Blezel G.

Torregosa, RN
Communication in Nursing
• Communication
– Helping – healing relationship
– Essential Nurse – Patient Relationship
• Vehicle – therapeutic relationship
• Includes influencing another which is a
successful outcome of Nurse – Patient
Interaction
Basic Elements
• Sender – encoder
• Message – content
– either verbal or nonverbal
• Receiver – decoder
• Feedback – message returned by receiver
Modes of Communication
• Verbal
– Spoken / written
– Ex: dialogue, document
• Non-Verbal
– Gestures, Facial Expression, Posture/Gait, Body
Movement, Physical Appearance & Body Language
NURSING PROCESS
• Systematic approach – step process
• Identify human response – plan – intervene –
evaluate
• Assessment
• Diagnosis, Nursing
• Planning
• Intervention
• Evaluation
Assessment
• Establish and verify a data about the patient
• Interview, observe, review health history,
perform PR, evaluate laboratory results,
interact with health team
Analysis
• Examine the data
• Analyze – conclusion
• Compare findings to normal
• Nursing Diagnosis
– Actual / Potential
Planning
• Assign prioritize to Nursing Diagnosis
• Specify goals
• Identifying interventions
• Specifying expected outcomes
• Document in the Nursing Care Plan
Goals
• Goals – general statement
– Patient centered
– Long term – takes times
– Short term – quick
– Specific
– Measurable
– Attainable
– Realistic
– Time-bounded
Maslow’s Needs
Implementation
• Action -> care patient
• It includes:
– Assisting patient in ADLs
– Counseling & Educating patient and family
– Giving care to patients
– Supervising & Evaluating the work of other
members of the health team
Types of Intervention
• Independent
– Within scope of nursing practice
• Dependent
– Order physician
• Interdependent
– Shared with other health team
Evaluation
• Measure patient’s response
• Observe results to expected outcomes
Beneficence, Non-maleficence
• Beneficence
• Beneficence is action that is done for the
benefit of others.
• expected to refrain from causing harm, but
they also have an obligation to help their
patients.

• Non-maleficence
• means “do no harm”
• must not do anything that would purposely
harm patients without the action being
balanced by proportional benefit.
Vital Signs
• When to assess VS:
– Admission
– Change condition
– Loss of consciousness
– Before and after diagnostic, surgery, activity
– After administration of medications that affect
heart and lungs
Temperature
• Types of Body Temperature
• A.) Core temperature
– Oral, Rectal, Tympanic, Bladder & Esophageal
• B.) Surface body temperature
– Axillary, skin (forehead)
Normal Temperature
Ranges

Oral 36.5 - 37.5

Axillary 35.8 - 37

Rectal 37 - 38.1

Tympanic 36.8 - 27.9

Oral
• Most accessible
• 2 – 3 minutes
• 15 minutes elapse between hot/cold foods
• Contraindication:
– Young children & infant
– Unconscious, disoriented
– Breath through mouth
– Seizure prone
– Dyspnea
– Using oxygen mask
– Coughing
– With oral lesions, post oral surgery with nasal pack
 Rectal
• Most accurate
• Position – lateral with his top leg flexed
• Provide privacy
• Lubricate before inserting
• Insert .5 – 1.5 inches
• 2 min in place
• Contraindication:
– Diarrhea
– Recent rectal surgery
– With anal fissure
– Significant hemorrhoids
– Myocardial Infarction (M.I)
– Clotting/Bleeding Disorders – hemophilia
Axillary
• Safest, non-invasive
• Pat dry
• Avoid rubbing
• Hold in place – 9 minutes
• Avoid if with lesions
• Use same thermometer on repeated taking
for consistency
Tympanic
• Lens should be clean and dry
• Stabilize head
– (0 – 3 y.o.) Gently pull the ear straight back and
slightly downward
– (> 3 y.o.) Back and upward
• Entire canal seal
• Do not touch tympanic membrane
• Hold in place for 1 second
Nursing Intervention in clients
with Fever
• Monitor VS
• Assess skin color and temperature
• Monitor WBC, hct and other labs
• Provide adequate foods and fruits
• Promote rest
• Monitor I&O
• Provide TSB (Tepid-Sponge Bath)
• Provide dry clothing & linens
• Give anti-pyretic as ordered
Pulse
• Wave of blood – contractions
• Adult = 60 – 100 bpm
• Tachycardia = > 100 bpm
• Bradycardia = < 60 bpm
• Irregular – uneven
• > Age = < Pulse Rate
• Adults: Radial (common), carotid
• Children: Brachial
• Other: Apical Pulse
 Pulse

