UNIT ONE
THE NURSING PROCESS

NURSING PROCESS – is a method or steps for organizing and delivering nursing care
plan to achieve a specific goal.

COMPONENTS OF NURSING PROCESS

• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

ASSESSMENT

TYPES OF DATA

• Subjective data
• Objective data

SOURCE OF DATA

• Client
• Family
• Health care team members
• Medical Records
• Other records – education, records, employment records

METHODS OF DATA COLLECTION

• Interview
• Nursing Health History
• Physical examination
• Result of laboratory and diagnosis test









UNIT TWO
ASEPSIS

- the nurse follows certain principles and procedures to prevent infection and control its spreads
- clients with high susceptibility to infection require special precaution to prevent exposure to pathogens

INFECTION CYCLE

Infection – is a disease state that results from the presence of pathogens in or on the body
Pathogen – is a disease producing microorganism, infection occurs as a result of a cycle
process

6 components in the infection cycle

• Infectious agent
• Reservoir
• Means of Transmission
• Portal of entry
• Susceptible host

STAGES OF INFECTION

• Incubation period
• Prodromal stage
• Full stage of an illness
• Convalescence period

CONTROL OR ELIMINATION OF INFECTIOUS AGENTS

• Cleaning
• Disinfection
• Sterilization

Cleaning – is the removal of all foreign materials such as soil and organic material from
objects.

Disinfection – eliminates pathogenic organisms or inanimate objects except bacterial
spores.

Sterilization – is the process of complete elimination and destruction of ALL
microorganisms including spores and viruses.



METHODS OF STERILIZATION

1. Physical method

a. Steam
b. Boiling water
c. Dry heat
d. Radiation

2. Chemical method

a. Ethylene
b. Oxide gas
c. Chemical solutions

PROTECTION FOR PERSONNEL

1. Gowns
2. Mask
3. Gloves
4. Protective eyewear
























UNIT THREE
VITAL SIGNS

VITAL SIGNS (Temperature, Pulse, Respiration, Blood pressure)

1. Measurement of vital signs provides data that can be used to determine a clients usual state of health, an alteration from normal may signal the need for medical or nursing intervention.
2. Vital signs are quick and efficient way of monitoring a condition or identify the presence of problems.

WHEN TO TAKE VITAL SIGNS

a. on the client admission to a health care facility
b. in a hospital on a routine schedule according to a physicians order or hospital policy
c. before and after surgical procedure
d. before and after an invasive diagnostic procedure
e. before and after administration of certain medication that affect cardiovascular, respiratory and temperature control functions.

A. BODY TEMPERATURE

 TEMPERATURE – is the hotness and coldness of a substance.

 THERMOMETER – register the body’s core temperature.

1. HYPERTHERMIA – when the body’s core temperature is HIGH or
RISES ABOVE NORMAL.

2. HYPOTHERMIA – when the body’s core temperature is LOW or
FALLS BELOW NORMAL.

TYPES OF THERMOMETER

• Mercury in glass
• Disposable
• Electronic
• Tympanic






SITES IN TAKING TEMPERATURE

1. The mouth
2. The rectum
3. The axillae
4. Tympanic
5. Forehead

NOTE :
The nurse has to wait 20 to 30 minutes after a client ingested hot or cold liquids or food or has been smoking or has been involved in strenuous exercise before temperature can be checked.

AVERAGE NORMAL TEMPERATURE FOR HEALTHY ADULTS AT A VARIOUS SITES:

ORAL - 37.0 ˚C
RECTAL - 37.5 ˚C
AXILLARY - 36.5 ˚C
TYMPANIC - 34.5 ˚C

FORMULAS IN CONVERTING TEMPERATURES:

FAHRENHEIT TO CELSIUS / CENTIGRADE

C = (F – 32) x 5/9

CELSIUS / CENTIGRADE TO FAHRENHEIT

F = (9/5 x C) + 32


B. PULSE

Is the palpable bounding of blood flow noted at various points in the body.


ASSESSMENT OF PULSE

• The radial and carotid arteries are the most accessible peripheral pulse sites for assessment.
• The radial pulses are the most common sites for assessment of vital signs.




