet the T. Helen Erickson, Evelyn Tomlin, and Mary
individual’s need for help through the Ann Swain (1983)
identification of the needs, administration  Developed Modeling and Role Modeling
of help, and validation that actions were Theory . The focus of this theory is on the
helpful. Components of clinical practice: person. The nurse models (assesses), role
Philosophy, purpose, practice and an art. models (plans), and intervenes in this
interpersonal and interactive theory.
Q. Jean Watson (1979-1992)  They asserted that each individual unique,
 Introduced the theory of Human has some self-care knowledge, needs
Becoming. She emphasized free choice of simultaneously to be attached to the
personal meaning in relating value separate from others, and has adaptive
priorities, co – creating the rhythmical potential. Nurses in this theory, facilitate,
patterns, in exchange with the nurture and accept the person
environment, and co transcending in man unconditionally.
dimensions as possibilities unfold.
U. Margaret Newman
R. Joyce Travelbee (1966,1971)  Focused on health as expanding
 She postulated the Interpersonal Aspects consciousness. She believed that human
of Nursing Model. She advocated that the are unitary in whom disease is a
goal of nursing individual or family in manifestation of the pattern of health.
preventing or coping with illness,  She defined consciousness as the
regaining health finding meaning in illness, information capability of the system which
or maintaining maximal degree of health. is influenced by time, space movement and
 She further viewed that interpersonal is ever – expanding.
process is a human-to-human relationship
formed during illness and “experience of V. Patricia Benner and Judith Wrude l (1989)
suffering”  Proposed the Primacy and Caring
 She believed that a person is a unique, Model. They believed that caring central
irreplaceable individual who is in a to the essence of nursing. Caring creates
continuous process of becoming, evolving the possibilities for coping and creates the
and changing possibilities for connecting with and
. concern for others.
S. Josephine Peterson and Loretta Zderad
(1976) W. Anne Boykin and Savina Schoenhofer
 Provided the Humanistic Nursing  Presented the grand theory of Nursing as
Practice Theory. This is based on their Caring. They believed that all person are
caring, and nursing is a response to a
 unique social call. The focus of nursing is expectations of the family, groups or nation and
on nurturing person living and growing in sees
caring in a manner that is specific to each this as right.
nurse-nurse relationship or nursing 3. At the third level, people make
situation. Each nursing situation is postconventiona l, autonomous, or principal level.
original. At this level, people make an effort to define valid
 They support that caring is a moral values and principles without regard to outside
imperative. Nursing as Caring is not based authority or to the expectations of others. These
on need or deficit but is egalitarian model involve respect for other human and belief that
helping. relationship are based on mutual trust.

Moral Theories Peter (1981)

1. Freud (1961)  Proposed a concept of rational morality
 Believed that the mechanism for right and based on principles. Moral development
wrong within the individua l is the is usually considered to involve three
superego, or conscience . He hypnotized separate components: moral emotion (what
that a child internalizes and adopts the one feels), moral judgment (how one
moral standards and character or character reasons), and moral behavior (how one
traits of the model parent through the acts).
process of identification.  In addition, Peters believed that the
 The strength of the superego depends on development of character traits or
the intensity of the child’s feeling of virtues is an essential aspect or moral
aggression or attachment toward the model development. And that virtues or character
parent rather than on the actual standards traits can be learned from others and
of the parent. encouraged by the example of others.
 Also, Peters believed that some can be
2. Erikson (1964) described as habits because they are in
 Erikson’s theory on the development of some sense automatic and therefore are
virtues or unifying strengths of the “good performed habitually, such as politeness,
man” suggest that moral development chastity, tidiness, thrift and honesty.
continuous throughout life. He believed
that if the conflicts of each psychosocial Gilligan (1982)
developmental stages favorably resolved,  Included the concepts of caring and
then an ‘egostrength” or virtue emerges. responsibility. She described three stages
in the process of developing an “Ethic of
3. Kohlberg Care” which are as follows.
 Suggested three levels of moral 1. Caring for oneself.
development. He focused on the reason for 2. Caring for others.
the making of a decision, not on the 3. Caring for self and others.
morality of the decision itself.  She believed the human see morality in
1. At first level called the premolar or th the integrity of relationships and caring.
preconventional level, children are responsive to For women, what is right is taking
cultural rules and labels of good and bad, right and responsibility for others as
wrong. However children interpret these in terms self-chosen decision. On the other hand, men
of the physical consequences of the actions, i.e., consider what is right to be what is just.
punishment or reward.
2. At the second level, the conventional level, the Spiritual Theories
individual is concerned about maintaining the Fowler (1979)
  Described the development of faith. He in a specialized area of practice (e.g.,
believed that faith, or the spiritual gerontology, oncology).
dimension is a force that gives meaning to  The nurse provides direct client care,
a person’s life. educates others, consults, conducts
 He used the term “faith” as a form of research, and manages care.
knowing a way of being in relation “to an  The American Nurses Credentialing Center
ultimate environment.” To Fowler, faith is provides national certification of clinical
a relational phenomenon: it is “an active specialists.
made-of-being-in-relation to others in 3. Nurse Anesthetist
which we invest commitment, belief, love,  A nurse who has completed advanced
risk and hope.” education in an accredited program in
anesthesiology.
 The nurse anesthetist carries out pre-
operative visits and assessments, and
ROLES AND FUNCTIONS OF THE NURSE Administers general anesthetics for surgery
 Care giver under the supervision of a physician
 Decision-maker prepared in anesthesiology.
 Protector  The nurse anesthetist also assesses the
 Client Advocate postoperative of clients
 Manager 4. Nurse Midwife
 Rehabilitator  An RN who has completed a program in
 Comforter midwifery.
 Communicator  The nurse gives pre-natal and post-natal
 Teacher care and manages deliveries in normal
 Counselor pregnancies.
 Coordinator  The midwife practices the association with
 Leader a health care agency and can obtain
 Role Model medical services if complication occurs.
 Administrator  The nurse midwife may also conduct
routine Papanicolaou smears, family
Selected Expanded Career Roles of Nurses planning, and routine breast examination.
1. Nurse Practitioner 5. Nurse Educator
 A nurse who has an advanced education  Nurse educator is employed in nursing
and is a graduate of a nurse practitioner programs, at educational institutions, and
program. in hospital staff education.
 These nurses are in areas as adult nurse  The nurse educator usually ha a
practitioner, family nurse practitioner, baccalaureate degree or more advanced
school nurse practitioner, pediatric nurse preparation and frequently has expertise in
practitioner, or gerontology nurse a particular area of practice.
practitioner. The nurse educator is responsible for classroom
 They are employed in health care agencies and of ten clinical teaching.
or community based settings. They usually 6. Nurse Entrepreneur
deal with non-emergency acute or chronic  A nurse who usually has an advanced
illness and provide primary ambulatory degree and manages a health-related
care. business.
2. Clinical Nurse Specialist  The nurse may be involved in education,
 A nurse who has an advanced degree or consultation, or research, for example.
expertise and is considered to be an expert
COMMUNICATION IN NURSING
COMMUNICATION nurse should be able to provide accurate
1. Is the means to establish a helping-healing information, to convey confidence and certainly in
relationships. All behavior communication what she says.
influences behavior.
2. Communication is essential to the nurse-patient Communicating With Clients Who Have
relationship for the following reasons: Special Needs
- Is the vehicle for establishing a therapeutic 1.Clients who cannot speak clearly (aphasia,
relationship. dysarthria, muteness)
- It the means by which an individual influences 1. Listen attentively, be patient, and do not
the behavior of another, which leads to the interrupt.
successful outcome of nursing intervention. 2. Ask simple question that require “yes” and “no”
answers.
Basic Elements of the Communication Process 3. Allow time for understanding and response.
1. SENDER – is the person who encodes and 4. Use visual cues (e.g., words, pictures, and
delivers the message objects)
2. MESSAGES – is the content of the 5. Allow only one person to speak at a time.
communication. It may contain verbal, nonverbal, 6. Do not shout or speak too loudly.
and symbolic language. 7. Use communication aid:
3. RECEIVER – is the person who receives the -pad and felt-tipped pen, magic slate, pictures
decodes the message. denoting basic needs, call bells or alarm.
4. FEEDBACK – is the message returned by the 2. Clients who are cognitively impaired
receiver. It indicates whether the meaning of the 1. Reduce environmental distractions while
sender’s message was understood. conversing.
2. Get client’s attention prior to speaking
Modes of Communication 3. Use simple sentences and avoid long
1. Verbal Communication – use of spoken or explanation.
written words. 4. Ask one question at a time
2. Nonverbal Communication – use of gestures, 5. Allow time for client to respond
facial expressions, posture/gait, body movements, 6. Be an attentive listener
physical appearance and body language 7. Include family and friends in conversations,
especially in subjects known to client.
