FUNDAMENTALS

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HEALTH PROMOTION a. Childbirth
1. Holism- this concept emphasizes the HCP b. Blood Clotting
must keep the whole person in mind and c. Lactation
strive to understand one area of concern 7. 2 MAJOR THEORETICAL FRAMEWORKS
relates to the whole person. THAT HCP USE IN PROMOTING HEALTH
2. Homeostasis a. Needs Theories
- introduced by Cannon (1939) • Maslow’s Hierarchy of
- tendency of the body to maintain state of Needs
balance or physiological equilibrium • Kalish’s Hierarchy of Needs
- PHYSIOLOGICAL HOMEOSTASIS b. Developmental Theory
1. Self-regulating - homeostatic 8. Maslow’s Hierarchy of Needs
mechanism automatically play in a a. Physiological Needs
healthy person O – Oxygen/air
2. Compensatory - counterbalancing; F – Fluid/water
ex: sudden drop of temp. the muscle F – Food
will E – Elimination (urinate/defecate)
shiver to create heat. The body will R – Rest/Sleep
temp remains stable despite of the S – Sex
cold.

3. Tend to be regulated by negative b. Safety Needs

feedback mechanism - S – Stability
4. May require several feedback T – Things like home and shelter
mechanisms to correct only one O – Orders/Routine
physiological P – Protection
imbalance c. Love and Belonging
3. Feed back. mechanism by which some of Affection
the output of a system returned to the Acceptance
system Inclusion
4. as input. d. ESTEEM NEED
5. Negative Feedback. inhibits change; Self Respect
Counteracting deviations from a set point, Self Esteem
essential for stable internal conditions. Respect from others
Example: e. Self Actualization
a. Blood Glucose Regulation Achieve full potential
b. Blood Pressure Regulation Self fulfillment
c. Body Temperature Regulation 9. Kalish’s Hierarchy of Needs
6. Positive Feedback. stimulates change; a. Richard Kalish (1983) – adapted
facilitates necessary physiological Maslow's hierarchy of needs in
changes, like childbirth and blood order to come up with a needs
clotting, by amplifying specific processes. theory for the family and safety
Example: and security needs.

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b. The sixth level refers to 16. Wellness is a state of well-being.

stimulation. 7 components of Wellness
c. This additional category includes • Physical Wellness
sex, activity, exploration, • Emotional Wellness
manipulation, and novelty. • Intellectual Wellness
10. LEVELS OF PREVENTION -Primary, • Social Wellness
Secondary, Tertiary • Spiritual Wellness
11. Primary Prevention • Environmental Wellness
Purpose: decrease risk or exposure of the • Occupational Wellness
individual or community to disease 17. Well-being is subjective perception of
• health promotion vitality and feeling well
• immunization 18. ILLNESS is a personal state in which the
• Risk assessment for a specific person feels unhealthy.
disease 19. Illness is a state in which a person’s
• Family planning physical, emotional, intellectual, social,
• Environmental sanitation developmental, or spiritual functioning is
12. Secondary Prevention diminished or impaired compared with
Purpose: early detection, intervention to previous experience.
alleviate health problems 20. Illness is not synonymous with disease.
• screening surveys and procedures 21. Stages of Illness
• encouraging check ups 1. Symptoms Experience- experience
• BSE, Testicular SE some symptoms, person believes
13. Tertiary Prevention something is wrong
Purpose: restoration and rehabilitation; Aspects –physical, cognitive, emotional
goal: to return to optimal level of 2. Assumption of Sick Role – acceptance of
functioning illness, seeks advice
• referring a client who has had a 3. Medical Care Contact - Seeks advice to
colostomy to support group professionals for validation of real illness,

• Teaching a client who has diabetes explanation of symptoms, reassurance or

to identify and prevent predict of outcome

complications 4. Dependent Patient Role

• referring a client with spinal cord The person becomes a client dependent
on the health professional for help.
injury to a rehab center
14. Health is a state of complete physical, Accepts/rejects health professional’s

mental, and social well-being and not suggestions. Becomes more passive and

merely the absence of disease or accepting.

5. Recovery/Rehabilitation
infirmity. (WHO)
Gives up the sick role and returns to
15. Health is multi-dimensional concept,
former roles and functions.
encompassing more than just the absence
of illness

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22. Disease - An alteration in body function b. Congenital – due to a defect in

resulting in reduction of capacities or a the development, hereditary
shortening of the normal life span. factors, or prenatal infection c.
23. Common Causes of Disease Metabolic – due to disturbances or
1. Biologic agent – e.g. microorganism abnormality in the intricate
2. Inherited genetic defects – e.g. cleft processes of metabolism. d.
palate Deficiency – results from
3. Developmental defects – e.g. inadequate intake or absorption of
imperforate anus essential dietary factor. e.
4. Physical agents – e.g. radiation, hot and Traumatic- due to injury f. Allergic –
cold substances, ultraviolet rays due to abnormal response of the
5. Chemical agents – e.g. lead, asbestos, body to chemical and protein
carbon monoxide substances or to physical stimuli. g.
6. Tissue response to irritations/injury – Neoplastic – due to abnormal or
e.g. inflammation, fever uncontrolled growth of cell. h.
7. Faulty chemical/metabolic process – Idiopathic –Cause is unknown; self-
e.g. inadequate insulin in diabetes originated; of spontaneous origin i.
8. Emotional/physical reaction to stress – Degenerative –Results from the
e.g. fear, anxiety degenerative changes that occur in
24. Risk Factors of a Disease the tissue and organs. j. Iatrogenic
– result from the treatment of the

1. Genetic and Physiological Factors For disease

example, a person with a family history of

diabetes mellitus, is at risk in developing
the disease later in life. 2. Age Age
increases and decreases susceptibility ( 2. According to Duration or Onset
risk of heart diseases increases with age for a. Acute Illness –short duration and
both sexes 3. Environment The physical is severe. Signs and symptoms
environment in which a person works or appear abruptly, intense and often
lives can increase the likelihood that subside after a relatively short
certain illnesses will occur. 4. Lifestyle period. b. Chronic Illness - longer
Lifestyle practices and behaviors can also than 6 months, and can also affects
have positive or negative effects on health. functioning in any dimension

Remission- periods during

which the disease is
controlled and symptoms are
25. Classification of Diseases not obvious. Exacerbations –
1. Etiologic Factors The disease becomes more
a. Hereditary – due to defect in the active with recurrence of
genes of one or other parent which pronounced symptoms.
is transmitted to the offspring

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c. Sub-Acute – Symptoms are d. Conscience - morals

pronounced but more prolonged e. Commitment - obligations
than the acute disease f. Comportment - physical presence
27. THE NURSING PROCESS
3. Disease may also be Described as: a. -Systematic, rational method,
a. Organic – results from changes and providing individualized
in the normal structure, from nursing care.
recognizable anatomical changes b. - Comprehensive, Goal oriented,
in an organ or tissue of the body. Interpersonal, Systematic,
b. Functional – no anatomical Dynamic
changes are observed to account c. - The nursing process is
from the symptoms present, may universally applicable.
result from abnormal response to d. - The nursing process is simply a
stimuli. way of thinking that systematizes
c. Occupational – Results from the way HCPs give care.
factors associated with the e. - The nursing process give HCPs
occupation engage in by the a structure for helping patients
patient. meet their health goals.
d. Venereal – usually acquired 28. PROBLEM SOLVING METHODS:
through sexual relation a. Trial and Error
e. Familial – occurs in several b. Scientific Method
individuals of the same family c. Intuitive Problem Solving
f. Epidemic – attacks a large 29. STEPS OF THE NURSING PROCESS
number of individuals in the a. Assessment
community at the same time. (e.g. b. Diagnosing
SARS) c. Planning
g. Endemic – Presents more or less d. Implementation
continuously or recurs in a e. Evaluation
community. (e.g. malaria, goiter) 30. Assessment. The systematic collection
h. Pandemic –An epidemic which is and analysis of patient data.
extremely widespread involving an 31. Diagnosing. Identifying patient problems
entire country or continent. based on the assessment data.
(covid19) 32. Planning. Developing a plan of care that
i. Sporadic – a disease in which outlines the strategies to address the
only occasional cases occur. (e.g. diagnosed problems.
dengue, leptospirosis) 33. Implementation. Executing the plan of
26. THE 6 C’S OF CARING care.
a. Compassion - Awareness of others 34. Evaluation. Assessing the patient's
b. Competence - having good response to the interventions.
judgement/knowledge 35. Assessment is continuously updated!!!
Confidence - trusting relationship
c. 36. Types of Data

