Procedure:

MEDICAL COLLEGES OF NORTHERN PHILIPPINES PERCUSSION

FUNDAMENTALS OF NURSING - “clapping”
SEMI-FINAL COVERAGE - forceful striking of the back with cupped hands to
mechanically dislodge tenacious secretions
INTERVENTIONS TO IMPROVE:
 OXYGENATION
 NUTRITION
 ELIMINATION
 ACTIVITY AND EXERCISE
 SLEEP AND COMFORT
 HYGIENE
 SAFETY AND COMFORT

 OXYGENATION VIBRATION
- vigorous quivering produced by hands that are
-Respiratory system replenishes the body’s oxygen supply placed flat against chest wall or back to loosen
and eliminates waste (CO2) secretions

Overview of the Anatomy and Physiology of Respiratory

System

A. Upper Airways
- Nasal cavity
- Pharynx
- Larynx
Functions:
-Transport gases to lower airways
- Protects lower airways POSTURAL DRAINAGE
- Warming, filtration and humidification of air - expulsion of secretions from various lung
B. Lower Airways segments by gravity.
- trachea - involves positioning based on the location of
- Bronchi secretions
- Pleura - each position is maintained for 10-15 mins
- Lungs
Functions:
- clearance mechanism (coughing)
- immunologic response
- exchange of gases
Respiratory Centers: medulla and pons

MEASURES TO PROMOTE ADEQUATE RESPIRATORY

FUNCTION

1. Man requires 21% of oxygen from the environment. The

higher the altitude, the lower the oxygen concentration
2. Deep breathing and coughing exercises (DBCE) to
promote lung expansion and loosen mucous secretions.
PROCEDURE: inhale deeply through the nose, hold breath
for few seconds and exhale through mouth slowly. On the
third breath, hold breath and cough to expectorate Nursing considerations during CPT:
secretions - the entire procedure should last for 30 minutes
3. Positioning. Semi-Fowler’s or high-fowler’s position only
promotes maximum lung expansion. By gravity, the - do gradual change in position to prevent
diaphragm moves down and abdominal organs do not exhaustion and postural hypotension
compress the diaphragm. - administer bronchodilator as ordered before CPT
4. Maintain a patent airway to promote adequate gaseous - Best done in the morning upon waking up, before
exchange. meals and before bedtime
Causes of Airway Obstruction: - offer oral hygiene after the procedure
- tongue - Contraindicated in patients with:
- mucous secretions - increased ICP
- edema of the airways - active bleeding
- spasm of airways - hemoptysis
- foreign bodies (aspiration) - head and neck injury
5. Maintain adequate hydration to maintain moisture of the 8. BRONCHIAL HYGIENE
mucous membrane. This is to liquefy retained secretions. MEASURES
Intake should be atleast 8 glasses a day. STEAM INHALATION
6. Avoid environmental pollutants such as alcohol and
smoking. These factors inhibit mucociliary function - to liquefy
7. Perform Chest Physiotherapy secretions
 - to warm and humidify inspired air - oxygen hood
- to relieve edema of the airways - Isolette
- to soothe irritated airways (see attached document for detailed discussion)
- to administer medications
- dependent nursing fxn Nursing considerations:
- Inform client and explain the procedure - assess signs of hypoxemia
- Position: SF or HF - verify DO
- Cover eyes with washcloth - Position: SF or HF
- place spout 12-18 inches away from the client - Regulate O2 flow accurately
- WOF first degree burns -Place a NO SMOKING sign at the bedside
- render therapy for 15-20 minutes (oxygen supports combustion)
- instruct pt to do DBCE post procedure - avoid oil, greases, alcohol near the client
- provide oral hygiene - avoid materials that generate static electricity such as
9. SUCTIONING wool blankets. Use cotton blankets instead
- humidify oxygen by placing sterile water in the O2
humidifier
- provide oral hygiene to prevent dryness of mucous
membrane
-assess effectiveness of O2 therapy by checking VS
especially RR