Characteristics of Good Communication 3. Client who are unresponsive
1. Simplicity – includes uses of commonly 1. Call client by name during interactions
understood, brevity, and completeness. 2. Communicate both verbally and by touch
2. Clarity – involves saying what is meant. The 3. Speak to client as though he or she could hear
nurse should also need to speak slowly and 4. Explain all procedures and sensations
enunciate words well. 5. Provide orientation to person, place, and time
3. Timing and Relevance – requires choice of 6. Avoid talking about client to others in his or her
appropriate time and consideration of the client’s presence
interest and concerns. Ask one question at a time 7. Avoid saying things client should not hear
and wait for an answer before making another 4. Communicating with hearing impaired client
comment. 1. Establish a method of communication
4. Characteristics of Good Communication (pen/pencil and paper, sign-language)
5. Adaptability – Involves adjustments on what 2. Pay attention to client’s non-verbal cues
the nurse says and how it is said depending on the 3. Decrease background noise such as television
moods and behavior of the client. 4. Always face the client when speaking
6. Credibility – Means worthiness of belief. To 5. It is also important to check the family as to
become credible, the nurse requires adequate how to communicate with the client
knowledge about the topic being discussed. The
6. It may be necessary to contact the appropriate 1. nurses are legally and ethically obligated to
department resource person for this type of keep information about clients confidential.
disability 2. Nurses may not discuss a client’s examination,
4. Client who do not speak English observation, conversation, or treatment with other
1. Speak to client in normal tone of voice clients or staff not involved in the client’s care.
(shouting may be interpreted as anger) 3. Only staff directly involved in a specific
2. Establish method for client o signal desire to client’s care have legitimate access to the
communicate (call light or bell) record.
3. Provide an interpreter (translator) as needed 4. Clients frequently request copies of their
4. Avoid using family members, especially medical record, and they have the right to read
children, as interpreters. those records.
5. Develop communication board, pictures or 5. Nurses are responsible for protecting records
cards. from all unauthorized readers.
6. Have dictionary (English/Spanish) available if 6. when nurses and other health care professionals
client can read. have a legitimate reason to use records for data
gathering, research, or continuing education,
Reports appropriate authorization must be obtained
 Are oral ,written, or audiotaped exchanges according to agency policy.
of information between caregivers. 7. Maintaining confidentiality is an important
Common reports: aspect of profession behavior.
1. Change-in-shift report 8.It is essential that the nurse safe-guard the client’
2. Telephone report right to privacy by carefully protecting
3. Telephone or verbal order – only RN’s are information of a sensitive, private nature.
allowed to accept telephone orders. 9. Sharing personal information or gossiping about
4. Transfer report others violates nursing
5. Incident report ethical codes and practice standards.
Documentation 10.It sends the message that the nurse cannot be
1. Is anything written or printed that is relied on as trusted and damages the interpersonal
record or proof for authorized person. relationships.
2. Nursing documentation must be:
3. accurate Guidelines of Quality Documentation and
4. comprehensive Reporting
5. flexible enough to retrieve critical data, 1.Factual
maintain continuity of care, track client outcomes, 1. a record must contain descriptive, objective
and reflects current standards of nursing practice information about what a nurse sees, hears, feels,
6. Effective documentation ensures continuity of and smells.
care, saves time and minimizes the risk of error. 2. The use of vague terms, such as appears, seems,
7. As members of the health care team, nurses and apparently , is not acceptable because these
need to communicate information about clients words suggests that the nurse is stating an opinion.
accurately and in timely manner  Example: “ the client seems anxious” (the
8. If the care plan is not communicated to all phrase seems anxious is a conclusion
members of the health care team, care can become without supported facts.)
fragmented, repetition of tasks occurs, and 2. Accurate
therapies may be delayed or omitted. 1. The use of exact measurements establishes
9. Data recorded, reported, or c0mmunicated to accuracy. (example: “Intake of 350 ml of water” is
other health care professionals are more accurate than “ the client drank an adequate
CONFIDENTIAL and must be protected. amount of fluid”
2. Documentation of concise data is clear and easy
CONFIDENTIALITY to understand.
3. It is essential to avoid the use of unnecessary  Blank ink is more legible when records are
words and irrelevant details photocopied or transferred to microfilm.
3. Complete  Legal Guidelines for Recording
1. The information within a recorded entry or a 6. If order is questioned, record that clarification
report needs to be complete, containing was sought.
appropriate and essential information.  If you perform orders known to be
Example: incorrect, you are just as liable for
 The client verbalizes sharp, throbbing pain prosecution as the physician is.
localized along lateral side of right ankle, 7. Chart only for yourself
beginning approximately 15 minutes ago  Never chart for someone else.
after twisting  You are accountable for information you
his foot on the stair. Client rates pain as 8 on a enter into chart.
scale of 0-10. 8. Avoid using generalized, empty phrases such as
4. Current “status unchanged” or “had good day”.
1. Timely entries are essential in the clients  Begin each entry with time, and end with
ongoing care. To increase accuracy and decrease your signature and title.
unnecessary duplication, many healthcare agencies  Do not wait until end of shift to record
use records kept near the client’s bedside, which important changes that occurred several
facilitate immediate documentation of information hours earlier. Be sure to sign each entry.
as it is collected from a client 9. For computer documentation keep your
5. Organized password to yourself.
1. The nurse communicates information in a  maintain security and confidentiality.
logical order.  Once logged into the computer do not
 For example, an organized note describes leave the computer screen unattended.
the client’s pain, nurse’s assessment, Assessing Vital Signs
nurse’s interventions, and the client’s Vital Signs or Cardinal Signs are:
response  Body temperature
Legal Guidelines for recording  Pulse
1. Draw single line through error, write word error  Respiration
above it and sign your name or initials. Then  Blood pressure
record note correctly. Pain
2. Do not write retaliatory or critical comments I. Body Temperature
about the client or care by other health care  The balance between the heat produced by
professionals. the body and the heat loss from the body.
 Enter only objective descriptions of
client’s behavior; client’s comments Types of Body Temperature
should be quoted.  Core temperature –temperature of the deep
3. Correct all errors promptly tissues of the body.
 errors in recording can lead to errors in  Surface body temperature
treatment Alteration in body Temperature
 Avoid rushing to complete charting, be  Pyrexia – Body temperature above normal
sure information is accurate. range( hyperthermia)
4. Do not leave blank spaces in nurse’s notes.  Hyperpyrexia – Very high fever,
 Chart consecutively, line by line; if space 41ºC(105.8 F) and above
is left, draw line horizontally through it  Hypothermia – Subnormal temperature.
and sign your name at end. Normal Adult Temperature Ranges
5. Record all entries legibly and in blank ink  Oral 36.5 –37.5 ºC
 Never use pencil, felt pen.  Axillary 35.8 – 37.0 ºC
 Rectal 37.0 – 38.1 ºC
  Tympanic 36.8 – 37.9ºC  Store chemical-dot thermometer in a cool
Methods of Temperature-Taking area because exposure to heat activates the
1. Ora l – most accessible and convenient method. dye dots.
a. Put on gloves, and position the tip of the 4. Tympanic thermometer
thermometer under the patients tongue on either of a. Make sure the lens under the probe is clean and
the frenulun as far back as possible. It promotes shiny
contact to the superficial blood vessels and ensures b. Stabilized the patient’s head; gently pull the ear
a more accurate reading. straight back (for children up to age 1) or up and
b. Wash thermometer before use. back (for children 1 and older to adults)
c. Take oral temp 2-3 minutes. c. Insert the thermometer until the entire ear canal
d. Allow 15 min to elapse between client’s food is sealed
intake of hot or cold food, smoking. d. Place the activation button, and hold it in place
e. Instruct the patient to close his lips but not to for 1 second
bite down with his teeth to avoid breaking the 5. Chemical-dot thermometer
thermometer in his mouth. a. Leave the chemical-dot thermometer in place
Contraindications for 45 seconds
 Young children an infants b. Read the temperature as the last dye dot that has
 Patients who are unconscious or change color, or fired.
disoriented Nursing Interventions in Clients with Fever
 Who must breath through the mouth a. Monitor V.S
 Seizure prone b. Assess skin color and temperature
 Patient with N/V c. Monitor WBC, Hct and other pertinent lab
 Patients with oral lesions/surgeries records
2. Rectal- most accurate measurement of d. Provide adequate foods and fluids.
temperature e. Promote rest
a. Position- lateral position with his top legs flexed f. Monitor I & O
and drape him to provide privacy. g. Provide TSB
b. Squeeze the lubricant onto a facial tissue to h. Provide dry clothing and linens
avoid contaminating the lubricant supply. i. Give antipyretic as ordered by MD
c. Insert thermometer by 0.5 – 1.5 inches II. Pulse – It’s the wave of blood created by
d. Hold in place in 2minutes contractions of the left ventricles of the heart.