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a. Objective Data or Signs 44. Goals must be realistic
b. Subjective Data or Symptoms 45. Goals serve as guides in selecting nursing
c. Verbal Data interventions.
d. Nonverbal Data 46. Goals must be S.M.A.R.T.
37. Sources of Data 47. Interventions (also called
a. Primary Data - client is the only implementations)
primary source of data 48. Interventions make the client goals come
b. Secondary Data - provided from true!!
someone else other than the client 49. THE LAST STEP IN INTERVENTION IS TO
but within the client’s frame of ACCURATELY DOCUMENT IT!!!
reference 50. Nursing interventions require
c. Tertiary Data - Outside the client’s INTELLECTUAL, INTERPERSONAL AND
frame of reference TECHNICAL SKILLS.
38. Validating is an act of double-checking 51. INTELLECTUAL SKILLS required of the
39. Cues are subjective or objective data that HCP include: problem identification, and
can be directly observed by the HCP. problem solving, critical thinking, and the
40. Inferences are the HCP’s interpretation or ability to make sound judgments.
conclusions made based on the cues. 52. A strong theoretical background is
necessary for these intellectual skills!

41. STEPS IN MAKING THE DIAGNOSIS: 53. INTERPERSONAL SKILLS used during

1. Interpret and validate client data; nursing intervention include:

analyze all data communicating, listening, conveying

2. Identify the client’s problems (and interest, compassion, empathy, and TLC.

strengths) These skills are invaluable in establishing

3. Formulate and validate the nursing rapport and building a therapeutic

diagnoses, both actual & potential relationship.

4. Prioritize a list of appropriate nursing

diagnoses (No client has only one 54. Technical skills. hands-on abilities
problem in only one realm.) developed through education, training,
42. Planning. TO END, HEAL OR OVER-COME and practice, crucial for patient care and
THE PROBLEMS IN THE PROBLEM safety.
STATEMENTS OF THE NURSING 55. Nursing interventions can be:
DIAGNOSES a. INDEPENDENT i.e.: when the HCP
1. Establish priorities (most life takes action alone, such as starting
threatening or disturbing first) oxygen on a client who has become
2. Select and write down (in cooperation cyanotic.
with the client) the goals b. DEPENDENT i.e.: giving the patient
which are also known as expected a medication (the HCP is
outcomes = goals. dependent on the OB/GYN to write
the medication order.)
43. EXPECTED OUTCOMES (GOALS) MUST c. COLLABORATIVE/INTERINDEPEN
ALWAYS BE DATED OR TIMED!!! DENT i.e.: consulting with a

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colleague such as a dietician, c. Intensity
physicians or another HCP before d. Etiology
taking action. 62. Pain means to ache, hurt, or be sore.
56. The last phase of the nursing process is 63. Pain is a warning from the body.
EVALUATION. 64. Pain is personal.
57. Two kinds of collecting data 65. Radiating Pain: Pain that starts at a
a. Subjective source and extends along nerves to other
b. Objective body parts.
58. Subjective 66. Referred Pain: Pain felt in an area away
a. Provided by the patient from the actual source.
b. Verified only by the patient 67. Visceral Pain: Deep, dull pain from
c. Include statements such as “my internal organs, often hard to localize.
head hurts” or “I am having 68. Chronic Pain: Persistent pain that lasts
troubles sleeping” beyond the usual course of an acute
• Pains and feelings or illness or healing of an injury, often for
emotion months or years.
• Anorexia 69. Acute Pain: Short-term pain that arises
• Increase fatigability suddenly in response to a specific injury
• Nauseated or illness, typically resolving once the
• Shortness of Breath cause is treated.
59. Objective 70. Cancer Pain: Pain associated with cancer
a. Are observed during a physical or its treatment, varying in intensity and

examination potentially chronic or acute.

b. Are verifiable 71.

c. Include findings such as a red, 72. Mild Pain: Discomfort that is noticeable

swollen arm in a patient

but does not significantly hinder daily
• Cyanosis activities or quality of life.
• Odor 73. Moderate Pain: Discomfort that is

• Lethargy distracting and may hinder but not

• Obtained Lab Results completely prevent daily activities.

• Redness/Rashes 74. Severe Pain: Intense discomfort that

60. International Association for the Study of significantly impairs or prevents normal
activities and significantly affects quality
Pain (IASP) defines pain as "an
of life.
unpleasant sensory and emotional
75. Nociceptive Pain: Arises from damage to
experience associated with, or resembling
body tissue, sensed by nociceptors (pain
that associated with, actual or potential
receptors). It is typically sharp, aching, or
tissue damage."
throbbing and can be caused by injury,
61. Pain may be described in terms of:
inflammation, or surgical procedures.
a. Location
b. Duration 76. Somatic Pain: A type of nociceptive pain
that comes from the skin, muscles, joints,

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bones, and ligaments. It is often localized Behaviors: Observe crying, restlessness,
and can be described as sharp, aching, or guarding the area.
throbbing. 83. Wong-Baker Faces Pain Rating Scale.
77. Neuropathic Pain: Caused by damage or Pediatric
disease affecting the somatosensory 84. Numeric Rating Scale (NRS). Adult
nervous system. 85. PHYSICAL ASSESSMENT TECHNIQUES
78. Neuropathic Pain: It may manifest as a. INSPECTION
burning, shooting, stabbing, or electrical b. PALPATION
shocks and often involves abnormal c. PERCUSSION
sensations known as dysesthesia or d. AUSCULTATION
allodynia. 86. INSPECTION
79. Peripheral Neuropathic Pain: Results a. Inspecting body system using
from damage to peripheral nerves outside vision, smell and hearing
the brain and spinal cord. Causes include b. Observe for color, size, location,
diabetes, chemotherapy, and physical movement, texture, symmetry,
injury to a nerve. odors, and sounds
80. Central Neuropathic Pain: Pain that arises 87. PALPATION
from dysfunction or damage to the brain a. Requires you to touch the patient
or spinal cord. It can be caused by 88. Types of palpation
conditions such as stroke, multiple a. Light Palpation (to feel surface
sclerosis, and spinal cord injury. abnormalities)
81. Sympathetically Maintained Pain (SMP): b. Deep Palpation (feel internal
A type of pain that is maintained by the organs and masses)
sympathetic nervous system, often 89. PERCUSSION
associated with complex regional pain a. Involves tapping of fingers or
syndrome (CRPS). hands quickly against the body of
82. How to Assess Pain the patient
Location: Identify where the pain is.
Onset & Duration: Determine when it
90. Types of percussion
started and how long it lasts.
a. Direct (identify tenderness)
Intensity: Rate the pain on a scale of 1-10.
b. Indirect
Description: Describe the pain (sharp,
91. Percussion elicit five sounds
dull, burning).
a. Resonance: Low-pitched, clear
Causes: Identify what triggers the pain.
sound over healthy lung tissue.
Vital Signs: Check heart rate, blood
b. Hyperresonance: Louder, lower-
pressure, etc.
pitched sound indicating excessive
Other Symptoms: Look for nausea,
air.
vomiting, etc.
c. Tympany: High-pitched, drum-like
Body Responses: Notice increased vital
sound over air-filled structures.
signs, sweating, etc.
d. Dullness: Medium-pitched, thud-
like sound over solid or fluid-filled
areas.

