FUNDAMENTALS IN NURSING MIDTERM

- The most important criterion in effective

COMMUNICATION communication
➢ Means of exchange of information • Humor
➢ Basic component of human relationship - Can be a positive and powerful tool in the
Levels of Communication nurse-client relationship
1. Intrapersonal communication - Important to consider the client’s perception
- Self-talk - This does not require professional skill and
- Enhance positive interaction with the patient can easily change people's moods
and family Non-verbal Communication
- Affect’s the nurses’ behavior • Personal Appearance
2. Interpersonal communication - Our choice of clothing, hairstyle, and other
- Occurs between 2 or more people with a appearance factors
goal to exchange message • Posture and Gait
3. Small Group communication - How people walk and carry themselves
- Involves more than two individuals • Facial Expression
interacting with each other to complete a - Express the person’s genuine emotions
common task or achieve a common goal • Gestures
- Nurses require this communication to - Emphasize and clarify the spoken words
participate in team meetings, patient care E-mail- most common form of electronic
conferences, and teaching sessions communication
4. Organizational communication Factors influencing communication process
- Occurs within an organization 1. Development
Modes of Communication - Language, psychosocial, and intellectual
1. Verbal communication development move through stages across the
- Spoken/written/printed (visual) lifespan
2. Non-verbal communication 2. Gender
- Gestures, facial expressions, touch - Females and Males communicate differently
- Sometimes called body language - Females: tend to seek confirmation
Verbal Communication - Males: establish independence and negotiate
• Pace and Intonation status within a group
- May indicate interest, anxiety, boredom or - Minimize differences, establish intimacy
fear 3. Values and Perception
• Simplicity 4. Personal space
- Learn to select appropriate, understandable - Distance between people prefer in
terms interactions with others
- Use of commonly understood words, brevity ➢ Intimate distance
and completeness 1. Touching/ 0-1 ½ feet
• Clarity and Brevity 2. Ex: observing an incision, and
- Saying precisely what is meant restraining a toddler for an injection.
- Need to speak slowly and enunciate ➢ Personal distance
carefully 1 ½- 4 feet
- Brevity is using the fewest words necessary 2 Conversation with the client/family
• Timing and Relevance 3 assessing patients and performing
- Timing needs to be appropriate to ensure procedures
that words are heard ➢ Social distance
• Adaptability 1. 4-12 feet
- Spoken messages need to be altered in ➢ Public distance
accordance with behavioral cues from the 1. 12 feet and beyond
client. 5. Territoriality
• Credibility 6. Roles and Relationship
- Means trustworthiness and reliability 7. Environment
8. Congruence
 9. Interpersonal Attitudes ➢ Using neutral “I hear what you are
10. Boundaries expressions to saying”
Therapeutic Communication Techniques encourage patients to
➢ Attentive/ Active Listening- listening actively continue talking
and with mindfulness, using all the senses, and RESTATING “You say you are
paying attention to what the client says, does, and ➢ Repeating the exact going home soon.”
feels as opposed to listening passively with just words of the patient “Your mother wasn’t
to remind them what happy to see you?”
the ear. It is probably the most important
they said, to let them
technique in nursing and is basic to all other know they are being
techniques. heard.
➢ Visibly Turning In VERBALIZING THE P: “There is nothing
➢ Physically Attending’s 5 aspect IMPLIED to do at home.”
S- sit squarely facing the patient ➢ Rephasing the N: “It sounds as if
O- observe an open posture patient’s words to you might be bored at
L- lean forward toward the client highlight an home”
E- establish eye contact underlying message.
R- relax CLARIFICATION “What do you mean
➢ Asking patient to by feeling sick
TECHNIQUES EXAMPLE restate, elaborate, or inside?”
OFFERING SELF “I’ll sit with you give examples of “Give me an example
➢ Making self- awhile” ideas or feelings of feeling lost”
available and MAKING “You seem restless”
showing interest and OBSERVATIONS
concern ➢ Commenting on what
is seen or heard to
ACTIVE LISTENING Face the patient, encourage
➢ Paying close maintain eye contact, discussion.
attention to verbal be open, alert, and PRESENTING REALITY “I know the voices
and non-verbal patient; respond ➢ Offering a view of are real to you, but I
communications, appropriately. what is real and what do not hear them”