ALTERATION IN RESPIRATORY FUNCTION

HYPOXIA
- to clear airways from secretions - insufficient oxygenation of tissues
Procedure:
- assess indications for suctioning (audible EARLY SIGNS LATE SIGNS
secretions during respiration and adventitious breath - tachycardia - Bradycardia
sounds upon auscultation) - Increased RR -Dyspnea
- Position: For conscious pts: SF -Slight increase in SBP - decrease SBP
Unconscious pts: Lateral -Cough
- Identify proper pressure on the suction machine/ -Hemoptysis
identify appropriate catheter size
GROUP PORTABLE WALL SIZE (Fr) Other signs of Acute Other signs of Acute
ADULT 10-15 mmHg 100-120 12-18 Hypoxia: Hypoxia:
CHILD 5-10 mmHg 95-110 8-10
INFANT 2-5 mmHg 50-95 5-8 - N&V - fatigue, lethargy
- don sterile gloves to prevent introduction of -Oliguria, anuria -polycythemia
microorganisms -headache -increased Hgb
- lubricate catheter using a water soluble lubricant/ -apathy concentration
sterile water -dizziness - clubbing of finger
- apply suction during withdrawal of the suction -irritability
catheter to prevent trauma to the mucous membranes -memory loss
- apply suction for 5-10 seconds, with 20-30 second
interval in between suctions Altered Breathing Patterns:
- hyperoxygenate pt before and after suctioning to Tachypnea
prevent hypoxia Bradynea
- provide oral and nasal hygiene Apnea
- assess effectiveness of suctioning

10. Incentive spirometry to enhance deep inspiration and to

prevent atelectasis
11. Administer supplemental oxygen
- indication: HYPOXEMIA
Signs of hypoxemia:
- restlessness
- increased PR
- rapid, shallow respiration
- dyspnea
- light-headedness
- flaring of nares
- intercostal retractions
- cyanosis
OXYGEN DELIVERY SYSTEMS
1. LOW FLOW DEVICES
- Nasal cannula (24-45% at 2-6 LPM)
- Simple Face mask (40-60% @ 5-8 LPm)
- Partial Rebreather (60-90% @ 6-10 LPM)
-Non rebreather (95-100% @ 6-15 LPm)
2. HIGH FLOW DEVICES Volume:
- venturi mask ( for patients with COPD) HYPERVENTILATION
- excessive amount of air in the lungs
-results from deep, rapid respirations 2. POTASSIUM
HYPOVENTILATION -promotes fluid and electrolyte balance
- decreased rate and depth of respiration -major cation in the intracellular fluid
-causes retention of carbon dioxide -affects muscular and cardiac activities
Hypokalemia: loss of K; manifested by apathy,
Rhythm muscular weakness, mental confusion, abdominal
CHEYNE-STOKES distention, nausea, lack of appetite, nervous irritability,
-waxing and waning respirations (very deep to shallow dysrhythmias
breathing with episodes of apnea) Hyperkalemia: excess K; weakened cardiac
KUSSMAUL’S RESP contraction, mental confusion, numbness of extremities
-increased rate and depth of respiration SOURCES: Banana, Avocado, Oranges, Strawberries,
APNEUSTIC Cantaloupe, Raisins, Raw tomatoes, Carrots, Mushroom,
- prolonged gasping inspiration followed by a very short, Pork, Beef, Fish
usually inefficient expiration
BIOT’S 3. SODIUM
- shallow breaths interrupted by apnea -maintains fluid balance
-major extracellular cation
 NUTRITION -maintain acid-base balance
- study of nutrients and the processes by which they are -allows passage of glucose through the cell wall
used by the body -maintains normal muscle excitability

TERMINOLOGIES: 4. IRON
DIGESTION - most abundant trace element
-process by which food is broken down for the body to -constituent of hemoglobin and myoglobin necessary in
use in growth, development, healing and prevention of maintaining adequate oxygenation in the blood
diseases - contributes to antibody formation, collagen synthesis
ABSORPTION SOURCES: pork liver, organ meats, enriched rice,
-process by which digested CHO, CHON, fats, minerals kamote leaves, soybeans, sea weeds, clams,
and vitamins are actively and passively transported into malunggay, ampalaya leaves, peanuts, pechay, sitaw
organs and tissues leaves, eggs
METABOLISM -Iron deficiency leads to anemia
-process by which nutrients are converted to energy to -excess Fe leads to hemosiderosis
support cellular growth and repair
5. IODINE
(PLS REVIEW ANATOMY AND PHYSIOLOGY OF GIT) -synthesis of thyroxine (thyroid gland)
-Cretinism: congenital disorder due to decrease Iodine
MACRONUTRIENTS: CHO,CHON, FAT during pregnancy
MICRONUTRIENTS: VITAMINS AND MINERALS -Hypothyroidism/Hyperthyroidism
SOURCES: iodized salt, seafood, milk, eggs, bread
CALORIE (KILOCALORIE)
- 1 g (CHO) - 4 CAL ASSESSMENT OF NUTRITIONAL STATUS
- 1 G (CHON) - 4 CAL
- 1 G (FAT) - 9 CAL  ANTHROPOMETRIC MEASUREMENTS
-height
Variable affecting Caloric Needs -weight (best indicator of nutritional status)
1. Age and growth -Skin folds (Fat folds)
2. Gender (higher BMR in males) -Arm Muscle circumference
3. Climate (cold=higher BMR) -BMI = wt in kg / (ht in meter)2
4. Sleep (lower BMR) -
BMI result:
5. Activity 20-25%- Normal
6. Fever 27.5-30%- mild obesity
7. Illness 30-40%- moderate obesity
Above 40%- severe obesity
Food and Fluid Regulatory Center: HYPOTHALAMUS
 Biochemical data
(SEE ATTACHED DOCUMENT FOR LIST OF - Hgb and Hct indices
VITAMINS ) -Serum Albumin
-Nitrogen Balance
MINERALS -Creatinine Excretion

