Fundamentals of Nursing Practice - Midterm

VITAL SIGNS Heat Loss

➢ Reflects the body’s physiologic status and ability Factors affecting heat loss:
to regulate temperature, maintain local and
1. Radiation
systematic blood flow, and oxygenated tissues
• Transfer of heat from one surface to
Components of Vital Signs another without contact between the
✓ Body Temperature – objective two objects
✓ Pulse – objective Ex. Use of infrared rays sunlight
✓ Respirations – objective exposure
✓ Blood Pressure – objective 2. Conduction
✓ Pain – subjective • Transfer of heat between two objects in
contract
Time to Assess Vital Signs
3. Convection
✓ Upon admission
✓ Institution policy • Dispersion of heat by air currents, warm
✓ Before and after invasive procedure air rises and is replaced by cooler air
✓ Change in client’s condition 4. Vaporization
✓ Before and after administration of medications • Evaporation of moisture from body
✓ Before and after nursing intervention surfaces

BODY TEMPERATURE Factors Affecting Body Temperature

➢ Reflects the balance between the hear produce 1. Age
and heat loss • Young: increased BMR = increased
➢ Measured in heat units called degrees temp
• Older: decreased BMR = decreased
Types: temp
1. Core Temperature 2. Diurnal Variations (circadian rhythms(
➢ Temperature of the deep tissues in the • Highest: between 8:00 pm and
body midnight
Ex. Abdominal cavity pelvic cavity • Lowest: during sleep between 4:00 and
2. Surface Temperature 6:00 am
➢ Temperature of the skin, subcutaneous 3. Exercise
tissue, and fats • Stimulates sympathetic nervous system
➢ In contrast to core temperature, it rises 4. Hormones
and fall in response to the environment • Epinephrine and norepinephrine –
increased BMR – increased temp
Heat Production • Progesterone – increased BMR –
Contributing Factors:
increased temp
✓ Basal Metabolic Rate (BMR): rate of energy 5. Stress
utilization • Stimulation of the sympathetic nervous
✓ Muscle Activity system
✓ Thyroxine output effect: chemical 6. Environment
thermogenesis
✓ Stress
✓ Fever

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• Body temperature fluctuates minimally
but always remains above normal
Alterations in Body Temperature

Pyrexia 5. Fever Spikes

➢ Abnormally high body temperature • A temperature which rises to fever level
➢ A.k.a hyperthermia and fever rapidly following a normal temperature
and then returns to normal within a few
Terminologies
hours
✓ Hyperpyrexia – a very high fever
✓ Febrile – a client who has a fever Types of Fever Resolution
1. Resolution-by-crisis
Differences between hyperthermia and fever ➢ A sudden drop from fever to normal; it
is considered as a sharp turning point
FEVER HYPERTHERMIA
during a diseased condition, which is
Resulting from pyrogen Arising from changes
marked by a drop in elevated body
within the body or by
changes in environment temperature
ability to regulate set- Set-point remains ➢ Fall in crisis is commonly associated
point remains intact, but unchanged or damaged, with marked weakness, profuse
is turned up at a high or effector organs fails sweating and a temporary slowing of
level functionally cardiac activity in some cases
rise of body temperature Body temperature may 2. Resolution-by-lysis
as an upper limit rise to a very high level ➢ Elevated temperature gradually returns
Treatment with Treatment with water- to normal; the fall in the body
antipyretics and alcohol bathing temperature follows a pattern of slow
measures and drugs to and gradual decrement of the body
eliminate the causes temperature
➢ This type of fall in body temperature is
Types of Fever seen in the case of infectious diseases
1. Intermittent Fever (e.g. measles, typhoid, scarlet fever).
• Alternating temperature at regular Hypothermia
intervals between periods of fever and ➢ Reflects body temperature that is lower than
periods of normal or subnormal normal
temperatures. (ex. Malaria)
2. Remittent Fever Types of Hypothermia
• Wide range of temperature fluctuations 1. Accidental
(more than 2°C [3.6°F]) occurs over the • Is an unintentional core body
24-hour period, all of which are above temperature of < 35°C when heat loss
normal to surroundings is greater than heat
3. Relapsing Fever generation. Most frequent cause is
• Short febrile periods of a few days are environment exposure such as:
interspersed with periods of 1 or 2 days A. Exposure to cold environment
of normal temperature B. Immersion in cold water
4. Constant Fever

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C. Lack of adequate clothing, shelter, •Body temperature changes slightly
or heat through the day and night, and may
2. Induced change based on your activity
• Aims to avoid the complications 4. Tympanic/Ear
associated with hypothermia • Readily accessible core temperature
• It is principally used in comatose cardiac assessment
• Involve risk of injuring the tympanic
arrest survivors, head injury, and
membrane
neonatal encephalopathy