patters or thinking, is not without
feelings and arguing with the
behaviors. patient.
SILENCE Maintain eye contact, ENCOURAGING “What do you think is
➢ Planned absence of convey interest and DESCRIPTION OF happening to you
verbal remarks to concern in facial PERCEPTION right now?”
allow patients to expressions. ➢ Asking for patient’s
think and say more. view of their
EMPHATY “I can hear how situation.
➢ Recognizing and painful it is for you to VOICING DOUBT “It’s hard to believe
acknowledging talk about this.” ➢ Expressing that.”
patient’s feelings. uncertainty about the “IS that the only way
(Nurse doesn’t lose reality of patient’s to interpret it?”
the objectivity in perceptions and
understanding the conclusions
client’s feelings) PLACING AN EVENT IN “When did you do
QUESTIONING “What happened? Tell TIME/SEQUENCE this?”
➢ Using open-ended me about it.” ➢ Asking for
questions to achieve 4 W’s relationship among
relevance and depth - WHAT? events
in discussion. - WHO? ENCOURAGING “How does this
- WHERE? COMPARISONS compare to the last
- WHY? ➢ Asking for time?”
GENERAL LEADS “Go on. I’m similarities and
listening” differences among
 feelings, behaviors, “What is different ENCOURAGING “What exactly will it
and events about your feelings FORMULATION OF A take to carry out you
today?” PLAN OF ACTION plan?’
IDENTIFYING THEMES “So, what do you do ➢ Probing for step-by- “What else do you
➢ Asking patients to each time you argue step actions that will need to do?”
convey recurrent with your wife?” be needed.
patterns of thoughts, TESTING OUT NEW “Tell me exactly what
feelings, and BEHAVIOR you will tell your
behaviors. REHEARSING wife on Sunday.”
SUMMARIZING “So far, you have ➢ Requesting a verbal
➢ Reviewing main said…” description of what
points and will be said or done
conclusions REPLAYING “I’ll play the
FOCUSING “Explain more ➢ Practicing behaviors employer to interview
➢ Pursuing a topic until about…” (the nurse plays a you…”
its meaning or role)
importance is clear. SUPPORTIVE “I know this isn’t
INTERPRETING “It sounds as if this is CONFRONTATION easy to do, but I think
➢ Providing a view of very important to ➢ Acknowledging the you can do it”
the meaning or you?” difficulty in changing
importance of “You seem to get in but pushing for
something trouble when you…” action
ENCOURAGING “How serious is this LIMIT SETTING “That’s a negative
EVALUATION for you?” ➢ Discouraging non- comment. Tell me
➢ Asking for patient’s “How important is it productive feelings something positive
views of the meaning to change this and behaviors, and about yourself”
or importance of behavior?” encouraging
something. productive ones
SUGGESTING “Let see if we can FEEDBACK “When you said…I
COLLABORATION find an answer” ➢ Pointing out specific felt…”
➢ Offering to help behaviors and giving
patients to solve impressions on
problems reactions
ENCOURAGING GOAL “What do you think ENCOURAGING “What was your
SETTING needs to change?” EVALUATION husband’s reaction?”
➢ Asking patient to ➢ Asking patient to
decide on the type of evaluate their actions
change needed and the outcomes
GIVING INFORMATION “There are self-help REINFORCEMENT “This new approach
➢ Providing groups available.” ➢ Giving feedback on worked for you. Keep
information that will “I can tell you about positive behaviors it up”
help patients make your medications”
better choices
ENCOURAGING “What might happen
CONSIDERATION OF if you try…?”
OPTIONS
➢ Asking patient to
THE NURSING PROCESS
consider the pros and ✓ a systematic, rational method of planning and
cons of possible providing individualized nursing care
options. ✓ a deliberate way of thinking by the nurses using
ENCOURAGING “Which is the best an organized, systematic framework (or
DECISIONS alternative for you?” structure) of interrelated activities that is a
➢ Asking patient to scientific problem-solving approach towards
make a choice among individualized dynamic and continuing
options interpersonal care for clients changing responses
and needs
Purpose: e. Consult with the client, his significant
➢ identify client’s health status others
➢ to establish plans to meet the identified needs
➢ to deliver specific nursing interventions to
meet those needs
Overview of the Nursing Process
• Process:
- “A series of steps or acts that lead to
accomplishment of some goal or purpose”
• Purpose is to provide client care that is:
- Individualized
- Holistic
- Effective
- Efficient
CHARACTERISTICS OF THE NURSING
PROCESS
•Open and Flexible
•Client Centered
•Individualized to meet the client’s needs
•Interpersonal and Collaborative
•Planned
•Goal-directed
•Permits creativity