1. CALCIUM  Clinical signs

- necessary for bone and teeth formation
-promotes muscular contraction
- promotes blood coagulation
- activates other enzymes for biological reactions
- deficiency: rickets, osteomalacia, tetany
- excess: calcium rigor (tonic contraction)
SOURCES: milk and dairy prod, greean and leafy
vegetables, whole grains, nuts, legumes, carrots, seafood,
tofu
- hair, skin, tongue, mucous membrane, abdominal
girth
 Dietary History
- 24 hr diet recall; 72 hr diet recall
MEASURES TO STIMULATE APPETITE
1. Serve food in pleasant and attractive manner
2. Place patient in a comfortable position (SF/HF to prevent
aspiration) A. NASOGASTRIC TUBE
3. Provide good oral hygiene measures - commonly used tube: LEVIN TUBE
4. Promote comfort Purposes:
5. Remember that color affects color -to provide feeding (gastric gavage)
6. Engage in pleasant conversation -to irrigate stomach (gastric lavage)
7. Assist weak patient in feeding -For decompression
-administration of meds
NURSING INTERVENTIONS FOR NAUSEA AND -administer supplemental fluid
VOMITING
1. Position conscious clients in SF or HF position; Insertion procedure:
unconscious patients in lateral position to prevent aspiration 1. Inform pt and explain procedure
2. Provide good oral hygiene measures 2. Place in HF position to facilitate insertion
3. Suction the mouth as needed if the client is unable to 3. Measure length of tube to be inserted starting from
expel vomitus the tip of the nose to the tip of the earlobe, to the
4. Relieve nausea by offering the client: xiphoid process)
- ice chips 4. Lubricate tip of catheter with water-soluble lubricant
- hot tea with lemon/ lime to reduce friction. Oil based lubricant may cause lipid
- hot ginger ale pneumonia
- dry toast or crackers 5. Hyperextend the neck and gently advance the
- cold cola beverage catheter toward the nasopharynx
5. Replace loss fluid by hydration and IV therapy 6. Tilt the patient’s head forward once the tube reaches
6. Observe for potential complications: the oropharynx (throat)and ask the patient to swallow
a. DEHYDRATION or sip fluid as tube is advanced.
- Thirst (first sign) 7. Secure the NGT by taping it to the bridge of the nose
- dry mouth and mucous membrane after checking the tube’s placement
- warm, flushed, dry skin
- fever, tachycardia, low bp
- weight loss
- sunken eyeballs
- oliguria
- dark, concentrated urine
- high urine SG
- poor skin turgor
- altered LOC
- elevated BUN, Crea
-elevated Hct
b. Acid-base balance
Metabolic Alkalosis: excessive vomiting
Metabolic Acidosis: excessive diarrhea
7. Administer antiemetic as ordered by the physician for
vomiting Administering Tube Feeding (gastric gavage)
Metoclopramide (Plasil) 1. Position pt in SF
Trimethobenzamide (Tigan) 2. Assess tube placement and patency
Promethazine (Phenergan) - introduce 5-20 ml of air into NGT and auscultate
Prochlorperazine maleate (Compazine) at the epigastric area. Gurgling sound indicates patency
-aspirate gastric content (yellowish/greenish)
SPECIAL DIETS -immerse tip of the tube in water, no bubbles
should be produced
1. CLEAR FLUIDS -measure pH of aspirated fluid (acid)
-include only liquids that lack residue Note: the most effective method of checking the NGT
Ex: water lemonade placement is radiograph verification.
Bouillon coffee/tea without dairy 3. Assess residual feeding contents. To assess
Clear broth hard candy absorption of the last feeding, should be less than 50ml
Gelatin carbonated beverage 4. Introduce feeding slowly to prevent flatulence,
Popsicles cramping and vomiting
5. Height of tube should be 12 inches above insertion
2. FULL LIQUID point.
- includes all fluids and food that become liquid at 6. Instill 30-60 ml of water into the NGT after feeding to
room temperature; with residue cleanse the lumen of the tube
Ex: plain ice cream strained soup 7. Clamp the NGT to prevent entry of air into the
Sherbet strained vegetable juices stomach
Milk 8. Maintain Fowler’s position for atleast 30 mins to
Pudding/custard prevent aspiration.
9. Document
3. SOFT DIET
- soft food with reduced fiber content which require BOWEL AND BLADDER ELIMINATION
less energy for digestion (puree, chopped meat, mashed
potato, scrambled egg, porridge)  Defecation
Related Nursing procedures - expulsion of feces from the rectum
Alternative Feeding Methods
Characteristics of Stool - subjective feeling of abdominal fullness or