e. Do not force to insert the thermometer Normal Pulse rate
Contraindications 1 year 80-140 beats/min
 Patient with diarrhea 2 years 80- 130 beats/min
 Recent rectal or prostatic surgery or injury 6 years 75- 120 beats/min
because it may injure inflamed tissue 10 years 60-90 beats/min
 Recent myocardial infarction Adult 60-100 beats/min
 Patient post head injury Tachycardia – pulse rate of above 100 beats/min
3. Axillary – safest and non-invasive Bradycardia- pulse rate below 60 beats/min
a. Pat the axilla dry Irregular – uneven time interval between beats.
b. Ask the patient to reach across his chest and What you need:
grasp his opposite shoulder. a. Watch with second hand
This promote skin contact with the thermometer b. Stethoscope (for apical pulse)
c. Hold it in place for 9 minutes because the c. Doppler ultrasound blood flow detector if
thermometer isn’t close in a body cavity necessary
Note: Radial Pulse
 Use the same thermometer for repeat a. Wash your hand and tell your client that you are
temperature taking to ensure more going to take his pulse
consistent result
b. Place the client in sitting or supine position with g. Use the bell of the stethoscope since the blood
his arm on his side or across his chest pressure is a low frequency sound.
c. Gently press your index, middle, and ring h. If the client is crying or anxious, delay
fingers on the radial artery, inside the patient’s measuring his blood pressure to avoid false-high
wrist. BP
d. Excessive pressure may obstruct blood flow Electronic Vital Sign Monitor
distal to the pulse site a. An electronic vital signs monitor allows you to
e. Counting for a full minute provides a more continually tract a patient’s vital sign without
accurate picture of irregularities having to reapply a blood pressure cuff each time.
Doppler device b. Example: Dinamap VS monitor 8100
a. Apply small amount of transmission gel to the c. Lightweight, battery operated and can be
ultrasound probe attached to an IV pole
b. Position the probe on the skin directly over a d. Before using the device, check the client7s
selected artery pulse and BP manually using the same arm you’ll
c. Set the volume to the lowest setting using for the monitor cuff.
d. To obtain best signals, put gel between the skin e. Compare the result with the initial reading from
and the probe and tilt the probe 45 degrees from the monitor. If the results differ call the supply
the artery. department or the manufacturer’s representative.
e. After you have measure the pulse rate, clean the V. Pain
probe with soft cloth soaked in antiseptic. Do not How to assess Pain
immerse the probe a. You must consider both the patient’s description
III. Respiration - is the exchange of oxygen and and your observations on his behavioral responses.
carbon dioxide between the atmosphere and the b. First, ask the client to rank his pain on a scale of
body 0-10, with 0 denoting lack of pain and 10 denoting
Assessing Respiration the worst pain imaginable.
Rate – Normal 14-20/ min in adult c. Ask:
 The best time to assess respiration is d. Where is the pain located?
immediately after taking client’s pulse e. How long does the pain last?
 Count respiration for 60 second f. How often does it occur?
 As you count the respiration, assess and g. Can you describe the pain?
record breath sound as stridor, wheezing, h. What makes the pain worse?
or stertor. i. Observe the patient’s behavioral response to
 Respiratory rates of less than 10 or more pain (body language, moaning, grimacing,
than 40 are usually considered abnormal withdrawal, crying, restlessness muscle twitching
and should be reported immediately to the and immobility)
physician. j. Also note physiological response, which may be
IV. Blood Pressure sympathetic or parasympathetic
Adult – 90- 132 systolic Managing Pain
60- 85 diastolic 1. Giving medication as per MD’s order
Elderly 140-160 systolic 2. Giving emotional support
70-90 diastolic 3. Performing comfort measures
a. Ensure that the client is rested 4. Use cognitive therapy
b. Use appropriate size of BP cuff. Height and weight
c. If too tight and narrow- false high BP a. Height and weight are routinely measured when
d. If too lose and wide-false low BP a patient is admitted to a health care facility.
e. Position the patient on sitting or supine position b. It is essential in calculating drug dosage,
f. Position the arm at the level of the heart, if the contrast agents, assessing nutritional status and
artery is below the heart level, you may get a false determining the height-weight ratio.
high reading
c. Weight is the best overall indicator of fluid a. Clamp the catheter for 30 min to 1 hour to allow
status, daily monitoring is important for clients urine to accumulate in the bladder and adequate
receiving a diuretics or a medication that causes specimen can be collected.
sodium retention. b. Clamping the drainage tube and emptying the
d. Weight can be measured with a standing scale, urine into a container are contraindicated after a
chair scale and bed scale. genitourinary surgery.
e. Height can be measured with the measuring bar, II. Stool Specimen
standing scale or tape measure if the client is 1. Fecalysis – to assess gross appearance of stool
confine in a supine position. and presence of ova or parasite
Pointers: a. Secure a sterile specimen container
a. Reassure and steady patient who are at risk for b. Ask the pt. to defecate into a clean , dry bed pan
losing their balance on a scale. or a portable commode.
b. Weight the patient at the same time each day. c. Instruct client not to contaminate the specimen
(usually before breakfast), in similar clothing and with urine or toilet paper( urine inhibits bacterial
using the same scale. growth and paper towel contain bismuth which
c. If the patient uses crutches, weigh the client interfere with the test result.
with the crutches or heavy clothing and subtract 2. Stool culture and sensitivity test
their weight from the total determined patient’ To assess specific etiologic agent causing
weight. gastroenteritis and bacterial sensitivity to various
Laboratory and Diagnostic examination antibiotics.
I. Urine Specimen 3. Fecal Occult blood test
1.Clean-Catch mid-stream urine specimen for are valuable test for detecting occult blood
routine urinalysis, culture and sensitivity test (hidden) which may be present in colo-rectal
a. Best time to collect is in the morning, first cancer, detecting melena stool
voided urine a. Hematest- (an Orthotolidin reagent tablet)
b. Provide sterile container b. Hemoccult slide- (filter paper impregnated with
c. Do perineal care before collection of the urine guaiac)
d. Discard the first flow of urine Both test produces blue reaction if occult blood
e. Label the specimen properly lost exceeds 5 ml in 24 hours.
f. Send the specimen immediately to the c. Colocare – a newer test, requires no smear
laboratory Instructions:
g. Document the time of specimen collection and a. Advise client to avoid ingestion of red meat for
transport to the lab. 3 days
h. Document the appearance, odor, and usual b. Patient is advise on a high residue diet
characteristics of the specimen. c. avoid dark food and bismuth compound
2. 24-hour urine specimen d. If client is on iron therapy, inform the MD
a. Discard the first voided urine. e. Make sure the stool in not contaminated with
b. Collect all specimens thereafter until the urine, soap solution or toilet paper
following day f. Test sample from several portion of the stool.
c. Soak the specimen in a container with ice
d. Add preservative as ordered according to Venipuncture
hospital policy Pointers
3. Second-Voided urine – required to assess a. Never collect a venous sample from the arm or a
glucose level and for the presence of albumen in leg that is already being use d for I.V therapy or
the urine. blood administration because it mat affect the
a. Discard the first urine result.
b. Give the patient a glass of water to drink b. Never collect venous sample from an infectious
c. After few minutes, ask the patient to void site because it may introduce pathogens into the
4. Catheterized urine specimen vascular system
c. Never collect blood from an edematous area, b. For HIV positive clients, induration of 5 mm is
AV shunt, site of previous hematoma, or vascular considered positive
injury. 2. Bronchography
d. Don’t wipe off the povidine-iodine with alcohol a. Secure consent
because alcohol cancels the effect of povidine b. Check for allergies to seafood or iodine or
iodine. anesthesia
e. If the patient has a clotting disorder or is c. NPO 6-8 hours before the test
receiving anticoagulant therapy, maintain pressure d. NPO until gag reflex return to prevent
on the site for at least 5 min after withdrawing the aspiration
needle. 3. Thoracentesis – aspiration of fluid in the
Arterial puncture for ABG test pleural space.
a. Before arterial puncture, perform Allen’s test a. Secure consent, take V/S
first. b. Position upright leaning on overbed table
b. If the patient is receiving oxygen, make sure c. Avoid cough during insertion to prevent pleural
that the patient’s therapy has been underway for at perforation
least 15 min before collecting arterial sample d. Turn to unaffected side after the procedure to
c. Be sure to indicate on the laboratory request slip prevent leakage of fluid in the thoracic cavity
the amount and type of oxygen therapy the patient e. Check for expectoration of blood. This indicate
is having. trauma and should be reported to MD
d. If the patient has just received a nebulizer immediately.