ACTIVITIES DURING ASSESSMENT:

1. Collecting Data
- gathering information about the client,
METHODS OF COLLECTION OF DATA
considering the physical, psychological,
a. Interview
emotional, socio-cultural, and spiritual
- planned purposeful U
factors that may affect his/her health status
- therapeutic communication
2. ASSESSMENT IS CONTINUOUSLY
- social communication
UPDATED!!!
b. Observation
3. Steps in the assessment phase of the nursing
- use of senses, use of units of measure,
process:
physical examination techniques,
1. Establish a data base by
interpretation of laboratory results
a. Taking the client’s vital signs
b. Performing a head-to-toe examination
SOURCES OF DATA
c. Taking a complete nursing history
a. Primary
d. Reviewing the client’s chart
- patient/ client
 b. Secondary - relates to the client’s preparedness to
- family members, significant others, patient’s implement behaviors to improve their health
record/chart, health team members, related condition
literature -Eg.: Readiness for Enhanced Nutrition

3. A risk nursing diagnosis

- a clinical judgment that a problem does
not exist, but the presence of risk factors
indicates that a problem is likely to develop
unless nurses intervene
- Risk for Infection

4. Syndrome Diagnosis
- assigned by the nurse clinical judgement to
4. Verifying/ Validating Data: describe a cluster of nursing diagnoses
- making sure your information is accurate that have similar interventions
- ex. If client says he ambulates without difficulty
but wife says he uses a cane FORMULATING DIAGNOSTIC STATEMENTS
5. Organizing Data: 1. Basic two-part statements
- clustering facts into groups of information - Problem (P)
- Etiology (E)
DIAGNOSING ➢ Joined by the words "related to”
- Add words if NANDA label contains the
➢ the process which results to a diagnostic statement word Specify
or nursing diagnosis
➢ clinical act of identifying problems
➢ to diagnose in nursing, it means to analyze
assessment information and derive meaning from
this analysis

2. Basic three-part statements

- PES format
• Problem (P)
• Etiology (E)
• Signs and symptoms (S)
- Recommended for beginning diagnosticians
- List signs and symptoms grouped by
subjective and objective data

STATUS OF THE NURSING DIAGNOSES:

1. An Actual Diagnosis
- is a client problem that is present at the
time of the nursing assessment; based on
the presence of associated signs and
symptoms
- Ineffective Breathing Pattern and Anxiety

2. A health promotion diagnosis

 PLANNING

Guidelines for Writing Goal/Outcome Statements

• Write in terms of the client responses
• Must be realistic
• Ensure compatibility with the therapies of
➢ Determining the strategies to be taken before the other professionals
implementation of nursing care • Derive from only one nursing diagnosis
➢ To be effective involve the client and family in • Use observable, measurable terms
planning • S - specific
➢ Establish priorities • M- measurable
- life threatening situations should be given • A - attainable
highest priority • R - realistic
-use the principle of ABC’s (Airways, • T - time-framed
Breathing, Circulation)
-use Maslow’s hierarchy of needs IMPLEMENTATION