OTHER PERIPHERAL PULSES

1. Temporal
2. Carotid
3. Brachial
4. Apical
5. Radial
6. Femoral
7. Popletial
8. Dorsalis pedis
9. Posterior tibial

• The apical pulses are the best sites for assessing an infant or young child pulse.
• If the pulse is not easily located on one side the other side can be tried.
• If the nurse is unable to palpate a pulse, a Doppler electronic stethoscope can be used.
• The nurse calculate the number of pulsation that would occur in 60 seconds. If a pulse is irregular an accurate measurement is made by counting for a full minute.
• The nurse may assess common variation in the heart rate;

TACHYCARDIA – is an abnormal elevated heat rate above 100/minute.
BRADYCARDIA – is a rate below 60/minute.

C. RESPIRATION

Human survival depends on the ability of OXYGEN (O2) to reach body cells and for
CARBON DIOXIDE (CO2) to be removed from the cells.

RESPIRATION INVOLVES TWO (2) DISTINCTLY DIFFERENT PROCESS:

1. EXTERNAL RESPIRATION – the movement of air between environment
and lungs.
2. INTERNAL RESPIRATION – the movement of oxygen between
Hemoglobin and cells.

TERMINOLOGIES IN THE ASSESSMENT OF RESPIRATION

TACHYPNEA - respiratory rate more than 20
BRADYPNEA - respiratory rate lower than 10
APNEA - is the ABSENCE OF BREATHING
DYSPNEA - difficulty in breathing
CYANOTIC - bluish color of nailbeds, lips, and skin due to REDUCED
ARTERIAL OXYGEN (O2) LEVEL





D. BLOOD PRESSURE

The force exerted by the blood against a vessel wall.
The standard unit for measuring blood pressure is millimeters of mercury (mmHg).
During a normal cardiac cycle blood pressure reaches the peak that is followed by trough:
SYSTOLE – the peak or maximum pressure occur, the left ventricle pumps
blood to the aorta.

DIASTOLE – the trough occurs, the ventricle relaxes.

The nurse records blood pressure with the systolic reading before the diastolic.
(ex. 120/80)

FACTORS INFLUENCING BLOOD PRESSURE
1. Age
2. Stress
3. Race
4. Medication
5. Diurnal variation

ABNORMALITIES IN BLOOD PRESSURE

HYPERTENSION – an average of two or more diastolic readings on at least
subsequent visits is 90 mmHg or average of two or more systolic readings on at least two visits is higher than
140 mmHg.

HYPOTENSION – the systolic BP falls to 90 mmHg or below.

EQUIPMETS:

SPHYGMOMAOMETER – Mercury or Anaroid
STETHTOSCOPE
NORMAL VALUE OF VITAL SIGNS ACCORDING TO AGE


AGE

PULSE / minute
RESPIRATION / minute

BLOOD PRESSURE
-New born 80 – 180 30 – 80 73/55 mmHg
1-3 year old 80 – 140 20 – 40 90/55 mmHg
6-8 year old 75 – 120 15 – 25 95/57 mmHg
12-21 year old 60 – 100 15 – 20 100/80 mmHg
Adult 60 – 100 12 – 20 120/80 mmHg
UNIT FOUR
PHYSICAL HEALTH ASSESSMENT AND GENERAL SURVEY


TWO COMPONENTS OF HEALTH ASSESSMENT

a. Health History
b. Physical assessment


A. HEALTH HISTORY

Is a collection of subjective and objective data that provides a detailed profile of the patient. Information collected during an interview.

B. PHYSICAL ASSESSMENT TECHNIQUES

a. Inspection
b. Auscultation
c. Palpation
d. Percussion

C. EQUIPMENT USE IN PHYSICAL ASSESSMENT

a. Ophthalmoscope
b. Otoscope
c. Snellen chart
d. Nasal speculum
e. Vaginal speculum
f. Tuning fork
g. Percussion hammer (reflex hammer)

D. POSITIONING

• Sitting position
• Supine position
• Dorsal Recumbent position
• Sims position
• Prone position
• Lithotomy position
• Knee-chest position
• Standing position



COMPONENTS OF PHYSICAL ASSESSMENT

1. Vital signs
2. Height and weight
3. General appearance – gender, nutritional status, mental alertness,
evidence of pain, body position, age, hygiene and grooming.
4. Integumentary system

Inspect for color

Erythema – redness of the skin
Cyanosis – bluish discoloration of the skin
Jaundice – yellow color of the skin
Pallor – resulting from inadequate amount of circulating
blood or hemoglobin.