Common Sites in Taking Body Temperature 5. Infrared or Digital Scanning

1. Oral/Mouth ➢ Digital thermometer scans the surface
• For this method, the thermometer is temperature usually at the forehead
placed under the tongue. This method
Types of Thermometers
is used for adults and children 4 and
1. Mercury-in-glass Thermometers
over who are able to hold thermometer
Benefits:
in mouth ✓ Mercury thermometers provide
• The reading may be inaccurate if client accurate temperature readings and can
has ingested hot or cold flood/fluid be used orally, rectally, or under the
• Thermometers can break if bitten arm
2. Rectal/Rectum ✓ They don’t require batteries
• For this method, the thermometer is Drawbacks:
inserted gently into the rectum. This is ✓ Since they are made from glass,
mostly done in babies but can used in mercury thermometers may break
children up to 3 years of age easily, allowing toxic mercury to escape
✓ They may also cause cuts or glass
• Reliable measurement contraindicated splinters if they break
for clients with MI, clotting d/o, rectal ✓ Since they contain a hazardous
surgery, significant hemorrhoids, least substance, mercury thermometers must
desirable in infants be disposed properly and can’t be
thrown into the trash
✓ They can be hard to read and must stay
in place for 3 minutes
2. Electronic/Digital Thermometers
✓ Digital thermometers provide accurate
readings in about 1 minute or less
✓ Batteries in thermometers should be
replaced periodically. Make sure you
have the right type of batteries on hand
for your device and that you
understand how to change them, so
3. Axillary/Axilla
you’re not left scrambling in an
• Preferred site for measuring
emergency
temperature in newborns. However,
3. Chemical Disposable Thermometers
may not be accurate to detect fever in
✓ Contains small chemical dots that
infants
change in color depending on the
temperature
✓ single-use and inexpensive
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✓ can be difficult to read ✓ Variations on user technique, such as
✓ takes longer time for accurate holding the scanner too far away from
measurement to be recorded (approx.. the forehead, also may affect accuracy.
7 minutes
4. Temperature-sensitive tape
✓ Does not indicate the core temperature
✓ Does not give an exact accurate reading
5. Infrared Thermometer
Benefits:
✓ Infrared thermometers provide quick
readings, within several seconds
✓ They are easily administered and can be
used on infants, children, and adults
Drawbacks: Temperature Scales
✓ Forehead thermometers must be Degrees
positioned accurately and according
to the manufacture’s instructions, ✓ Celsius Centigrade
or they will not provide the right ✓ Fahrenheit
reading
✓ Readings can be affected by
external factors, including drafts,
wind, indoor heating, and direct
sunlight
✓ Wearing certain clothing, such as
hats or heavy coarse can skew the
results
6. Temporal Artery Thermometer
Benefits:
✓ Temporal thermometers take
advantage of the temporal artery’s Normal Temperature Ranges
location as it is an easily accessible ➢ Oral Temperature: 36.1 - 37.2 C or 97 - 99 F (ave
o o

artery with constant blood flow 37 C)

o

✓ This combination, along with the ➢ Rectal: 36.7 - 37.8 C or 98 - 100 F (ave 37.5 C)
o o o

arteries’ shallow depth from the skin ➢ Axillary: 35.6 – 36.7 C or 97 - 99 F (ave 36.7 C)
o o o

surface, provides the scanner a clinically ➢ Tympanic: 37.5 C or 99.5 F

o o

accurate and non-invasive way of taking

a temperature measurement
Drawbacks: PULSE
• Wave of blood created by contraction of the left
✓ A temporal artery thermometer may be ventricle of the heart
more expensive than other types of • Represents the stroke volume output and the
thermometers amount of blood that enters the arteries with
✓ This type of thermometer may be less each ventricular contraction
accurate than other types • Expressed in beats per minute (bpm)
✓ Direct sunlight, cold temperature or a Definition of Terms
sweaty forehead can affect 1. Compliance
temperature readings ✓ Ability to contract and expand

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2. Cardiac Output D. Apical
✓ The volume of blood pumped into the ✓ Children below 3 years age
arteries by the heart: CO= SV x HR E. Brachial
3. Peripheral Pulse ✓ Used to measure BP
✓ A pulse located away from the heart ✓ Cardiac arrest for infants
4. Apical Pulse F. Femoral
✓ A central pulse located at the apex of ✓ Cardiac arrest/shock
the heart ✓ Determine circulation of the leg
G. Popliteal
Pulse Sites ✓ Determine circulation of the LL
A. Temporal H. Tibialis & D. Pedis
B. Femoral ✓ Determine circulation of the foot
C. Popliteal
D. Posterior Tibial
E. Carotid
F. Brachial
G. Radial Pulse can be assessed through the following:
H. Dorsalis Pedis
Palpation

Auscultation

Reasons for using sites

A. Radial Doppler Ultrasound Stethoscope
✓ Readily accessible
B. Temporal
✓ Used when radial is not accessible
C. Carotid
✓ Cardiac arrest/shock
✓ Determine circulation to the brain

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c. Clients with known cardiovascular, pulmonary,
and renal diseases
d. Commonly assesses prior to administering
cardiotonic
e. Newborns, infants, and children up to0 2-3
years old
APICAL-RADIAL PULSE:
Normal
Things to note in assessing pulses: ➢ Apical and radial rates are identical
1. Rate Abnormal
• Tachycardia – excessively fast heart ➢ Apical pulse rate greater than a radial pulse rate
rate; above the normal rate Pulse Deficit
• Bradycardia – decrease rate than ➢ Any discrepancy between the two pulse rates
normal Notes: an apical pulse will never be lower than the
2. Rhythm radial pulse
• Dysrhythmia or Arrhythmia – an VARIATIONS IN PULSE BY AGE:
irregular rhythm may consist of
random, irregular beats or a predictable
pattern of irregular beats, ECG or EKG is
necessary to define the dysrhythmia
further
3. Volume/Pulse Volume – refers to the force of
blood with each beat a.k.a pulse strength or
amplitude
CARDIAC
• Normal Pulse – cam be felt with
Cardiovascular System
moderate pressure or the fingers
• Full or Bounding – a forceful or full ➢ Oxygen transport
blood volume and difficult to obliterate ➢ Nutrition
• Weak, Feeble, or Thready – a pulse that ➢ Removal of the waste products
is readily obliterated with pressure from Heart
the fingers ➢ A hallow, cone-shaped organ about the size of a
4. Arterial wall elasticity – reflects its expansibility fist
or deformities ➢ Located in the mediastinum, between the lungs,
➢ Normal artery feels straight, smooth, and underlying the sternum
soft, and pliable Cardiac Cycle
5. Presence or absence of bilateral equality ➢ A.k.a heartbeat
➢ Systole (contraction) – when the heart ejects
APICAL PULSE ASSESSMENT: the blood into the pulmonary and systematic
Indications: circulation
a. Peripheral pulse is irregular ➢ Diastole (relaxation) – when the ventriccles fill
b. Unavailable peripheral pulses with blood

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Phases of the Cardiac Cycle

Contractility
➢ Inotropic state of the myocardium
Indicators to the Heart Function ➢ Strength of contraction
Stroke Volume
➢ Amount of blood ejected from the heart with Factors Affecting Heart Rate
each beat ✓ Age
Cardiac Output ✓ Gender
➢ Amount of blood ejected from the heart each ✓ Exercise
minute: CO = SV x HR ✓ Fever
Heart Rate ✓ Medications
➢ Number of beats each minute ✓ Hypovolemia
➢ HR is directly proportional to CO ✓ Stressors
✓ Positioning Changes
✓ Pathology

