Bioethics

THEORIES AND PRINCIPLES OF HEALTH CARE ETHICS

- Ethics is the moral principles that govern a person’s behaviour or the conducting of an activity.
- Morals are concerned with the principles of right and wrong behaviour and the goodness or badness of
human character.

Ethical Issues in Nursing

Abortion - Sanctity of life vs.
principle of
Autonomy and the
woman’s right to
control her own body.
- No public consensus
has yet been reached.
- Nurses have no right
to impose their
personal values,
instead, nurses have
the right to inform and
counsel the client in
making decisions.
Management of - Nurses should help
Computerized develop and follow
Information security measures and
policies to ensure
appropriate use of
client’s data.
End-of-Life - Advance Directives
Issues - Euthanasia
- Termination of Life-
Sustaining treatment
- Withdraw or
withholding Food and
fluids
Allocation of - Health resources
scarce resources

Theories of Ethics
- Utilitarianism (Consequentalism)
- Act-utilitarianism
- Rule-utilitarianism

- Deontology

Utilitarianism
- Right action is that which has greatest utility or usefulness
- No action is, in itself, either good or bad
- The only factors that make actions good or bad are the outcomes

Act-Utilitarianism
- A person performs the acts that benefit the most people, regardless of personal feelings or the
societal constraints such as laws.

Rule-Utilitarianism
 - Seeks to benefit the most people but through the fairest and most just means available. It takes
into account the law and is concerned with fairness.

Deontology (Kantianism)
- The rightness or wrongness of an act depends upon the nature of the act, rather than its
consequences.
- People should adhere to their obligations and duties when engaged in decision making when
ethics are in play
- A person who adheres to deontological theory will produce very consistent decisions since they
will be based on the individual’s set duties

Virtue Ethics
- Judges a person by his/her character rather than by an action that may deviate from his/her
normal behaviour
- One weakness of virtue ethical theory is that it does not take into consideration a person’s
change in moral character.
ETHICAL PRINCIPLES
- AUTONOMY - NONMALEFICENCE
- BENEFICENCE - JUSTICE
- FIDELITY - CONFIDENTIALITY
- VERACITY - ACCOUNTABILITY

Autonomy
- The freedom to make decisions about oneself
- The right to self-determination
- Healthcare providers need to respect patients’ rights to make choices about healthcare, even if the
healthcare providers do not agree with the patient’s decision.

INFORMED CONSENT relates to a process by which patients are informed of the possible outcomes,
alternatives, and risks of treatments, and are required to give their consent freely.

It assures the legal protection of a patient’s right to personal autonomy in regard to specific treatment and
procedures.

Patients are given the opportunity to autonomously choose a course of action in regard to plans of medical
care.

NONCOMPLIANCE – unwillingness of the patient to participate in health care activities

Nonmaleficence
- Requires that no harm be caused to an individual, either unintentionally or deliberately
- This principle requires nurses to protect individuals who are unable to protect themselves

Beneficence
- This principle means “doing good” for others
- Nurses need to assist clients in meeting all their needs:
 Biological
 Psychological
 Social

3 major components:
1. Do or Promote Good
2. Prevent Harm
3. Remove Evil or Harm

Justice
 - Every individual must be treated equally
- This requires nurses to be nonjudgmental

DISTRIBUTIVE JUSTICE – fair and equitable distribution of goods and services

Fidelity
- Loyalty
- The promise to fulfill all commitments
- The basis of accountability
- Includes the professionals faithfulness or loyalty to agreements & responsibilities accepted as part
of the practice of the profession

Confidentiality
- Anything stated to nurses or health-care providers by patients must remain confidential
- The only times this principle may be violated are:
• If patients may indicate harm to themselves or others
• If the patient gives permission for the information to be shared

Veracity
- This principle implies “truthfulness”
- Nurses need to be truthful to their clients
- Veracity is an important component of building trusting relationships
-
Accountability
- Individuals need to be responsible for their own actions
- Nurses are accountable to themselves and to their colleagues

Ethical Dilemmas
- Occur when a problem exists between ethical principles
- Deciding in favor of one principle usually violates another
- Both sides have “goodness” and “badness” associated with them

RELEVANT ETHICAL PRINCIPLES

Principle Of Double Effect

• One act can embrace two effects – an intended good effect and an unintended bad effect
• Morality of the act is governed by the intended effect
• Ethically permissible only if:
- Act is morally good or at least morally neutral
- Only good effect is intended
- Good results outweighs the bad result

Principle of Double Effect

When can the principle of double effect not be invoked?

1. When the act by its nature is evil.
2. When the good effect directly proceeds from the evil effect and not from the act itself.
3. When there is no sufficient reason for the performance of an act with two effects, one- good, the other-
evil.
4. When the motive of the agent is not honest.

Principle of Cooperation
 COOPERATION is working with another in the performance of an action.
 The degrees of cooperation may vary according to the gravity or essentiality of the shared act in the
performance of an evil action.
 FORMAL COOPERATION - consists of an explicit intention and willingness for the evil act. The
one formally cooperating categorically wills and intends the evil action.

Ex: a medical director who wills and intends the evil act of contraception by means of hysterectomy at the
request of an interested party, by arranging with the members of the O.R. team as to the operation and its
schedule.

• MATERIAL COOPERATION - consists of an act other than the evil act itself but facilitates and
contributes to its achievement. The one materially cooperating may provide means apart from the evil act
itself which is used to carry out the performance of an evil act.

Principle of Common Good and Subsidiarity

• The common good is the “good that comes into existence in a community of solidarity among active,
equal agents.”
• Essential to the common good is participation by all in all spheres of society.
• PRINCIPLE OF SUBSIDIARITY- means that what an individual, lower or smaller group can achieve
within his/her or its capacity should not be taken away and transmitted to the custody and performance of
a higher or bigger group.

Ex: in an effort to control the apparent rapid population growth in the country, the State formulates
program on responsible parenthood which rebounds to the enactment of a law mandating every family to
just limit the number of its offspring only to one or two under pain of penalty. And so, the State through
the Department of Health conducts contraceptive programs and distributes various forms of contraceptive
methods to ensure the State-directed number of children every family ought to raise.

Principles of Bioethics
Principle Of Stewardship
• Human life comes from God and no man is the master of its own body.
• Humans are mere stewards or caretakers, with responsibility of protecting and cultivating spiritual
bodily functions.
• We are obliged to take care of ourselves.
• STEWARDSHIP refers to the expression of one’s responsibility to take care of, nurture and cultivate
what has been entrusted to him.

“No one can in any circumstance, claim for himself the right to destroy an innocent human being.”
-Donum Vitae

-Donum Vitae is the "Instruction on Respect for Human Life in Its Origin and on the Dignity of
Procreation" which was issued on February 22, 1987, by the Congregation for the Doctrine of the Faith.

Principles of Integrity and Totality

• These principles dictate that the well-being of the whole person must be taken into account in deciding
about any therapeutic intervention or use of technology.
• Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified only by
a proportionate benefit to the patient.
• INTEGRITY refers to each individuals duty to “preserve a view of the whole human person in which
the values of the intellect, will, and conscience are highly distinguished”.
• TOTALITY refers to the duty to preserve intact the physical component of the integrated bodily and
spiritual nature of human life, whereby every part of the human body “exists for the sake of the whole as
the imperfect for the sake of the perfect”.
• The whole is greater than any of its parts.

Organ Donation Ethical Issues

- Because these donations require a transplant from one living person to another, a moral dilemma
involving the principle of totality arises. According to this principle, the parts of the body are ordered to
the good of that specific body. Therefore, the surgical mutilation of a donor for the good of the recipient
must not seriously impair or destroy bodily functions or beauty of the donor.

For example, both eyes are necessary for certain visual functions. A living person would seriously impair
his ability to see if an eye were donated to another. Such a sacrifice would detract from the wholeness or
full functioning of the donor's body. It would be a bad means to a good end, and therefore morally wrong.

Principle of Ordinary and Extraordinary Means

• Ordinary means = reasonable hope of benefit/success; not overly burdensome; does not present an
excessive risk and are financially manageable
• Proportionate to the state of the patient
• “Ethically indicated” (Strong 1981 p. 84).
• Extraordinary means = no reasonable hope of benefit/success; overly burdensome; excessive risk and
are not financially manageable
• No obligation to use it/morally optional

Principle of Personalized Sexuality

• Personalized Sexuality is based on an understanding of sexuality as one of the basic traits of a person
and must be developed in ways consistent with enhancing human dignity.
• The gift of human sexuality must be used in marriage in keeping with its intrinsic, indivisible,
specifically human teleology.
• It should be a loving, bodily, pleasurable expression of the complimentary, permanent self-giving of a
man and a woman to each other, which is open to fruition in the perpetuation and expansion of this
personal communion through the family they beget and educate.
FOUNDATIONS OF LAW
Law
 A body of rules of action or conduct prescribed by controlling authority and having binding legal
force.
 Minimum standard of expected performance between individuals in a society.
Basic Sources for Modern Law

Fundamental Principles of Law

- Justice and fairness
- Plasticity and change
- Doctrine of Individual Rights and Responsibilities

Lawsuit
- begins when a plaintiff files a complaint or petition with the court that addresses the elements of prima
facie case (legally sufficient to establish a case)
Plaintiff a person who brings an action in a court of law

Defendant a person against whom an action is brought

Steps in Lawsuit

Public Law
Crimes according to seriousness and level of punishment…
Felony Misdemeanor
More serious Punishable by less
breach of law than a year of
imprisonment in a jail
Punishable by Theft of small
death or amount
imprisonment
Murder Disorderly conduct
Rape
Robbery

Private Law

Types of Private Law

Tort Contract Law

A private or civil Breech of contract
wrong or injury

Breach of Contract
- Failure, Without legal excuse, to perform any promise that comprises the whole part of the contract

Basic Objectives of Tort Law

1. Preservation of peace between individuals
2. Determining of fault
3. Compensation for injury

Categories of Torts
• Negligent Tort
• Intentional Tort
Negligent Torts
 Negligence is the unintentional commission or omission of an act that a reasonably prudent person
would or would not do under the same or similar circumstances
 Harm caused by carelessness of a professional health provider
 Malpractice is a type of negligence
Forms of Negligence
Malfeasance – execution of an unlawful or improper act
Misfeasance – the improper performance of an act that leads to injury
Nonfeasance – failure to perform an act, when there is a duty to act

4 Ds of Negligence
• Duty
• Dereliction of Duty
• Direct Cause
• Damage

Legal doctrines associated with medical malpractice..

Res Ipsa Loquitor (the thing speaks for itself) – in order to prove negligence in a personal injury lawsuit,
a plaintiff must present evidence to demonstrate that the defendant's negligence resulted in the plaintiff's
injury

Respondeat Superior (let the master answer) – allow liability assessment against employers for negligent
acts committed by their employees during the course of their work

Intentional Torts
• Assault and Battery
• Assault – committed without physical contact, such as someone verbally cursing and
threatening
• Battery – requires physical contact of some sort
• Defamation of Character
• Violation of patient’s right to privacy which results to one person communicates to a second person
about a third in such a manner that the reputation of the person about whom discussion was held is
harmed
• Libel – written communication
• Slander – spoken defamation

• False Imprisonment
• Illegal confinement of an individual against his or her will by another individual in a manner that
violates the confined individual’s right to be free from restraint of movement

• Invasion of Privacy
• Right to live one’s life without having one’s name, picture, or private affairs made public against one’s
will.

REPRODUCTIVE ISSUES
Abortion
 Expulsion of a living fetus from the mother’s womb before it is viable.
 Termination of pregnancy, spontaneously or by induction, prior to viability.
 14-20 before weeks of viability

In the Philippines any form of abortion is illegal

 Article II, 1987 constitution: Under the family code
 Section 12: Recognizes sanctity of life and shall protect and strengthen the family.
 Protect life of mother and the life of the unborn from conception.
Criminalized by the Philippine law: Art. 256, 258(highest prison term on the woman or parents), and 259:
RPC imprisonment for women who undergo abortion, as well as those who assist in the procedure.
 Misoprostol- drug inserted in the vagina used for abortion
 RH Bill/Law- prevention of abortion and management of post abortion complications.
 Intention: Responsible parenthood, family planning
 Address cause of abortion, fetal death, and teenage pregnancy
 Ensures that women needing care for post-abortion complications shall be treated and counseled in
humane, non-judgmental and compassionate manner.”
 but “Abortion remains a crime and is punishable”

Types of Abortion
 Natural abortion(spontaneous/ accidental)- unintentional and involuntary
 Direct or Intentional Abortion- induced expulsion of a living fetus
 Therapeutic abortion- induced expulsion of a living fetus in order to save the mother from the
danger of death brought on by pregnancy.
 Eugenic abortion- recommended in cases where certain defects are discovered in the developing
fetus.
 Indirect abortion- removal of the fetus occurs as a secondary effect of a legitimate action, which
is direct and primary object of the intention.