Inspect for vascularity (bleeding and bruising)

Echymosis – collection of blood in subcutaneous tissue.
Petechiae – small hemorrhagic spots caused by capillary
bleeding.
Lesions – areas of diseased or injured tissues.

5. Hair and scalp

Assess the hair for color, texture, and distribution
Inspect the scalp for color, dryness, lesion, or lice
Palpate for any mass, note the location, size, tenderness and mobility

6. Head and Neck

Skull – inspect the size and shape and palpate for any abnormality

Face – assess for color, symmetry and distribution of facial hair, facial nerve and
facial muscles, and any abnormal finding should be noted and document

Eyes – assessment includes external and internal eye structure, visual acuity, extra
ocular movements, and peripheral visions

External eye structure includes:
• Eyebrows
• Eyelids
• Eyelashes
• Lacrimal gland
• Pupil and iris
Internal eye structure includes:
• Retina
• Optic nerve
• Macula and retinal vessels (assess it with the use of
ophthalmoscope)

Ears (external ear, middle ear, and inner ear)

External ear – inspect for the shape, size and lesion, palpate gently each
ear auricle for pain

Middle ear – with the use of Otoscope assess the ear canal and tympanic
membrane

Inner ear – assess one ear at a time by determining whether the patient
can hear a whispered voice.

Nose and Sinuses

Inspect the nose for shape, size, location and nasal patency by occluding one nostril at a time.

The mucus membrane are examined from color and presence of
exudates.

The frontal and maxillary sinuses are examined for pain and edema.

Mouth and Pharynx

Inspect the lips, gums, teeth, tongue and soft palate and check for
abnormality.

Check for any inflammation, exudates, or masses in the pharynx and note
any absence or presence, size, ulceration, exudates or inflammation in the tonsils.

Neck

Assess muscle symmetry and range of motion.

Note any masses, unusual edema or pulsations.

Observe for enlargement of thyroid area.




7. Thorax and Lungs

Observe for chest color, shape, breathing patterns and muscle development

Palpate the ribs and costal margins for symmetry, mobility and tenderness, palpate the spine for tenderness and vertebral position

Auscultation is used to detect airflow within the respiratory tract.

8. Cardiovascular and Peripheral Vascular System

Heart – observe for visible pulsations, palpate for presence of pulsations and
auscultate to determine the heart sound.

The first heart sound which is heard as “lub” occurs as a result of closure of mitral and tricuspid valve heard over apical area.

The second heart sound which is “dub” is a result of closure of aortic and pulmonary valves.

Peripheral Vascular system – measuring blood pressure and assessing
peripheral pulses and perfusion. Palpate
peripheral pulses.

9. Breast and Axillae

Inspect the areola for size and shape and the nipples for discharge, palpate to detect any abnormal mass or lumps, nipples and areola are palpated also.

10. Abdomen Cavity (stomach, small intestines, large intestines, liver, and gall bladder, pancreas, spleen, kidney, urinary bladder, and reproductive system)

Inspect the abdomen for skin color and surface characteristic including the umbilicus contour, peristalsis, pulsation and masses.

Auscultate abdominal sounds and note for frequency and character.

Palpate for abdominal spasm and pain.

11. Musculoskeletal system

The muscle are examined by inspection and palpitation of muscle groups and by muscles tone.

Bones are palpated for normal contour and prominence as well as bilateral symmetry, joints are assess for full range of motion and palpated for swelling and tenderness.