Preload Actual Site of Assessment: at 4th, 5th, or 6th Intercostal

➢ Left ventricle end diastolic volume; stretch of Space, Left Midclavicular Line
the myocardium
Afterload Normal Results:
➢ Resistance against which the heart must pump ➢ S1 (lub) heard at all sites but louder at the apex
to eject the blood into the circulation ➢ S2 (dub) heard at all sites but louder at the base
➢ S3 heard in children and young adults
➢ S4 heard in many older adults

BLOOD PRESSURE
• A measure of the pressure exerted by the blood
as it flows through the arteries
✓ Systolic Pressure

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✓ Diastolic Pressure • Palpatory
PULSE PRESSURE
➢ The difference between the DBP and SBP KOROTKOFF’S SOUNDS
Normal: 40-100 mmHg ➢ Series of sounds heard during auscultatory
checking of the BP
Determinants of Blood Pressure Phases:
✓ Cardiac Contractility ✓ Sharp tapping
✓ Peripheral Vascular Resistance ✓ Swishing or whooshing
✓ Blood Volume ✓ Thump
✓ Blood Viscosity ✓ Muffled blowing
✓ Silence
BLOOD SITES: Errors in Blood Pressure Taking
• BP cuff too narrow
• BP cuff too wide
• Arm unsupported
• Insufficient rest before checking
• Failure to use same arm consistently
• Arm above level of the heart
• Arm below level of the heart
❖ BP cannot be measured on either arm
❖ BP comparison Normal Ranges:
❖ Presence of bulky cast • Infant: 50/40 mmHg
❖ Limb Surgery • Children: 87/48 – 117/64 mmHg
❖ IVF infusion • Adult: 110/70 – 130/90 mmHg
❖ AV fistula or shunt
Factors Affecting Blood Pressure RESPIRATORY RATE
✓ Age Respiration
✓ Exercise • Simply the act of breathing
✓ Stress Ventilation
✓ Race • Also used to refer to the movement of air in and
✓ Gender out of the lungs
✓ Medications Types of Respiration
✓ Obesity 1. External Respiration
✓ Diurnal Variations o Changes of gases with the external
✓ Disease Process environment, and occurs in the alveoli
Methods of Checking Blood Pressure of the lungs
Direct
• Involves the insertion of a catheter into a
brachial, radial, or femoral artery
Indirect
• Auscultatory
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Types of Breathing
2. Internal respiration 1. Costal (Thoracic) Breathing
o Exchange of gases with the internal ➢ Involves the external intercostal muscles
environment, and occurs in the tissue and other accessory muscles, such as the
sternocleidomastoid muscles
➢ “Chest Breath”

PROCESS:
1. Inhalation or Inspiration
o Refers to the intake of air into the lungs
2. Exhalation or Expiration
o Refers to breathing out or the
movement of gases from the lungs to
the atmosphere
RESPIRATION PROCESS:

2. Diaphragmatic (Abdominal) Breathing

➢ Involves the contraction and relaxation of
the diaphragm
➢ “Belly Breath”

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Normal Ranges:
• Infants; 30-40/minute
• Children: 20-25/minute
• Adult: 16-20/minute

THINGS TO NOTE IN ASSESSING RESPIRATIONS:

✓ Rate
✓ Depth
✓ Rhythm
✓ Quality and Effectiveness
Abnormal Patterns VITAL SIGNS DOCUMENTATION
1. Rate Vital Signs:
✓ Blood Pressure
✓ Tachypnea
✓ Temperature
✓ Bradypnea ✓ Pulse Rate
✓ Apnea ✓ Respiration Rate
✓ Eupnea
2. Volume Considerations
✓ Hyperventilation • Make necessary reassessment of abnormal
✓ Hypoventilation results before recording
3. Ease of Effort • Follow agencies protocol regarding the use of
appropriate pen colors
✓ Dyspnea
✓ 7-3: BLACK (AM)
✓ Orthopnea ✓ 3-11: BLUE (PM)
4. Quality and Character ✓ 11-7: RED (NOC)
✓ Stridor • Ask permission before using patient’s chart
✓ Stertorous • A mistaken entry in the chart is not allowed
✓ Wheezing • No tempering of entries
BREATHING PATTERNS:
Vital Signs
• Documented on graphic charts, which allow you
to monitor or plot the patterns of the vital signs

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Normal Body Temperature Normal Ranges:
Oral Temperature 1. Infant: 50/40 – 80/50
✓ 36.1-37.2C or 97-99F (Ave: 37C) 2. Children: 87/48 – 117/64
Rectal Temperature 3. Adult: 110/70 – 130/90
✓ 36.7-37.8C or 98-100F (Ave: 37.5C)
Axillary Temperature Where to Record the Vital Signs Taken?
✓ 35.6-36.7C or 97-99F (Ave: 36.7C) 1. Vital Signs Master List
Tympanic Temperature 2. TPR Sheet
✓ 37.5C or 99.5F 3. Patient’s Chart
a. Graphic Chart
Normal Pulse Rate b. Vital Signs Sheets
c. Nurses Notes
1. Vital Signs Master List
o Is usually seen in the station for
documentation of vital signs in all
patients in the ward/area without
needing to see the chart

2. TPR Sheet
o Also seen usually in the station, that
aside from writing on the vital signs
Normal Respiration Rate taken, the frequency of urination and
defecation can be seed readily in the
sheet

3. Patient’s Chart
a. Graphic Char
o We also term this as the TPR graphic
chart. In this sheet, the progress of the
vital signs recorded can be seen right
away thru the plotting done in it. It is
usually seen attached in the patient’s
chart

Blood Pressure Range

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3. Vital Signs in Patient’s Chart

b. Vital Signs Sheet

o Vital signs documentation in tabulated 4. The Graphic Chart of San Pedro Hospital
form and is usually found in the (Sample Graphic Chart with Data)
patient’s chart

c. Nurses Notes
o Documentation of vital signs in a
narrative form along with nurse’s notes