Age Normal Range

1 year old 80 – 140 bpm
2 years old 80 – 130 bpm
6 years old 80 – 120 bpm
10 years old 60 – 100 bpm
and above
Respiration
• Rate – (N) 14 – 20 / min
• Best time to assess respiration after pulse
• 60 seconds
• Assess & record breath sounds
– Normal: bronchial, bronchovesicular
– Abnormal: Stridor, Wheeze, Friction rub,
Crackles, Rhonchi, Rales
Blood Pressure
• Adult: 90 – 132
• Elderly: 140 – 160
• Ensure client rested
• Use appropriate size of cuff
– Loose & wide, elevated arm = false low
– Narrow & tight, lowered arm = false high
• Take BP at the level of the heart
• Crying / Anxious – delay measurement of
BP to avoid false high BP
 Pain
• Consider patient description and observation
• Rank pain 1 – 10
– Ask:
– Where located?
– How long?
– How often occur?
– Describe pain.
– What makes pain worse?
• Observe Patient’s behavioral response
– Body language, moaning, grimacing, muscle
twitching
• Note physiological response which may be
sympathetic / parasympathetic
Interventions:
• Give emotional support
• Perform comfort measure
– ex.: backrub massage
• Cognitive therapy
– ex: use of guided imagery
Suctioning
• Asses the lungs before procedure for
baseline info
• Position:
• Conscious: semi-fowlers position
• Unconscious: lateral position
• Hyperoxygenate patient before and after
procedure
• Observe sterile technique
• Maximum time per suctioning: 15 seconds
– Adult: 10 seconds
– Pedia: 5 seconds
NGT (Nasogastric Tube)
• Semi-fowlers position
• Assess tube placement
– Aspirate gastric content & check for pH
– Instill 10 to 15 ml of air
• Height of feeding is 12 inches above the
tube’s point of insertion
• Client remains upright for 30 minutes
• Hazard: Regurgitation and Aspiration
– (R) side: facilitate gastric emptying
– (L) side: gastric delaying
Enema
• Check medical order
• Provide privacy
• Position: left lateral
• If abdominal cramps occur, temporarily
stop the flow until cramps are gone.
• D/C enema; if clear or bloody
Catheterization
• Verify medical order
• Strict asepsis
• Perineal care before procedure
• Length of catheter insertion:
– Male: 6 – 9 inches
– Female: 3 – 4 inches
• All collecting bags must be drained when
½ or ¾ full.
Principles of Medication
Administration
• ® Med – check label 3x
» Remove from cabinet, preparing
med, returning
• ® Dose
• ® Client – Patient identification
» State name, check ID band
• ® Route
• ® Time
 Parenteral Administration
• Intradermal (ID)
– Angle: 10 – 15*
• Subcutaneous (SQ)
– Obese: 90*
– Thin: 45*
• Intramuscular (IM)
– Angle: 90*
 Computation in Medication
Ordered Dose
Quantity = Dosage
Drug at Hand

• Sample Problem:
1. The doctor ordered 750 mg of Penicillin G IV
given to an adult patient. The vial was labeled
with Penicillin G 1 gram which was to be
dissolved in 10 ml of sterile water.
What is the dosage?
Solution: 750 mg
10 ml = Dosage
1 gram (1000 mg)
0.750 10 ml = Dosage

7.5 ml = Dosage
 Compute
1. The patient was to receive
a 500 mg dose of
Paracetamol syrup PO. The
stock reads 250 mg / ml.
What is the dosage?
 Computation in IV Regulation
Volume (cc) Drop Factor (gtt/cc)

Hours to run (hr) 60 min/hr

= Drop rate (gtt/min)

• Sample Problem:
1. The doctor ordered 2000 ml of PNSSiL to
be infused over a period of 24 hours. The
IV set reads 15 gtt/cc. What is the drop
rate in gtt/min?
Solution:
2000 cc 15 gtt / cc

24 hours
= Drop rate (gtt/min)
60 min/hr
83.33 cc 1 gtt
1 4 min
= Drop rate (gtt/min)

21 gtts / min = Drop rate (gtt/min)

 Compute
1. The patient was having
an IV infusion treatment
with 1 bottle of PLRiL to
be run over 9 hours. The
IV set reads 60 gtts/cc.
What is the drop rate?
Difference of Vial and Ampule
 Blood Transfusion
• Priority: Cross Matching x 3
» Rh incompatibility
» Patient’s name
» Serial number
» Blood type
• Blood Types: A, B, AB, O
• Timeline: 1st 30 min
» VS q 15 minutes
» KVO
» Don’t leave patient
• Solution: NSS
• Gauge: 18 G
• If with Reaction: Close BT line, Open NSS line, Report to
doctor
• Be culturally sensitive: religion, taboos