12. Neurological System ( cerebral function, cranial nerve function, cerebral function, motor and sensory function and reflexes)

Mental Status Assessment

• Orientation (ask for time, place and person)
• Level of consciousness – is the degree of wakefulness

Level of consciousness is described as follows:
1. Awake and alert – fully oriented, responding to commands
2. Lethargic – appears drowsy or sleepy most of the time respond to
gentle shaking.
3. Stuporous – is unconscious most of the time, respond to painful
stimuli.
4. Comatose – not responding to painful stimuli.

• Motor Function
a. Balance and gait
b. Motor function and coordination
c. Sensory function
d. Reflex function
- babinski’s reflex
- biceps reflex



















UNIT FIVE
MEDICATION ADMINISTRATION

Drug or Medication – is any substance that modifies body function when taken into the
body.

Pharmacology – the study that deals with chemicals that affects the body’s functions.

Pharmacist – a person licensed to prepare and dispense drugs.

Physician – is legally responsible for prescribing medication.

Pharmacokinetics – the study of the movement of drug molecules in the body in relation
to the drugs absorption, distribution, metabolism and excretion.

DIFFERENT DRUG NAMES

A. Chemical Name
B. Generic Name
C. Trade Name

TYPES OF PREPARATION

a. Oral
b. Topical
c. Injectibles
d. Suppository – an easily melted medication preparation in a firm base (gelatin)
that is inserted into the body (rectal, vaginal).

ORAL PREPARATION

1. Capsule
2. Tablet
3. Syrup
4. Suspension

TOPICAL PREPARATION

1. Lotion
2. Ointment

INJECTIBLE PREPARATION

1. Solution
2. Powder

ABSORPTION – is the process by which a drug is transferred from its site of entry in to
the body to the blood stream.

DRUG ABSORPTION DEPENDS ON:
• Route of administration
• Drug solubility
• pH
• Local condition of the site of administration

DISTRIBUTION – after the drug has been absorbed into the blood stream, it is
distributed throughout the body.

METABOLISM – is the breakdown of the drug to an active form. The liver is the
primary site for drug metabolism.

EXCRETION – most drugs are excreted by the kidneys and some are excreted by the
lungs or the intestine.

FACTORS AFFECTING DRUG ACTION

1. Developmental consideration
2. Weight
3. Sex
4. Psychological factors
5. Timing of administration

ADVERSE EFECTS – side effects occur as a result of analgesics, sedatives, antibiotics
and antipsychotics.

Nurse must be aware and alert for drug interaction and effect of
drug therapy.

PARTS OF THE MEDICATION ORDER

• Patients name
• Date and Time
• Name of Drug
• Dosage of the Drug
• Route by which the drug to be administered
• Frequency of administration
• Signature of the person who writes the order





DOSAGE AND CALCULATION


CONVERTING DOSAGES

1000 milliliters (mL) = 1 Liter (L)
1000 cubic centimeter (cc) = 1 Liter
1 milliliter (mL) = 1 cubic centimeter (cc)
1000 milligrams (mg) = 1 gram (g)
1000 grams (g) = 1 kilogram (kg) = 2.2 pounds (lb)
60 drops (gtts) = 1 teaspoon (tsp or t)
3 teaspoons (tsp) = 1 tablespoon (Tbs or T)
5 mL = 1 tsp
15 mL = 1 Tbs
180 mL = 1 full teacup


COMPUTING DRUG DOSAGE

FORMULA:

Dose desired
_______________ x Quantity on Hand = Desired Quantity

Dose on Hand


SAFETY MEASURES WHILE PREPARING DRUGS

- Three checks – the label of medication should be checked three times (3x).
• When the nurse reaches for the container
• Immediately before opening the medication
• When replacing the container o the drawer or shelf before giving the unit dose

- The 6 Rights

• RIGHT Medication
• RIGHT Patient
• RIGHT Dosage
• RIGHT Time
• RIGHT Route
• RIGHT Documentation




- Maintain safe environment
• Good light and avoid distractions while preparing drugs
• Use of aseptic technique
• The nurse who prepare the drug is also the one who administer it
• Keep recording and documentation as soon as possible.

- Identify the Patient
• Before administering the meds, the nurse check carefully the right drug is given to the right patient.