GRAPHIC DATA
a. Completing the Patient’s Information Section
➢ For this section of the graphic chart,
make sure that patient’s name,
attending physician, room number, and
Sample Plotting on the Different VS Sheets hospital number are filled out. Always
1. Vital Signs Mastery List use BLACK PEN when filling out this
part

b. Filling out of date, hosp. day, post-operative ,

and post-partum section
2. TPR Sheet
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c. The vertical lines and spaces of time

d. Plotting the pulse and temperature

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e. Plotting respirations, weight, activity, diet, pt.
fed, urine, and stools
Functions of the Skin
✓ Protects underlying tissues
✓ Regulations of body temperature
✓ Transmits sensations through nerve receptors
✓ It produces and absorbs vitamin D
SECRETION OF SEBUM
• Softens and lubricates the hair and skin
• Prevents hair from becoming brittle
• Decreases water loss from the skin
• Lessens the amount of heat loss
• Kills microorganisms

Sweat Glands
Eccrine Glands – over most of your body and open
directly onto the top layer of the skim
Apocrine Glands – develop where there is a large
✓ supply of hair follicles. The bacterial breakdown of
apocrine sweat often causes an odor
PROVISION OF HYGIENE
Common Skin Problems
Hygiene 1. Abrasion
• Science of health and its maintenance
Personal Hygiene
❖ Self-care by which people attend to
functions like
a. Bathing
b. Toileting
c. General body hygiene
d. Grooming
• Skin, hair, nails, teeth, oral, and nasal cavities,
2. Excessive Dryness
eyes, ears, perineal-genital areas

Factors Influencing individual Hygienic Practices

• Placed value on cleanliness
• Emphasis of privacy in bathing
• Viewpoints such as body odor
1. Culture
2. Religion – ceremonial washing
3. Environment – availability of facilities
constraints of resources 3. Ammonia Dermatitis (diaper rash)
4. Developmental Level – capacity in carrying out
tasks
5. Health and Energy – restrictions to impairment
6. Personal Preferences

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4. Acne 8. Bromhidrosis

General Guidelines for Skin Care

1. An intact, healthy skin is the body’s first line of
5. Erythema defense
2. The degree to which the skin protects the
underlying tissues from injury depends on the
general health pf the cells, the amount of
subcutaneous tissue, and the dryness of skin
3. Moisture in contact with the skin for more than
a short time can result in increased bacterial
growth and irritation
4. Body odors are caused by resident skin bacteria
acting on body secretions
5. Skin sensitivity to irritation and injury varies
6. Hirsutism among individuals and in accordance with their
health
6. Agents used for skin care have selective actions
and purposes

Types of Hygienic Care

Early Morning Care
• Provided to clients as they awaken in the
morning
a. Providing urinal or bedpan
7. Hyperhidrosis b. Washing of face and hands
c. Giving of oral care
Morning Care
• Often provided after clients have breakfast
a. Provision of elimination needs
b. A bath or shower
c. Perineal care
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d. Back massage 4. Pediculosis
e. Oral, nail, hair care ➢ Lice that infest mammals
f. Bed making 5. Scabies
HS or PM Care ➢ A contagious skin infestation by the itch
• Provided before client retire mite
a. Provision of elimination needs ✓ Pediculus capitis (head louse) – scalp, stay
b. Washing of face and hands hidden in the hairs
c. Giving oral care ✓ Pediculus pubis (crab louse) – pubic hair
d. Back massage ✓ Pediculus corporis ( body louse ) – tends to clin
• As needed (prn) care on clothing
Shampoo in Bed 6. Hirsutism
• Washing of hair with the use of shampoo or ➢ Excessive growth of body hair
bath soap as often as necessary to keep it clean Oral Care
• Depends on the health, strength, and age GOOD ORAL CARE
• Shower, shampoo while sitting, shampoo in • Daily stimulation of the gums, mechanical
stretcher brushing and flossing of the teeth and flushing
of the mouth
Purposes
✓ Prevention of tooth decay
PURPOSES ✓ Removal of food particles
✓ To cleanse the hair and scalp
✓ To maintain or improve self-esteem
✓ To treat conditions of the scalp with topical Recommendations
applications of medications ✓ Brushing should be done after meals and at
✓ To remove substances on the head bedtime
ASSESSMENT ✓ Floss teeth daily
✓ Examine the hair ✓ Ensure adequate intake of nutrients,
✓ Inspect the scalp for any lesions particularly calcium, phosphorus, vitamins A, C,
✓ Observe the patient for signs of any itchiness and Dm fluoride
✓ Note signs of dandruff ✓ Avoid sweet foods and drinks between meals
✓ Determine if the patient has been receiving ✓ Eat course, fibrous foods
chemotherapeutic agent ✓ Topical fluoride application as recommended
✓ Read the patient’s medical records ✓ See dentist every 6 months
✓ Identify any deficits
✓ Identify patient’s usual routine in shampooing Common Problems of Mouth
✓ Inquire if the patient experienced any itching, Halitosis
burning, or tenderness of the scalp − Bad breath
Glossitis
Common Problems − Inflammation of the togue
1. Dandruff Gingivitis
➢ Diffuse scaling of the scalp − Inflamed gums
2. Hair Loss Periodontal Disease
➢ A hereditary condition of permanent − Gums appear spongy and bleed
thinning of hair Reddened/Excoriated Mucosa Cheilosis
3. Ticks − Cracking of lips
➢ Small gray-brown parasites that bite Sordes
into tissue and such blood