treatment, wait about 20 minutes before collecting 4.Holter Monitor
the sample. a. it is continuous ECG monitoring, over 24 hours
IV. Blood specimen period
a. No fasting for the following tests: b. The portable monitoring is called telemetry unit
- CBC, Hgb, Hct, clotting studies, enzyme studies, 5. Echocardiogram –
serum electrolytes a. ultrasound to assess cardiac structure and
b. Fasting is required: mobility
- FBS, BUN, Creatinine, serum lipid ( cholesterol, b. Client should remain still, in supine position
triglyceride) slightly turned to the left side, with HOB elevated
V. Sputum Specimen 15-20 degrees
1.Gross appearance of the sputum 6. Electrocardiography
a. Collect early in the morning If the patient’s skin is oily, scaly, or diaphoretic,
b. Use sterile container rub the electrode with a dry 4x4 gauze to enhance
c. Rinse the mount with plain water before electrode contact.
collection of the specimen b. If the area is excessively hairy, clip it
d. Instruct the patient to hack-up sputum c. Remove client`s jewelry, coins, belt or any
2. Sputum culture and sensitivity test metal
a. Use sterile container d. Tell client to remain still during the procedure
b. Collect specimen before the first dose of 7. Cardiac Catheterization
antibiotic a. Secure consent
3. Acid-Fast Bacilli b. Assess allergy to iodine, shelfish
a. To assess presence of active pulmonary c. V/S, weight for baseline information
tuberculosis d. Have client void before the procedure
b. Collect sputum in three consecutive morning e. Monitor PT, PTT, ECG prior to test
4. Cytologic sputum exam- f. NPO for 4-6 hours before the test
-to assess for presence of abnormal or cancer cells. g. Shave the groin or brachial area
Diagnostic Test h. After the procedure : bed rest to prevent
1. PPD test bleeding on the site, do not flex extremity
a. read result 48 – 72 hours after injection.
i. Elevate the affected extremities on extended d. Place the client in supine at the right side of the
position to promote blood supply back to the heart bed
and prevent thrombplebitis e. Instruct client to inhale and exhale deeply for
j. Monitor V/S especially peripheral pulses several times and then exhale and hold breath
k. Apply pressure dressing over the puncture site while the MD insert the needle
l. Monitor extremity for color, temperature, f. Right lateral post procedure for 4 hours to apply
tingling to assess for impaired circulation. pressure and prevent bleeding
8. MRI g. Bed rest for 24 hours
a. secure consent, h. Observe for S/S of peritonitis
b. the procedure will last 45-60 minute 12. Paracentesis
c. Assess client for claustrophobia a. Secure consent, check V/S
d. Remove all metal items b. Let the patient void before the procedure to
e. Client should remain still prevent puncture of the bladder
f. Tell client that he will feel nothing but may hear c. Check for serum protein. Excessive loss of
noises plasma protein may lead to hypovolemic shock.
g. Client with pacemaker, prosthetic valves, 13. Lumbar Puncture
implanted clips, wires are not eligible for MRI. a. obtain consent
h. Client with cardiac and respiratory complication b. instruct client to empty the bladder and bowel
may be excluded c. position the client in lateral recumbemt with
i. Instruct client on feeling of warmth or shortness back at the edge of the examining table
of breath if contrast medium is used during the d. instruct client to remain still
procedure e. obtain specimen per MDs order
9.UGIS – Barium Swallow NURSING PROCEDURES
a. instruct client on low-residue diet 1-3 days 1. Steam Inhalation
before the procedure a. It is dependent nursing function.
b. administer laxative evening before the b. Heat application requires physician’s order.
procedure c. Place the spout 12-18 inches away from the
c. NPO after midnight client’s nose or adjust the distance as necessary.
d. instruct client to drink a cup of flavored barium 2. Suctioning
e. x-rays are taken every 30 minutes until barium a. Assess the lungs before the procedure for
advances through the small bowel baseline information.
f. film can be taken as long as 24 hours later b. Position: conscious – semi-Fowler’s
g. force fluid after the test to prevent c. Unconscious – lateral position
constipation/barium impaction d. Size of suction catheter- adult- fr 12-18
10.LGIS – Barium Enema e. Hyper oxygenate before and after procedure
a. instruct client on low-residue diet 1-3 days f. Observe sterile technique
before the procedure g. Apply suction during withdrawal of the catheter
b. administer laxative evening before the h. Maximum time per suctioning –15 sec
procedure 3. Nasogastric Feeding (gastric gavage)
c. NPO after midnight Insertion:
d. administer suppository in AM a. Fowler’s position
e. Enema until clear b. Tip of the nose to tip of the earlobe to the
f. force fluid after the test to prevent xyphoid
constipation/barium impaction Tube Feeding
a. Semi-Fowler’s position
11. Liver Biopsy b. Assess tube placement
a. Secure consent, c. Assess residual feeding
b. NPO 2-4 hrs before the test d. Height of feeding is 12 inches above the tube’s
c. Monitor PT, Vit K at bedside point of insertion
e. Ask client to remain upright position for at least 11. Restraints
30 min. g. Secure MD’s order for each episode of
f. Most common problem of tube feeding is restraints application.
Diarrhea due to lactose intolerance h. Check circulation every 15 min
4. Enema i. Remove restraints at least every 2 hours for 30
a. Check MD’s order minutes
b. Provide privacy
c. Position left lateral Normal Values
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube Bleeding time 1-9 min
f. If abdominal cramps occur, temporarily stop the Prothrombin time 10-13 sec
flow until cramps are gone. Hematocrit Male 42-52%
g. Height of enema can – 18 inches Female 36-48%
5. Urinary Catheterization Hemoglobin male 13.5-16 g/dl
a. Verify MD’s order female 12-16 g/dl
b. Practice strict asepsis Platelet 150,00- 400,000
c. Perineal care before the procedure RBC male 4.5-6.2 million/L
d. Catheter size: male-14-16, female – 12 – 14 female 4.2-5.4 million/L
e. Length of catheter insertion Amylase 80-180 IU/L
male – 6-9 inches ,female – 3-4 inches Bilirubin(serum) direct 0-0.4 mg/dl
For retention catheter: indirect 0.2-0.8 mg/dl
Male –anchor laterally or upward over the lower total 0.3-1.0 mg/dl
abdomen to prevent penoscrotal pressure pH 7.35- 7.45
Female- inner aspect of the thigh PaCo2 35-45
6. Bed Bath HCO3 22-26 mEq/L
a. Provide privacy Pa O2 80-100 mmHg
b. Expose, wash and dry one body part a time SaO2 94-100%
c. Use warm water (110-115 F) Sodium 135- 145 mEq/L
d. Wash from cleanest to dirtiest Potassium 3.5- 5.0 mEq/L
e. Wash, rinse, and dry the arms and leg using Calcium 4.2- 5.5 mg/dL
Long, firm strokes from distal to proximal area – Chloride 98-108 mEq/L
to increase venous return. Magnesium 1.5-2.5 mg/dl
7. Foot Care BUN 1 0-20 mg/dl
a. Soaking the feet of diabetic client is no longer Creatinine 0.4- 1.2
recommended CPK-MB male 50 –325 mu/ml
b. Cut nail straight across female 50-250 mu/ml
8. Mouth Care Fibrinogen 200-400 mg/dl
a. Eat coarse, fibrous foods (cleansing foods) such FBS 80-120 mg/dl
as fresh fruits and raw vegetables Glycosylated Hgb 4.0-7.0%
b. Dental check every 6 mounts (HbA1c)
9. Oral care for unconscious client Uric Acid 2.5 –8 mg/dl
a. Place in side lying position ESR male 15-20 mm/hr
b. Have the suction apparatus readily available Female 20-30 mm/hr
10. Hair Shampoo Cholesterol 150- 200 mg/dl
c. Place client diagonally in bed Triglyceride 140-200 mg/dl
d. Cover the eyes with wash cloth Lactic Dehydrogenase 100-225 mu/ml
e. Plug the ears with cotton balls Alkaline phospokinase 32-92 U/L
f. Massage the scalp with the fatpads of the fingers Albumin 3.2- 5.5 mg/dl
to promote circulation in the scalp.
COMMON THERAPEUTIC DIETS Foods Allowed:
1. CLEAR-LIQUID DIET  very tender minced, ground, baked broiled,
Purpose: roasted, stewed, or creamed beef, lamb,
 relieve thirst and help maintain fluid veal, liver, poultry, or fish; crisp bacon or
balance. sweet bread; cooked vegetables; pasta; all
Use: fruit juices; soft raw fruits; soft bread and
 post-surgically and following acute cereals; all desserts that are soft; and
vomiting or diarrhea. cheeses.