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e. Flatness: Soft, high-pitched sound 96. Times to assess Vital Signs
over dense areas like bone or • On Admission
muscle. • change in health status or reports
92. AUSCULTATION • before and after surgery or any invasive
a. Involves listening for various procedures
breath, heart and bowel sounds • before and after administration of
with a use of stethoscope medication
b. Auscultation is listening to internal • before and after any interventions
body sounds. 97. Body Temperature
c. It involves direct auscultation 98. Heat is a by-product of metabolism
(unaided ear) and indirect 99. heat produce = heat lost: heat balance
auscultation (using a stethoscope). 100. FACTORS AFFECT THE BODY’S
d. A stethoscope has a flat disc HEAT PRODCUTION:
diaphragm for high-pitched a. BMR (Basic Metabolic Rate)
sounds like bronchial sounds and a b. Muscle Activity
bell for low-pitched sounds like c. Thyroxine output
some heart sounds. d. Epinephrine, Norepinephrine, and

93. GENERAL ASSESSMENT sympathetic stimulation

a. I-PA-PE-A e. Fever
1. INSPECTION 101. Heat Loss Mechanism
2. PALPATION a. Radiation: Heat goes from your
3. PERCUSSION body into the cooler air around
4. AUSCULTATION you, like when you feel colder
standing in a chilly room.
94. ABDOMEN b. Conduction: Heat moves from your
I-A-PE-PA body to something else when you
1. INSPECTION touch it, like when you sit on a cold
2. AUSCULTATION bench.
3. PERCUSSION c. Convection: Heat is carried away
4. PALPATION from your body by moving air or
water, like feeling cooler when a
95. vital signs - Body temperature, pulse, breeze blows on you.
respirations, and Blood Pressure d. Evaporation: Sweat on your skin
• Monitor functions of the body evaporates, taking heat away with
• Should be a thoughtful, scientific it, which cools you down, like
assessment when you sweat on a hot day.
• VITAL SIGNS MUST BE MEASURED, 102. NB can conserve heat by
REPORTED, AND RECORDED constricting blood vessels.
ACCURATELY 103. Brown fat - found in term NB can
• IF YOU ARE NOT SURE OF A help conserve/produce heat by increasing
MEASUREMENT, RECHECK IT metabolism.

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104. Great amount of brown fats: e. Stress

intrascapular region, thorax, perirenal f. Environment
area. 112. The body's normal temperature,
105. Kangaroo care - skin-to-skin taken orally, is 98.6°F (37°C), with a
106. NB Stabilizes at 37°C (98°F) within range of 97.8 to 99.1°F (36.5-37.2°C).
4 hours after birth. 113. A pyrexia, hyperpyrexia or fever is
107. Heat Loss Mechanism a temperature of 101°F (38.3°C) or higher
(Prevention): in an infant younger than three months or
a. Convection above 102°F (38.9°C) for older children and
Eliminate air drafts from windows adults.
and air conditioners 114. Four common types of fever
b. Conduction a. Intermittent Fever
Cover surface with a blanket or dry b. Remittent Fever
towel c. Relapsing Fever
c. Radiation d. Constant (or Sustained) Fever
Move NB as far away from the cold 115. Intermittent Fever - body
surface temperature alternates at regular
d. Evaporation intervals between periods of fever and
dry NB as possible periods of normal or sub-normal
cover the hair/head with a cap temperatures
after drying a. example: malaria, sepsis
108. Normal Temperature: 36.5°C to 116. Remittent Fever - wide range of
37.2°C fluctuation >1-2°C (3.6°F)
109. Sign of Distress: a. example: cold, influenza, viral
a. < 36.5°C - Hypothermia infections
b. > 37.2°C - Hyperthermia 117. Relapsing Fever - short febrile
110. Regulation of the Body episodes for a few days are interspersed
Temperature with periods of afebrile episodes
a. Sensors in the periphery and the a. example: Hodgkin lymphoma,
core borreliosis (lyme disease)
b. hypothalamus 118. Constant Fever - fluctuates
c. Effector system minimally but always remains above
d. Hypothalamic Integrator - center normal.
of the core temperature a. example: typhoid fever, viral
111. Factors affecting body pneumonia
temperature 119. Fever Spike. temperature that
a. Age rises to fever level rapidly following a
b. Diurnal Variations (circadian normal temperature and then returns to
rhythms) normal level within a few hours
c. Exercise 120. Some of elevated fever are not true
d. Hormones fever (Heat exhaustion and Heat stroke)

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121. Heat Exhaustion. result of • lack of muscle coordination

excessive heat and dehydration • disorientation
a. S/Sx: • drowsiness progressing to coma
• paleness 125. Axillary, under the armpit. This
• dizziness method provides the least accurate
• nausea results.
• vomiting 126. Orally, under the tongue. This
• fainting method is never used with infants or very
• increased temperature (38.3°C to young children because they may
38.9°C accidentally bite or break the
122. Heat stroke. It occurs when the thermometer. They also have difficulty
body can no longer control its holding oral thermometers under their
temperature: the body's temperature tongues long enough for their
rises rapidly, the sweating mechanism temperatures to be accurately measured.
fails, and the body is unable to cool down. 127. Rectally, inserted into the rectum.
When heat stroke occurs, the body This method provides the most accurate
temperature can rise to 106°F or higher recording of recording the temperature. It
within 10 to 15 minutes. is most often used for infants
a. S/Sx: 128. Oral
• warm, flushed skin a. Easy and convenient

• often do not wet b. Accessible

• c. Relatively accurate
delirious
• d. can be affected by recent food or
unconcsious
• having seizures drink intake

123. e. Not suitable for patients who

Hypothermia is recognized as a
temperature below 96°F (35.5°C). breathe through their mouth or

124. Physiological mechanism: are unconscious

a. excessive heat loss 129. Rectal

b. inadequate heat production to a. Considered most accurate for core

counteract heat loss temperature

c. impaired hypothalamic b. Reliable

c. Invasive and uncomfortable
thermoregulation
d. s/sx: d. Not suitable for all patients

• decreased body temp, pulse, and rr e. Risk of cross-contamination

• 130. Axillary (Armpit)

severe shivering (initial)
a. Non-invasive
• feelings of cold and chills
b. Safe for use in newborns and
• pale, cool, waxy skin
unconscious patients
• frostbite
c. Less accurate; influenced by
• hypotension
external factors
• Decreased urinary output

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d. Requires longer time to obtain 136. Infrared Ear (Tympanic)
stable reading Thermometer:
131. Tympanic (Ear) a. Use: Measures temperature from
a. fast and easy to use the ear canal.
b. Less invasive b. Advantages: Fast and less invasive,
c. Reflects core temperature" good for children and adults.
d. Can be affected by earwax or small c. Disadvantages: Can be affected by
ear canals ear wax, requires correct
e. Technique sensitive for accurate positioning.
readings" 137. Temporal Artery Thermometer:
132. Temporal Artery a. Use: Forehead scan.
a. Non-invasive b. Advantages: Non-invasive, fast,
b. Quick to use suitable for all ages.
c. Suitable for all age c. Disadvantages: Can be expensive;
d. Can be affected by sweat or skin accuracy may be affected by sweat
oils or improper use.
e. requires specific technique for 138. Strip Thermometers:
accurate reading" a. Use: Forehead.
133. Forehead (Skin) b. Advantages: Disposable, easy to
a. Very non-invasive use.
b. Quick and eas c. Disadvantages: Least accurate,
c. Less accurate; influenced by affected by external temperatures.
environmental factors Temperature Scales
134. Mercury Thermometer: 139.