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− Accumulation of foul matters; food, 1. Ensure privacy. If in the ward, the bed should be
microorganisms, epithelial elements screened; in the PR the windows should be
Stomatitis adjusted
− Inflammation of the oral mucosa 2. Bed bath should be given one hour before
Parotitis meals or one hour after meals
3. Always have everything ready before giving the
bath
4. If the patient is quite weak all assistance should
be given to free the patient from exertion
5. Children should never be left alone while bath is
going on
Plaque 6. Unnecessary exposure or chilling must be
− Invisible soft film that adheres the enamel avoided
Tartar 7. Special attention must be given to regions
− Visible, hard deposit of plaque and dead behind ears, axillae , umbilicus, the pubis,
bacteria that forms at the gum lines groins, spaces between fingers and toes and
areas where two skin surfaces come in contact
Common Foot Problems 8. During bed bath, the patient must be observe
• Callus – thickened portion of epidermis, for objective signs such as rashes, swelling,
painless and flat found in the bottom or side of discoloration, pressure sores, dischargesm
the foot abrasions, lice, burns, etc.
• Corn – a keratosis. Caused by friction and Note: the findings should be reported in the
pressure from a shoe, occurs commonly on the nurse’s notes and reported to the physician if
4th or 5th toe, usually in bony prominence they seem important
9. All treatment such as enema, douches or
• Plantar Warts – cause by the virus papovavirus
preparation for fields of operation should be
huminis, commonly appears at the sole of the
done before the bath so that the patient will
foot, painful and often make walking difficult
remain clean and undisturbed afterwards
• Fissures – deep grooves between the toes as a
10. The nurse may usually work quickly but it
result of dryness and cracking of the skin
should be in a quiet soothing and unhurried
• Tinea/Pedis – ringworm of foot – caused by
fashion. Strokes should be smooth and firm and
fungus resulting to scaling and cracking of the
ends of the wash cloth should not be allowed to
skin, particularly between toes
dangle
• Ingrown Nails – growing inward of the nail into
soft tissues around it due to improper nail
CLEANSING BED BATH
trimming
• A bath given to weak and bedridden patients
• The nurse washes the entire body of a
CLEANSING BED BATH
dependent client on bed
Purposes
Purposes
✓ To cleanse the body
✓ To cleanse the body
✓ To refresh the patient
✓ To refresh the patient
✓ To stimulate circulation
✓ To stimulate circulation
✓ To exercise muscles and joints
✓ To exercise muscles and joints
✓ To provide tactile stimulation
✓ To provide tactile and stimulation
✓ To promote comfort and relaxation
✓ To promote comfort and relaxation
✓ To improve self-concept
✓ To improve self-concept
✓ To facilitate head-to-toe assessment
✓ To facilitate head-to-toe assessment
General Instructions
General Instructions
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1. Ensure privacy. If in the ward, the bed should be g. Paper for lining
screened; in the private room the windows h. Bath thermometer
should be adjusted 7. Pail for used water
2. Bed bath should be given one hour before 8. Bedpan or urinal
meals or one hour after meals 9. Laundry bag
3. Always have everything ready before giving the 10. Working gloves (2 pairs)
bath
4. If the patient is quite weak all assistance should BACK MASSAGE
be given to free the patient from exertion • Stimulation of the skin and underlying tissues
5. Children should never be left alone while bath is with varying degrees of hand pressure
going on Purposes
6. Unnecessary exposure or chilling must be ✓ To provide an opportunity to assess the skin on
avoided the back
7. Special attention must be given to regions ✓ To stimulate blood flow to the skin and
behind ears, axillae , umbilicus, the pubis, underlying tissues
groins, spaces between fingers and toes and ✓ To nonverbally communicate a concern for the
areas where two skin surfaces come in contact patient’s comfort
8. During bed bath, the patient must be observe ✓ To relax tense muscle thereby relieving pain
for objective signs such as rashes, swelling, ✓ To promote rest or sleep
discoloration, pressure sores, dischargesm
abrasions, lice, burns, etc. Contradictions
Note: the findings should be reported in the ✓ Red and tender areas since such signs may
nurse’s notes and reported to the physician if indicate presence of thrombus
they seem important ✓ Rib fractures
9. All treatment such as enema, douches or ✓ Surgical incisions in the chest and back
preparation for fields of operation should be ✓ Recent back trauma
done before the bath so that the patient will
remain clean and undisturbed afterwards
10. The nurse may usually work quickly but it
should be in a quiet soothing and unhurried
fashion. Strokes should be smooth and firm and Strokes
ends of the wash cloth should not be allowed to Effleurage
dangle • Gliding and long rhythmic strokes with the use
Requisites of the whole hands
1. Bath blanket or large towel • Firm, even-pressured strokes are directed
2. Bath towels (3), towelette (1) toward the heat to assist blood return
3. Washcloths (1) • Lighter pressure is used when moving away
4. Patients clothing as called for from the heat
5. Linen as called for Petrissage
6. Tray containing the following: • Pressing, squeezing, kneading, and rolling
a. Wash basin half filled with water or water movement with the use of the both hands
temperature as preferred by patient - deep circulation is enhanced
b. Soap in soap dish • C-shaped motions stimulate the muscle body
c. Patient’s comb/hairbrush • Promotes muscle relaxation
d. Talcum powder/lotion/oil Friction
e. A pair of nail cutter if necessary
• Focused, deep, circular motions with the use of
f. Two pitchers (one with cold and the other
thumb pads, heel of hand, or fingertips
one with hot water)
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• Penetrates deeper muscle layers 4. Boiling Water
• Done after effleurage and petrissage ➢ Least expensive and least efficient
Tapotement because some spores resist boiling
• Brisk, vigorous, rhythmic, percussive hand point
movements palms, fingertips, and knuckles are 5. Chemical
used to alternately tap, cup, slap, and pummel ➢ Gas autoclave
muscle ➢ Disinfectant – used to eliminate
• Alternately tap, cup, slap, and pummel muscle microbes on inanimate objects and it is
• Palms, fingertips, and knuckles are used harmful to tissues
• Invigorates and stimulates tired muscles ➢ Antiseptic – used on skin/tissues

Equipment Indications for Sterile Technique

✓ Massage lubricant or lotion as preferred by the ✓ When skin is intentionally perforated/incised
patient like in DR, OR
✓ Powder
✓ Bath blanket
✓ Towel
✓ Stethoscope
✓ Sphygmomanometer

✓ When skin is diseased/injured (burn)

PRINCIPLES OF SURGICAL ASEPSIS
Surgical Asepsis
• A system of practices to remove all
microorganisms from an object/area and to
prevent new microorganism from
contaminating it
Sterilization
• Complete elimination of all microorganisms ✓ When a catheter/surgical instrument is inserted
including spores from an item or area into a body cavity that is considered sterile