 Color: yellow or golden brown (due to bile pigment) bloating
 Odor: aromatic upon defecation - apparent abdominal distension
 Amount: depends on the bulk of the food intake (150- - N&V
300 g/day) MNGT:
 Consistency: soft, formed - manual extraction or fecal disimpaction as
 Shape: cylindrical ordered
 Frequency: variable; usual range 1-2 per day to 1 every - Increase OFI
2-3 days - Sufficient bulk in the diet
- Adequate activity and exercise
 Alteration on the characteristics of Stool
3. DIARRHEA
Alcoholic Stool - frequent evacuation of watery stool due to
- gray, pale or clay colored stool due to absence of increased gastric motility
stercobilin caused by biliary obstruction MNGT:
Hematochezia - replace fluid and electrolyte losses
-passage of stool with bright red blood due to lower GI - provide good perianal care. Diarrheal stool is
bleeding oftentimes acidic and can cause soreness and irritation
Melena in the area
-passage of black,tarry stool due to UGIB - promote rest
Steatorrhea -eat small amount of bland food
-greasy, bulky, foul-smelling stool due to undigested -low fiber diet
fats like in hepato-biliary obstructions -BRAT diet (Banana, Rice Am, Apple, Toast)
-avoid excessively hot or cold fluid
Common Fecal Elimination Problems -increase intake of K-rich food
-administer antidiarrheal drugs as ordered
1. CONSTIPATION - Demulcents: mechanically coat the irritated
- passage of small, dry, hard stools bowel and act as protectives
Nursing interventions: - Absorbents: absorbs gas or toxic substances
-increase OFI (1500-2000 ml/day) from the bowel
-increase fiber intake to provide bulk of the stool - Astringents: shrink swollen or inflamed
(fresh or cooked fruits and vegetables, whole grain, tissues in the bowel
breads and cereals, fruit and vegetable juices)
- establish regular pattern of defecation Note: Do not administer antidiarrheal at the start of
-respond stat to urge to defecate diarrhea as it is the body’s protective mechanism to get
-minimize stress. SNS activation decreases rid of toxins or bacteria
peristalsis
- maintain exercise to promote muscle tone and 4. FLATULENCE
stimulate peristalsis - presence of excessive gas in the intestines
- assume sitting or semi-squatting position. Allows Common causes:
gravity to assist the elimination of feces and easier - constipation
contraction of abdominal and pelvic muscles -codein, barbiturates and other meds that
-administer laxatives as ordered decrease intestinal motility
-anxiety
TYPES OF LAXATIVES -eating gas forming food (cabbage, onions,
1. CHEMICAL IRRITANTS rootcrops, legumes)
-provide chemical stimulation to intestinal wall thereby -rapid food or fluid ingestion
increasing peristalsis. Ex. Dulcolax (Bisacodyl), castor oil, -excessive drinking of carbonated drinks
Senokot (Senna) -gum chewing, candy sucking, smoking
2. STOOL LUBRICANT -abdominal surgery
- lubricates feces and facilitates expulsion (mineral oil) MNGT:
3. STOOL SOFTENERS -avoid gas forming food
- Na Docussate -provide warm liquids to drink to increase peristalsis
4. BULK FORMERS -promote early ambulation among post op pts
-increases bulk of stool, increasing mechanical pressure -promote adequate rest and activity
and distention of the intestine, thereby increasing peristalsis -limit carbonated beverages
(ex. Psyllium) -Rectal tube insertion as ordered
5. OSMOTIC AGENTS - position: left lateral
- attract fluids from the intestinal capillaries (Lactulose, -insert 3-4 inches of lubricated tube in rotating
Magnesium Hydroxide) motion
-use appropriate size (Fr. 22-30)
2. FECAL IMPACTION -retain rectal tube for 30 minutes
- mass or collection of hardened, putty-like feces -administer carminative enema as ordered
in the folds of the rectum. -administer cholinergics as ordered
- inability to evacuate stool voluntarily (neostigmine)
S/sx:
- absence of bowel movement for 3-5 days 5. FECAL INCONTINENCE
- passage of liquid fecal seepage -involuntary elimination of bowel contents often
- hardened fecal mass palpated during DRE associated with neurologic, mental or emotional
- nonproductive desire to defecate and rectal pain impairments
- anorexia, body malaise -seen in patients with injury to cerebral cortex
 (pt is unable to perceive that rectum is distended or water)
unable to initiate the motor response required to inhibit
defecation voluntarily) -Normal saline
-pts with spinal cord injury (sacral region) (9ml of NaCl to
1000ml of water)