a. Use: Traditionally used for oral, a. Celsius to Fahrenheit

rectal, and axillary temperature b. C = (F-32)/1.8

measurements. c. Fahrenheit to Celsius

b. Advantages: Highly accurate. d. F = (1.8xC) + 32

c. Disadvantages: Mercury is toxic if 140. Oral Thermometer:

a. Placement: Place the thermometer
the thermometer breaks; these are under the tongue, in the posterior
now less commonly used or sublingual pocket, ensuring
banned in many places. contact with the tissue. Instruct
135. Digital Thermometer: the person to keep their mouth
a. Use: Can be used orally, rectally, closed around the thermometer.
and under the arm. b. Considerations: Wait at least 15
b. Advantages: Easy to read, fast minutes after eating, drinking, or
readings, versatile. smoking before taking an oral
c. Disadvantages: Requires batteries; temperature to avoid inaccurate
accuracy can vary depending on readings.
the model. 141. Rectal Thermometer:

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a. Placement: Apply a lubricant to the 145. Pulse

tip of the thermometer. Gently a. Is a wave of blood created by
insert it into the rectum (about ½ contraction of the left ventricle of
to 1 inch for infants and up to 1 the heart
inch for adults) with care to b. Represents the amount of blood
ensure it's not forced in. that enters the arteries with each
b. Considerations: Often ventricular contraction
recommended for infants and 146. Cardiac Output - volume of blood
young children for accuracy but pumped into the arteries by the heart and
must be done with caution to avoid equals the result of the stroke volume
injury. 147. pulse reflects the heart beat
142. Axillary (Armpit) Thermometer: 148. Peripheral pulse - a pulse located
a. Placement: Place the thermometer away from the heart Ex. Foot or wrist
tip in the center of the armpit. 149. Apical pulse - is the central pulse
Ensure that it's in direct contact that is located at the apex of the heart;
with the skin and not clothing. also referred as PMI (point of maximal
Lower the arm and press it against impulse)
the body to keep the thermometer 150. Factors affecting Pulse
in place. a. Age - age increase, pulse gradually
b. Considerations: May be less decrease
accurate than oral or rectal b. Sex - after puberty, male is slightly
measurements. Suitable for quick slower than female
screenings or when other methods c. Exercise - PR increases with
are not practical. activity. normal
143. Tympanic (Ear) Thermometer: d. Fever - increased metabolic rate;
a. Placement: Gently pull the ear
increase in response to lowered BP
back to straighten the ear canal for that results from peripheral
adults (up and back for children). vasodilation
Insert the thermometer gently into e. Medications
the ear canal, ensuring it's aimed f. Hypovolemia/Hydration - loss
towards the eardrum without circulating blood volume,
forcing it. increases the PR
b. Considerations: Earwax, small ear g. Stress
canals, or improperly aimed h. Position
thermometers can affect accuracy. i. Pathology - heart condition
144. Care of Thermometer 151. Pulse Site
a. Before use - Bulb to Stem (moist a. Radial - Readily accessible
cotton balls) b. Temporal - When radial pulse is
b. After use - Stem to Bulb (dry not accessible
swab)
c. Wipe with downward motion

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c. Carotid - During cardiac d. if engaged in any activities, wait

arrest/shock in adults Determine for 10-15 minutes
circulation to the brain e. sitting position
d. Apical - Infants and children up to 154. Collect:
3 years of age, Discrepancies with 155. rate
radial pulse, Monitor some a. tachycardia - > 100 bpm
medications b. bradycardia - < 60 bpm
e. Brachial - Blood pressure, Cardiac 156. rhythm - pattern of the beats and
arrest in infants the intervals between the beats; equal
f. Femoral - Cardiac arrest/shock, time elapses between beats of normal
Circulation to a leg pulse.
g. Popliteal - Circulation to lower leg h. a. dysrhythmia or arrhythmia -
Posterior tibial - Circulation to the irregular; Diagnostic test: ECG
157. volume - aka pulse strength or
foot
i. Dorsalis pedis - Circulation to the amplitude; force of the blood with each
foot beat
152. AGE PULSE a. range from absent to bounding
RESPIRATIONS b. bounding pulse - full/forceful
NB 130 (80-180) 35 (30-60) blood volume that obliterated only
1 YEAR 120 (80 - 140) 30 w/ difficulty
(20-40) c. weak, feeble, thready - readily
TEEN 75 (50-90) 18 (15-20) obliterated with pressure from
ADULT 80 (60-100) 16 (12-20) fingers
OLDER ADULT 70 (60-100) 16 158. d. arterial wall elasticity
(15-20) a. normal artery - feels straight,
smooth, soft, and pliable
153. Assessing the Pulse b. adult - tortuous (twisted),
a. Usually assessed by palpating and irregular on palpation
auscultation. 159. e. presence or absence of bilateral
b. via palpation: equality
• apply moderate pressure a. when peripheral pulse is located, it
with the 3 middle fingers of indicates that pulses more
the hand proximal to that location is
• the pads on the most distal present.
aspects are the most 160. Apical - Radial Pulse
sensitive areas for detecting a. Locate apical and radial sites
a pulse b. Two nurse method:
• excessive pressure can c. Decide on starting time

obliterate a pulse d. HCP counting radial says “start”

c. any medication can affect the PR e. Both count for 60 seconds
f. HCP counting apical says “stop”

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g. Radial can never be greater than • peripherally in the carotid and

apical aortic bodies
h. The difference in pulses is called 171. Mechanism and regulation
the pulse deficit (CBQ) breathing:
161. Apical Pulse INHALATION.
a. Taken with a stethoscope • Diaphragm contracts
b. Counted by placing the (flattens)
stethoscope over the heart • Ribs move upward and
c. Counted for one full minute outward
d. The heart beat normally sounds • Sternum moves outward
like a lub-dub. Each lub-dub is • Enlarging the size of the
counted as one heartbeat. thorax
e. Do not count the lub as one EXHALATION.
heartbeat and the dub as another.
f. The apical pulse is taken on • Diaphragrelaxes

patients who have heart disease, • Ribs move downward and

an irregular pulse rate, or take inward

medications that can affect the • Sternum moves inward

heart. One respiration consists of • Decreasing the size of the

162. one thorax
inspiration and one expiration 2. Things to consider before assessing
163. The chest rises during inspiration respiration:
(breathing in) and falls during expiration • Px normal breathing pattern
(breathing out) • influences of the px’s health
164. Count each time the chest rises problems on respiration
165. Do not let the person know you are • medication
counting their respirations • therapy
166. Count after taking the pulse – keep • relation of respiration to
your fingers on the pulse site cardiovascular function (COPD)
167. Normal respiratory rate for adult
172. Assess
is 12 – 20 breaths per min.
168. a. Rate
Respiration - Act of breathing
169. b. Depth
Ventilation - movement of air in
c. Rhythm
and out of the lungs
170. d. Quality
Respiration is controlled by:
a. Respiratory center e. Effectiveness

• medulla oblangata 173. Rate - described in breaths per

• minute
pons of the brain
a. bradypnea - <12 breaths per
b. chemoreceptors
• medulla minute