Methods of Sterilization
1. Moist Heat
➢ Use of steam under pressure where
temperature exceeds boiling point
➢ Autoclave
2. Dry Heat Sterilizer
➢ Operates like an oven used to sterilize Sterile Field
sharp instruments • A microorganism-free area
3. Radiation Establish a Sterile Field by:
➢ Used to sterilize drugs, food, and other ✓ Using the innermost side of a sterile wrapper
heat sensitive items ✓ Using a sterile drape
➢ Makes use of ionizing radiation to Maintain a Sterile Field by:
penetrate deeply into objects ✓ Wrapping equipment in a variety of materials
➢ Disadvantage: highly expensive and can like plastic, paper, glass
cause sterility among personnel
Principles of Surgical Asepsis
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1. All objects in the sterile field must be sterile
2. Sterile objects become unsterile when touched
by unsterile objects
3. Sterile items that are out of vision or below the
waist level of the nurse must be considered
unsterile
4. Sterile objects become unsterile by prolonged
exposure to airborne microorganisms
5. Fluid flow in the direction of gravity
6. Moisture that passes thru a sterile object draws
microorganisms from unsterile surfaces above
or below it to the sterile surface by capillary
action
7. The edges of a sterile field are considered
unsterile 4. Sterile drapes are used to create a sterile field.
8. The skin cannot be sterilized and is therefore Only the top surface of a draped table is
unsterile considered sterile
9. Conscientiousness, alertness and honesty are
essential qualities in maintaining surgical
asepsis

Basic Principles of Aseptic Technique

1. All materials in contact with the surgical wound
and used within the sterile field must be sterile
2. Sterile surfaces or articles may touch other
sterile surfaces or articles and remain sterile;
contact with unsterile objects at any point
renders a sterile are contaminated

5. Items should be dispensed to a sterile field by

methods that preserve the sterility of the items
and the integrity of the sterile field

3. Gowns of the surgical team are considered

sterile in front the chest to the level of the
sterile field

6. The movements of the surgical teams are from

sterile to sterile areas and from unsterile to
unsterile areas. Scrubbed persons and sterile
items contact only sterile only; circulating

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nurses and unsterile field items contact only Do’s and Don’ts
unsterile areas • Do keep your hands above your waist
7. Movement around a sterile filed must not cause • Don’t reach over the sterile field
contamination of the filed. Sterile areas must be • Don’t touch anything in the sterile field with
kept in view during movement around the area. your bare hands
At least a 1-foot distance from the sterile field • Don’t talk over the sterile field
must be maintained to prevent inadvertent • Don’t turn your back on the sterile field
contamination
EXTERNAL DOUCHE/PERINEAL CARE
External Douche
• Washing of genitals and anal area with plain
water and medicated solution
Perineal – Genital Care (Kozier)
• Referred to as perineal care or peri care

Indications:
✓ Patients who underwent perineal, rectal or
genital surgery

Purposes
8. Whenever a sterile barrier is breached, the area ✓ To cleanse area od secretion and excretion
must be considered contaminated. A tear or ✓ To reduce unpleasant odor
puncture of the drape permitting access to an ✓ To prevent skin irritation and excoriation
unsterile surface underneath renders the area ✓ To control the potential for infection
unsterile. Such a drape must be replaced ✓ To promote comfort
9. Every sterile field should be constantly
monitored and maintained. Items of doubtful
Assess for the presence of:
sterility are considered unsterile. Sterile fields
✓ Irritation, excoriation, inflammation, swelling
should be prepared as close as possible to the
✓ Excessive discharge
time of use.
✓ Odor; pain or discomfort
✓ Urinary or fecal incontinence
✓ Recent rectal or perineal surgery
✓ Indwelling catheter

Female Anatomy and Physiology

Additional Principles:
1. Tables are sterile only at table level
2. Unsterile persons avoid reaching over a sterile
field; sterile persons avoid leaning over an
unsterile area

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➢ Contains more nerve endings than the glans
penis
➢ Very sensitive because of rich nerve supply
➢ Sensitive to temperature and touch
➢ Secretes a fatty substances called the smegma
Vaginal Orifice
• Elastic partial fold of tissue surroundings
opening to the vagina
Urethral Orifice
• External opening to the urinary bladder
Perineum
• Muscular, skin-covered area between vaginal
opening and anus

Episiotomy Assessment
R – redness
E – Edema
E – Ecchymosis
D – Discharge
A – Approximation

Secretions Post Delivery

Lochia Rubra (1-3 days)
• Dark-red discharges in moderate amount
Labia Minora
Lochia Serosa (4th-7th day)
➢ Thinner, lengthwise with hairless skin
• Pinkish to brownish discharges in decreased
➢ Fxn: glands in the labia minora lubricates the
amount
vulva
Lochia Alba (8th day – 2 weeks)
• Whitish scantly discharges
Clitoris
➢ Small erectile organ located beneath the arch of
the pubis

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Equipment
1. Bedpan with cover
2. Waterproof underpad
3. Bath blanket
4. A tray containing the ff:
a. Sterile covered flushing can with sterile
water or solution to be used
Postpartum Hemorrhage b. Sterile pick up forceps in a disinfectant
• Defined as blood loss of: solution
o 500 ml or more – after vaginal birth c. A jar of dry sterile CB
o 1000 ml or more – after cesarean birth d. A jar sterile CB soaked in soap sud solution
e. A jar of sterile CB soaked in antiseptic
Characteristics of Bleeding solution
➢ From birth of fetus until separation of placenta, f. Kidney basin lined in paper for waste
the character and quantity of the blood passed g. Toilet paper (patient’s supply)
can suggest excessive bleeding h. A piece a paper to wrap vaginal pads
✓ Dark blood – venous (superficial i. Working forceps in a sterile packs
laceration) j. Working gloves
✓ Bright blood – arterial (deep) 5. Adult diaper or sanitary pad (patient’s supply
✓ Spurts of blood with clots – partial Cleaning Process/Direction:
placenta separation

What else to assess?