-Hypertonic
ENEMAS Solution/Fleet
enema (90-120
ml)
HT OF SOL. 18 inches above 12 inches above
rectum rectum
TEMP OF SOL 115-125 F 105-110 F
TIME REQUIRED 5-10 mins 1-3 hrs

Nursing considerations when administering

enema:

Purposes: -check the doctor’s order

-relieve constipation and fecal impaction -provide privacy
-relieve flatulence -promote relaxation to facilitate insertion of tube
-administer medication -position the pt (adult: left lateral position; children:
-evacuate feces in prepartion for diagnostic dorsal recumbent)
procedure or surgery -identify appropriate catheter size:
Adult: Fr 22-32
TYPES OF ENEMAS Children: Fr. 14-18
Infant: Fr. 12
1. CLEANSING ENEMA -lubricate 5 cm (2in) of the rectal tube
- stimulates peristalsis by irritating the colon -allow solution to flow through the tube to expel air
and rectum and or by distending the intestine with before insertion.
the volume of fluid introduced -insert 7-10 cm (3-4 inches) of rectal tube in gentle
A. HIGH cleansing enema: cleanse as much of rotation motion to prevent irritation of anal and rectal
the colon as possible; 1000 ml of sol’n is tissues
administered in adults -introduce solution slowly to prevent sudden stimulation
B. LOW cleansing enema: to cleanse the of peristalsis
rectum and sigmoid colon only; 500 ml of sol’n is -change the position to distribute solution well in the
administered in adults colon (high enema), if low, remain in LLP.
-if abdominal cramps occur, temporaily stop the flow of
2. CARMINATIVE solution by clamping the tube
- to expel flatus -after the procedure, press the buttocks to inhibit the
-60-80 ml of fluid is introduced urge to defecate
-assist pt to the toilet
3. RETENTION ENEMA -do perianal care
-introduces oil into the rectum and sigmoid -document
colon; oil is retained in the colon for 1-3 hrs
-softens feces and lubricates the rectum and
anal canal to facilitate passage of stool URINARY ELIMINATION