Moral Issues
 Euthanasia and impaired infants
 Personhood
 Sanctity of life
 Quality of life
 Autonomy
 Mercy

Two positions
 Pro-life position- anti-abortion, believes that abortion is murder
 Pro-choice position- believes that the decision to abort is one of personal liberty and thus should
be legal
 Has two sub-components:
 Abortion is wrong but it is an individual autonomy
 Abortion is not wrong but depending on the situation

Principle of Double Effect

 Distinguish the intended effect of an action from the other, the unintended effects
 It would be impermissible, to perform an abortion to save a mother from death if the procedure
involved the direct killing of the fetus
 Permissible if the death of the fetus is an indirect cause of the death

Nursing Ethical Dilemma: Ethical Rights and Responsibilities in Abortion

 Nurses are agreeable if medically indicated
 Should respect the choices of the mother for as long as the abortion is legal under the state of law
 Should provide the information of alternative and respecting the patient’s right to freedom from
imposition and the right to receive the utmost care in an environment that provides privacy,
culturally appropriate, and specific nursing expertise. (ANA, 2011)
 If abortion is against the personal moral, ethical, and religious values of the nurse, the nurse has
the right to refuse to participate in a voluntary termination of pregnancy
o Except in emergency situations; patient’s needs should not be subjected to coercion,
censure, or discipline for reasons of such refusal
 Should be aware of abortion laws within the state of practice to be more legally binding
Ethical Issues in Assisted Reproductive Technologies

Assisted reproductive technologies (ART)

 All treatments or procedures that include the in vitro handling of human oocytes and human
sperm or embryos for the purpose of establishing pregnancy
 First successful IVF: Louise Brown; 1978

Issues/Concerns
 Rapid development in the field of ART
 “Moral panic” about the changes that ICF brought about
 Continuous ethical dilemmas
 Legislation

Rapid Developments
 Better protocols for ovulation induction
 Success rates
 PGD
o Preimplantation genetic diagnosis (PGD)
o Screening of embryos for specific genetic traits before it is implanted
o “Embryo biopsy”
o Enables couples at risk for certain genetic diseases to determine which of their embryos
are affected and which are not

Moral Panic
 No society has been neutral about reproduction
 Social values
 Morals
 Fears
 Separation of sex from reproduction
 Reproduction with the involvement of a third party
 Gender issue
 Ethical Issue
 Ideology or religion
o Status of the embryo
o Sanctity of the family’s genetic lineage
 Utilitarian principles
o Best for society
o Best interest of the child

ETHICAL CONCERNS
Autonomy
o Patient’s autonomy (respect for autonomy)
o Reproductive freedom
o Decision based on accurate information
o Issue of success rates
o Eligibility
 All infertile couples
 Only married couples
 Single women without partners
 Gay couples
 Lesbian couples
 Menopausal women
 HIV-positive women or couples
Gamete donor
 Sperm
 Oocyte

Donor anonymity
 Right of autonomy of privacy of the parents
 Right of privacy of the donor
 Right of the child to know his/her origins

Pre-implantation genetic diagnosis (PGD)

o Screening of cells from pre-implantation embryos for the detection of genetic and/or
chromosomal disorders before embryo transfer
o Status of the embryo
 Discrimination
 “Designer” babies
 Sex selection
 Destruction of unwanted embryos

Ethical Issues/Risk-benefits
 Welfare of the child
o Medical risks
o Family environment
o Social environment
 Who is making the decisions for the welfare of the child?
o Parents
o Medical personnel
o Society and the law
 Is it one’s best interest to be born?

The issues
 The outcomes related to their care should be their own wishes
 The decision may involve the choice for:
o Organ and tissue donations
o Advance directives
o Resuscitation

Advanced directives- a general term used to describe the documents that give instructions about future
medical
care and treatments
o Living will
o Do not resuscitate order
o Withholding or withdrawing treatments
o Should have proper documentation and consent/ waiver

Living will- the lay term used to frequently to describe any number of documents that give
instructions about future medical care and treatments or the wish to be allowed to die w/o heroic or
extraordinary measures should the patient be unable to communicate for self

• No uniformity in laws on living wills and surrogate decision makers

• In some states, the advanced directives go into effect only if a patient is terminally ill and death is
imminent
• Due to inconsistencies and limitation, many authorities recommend the use of durable power of
attorneyover a living will
• What to and what not to do

Durable power of attorney

• A power of attorney is a legal document that gives someone you choose the power to act in your place,
in case you become, mentally incapacitated, you’ll need what are known as “durable” powers of attorney
for medical care and finances
• This allows you to name someone as proxy, with the authority to make medical decisions on your behalf
should you become incompetent and unable to make decisions for yourself

DNR (Do not resuscitate)

• A written physician’s order instructing health care providers not attempt CPR
• Often requested by the family
• Must be signed by the physician to be valid must have a witness
• Several types of CPR decisions can be made including:
o Full code
o Chemical code
o DNR or “no code”- avoid use of CPR
o Slow codes- slows process

Orders: Code

 A call for CPR efforts

 Contains all elements of ACLS (advanced cardiac life support; oxygenation, ventilation, cardiac
massage, electroshock as necessary, emergency drugs)

Orders: No code or Code blue

 DNR
 Written order placed in medical chart to avoid the use of CPR efforts

Orders: Slow codes

• Health care teams slows the process of emergency resuscitation so as to appear to be providing the care
but in actual fact is only providing illusion
• Intent is more for family comfort than patient benefit

Orders: Chemical code

• Provides the drugs needed for resuscitation but does not provide the other services
• Emergency drugs only

DNR Guidelines
• Should be documented
• Should specify the exact nature of the treatments to be withheld
• Patients, when they are able, should participate in DNR decisions
• Decisions to withhold CPR should be discussed with the health care team
• DNR status should be reviewed on a regular basis

Ethical Issues
- Do DNR patients belong on intensive care units (ICU)?

Withholding or withdrawing treatments

 What is to be done and what is not to be done must be included in clear terms
 Honoring the refusal of treatments that a patient does not desire, are disproportionately
burdensome to the patient, or will not benefit the patient can be ethically and legally permissible

Organ donations
 When it is permissible to remove organs?
  Who should receive them?
 How is it to be financed?

Ethical issues
 Document the gift that an individual executes before death
 Commercialization (exploitation, pay for a service)
 The need to obtain family consent in a time of grief and stress has been a major barrier to organ
 procurement

Legal and social standing of euthanasia

 Euthanasia is currently conceptualized as an action that aims to end the life of a human being
taking into account humanistic considerations in relation to the person or society
o Quickening of death
o Passive euthanasia- the allowance of deadly process to proceed without intervention
o Active euthanasia- requires action that speeds the process of dying
o Involuntary euthanasia-ignores the individual’s autonomous rights and could potentially
bring about the death of an unwilling victim
o Voluntary euthanasia- done upon patient’s request
 Orthotanasia refers to the art of promoting a humane and correct death
o Usual death/normal death
 Dysthanasia is the term for futile or useless treatment treatment, which does not benefit a
terminal patient. It is a process through which one merely extends the dying process and not life
per se

Euthanasia vs. suicide

 A person has committed suicide when:
o Person brings about his/her own death
o Others do not coerce him/her to do the action
o Death is caused by condition arranged by the person for the purpose of bringing about his/her
death

 Physician-assisted suicide- allowed in the Netherlands in 2002

 Patient must request the assistance freely and frequently after careful consideration
 Physician may act on request only if the patient is terminally ill, with no hope of improvement
and
 in severe pain
 May be actively-assisted
 Physician must consult with another physician and file a coroner (an official who examines a
 person’s cause of death)
 Germany
o Does not allow active-assisted suicide—where the physician prescribes and administers the lethal
dose
 Does not allow direct participation of the physician
o Allow assisted suicide, so long as the drug is taken without any help
 Belgium
o Legalized physician-assisted suicide
o If an inpatient expresses a desire for euthanasia, prior to becoming comatose, physician may
comply with the request
o Include children who with the expressed permission of their parents may receive lethal injection
o The child must be terminally ill and be conscious of their decision
 USA
o Doctors are allowed to prescribe lethal doses of drugs to terminally ill patients to “aid in dying”
 Only 5 states allow physician-assisted suicide
  Oregon (1st state to legalize), Washington, Vermont, Montana, and New Mexico
o Active euthanasia is illegal
o Oregon act: allows a terminally ill patient to obtain a physician’s prescription for a fatal drug

CODE OF ETHICS
 Systematic guides for developing ethical behavior
 Answers normative questions of what beliefs and values should be morally accepted

Code of Good Governance

▪ Promulgated by the Professional Regulation Commission on July 23, 2003
▪ States that the hallmark of all professionals is their willingness to accept a set of professional and ethical
principles which they will follow in the conduct of their daily lives.

Code of Good Governance

General Principles
1. Service to Others
2. Integrity and Objectivity
3. Professional Competence
4. Solidarity and Teamwork
5. Social and Civic Responsibility
6. Global Competitiveness
7. Equality of All Professions

Code of Ethics for Filipino Nurses

 Provides direction for nurses to act morally
 Emphasizes the four-fold responsibility of nurses
- To promote health
- To prevent illness
- To alleviate suffering
- To restore health
 Emphasizes universality of the nursing practice, scope of responsibility

Code of Ethics for Filipino Nurses

 1982 – PNA (Dean Sotejo) developed a Code of Ethics for Filipino Nurses, approved but was not
implemented
 1984 – PRC-BON adopted the Code of Ethics of ICN, added fifth-fold responsibility “promotion of
spiritual environment”
 1989 – Code of Ethics promulgated by PNA was approved by PRC-BON

ARTICLE I
PREAMBLE
Sec. 1. Health is a fundamental right of every individual. The Filipino registered nurse believing in the
worth and dignity of each human being, recognizes the primary responsibility to preserve health at all
cost. This responsibility encompasses promotion of health, prevention of illness, alleviation of suffering,
and restoration of health. However, when the foregoing are not possible, assistance towards a peaceful
death shall be his/her obligation.

Sec. 2. To assume this responsibility, registered nurses have to gain knowledge and understanding of a
man’s cultural, social, spiritual, psychological, and ecological aspects of illness, utilizing the therapeutic
process. Cultural diversity and political and socio-economic status are inherent factors to effective
nursing care.

Sec. 3. The desire for the respect and confidence of clientele, colleagues, co-workers, and the members of
the community provides the incentive to attain and maintain the highest possible degree of ethical
conduct.
ARTICLE II
REGISTERED NURSES AND PEOPLE
Sec. 4. Ethical Principles
1. Values, customs, and spiritual beliefs held by individuals shall be represented.
2. Individual freedom to make rational and unconstrained decisions shall be respected.
3. Personal information acquired in the process of giving nursing care shall be held in strict confidence.

Sec. 5. Guidelines to be observed

Registered Nurse must:
 consider the individuality and totality of patients when they administer care;
 respect the spiritual beliefs and practices of patients regarding diet and treatment;
 uphold the rights of individuals; and
 take into consideration the culture and values of patients in providing nursing care. However, in the
conflicts, their welfare and safety must take precedence.

ARTICLE III
REGISTERED NURSES AND PRACTICE

Sec. 6. Ethical Principles

Registered Nurse must:
1. Human life is inviolable.
2. Quality and excellence in the care of patients are the goals of nursing practice.
3. Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing
accountability.

Sec. 7. Guidelines to be observed

Registered Nurse must:
a. Know the definition and scope of nursing practice which are in the provisions of R.A. No. 9173,known
as the Philippine Nursing Act of 2002 and Board Res. No. 425,Series of 2003, the Rules and Regulations
Implementing the Philippine Nursing Act of 2002, (the IRR);

b. Be aware of their duties and responsibilities in the practice of their profession as defined in the
Philippine
Nursing Act of 2002 and the IRR;

c. Acquire and develop the necessary competence in knowledge, skills and attitudes to effectively render
appropriate nursing services through varied learning situations;

d. If they are administrators, be responsible in providing favourable environment for the growth and
development of Registered Nurses in their charge;

e. Be cognizant that professional programs for specialty certification by the BON are accredited through
the Nursing Specialty Certification Council (NSCC);

f. See to it that quality nursing care and practice meet the optimum standard of safe nursing practice;

g. Ensure that patient’s records shall be available only if they are to be issued to those who are
professionally and directly involved in their care and when they are required by law.
h. Insure that modification of practice shall consider the principles of safe nursing practice;

i. If in position of authority in a work environment, be normally and legally responsible for devising a
system of minimizing occurrences of ineffective and unlawful nursing practice.