➢ Is putting the nursing care plan into action

➢ The goal is to carry out planned nursing
interventions to help the client attain goals and
achieve optimal level of health
ACTIVITIES:
• Reassessing
- to ensure prompt attention to emerging problems
• Set priorities
- to determine the order in which nursing
interventions are carried out
• Perform nursing interventions
- these maybe independent, dependent or
collaborative
• Record actions
➢ Goals maybe short term or long term - to complete nursing interventions, relevant
• Short-term goal documentation should be done
- can be met in a relatively short period
(within days or less than a week) TYPES OF NURSING INTERVENTIONS
• Long-term goal 1. INDEPENDENT OR NURSE- INITIATED
- requires more time (several weeks or INTERVENTIONS
months) - Autonomous action based on scientific
rationale that is executed to benefit the client
in a predicted way related to the nursing
diagnosis and client-centered goals.
 - Without consultation or collaboration METHODS IN DOCUMENTATION
with physicians or other health care • Narrative
professionals • PIE (problem, interventions, evaluation)
- Example: nurse gives health teachings on “SOMETHING THAT IS NOT WRITTEN IS
the ill- effects of cigarette smoking alcohol CONSIDERED AS NOT DONE”
abuse and drug abuse
2. DEPENDENT OR PHYSICIAN –
INITIATED INTERVENTIONS HEALTH PROMOTION
- The nurse intervenes by carrying out Maslow’s Hierarchy of needs
physician’s written orders, but requires
nursing judgement or decision making
- Example: The nurse administers antibiotics
to the client with infection
3. INTERDEPENDENT OR
COLLABORATIVE INTERVENTIONS
- therapies that require the knowledge, skills
and expertise of multiple health care
professionals.
- Example: The nurse assists the client in
walking using crutches after conferring with
the physical therapist

REQUIREMENTS OF IMPLEMENTATION • Physiological Needs- air, food, water, shelter, rest,