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b. tachypnea - >20 breaths per a. Hyperventilation- overexpansion

minute of the lungs characterized by rapid
c. apnea - absence/cessation of and deep breaths
breathing b. Hypoventilation- under expansion
174. Depth - can be describe as: normal, of the lungs characterized by
deep, and shallow shallow respirations
a. normal - 500mL of air (Tidal 180. Rhythm
Volume) a. Cheyne- Stroke breathing-
b. deep - large volume of air is rhythmic waxing and waning of
inhaled and exhaled, inflating most respirations, from very deep to
of the lungs very shallow breathing and
c. shallow - exchange of small temporary apnea
volume of air with minimal use of 181. Ease or Effort
lung tissue a. Dyspnea- difficult and labored
d. hyperventilation - deep, rapid breathing during which the
respirations individual has a persistent,
e. hypoventilation - very shallow unsatisfied need for air and feels
respiration distressed
175. Rhythm - regularity of the b. Orthopnea- ability to breathe only
expiration and inspirations in upright sitting or standing
a. regular positions Altered Breathing
b. irregular 182. Sounds a. Stridor – a shrill, harsh
176. Quality - aspects of breathing that sound heard during inspiration
are different from normal, effortless with laryngeal obstruction
breathing
a. labored breathing - substantial b. Stertor - snoring respiration, due
effort to partial obstruction of the upper
177.Effectiveness - measured part by airway
uptake of O2 from the air into the blood c. Wheeze - continuous, high pitched
and release of CO2 from the blood expel musical squeak or whistling sound
to the air. occurring on expiration
a. Pulse oximeter (o2 sat) d. Bubbling - gurgling sounds heard
178. Rate as air passes through moist
a. Tachypnea – quick, shallow secretions of RT
breaths 183. Chest movements
b. Bradypnea- abnormally shallow a. Intercostal retraction - indrawing
breathing between the ribs
c. Apnea- absence or cessation of b. substernal retraction - indrawing
breathing beneath the breastbone
179. Volume c. suprasternal retraction -
indrawing above the clavicle

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184. Secretions and couching

a. Hemoptysis - the presence of
blood in the sputum
b. productive cough - a cough
accompanied by expectorated
secretions
c. non-prod cough - a dry, harsh
cough w/o secretions
185. Systolic - Contraction of the 196. Hypotension
ventricles a. BP below normal
186. Diastolic - Ventricles are at rest; b. Orthostatic Hypotension - BP
Lower pressure present at all times decrease when Px sits or stands
187. Pulse Pressure - difference 197. Assessing BP
between systolic and diastolic pressures a. Direct (Invasive Monitoring)
188. Measured in mm Hg b. Indirect
189. Recorded as a fraction, e.g. 120/80 • Auscultatory
190. Systolic = 120 and • Palpatory
191. Diastolic = 80 198. Sites
192. Factors affecting BP a. Upper arm (brachial artery)
a. age b. Thigh (popliteal artery)
b. exercise 199. Instrument
c. stress a. BP cuff (bladder: can be inflated
d. race with air; too narrow - elevated; too
e. sex wide - too low
f. medications • W - 40% circumference or
g. obesity 20% wider that the dia of
h. diurnal variation the midpoint ; 2/3 of the
i. medical condition limb’s circumference
j. temperature b. Stethoscope
193. Hypertension c. sphygmomanometer
a. BP persistently above normal 200. The Korotkoff sounds are
b. primary hypertension - unknown categorized into five phases:
cause a. Phase 1: The first detection of
c. secondary hypertension - known faint, clear tapping sounds that
cause gradually increase in intensity; this
194. Systolic: 80-89 mmHg; Diastolic: is considered the systolic blood
120-139 mmHg (Prehypertensive) pressure.
195. b. Phase 2: A murmuring or
whooshing sound may follow the
tapping sounds.

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c. Phase 3: The sounds become • Discard the first flow of
crisper and louder. urine
d. Phase 4: The sounds become • Label the specimen
muffled and softer. properly
e. Phase 5: The sounds disappear • Send the specimen
completely; this point is immediately to the
considered the diastolic blood laboratory
pressure. • Document the time of
201. Pulse Oximetry specimen collection and
a. Noninvasive transport to the lab.
b. Estimates arterial blood oxygen • Document the appearance,
saturation (SpO2) odor, and usual
c. Normal SpO2 95-100%; < 70% life characteristics of the
threatening specimen.
d. Detects hypoxemia before clinical b. 24-hour urine specimen
signs and symptoms • Discard the first voided
e. Sensor, photodetector, pulse urine.
oximeter unit • Collect all specimen
202. Factors that affect accuracy thereafter until the
include: following day
a. Hemoglobin level • Soak the specimen in a
b. Circulation
container with ice
c. Activity
• Add preservative as
d. Carbon monoxide poisoning
ordered according to
203. Measuring Pulse Oximetry hospital policy
a. Prepare site • 3. Second-Voided urine –
b. Align LED and photodetector
required to assess glucose
c. Connect and set alarms
level and for the presence
d. Ensure client safety
of albumin in
e. Ensure accuracy
c. Second-Voided urine – required to
f. Document
assess glucose level and for the
204. Laboratory and Diagnostic
presence of albumin in the urine.
examination • Discard the first urine
a. Clean-Catch mid-stream urine
• Give the patient a glass of
specimen for routine urinalysis,
water to drink
culture and sensitivity test
• After few minutes, ask the
• Best time to collect is in the
patient to void
morning, first voided urine
d. Catheterized urine specimen
• Provide sterile container
• Clamp the catheter for 30
• Do perineal care before
min to 1 hour to allow urine
collection of the urine

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to accumulate in the • - CBC, Hgb, Hct, clotting

bladder and adequate studies, enzyme studies,
specimen can be collected. serum electrolytes
• Clamping the drainage tube h. Fasting is required:
and emptying the urine into • - FBS, BUN, Creatinine,
a container are serum lipid (cholesterol,
contraindicated after a triglyceride)
genitourinary surgery. 205. Drug Name
e. Fecalysis – to assess gross a. Generic Name
appearance of stool and presence b. Brand Name/Trade Name
of ova or parasite c. Official Name
• Secure a sterile specimen d. Chemical Name
container 206. Generic Name
• Ask the pt. to defecate into a. The official, non-proprietary name
a clean , dry bed pan or a of the drug. It is universally
portable commode. accepted and used by healthcare
• Instruct client not to professionals.
contaminate the specimen Example: Ibuprofen.
with urine or toilet 207. Brand Name/Trade Name
paper(urine inhibits a. The trademarked name given by a
bacterial growth and paper drug's manufacturer. It is used for
towel contain bismuth marketing purposes and is often

which interfere with the more well-known to the public.

test result) b. Example: Advil®.

f. Stool culture and sensitivity test 208. Official Name
• To assess specific etiologic a. listed in pharmacopeias is typically

agent causing referred to as the "International

gastroenteritis and Nonproprietary Name" (INN) or

bacterial sensitivity to the "United States Adopted Name"

various antibiotics. (USAN) in the United States. These

• 3. Fecal Occult blood tests names are universally recognized

and used to ensure a clear and
are valuable test for
consistent identification of
detecting occult blood
pharmaceutical substances.
(hidden) which may be
209. Chemical Name
present in colo-rectal
cancer, detecting melena a. name by which a chemist knows it

stool b. describes the constituents of the

g. a. No fasting for the following drug precisely

tests: 210. Pharmacology

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211. Pharmacology is the branch of 217. Toxic Effects:

biology concerned with the study of drug a. Toxic effects occur when the drug
action. level exceeds the therapeutic
212. two main areas: range, leading to harmful or
a. pharmacodynamics (the effects of potentially life-threatening
drugs and their mechanisms of reactions.
action within the body) b. can result from overdosing, drug
b. pharmacokinetics (the absorption, interactions, or sensitivity to
distribution, metabolism, and specific medications.
excretion of drugs). c. example, liver damage can occur
213.pharmacist is a healthcare from the overuse of
professional who practices in pharmacy, acetaminophen, a common pain
the field of health sciences focusing on reliever.
safe and effective medication use. 218. Addiction and Dependence:
214. Pharmacy science and technique of a. Certain drugs, especially those
preparing, dispensing, and reviewing affecting the central nervous
drugs and providing additional clinical system, can lead to psychological
services. or physical dependence, addiction,
215. Therapeutic Effects: and abuse.
a. These are the intended or b. These effects are characterized by
desirable effects for which a drug a compulsive need to use the drug
is prescribed. despite harmful consequences.
b. aim to improve health conditions, 219. Tolerance:
alleviate symptoms, or cure a. Tolerance occurs when repeated
diseases. use of a drug diminishes its
c. ex.: antihypertensive drugs are effectiveness, leading to the need
used to lower high blood pressure, for higher doses to achieve the
and antibiotics are used to treat same therapeutic effect.
bacterial infections. b. This is common with drugs like
216. Side Effects: opioids and benzodiazepines.
a. unintended 220. Withdrawal Symptoms:
b. often undesirable effects that a. Withdrawal symptoms can occur
occur in addition to the when stopping or reducing the use
therapeutic effects. of a drug on which the body has
c. While most side effects are mild become dependent.
and manageable, some can be b. These symptoms can range from
severe and impact the patient's mild to severe, depending on the
quality of life. drug and duration of use.
d. ex.: a common side effect of 221. Allergic Reactions:
chemotherapy drugs is nausea and a. Some individuals may experience
vomiting. allergic reactions to certain drugs,

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which can range from mild 225. Agonist:

symptoms like rashes to severe a. Binds to and activates receptors.
reactions such as anaphylaxis. b. Produces a response that
222. therapeutic actions of a drug mimics/enhances natural
a. Palliative Relieves symptoms regulatory molecules.
without addressing the underlying c. Example: Morphine at opioid
cause of the disease. Used to receptors for pain relief.
improve quality of life.
b. Curative Aims to cure the 226. Antagonist:
disease or condition. a. Binds to receptors without
c. Supportive Supports body activating them.
functions while the body recovers b. Blocks or dampens the action of
from illness or injury. agonists or natural molecules.
d. Substitutive Replaces body fluids c. Can diminish or prevent
or substances that are missing or physiological responses.
deficient. d. Example: Naloxone as an opioid
e. Chemotherapeutic "Destroys or antagonist against opioid
inhibits the growth of harmful overdose.
cells, such as cancer cells or 227. Synergist:
pathogens. a. A substance that enhances the
f. Restorative Helps to restore effect of another drug or substance
normal body function after injury when used together.
or illness. b. Works by different mechanisms to
223. Branch of pharmacology studying improve efficacy or reduce adverse
drug effects on the body. effects.
a. Interactions between drugs and c. Can lead to a greater effect than
targets (receptors, enzymes, ion either substance alone.
channels). d. Example: The combination of
b. Purpose: Understand how these amoxicillin and clavulanic acid,
interactions lead to therapeutic where clavulanic acid inhibits
effects, side effects, and toxic beta-lactamase enzymes, thereby
effects. enhancing the antibacterial effect
c. Key Question: "What does the drug of amoxicillin.
do to the body?"
224. Pharmacokinetics:
Receptor
a. Specific protein on or inside cells.
228. The study of how the body
b. Binds drugs, neurotransmitters,
absorbs, distributes, metabolizes, and
hormones, signaling molecules.
excretes drugs.
c. Initiates biochemical/physiological 229. ADME:
response, mediating drug effects.
d. Critical for drug action mediation.

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a. Absorption: The process by which fine particles of drug suspended in
a drug enters the bloodstream a liquid.
from its site of administration. c. Topical Preparations: Designed for
b. Distribution: The dispersion or external application to the skin or
dissemination of substances mucous membranes. These include
throughout the fluids and tissues creams, ointments, gels, and
of the body. patches.
c. Metabolism: The chemical d. Suppositories: Solid preparations
transformation of a drug within designed to be inserted into the
the body, often into more water- rectum, vagina, or urethra, where
soluble compounds for easier they dissolve or melt at body
excretion. temperature, releasing the drug.
d. Excretion: The removal of the e. Inhalers: Aerosol or powder
substances from the body, mainly preparations intended for
through the kidneys (urine) or in inhalation. They deliver the drug
the feces. directly to the lungs for a local or
230. 10 Rights of Medication systemic effect. Drops: Liquid
Administration f. preparations intended for
a. Right CLIENT administration to the eyes, ears, or
b. Right MEDICATION nose. They provide a local effect at
c. Right DOSAGE the site of application.
d. Right ROUTE
e. Right TIME
g. Transdermal Patches: Adhesive
f. Right ASSESSMENT
patches that deliver a drug
g. Right DOCUMENTATION
through the skin into the
h. Client’s right to REFUSE
bloodstream for a systemic effect.
i. Client’s right to EDUCATION h. Implants: Solid preparations
j. Right EVALUATION designed to be inserted under the
skin. They release the drug slowly
231. TYPES OF DRUG PREPARATIOn over a long period.
a. Tablets and Capsules: Solid forms i. Powders: Fine particulate forms
that contain a drug in a specific that can be used internally (e.g.,
dose. Tablets can be coated or mixed with food or drink) or
uncoated, and capsules often externally (applied to the skin).
contain the drug in powder or
liquid form. 232. routes of drug administration
b. Solutions and Suspensions: Liquid Oral administration
preparations. Solutions contain a. The easiest and most desirable way to
drugs that are dissolved in a liquid administer medication
carrier, while suspensions contain b. Most convenient
c. Safe, does nor break skin barrier

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d. Usually less expensive c. Client should be taught to alternate the

cheeks with each subsequent dose to avoid
Disadvantages mucosal irritation
a. Inappropriate if client cannot swallow Advantages:
and if GIT has reduced motility a. Same as oral
b. Inappropriate for client with nausea b. Drug can be administered for local effect
and vomiting c. Ensures greater potency because drug
c. Drug may have unpleasant taste directly enters the blood and bypass the liver
d. Drug may discolor the teeth Disadvantages:
e. Drug may irritate the gastric mucosa a. If swallowed, drug may be inactivated by
f. Drug may be aspirated by seriously ill gastric juice
patient.
235. Dermatologic – includes lotions,
233. SUBLINGUAL

liniment and ointments, powder.

a. A drug that is placed under the tongue, a. Before application, clean the skin
where it dissolves. thoroughly by washing the area gently
b. When the medication is in capsule and with soap and water, soaking an involved
ordered sublingually, the fluid must be site, or locally debriding tissue.
aspirated from the capsule and placed b. Use surgical asepsis when open wound
under the tongue. is present
c. A medication given by the sublingual c. Remove previous application before the
route should not be swallowed, or desire next application
effects will not be achieved d. Use gloves when applying the
Advantages: medication over a large surface. (e.g large
a. Same as oral area of burns)

b. Drug is rapidly absorbed in the e. Apply only thin layer of medication to

bloodstream prevent systemic absorption.

Disadvantages 236. Opthalmic - includes instillation

a. If swallowed, drug may be inactivated and irrigation
by gastric juices. a. Instillation – to provide an eye
b. Drug must remain under the tongue medication that the client requires.
until dissolved and absorbed b. Irrigation – To clear the eye of noxious
234. BUCCAL or other foreign materials.
a. A medication is held in the mouth against c. Position the client either sitting or lying.
the mucous membranes of the cheek until the d. Use sterile technique
drug dissolves. e. Clean the eyelid and eyelashes with
b. The medication should not be chewed, sterile cotton balls moistened with sterile
swallowed, or placed under the tongue (e.g normal saline from the inner to the outer
sustained release nitroglycerine, canthus
opiates,antiemetics, tranquilizer, sedatives) f. Instill eye drops into lower conjunctival
sac.