✓ Assess also if the discharge is dark red – this
may indicate retained placental fragments
✓ Check also for the smell – must never have foul,
musty smell, may indicate infection
✓ Check for the amount of discharge – if it
exceeds 250 – 300 cc of blood, this may indicate
post-partum hemorrhage

Hypovolemic Shock
Shock - an emergency situation, with 30%-40% blood
loss

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Scrotum
Male Anatomy and Physiology ➢ A small walnut shaped wrinkled bag of skin that
Circumcised Adult Penis holds the testicles
Testicles
➢ Where seminiferous tubules are found
➢ Manufactures more than 250 million sperm
cells each day

Penis
• Consist of spongy tissue called cavernous
bodies-sound fill with blood
• Main vehicle used to transport semen from the
male into the vagina of the female for
Prostate Gland
reproductive purposes
➢ Acts as a control mechanism to stop urine
and semen from mixing together
➢ Urine and semen are discharged through
the urethra

Uncircumcised Penis and Circumcised Penis

Male External Douche

1. Meatus to glans penis in circular motion
2. Sulcus or base of glands penis
3. Shaft downward stroke only
4. Base of shaft 1x only
5. Scrotum 1 direction only (going away)
6. Back to scrotum going to perineal area
7. Perineal area in zigzag motion up to anus
Note: if the client is uncircumcised, retract the prepuce
(foreskin) to expose the glans penis (the tip of the penis)
for cleaning. Replace the foreskin after cleaning the
glans penis.

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URINARY ELIMINATION Altered Urinary Production
Urinary System ➢ Normal range of urine output (30-60 cc/hour)
• A system of organs that produce and excrete ➢ Polyuria – more than 100 cc/hr
urine, the liquid waste product of the body ➢ Oliguria – less than 30 cc/hr
Components ➢ Anuria – less than 10 cc/hr or none
o Kidneys
o Ureters Altered Urinary Frequency
o Bladder ➢ Frequency
o Urethra ➢ Nocturia – increased urinary frequency at night
➢ Urgency – urge to void but different in voiding
Functions of the Urinary System ➢ Incontinence
• Ureters transport urine from kidneys to the ➢ Retention
urinary bladder ➢ Dysuria – painful urination
• Bladder stores urine ➢ Hesitancy – difficulty in initiating voiding of at
• Urethra discharges urine from the body least 5 sec
• Kidneys excrete wastes in urine, regulate blood ➢ Pollakuria – frequent, scantly urination
volume and composition, help regulate blood
pressure, synthesize glucose, release Clinical Signs of Urinary Retention
erythropoietin and participate in Vit. D a. Discomfort
synthesis b. Bladder distention
c. Inability to avoid or frequent voiding of small
Normal Urine volumes
Routine Urinalysis d. A disproportionately small amount of output in
➢ pH: 4.6-8.0 relation to fluid intake
➢ Appearance: clear e. Increasing restlessness and feeling of need to
➢ Color: amber/straw void
➢ Odor: aromatic
➢ Specific gravity: 1.010-1.025 Nursing Interventions to Induce Voiding
➢ Protein (albumin): absent 1. Provide privacy (most effective)
➢ Glucose: none 2. Encourage increased OFI (unless
➢ Ketones: none contraindicated) CHF, CRF
➢ Blood: up to 2 RBCs CRF- decreased function of kidneys
➢ Microscopic exam: 3. Assist the patient in the anatomical position of
✓ RBC: 1-2/low power field voiding
✓ WBC: 0-4/ low power field 4. Serve clean, warm and dry bedpan or urinal
✓ Bacteria: none 5. Allow the patient to listen to the sound of
Problems in Urinary Elimination running water
➢ Altered urine composition 6. Dangle fingers of patient in warm water
➢ RBC (hematuria) 7. Pour warm water over the perineum
➢ Pus (pyuria) 8. Provide adequate time for voiding
➢ Bacteria 9. Perform crede’s maneuver as ordered
➢ Albumin (albuminuria) o If bladder is distended C/I crede’s. order
➢ Protein (proteinuria) if with difficulty in voiding and without
➢ Glucose (glucosuria) distention
➢ Ketones (ketonuria) 10. Administer cholinergic as ordered

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Types of Catheter ✓ Contractures
1. Straight ✓ Open wound
o For urine specimen, also for one time
removal of urine from bladder 2 forms of Heat Application
2. 2 way or retention or foley cath ✓ Dry
3. 3 way catheter for cytolysis (for continuous ✓ Moist
bladder irrigation) – for BPH, or for instilling
medications into the bladder Forms of Heat Application: Dry Heat
➢ Applied locally (heat conduction)
Heat and Cold Application ✓ Hot water bottle
✓ Aquathermia pad
Heat and Cold: Local and Systemic Effects ✓ Disposable heat pack
✓ Electric pad
1. Hot water bag/bottle
• Measure the temperature of the water
using a bath thermometer
• Fill the bag about two-thirds full. Expel
the remaining air and secure the top.
With the air removed, the bag can be
molded to the body part
• Dry the bag and hold it upside down to
test for leakage
• Wrap the bag in a towel or cover and
place it on the body site
• Remove for 30 minutes or in
accordance with agency protocol
Physiological Response
✓ Local effects of heat Forms of Heat Application: Moist Heat
✓ Causes vasodilation (skin red and warm) ➢ Moist heat can be provided by:
✓ Increase blood flow to affected area ✓ Compress
✓ Increased oxygen, nutrients, and antibodies ✓ Hot pack
✓ Soak
Heat ✓ Sitz bath
✓ Increases inflammatory process by increasing Physiologic Response
both the action of phagocytic cells that ingest ✓ Systemic effects
foreign material ✓ Local application done in a large body area
✓ Promotes soft tissues healing and increases ✓ Increase CO and pulmonary ventilation d/t
suppuration increase peripheral vasodilation which diverts
✓ Increases blood flow, dissipates heat large supplies of blood (internal) organs and
products decrease BP
Heat Application ✓ Sx: fainting, evident much in patient with
Warning circulatory disturbance: atherosclerosis
➢ Increase capillary permeability – edema
formation or increasing existing edema Cold Application
Indications ✓ More recent than heat therapy
✓ Joint stiffness from arthritis ✓ Effects are opposite with heat
✓ Low back pain