4. RETURN FLOW ENEMA/HARRIS Function/s of the urinary tract:

FLUSH/COLONIC IRRIGATION - maintains homeostasis by maintaining body fluid
- done also to expel flatus composition and volume
-300-500 ml of fluid is introduced into and out
of the large intestine (PLS REVIEW ANATOMY AND PHYSIOLOGY OF THE
-solution container is lowered so that the fluid URINARY SYSTEM AND URINE FORMATION AS WELL)
backs out through the rectal tube container
-the inflow-outflow process is repeated 5-6 Micturition
times -act of expelling urine from the bladder
-replace the sol’n several times as it becomes -urination, voiding
thick with feces -initiated by parasympathetic nervous system
-procedure may take 15-20 mins to be activation
effective
Normal Characteristics of Urine:
NON RETENTION Color: Amber/straw
RETENTION Odor: Aromatic
SOLUTIONS -Tap water Carminative Transparency: Clear
USED (500-1000 mls) enema pH: slightly acidic (4.6 - 8; average: 6)
Specific gravity: 1.010- 1.025
-Soap suds (20 Oil (90-120 of
ml of castile mineral oil, olive ALTERATION IN URINE COMPOSITION
soap in 500- or cottonseed RBC in the urine - hematuria
1000 ml of oil) Pus in the urine - pyuria
Bacteria - bacteriuria -allow the patient to listen to the sound of running
(signs of UTI) water
Albumin in the urine: Albuminuria -dangle fingers in warm water
Protein in the urine: Proteinuria -pour warm water over the perineum
Glucose: - Glycosuria -promote relaxation
Ketones: - Ketonuria -provide adequate time for voiding
-perform crede’s maneuver as ordered. Apply pressure
ALTERED URINE PRODUCTION on the suprapubic area
Polyuria -administer cholinergics as ordered
- excessive urine production; more that 100 ml/hr or -LAST RESORT: URINARY CATHETERIZATION
2500 ml/day; diuresis
Urinary Catheterization
Oliguria
- decreased amount of urine; less than 30 ml/hr or less
than 500ml/day

Anuria
- little to no urine production; 10 ml/hr; urinary
suppression
Purposes:
ALTERED URINARY FREQUENCY
-to relieve bladder distension
Frequency
-to instill medications into the bladder
-Voiding at frequent intervals
-to irrigate the bladder
Nocturia
-to measure hourly urine output accurately
-Increased frequency at night
-to collect urine specimen
Urgency
-to empty bladder in preparation for diagnostic
-Strong feeling that the person wants to void
procedure and surgery
Dysuria
-painful or difficult voiding
Nursing considerations:
Hesitancy
-verify doctor’s order and identify the pt
-difficulty initiating voiding
-explain procedure and provide privacy
Enuresis
-do perineal care
-repeated involuntary voiding beyond 4-5 years of age
-use appropriate catheter size:
Pollakuria
Male: 16-18
-Frequent, scanty urination
Female: 12-14
Urinary Incontinence
-position: Male> supine with legs abducted
 Total Incontinence:
Female> dorsal recumbent
-continuous and unpredictable loss of urine
-don sterile gloves
 Stress Incontinence
-locate meatus: Male> tip of glans penis
- leakage of less than 50 ml of urine as a
Female> between clitoris and
result of a sudden increase in intra-abdominal
vaginal orifice
pressure
-cleanse the meatus with antiseptic sol’n from front
 Urge Incontinence
to back
- follows a sudden strong desire to urinate
-lubricate cathete with water-soluble sol’n
and leads to involuntary detrusor contraction
-insert the catheter and advance until urine flows
 Functional Incontinence
through the tubing
- involuntary unpredictable passage of urine
-anchor the catheter by inflating the balloon with 5-
 Reflex Incontinence
10 ml of sterile water
- Involuntary loss of urine occurring at
-anchor the tubing: M>laterally upward over the
somewhat predictable intervals when specific
lower abdomen to prevent penoscrotal pressure
bladder volume is reached
F>inner aspect of the thigh
Retention
- accumulation of urine in the bladder with associated
inability of the bladder to empty itself
(240-450 ml triggers micturition)

Clinical Signs of Bladder Retention

A. Discomfort in the pubic area
B. Bladder distension (palpation and percussion)
C. Inability to void or frequent voiding of small volumes (25-
50 ml)
D. A disproportionately small amount of output in relation to
fluid intake
E. Increasing restlessness and feeling of need to void