Foods Allowed: Foods Avoided:
 carbonated beverages; coffee (caffeinated  coarse whole-grain cereals and bread; nuts;
and decaff.); tea; fruit-flavored drinks; raisins; coconut; fruits with small seeds;
strained fruit juices; clear, flavored fried foods; high fat gravies or sauces;
gelatins; broth, consomme; sugar; spicy salad dressings; pickled meat, fish, or
popsicles; commercially prepared clear poultry; strong cheeses; brown or wild
liquids; and hard candy. rice; raw vegetables, as well as lima beans
Foods Avoided: and corn; spices such as horseradish,
 milk and milk products, fruit juices with mustard, and catsup; and popcorn.
pulp, and fruit. 4. SODIUM-RESTRICTED DIET
2. FULL-LIQUID DIET Purpose:
Purpose:  reduce sodium content in the tissue and
 provide an adequately nutritious diet for promote excretion of water.
patients who cannot chew or who are too Use:
ill to do so.  heart failure, hypertension, renal disease,
Use: cirrhosis, toxemia of pregnancy, and
 acute infection with fever, GI upsets, after cortisone therapy.
surgery as a progression from clear liquids. Modifications:
Foods Allowed:  mildly restrictive 2 g sodium diet to
 clear liquids, milk drinks, cooked cereals, extremely restricted 200 mg sodium diet.
custards, ice cream, sherbets, eggnog, all Foods Avoided:
strained fruit juices, creamed vegetable  table salt; all commercial soups, including
soups, puddings, mashed potatoes, instant bouillon; gravy, catsup, mustard, meat
breakfast drinks, yogurt, mild cheese sauce sauces, and soy sauce; buttermilk, ice
or cream, and sherbet; sodas; beet greens,
pureed meat, and seasoning. carrots, celery, chard, sauerkraut, and
Foods Avoided: spinach; all canned vegetables; frozen
 nuts, seeds, coconut, fruit, jam, and peas;
marmalade  all baked products containing salt, baking
3. SOFT DIET powder, or baking soda; potato chips and
Purpose: popcorn; fresh or canned shellfish; all
 provide adequate nutrition for those who cheeses; smoked or commercially prepared
have troubled chewing. meats; salted butter or margarine; bacon,
Use: olives; and commercially prepared salad
 patient with no teeth or ill-fitting dentures; dressings.
transition from full-liquid to general diet; 5. RENAL DIET
and for those who cannot tolerate highly Purpose:
seasoned, fried or raw foods following control protein, potassium, sodium, and fluid
acute infections or gastrointestinal levels in the body.
disturbances such as gastric ulcer or Use:
cholelithiasis.
  acute and chronic renal failure, Use:
hemodialysis.  high uric acid retention, uric acid renal
 Foods Allowed: stones, and gout.
 high-biological proteins such as meat, Foods Allowed:
fowl, fish, cheese, and dairy products range  general diet plus 2-3 quarts of liquid daily.
between 20 and 60 mg/day. Foods Avoided:
 Potassium is usually limited to 1500  cheese containing spices or nuts, fried
mg/day. eggs, meat, liver, seafood, lentils, dried
 Vegetables such as cabbage, cucumber, peas and beans, broth, bouillon, gravies,
and peas are lowest in potassium. oatmeal and whole wheat, pasta, noodles,
 Sodium is restricted to 500 mg/day. and alcoholic beverages. Limited quantities
 Fluid intake is restricted to the daily of meat, fish, and seafood allowed.
volume plus 500 mL, which represents 8. BLAND DIET
insensible water loss. Purpose:
 Fluid intake measures water in fruit,  provision of a diet low in fiber, roughage,
vegetables, milk and meat. mechanical irritants, and chemical
Foods Avoided: stimulants.
 Cereals, bread, macaroni, noodles, Use:
spaghetti, avocados, kidney beans, potato  Gastritis, hyperchlorhydria (excess
chips, raw fruit, yams, soybeans, nuts, hydrochloric acid), functional GI disorders,
gingerbread, apricots, bananas, figs, gastric atony, diarhhea, spastic
grapefruit, oranges, percolated coffee, constipation, biliary indigestion, and hiatus
Coca-Cola, orange crush, sport drinks, and hernia.
breakfast drinks such as Tang or Awake Foods Allowed:
 varied to meet individual needs and food
6. HIGH-PROTEIN, HIGH tolerances.
CARBOHYDRATE DIET Foods Avoided:
Purpose:  fried foods, including eggs, meat, fish, and
 to correct large protein losses and raises sea food; cheese with added nuts or spices;
the level of blood albumin. May be commercially prepared luncheon meats;
modified to include lowfat, cured meats such as ham; gravies and
 low-sodium, and low-cholesterol diets. sauces; raw vegetables;
Use:  potato skins; fruit juices with pulp; figs;
 burns, hepatitis, cirrhosis, pregnancy, raisins; fresh fruits; whole wheats; rye
hyperthyroidism, mononucleosis, protein bread; bran cereals;
deficiency due to poor eating habits,  rich pastries; pies; chocolate; jams with
geriatric patient with poor intake; nephritis, seeds; nuts; seasoned dressings;
nephrosis, and liver and gall bladder caffeinated coffee; strong tea; cocoa;
disorder. alcoholic and carbonated beverages; and
Foods Allowed: pepper.
 general diet with added protein. 9. LOW-FAT, CHOLESTEROL-
Foods Avoided: RESTRICTED DIET
 restrictions depend on modifications added Purpose:
to the diet. The modifications are  reduce hyperlipedimia, provide dietary
determined by the patient’s condition. treatment for malabsorption syndromes
7. PURINE-RESTRICTED DIET and patients having acute intolerance for
Purpose: fats.
 designed to reduce intake of uric acid- Use:
producing foods.
  hyperlipedimia, atherosclerosis, Foods Avoided:
pancreatitis, cystic fibrosis, sprue (disease  concentrated sweets or regular soft drinks.
of intestinal tract 11. ACID AND ALKALINE DIET
characterized by malabsorption), gastrectomy, Purpose:
massive resection of small intestine, and  Furnish a well balance diet in which the
cholecystitis. total acid ash is greater than the total
Foods Allowed: alkaline ash each day.
 nonfat milk; low-carbohydrate, low-fat Use:
vegetables; most fruits; breads; pastas;  Retard the formation of renal calculi. The
cornmeal; lean meats; type of diet chosen depends on laboratory
unsaturated fats analysis of the stone.
Foods Avoided: Acid and alkaline ash food groups:
 remember to avoid the five C’s of a. Acid ash: meat, whole grains, eggs, cheese,
cholesterol- cookies, cream, cake, coconut, cranberries, prunes, plums
chocolate; whole milk and whole-milk or b. Alkaline ash: milk, vegetables, fruits (except
cream products, avocados, olives, cranberries, prunes and plums.)
commercially prepared baked goods such c. Neutral: sugar, fats, beverages (coffee, tea)
as donuts and muffins, poultry skin, highly Foods allowed:
marbled meats  Breads: any, preferably whole grain;
 butter, ordinary margarines, olive oil, lard, crackers; rolls
pudding made with whole milk, ice cream,  Cereals: any, preferable whole grains
candies with chocolate, cream, sauces,  Desserts: angel food or sunshine cake;
gravies and commercially fried foods. cookies made without baking powder or
soda; cornstarch,
10. DIABETIC DIET  pudding, cranberry desserts, ice cream,
Purpose: sherbet, plum or prune desserts; rice or
 maintain blood glucose as near as normal tapioca pudding.
as possible; prevent or delay onset of  Fats: any, such as butter, margarine, salad
diabetic complications. dressings, Crisco, Spry, lard, salad oil,
Use: olive oil, ect.
 diabetes mellitus  fruits: cranberry, plums, prunes
Foods Allowed:  Meat, eggs, cheese: any meat, fish or fowl,
 choose foods with low glycemic index two serving daily; at least one egg daily
compose of:  Potato substitutes: corn, hominy, lentils,
a. 45-55% carbohydrates macaroni, noodles, rice, spaghetti,
b. 30-35% fats vermicelli.
c. 10-25% protein  Soup: broth as desired; other soups from
 coffee, tea, broth, spices and flavoring can food allowed
be used as desired.  Sweets: cranberry and plum jelly; plain
 exchange groups include: milk, vegetable, sugar candy
fruits, starch/bread, meat (divided in lean,  Miscellaneous: cream sauce, gravy, peanut
medium fat, and butter, peanuts, popcorn, salt, spices,
 high fat), and fat exchanges. vinegar, walnuts.
 the number of exchanges allowed from Restricted foods:
each group is dependent on the total  no more than the amount allowed each day
number of calories allowed. 1. Milk: 1 pint daily (may be used in other ways
 non-nutritive sweeteners (sorbitol) in than as beverage)
moderation with controlled, normal weight 2. Cream: 1/3 cup or less daily
diabetics.