Sec. 8. Ethical Principle

4. Registered Nurses are the advocates of the patients: they shall take appropriate steps to safeguard their
rights and privileges
Sec. 9. Guidelines to be observed
Registered Nurses must:
a. Respect the Patient’s Bill of Rights in the delivery of nursing care;

b. Provide the patients or their families with all pertinent information except those may be deemed
harmful
to their well-being and

c. Uphold the patients’ rights when conflict arises regarding management of their care.

Sec. 10. Ethical Principle

5. Registered Nurses are aware that their actions have professional, ethical, moral and legal dimensions.
They strive to perform their work in the best interest of all concerned.

Sec. 11. Guidelines to be observed

Registered Nurses must:
a. perform their professional duties in conformity with existing laws, rules regulations. measures, and
generally accepted principles of moral conduct and proper decorum.

b. not allow themselves to be used in advertisement that should demean the image of the profession (i.e.
indecent exposure, violation of dress code, seductive behavior, etc.).

c. decline any gift, favor or hospitality which might be interpreted as capitalizing on patients.

Sec. 11. Guidelines to be observed

Registered Nurses must:
a. not demand and receive any commission, fee or emolument for recommending or referring a patient to
a physician, a co-nurse or another health care worker; not to pay any commission, fee or other
compensations to the one referring or recommending a patient to them for nursing care.

b. avoid any abuse of the privilege relationship which exists with patient and of the privilege access
allowed to their property, residence or workplace.

ARTICLE IV
REGISTERED NURSES AND CO-WORKERS

Sec. 12. Ethical Principles

a. The Registered Nurse is in solidarity with other members of the healthcare team in working for the
patient’s best interest.

b. The Registered Nurse maintains collegial and collaborative working relationship with colleagues and
other health care providers.

c. maintain their professional role/identity while working with other members of the health team.

d. conform with group activities as those of a health team should be based on acceptable, ethico-legal
standards.

e. contribute to the professional growth and development of other members of the health team.
f. actively participate in professional organizations.

g. not act in any manner prejudicial to other professions.

h. honor and safeguard the reputation and dignity of the members of nursing and other professions; refrain
from making unfair and unwarranted comments or criticisms on their competence, conduct, and
procedures; or not do anything that will bring discredit to a colleague and to any member of other
professions.

i. respect the rights of their co-workers.

ARTICLE V
REGISTERED NURSES, SOCIETY, AND ENVIRONMENT
Sec. 14. Ethical Principles

1. The preservation of life, respect for human rights, and promotion of healthy environment shall be a
commitment of a Registered Nurse.

2. The establishment of linkages with the public in promoting local, national, and international efforts to
meet health and social needs of the people as a contributing member of society is a noble concern of a
Registered Nurse.

Sec. 15. Guidelines to be observed

Registered Nurses must:
a. be conscious of their obligations as citizens and, as such, be involved in community concerns.

b. be equipped with knowledge of health resources within the community and take active roles in primary
health care.

c. actively participate in programs, projects, and activities that respond to the problems of society.

d. lead their lives in conformity with the principles of right conduct and proper decorum.

e. project an image that will uplift the nursing profession at all times.

ARTICLE VI
REGISTERED NURSES AND THE PROFESSION

Sec. 16. Ethical Principles

1. Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal.

2. Compliance with the by-laws of the accredited professional organization (PNA), and other professional
organizations of which the Registered Nurse is a member is a lofty duty.

3. Commitment to continual learning and active participation in the development and growth of the
profession are commendable obligations.

4. Contribution to the improvement of the socio-economic conditions and general welfare of nurses
through appropriate legislation is a practice and a visionary mission.

Sec. 17. Guidelines to be observed

Registered Nurses must:
a. be members of the Accredited Professional Organization (PNA).

b. strictly adhere to the nursing standards.

c. participate actively in the growth and development of the nursing profession.

d. strive to secure equitable-economic and work conditions in nursing through appropriate legislation and
other means; and

e. assert for the implementation of labor and work standards.

ARTICLE VII
ADMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY

Sec. 18.
The Certificate of Registration of Registered Nurse shall either be revoked or suspended for violation of
any provisions of this Code pursuant to Sec. 23 (f), Art. IV of R. A. No. 9173 and Sec. 23 (f), Rule III of
Board Res. No. 425, Series of 2003, the IRR.

Sec. 19.
The Amended Code of Ethics promulgated pursuant to R. A. No. 877 and P.D. No. 223 is accordingly
repealed or superseded by the herein Code.

Sec. 20.
This Code of Ethics for Nurses shall take effect after fifteen (15) days from its full and complete
publication in the Official Gazette or in any newspapers of general circulation. Done in the City of
Manila, this 14th day of July, 2004.

ETHICS IN GENETICS
Genetics
Branch of biology concerned with the study of genes, genetic variation, and heredity in organisms

Three Main Reasons Why Genetics is Ethically Interesting

1. Genetic information often identifies risks of medical conditions that don’t yet affect the patient
- The ‘at risk’ patient
2. Genetic information is about families as well as individuals
- As such, it sometimes doesn’t fit well into our usual individualistic ways of thinking about consent,
confidentiality, etc.

3. Genetic research is commercially driven to a very substantial degree

- This raises questions about whether it is legitimate to allow genes to be ‘owned’ and what people should
expect in return for participating in genetic research

Case Study: Huntington’s Disease

One day a woman’s father comes home and starts ranting and raving. She has never seen him like this.
His limbs begin moving in strange ways, and he begins to have seizures. Finally, the doctors have the
diagnosis: Huntington’s disease. Now she founds out that, because her father’s disease is the result of a
dominant gene, she has a fifty-fifty chance of getting it herself.

 A disease which causes deterioration of nerve cells in the brain

 Slowly destroys the affected individual's ability to walk, think, swallow, talk, ...
 Normally begins affecting people when they are between 30 and 50 years old
 Death (due to pneumonia, heart failure or other complications) usually occurs between 10 and 25
years after symptoms first appear

Genetics for Philosophers

 Our chromosomes (which contain our genes) come in pairs.
 We inherit one chromosome from each pair from each of our parents
 The paired chromosomes, while similar, are not identical
 About 1 in 10,000 people are thought to carry a mutation linked to Huntington’s Disease

Inheriting Huntington’s
 Huntington’s is an example of a dominant genetic condition
– i.e., you only need to inherit one copy of a gene for Huntington’s in order to be almost certain
to
 contract the condition at some point
 If one of your parents carries a mutation linked to Huntington’s, you have a 50% chance of having
inherited such a gene yourself.

Testing for Huntington’s

 Huntington’s is caused by having an enlarged gene on chromosome 4
 Since the early 90’s a very reliable genetic test for such an enlargement has existed
 Even if you presently show no signs of Huntington’s, it can tell you with great reliability whether you
carry a gene that makes it extraordinarily likely that you will develop Huntington’s.
 There is no cure

Assessing Purdy’s Argument

 “if it is true that sufferers [from Huntington’s] live substantially worse lives than do normal persons,
those who might transmit it should not have children.”
 Response: this is a pretty big ‘if’
– It seems to require making judgments about what sort of live is worth living that are deeply
troubling
 Nonetheless, thinking about this issue should allow you to appreciate why genetics raises some
distinct ethical questions.

Some Issues Raised by Genetic Testing

1. Risks of being tested
2. Problems posed by public conceptions of genetics
3. Problems with confidentiality &consent
4. ‘Commodifying’ our genes

1. Risks of Being Tested

▪ Psychological
– If positive for a ‘bad’ mutation:
 Burden of knowing you have the predisposition, particularly if no treatment is available
 Genetic determinism: possible overestimation of likelihood of actually becoming afflicted
 The situation with Huntington’s is not typical

– If negative:
 Evidence of ‘survivor guilt’ in some cases
 Possible over-confidence
 E.g., thinking you won’t get breast cancer because your test for BRCA1 & 2 came out OK

More Risks of Being Tested

 Practical
– Employment
– Life insurance
– Health Insurance (more important in US)
 Is it fair for companies to take genetic information into account when making hiring decisions or
decisions about whether to insure a person?
 Do these risks justify being paternalistic regarding who is given a genetic test, as DeGrazia suggests
(pp. 474-490)?
- ‘Traditionally,’ tests have not been given without genetic counselling, although this is likely to
change.
- Recall the Rule of Justified Paternalism

2. Popular Beliefs about Genetics

 Genetic Determinism: The common misconception that all genes work like the gene for
Huntington’s, i.e., the idea that having a particular gene will guarantee having a particular trait
- For the most part, having a particular gene mutation will just increase your chance of developing
some trait, not guarantee it.
– Furthermore, most ‘genetic conditions’ are the result of a number of different gene mutations (as
well as interactions with the environment)
 We are unlikely to discover ‘the gene makes you good at math’

3. Confidentiality & Consent

▪ In medical ethics, a great deal of importance is placed on the idea of individual informed consent
– One aspect of this is that your personal health information is not supposed to be released
without your consent
– But the nature of genetic information sometimes gets in the way of this
– Finding out genetic information about you also reveals genetic information about the people
you’re related to

Case: Confidentiality & Huntington’s

 Suppose there is a known history of Huntington’s in your family, but you don’t want to know whether
you personally carry a mutation for Huntington’s.
 Your son does, however. He gets tested and discovers that he has a mutation for Huntington’s.
 This almost guarantees that you also carry such a mutation.
 We have discovered personal information about you without your consent
– How should we deal with this?
– Should we put restrictions on who your son can reveal this information to?

Confidentiality & Duty to Warn

 Most ethicists agree that, while confidentiality is important, there are situations in which
confidentiality can be broken
 The most common example involves a duty to warn
– E.g., a psychiatrist who is told by one of his patients that the patient plans to kill his wife tomorrow
 Is there a genetic duty to warn?
– Must we warn family members who are at risk?
– Should we warn employers if a person possesses a genetic mutation that may someday pose a
threat?
 E.g., the bus driver at high genetic risk of heart failure

Case Study: BRCA 1 & 2

 About 5-10% of breast cancer is thought to be hereditary
 It has been discovered that those women with particular mutations in the BRCA 1 or 2 gene are at an
elevated risk of contracting breast cancer
– Without these mutations: 2% by age 50, 7% by age 70
– With the mutations: 33-50% by age 50, 56- 87% by age 70
– Note: information is from Myriad Genetics’ Website

Myriad Genetics & BRCA

 Myriad Genetics (Utah, USA) holds patents on BRCA 1 & 2
 They have recently been insisting that only they (or companies they have a licensing agreement with)
may perform testing for the BRCA 1& 2 mutations.
 The government of Ontario has refused to obey, preferring to perform its own test, which it claims is
both cheaper and more accurate

4. Commodifying Genes
 The Myriad example raises a number of questions regarding the commercialization of genetic
research
– Is gene patenting ethically acceptable?
 – If our genes are a valuable commercial resource, should we be paid for them?
– Are genes property or person?

Newfoundland & Labrador

 Questions about commercial research are particularly relevant in Newfoundland and Labrador
 Most of the present population of the province can trace their ancestry back to settlers in the 1800s or
earlier
– Some argue that Newfoundland has a ‘homogeneous’ gene pool that is very valuable for genetic
research
– We have an elevated rate of some genetically influenced conditions (e.g., psoriasis)
 For these reasons, Newfoundland had been described as "something of a motherlode to the drug
development industry" (National Post, 2000).

Should You Be Paid for Your DNA?

 There has been some local debate about whether individuals should be paid for providing their DNA
to researchers
– One former professor at MUN suggested $50,000 (US) per donation

A Recent Report
 Policy Implications of Commercial Human Genetic Research in Newfoundland and Labrador
– Pullman & Latus, 2003
 Argues that human DNA should be viewed as neither property nor person, but something in between
– Payments may sometimes be OK, not individual ones.
– In keeping with our general approach to health care as a public good, payment should go to improve
health care & research
– Gene patenting should be reconsidered
▪ This by no means settles the issue

So what was the point of all this?

 Genetics provides a good final example for this course:
– New developments in health care almost invariably raises new ethical problems
– New developments often cast old problems in new light
– Health ethics will never run out of problems

But ...
 ‘All you’ve done is raise questions and problems. What was the point of that?’
 Answer #1: Sometimes these problems don’t have clear solutions.
– Sometimes making people sensitive to problems is the best solution we can hope for
– E.g., while we may not be able to stop a genetic test on Mary’s son from revealing information about
Mary, but by being aware we can at least try to minimize this problem
 Answer #2: Ethics is hard
– Progress does occur, but it’s very slow because these are difficult problems.
– The least we can do is subject these issues to a serious public debate.

RIGHTS AND RESPONSIBILITIES

Patient Reponsibilities
1. Providing Information
2. Complying with instructions
3. Informing the physician of refusal to treatment
4. Paying hospital charges
5. Following hospital rules and regulations
6. Showing respect and consideration

Nurses’ Bill of Rights

1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who
receive nursing care.

2. Nurses have the right to practice in environments that allow them to act in accordance with
professional standards and legally authorized scopes of practice.