• Knowledge sleep, activity and temperature maintenance are crucial
• Technical Skills for survival
• Communication Skills • Safety and Security Needs- has both physical and
• Therapeutic Use of self psychological aspects; person need to feel safe, both in
the physical environment and in relationships
EVALUATING • Love and Belonging Needs- giving and receiving
affection, attaining a place in a group and maintaining a
➢ is assessing the client’s response to nursing feeling of belonging
interventions and then comparing the response to • Self-esteem Needs- needs self- esteem and esteem
predetermined standards or outcome criteria from others
• Self-actualization- innate need to develop one’s
maximum potential and realize one’s abilities and
qualities
LEVELS OF PREVENTION
1. PRIMARY PREVENTION
- focuses on health promotion and protection
against specific health problems
- prevention or delay of the actual
occurrence of a specific illness or disease
 - the purpose is to decrease the risk of 1. Environmental
exposure of the individual or community to - ability not promote health measures to
- disease improve the standard and quality of living
- Health promotion-ex. good nutrition, - includes influences (food, water, air)
exercise, avoid stressors 2. Social
- Specific protection- ex. immunizations, - ability to interact successfully
protection from accidents (helmet, seatbelt) - to develop and maintain intimacy
2. SECONDARY PREVENTION 3. Emotional
- also known as health maintenance - ability to manage stress and to express
- focus on early identification of health emotions appropriately
problems and prompt intervention to - express feelings and accept one’s limitations
alleviate health problems 4. Physical
- ex. Breast self-examination, annual physical - ability to carry out tasks, achieve fitness
examination and maintain adequate nutrition
- Screenings: Blood Pressure, cholesterol, 5. Spiritual
glaucoma, HIV, Skin Cancer - a belief in some force; person’s own morals,
- Pap smear values and ethics
- Mammograms 6. Intellectual
- Testicular examinations - the ability to learn and use information
- Family counseling effectively; striving for continued growth
- TB screening and learning to deal with challenges
- Genetic counseling 7. Occupational
3. TERTIARY PREVENTION - the ability to achieve a balance between
- restoration and rehabilitation work and leisure time
- occurs after a disease or disability has ➢ Well-being is a subjective perception of vitality and
occurred and the recovery phase has begun feeling well; can be described objectively, experienced,
- With the goal of returning the individual to and measured
an optimal level of functioning MODELS OF HEALTH
- ex. cardiac rehabilitation, CBC before ➢ Attempts to explain health and in some instance its
chemotherapy, blood glucose monitoring relationship to illness and injury
- Medications ➢ (CARE)
- Medical therapy • Clinical Model
- Surgical treatment - The narrowest interpretation of health;
- Rehabilitation health is the absence of signs and symptoms
- Physical therapy of disease or injury
- Occupational therapy - Considered the state of not being “sick”
- Job training • Adaptive Model
- Disease is a failure in adaptation or
maladaptation. The aim of the treatment is to
HEALTH, WELLNESS AND ILLNESS assist the person to cope or adapt
- The focus of this model is stability, there is
also an element of growth and change
HEALTH • Role Performance Model
➢ state of complete physical, mental and social well- - Health is defined in terms of an individual’s
being and not merely the absence of disease or ability to fulfill societal roles, that is to
infirmity (WHO) perform his/her work
➢ the ability to maintain homeostasis - People who can fulfill their roles are
➢ state and a process of being and becoming an healthy even if they have clinical illness
integrated and whole person (Roy) • Eudaimonistic Model
WELLNESS AND WELL- BEING - Health is defined as a condition of
➢ Wellness is a state of well-being actualization or realization of a person’s
➢ There are seven components of wellness potential
 -Illness is a condition that prevents self- - How the person feels towards sickness
actualization TYPES OF ILLNESS
AGENT-HOST-ENVIRONMENT MODEL 1. Acute illness
Has 3 dynamic interactive factor or stressor - Typically characterized by symptoms of
1.Agent- any environmental factor or stressor that by its relatively short duration
presence or absence can lead to illness or disease 2. Chronic Illness
2. Host- person/s who may or may not be at risk of - One that lasts for an extended period,
acquiring a disease; family history, age, and lifestyle usually 6 months or longer
habits influence the host’s reaction - Remission (when the symptoms disappear),