NURSING INTERVENTIONS TO INDUCE VOIDING

ACTIVITY, MOBILITY AND EXERCISE
-provide privacy
BODY MECHANICS
-provide fluids to drink unless contraindicated
-assist pt in anatomical position of voiding
-serve clean, warm and dry bedpan or urinal
 - efficient, coordinated and safe use of the body to
produce motion and maintain balance during the activity. It
prevents injury to self and clients
PRINCIPLES OF BODY MECHANICS
1. Balance is maintained and muscle strain is avoided as
long as the line of gravity passes through the base of
support
a) Start body movement with proper alignment
b) Stand as close as possible to the object to be
moved
c) Avoid stretching, reaching and twisting
2. The wider the base of support and the lower the center
of gravity, the greater the stability. Before moving objects
put your feet apart, flex the hips, knees and ankles
3. Balance is maintained with minimal effort when the base
of support is enlarged in the direction in which the
movement will occur
-when pushing an object, enlarge the base of support
by moving the front foot forward
-when pulling an object, enlarge the base of support by
either moving the rear leg back if facing the object or
moving the front foot forward if facing away from the object
4. Objects that are close to the center of gravity are moved
with least effort
5. The greater the preparatory isometric tensing or
contraction of muscles before moving an object, the less
energy required to move it and the less musculoskeletal
strain injury.
6. The synchronized use of as many large muscle groups as
possible during an activity increases overall strength and
prevents muscle fatigue and injury
7. The closer the line of gravity to the center of the base of
support the greater its stability
-when moving or carrying objects, hold them as close
as possible to the center of gravity
-pull an object toward self whenever possible rather
than pushing it away
8. The greater the friction against the surface beneath an
object, the greater the force required to move the object.
Provide a firm, smooth, dry bed foundation when moving
the client
9. Pulling creates less friction than pushing
10. The heavier an object, the greater the force needed
to move an object
-encourage the client to assist as much as possible
by pushing or pulling\
-use own body weight to counteract the weight of
the object
-obtain the assistance of other persons or use
mechanical devices to move objects that are too heavy
11. Moving an object along a level surface requires less
energy than moving an object up an inclined surface or
lifting it against the force of gravity
12. Continuous muscle exertion can result in muscle
strain and injury. Alternate rest periods with periods of
muscle use to help prevent fatigue
PHYSIOLOGIC RESPONSES TO IMMOBILITY
Decrease in muscle strength
Muscle atrophy
Disuse osteoporosis
Fibrosis and ankylosis
Contracture
PATHOGENESIS OF PRESSURE ULCERS
-also known as Pressure sores, decubitus ulcers,
bedsores or distortion sores
-reddened areas, sore or ulcers of the skin occurring
over bony prominences
-occurs due to interruption of the blood circulation to
the tissue
CAUSES OF PRESSURE SORES
1. Pressure
- primary cause; perpendicular force exerted on the
skin by gravity
2. Friction
-parallel force acting on the skin
3. Shearing Force
-combination of friction and pressure
STAGES OF PRESSURE ULCERS
Stage I
>Non-blanchable erythema of intact skin
Stage II
>Partial thickness skin loss involving epidermis and
or dermis. The ulcer is superficial and presents clinically
as abrasion, blister.
Stage III
>Full thickness skin loss involving damage or
necrosis of subcutaneous tissue that may extend down
to but not through underlying fascia.
>deep crater
Stage IV
>Full thickness skin loss involving damage to
muscle,bone or supporting structures such as tendon or
joint capsule
PREVENTING AND TREATING PRESSURE SORES
>Provide smooth, firm, wrinkle free foundation on which the
client can lie
>use foam, rubber pads, egg crate mattress under pressure
areas
>apply thin layer of cornstarch to the bedsheet
>reduce shearing force by elevating the head of the bed to
no more than 30 degrees
>frequent position changes
>provide meticulous hygiene
>keep skin clean and dry
>avoid massaging bony prominences with soap

TREATMENT
>clean pressure sore daily
>clean and dress pressure sore using surgical asepsis
>if sore is not infected, cover it with occlusive dressing
>if sore is infected, obtain sample for C&S
>reposition client q 2 hours
>encourage ambulation in post op patients
>provide ROM exercises