3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance
with the Code of Ethics for Nurses and its interpretive statements.

4. Nurses have the right to freely and openly advocate for themselves and their patients without fear of
retribution.

5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience
and professional responsibilities.

6. Nurses have the right to a work environment that is safe for themselves and their patients.

7. Nurses have the right to negotiate the conditions of their employment, either as individuals or
collectively in all practice settings.

Responsibilities of the Nurse to the Physician

Sec 28 (a) of RA 9173 states that: It shall be the duty of the nurse to:
A. Provide nursing care through the utilization of the nursing process. Nursing care includes, but not
limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques
and procedures, essential primary health care, comfort measures, health teachings, and administration of
written prescription for treatment, therapies, oral, topical and parenteral medications, internal examination
during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration,
special training shall be provided according to protocol established;
- Reports results of therapies
▪ If any medical orders were not carried out:
– Report to physician
– Document
– Explore patient’s reason
▪ Familiarize themselves with various routines and methods of Physicians

Responsibility of the Nurse to their Colleagues

- Get along smoothly
- Adjust to the organization and know its policies and procedures
- Establish good working relationship
- Constructive criticism
- Nurses who are cranky, too sensitive, who “backbite”, who do not see any good in their colleagues, are
the type of nurses who will not be happy in their work

Responsibility of the Nurse to Themselves

- Continuous learning
- Self respect
- To look neat and attractive
 BLOOD VESSELS

ARTERIES & VEINS

- 3 Layers of its walls
Tunica Intima – Endothelium (Innermost Layer)
Tunica Media – Smooth Muscle (Middle Layer)
Tunica Adventitia – White Fibrous Tissue (Outermost Layer)

Difference between Arteries and Veins

CHARAC ARTERIES VEINS

TERS
Blood The pure, The impure,
oxygenated deoxygenated
blood, rich in blood, rich in
nutrients is waste materials
 carried by the is carried by the
Arteries. Veins.
Walls Arteries walls Veins walls are
are rigid, thin and
thicker and collapsible walls.
highly
muscular.
Body They are They are
location deeply superficial,
situated peripherally
within the located closer to
body. the skin.
Colour Arteries are Veins are blue in
red in color. color.
The Arteries Veins carry
direction carries blood blood from the
of Blood away from various parts of
Flow the heart to the body towards
various parts the heart.
of the body.
Flow The pressure The pressure is
pressure is high as the low as the blood
blood flows flows by the
by the capillary action
pumping of the veins.
pressure of
heart.
Oxygen Oxygen Oxygen level is
level levels are low
quite high in comparatively.
the arterial
blood.
TERMS
NEURON
- Transmits information/s called nerve impulses in the form of electrochemical changes
- Also known as neurones, nerve cells and nerve fibres
- Core components of the brain, spinal cord and peripheral nerves

ARTERIES
- TWO MAJOR PROPERTIES: Elasticity & Contractility
- Must be able to expand to accommodate blood
- It supplies blood to the brain by 700cc-1000cc per/minute

VEINS
- Contains valves to ensure blood flows in one direction, preventing backflow of blood (Mitral
regurgitation)

ARTERIOLES
- Small arteries that delivers blood to the capillaries

VENULES
- Small vessels that connects capillaries to the veins

CAPILLARIES
- It is where the exchange of oxygen, nutrients, and wastes happens
- They bring nutrients and oxygen to tissues and remove waste products
- It connects arterioles and venules
- Made up of simple squamous epithelial cells

VASCULAR / VEINOUS SINUSES

- Veins with thins walls

LUMEN
- A hollow core / cavity in both arteries and veins
- It is where the blood flows

ANASTOMOSIS
- Junction of two or more blood vessels

NEUROGLIA
- These cells that form myelin, protect, support, and maintain equilibrium in your nervous system are
called glial cells.
- They are also commonly known as neuroglia and even more simply glia. In more detailed terms,
neuroglia are cells in your nervous system that are not neurons.

NERVE FIBRES
AXON
- Conducts electrical impulses away from the neuron's cell body or soma
- A nerve cell have only one axon

DENDRITES
- Receptive areas of the neurons and a multipolar neuron will have many dendrites

AXON TERMINALS
- The very end of a branch of a nerve's axon
- Comes in contact with dendrites of other neurons
 TYPES OF NEUROGLIA

ASTROCYTES
- Star-shaped cells that function in the blood-brain barrier to prevent toxic substances from entering the
brain, it serves as a filter system so that not all can pass through
- **Astrocyte is not yet present in children
- Provides structural framework for the neurons of the brain and spinal cord
- They are the most abundant glial cells in the brain that are closely associated with neuronal synapses.
- They regulate the transmission of electrical impulses within the brain.
- Astrocytes maintain homeostasis of excitatory substances, such as extracellular potassium, by
immediate uptake through specific potassium channels and sodium potassium pumps.

MICROGLIAL CELL
- Specialized population of macrophages that are found in the central nervous system (CNS).
**It functions like wbc of the body
**Acts as a wandering police force and janitorial service
- They remove damaged neurons and infections and are important for maintaining the health of the CNS.
- Involved in the phagocytosis of unwanted substances

EPENDYMAL CELLS
- Form the lining of the cavities in the brain and spinal cord
- They help in the movement of fluid in the in the brain
- Ependymal cells, which create cerebral spinal fluid (CSF), line the ventricles of the brain and central
canal of the spinal cord.
- These cells are cuboidal to columnar and have cilia and microvilli on their surfaces to circulate and
absorb CSF.
- Covered with cilia – persists in adults only
- Remove waste products in CSF

OLIGODENDROCYTES
- Provides support and connection
- Oligodendrocytes myelinate axons in the central nervous system
- Oligodendrocytes secrete the myelin sheaths around the axons.

SCHWANN CELLS
- Located only in the PNS and make up the neurilemma and myelin sheath
- Schwann cells myelinate axons in the peripheral nervous system
- Schwann cells myelinate, their cellbody's actually wrap around the axon
VENTRAL GRAY HORN
- The grey matter, in the center of the cord, is shaped like a butterfly and consists of cell bodies of
interneurons and motor neurons, as well as neuroglia cells and unmyelinated axons.
Cell Functions and Structures

Cell – basic living unit of the body/life

Cytology – study of cellular structures
Cell Physiology – study of cellular function
Organelles – specialized structures

1. Cell Membrane (plasma)

- separates internal organs from external environment
- encloses organelles w/in the cell
- outer boundary
- fragile, transparent
- selective barrier: determines what enters or leaves
- 2 phospholipids where proteins float. Chol.carbs.
- - polar: hydrophilic, non: hydrophobic

2. Cytoplasm
- surrounds nucleus
- contains: ORGANELLES & CYTOSOL

3. Nucleus – contains genetic material; ribosomal site

CELL MEMBRANE
 Extracellular – outside the cell
 Intracellular – inside the cell
 Membrane channels –involved with the movement of subs
 Receptor Molecules – intercellular communication enables cell recognition
 Selectively permeable – allows substances to pass in or out
 Diffusion – solutes move from higher concentration to lower
 Solution – composed of substance dissolved in liquid or gas
 Solute – substance to be dissolve
 Solvent – liquid or gas
 Concentration gradient – diff. in concentration of solute
 Leak channels – allows ions to pass
 Gated channels - limit the movement of ions
 Osmosis – diffusion of water/solvent
 Osmotic pressure – force required to prevent the movement of water
 Hypnotic solution – cells swell and can undergo lysis
 Isotonic solution – neither swell nor shrink
 Hypertonic solution - shrink undergo crenation
 Endocytosis – movement of material into cells by formation of vesicle
 Exocytosis – secretion of materials from cell by vesicle

ORGANELLES
 Ribosomes – site of protein synthesis; 1 large 1 small
 Rough ER reticulum – have ribosomes attached; protein synthesis
 Smooth ER reticulum - lipid synthesis
 Nucleus
-nucleoli: RNA & protein
-envelope: 2 separate membranes, nuclear pores
-CHROMATIN: proteins & DNA (hereditary material; control cell activities)
 Golgi Apparatus –closely packed membrane sacs, collect/distributes lipids or proteins
 Secretory Vesicles – membrane-bound sacs carry subs from golgi
 Lysosomes – break down phagocytized; MBS contain ezymes
 Peroxisomes – break down fatty, amino; MBS contain ezymes
 Mitochondria – production of ATP; carry out aerobic respiration
 Cytoskeleton – supports cytoplasm & organelles / movements; microtubules.filaments
 Centrioles- facilitate chromosome movement; located in centrosome
 Cilia – move subs over surface of cells
 Flagella – propel sperm cells, longer than cilia
 Microvilli – increase surface area of cell, aid absorption

CELL LIFE CYCLE

2 PHASES
1. Interphase – non dividing; cells spends most of it life cycle; DNA is replicated->2 new strands
combined with 2 template strand -> 2 complete sets of genetic material -> dispersed chromatin (thin
threads)

2. Cell division – formation of daughter cells from a single parent cell

a. Mitosis (PMAT) – growth and tissue repair; parent cell divides
 Prophase – CHROMATIN CONDENSES (2; CHROMATIDS) at centromers (s.r)
 Metaphase – chromosomes align
 Anaphase – chromatids separate -> chromosome, two 46 reached opposite pole, cytoplasm begins to
divide
 Telophase – two separate nuclei, chroms begin to unravel and resemble genetic material

b. Meiosis – sex cells

46 chromosomes -> 23 pairs

22 autosomes; 1 pair of sex chromosomes
XX- FEMALE
XY - MALE
 Differentiation – sperms developed specialized structures and functions
 Apoptosis – programmed death of cells; regulates cells within tissues
THE CHEMICAL BASIS OF LIFE
CHEMISTRY – the scientific discipline concerned with the atomic composition and STRUCTURE OF
SUBSTANCESand THE REACTIONS they undergo. Examples of these reactions are nerve impulse
generation, digestion, muscle contraction (sodium and potassium) and metabolism (energy).

MATTER – anything that occupies space and has mass

MASS – amount of matter in an object

WEIGHT – gravitational force acting on an object of a given mass

ELEMENT – the simplest type of matter having unique chemical properties or characteristics (examples:
CHON, Na, Ca, K = 96% of the body’s weight)

ATOM – the smallest particle of an element; “indivisible”

THREE MAJOR TYPES OF SUBATOMIC PARTICLES:

1. NEUTRON – has no electrical charge
2. PROTON – has a positive charge
3. ELECTRON – has a negative charge

ATOMIC NUMBER = the number of PROTONS or the number of ELECTRONS

MASS NUMBER = sum of the number of PROTONS/ELECTRONS and number of NEUTRONS

NUCLEUS – formed by the protons and the neutrons = 99.97% of the atomic mass

ELECTRON CLOUD – where electrons are most likely to be found

CHEMICAL BONDING – occurs when the outermost ELECTRONS are shared or transferred between
atoms

TWO TYPES OF CHEMICAL BONDING:

1. IONIC BONDING – the TRANSFER (sharing or gaining) of electrons
IONS – a CHARGED particle – formed when an atom loses or gains electrons

2. COVALENT BONDING – the SHARING of electrons

– the resulting combination of atoms is called a MOLECULE

TYPES OF COVALENT BONDS:

a. SINGLE COVALENT BOND – sharing of ONE PAIR of electrons
b. DOUBLE COVALENT BOND – sharing of TWO PAIRS of electrons
c. POLAR COVALENT BOND – UNEQUAL and ASYMMETRICAL sharing of electrons
d. NON-POLAR COVALENT BOND – EQUAL and SYMMETRICAL sharing of electrons
 POLAR MOLECULES – have asymmetrical electrical charge
 NON-POLAR MOLECULES – have symmetrical electrical charge

IMPORTANT IONS IN THE HUMAN BODY

ION SIGNIFICANCE ION SIGNIFICANC
E
Calcium Parts of bones and Bicarbonate Acid-base
(Ca2+) teeth; (HCO3 balance
blood clotting; -)
muscle
contractions, release
of
neurotransmitters

Sodium Membrane Ammonium Acid-base

(Na+) potentials; (NH4 balance
water balance +)

Potassium Membrane Phosphate Part of bones

(K+) potentials (PO4 and teeth;
3-) energy
exchange;
acidbase balance

Hydrogen Acid-base balance Iron RBC function

(H+) (Fe2+)

Hydroxide Acid-base balance Magnesium Necessary for

(OH-) (Mg2) enzymes

Chloride Water balance Iodide (I-) Present in

(Cl-) thyroid
hormones

*A polar molecule has a POSITIVE END and a NEGATIVE END

*A positive end of one polar molecule can be WEAKLY ATTRACTED to the negative end of another
polar
molecule
HYDROGEN BOND – the term for the attraction stated above
– it is not a chemical bond because electrons are NEITHER TRANSFERRED NOR SHARED
– plays an important role in DETERMINING THE SHAPE OF COMPLEX MOLECULES
– can occur between different polar parts of a single large molecule to hold the molecule in its normal
threedimensional shape
MOLECULE – formed when two or more atoms chemically combine to form a structure that behaves as
an
independent unit
COMPOUND – substance resulting from the chemical combination of two or more different types of
atoms.
(Note: NOT ALL MOLECULES ARE COMPOUNDS)