3. Environment- all factors external to the host; - Exacerbation (when the symptoms
climate conditions, sound, noise levels economic level, reappear)
Loss of family, spouse, closest friend living conditions
(may affect mental health) THE FIVE STAGES OF ILLNESS
*These factors constantly interact with the others, 1. SYMPTOM EXPERIENCE
when the variables are in balance, health is - the person believes something is wrong;
maintained, when the variables are not in balance, experience some symptoms
disease occurs - 3 aspects
HEALTH BELIEF MODEL 1. Physical experience of symptoms
➢ concerned with what people believe or perceive to 2. Cognitive aspect (interpretation of the
be true about themselves in relation to their health symptoms)
➢ INDIVIDUAL PERCEPTIONS: 3. Emotional response (anxiety, fear)
1. Perceived susceptibility - usually consults others about the symptoms
- awareness of personal high-risk lifestyle or feelings, validating with support people
behaviors; if with family history, may make that the symptoms are real
individual feel at increased risk 2. ASSUMPTION OF THE SICK ROLE
2. Perceived seriousness - accepts the sick role and seeks
- does the illness cause a death or have serious confirmation form family and friends
consequences - When symptoms of illness persist or
3. Perceived threat increase, the person is motivated to seek
- combined perceived susceptibility and professional help
perceived seriousness 3. MEDICAL CARE CONTACT
➢ MODIFYING FACTORS - seeks advice of health professionals for the
-factors that modify a person’s perceptions following reasons:
*Demographic variables *Validation of real illness
*Sociopsychological variables *Explanation of symptoms
*Structural variables *Reassurance that they will be alright or
*Cues to action prediction of what the outcome will
➢ LIKELIHOOD OF ACTION be.
-perceived benefits of the action 4. DEPENDENT CLIENT ROLE
*In order to prevent from lung cancer, one - the person becomes a client dependent on
refrains from smoking and to maintain the health professional for help
weight, one eats nutritious foods 5. RECOVERY OR REHABILITATION
-perceived barriers to action - resumes former roles and responsibilities
*Inconvenience, lifestyle changes - for clients with acute illness, the recovery is
rapid
ILLNESS AND DISEASE - for those people with long term illness, they
may find recovery more difficult
ILLNESS DISEASE
-Highly personal state in which the person’s physical, -an alteration in body functions resulting in a reduction
emotional, intellectual, social, development or spiritual of capacities or a shortening of the normal lifespan
functioning is thought to be diminished
-highly subjective; may or may not be related to disease
 • Late signs- bradycardia, dyspnea, decreased systolic
OXYGENATION BP cough, hemoptysis
ALTERED BREATHING PATTERN
FACTORS AFFECTING RESPIRATORY 1. Rate
FUNCTION • Tachypnea- rapid respiratory rate
• Bradypnea- slow respiratory rate
1. Age • Apnea- cessation of breathing
- Changes compromised by infection, physical 2. Volume
or emotional stress, surgery, anesthesia, or • Hyperventilation- excessive amount of air in the
other procedures. lungs___ It results from deep rapid respiration
- Chest wall, airways more rigid and less • Hypoventilation- decreased rate and depth of
elastic respiration___ It causes retention of carbon
- Increased risk of aspiration from GERD dioxide
- (Gastroesophageal reflux disease) 3. Rhythm
2. Environment • Cheyne- stokes. Rhythmic waxing, waning of
- Heat- increase environmental temperature is respirations from very deep to very shallow
accompanied by vasodilatation increases O2 • Kussmaul’s ( Hyperventilation). Increased rate
demand and depth of respiration, seen in metabolic acidosis
- Pollutants and renal failure.
3. Lifestyle • Apneustic- Prolonged gasping inspiration, followed
- Cigarette smoking by a very short, usually inefficient expiration.
- Occupation • Biot’s- Shallow breaths interrupted by apnea.
- Sedentary life style 4. Ease of effort
OTHERS: • Dyspnea-Difficulty breathing
1. BODY POSITION • Shortness of breath (SOB)
- Upright position allows greatest ease of • Nostril flaring
lung expansion • Increased heart rate
- Lying position causes the greatest difficulty • Orthopnea-Difficulty breathing while lying down
of expansion
2. ACTIVITY AND EXERCISE
- Strenuous exercise increases oxygen
demand by the body and carbon dioxide
production which results in increase depth
and rate of respiration
3. PREGNANCY
- The pregnant uterus is large enough to
displace the diaphragm upward
- Excess weight during pregnancy increases
oxygen demand and CO2 production
4. BODY WEIGHT
- Protuberant abdomen displaces the
diaphragm upward

