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ARTERIAL WALL ELASTICITY- artery feels straight, smooth, soft & pliable
PRESENCE/ABSENCE OF BILATERAL EQUALITY- absence indicates CV disorder
Temporal pulse perfusion f face
Carotid pulse pulse during cardiac arrest; circulation in the brain
o Carotid massage stimulates vagal nerve decrease HR
Brachial pulse assess BP; cardiac arrest in infants; ABG specimen
Radial pulse normal routine; assessment pulse for adults; used in
checking pulse deficit; ABG specimen
Apical pulse children </= 3 yrs. Old and older adults; checking for pulse
deficit; cardio medicine drugs
Femoral pulse perfusion in the lower extremities; ABG specimen
Popliteal pulse perfusion of the lower leg; alternative site for BP taking
Posterior Tibial and Dorsalis Pedis perfusion of the foot
RESPIRATORY RATE
- Act of breathing
Pulse Rate
- represent stroke volume
PROCESSES:
1. Ventilation
- Inhalation/ inspiration 1.5 secs
- Exhalation 3 secs
2. Diffusion
3. Perfusion
Costal thoraxic muscle 7 years old
Diaphragmatic abdominal muscle
CHEST MOVEMENTS
1. INTERCOSTAL RETRACTION outline of the ribs; pneumonia
2. SUBSTERNAL RETRACTION under breast bone
3. SUPRASTERNAL RETRACTION above clavicle; ASTHMA
RESPIRATORY CENTERS
1. Medulla Oblongata primary
2. Pons contains:
- Pneumotaxic Center-responsible for rhythmic quality
- Apneustic Center- responsible for deep, prolonged inspiration
3. Carotid & Aortic bodies-contains peripheral chemoreceptors
4. Muscle & joints contains proprioreceptors
ASSESSMENT OF THE RESPIRATORY RATE
BLOOD PRESSURE
Medication Administration
Medications substance administered for diagnosis, cure, treatment, relief or
prevention of disease. AKA as drug
Prescription Name name given to a drug before it becomes official
Official Name name after which the drug is listed in one of the official
publications
Chemical Name- name that describes precisely the constituents of drugs
Brand name- name given to a drug by the manufacturer. AKA trademark.
Pharmacology study of effects of drugs on living organisms
Posology study of dosage or amount of drugs given in the treatment of
diseases
Types of Doctors Orders
Standing Order carried out until the specified period of time or until
discontinued by an order
Single Order carried out for only once
STAT Order carried out at once
Palliative relieves symptoms of disease but does not affect the disease itself
Curative treats the disease condition
Supportive sustains body functions until other treatment of the bodys
response can take over
Substitutive replaces body fluids / substances
Chemotherapeutic destroys malignant cells
Restorative returns/repairs body to health
Principles of Drug Administration
1. Observe the 7 Rights of drug administration.
-RIGHT drug,dose,time,route,patient, recording, approach
2. Practice asepsis.
3. Nurses administering medications are responsible for their own actions.
4. Be knowledgeable about the meds you administer.
5. Keep narcotics locked.
6. Use only medications that are clearly labeled.
7. Return liquid that are cloudy in color.
8. Identify patient correctly before administering medications.
9. Do not leave medications at the bedside.
10. The nurse who prepares the drug must be the one to administer it.
11. If patient vomits, report to nurse in charge or physician.
12. Preoperative meds are usually discontinued during postop unless ordered to
be continued.
13. When meds is omitted for any reason, record the fact & the reason.
14. When med error is made, report ASAP.
Routes of Drug Administration
I. ORAL
ADVANTAGES: most convenient, less expensive, safe & does not break the skin
barrier
DISADVANTAGES: inappropriate for those with nausea & vomiting, dysphagia,
reduced GIT motility, seriously ill
May give unpleasant odor/taste, discolor teeth, irritate gastric mucosa
Oral Drug Forms
1. SOLID tablet, capsule, pill, powder
2. LIQUID syrup, suspension, emulsion, elixir, milk, other alkaline substance
SYRUP-sugar-based
SUSPENSION-water-based
EMULSION- oil-based
ELIXIR- alcohol-based
- Never crush enteric-coated or sustained-release medication
II. SUBLINGUAL
- Drugs placed under the tongue
SITES: inner lower arm, upper chest & back, beneath the scapulae
INDICATIONS: for allergy & tuberculin testing & vaccinations
Needle at 10-15 degrees angle, bevel up
Inject over 3-5 sec to form a wheal/bleb
Do not massage the site
2. SUBCUTANEOUS
SITES: outer aspects of UA, anterior aspect of thighs, abdomen, scapular area of
the back, ventrogluteal & dorsogluteal areas
INDICATIONS: vaccines, preoperative meds, narcotics, insulin, heparin
Small doses only 0.5-1 ml & rotate sites
Use 5/8 needle for adults when given at 45 degrees (thin pts.), for 90 degrees
(obese pts)
Insulin Injection- do not massage & give at 90
3. INTRAMUSCULAR use 1 2 needle to reach the muscle layer
SITES: ventrogluteal, dorsogluteal (<3 y/o), vastus lateralis, rectus femoris,
deltoid, Z-track
4. INTRAVENOUS direct IV, IV push or infusion
- Most rapid route, predictable
INDICATIONS: pts with compromised GI function, rapid introduction of medications
TYPES OF IV FLUIDS:
A. Isotonic Solution- same concentration as body fluids (D5W, NaCl 0.9%, plain LR,
plain NM)
B. Hypotonic has lower concentration than body fluids (NaCl 0.3%)
C. Hypertonic has higher concentration than body fluids (D10W, D50W, D5LR,
D5NM)
Nursing Interventions:
1. Know the type, amount, indications of IV.
2. Inform client & explain purpose of IV therapy.
3. Prime IV tubing to expel air.
4. Change IV tubing every 72 hours.
5. Change /alter IV needle insertion site every 72 hours.
6. Regulate every 15-20 minutes.
7. Observe for complications.
mL
Gauge
Intradermal
1 mL
Subcutaneous
1 or 2 mL
25 -27
25
Intramuscular
1,2,3 or 5 mL p to 10
mL
Deltoid
Non -
deltoid
21-22
1.5 inch
length
- 5/ 8
3/8 5/8
23 -25
1 in
degree
Average = 45
degrees
Fat = 90 degress
Average = 90
degrees
Thin= 45 degrees
Complications of IV Infusion:
1. Infiltration needle out of vein, fluids accumulate in the subcutaneous tissues
S/S: pain, swelling, cold skin, pallor at site, IV rate decreases/stops, no backflow
NSG.INT: change IV site, apply warm compress
2. Circulatory Overload from administration of excessive volume of IV fluids
S/S: headache, flushed skin, increased PR,BP,RR, weight, SOB, syncope, cough,
increased venous pressure, pulmonary edema, shock
NSG. INT: slow IV infusion (KVO), high fowlers position, administer diuretic,
bronchodilator as ordered
3. Drug Overload excessive amount of drugs in the fluids
S/S: dizziness, fainting, shock
NSG. INT.: slow IV infusion (KVO), inform physician
4. Superficial Thrombophlebitis due to overuse of vein, irritating soln/drugs, clot
formation, large bore catheter
S/S: pain along the vein, vein feels hard & cordlike, edema & redness over site,
affected arm warmer than the other
NSG. INT: change IV site every 72H, use large veins for irritating fluids, stabilize
area, apply cold compress immediately then warm compress after
5. Air Embolism - air enters the system (at least 5 ml or more)
S/S: chest/shoulder/back pain, hypotension, dyspnea, tachycardia, cyanosis,
increases venous pressure, LOC
NSG.INT: do not allow bottle to run dry, prime tubings before starting IV, turn to
left side in Trendelenburg position
6. Nerve Damage due to overly tight tying of the splint
S/S: numbness of fingers/hands
NSG.INT: massage area & move shoulders thru ROM, open/close hands several
times each hour, PT if required
7. Speed Shock D/T rapid administration of IV fluids
NSG.INT: to avoid speed shock & cardiac arrest, give most IV push meds over 3-5
minutes
Blood Transfusion
4 objectives / Purpose
1) To replace circulating blood volume
BT REACTION
H- emolytic
A- llergic
P- yrogenic
C- irculatory overload
A- ir embolism
T- hrombo cytophenia
C- itrate intoxication
H- yperkalemia
MODES OF TRANSMISSION
- CONTACT TRANSMISSION direct/indirect
- DROPLET TRANSMISSION when MM are exposed to secretions of an infected
personwho is coughing, sneezing, laughing within 3 feet
- VEHICLE TRANSMISSION transfer by way of vehicles or contaminated items
(food, water, milk, utensils, pillows, mattress)
- AIRBORNE TRANSMISSION when fine particles are suspended in the air for a
long time & dispersed by air current then inhaled/deposited to a host
VECTOBORNE TRANSMISSION
- vectors can be biologic or mechanical
- Biologic animals (rats, snails, mosquitoes)
- Mechanical infected inanimate objects (contaminated needles/syringes)
PORTAL OF ENTRY
- permits organism to enter host
- Through body orifice such as mouth, nose, vagina, rectum OR breaks in the skin
or MM
SUSCEPTIBLE HOST
host is a person who is at risk for infection, whose body defense mechanism are
unable to withstand the invasion of the pathogen
TYPES OF IMMUNIZATION
ASEPTIC PRACTICES
1. HANDWASHING
Handwashing is the single most important infection control practice.
Handwashing for medical asepsis is done by holding hands lower than the
elbows
Use running water, soap & friction for 15-30 seconds each hand
Wash hands before and after client contact
2. CLEANING, DISINFECTION & STERILIZATION
Cleaning physical removal of dirt & debris by washing, dusting or mopping
Disinfection chemical or physical process to reduce number of potential
pathogens on a surface but not necessarily the spores
Sterilization complete destruction of all microorganisms including spores
METHODS OF STERILIZATION
STEAM STERILIZATION autoclaving uses supersaturated steam under
pressure
- non-toxic , inexpensive, sporicidal & penetrates fabric
- Color indicator strips change color to indicate sterilization
GAS STERILIZATION
ethylene oxide is colorless gas that can penetrate plastic, rubber, cotton or
other subs. Used for oxygen, suction gauges, BP apparatus, stethoscope, catheter
- Expensive & requires 2-5 hours
- Ethylene oxide is toxic to humans
RADIATION
- ionizing radiation penetrates deeply to objects
- Used for drugs, food & other heat-sensitive items
CHEMICALS are effective disinfectants
- Attacks all types of microorganisms rapidly, inexpensive & stable in light & heat.