DISSOCIATION – when ionic compounds dissolve in water, their ions separate from each other because
the
positively charged ions are attracted to the negative ends of water molecules…
ELECTROLYTES – dissociated ions

CLASSIFICATION OF CHEMICAL REACTIONS:

1. SYNTHESIS REACTION – two or more reactants combine to form a larger, more complex product
– A + B  AB
2. DECOMPOSITION REACTION – reactants are broken down into smaller, less complex products
– AB  A + B
3. EXCHANGE REACTION – combination of a synthesis reaction and a decomposition reaction
– AB + CD  AC + BD
*REVERSIBLE REACTIONS – chemical reaction that can proceed from reactants to products and
from products
to reactants
*EQUILIBRIUM – rate of product formation = rate of reactant formation
ENERGY – the capacity to do work or to move matter

SUBDIVISIONS OF ENERGY:
1. POTENTIAL ENERGY – STORED energy that could do work but is not doing so
2. KINETIC ENERGY – energy caused by the MOVEMENT OF AN OBJECT and is the form of
energy that actually does work

ENERGY has different forms: chemical, mechanical, heat, electrical, electromagnetic/radiant, etc.
CHEMICAL ENERGY – a form of potential energy stored in chemical bonds
MECHANICAL ENERGY – energy resulting from the position or movement of objects
ELECTRICAL ENERGY – energy that results from the movement of charged particles
RADIANT ENERGY – energy that travels in waves
HEAT ENERGY – flow of energy from a warm object to a cooler object
LAW OF CONSERVATION OF ENERGY – the total energy in the universe is constant. Therefore,
energy is neither created nor destroyed (but it can be changed  example: potential to kinetic)

TWO CONDITIONS IN CHEMICAL REACTIONS:

1. If the products of a chemical reaction contain LESS potential energy than the reactants, energy is
RELEASED. (example: breakdown of ATP)

2. If the products of a chemical reaction contain MORE energy than the reactants, energy must be
ADDED. (example: building up of ATP)

FACTORS AFFECTING THE RATE OF CHEMICAL REACTIONS:

1. REACTANTS – reactants differ from one another in their ABILITY TO UNDERGO chemical
reactions
2. CONCENTRATION – the GREATER the CONCENTRATION of the reactants, the GREATER the
chemical
REACTION RATE is. (Example: The normal oxygen concentration in the cells allows it to come in
contact with other molecules, producing chemical reactions necessary for life. If the oxygen concentration
decreases, it can impair cell function or worse, death.)
3. TEMPERATURE – the temperature is DIRECTLY PROPORTIONAL to the reaction rate
4. CATALYST – INCREASES THE RATE OF REACTION without itself being permanently changed
or depleted.

*ENZYMES are protein molecules that act as catalysts.

Examples of enzymes: AMYLASE (speeds up breakdown of carbohydrates, starch and sugar) and
PROTEASE (speeds up breakdown of proteins in most dairy products)

ACID – has a SOUR taste and DISSOLVES IN many METALS

– PROTON DONORS (loses H+)
– releases hydrogen ions when dissolved in water

BASE – has a BITTER taste and it feels SLIPPERY (due to the oils in the skin)
– PROTON ACCEPTORS (gains H+)
– HYDROXIDES – ionize and dissociate in water
NEUTRAL SOLUTION – equal number of H+ and OH- and thus a pH of 7.0
ACIDIC SOLUTION – greater concentration of H+ than OH- and thus a pH less than 7.0
BASIC SOLUTION (ALKALINE) – fewer H+ than OH- and thus a pH greater than 7.0
NORMAL BODY pH = 7.35-7.45
ACIDOSIS = pH below 7.35
ALKALOSIS = pH above 7.45
SALTS (Acid + Base Reaction) – compound consisting of a positive ion other than H+ and a negative
ion other
than OH
BUFFER – RESISTS CHANGES IN THE PH when either the acid or a base is added to a solution
containing the buffer
INORGANIC CHEMISTRY – deals with substances that do not contain carbon
ORGANIC CHEMISTRY – study of carbon-containing substances
OXYGEN (O2) – a small, non-polar inorganic molecule consisting of two oxygen atoms bound together
by a double covalent bond; 21% of the gas in the atmosphere; essential for most living organisms; used in
metabolism
CARBON DIOXIDE (CO2) – consists of one carbon atom bound to two oxygen atoms (via double
covalent bond); a product of GLUCOSE METABOLISM

WATER (H2O) – an inorganic molecule that consists of one atom of oxygen joined by polar covalent
bonds to two atoms of hydrogen.

FUNCTIONS OF WATER:
a. Stabilize Body Temperature
b. Provide Protection
c. Facilitating Chemical Reactions
d. Transporting Substances

ORGANIC MOLECULES
Carbon – has an ability to form COVALENT BONDS… makes possible the formation of large, diverse,
complicated molecules necessary for life… constitute the FRAMEWORK of many large molecules
TWO MECHANISMS (That allow the formation of a wide variety of molecules):
1. Variation in Length of the Carbon Chains
2. Combination of the Atoms Bound to the Carbon Framework

FOUR MAJOR GROUPS OF ORGANIC MOLECULES:

1. CARBOHYDRATES – “CHO”
- in most carbohydrates, each carbon atom has TWO HYDROGEN atoms and ONE OXYGEN atom (2:1
ratio)
 MONOSACCHARIDES – BUILDING BLOCKS of carbohydrates – “SIMPLE
SUGARS”(examples: glucose/blood sugar and fructose/fruit sugar)
 DISACCHARIDES – TWO MONOSACCHARIDES are joined by a COVALENT bond (example:
glucose + fructose = sucrose/table sugar)
 POLYSACCHARIDES – consists of MANY MONOSACCHARIDES bound in long chains
(examples: GLYCOGEN/ANIMAL STARCH – the polysaccharide of glucose; PLANT STARCH
– also a polysaccharide of glucose; CELLULOSE – another polysaccharide of glucose, important
structural component of plant cell walls)

2. LIPIDS – “CHO, PN in some”

- dissolve in NON-POLAR solvents; contain a LOWER proportion of OXYGEN to CARBON
 FATS – important ENERGY-STORAGE molecules; PAD and INSULATE the body
 GLYCEROL and FATTY ACIDS – building blocks of fats
 GLYCEROL – a 3-CARBON molecule with a HYDROXYL group (-OH) attached to each carbon
 FATTY ACIDS – a CARBON CHAIN with a CARBOXYL group attach to one end (-COOH)
 CARBOXY GROUP – responsible for the acidic nature of the molecule of fatty acids
 TRIGLYCERIDES – most common type of fat molecules
-THREE FATTY ACIDS bound to a GLYCEROL molecule
 FATTY ACIDS – differ from one another according to the LENGTH and DEGREE of saturation of
their carbon atoms; most naturally occurring fatty acids contain 14-18 CARBON atoms

TYPES OF FATTY ACIDS:

A. SATURATED – SINGLE covalent bonds between carbon atoms; may cause
BLOCKING/CLOGGING of blood vessels

B.UNSATURATED – one or more DOUBLE covalent bonds; best type of fats; does not
contribute to the development of cardiovascular disease
TYPES OF UNSATURATED FATS:
A. MONOUNSATURATED FATS – one double covalent bond between carbon atoms
(examples: olive oil and peanut oils)
B. POLYUNSATURATED – two or more double covalent bonds between carbon atoms
(examples: safflower, sunflower, corn and fish oils)

 TRANS FATS – unsaturated fats that have been CHEMICALLY ALTERED by the ADDITION OF
H atom… the process make them MORE SATURATED and have a LONGER SHELF-LIFE…
GREATER FACTOR in the risk for CVD than saturated fats
 PHOSPHOLIPIDS – SIMILAR to TRIGLYCERIDES except that one of the fatty acids bound to the
glycerol is replaced by a molecule containing PHOSPHORUS
- makes up the PHOSPHOLIPID BILAYER (cell membranes)
- has a POLAR end which is HYDROPHILIC or water-loving and a NON-POLAR end which is
HYDROPHOBIC (water-fearing)
 EICOSANOIDS – group of important CHEMICALS DERIVED FROM FATTY ACIDS… made in
most cells and are important regulatory molecules… have a role in RESPONSE OF TISSUES to
injuries (example: prostaglandins – regulates the secretion of some hormones, blood clotting, some
reproductive functions, etc.)
 STEROIDS – composed of CARBON atoms bound together into FOUR RING-LIKE structure
- they are anabolic (build up)
- examples: CHOLESTEROL –synthesizes other steroid molecules… important component of cell
membranes; BILE SALTS – increase fat absorption in the intestines…; ESTROGEN,
PROGESTERONE, TESTOSTERONE

3. PROTEINS – “CHON”… may have some sulfur

AMINO ACIDS – building blocks of proteins – contains an AMINE GROUP (-NH2) and a carboxyl
group (-
COOH) – there are 20 basic types
*Humans can synthesize 12 of them… the remaining 8, the “essential amino acids”, must be obtained in
the diet
*Different proteins have different kinds and numbers of amino acids
*Hydrogen bonds between amino acids in the chain cause the chain to fold or coil into a specific
threedimensional shape
*The ability of proteins to perform their functions depends on their shape
*If the hydrogen bonds that maintain the shape of the protein are broken, the protein becomes
nonfunctional.

DENATURATION – change in shape… caused by abnormally high temperatures or PH changes

ENZYME – a protein CATALYST – increases the rate of chemical reaction… “SPECIFICITY”

- LOWERS ACTIVATION ENERGY
LOCK-AND-KEY MODEL – the SHAPES OF AN ENZYME and those of the REACTANTS allow
EASY BINDING thus reduces the activation energy needed for the reaction

4. NUCLEIC ACID: DNA and RNA

DEOXYRIBONUCLEIC ACID (DNA) – the GENETIC MATERIAL of cells… copies of DNA are
transferred from one generation of cells the next… determines the PROTEIN STRUCTURE of cells
RIBONUCLEIC ACID (RNA) – structurally related to DNA… its three types play important roles in
GENE EXPRESSION or PROTEIN SYNTHESIS

NUCLEIC ACIDS – large molecules composed of “CHONP”

NUCLEOTIDES – building blocks of nucleic acids… composed of a SUGAR (monosaccharide) to

which a

NITROGENOUS ORGANIC BASE and a PHOSPHATE group are attached

DEOXYRIBOSE is the sugar for DNA and RIBOSE is the sugar for RNA
The single-ringed organic molecules (nitrogen bases) are THYMINE, CYTOSINE and URACIL
The double-ringed organic molecules (nitrogen bases) are ADENINE, GUANINE (and ADENINE)

DOUBLE-HELIX – the twisted, ladder-like structure (two strands of nucleotides) of DNA

The SIDES OF THE LADDER are formed by COVALENT bonds between SUGAR MOLECULES and
PHOSPHATE
GROUPS of adjacent nucleotides
The RUNGS OF THE LADDER are formed by the bases of the nucleotides (AT, CG, and UA)

ADENINE-THYMINE – their structure allows TWO HYDROGEN BONDS to form between them

CYTOSINE-GUANINE – their structure allows THREE HYDROGEN BONDS to form between them
*The sequence of DNA molecules determines the TYPE and SEQUENCE OF AMINO ACIDS found in
protein molecules
*DNA structure determines the RATE AND TYPE OF CHEMICAL REACTIONS… by controlling
enzyme structure

ADENOSINE TRIPHOSPHATE (ATP) – consists of ADENOSINE and 3 PHOSPHATE groups

- “the ENERGY CURRENCY of cells” (capable of STORING and PROVIDING energy)
*The potential energy stored in the COVALENT BOND between the 2ND and 3RD PHOSPHATE
GROUPS is important to living organisms because it provides the energy used in nearly all of the
chemical reactions within cells.