3. Fruits: one serving of fruits daily( in addition to 1. The Right Medication – when administering
the prunes, plums and cranberries) medications, the nurse compares the label of the
4. Vegetable: including potatoes: two servings medication container with medication form.
daily The nurse does this 3 times:
5. Sweets: Chocolate or candies, syrups. a. Before removing the container from the drawer
6. Miscellaneous: other nuts, olives, pickles. or shelf
12. HIGH-FIBER DIET b. As the amount of medication ordered is
Purpose: removed from the container
 Soften the stool c. Before returning the container to the storage
 exercise digestive tract muscles 2. Right Dose –when performing medication
 speed passage of food through digestive calculation or conversions, the nurse should have
tract to prevent exposure to cancer causing another qualified nurse check the calculated dose
agents in food 3. Right Client – an important step in
 lower blood lipids administering medication safely is being sure the
 prevent sharp rise in glucose after eating. medication is given to the right client.
 Use: diabetes, hyperlipedemia, a. To identify the client correctly:
constipation, diverticulitis, b. The nurse check the medication administration
anticarcinogenics (colon) form against the client’s identification bracelet
Foods Allowed: and asks the client to state his or her name to
 recommended intake about 6 g crude fiber ensure the client’s identification bracelet has the
daily correct information.
 All bran cereal 4. RIGHT ROUTE – if a prescriber’s order does
 Watermelon, prunes, dried peaches, apple no designate a route of administration, the nurse
with skin; parsnip, peas, Brussels sprout, consult the prescriber. Likewise, if the specified
sunflower seeds. route is not recommended, the nurse should alert
the prescriber immediately.
LOW RESIDUE DIET 5. RIGHT TIME
Purpose: a. the nurse must know why a medication is
 Reduce stool bulk and slow transit time ordered for certain times of the day and whether
Use: the time schedule can be altered
 Bowel inflammation during acute b. each institution has are commended time
diverticulitis, or ulcerative colitis, schedule for medications ordered at frequent
preparation for bowel surgery, esophageal interval
and intestinal stenosis. c. Medication that must act at certain times are
Food Allowed: given priority (e.g insulin should be given at a
 eggs; ground or well-cooked tender meat, precise interval before a meal)
fish, poultry; milk, cheeses; strained fruit 6. RIGHT DOCUMENTATION –
juice (except prune): cooked or canned Documentation is an important part of safe
apples, apricots, peaches, pears; ripe medication administration
banana; strained vegetable juice: canned, a. The documentation for the medication should
cooked, or strained asparagus, beets, green clearly reflect the client’s name, the name of the
beans, pumpkin, squash, spinach; white ordered medication, the time, dose, route and
bread; refined cereals (Cream of Wheat) frequency
b. Sign medication sheet immediately after
administration of the drug
CLIENT’S RIGHT RELATED TO
PRINCIPLES OF MEDICATION MEDICATION ADMINISTRATION
ADMINISTRATION A client has the following rights:
“Six Rights” of drug administration
a. To be informed of the medication’s name, XIII- When a medication is omitted for any
purpose, action, and potential undesired effects. reason, record the fact together with the reason.
b. To refuse a medication regardless of the XIV – When the medication error is made, report
consequences it immediately to the nurse in charge or physician.
c. To have a qualified nurses or physicians assess To implement necessary measures immediately.
medication history, including allergies This may prevent any adverse effects of the drug.
d. To be properly advised of the experimental Medication Administration
nature of medication therapy and to give written 1. Oral administration
consent for its use Advantages
e. To received labeled medications safely without a. The easiest and most desirable way to
discomfort in accordance with the six rights of administer medication
medication administration b. Most convenient
f. To receive appropriate supportive therapy in c. Safe, does nor break skin barrier
relation to medication therapy d. Usually less expensive
g. To not receive unnecessary medications Disadvantages
II – Practice Asepsis – wash hand before and a. Inappropriate if client cannot swallow and if
after preparing the medication to reduce transfer of GIT has reduced motility
microorganisms. b. Inappropriate for client with nausea and
III – Nurse who administer the medications are vomiting
responsible for their own action. c. Drug may have unpleasant taste
Question any order that you considered incorrect d. Drug may discolor the teeth
(may be unclear or appropriate) e. Drug may irritate the gastric mucosa
IV – Be knowledgeable about the medication that f. Drug may be aspirated by seriously ill patient.
you administer Drug Forms for Oral Administration
“A FUNDAMENTAL RULE OF SAFE DRUG a. Solid: tablet, capsule, pill, powder
ADMINISTRATION IS: “NEVER b. Liquid: syrup, suspension, emulsion, elixir,
ADMINISTER AN UNFAMILIAR milk, or other alkaline substances.
MEDICATION” c. Syrup: sugar-based liquid medication
V – Keep the Narcotics in locked place. d. Suspension : water-based liquid medication.
VI– Use only medications that are in clearly Shake bottle before use of medication to properly
labeled containers. Relabeling of drugs are the mix it.
responsibility of the pharmacist. e. Emulsion: oil-based liquid medication
VII – Return liquid that are cloudy in color to the f. Elixir: alcohol-based liquid medication. After
pharmacy. administration of elixir, allow 30 minutes to elapse
VIII – Before administering medication, identify before giving water. This allows maximum
the client correctly absorption of the medication.
IX – Do not leave the medication at the bedside. “NEVER CRUSH ENTERIC-COATED OR
Stay with the client until he actually takes the SUSTAINED RELEASE TABLET”
medications. Crushing enteric-coated tablets – allows the
X – The nurse who prepares the drug administers irrigating medication to come in contact with the
it.. Only the nurse prepares the drug knows what oral or gastric mucosa, resulting in mucositis or
the drug is. Do not accept endorsement of gastric irritation.
medication. Crushing sustained-released medication –
XI – If the client vomits after taking the allows all the medication to be absorbed at the
medication, report this to the nurse in charge or same time, resulting in a higher than expected
physician. initial level of medication and a shorter than
XII – Preoperative medications are usually expected duration of action
discontinued during the postoperative period 2. SUBLINGUAL
unless ordered to be continued.
a. A drug that is placed under the tongue, where it e. Apply only thin layer of medication to prevent
dissolves. systemic absorption.
b. When the medication is in capsule and ordered 2. Opthalmic - includes instillation and irrigation
sublingually, the fluid must be aspirated from the a. Instillation – to provide an eye medication that
capsule and placed under the tongue. the client requires.
c. A medication given by the sublingual route b. Irrigation – To clear the eye of noxious or other
should not be swallowed, or desire effects will not foreign materials.
be achieved c. Position the client either sitting or lying.
Advantages: d. Use sterile technique
a. Same as oral e. Clean the eyelid and eyelashes with sterile
b. Drug is rapidly absorbed in the bloodstream cotton balls moistened with sterile normal saline
Disadvantages from the inner to the outer canthus
a. If swallowed, drug may be inactivated by gastric f. Instill eye drops into lower conjunctival sac.
juices. g. Instill a maximum of 2 drops at a time. Wait for
b. Drug must remain under the tongue until 5 minutes if additional drops need to be
dissolved and absorbed administered. This is for proper absorption of the
3. BUCCAL medication.
a. A medication is held in the mouth against the h. Avoid dropping a solution onto the cornea
mucous membranes of the cheek until the drug directly, because it causes discomfort.
dissolves. i. Instruct the client to close the eyes gently.
b. The medication should not be chewed, Shutting the eyes tightly causes spillage of the
swallowed, or placed under the tongue (e.g medication.
sustained release nitroglycerine, j. For liquid eye medication, press firmly on the
opiates,antiemetics, tranquilizer, sedatives) nasolacrimal duct (inner cantus) for at least 30
c. Client should be taught to alternate the cheeks seconds to prevent systemic absorption of the
with each subsequent dose to avoid mucosal medication.
irritation 3. Otic Instillation – to remove cerumen or pus or
Advantages: to remove foreign body
a. Same as oral a. Warm the solution at room temperature or body
b. Drug can be administered for local effect temperature, failure to do so may cause vertigo,
c. Ensures greater potency because drug directly dizziness, nausea and pain.
enters the blood and bypass the liver b. Have the client assume a side-lying position ( if
Disadvantages: not contraindicated) with ear to be treated facing
 If swallowed, drug may be inactivated by up.