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✓ Decrease temperature of skin and underlying Precautions (Specific Conditions)
tissue-can cause vasoconstriction a. Neurosensory impairment
o Decrease blood flow (dec. 02 supply, b. Impaired mental status
metabolites, waste removal) c. Impaired circulation
✓ Sx. Skin pallor, bluish discoloration, coolness d. Immediately after injury or surgery
✓ Decrease blood flow – help control bleeding e. Open wounds
✓ Prolonged exposure – cell deprivation and REBOUND PHENOMENON
subsequent damage to tissues
• heat produces maximum vasodilation
✓ Sx – bluish-purple mottled appearance of skin
• in 20-30 mins. Beyond 30-45 brings
numbness, stiffness, pallor, blister, pain
Indicated: tissue congestion and bld. vessel
constrict
• Sprains, strains, fractures
• risk for burns
▪ Limit after injury swelling, and
• cold produces maximum constriction
bleeding
• 15 degree (60°F); beyond 15
Systematic Effects
vasodilation begins (protective mech)
✓ BP increase due to blood is shunted from the
cutaneous to internal blood vessels (body’s APPLYING HEAT & COLD
attempt to maintain core temp.)
✓ SX: shivering – a generalized effect of prolonged • Conduction: hot water bags, electric pads
cold (is normal to warm patient’s body) • Radiation: heat lamps, heat cradles apply dry
heat
• Conduction: hot compress, sitz bath, soaks
VARIABLES AFFECTING PHYSIOLOGICAL TOLERANCE TO provides moist heat
HEAT & COLD • Follow guidelines
• BODY PART – The back of the hand and foot are GUIDELINES
not very temperature sensitive. In contrast, the
inner aspect of the wrist and forearm, the neck, • Determine – Determine the client’s ability to
and the perineal area are temperature tolerate the therapy.
sensitive. • Identify – Identify conditions that might
• SIZE OF THE EXPOSED BODY PART – The larger contraindicate treatment (e.g., bleeding,
the area exposed to heat and cold, the lower circulatory impairment).
the tolerance. • Explain – Explain the application to the client.
• INDIVIDUAL TOLERANCE – The very young and • Assess – Assess the skin area to which the heat
the very old generally have the lowest or cold will be applied.
tolerance. Individuals who have neurosensory • Ask – Ask the client to report any discomfort.
impairments may have a high tolerance, but the • Return – Return to the client 15 minutes after
risk of injury is greater. starting the heat or cold therapy and observe
• LENGTH OF EXPOSURE – People feel hot and the local skin area for any untoward signs (e.g.,
cold applications most while the temperature is redness). Stop the application if any problems
changing. After a period of time, tolerance occur
increases. • Remove – Remove the equipment at the
• INTACTNESS OF SKIN – Injured skin areas are designated time and dispose of it appropriately.
more sensitive to temperature variations. • Examine – Examine the area to which the heat
or cold was applied and record the client’s
response.

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CONTRAINDICATIONS WITH USE OF HEAT Electric pads
APPLICATION
• constant, even heat, are lightweight, can be
• The first 24 hours after traumatic injury molded to a body part. May burn pt if setting is
• Active hemorrhage or bleeding too high. E
• Non-inflammatory edema
• Localized malignant tumor Heat cradle
• Skin disorder that causes redness and blisters • metal frame with a row of 25-watt light
bulbs.cradle place over
CONTRAINDICATIONS WITH USE OF COLD • pt and cover w/blanket pt assessed every 10
APPLICATION minutes
• Open wounds • Heat is provided by radiation
• Impaired circulation
• Allergy or hypersensitivity Heat Ice
Heat lamp – gooseneck Ice bag, ice glove, ice
TEMPERATURE FOR HEAT AND COLD APPLICATION lamp with a 60-watt bulb. collar – either filled
Lamp placed 45-60 cm (18- with ice chips or with
24 inches) from the area to ROH based solution
be heated (cold to specific area)
• heat provided is radiation

MOIST HEAT AND COLD

Compresses
DRY HEAT AND COLD
• either warm/cold Is a moist gauze dressing
Hot water bag applied frequently to an open wound. HOT
compress are ordered, solution heated to the
• used in the home temp ordered/agency protocol
• inexpensive yet dangerous If with skin break
• Normal adult – 52C (125F) • Sterile technique (sterile; gloves)
• Debilitated/unconscious – 40.5-46C (105-115F) • Sterile thermometer (if not poss. Measure in a
• Child under 2 y.o. – 40.5-46C (105- 115F) small basin some contents of that water and
Aquathermia pad discard after)
• Hot compress applied hasten healing
• aquamatic pad, K-pad (pad constructed with • Cold compress prevent/decrease, bleeding, dec
tubes containing water,pad is attached by inflammation
tubing to an electrically powered control unit
that has an opening for for water & temp gauge Packs

Hot & cold packs • is a moist cloth applied to the body part. May
be hot/cold. Unsterile, after application, usually
• commercially prepared provide heat/cold at covered w/ moistureresistant matl (plastic
designated time. Prep depends on wrap)
manufacturer (squeezing,striking) • (contain moisture, prevent transfer
microorganism)
• Hot packs – relieve muscle spasms/pain reduce
pressure of accumulated fluid in a tissue/joint,
congestion in underlying organ.

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• Cold packs – prevent swelling of the tissues.
Soaks
• immersing a body part in a solution or wrapping
a part in gauze dressings and then saturating
the dressing with a soln. (STERILE TECH)
Sitz Bath
• (40-43C)/(105-110F)
• Hip bath, soaks pt pelvic area in a special
tub/chair usually immersed fr. the midthighs to
the iliac crest or umbilicus duration 15-20
minutes
Cooling sponge baths
• 18-32°C (65-90F)
• Purpose-dec. pt. Fever thru heat loss by air
conduction and vaporation
• H2O & ROH – used before to remove body heat
rapidly yet DRYING EFFECT
Tepid Sponge Bath
• water temp is 32°C(90F) beginning of the bath
• lowered gradually to 18°C (65F) by adding ice
chips during the bath
• Fan may be used to increase air movement (dec
pts temp by convection)
• Some requires M.D. order, other w/o

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