ADENOSINE DIPHOSPHATE – consists of ADENOSINE and 2 PHOSPHATE groups only

INORGANIC (WABS)
1. Water – most important and abundant inorganic compound
- Found in joints and knees
-Functions: as solvent, acts in chemical reactions, lubricant
- High heat capacity

2. Acids – dissolve into H+; anionas/negatively charge

a. Sour taste, can dissolve many metals, highly acidic
b. Proton donors
c. Dissolved in water -> H+

Bases
a. Bitter; feel slippery
b. Proton acceptor
c. Hydroxides are common examples OHd. OH= ionizes

3. Salts – acid +bases

- Positive ions than H+; Negative ions than OH-
*pH – measurement of acidity/ amount of hydrogen in a sol’n
*7 – neutral; midpoint
*0-6 – acidic
*8-14 – basic/alkalinic
NORMAL BLOOD Ph: 7.35-7.45
*acidosis – pH drops below 7.35
*alkalosis- above 7.45

ORGANIC
1. Carbohydrates
a. Monosaccharide – smallest; simple sugars; 3-7 C; GLUC,FRUC,GALA,RIBO,DEOX;2:1

b. Disaccharides – double sugars; dehydration; base:glucose

c. Polysaccharides – ling branching chains linked simple sugars

*starch – potatoes, carrots, rice
*glycogen – animal tissue
*cellulose – plants, most abundant organic

2. Lipids -18-25%; CHO 1:1;nonpolar; hydrophobic; meat, egg, oil, dairy

a. Triglycerides- most abundant lipid’ most highly concentrated; saturated, monounsaturated,

polyunsaturated; adipose; protection, insulation

b. Phospholipids – MAJOR COMPONENT of cell membrane; transports of liquids in plasma; abundant

in brain

c. Steroids – 4 rings of carbon

 Cholesterol – precursor of all body steroids; MINOR COMPONENT of C.M.
 Bile salts – absorption of dietary lipids (fat); regulates calcium
 Adrenocortical hormones- regulates metabolism; res.to stress; salt & water balance
 Sex Hormones – stimulate reproductive functions & sexual characteristics
(testosterone ,progesterone ,estrogen)
 Eicosanoids – diverse in blood clotting inflammation & immunity; prostaglandins & leukotrines
 Other lipids – Fatty acids (ATP); Carotenes (Vit.A); Vit. E (wound, antioxidant ,scar); Vit.K (blood
clot proteins); Lipoproteins (transport lipids)

3. Proteins – CHONS
Functions:
 STRUCTURAL – structural framework; keratin, collagen
 REGULATORY- hormones: neurotransmitter & insulin
 CONRACTILE – shortening of muscle cells; myosin, actin
 IMMUNLOGICAL – antibodies & interleukins
 TRANSPORT – hemoglobin (oxygen-carrying)
 CATALYTIC – salivary amylase, sucrose, ATPase(destroys)
* Enzyme- protein catalyst

4. Nucleic Acid – CHONP

 DNA (blue print of genes/genetic material) & RNA (gene exp. and synthesis)
 NUCLEOTIDES – monosaccharide (ribose, d. ribose) & nitrogenous base (thyamine, ctosine, uracil),
phosph group

5. Adenosine Triphosphate – energy currency of living organism

 Storing and providing energy

Building Blocks:
 FATS – glycerol, fatty acids
  PROTEINS- amino acid
 DNA/RNA - nucleotides (monomers of nucleic acid)

DNA – AT CG; RNA - AUCG

 Adenine- Thymine; Cytosine- Guanine
 Adenine- Uracil; Cytosine- Guanine

Matter – anything that occupies space and has mass

Mass – amount of matter
Weight – gravitational attraction

Chemical Element
 Simplest type of matter
 118; 92 (earth), 26 (body)
 1 atom

Atom - smallest particle of an element; neutral

sub particles:
1. Neutron
2. Proton
3. Electron – outside the nucleus; involve in bonding and chemical reaction

Mass number – protons + neutrons; top

Atomic number – number of protons/ electrons
Chemical bonds – occurs when the outermost electrons are shared or transferred
Ionic Bond – transfer e.g. salt
Covalent Bond – share e.g. water
SPDF – 2,6,10,14

1. Number of protons is equal to numbers of electrons

2. In order for an atom to become chemically stable it must have 2 or 8 valence electron

96%
 O (65%) – water, ATP
 C (18.5%) – backbone of organic
 H (9.5%) – makes body MORE ACIDIC
 N (3.2%) – protein and nucleic
 Ca (1.5%) – bones, teeth, blood clot, hormones
 P (1.0%) – bones, teeth, ATP, nucleic
 K (.35%) – brain signals, muscle con.HEART, action potentials
 S (0.25%) - vitamins
 Na (.2%) – water balance ,action potentials
 Cl (.2%) - water balance
 Mg (.1%) – increase rate of chem reactions
 Fe (.005%) – hgb, enzymes

3.8%
Ca, P, K, S, Na, Cl, Mg, Fe

.2% -TRACE ELEMENTS

Al, B, Cr, Co, Cu, Mn, Mo, Se, Si, Sn, V, Zn

INORGANIC (WABS)
1. Water
2. Acids
3. Bases
4. Salts
5. Ph

ORGANIC (CLPNA)
1. Carbohydrates (MPD)
1.1 Monosaccharide
1.2 Polysaccharides
1.3 Disaccharides

2. Lipids (TPD)
2.1Triglycerides
2.2 Phospholipids
2.3 Steroids

3. Proteins (CHONS)

4. Nucleic Acid (CHONP)

 DNA
 RNA
 NUCLEOTIDES

5. Adenosine Triphosphate
ORGANIC

6. Carbohydrates
d. Monosaccharide – simple sugars; 3-7 C; GLUC,FRUC,GALA,RIBO,DEOX;2:1
e. Disaccharides – double sugars; dehydration; base:glucose
f. Polysaccharides – ling branching chains linked simple sugars
*starch – potatoes, carrots, rice
*glycogen – animal tissue
*cellulose – plants, most
abundant organic

7. Lipids -18-25% ; CHO 1:1; hydrophobic; meat, egg, oil, dairy

d. Triacylglycerol- most abundant lipid’ most highly concentrated; saturated, monounsaturated,

polyunsaturated; adipose; protection, insulation

e. Phospholipids – MAJOR COMPONENT of cell membrane; transports of liquids in plasma; abundant

in brain
f. Steroids – 4 rings of carbon
 Cholesterol – precursor of all body steroids; MINOR COMPONENT of C.M.
 Bile salts – absorption of dietary lipids; regulates calcium
 Adrenocortical hormones- regulates metabolism; res.to stress; salt & water balance
 Sex Hormones – stimulate reproductive functions & sexual characteristics
 Eicosanoids
 Other lipids

8. Proteins

9. Nucleic Acid – DNA & RNA

10. Adenosine Triphosphate – energy currency of living organism
STEROIDS
1. Cholesterol
2. Bile salts
3. Adrenocortical hormones
4. Eicosanoids
5. Sex Hormones
6. Other lipids

COMMUNITY HEALTH NURSING

COMMUNITY HEALTH NURSING

•The utilization of the nursing process in the different levels of clientele-individuals, families, population
groups and communities, concerned with the promotion of health, prevention of disease and disability and
rehabilitation (Maglaya, et al).

Characteristics
1. Promotion of health and prevention of disease
2. Comprehensive, general, continual, and not episodic
3. Levels of clientele – individuals, families and population groups
4. The nurse and the client have greater control in making decisions related to healthcare and they
collaborate as equals
5. The nurse recognizes the impact of different factors on health and has a greater awareness of his/her
client’s lives and situations

Roles of Community Health Nurse

1. Client-oriented roles
 Caregiver, educator, counselor, referral resource, role model and case manager
2. Delivery-oriented roles
 Coordinator, collaborator, and liaison
3. Population-oriented roles
 Case finder, leader, change agent, community mobilizer, coalition builder, policy advocate, social
marketer and researcher

Framework for Community Health Nursing

1. Health care delivery system
2. The clients
3. Health
4. Economic, sociocultural, political and environmental factors

Clients of Community Health Nurses

 Individual
 Family
 Population Group
 Community
Public Health Nursing
•The practice of nursing in local/national health departments (which includes health centers and rural
health units and public schools
•Implementers of the local government units’ mandate in promoting and protecting the health of their
constituents.

Occupational Health Nursing

•Assisting workers in all occupations to cope with actual and potential stresses in relation to their work
and work environment.
•Primarily geared at helping workers attain and maintain optimum level of physical and psychological
functioning.
•In labor code, if a company has more than 50 workers, the service of a full time nurse should be
provided.

Function:
1. Emergency and palliative care
2. Family planning
3. Counseling
4. Immunization
5. Environmental sanitation
6. Work safety
7. Disaster prevention and control
8. Orientation of new employees
9. Dissemination of health information / health education
10. Administrative

School Nursing
•Promote the health of school personnel and pupil/students.
•Prevent health problems that could hinder students’ learning and performance of their developmental
tasks

Functions:
1. Health and nutrition assessment, screening, and case-finding
2. Treatment of common ailments and attending to emergency cases
3. Counseling and health education
4. Nursing procedures
5. Supervision of health and safety of the school
6. Referrals and follow-ups of pupils and personnel

STANDARDS OF PUBLIC HEALTH NURSING IN THE PHILIPPINES

Nursing Service
•Separate and distinct unit of the local health agency/unit which is composed of nurses, midwives and
auxiliaries such as barangay health workers, nursing aides and volunteers

I. Organization and Management

•A nursing service is organized in a local health agency to ensure the effective delivery of nursing
services and nursing component of public health programs.

•The nursing service is headed by a qualified chief nurse (RA 9173)

• Has a bachelor’s degree in nursing and a registered nurse in the Philippines
• Has at least 5 years experience in general nursing service administration
• Has masters degree in nursing
• Member of a good standing of accredited professional organization of nurses

•The supervising PHN who heads a nursing unit should have the following qualifications:
• BSN, RN
• 5 years of supervisory experience in public health
• Masters degree in public health or nursing
• Member of good standing of the accredited professional organization of nurses

•The nursing service has a written vision, mission, philosophy, goals and objectives.

•Formulates/reviews and implements the nursing service plan, manual of policies and nursing standards.
•Participates for the health agency’s physical facilities, equipment and supplies and in monitoring their
use.

•Participates in the official recruitment, selection, promotion, and discharge process at all levels involving
nursing personnel and in making decisions involving nurses and midwives and nursing practice.

•Initiates/strengthens mechanisms within the agency that enhance nursing and midwifery contribution to
the overall community health goals.

II. Qualifications and Function of PHN

•Graduate of BSN and a RN

•Personal and professional competencies

• Good physical and mental health
• Interest and willingness to work in the community
• Leadership potentials
• Resourcefulness and creativity
• Honesty and integrity
• Active membership to professional nursing organizations

•The PHN performs functions and activities in accordance with the dominant values of public health
nurses
• Management training, supervision, provision of nursing care, health promotion and education
and coordination are consistent with RA 9173 and program policies formulated by DOH
• Considers the needs of her/his clients and their available resources for heath and health care

•The PHN, in coordination with the faculty of colleges of nursing, participates in teaching, guidance and
supervision of students in nursing and midwifery for their RLE in the community setting
•Participates in the conduct of research and utilizes research findings in his/her nursing practice

III. Supervision
IV. Interdisciplinary and Intersectoral Collaboration
V. Nursing Process
A. Establishes a working relationship to help ensure good quality data and to facilitate on enhance
partnership in addressing identified health needs and problems

B. Systematically collects data that are appropriate and accurate

Individual – signs and symptoms, nursing history, knowledge, attitudes and practices, ability to
cope, lifestyle, help-seeking behavior, and utilization of health services.
Family – family structure and characteristics, socioeconomic and cultural factors, environmental
factors, health assessment of each member, value paced on the prevention of disease, and
competencies on family health care.
Community – population characteristics, physical characteristics, environmental factors,
health/illness data, KAP, community resources, leadership and communication, culture,
socioeconomic stratification, people’s participation in health programs, and reasons for the failure
of past health programs.

C. Recognizes the broad impact of certain factors on the client’s health and nursing problems

D. Analyzes data collected about the community, family and individual to determine the diagnoses

E. Formulates a nursing/community diagnosis

F. Develops jointly with the client a nursing care plan or program plan for the priority nursing problems

G. Implements the nursing care plan/program plan to promote, maintain, or restore health, to prevent
illness, to effect rehabilitation and to improve the capability of clients

H. Evaluates the responses of her/his clients to interventions in order to revise data base, diagnoses and
plan and to formulate recommendations

VI. Health Promotion and Health Education

VII. Demonstrating Professional, Responsibility and Accountability

HEALTH CARE DELIVERY SYSTEM

•Societal services and activities designed to protect or restore the health of individuals, families, groups
and communities.

Millennium Developmental Goals

-The United Nations Millennium Development Goals are eight goals that all 191 UN member states have
agreed to try to achieve by the year 2015.

- Signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy,
environmental degradation, and discrimination against women.

Millennium Developmental Goals

The Eight Millennium Development Goals are:
1. to eradicate extreme poverty and hunger;
2. to achieve universal primary education;
3. to promote gender equality and empower women;
4. to reduce child mortality;
5. to improve maternal health;
6. to combat HIV/AIDS, malaria, and other diseases;
7. to ensure environmental sustainability; and
8. to develop a global partnership for development.