gastric juice c. Perform hand hygiene. Apply gloves if drainage
4. TOPICAL – Application of medication to a is present.
circumscribed area of the body. d. Straighten the ear canal:
1. Dermatologic – includes lotions, liniment and  0-3 years old: pull the pinna downward and
ointments, powder. backward
a. Before application, clean the skin thoroughly by  Older than 3 years old: pull the pinna
washing the area gently with soap and water, upward and backward
soaking an involved site, or locally debriding e. Instill eardrops on the side of the auditory canal
tissue. to allow the drops to flow in and continue to adjust
b. Use surgical asepsis when open wound is to body temperature
present f. Press gently bur firmly a few times on the tragus
c. Remove previous application before the next of the ear to assist the flow of medication into the
application ear canal.
d. Use gloves when applying the medication over g. Ask the client to remain in side lying position
a large surface. (e.g large area of burns) for about 5 minutes
h. At times the MD will order insertion of cotton 6. Vagina l – drug forms: tablet liquid (douches).
puff into outermost part of the canal. Do not press Jelly, foam and suppository.
cotton into the canal. Remove cotton after 15 a. Close room or curtain to provide privacy.
minutes. b. Assist client to lie in dorsal recumbent position
4. Nasal – Nasal instillations usually are instilled to provide easy access and good exposure of
for their astringent effects (to shrink swollen vaginal canal, also allows suppository to dissolve
mucous membrane), to loosen secretions and without
facilitate drainage or to treat infections of the nasal escaping through orifice.
cavity or sinuses. Decongestants, steroids, c. Use applicator or sterile gloves for vaginal
calcitonin. administration of medications.
a. Have the client blow the nose prior to nasal Vaginal Irrigation – is the washing of the vagina
instillation by a liquid at low pressure. It is also called
b. Assume a back lying position, or sit up and lean douche.
head back. a. Empty the bladder before the procedure
c. Elevate the nares slightly by pressing the thumb b. Position the client on her back with the hips
against the client’s tip of the nose. While the client higher than the shoulder (use bedpan)
inhales, squeeze the bottle. c. Irrigating container should be 30 cm (12 inches)
d. Keep head tilted backward for 5 minutes after above
instillation of nasal drops. d. Ask the client to remain in bed for 5-10 minute
e. When the medication is used on a daily basis, following administration of vaginal suppository,
alternate nares to prevent irritations cream, foam, jelly or irrigation.
5. Inhalation – use of nebulizer, metered-dose 7. RECTAL – can be use when the drug has
inhaler objectionable taste or odor.
a. Simi or high-fowler’s position or standing a. Need to be refrigerated so as not to soften.
position. To enhance full chest expansion allowing b. Apply disposable gloves.
deeper inhalation of the medication c. Have the client lie on left side and ask to take
b. Shake the canister several times. To mix the slow deep breaths through mouth and relax anal
medication and ensure uniform dosage delivery sphincter.
c. Position the mouthpiece 1 to 2 inches from the d. Retract buttocks gently through the anus, past
client’s open mouth. As the client starts inhaling, internal sphincter and against rectal wall, 10 cm (4
press the canister down to release one dose of the inches) in adults, 5 cm (2 in) in children and
medication. This allows delivery of the medication infants. May need to apply gentle pressure to hold
more accurately into the bronchial tree rather than buttocks together momentarily.
being trapped in the oropharynx then swallowed e. Discard gloves to proper receptacle and perform
d. Instruct the client to hold breath for 10 seconds. hand washing.
To enhance complete absorption of the f. Client must remain on side for 20 minute after
medication. insertion to promote adequate absorption of the
e. If bronchodilator, administer a maximum of 2 medication.
puffs, for at least 30 second interval. Administer 8. PARENTERAL- administration of medication
bronchodilator before other inhaled medication. by needle.
This opens airway and promotes greater Intradermal – under the epidermis.
absorption of the medication. a. The site are the inner lower arm, upper chest
f. Wait at least 1 minute before administration of and back, and beneath the scapula.
the second dose or inhalation of a different b. Indicated for allergy and tuberculin testing and
medication by MDI for vaccinations.
g. Instruct client to rinse mouth, if steroid had c. Use the needle gauge 25, 26, 27: needle length
been administered. This is to prevent fungal 3/8”, 5/8” or ½”
infection. d. Needle at 10–15 degree angle; bevel up.
e. Inject a small amount of drug slowly over 3 to 5 Sites:
seconds to form a wheal or bleb. Ventrogluteal site
f. Do not massage the site of injection. To prevent a. The area contains no large nerves, or blood
irritation of the site, and to prevent absorption of vessels and less fat. It is farther from the rectal
the drug into the subcutaneous. area, so it less contaminated.
Subcutaneous – vaccines, heparin, preoperative b. Position the client in prone or side-lying.
medication, insulin, narcotics. c. When in prone position, curl the toes inward.
The site: d. When side-lying position, flex the knee and hip.
 outer aspect of the upper arms These ensure relaxation of gluteus muscles and
 anterior aspect of the thighs minimize discomfort during injection.
 Abdomen e. To locate the site, place the heel of the hand
 Scapular areas of the upper back over the greater trochanter, point the index finger
 Ventrogluteal toward the anterior superior iliac spine, then
 Dorsogluteal abduct the middle (third) finger. The triangle
a. Only small doses of medication should be formed by the index finger, the third
injected via SC route. finger and the crest of the ilium is the site.
b. Rotate site of injection to minimize tissue Dorsogluteal site
damage. a. Position the client similar to the ventrogluteal
c. Needle length and gauge are the same as for ID site
injections b. The site should not be use in infant under 3
d. Use 5/8 needle for adults when the injection is years because the gluteal muscles are not well
to administer at 45 degree angle; ½ is use at a 90 developed yet.
degree angle. c. To locate the site, the nursedraw an imaginary
e. For thin patients: 45 degree angle of needle line from the greater trochanter to the posterior
f. For obese patient: 90 degree angle of needle superior iliac spine. The injection site id lateral
For heparin injection : and superior to this line.
h. do not aspirate. d. Another method of locating this site is to
i. Do not massage the injection site to prevent imaginary divide the buttock into four quadrants.
hematoma formation The upper most quadrant is the site of injection.
For insulin injection: Palpate the crest of the ilium to ensure that the site
k. Do not massage to prevent rapid absorption is high enough.
which may result to hypoglycemic reaction. e. Avoid hitting the sciatic nerve, major blood
l. Always inject insulin at 90 degrees angle to vessel or bone by locating the site properly.
administer the medication in the pocket between Vastus Lateralis
the subcutaneous and muscle layer. Adjust the a. Recommended site of injection for infant
length of the needle depending on the size of the b. Located at the middle third of the anterior
client. lateral aspect of the thigh.
m. For other medications, aspirate before injection c. Assume back-lying or sitting position.
of medication to check if the blood vessel had Rectus femoris site –located at the middle third,
been hit. If blood appears on pulling back of the anterior aspect of thigh.
plunger of the syringe, remove the needle and Deltoid site
discard the medication and equipment. a. Not used often for IM injection because it is
Intramuscular relatively small muscle and is very close to the
a. Needle length is 1”, 1 ½”, 2” to reach the radial nerve and radial artery.
muscle layer b. To locate the site, palpate the lower edge of the
b. Clean the injection site with alcoholized cotton acromion process and the midpoint on the lateral
ball to reduce microorganisms in the area. aspect of the arm that is in line with the axilla.
c. Inject the medication slowly to allow the tissue This is approximately 5 cm (2 in) or 2 to 3
to accommodate volume. fingerbreadths below the acromion process.
IM injection – Z tract injection 17.Evaluate effectiveness of the procedure and
a. Used for parenteral iron preparation. To seal the make relevant documentation.
drug deep into the muscles and prevent permanent Intravenous
staining of the skin. The nurse administers medication intravenously
b. Retract the skin laterally, inject the medication by the following method:
slowly. Hold retraction of skin until the needle is 1. As mixture within large volumes of IV fluids.
withdrawn 2. By injection of a bolus, or small volume, or
c. Do not massage the site of injection to prevent medication through an existing intravenous
leakage into the subcutaneous. infusion line or intermittent venous access
GENERAL PRINCIPLES IN PARENTERAL (heparin or saline
ADMINISTRATION OF MEDICATIONS lock)
1. Check doctor’s order. 3. By “piggyback” infusion of solution containing
2. Check the expiration for medication – drug the prescribed medication and a small volume of
potency may increase or decrease if outdated. IV fluid through an existing IV line.
3. Observe verbal and non-verbal responses a. Most rapid route of absorption of medications.
toward receiving injection. Injection can be b. Predictable, therapeutic blood levels of
painful.client may have anxiety, which can medication can be obtained.
increase the pain. c. The route can be used for clients with
4. Practice asepsis to prevent infection. Apply compromised gastrointestinal function or
disposable gloves. peripheral circulation.