Eupnea –Is normal breathing.

- It is effortless, noiseless breathing.

ALTERATION IN RESPIRATORY FUNCTION

Hypoxia
• insufficient oxygenation of tissues.
Clinical signs of hypoxia
Early Signs- tachycardia, increased rate and depth or
respiration, slight increase in systolic BP
 CONDITIONS AFFECTING DIFFUSION
• Hypoxemia
• Reduced oxygen level in blood
• May be caused conditions that impair alveolar-
capillary diffusion (e.g., pulmonary edema)
• Hypoxia
• Signs and symptoms
• Flaring of nares
• Substernal or intercostal retractions
• Cyanosis
• Bluish discoloration of skin, nail beds, mucous
membranes due to reduced hemoglobin-oxygen
saturation
• Anemia or epinephrine diminish signs.
CONDITIONS AFFECTING TRANSPORT
•Congestive heart failure
• Hypovolemia

DEPENDENT
Incentive spirometry
• Sustained maximal inspiration device (SMI)
• Improves pulmonary ventilation
• Counteracts effects of anesthesia or hypoventilation
• Loosens respiratory secretions
• Facilitates respiratory gaseous exchange
• Expands collapsed alveoli
• Percussion
• Cover area with towel or gown to reduce discomfort
• Ask client to breathe slowly and deeply
• Alternately flex and extend wrists rapidly to slap
the posterior chest
• Percuss each affected lung segment for 1–2 minutes
•Vibration OXYGEN DELIVERY SYSTEMS
• Place hands, palms down, on chest area to be
drained 1. Nasal Cannula (24-45% at 2-6 LPM)
• Ask client to inhale deeply and exhale slowly - may be used for clients with COPD at 2-
• During exhalation vibrate the hands 3L/min if venturi mask is not available
• Vibrate during five exhalations 2. Simple Face Mask (40-60% at 5-8LPM)
• After each vibration, ask client to cough and 3. Partial Rebreathing Mask (60-90% at 6-10
expectorate secretions LPM)
• Postural drainage 4. Non-Rebreathing Mask (95-100% at 10- 15
• Place client in appropriate positions to allow gravity LPM)
to drain affected areas of lung Venturi mask- low concentration venturi mask preferred
• Lower lobes require drainage more often than upper for clients with COPD (Chronic Obstructive
lobes Pulmonary Disease) because it provides accurate
• Usually scheduled before meals to prevent vomiting amount of oxygen; they require 2-3 LPM or 28% oxygen

Note: oxygen is colorless, odorless, tasteless and dry gas

that supports combustion

NURSING PLANNING, INTERVENTIONS AND

EVALUATION IN THE ADMINISTRATION OF
OXYGEN THERAPY
• Assess signs and symptoms of hypoxemia
• Check doctor’s order
• Position patient preferably semi-fowler’s
• Open source of oxygen device
• Regulate oxygen flow rate accurately
• Place a “NO SMOKING” sign at the bedside
Bronchial hygiene measures • Avoid use of oil, greases. alcohol
a. steam inhalation • Check electrical appliances before use
- instruct deep breathing and coughing • Humidify oxygen; place sterile water into the
exercises after the procedure to facilitate humidifier___ Provide good oronasal hygiene
expectoration of secretions • Lubricate nares with water-soluble lubricant; do not use
- provide good oral hygiene oil
• Oxygen therapy • Assess effectiveness of suctioning
• Check vital signs and oxygen saturation level • Document relevant data
• Ordered for clients with hypoxemia, anemia, blood Artificial airways
loss • Endotracheal tubes
• Primary care provider specifies concentration, • Anesthesia or ventilation
method of delivery, liter flow per minute. • Tracheostomy
 • Opening into trachea EVALUATING
• Client cannot speak.
• Tube with outer and inner cannula, obturator, • Collect data to evaluate effectiveness of interventions.
flange with tubes or ties
Suctioning • If outcomes not achieved, explore reasons before
• Aspirating secretions through a catheter connected to modifying the care plan
suction machine or wall suction outlet • Review client perceptions and symptoms,
• Assess for signs of respiratory distress medications, and treatments
• Client inability to cough up and expectorate • Inquire about exposure to URI, other factors
secretions • Ask about sleep, rest, assistive devices, assistance
Suctioning (oropharyngeal and nasopharyngeal) with ADL, nutrition
-to clear the airways from mucus secretions
a. assesses indicators for suctioning
b. position
c. pressure of suction equipment to prevent
trauma to mucous membrane of airways
wall unit:
adult: 100-120 mmHg
child: 95-110 mmHg
infant: 50-95 mmHg
portable unit:
adult: 10-15 mmHg
child: 5-10 mmHg
infant: 2-5 mmHg
d. appropriate size of sterile catheter
adult: Fr.12-18
child: Fr. 8-10
infant; Fr. 5-8
e. don sterile gloves
f. length of catheter
•Measure from the tip of the client’s nose to the earlobe
or about 13 cm (5 in) for an adult.
g. lubricate catheter
h. apply suction during withdrawal of the
suction catheter (never during insertion)
i. apply suction for 5-10 seconds (maximum 15
seconds); over suctioning causes hypoxia
j. hyperventilate client with 100% oxygen before
and after suctioning
k. allow 20-30 seconds interval between each
suction
l. provide oral and nasal hygiene
m. dispose articles safely to prevent
contamination
(use one sterile suction catheter foe each episode
of suctioning)
n. assess effectiveness of suctioning
o. document relevant data