MEDICAL ABBREVIATIONS USED IN MEDICATION ADMINISTRATION

• OD - once a day
• b.i.d - 2x a day
• t.i.d - 3x a day
• q.i.d - 4x a day
• P.R.N. - if necessary
• Stat - immediately
• a.c - before meal
• p.c - after meal
• P.O. - per orem (orally)
• SL - sublingual
• IM - intramuscular
• IV - intravenous
• SC - subcutaneous
• cap. - capsule
• Tab. - Tablet
• sup./supp. - suppository
• syp. - syrup
• Rx - treatment
• NPO - nothing per orem
• gtts - drops

NURSING RESPONSIBILITIES FOR ADMINISTERING DRUGS

A. Assessment of the patient and clear understanding of why the patient is receiving a particular drug
B. Preparing the medication to be administer
C. Accurate dosage calculations
D. Administration of the medication
E. Documentation of medication given
F. Monitoring the patients reaction and evaluate the patients response
G. Educating the patient regarding his/her medication and medication regimen.



ADMINISTERING ORAL MEDICATION

1. ORAL ROUTE – is the most common route of administration. The most
convenient, comfortable and safe route.

2 forms of oral medication
1. solid preparation
2. liquid preparation

Important points to remember
a. a medication should never be given from a bottle without a label or the
label is difficult to read
b. care should be taken while pouring to prevent unnecessary loss
c. a medication should not be used if its color has changed

2. SUBLINGUAL ROUTE – the tablet or capsule is place under the patients
tongue. This area is rich in blood supply which allows the drug to be absorbed rapidly.

ADMINISTERING INJECTION MEDICATIONS

A. TYPES OF INJECTIBLE MEDS
a. Ampoules
b. Vials
c. Prefilled Cartridges

B. MIXING MEDICATION IN ONE SYRINGE
1. The meds in the vial is prepared first then the meds in the ampoules is drawn up.
2. When mixing meds the nurse must be aware of drug incompatibilities, certain drugs are incompatible with other drugs in the same syringe.

Points to remember:
1. Incompatible drugs may become cloudy or form a precipitate in the syringe
2. Discard cloudy drugs and prepared in separate syringes
3. Mixing more than 2 drugs in one syringe is not recommended.

C. INTRADERMAL MEDICATION

D. SUBCUTANEOUS MEDICATION


E. INTRAMUSCULAR MEDICATION

• IM route is given at 90 degree angle
• Maximum amount to be given in one site for adults is 4 mL only



DIFFERENT IM SITES
• Ventrogluteal site
• Vastus Lateralis site
• Deltoid Muscle site
• Dorsogluteal site

POINTS TO REMEMBER IN GIVING IM INJECTIONS

• Use Z-track technique when giving IM injection
• Be sure the needle is free of medication that may irritate superficial tissues as the needle is inserted
• Inject the drug into the relaxed muscle
• Insert the needle with a dart like motion without hesitation and remove it quickly at the same angle at which it was inserted
• Do not inject areas that feel hard on palpation or tender to touch
• Inject solution slowly so that it may disperse more easily into the surrounding tissues
• Apply gentle pressure after injection unless this technique is contraindicated
• Rotate the site when the patient is to receive repeated injection

F. INTRAVENOUS MEDICATION
• The most dangerous route of administration because the drug is placed directly into the bloodstream
• Used in most emergency situations when immediate absorption is required

SEVERAL WAYS TOADMINISTER IV MEDS
1. Medicines may be added to the patients infusion solution
2. Medicines administered as IV bolus or push
3. Medicines administered by intermittent IV infusion

CALCULATING IV INFUSION

FORMULA:

Solution Amount in mL x Dropping Factor
___________________________________________ = Drops/minute

Time in minutes

G. TOPICAL MEDICATION

SKIN APPLICATION – skin is chemical or mechanical barrier that protect the
underlying tissues.
TYPES OF PREPARATION APPLIED TO THE SKIN AREA

• Powders
• Ointments
• Creams and oils
• Lotions
• Transdermal route

H. INHALATION MEDICATION
I. DOCUMENTING MEDICATION ADMINISTRATION