Chlorine is used.
BOILING WATER least expensive, at least 15 minutes
3. USE OF BARRIERS
a. Masks
b. Gowns
CLASSIFICATIONS:
A. Standard Precautions
- Universal Precaution & Body-Substance Isolation
- Prevent transmission of bloodborne & moist body substance pathogens
1. Wear clean gloves
2. Perform handwashing
3. Wear masks, goggles, face shield if sprays/splashes are expected
4. Wear gown if soiling & splashes are expected
5. Remove soiled protective items immediately
6. Clean & reprocess all equipment
7. Discard all single-used items
8. Prevent injuries
9. Use private room or consult with Infection Control Department
B. Transmission-Based Precautions
1. AIRBORNE PRECAUTION
- for small-particle droplet that may remain suspended in the air & dispersed by
air current (varicella, TB, measles
-Private room, negative airflow, wear masks
2. DROPLET PRECAUTION
- for large-particle droplet & dispersed by air current (H. influenza, diphtheria,
rubella, mycoplasma pneumoniae)
- Private room, wear masks within 3 ft.
3. CONTACT PRECAUTION
- for those transferred by hand-or skin-to-skin contact (clostridium difficile,
shigella, impetigo)
- Private room, use gloves, gowns & other protective barriers when exposure to
infected material is likely
C. Protective Isolation
- prevent infection for people with compromised resistance (leukopenia,
undergoing chemoRx, extensive burns)
- Private room, restrict visitors, no fresh fruits/flowers, raw foods, potted plants
allowed, only cooked/canned foods allowed
5. SURGICAL ASEPSIS
PRINCIPLES:
a. Moisture causes contamination.
Wound Care
TYPES OF WOUNDS: According to contamination
1. Clean Wounds uninfected, minimal inflammation, closed
- respiratory, GIT & urinary tract are not entered
2. Clean-contaminated Wounds also surgical wounds, no infection
- respiratory, GIT & urinary tract entered
3. Contaminated Wounds- open, fresh, accidental wounds, with evidence of
inflammation
4. Dirty/Infected Wounds with dead tissue & evidence of infection
TYPES OF WOUND: According to cause
1. Incision
2. Contusion
3. Abrasion
4. Puncture
5. Laceration
6. Penetrating wound
TYPES OF WOUND HEALING
1. Primary Intention healing
2. Secondary Intention healing
PHASES OF WOUND HEALING
1. Inflammatory Phase immediate, 3-6 days
2. Proliferative Phase 3rd to 21 days
3. Maturation Phase 21 days to 2 years
STAGES OF PRESSURE ULCER FORMATION
Stage 1 non-blanchable erythema signaling potential ulceration
Stage 2 partial-thickness skin loss (abrasion, blister or shallow crater) involving
epidermis & dermis
Stage 3 full-thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down but not thru fascia. Deep crater.
Oxygenation
SUCTIONING
1. Assess indications for suctioning.
2. Position properly:
a. conscious: semi-fowlers
b. unconscious: lateral position
3. Apply proper pressure
4. Use appropriate size of catheter
Adult: Fr 12-18
Child: Fr 8-10
Infant: Fr 5-8
5. Don sterile gloves
6. Insert proper length of catheter
7. Lubricate catheter
8. Apply suction during withdrawal of catheter
9. Apply suction for 5-10 seconds (max 15)
10. Hyperventilate 100% before & after
11. Allow 20-30 sec interval between each suction
12. Provide oral & nasal hygiene
13. Dispose contaminated equipment/matls safely
14. Assess effectiveness / document
INCENTIVE SPIROMETRY
-Enhance deep inspiration
INTERMITTENT POSITIVE PRESSURE BREATHING
Administer oxygen at pressures higher than the atmospheric pressure
OXYGEN SYSTEMS
1. Low flow administration devices
2. High flow administration devices
ADMINISTRATION OF OXYGEN
Indications: hypoxemia
Signs of Hypoxemia:
- Restlessness
- Increased pulse rate
- Rapid, shallow breathing, DOB, nasal flaring
- Light headedness
- Substernal / intercostals retractions
- Cyanosis
ALTERATIONS IN RESPIRATORY FUNCTION
HYPOXIA
Insufficient oxygenation of tissues
CLINICAL SIGNS:
RHYTHM
CHEYNE-STOKES marked rhythmic waxing & waning of respirations from very
deep to very shallow and temporary apnea
KUSSMAULS (Hyperventilation) increased rate & depth of respiration
APNEUSTIC prolonged gasping inspiration followed by very short inefficient
expiration
BIOTS shallow breaths interrupted by apnea