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g. Instill a maximum of 2 drops at a time. b. Assume a back lying position, or sit up

Wait for 5 minutes if additional drops and lean head back.
need to be administered. This is for c. Elevate the nares slightly by pressing
proper absorption of the medication. the thumb against the client’s tip of the
237. Otic Instillation – to remove nose. While the client inhales, squeeze the
cerumen or pus or to remove foreign bottle.
body d. Keep head tilted backward for 5
a. Warm the solution at room temperature or minutes after instillation of nasal drops.
body temperature, failure to do so may cause e. When the medication is used on a daily
vertigo, dizziness, nausea and pain. b. Have basis, alternate nares to prevent
the client assume a side-lying position ( if not irritations
contraindicated) with ear to be treated facing 239. Inhalation – use of nebulizer,
up. c. Perform hand hygiene. Apply gloves if metered-dose inhaler
drainage is present. d. Straighten the ear
canal: a. Semi or high-fowler’s position or standing
position. To enhance full chest expansion
• 0-3 years old: pull the pinna allowing deeper inhalation of the medication
downward and backward b. Shake the canister several times. To mix
• Older than 3 years old: pull the pinna the medication and ensure uniform dosage
upward and backward delivery
c. Position the mouthpiece 1 to 2 inches from
e. Instill eardrops on the side of the auditory the client’s open mouth. As the client starts
canal to allow the drops to flow in and inhaling, press the canister down to release
continue to adjust to body temperature one dose of the medication. This allows
f. Press gently but firmly a few times on the delivery of the medication more accurately
tragus of the ear to assist the flow of into the bronchial tree rather than being
medication into the ear canal. trapped in the oropharynx then swallowed
g. Ask the client to remain in side lying d. Instruct the client to hold breath for 10
position for about 5 minutes seconds. To enhance complete absorption of
h. At times the MD will order insertion of the medication.
cotton puff into outermost part of the canal. e. If bronchodilator, administer a maximum
Do not press cotton into the canal. Remove of 2 puffs, for at least 30 second interval.
cotton after 15 minutes. Administer bronchodilator before other
238. Nasal – Nasal instillations usually inhaled medication. This opens airway and
are instilled for their astringent effects (to promotes greater absorption of the
shrink swollen mucous membrane), to medication.
loosen secretions and facilitate drainage f. Wait at least 1 minute before
or to treat infections of the nasal cavity or administration of the second dose or
sinuses. Decongestants, steroids, inhalation of a different medication by MDI
calcitonin. g. Instruct client to rinse mouth, if steroid had
a. Have the client blow the nose prior to been administered. This is to prevent fungal
nasal instillation infection.

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240. Vaginal – drug forms: tablet liquid 243. Nasal Solutions: Liquid solutions
(douches). Jelly, foam and suppository. administered through the nostrils for
a. Close room or curtain to provide privacy. b. local or systemic effects.
Assist client to lie in dorsal recumbent 244. Enemas: Liquid treatments
position to provide easy access and good introduced into the rectum to clear the
exposure of vaginal canal, also allows bowels or administer drugs.
suppository to dissolve without escaping 245. Mouthwashes: Solutions used to
through orifice. c. Use applicator or sterile rinse the mouth, often antiseptic, for oral
gloves for vaginal administration of hygiene or treatment of oral conditions.
medications. 246. Syrups: Sweetened liquid
241. Vaginal Irrigation – is the washing medications used for oral administration,
of the vagina by a liquid at low pressure. often for cough or sore throat.
It is also called douche. 247. Suspensions: Finely divided drug
particles dispersed in a liquid medium,
a. Empty the bladder before the procedure
which must be shaken before use.
b. Position the client on her back with the
hips higher than the shoulder (use bedpan) 248. PARENTERAL- administration of
c. Irrigating container should be 30 cm (12 medication by needle.
inches) above 249. Intramuscular (IM): Injection into
d. Ask the client to remain in bed for 5-10 a muscle, typically at a 90-degree angle.
minute following administration of vaginal 250.Subcutaneous (SubQ): Injection into the
suppository, cream, foam, jelly or irrigation. fatty tissue under the skin, at a 45-
242. RECTAL – can be use when the degree angle.
drug has objectionable taste or odor. 251. Intravenous (IV): Injection directly
a. Need to be refrigerated so as not to soften. into a vein, usually at a 25-30-degree
b. Apply disposable gloves. angle.
c. Have the client lie on left side and ask to 252. Intradermal (ID): Injection just
take slow deep breaths through mouth and under the skin, at a shallow angle, usually
relax anal sphincter. less than 15 degrees.
d. Retract buttocks gently through the anus, 253. Z-track method is a technique for
past internal sphincter and against rectal intramuscular injection that involves
wall, 10 cm (4 inches) in adults, 5 cm (2 in) in pulling the skin and subcutaneous tissue
children and infants. May need to apply 254. to the side before injecting the
gentle pressure to hold buttocks together medication.
momentarily. 255.
e. Discard gloves to proper receptacle and 256. Bacteria - most common infection-
perform hand washing. causing microorganism
f. Client must remain on side for 20 minute 257. Fungi - like yeast and mold
after insertion to promote adequate 258. Viruses - must enter a living
absorption of the medication. organism to reproduce. ex: rhinovirus
(common cold), hepatitis, herpes, HIV

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259. Parasites - live on other living c. Portal of Exit

organisms; include protozoa such as the d. Route of Transmission
one that causes malaria, helminths, and e. Portal of Entry
arthropods (fleas, mites, ticks) f. Susceptible Host
260. Pathogenic: Capable of causing 273. Infectious Agent - any disease-
disease. causing microorganism (pathogen)
261. Disease-causing: Refers to 274. Reservoir Host - the organism in
organisms or agents that can induce which the infectious microbes reside
illness. a. Hosts that do not show any
262. Infectious agent: Microorganisms outward signs or symptoms of a
or pathogens that can cause infections. disease but are still capable of
263. Causes disease in healthy person: transmitting the disease are
Pathogens that can lead to illness even in known as carriers
individuals with no apparent weakness or 275. Portal of Exit - route of escape of
immune compromise. the pathogen from the reservoir.
264. Opportunistic pathogen: a. Examples: respiratory secretions,
Microorganisms that cause disease blood exposure, breaks in skin.
primarily in individuals with weakened 276. Route of Transmission - method by
immune systems; Causes disease in which the pathogen gets from the
susceptible person reservoir to the new host
265. Virulence: The degree to which a a. Direct Contact - person to person
pathogen can cause severe disease. transfer of organism.
266. Communicable diseases: Illnesses • Direct skin to skin contact –
that can be transmitted from person to by handshaking
person or through vectors. • Direct mucous membrane -
267. Non-pathogenic: Organisms that to- mucous membrane
typically do not cause disease in healthy contact by kissing or sexual
individuals. intercourse.
268. Resident flora: Microorganisms 277. Route of Transmission - method
that normally reside on or in the body by which the pathogen gets from the
without causing disease. reservoir to the new host
269. Colonization: The presence and 278. Indirect Contact - occurs when the
growth of microorganisms on or in a host susceptible person comes in contact with
without causing disease. a contaminated object.
270. Bacteremia when microbes enter 279. Indirectly via contamination of
blood stream food and water by fecal materials.
271. Septicemia – when bacteremia 280. Indirectly via transfusion of
spreads through all of the body systems contaminated blood from ill person or by
272. Six links in the chain of infection: parenteral injections.
a. Infectious Agent 281. Droplet spread - Contact with
b. Reservoir Host respiratory secretions, when the infected