Sustainable Developmental Goals

•The Sustainable Development Goals are the blueprint to achieve a better and more sustainable future for
all.
•They address the global challenges we face, inequality, climate, environmental degradation, prosperity,
and peace and justice.

•The Goals interconnect and in order to leave no one behind, it is important that we achieve each Goal
and target by 2030

Sustainable Developmental Goals

1. End poverty in all its forms everywhere
2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
3. Ensure healthy lives and promote well-being for all at all ages
4. Ensure inclusive and equitable quality education and promote life-long learning opportunities for all
5. Achieve gender equality and empower all women and girls
6. Ensure availability and sustainable management of water and sanitation for all
7. Ensure access to affordable, reliable, sustainable, and modern energy for all
8. Promote sustained, inclusive and sustainable economic growth, full and productive employment, and
decent work for all
9. Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation
10. Reduce inequality within and among countries
11. Make cities and human settlements inclusive, safe, resilient and sustainable
12. Ensure sustainable consumption and production patterns
13. Take urgent action to combat climate change and its impacts
14. Conserve and sustainably use the oceans, seas, and marine resources for sustainable development
15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests,
combat desertification, halt and reverse land degradation, and halt biodiversity loss
16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all,
and build effective, accountable and inclusive institutions at all levels
17. Strengthen the means of implementation and revitalize the global partnership for sustainable
development

Department of Health
 The Department of Health (DOH) holds the over-all technical authority on health as it is a national
health policy-maker and regulatory institution.
 DOH has three major roles in the health sector:
 leadership in health
 enabler and capacity builder
 administrator of specific services.

DOH Mission and Vision

VISION
Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040

MISSION
To lead the country in the development of a productive, resilient, equitable and people- centered health
system
DOH
Goals
The Health System We Aspire For
FINANCIAL PROTECTION
Filipinos, especially the poor, marginalized, and vulnerable are protected from high cost of health care.

BETTER HEALTH OUTCOMES

Filipinos attain the best possible health outcomes with no disparity.

RESPONSIVENESS
Filipinos feel respect, valued, and empowered in all of their interaction with the health system.

Persistent in Health Outcomes

- Every year, around 2000 mother die due to pregnancy-related complications
- A Filipino child born to the poorest family is 3 times more likely to not reach his 5 th birthday,
compared to one born to the richest family.
- Three out of 10 children are stunted.

Restrictive and Impoverishing Healthcare Costs

- Every year 1.5 million families are pushed to poverty due to health care expenditures.
- Filipinos forego or delay care due to prohibitive and unpredictable user fees or co-payments.
- Php 4, 000/month healthcare expenses considered catastrophic for single income families

Poor quality and undignified care synonymous with public clinics and hospitals
- Long wait times
- Limited autonomy to choose provider
- Less than hygienic restrooms, lacking amenities
- Privacy and confidentiality taken lightly
- Poor record-keeping
- Overcrowding & under-provision of care
PRIMARY HEALTH CARE
- Essential health care made universally accessible to individuals and families in the community by means
acceptable to them through their full participation and at a cost that the community and country can afford
at every stage of development.
 Partnership and empowerment of the people
 Responsibility for health on the individual, family and the community
 Interrelationship between health and the overall political, sociocultural and economic development of
society

Elements of Primary Health Care

1. Environmental Sanitation
2. Control of Communicable Diseases
3. Immunization
4. Health Education
5. Maternal and Child Health and Family Planning
6. Adequate Food and Proper Nutrition
7. Provision of Medical Care and Emergency Treatment
8. Treatment of Locally Endemic Diseases
9. Provision of Essential Drugs

Four Pillars in PHC

1. Active community participation
2. Intra and inter-sectoral linkages
3. Use of appropriate technology
4. Support mechanism made available

Strategies
1. Reorientation and reorganization of the national health care system
2. Effective preparation and enabling process for health action at all levels
3. Mobilization of the people to know their communities
4. Development and utilization of appropriate technology
5. Organization of communities arising from their expressed needs
6. Increase opportunities for community participation
7. Development of intra-sectoral linkages
8. Emphasizing partnership

Types of PHC Workers

1. Barangay Health Workers (BHW) – this refers to trained community health workers or health
auxiliary volunteer
or a traditional birth attendant or healer.

2. Intermediate level health workers –General medical practitioners, public health nurse, rural sanitary
inspectors,
midwives

Levels of Health Care and Referral System

1. Primary Level of Care – first contact between the community members and the other levels of health
facility

2. Secondary Level of Care – given in health facilities either privately owner or government operated.
Capable of performing minor surgeries and perform some simple laboratory examinations

3. Tertiary Level of Care – rendered by specialists. Complicated cases and intensive care.
 Na
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R e g io nSael H e a lth
S e rv ic e s
D is trict H rve a lthi S e rv ic e s
R u ra l (Loc c ael H o sp ita l)
S e rv ic e s
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RHUs
B a ra n g a y H E a lth
S ta ti o n

THE FAMILY
Family
• A family is defined by the U.S. Census Bureau (2009) as “a group of people related by blood, marriage,
or adoption living together.”

• Allender and Spradley (2008) define the family in a much broader context as “two or more people who
live in the same household (usually), share a common emotional bond, and perform certain interrelated
social tasks.”

• Almost all families, regardless of type, share common activities (Cherlin, 2008).

• They influence the health and activities of their members (Chen, Shiao, & Gau, 2007).

• Specific descriptions of family types vary greatly depending on family roles, generational issues, means
of family support, and sociocultural influences.

Characteristics of Family
• Every family is a social system
• Every family has its own cultural values and rules
• It is the first social group to which the individual is exposed
• Every family has a structure
• Every familyhave certain basic function
• Every family moves through stages
Types of Family
The Dyad Family
• Consists of two people living together, usually a woman and a man, without children.
• Newly married couples
• single young same sex adults who live together as a dyad in shared apartments, dormitories, or homes
for companionship and financial security while completing school or beginning their careers.

The Cohabitation Family

• Composed of heterosexual couples, and perhaps children, who live together but remain unmarried
• Couples who cohabit before marriage have a higher divorce rate than those who do not (Cherlin, 2008).
• This may occur because cohabitation couples enter the union without a real commitment

The Nuclear Family

• traditional nuclear family structure is composed of a husband, wife, and children
The Polygamous Family
- Polygamy (a marriage with multiple wives)

The Extended (Multigenerational) Family

• An extended family includes not only the nuclear family but also other family members such as
grandmothers, grandfathers, aunts, uncles, cousins, and grandchildren.

The Single-Parent Family

 Single parents also may have difficulty with role modeling or clearly identifying their role in the
family (i.e., they must provide duplicate roles, or financial support as well as child care).
 Single-parent families have a special strength in that such a family can offer the child a special
parent–child relationship and increased opportunities for self- reliance and independence.

The Blended Family

• In a blended family, or a remarriage or reconstituted family, a divorced or widowed person with children
marries someone who also has children

The Communal Family

• Communes are formed by groups of people who choose to live together as an extended family.
• Their relationship to each other is motivated by social or religious values rather than kinship (Cherlin,
2008).

The Gay or Lesbian Family

• In homosexual unions, individuals of the same sex live together as partners for companionship, financial
security, and sexual fulfillment
• Some lesbian and gay families include children from previous heterosexual marriages or through the use
of artificial insemination, adoption, or surrogate motherhood.

The Foster Family

• Children whose parents can no longer care for them may be placed in a foster or substitute home by a
child protection agency (Risley-Curtiss & Stites, 2007).

Family Functional Type

FAMILY OF PROCREATION
- refers to the family you yourself created.

FAMILY OF ORIENTATION
- refers to the family where you came from.

Decisions in the Family (Authority)

• PATRIARCHAL – full authority on the father or any male member of the family e.g. eldest son,
grandfather
• MATRIARCHAL – full authority of the mother or any female member of the family, e.g. eldest sister,
grandmother
• EGALITARIAN - husband and wife exercise a more or less amount of authority, father and mother
decides
• DEMOCRATIC – everybody is involve in decision making
• LAISSEZ-FAIRE - “full autonomy”
• MATRICENTRIC - the mother decides/takes charge in absence of the father (e.g. father is working
overseas)
• PATRICENTIC - the father decides/ takes charge in absence of the mother

Functions of Developmental Stages

• Studies family from lifecycle perspective by examine members changes roles and tasks in each
progressive life cycle.
• Families, like individuals, pass through predictable developmental stages (Duvall & Miller, 1990).

Stage 1: Marriage
• Establish a mutually satisfying relationship
• Learn to relate well to their families of orientation
• If applicable, engage in reproductive life planning

Stage 2: The Early Childbearing Family

• Having and adjusting to infant
• Support needs of all three members
• Renegotiating marital relationship

Stage 3: The Family With a Preschool Child

• Adjusting to cost of family life
• Adapting to needs of pre-school children to stimulate growth and development
• Coping and parental loss of energy and privacy

Stage 4: The Family With a School-Age Child

• Adjusting to the activity of growing children
• Promoting joint decision making between children and parents.
• Encouraging and supporting children’s educational achievements

Stage 5: The Family With an Adolescent

• Maintaining open communication among members.
• Supporting ethical and moral values within the family.
• Balancing freedom with responsibility of teenagers.
• Releasing rituals and assistance
• Strengthening marital relationship.
• Maintaining supportive home base young adults with appropriate

Stage 6: The Launching Stage Family: The Family With a Young Adult
• Children leave to establish their own households
• May represent a loss of self-esteem for parents, who feel themselves being replaced by other people in
their children’s lives.

Stage 7: The Family of Middle Years

• partners may view this stage either as the prime time of their lives (an opportunity to travel, economic
independence, and time to spend on hobbies) or as a period of gradual decline (lacking the constant
activity and stimulation of children in the home, finding life boring without them, or experiencing an
“empty nest” syndrome).
• Because the family has returned to a two-partner union, support people may not be as plentiful as they
were.

Stage 8: The Family in Retirement or Older Age

• Adjusting to retirement
• Adjusting to loss of spouse
• Closing family house
• Many grandparents care for their grandchildren while the parents are at work.

Family Tasks
Duvall and Miller (1990) identified eight tasks that are essential for a family to perform to survive as a
healthy unit.

• Physical maintenance: A healthy family provides food, shelter, clothing, and health care for its
members. Being certain that a family has enough resources to provide for a new or ill member is an
important assessment.
• Socialization of family members: This task involves preparing children to live in the community and
to interact with people outside the family. It means the family has an open communication system among
family members and outward to the community. A family that lives in a community with a culture or
values different from its own may find this a difficult task.

• Allocation of resources: Determining which family needs will be met and their order of priority is
allocation of resources. In healthy families, there is justification, consistency, and fairness in the
distribution. Resources include not only material goods but also affection and space. In some families,
resources are limited, so, for example, no one has new shoes. A danger sign would be a family in which
one child is barefoot while the others wear PHP 5,000 sneakers.

• Maintenance of order: This task includes establishing family values, establishing rules about expected
family responsibilities and roles, and enforcing common regulations for family members such as using
“time out” fortoddlers. Determining the place of a new infant and what rules will pertain to him or her
may be an important task for a developing family. In healthy families, members know the family rules
and respect and follow them.

• Division of labor: Healthy families evenly divide the work load among members and are flexible
enough that they can change work load as needed. Pregnancy or the illness of a child may change this
arrangement and cause the family to have to rethink family tasks.

• Reproduction, recruitment, and release of family members: Often not a great deal of thought is
given to this task; who lives in a family often happens more by changing circumstances than by true
choice. Having to accept a new infant into an already crowded household may make a pregnancy a less-
than-welcome event or cause reworking of this task.

• Placement of members into the larger society: Healthy families realize that they do not have to
operate alone but can reach out to other families or their community for help when needed. Because they
have the ability to be sensitive to the needs of individual family members they are able to select
community activities, such as schools, religious affiliation, or a political group, that correlate with the
family’s beliefs and values. Selecting a birth setting, a special school setting, or choosing a hospital or
hospice setting is part of this task.

• Maintenance of motivation and morale: Healthy families are able to maintain a sense of unity and
pride in the family. When this is created, a sense of pride helps members defend the family against threats
as well as serve as support people for each other during crises. It means that parents are growing with and
through the experience of their children the same as children are growing through contact with the
parents. Assessing whether this feeling is present tells you a lot about the overall health of a family

Family Health Task

• Recognizing interruptions of health or development.
• Seeking health care
• Managing health and non-health crises
• Providing nursing care to the sick, disabled and dependent member of the family.
• Maintaining a home environment conductive to good health and personal development.
• Maintaining a reciprocal relationship with the community and health and institutions

Characteristics of Healthy Family

1. Facilitative interaction among members
2. Enhancement of individual development
3. Effective structuring of relationship
4. Active coping effort
5. Healthy environment and lifestyle
6. Regular link with the border community
Family Health Assessment
Overview
• Focus on Family in CHN is based on its characteristics as an open and developing system of interacting
personalities, with a structure and process enacted in relationships among individual members, regulated
by resources and stressors, and existing within the larger community (Maurer and Smith, 2005)

• Family nursing practice emphasizes the need to understand the behavior of the family as a dynamic,
functioning unit which affects its capability to help itself and maintain system integrity, or its readiness to
work with the nurse in enhancing wellness or addressing problems on health and illness

Family Health Task

1. Recognize the presence of wellness state or health condition or problem
2. Make decisions about taking appropriate health action to maintain wellness or manage the health
problem
3. Provide nursing care to the sick, disabled, dependent or at-risk members
4. Maintain a home environment conducive to health maintenance and personal development
5. Utilize community resources for health care.