TYPES OF EXERCISES TYPES OF RESPONSES TO PAIN

Active ROM 1. INVOLUNTARY RESPONSES
Done by the client - mediated by the autonomic nervous system.
Passive ROM -mild to moderate: SNS
Done for the client by health care providers -severe: PNS
Active-Resistive ROM 2. VOLUNTARY RESPONSE
-Done by the client against a weight or force -Behavioral responses: crying, grimacing, splinting
Active Assistive ROM area, tossing in bed
-done by the stronger arm and leg to the weaker arm -Emotional responses: depression, withdrawal,
and leg social isolation
Isotonic
-involves change in muscle strength and STAGES OF PAIN RESPONSE
tension(running, walking)  ACTIVATION
Isometric - begins with the perception of pain; body assumes
-involves change in muscle tension only (kegel’s a fight or flight response
exercise)  REBOUND
-pain is intense but brief. PNS dominates
COMFORT, REST AND SLEEP  Adaptation
-person adapts to pain may be due to endorphins.
PAIN
>sensation of physical or mental hurt or suffering that CLASSIFICATION OF PAIN
causes distress or agony to the one experiencing it A. TYPES OF PAIN
 CUTANEOUS/SUPERFICIAL
THEORIES OF PAIN -occurs over the body surface or skin segment
1. Pattern Theory  SOMATIC
- states that pain is perceived whenever the stimulus is - may be deep or superficial
intense enough -occurs in the skin, mucles, joints
2. Specificity Theory  VISCERAL PAIN
- states that there are specific nerve receptors for -arises from stimulation of pain receptors in the
particular stimuli abdominal cavity or thorax
-nociceptor: noxious stimuli  REFERRED PAIN
-thermoreceptors: heat or cold - pain is perceived at an area other than the site of
-mechanoreceptore: pressure injury
-chemoreceptor: chemicals  INTRACTABLE
3. Gate Control Theory - resistant to cure or relief
-there is a gate in the spinal cord called substantia  PHANTOM
gelatinosa. When gate is open, pain is transmitted and is -actual pain felt in a body part that is no longer
perceived. present
4. Affect Theory  RADIATING
- it avers that pain is emotional. The intensity of pain -felt at the source and extends to surrounding
perceived depends on the value of the organ affected to the tissues
individual  PSYCHOGENIC
5. Parallel Processing Model - primarily due to emotional factors with no
- the physiologic or neurologic deciphering physiologic basis
 INTERMITTENT
PHYSIOLOGY OF PAIN -pain stops and starts again

B. LOCATION
C. DURATION
Acute: lasts for less than 6 months
 Chronic: lasts for more than 6 months - decrease metabolism, brain waves, muscles
D. CHARACTER/QUALITY relaxed
E. INTENSITY/SEVERITY
F. AGGRAVATING/ALLEVIATING FACTORS 2. REM (RAPID EYE MOVEMENT) STAGE
(increase in systhetic processes in the brain)
Eyes appear to roll
NURSING INTERVENTIONS TO RELIEVE PAIN Close to wakefulness but difficult to arouse
Dreamstate of sleep
1. Techniques that stimulate the skin SNS dominates
Rationale: enhances secretion of serotonin which blocks Flow of gastric acid increases
transmission of pain impulses Sleeper’s reviews the day’s events and processes
 Therapeutic touch and stores information
 Contralateral stimulation: stimulating the skin in an
area opposite to the painful area Nursing interventions to Promote Sleep
 Vibration 1. Promote comfort and relaxation
 Heat and cold application 2. Create a restful environment
 Acupuncture/ Acupressure 3. Attend to bedtime rituals
 TENS (Transcutaneous Electrical Nerve Stimulation) 4. Provide adequate exercise atleast 2 hours before
2. Techniques to distract attention sleep to enhance NREM
 Staring 5. Encourage intake of high Protein food. It
 Slow, rhythmic breathing contains Tryptophan which enhances sleep
 Recite, sing 6. Avoid caffeine and alcohol in the evening
 Listening to music 7. Go to bed when sleepy
3. Techniques to promote relaxation 8. Use the bed mainly for sleep
 Conventional Methods
-relax muscles
-listen to music Common Sleep Disorders
-guided imagery
-meditation, yoga 1. Insomnia
 Analgesics -difficulty in falling asleep
 Placebo -premature awakening

REST AND SLEEP 2. Hypersomnia

-excessive sleep
REST -r/t psychological problems, CNS damage
- diminished state of activity, calmness, relaxation
without emotional stress; freedom from anxiety 3. Narcolepsy
- sleep attack
SLEEP - overwhelming sleepiness
-state of consciousness in which the individual’s - REM uncontrolled
perception and reaction to the environment are decreased
4. Sleep Apnea
>RETICULAR ACTIVATIONG SYSTEM: maintains -periodic cessation of breathing during asleep
wakefulness characterized by snoring
>Serotonin: neurotransmitter associated with sleep
5. Parasomnias
Stages of Sleep Somnambolism - sleep walking
Night Terrors - child bolts upright in bed,
1. NREM (NON-RAPID EYE MOVEMENT) STAGE shakes, screams, appears pale and terrified
(body restoration) Nocturnal Enuresis- bed wetting
STAGE 1 Soliloquy - Sleep talking
- very light sleep Nocturnal Erections - “wet dreams”
- drowsy, relaxed Bruxism - clenching and grinding of teeth
- readily awakened during sleep

STAGE 2
- light sleep
- eyes are still
- HR and RR decreases slightly
- body temperature falls

STAGE 3
- domination of PNS
- body process slows further
- difficult to arouse

STAGE 4
- deep sleep
- difficult to arouse
- decrease BP, RR, PR, Temp