5. Use appropriate needle size. To minimize tissue d. Large dose of medications can be administered
injury. by this route.
6. Plot the site of injection properly. To prevent e. The nurse must closely observe the client for
hitting nerves, blood vessels, bones. symptoms of adverse reactions.
7. Use separate needles for aspiration and injection f. The nurse should double-check the six rights of
of medications to prevent tissue irritation. safe medication.
8. Introduce air into the vial before aspiration. To g. If the medication has an antidote, it must be
create a positive pressure within the vial and allow available during administration.
easy withdrawal of the medication. h. When administering potent medications, the
9. Allow a small air bubble (0.2 ml) in the syringe nurse assesses vital signs before, during and after
to push the medication that may remain. infusion.
10.Introduce the needle in quick thrust to lessen Nursing Interventions in IV Infusion
discomfort. a. Verify the doctor’s order
11.Either spread or pinch muscle when b. Know the type, amount, and indication of IV
introducing the medication. Depending on the size therapy.
of the client. c. Practice strict asepsis.
12.Minimized discomfort by applying cold d. Inform the client and explain the purpose of IV
compress over the injection site before therapy to alleviate client’s anxiety.
introduction of medicati0n to numb nerve endings. e. Prime IV tubing to expel air. This will prevent
13.Aspirate before the introduction of medication. air embolism.
To check if blood vessel had been hit. f. Clean the insertion site of IV needle from center
14.Support the tissue with cotton swabs before to the periphery with alcoholized cotton ball to
withdrawal of needle. To prevent discomfort of prevent infection.
pulling tissues as needle is withdrawn. g. Shave the area of needle insertion if hairy.
15.Massage the site of injection to haste h. Change the IV tubing every 72 hours. To
absorption. prevent contamination.
16.Apply pressure at the site for few minutes. To i. Change IV needle insertion site every 72 hours
prevent bleeding. to prevent thrombophlebitis.
j. Regulate IV every 15-20 minutes. To ensure  Place patient in high fowler’s position. To
administration of proper volume of IV fluid as enhance breathing
ordered.  Administer diuretic, bronchodilator as
k. Observe for potential complications. ordered
Types of IV Fluids 3. Drug Overload – the patient receives an
Isotonic solution – has the same concentration as excessive amount of fluid containing drugs.
the body fluid Assessment:
a. D5 W  Dizziness
b. Na Cl 0.9%  Shock
c. plainRinger’s lactate  Fainting
d. Plain Normosol M Nursing Intervention
Hypotonic – has lower concentration than the  Slow infusion to KVO.
body fluids.  Take vital signs
a. NaCl 0.3%  Notify physician
Hypertonic – has higher concentration than the 4. Superficial Thrombophlebitis – it is due to
body fluids. o0veruse of a vein, irritating solution or drugs, clot
a. D10W formation, large bore catheters.
b. D50W Assessment:
c. D5LR  Pain along the course of vein
d. D5NM  Vein may feel hard and cordlike
Complication of IV Infusion  Edema and redness at needle insertion site.
1. Infiltration – the needle is out of nein, and  Arm feels warmer than the other arm
fluids accumulate in the subcutaneous tissues. Nursing Intervention:
Assessment:  Change IV site every 72 hours
 Pain, swelling, skin is cold at needle site,  Use large veins for irritating fluids.
pallor of the site, flow rate has decreases or  Stabilize venipuncture at area of flexion.
stops.  Apply cold compress immediately to
 Nursing Intervention: relieve pain and inflammation; later with
 Change the site of needle warm compress to stimulate circulation
 Apply warm compress. This will absorb and promotion absorption.
edema fluids and reduce swelling.  “Do not irrigate the IV because this could
2. Circulatory Overload - Results from push clot into the systemic circulation’
administration of excessive volume of IV fluids. 5. Air Embolism – Air manages to get into the
Assessment: circulatory system; 5 ml of air or more causes air
Headache embolism.
Flushed skin Assessment:
Rapid pulse  Chest, shoulder, or backpain
 Increase BP  Hypotension
 Weight gain  Dyspnea
 Syncope and faintness  Cyanosis
 Pulmonary edema  Tachycardia
 Increase volume pressure  Increase venous pressure
 SOB  Loss of consciousness
 Coughing Nursing Intervention
 Tachypnea  Do not allow IV bottle to “run dry”
 shock  “Prime” IV tubing before starting infusion.
Nursing Interventions:  Turn patient to left side in the
 Slow infusion to KVO trendelenburg position. To allow air to rise
 in the right side of the heart. This prevent f. Warm blood at room temperature before
pulmonary embolism. transfusion to prevent chills.
6. Nerve Damage – may result from tying the arm g. Identify client properly. Two Nurses check the
too tightly to the splint. client’s identification.
Assessment h. Use needle gauge 18 to 19. This allows easy
 Numbness of fingers and hands flow of blood.
 Nursing Interventions j.Use BT set with special micron mesh filter. To
 Massage the arm and move shoulder prevent administration of blood clots and particles.
through its ROM k. Start infusion slowly at 10 gtts/min. Remain at
 Instruct the patient to open and close hand bedside for 15 to 30 minutes.
several times each hour. Adverse reaction usually occurs during the first 15
 Physical therapy may be required to 20 minutes.
Note: apply splint with the fingers free to move. l. Monitor vital signs. Altered vital signs indicate
7. Speed Shock – may result from administration adverse reaction.
of IV push medication rapidly.  Do not mixed medications with blood
 To avoid speed shock, and possible cardiac transfusion. To prevent adverse effects
arrest, give most IV push  Do not incorporate medication into the
medication over 3 to 5 minutes. blood transfusion
BLOOD TRANSFUSION THERAPY  Do not use blood transfusion line for IV
Objectives: push of medication.
1. To increase circulating blood volume after m. Administer 0.9% NaCl before, during or after
surgery, trauma, or hemorrhage BT. Never administer IV fluids with dextrose.
2. To increase the number of RBCs and to Dextrose causes hemolysis.
maintain hemoglobin levels in clients with severe n. Administer BT for 4 hours (whole blood,
anemia packed rbc). For plasma, platelets, cryoprecipitate,
3. To provide selected cellular components as transfuse quickly (20 minutes) clotting factor can
replacements therapy (e.g clotting factors, easily be destroyed.
platelets, albumin) Complications of Blood Transfusion
Nursing Interventions: 1. Allergic Reaction – it is caused by sensitivity
a. Verify doctor’s order. Inform the client and to plasma protein of donor antibody, which reacts
explain the purpose of the procedure. with recipient antigen.
b. Check for cross matching and typing. To ensure Assessments
compatibility  Flushing
c. Obtain and record baseline vital signs  Rush, hives
d. Practice strict Asepsis  Pruritus
e. At least 2 licensed nurse check the label of the  Laryngeal edema, difficulty of breathing
blood transfusion 2. Febrile, Non-Hemolytic – it is caused by
Check the following: hypersensitivity to donor white cells, platelets or
 Serial number plasma proteins. This is the most symptomatic
 Blood component complication of blood transfusion
 Blood type Assessments:
 Rh factor  Sudden chills and fever
 Expiration date  Flushing
 Screening test (VDRL, HBsAg, malarial  Headache
smear)  Anxiety
- this is to ensure that the blood is free from blood- 3. Septic Reaction – it is caused by the
carried diseases and therefore, safe from transfusion of blood or components contaminated
transfusion. with bacteria.
Assessment:
  Rapid onset of chills 8. Blood container, tubing, attached label, and
 Vomiting transfusion record are saved and returned to the
 Marked Hypotension laboratory for analysis.
 High fever
4. Circulatory Overload – it is caused by
administration of blood volume at a rate greater
than the circulatory system can accommodate.

Assessment
 Rise in venous pressure
 Dyspnea
 Crackles or rales
 Distended neck vein
 Cough
 Elevated BP
5. Hemolytic reaction. It is caused by infusion of
incompatible blood products.
Assessment
 Low back pain (first sign). This is due to
inflammatory response of the kidneys to
incompatible blood.
 Chills
 Feeling of fullness
 Tachycardia
 Flushing
 Tachypnea
 Hypotension
 Bleeding
 Vascular collapse
 Acute renal failure
Nursing Interventions when complications
occurs in Blood transfusion
1. If blood transfusion reaction occurs. STOP THE
TRANSFUSION.
2. Start IV line (0.9% Na Cl)
3. Place the client in fowlers position if with SOB
and administer O2 therapy.
4. The nurse remains with the client, observing
signs and symptoms and monitoring vital signs as
often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency
drugs such as antihistamines, vasopressor, fluids,
and steroids as per physician’s order or protocol.
7. Obtain a urine specimen and send to the
laboratory to determine presence of hemoglobin as
a result of RBC hemolysis.