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person coughs, sneezes or talks; Microbes d. as another means of fighting

carried in droplets can travel up to 3 ft. or pathogens by breaking the disease
1 meter. The organism is not suspended chain.
in the air but settle on a surface. e. Referred to as the clean technique.
282. Air – borne Transmission - fine 289. Practices that reduce possibility of
microbial particles or dust particles disease by reducing the number of
containing microbes remain suspended in pathogens or interrupting their
the air for a prolong period; spread by air transmission
current and inhaled. a. Practices that reduce pathogens.
283. Route of Transmission - method by • Interrupts chain level at of
which the pathogen gets from the causative agents and
reservoir to the new host reservoir.
a. Vector Borne transmission - • Hand washing
• Use of disinfectants and
intermediate carriers, such as flea, antiseptics on people and
flies, mosquitoes, transfer the objects
microbes to another living
organism, brought about by bites b. Practices that interrupt
of arthropods. transmission
284. Portal of Entry - route through • Interrupts chain level at
which the pathogen enters its new host. level of portal of exit,
a. inhalation transmission, and portal of
b. ingestion entry
c. coitus • Use of personal protective
d. breaks in skin equipment (Latex gloves,
285. Susceptible Host - the organism Gowns, Mask, goggles)
that accepts the pathogen • Use of isolation procedure.
286. Asepsis is any therapy, protocol or c. Antibiotics can also interrupt the
medical procedure used to defeat or infection cycle. These are
prevent sepsis. medications that kill many types of
287. Sepsis is a life-threatening illness. bacteria.
Your body's response to a bacterial 290. Applying medical asepsis.
infection usually causes it. a. Perform Patient Care Hand wash.
288. Medical asepsis b. Disinfect Materials as Required
a. is the state of being free from c. Maintain Clean Patient Care
disease cause microorganisms. Environment.
b. concerned with eliminate the d. Concurrent cleaning
spread of microorganisms through e. Terminal cleaning
facility practices. f. Use Clean and Dirty Utility Rooms
c. protects both residents and g. HANDWASHING
caregivers from becoming ill.

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291. Hand washing - the single most 306. Global Applicability: Can be
effective and important way to prevent implemented effectively in developed,
spread of microorganisms. transitional, and developing countries.
292. Occurs through friction – 307. Endogenous source - originate
loosening the microorganisms so they can from the clients
be removed. 308. Exogenous source - hospital
293. Use of antiseptic soap – killing environment and hospital personnel
numbers of microorganisms. 309. Hand washing tips and procedures
294. Importance of Handwashing: for your use.
295. Primary defense: Against Health 310. Consider the sink, including the
Care-associated Infections (HCAIs). faucet controls, contaminated.
296. Reduces transmission: Of 311. Avoid touching the sink.
nosocomial (hospital-acquired) 312. Turn water on using a paper towel
infections. and then wet your hands and wrists.
297. Health Care-associated Infections 313. Work soap into a lather.
(HCAIs). 314. Vigorously rub together all
298. An infection occurring in a patient surfaces of the lathered hands for 15
during the process of care in a hospital or seconds. Friction helps remove dirt and
other health-care facility which was not microorganisms. Wash around and under
present or incubating at the time of rings, around cuticles, and under
admission. acquired in the health-care fingernails
facility but appearing after discharge, and 315.Rinse hands thoroughly under a
also occupational infections among stream of water. Running water carries
health-care workers of the facility. away dirt and debris. Point fingers down
299. Use of antiseptic soap – killing so water and contamination won't drip
numbers of microorganisms. toward elbows.
300. Strategies for Preventing Health 316. Dry hands completely with a clean
Care-Associated Infections (HCAIs) dry paper towel.
301. Effective Prevention Strategies: 317. Use a dry paper towel to turn
302. Evidence-based: Adoption of faucet off.
validated and standardized prevention 318. To keep soap from becoming a
protocols. breeding place for microorganisms,
303. High Impact: Potential to prevent thoroughly clean soap dispensers before
at least 50% of HCAIs with proper refilling with fresh soap.
practices. 319. When hand washing facilities are
304. Implementation: not available at a remote work site, use
305. Simple Solutions: Most prevention appropriate antiseptic hand cleaner or
measures are straightforward and not antiseptic towelettes. As soon as possible,
resource-intensive. rewash hands with soap and running
water.

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320. disinfectants and antiseptics on e. Surgery

people and objects 325. Used in specialized areas & skills
a. Disinfectant - substance that a. Operating room
reduces the number of b. Labor room
microorganisms, but does not c. Major diagnostic areas
eliminate them. Destruction of d. At client’s bedside 
pathogens other than spores, • Inserting IV catheters
Irritate or damage skin • Urinary catheters
b. Boiling water and chemicals • Suctioning
• Bleach solutions tracheobronchial airway
• Zephirin • Dressing wounds
c. Used on objects not people • Injections
d. antiseptic – substance that can be 326. Principles of Surgical Asepsis
applied to skin to reduce the 327. A sterile object remains sterile
number of microorganisms only when touched by another sterile
• Prevent or inhibit growth of object
pathogenic organisms 328. Sterile touching sterile remains
• Not effective against spores sterile
or viruses 329. Sterile touching clean becomes
• Can be use on the skin contaminated
1. 330. Sterile touching contaminated
a. becomes contaminated
i. Alcoho 331. Sterile state is questionable
l 332. Only sterile objects may be placed
ii. Betadi on a sterile field
ne 333. A sterile object held below a
321. Surgical asepsis person’s waist is contaminated
322. a sterile technique that requires 334. A sterile object or field becomes
nurses to use different precautions than contaminated by prolonged exposure to
they do for medical asepsis. air
323. It includes procedures used to 335. When a sterile surface comes in
eliminate all microorganisms, including contact with a wet, contaminated surface,
pathogens and spores, from an object or the sterile object/filed becomes
area. contaminated by capillary reaction
324. followed when performing an 336. Fluid flow in the direction of
invasive procedure into a body cavity gravity
normally free of microorganisms. 337. The edges (I inch or 2.5 cm)of a
a. Used in specialized areas & skills sterile field or container are considered to
b. Care of surgical wounds be contaminated
c. Catheter insertion 338. Hold sterile objects above the level
d. Invasive procedures of the waist

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339. The edges (I inch or 2.5 cm)of a different metals when placed in
sterile field or container are considered to water
be contaminated 347. Do not soak instruments for more
340. Hold sterile objects above the level than 10 minutes
of the waist 348.Do not soak instruments that are
341. Avoid talking, coughing, sneezing, electroplated (not 100% stainless steel)
or reaching over a sterile field or object even in plain water because rusting will
342. Never walk away from or turn occur
your back on a sterile field 349. After decontamination,
343. Use dry, sterile forceps when instruments should be rinsed
necessary immediately with cool water to remove
344. All items brought into contact with visibly organic matter before thoroughly
broken skin or used to penetrate the skin cleaned.
in order to inject substances into the
350. Cleaning
body, or to enter normally sterile body
351. is the process that removes
cavities, should be sterile
345. Decontamination process contaminants including dust, soil, large

a. numbers of micro-organisms and organic

b. The process by which microbes matter (e.g., blood, vomit).

352. It is an essential prerequisite to
are passed from one infected disinfection and sterilization.
person, to cause infection in 353. It also removes the organic matter
another, is known as ‘cross- on which micro-organisms might
infection’. subsequently thrive. Soap - Clean water -
c. Cleaning, disinfection and Drying
sterilization are all procedures 354. •Wear all necessary PPE
that are used in the 355. •Keep the instruments being
decontamination process. washed under water
d. Decontamination reduces the risks 356. surface
of cross infection and helps to 357. •Use a soft brush
maintain the useful life of 358. •Do not use vim or steel wool
equipment. because these can
e. Cleaning, disinfection and 359. cause scratches that can harbor
sterilization microorganisms
346. Use a plastic container for 360. Methods of Sterilization
decontamination to prevent; a. Thermal (Physical) b.
a. Dulling sharps(scissors) due to Thermal (Physical) c. Boiling
contact with metal containers water d. Dry heat e.
b. Rusting of Instruments due to Chemical(Chemosterilizer) f.
chemical reactions (electrolysis) Chemical solutions g. Gas
that can occur between two h. Radiation (Physical) X-ray

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