Nursing Assessment
• Data collection, data analysis or interpretation and problem definition or nursing diagnosis
1. First-level assessment
2. Second-level assessment
Data Collection
First-Level Assessment
• Data about the current health status of individual members, the family as a system and its environment
are compared against norms or standards of personal, social, and its environmental health and interactions
and/or interpersonal relationships within the family system.
1. Family structure, characteristics and dynamics
2. Socio-economic and cultural characteristics
3. Home and environment
4. Health status of each member
5. Values and practices on health promotion/maintenance and disease prevention
• Health Status of Family / Household Member:
• Health Assessment
• Laboratory / Diagnostic Test Results
• Records / Reports
• Home and Environment
• Observation / Ocular Survey
• Interview
• Laboratory/Diagnostic Test Results
• Records/Reports

Second-Level Assessment
• Describe the family’s realities
• Perceptions about and attitudes related to the assumption or performance of family health task on each
health condition or problem identified during the first-level assessment
• In-depth interview on realities/perceptions about and attitudes towards assumption / performance of
health tasks
• Observation: Relate verbal and non-verbal cues
1. The family’s perception of the condition or problem
2. Decisions made and appropriateness; if none, reasons
3. Actions taken and results; if none, reasons
4. Effects of decisions and actions on other family members

Data Gathering Methods and Tools

• Observation
• Physical Examination
• Interview
• Record Review
• Laboratory / Diagnostic Tests

Genogram
• Graphically display information about family members and their relationships over at least three
generations

Please refer to Nursing Practice in the Community (Maglaya, 2009) Pages 449 - 452

Family Coping Index

• The objective of this indicator is to present benchmark for approximating the nursing needs of a
particular family.

• It is the coping capacity and not the underlying problem that is being rated, and it is designed to record
family rather than individual coping capacity.

• In public health nursing, the family cannot be seen only as a factor that affects health; rather, the family
is the patient.

Direction for Scaling

• Two parts of the Coping Index:
• A point on the scale
• A justification statement
• The scale enables you to place the family in relation to their ability to cope with the nine areas of family
nursing at the time observed and as you would expect it to be in 3 months or at the time of discharge if
nursing care were provided.

Direction for Scaling

• Coping capacity is rated from 1 (totally unable to manage this aspect of family care) to 5 (able to handle
this aspect of care without help from community sources). Check “no problem” if the particular category
is not relevant to the situation.

• The justification consists of brief statement or phrases that explain why you have rated the family as you
have.

• Rating should be done after 2-3 home visits when the nurse is more acquainted with the family.

• Terminal rating is done at the end of the given period of time. This enables the nurse to see progress the
family has made in their competence; whether the prognosis was reasonable; and whether the family
needs further nursing service and where emphasis should be placed.

Family Data Analysis

Data Analysis
• Utilizing data generated from the tool on Assessment Data Base.
• Sorts out and classifies or groups data by type or nature
1. Wellness states
2. Health threats
3. Health deficits
4. Stress points or foreseeable crises

Data Analysis
1. Sorting of data for broad categories
2. Clustering of related cues to determine relationships between and among data
3. Distinguishing relevant from irrelevant data
4. Identifying patterns (e.g. function, behavior, lifestyle)
5. Relating family data to relevant clinical/research findings and comparing patterns with norms
6. Interpreting results
7. Making inferences or drawing conclusions about the reasons for the existence of health condition or
problem

Typology of Nursing Problems in Family Nursing

First-Level Assessment
1. Presence of Wellness Condition (Potential or Readiness)
• A clinical or nursing judgement about a client in transition from specific level of wellness or capability
to a higher level (NANDA).
• Wellness Potential – NO explicit expression of client desire
• Readiness for Enhanced Capability – explicit expression of desire to achieve a higher level of state or
function

2. Health Threats
• Conditions that are conducive to disease and accident, or may result to failure to maintain wellness or
realize health potential.

3. Health Deficits
• Instances of failure in health maintenance

4. Stress Points / Foreseeable Crisis

• Anticipated periods of unusual demand on the individual or family in terms of adjustment/family
resources; transitions.

Second-Level Assessment
1. Inability to recognize the presence of the condition due to.
2. Inability to make decisions with respect to taking appropriate health action due to.
3. Inability to provide nursing care to the sick, disabled, dependent or at-risk member of the family due to.
4. Inability to provide a home environment which is conducive to health maintenance and personal
development due to.
5. Failure to utilize community resources for health care due to.

Community Health Nursing

FNCP: Defined
 Blueprint of the care
o Systematically minimize or eliminate identified health and family nursing problems through
explicitly formulate outcomes of care and chose sets of interventions, resources and
evaluation criteria, standards, methods and tools.
o Systematic way to guide the nurse on how to enhance the family’s capability for health and
health care resource, and utilization
 Done by a nurse to achieve desired specific desired outcomes of prioritized health condition/problems

Characteristics of FNCP
 Focuses on action to solve/ minimize existing problems
 Product of deliberate systematic process—data analyses
 Relates to the future; projects future scenarios
 Based upon the initial data base or assessment data base
o Identified health and nursing problems—starting points
 Means to an end, not an end to itself
o Deliver the most appropriate care to the client by eliminating barriers to family health
development.
 A continuous process—must be evaluated for its effectiveness.

Desirable Qualities of FNCP

 Should be based on clear, explicit definition of problems
o Must be based in comprehensive analysis of the problem
o A good plan is realistic
 Prepared jointly with the family
o Nurse works with the family; not works for the family
o Involves family in determining the health needs and problems, priorities, appropriate actions,
implementation, and evaluation of outcomes
 A means of communication
o Within the profession and other professions
o Dependent, independent, and interdependent.

Steps in developing a family nursing care plan

 Assessment phase- generated health conditions and corresponding nursing problems
o Basis for development of the nursing care plan
 Involves steps:
o Prioritized health condition/s or problems
o Goals and objectives of nursing care
o Intervention plan
o Evaluation plan
Prioritize the Health Develop the
conditions and evaluation plan:
Problems based on: Specify:
 Nature of  Criteria,
condition standards,
 Modifiability outcomes based
 Preventive on objectives of
potential care
 Salience  Methods/tools

Develop the
intervention plan
Define goals and  Focused on the
objectives of care: alternatives and
decisions on
appropriate
Formulate:
nursing
 Expected interventions
outcomes based on specific
 Conditions objectives
which sustain formulated.
wellness  Decide on:
 Conditions to
be observed to Measures to help
show problem family eliminate:
 Barriers to
is prevented,
performance of
controlled, health tasks
resolved or  Underlying
eliminated cause/s of on-
 Client’s performance of
response/s or health tasks
behavior
(competency Family-centered
outcomes) alternatives to
 Specific recognize/detect,
monitor, control,
measurable
or manage health
clientcentered
conditions or
statement/ problems
competencies
Determine methods of
nursefamily contact

Notes:
 Nature of the problems- from the first level; subjective data
 Wellness state- is not a problem but is a nursing diagnosis
 Should be maintained
 Highest score- 3; weight- 2
 Salience- depends on the second level assessment; do they see it as a problem?
 Scoring will depend on knowledge and resources.
 The higher the score, the higher the need to immediately solve the problem
 Because it would lead to the resolution of the following problems
 Current management- how do they manage the problem? Is it appropriate or not?
 High risk groups- communicable diseases and surroundings of the family
 Modifiability and preventive potential depends on the resources of the family and the knowledge of
the nurses

Prioritizing health conditions and problems

 A number of health conditions and family nursing problems cannot be addressed all at the same time
within a specific period.
 The nurse can rank the identified health condition/s or problems into priorities.
 A devised tool called scale for ranking health conditions and problems according to priorities.
o Aims to facilitate decision-making in determining which particular health conditions and
their corresponding nursing problems can be addressed by the nurse with the family as client-
partner at appropriate points in time.
 Four criteria for prioritizing:
o Nature of the condition or problem presented
o Modifiability of the condition or problem- probability of success
o Preventive potential- nature and magnitude of future problems that can be minimized or
totally prevented
o Salience- perception and evaluation of the family to the condition or problem in terms of
seriousness and urgency of attention needed or family readiness

Factors that would Affect the Priority Setting

 Nature of the problem
 Biggest weight given to wellness state or potential- premium on client’s efforts or desire to
sustain/maintain high level wellness
 Greater weight on health deficit= needs more immediate attention and felt by the patient over
a health threat
 Health threat= only a risk; still not seen by a patient
 Foreseeable crisis= lowest score d/t culture- linked variable/factors that provide our client
with adequate support to cope
o Still doesn’t have signs and symptoms
o No risk yet
 Modifiability
 Current knowledge, tech, and interventions to enhance wellness or manage the problem
 Resources of the family- physical, financial, and man power
 Resources of the nurse- knowledge, skills, and time
 Resources of the community- facilities and community org/support

 Preventive potential
 Gravity/severity of the px= disease progression extent, damage on the pt/fam= the more
severe or advanced, the lower is the preventive potential
 Duration of the px- length of time the problem has been existing
o Has a direct relationship to gravity and preventive potential
o Current management- presence of appropriateness of intervention measures instituted
to enhance the wellness state or remedy of the problem.
  Institution of appropriate intervention increases the preventive potential
o Exposure of any vulnerable or high-risk group- increases preventive potential of a
condition or problem
 Salience
 Evaluates family’s perception of the condition or problem
o Concerns, felts, needs, and/or readiness increase the score on salience
 Scoring
 Higher score of a given condition or problem=more like taken as a priority

Formulation of goals and objectives of nursing care

Goals Objectives
 General statement  More specific
of the condition or statements of
state to be brought desired results or
about by specific outcomes of care
courses of action  Specify the criteria
 Client outcomes by which the
 Goals tell where degree of
the family is going effectiveness of
care are to be
measured
 Must be specific in
in order to
facilitate its
attainment
 Milestones to reach
destination

 Should be based on nursing diagnosis from the assessment data base

 Address assessment data
 Should be SMART
 Take into consideration the factors that affect the modifiability

Goals
 Must be set together with the family
o Consider the state of your clients
 Family must be able to recognize and accept the presence of existing health needs and problems
o Consider the perception of the family
 Nurse must ascertain the family’s knowledge and acceptance of the problems and the desire to make
actions to resolve them
o Ascertain that the patient sees it as a problem in order to desire actions to resolve them
o Assess if patient is aware of the present problems

Barriers to the goal-setting

 Failure of the family to perceive the existence of the problem
o May feel satisfied with the existing situation
 Family is too busy with other concerns or preoccupations at the moment
 Family does not see the existence of a problem as serious enough to necessitate attention
 Family may perceive the problem and the need to take action, but they face to do something about the
situation
o Both the nurse and family sees the solution, but solution of the family differs from the
solution of the nurse
Reasons for not doing any action
 Fear of consequence of doing action
o Social stigma/financial reasons
 Respect for tradition
 Failure to perceive the benefits of actions proposed
o Based on previous experiences
 Failure to relate the proposed action to the family’s goals
o Family has different perception or interventions for the problem
 Failure between the nurse and the family to establish a working relationship
o Trust and confidence should be established
o Without rapport there will be a lot of barriers for interventions

Time span of objectives

 Short-term/immediate objectives
o Immediate attention is needed; results: can be observed in a period of short time
 Medium-term/intermediate objectives
o Require to attain long term objectives
 Long-term/ultimate objectives
o Several nurse-family encounter more resources
o Takes time to see the results

Selection of appropriate nursing interventions

 Nurse must choose among set of alternatives
 Nurse must specify the most effective or efficient method of nurse-family contact
o Home visits
o Clinic conference
o Visit in the work, place, and school
o Telephone call
o Group approach- gather families together
o Mail
 Nurse must specify the most effective or efficient resources
o Teaching kits- visual aids, handouts, and charts
o Human- other team members and community leaders

How to choose the appropriate nursing intervention?

 It will depend on your plan, assessment, and problems
 Should be family and patient-centered
 Analyze with the family the current situation and determine choices and possibilities based on a lived
experience of meaning and concerns
o Revise plans depending on the capabilities of the family
 Develop/enhance family’s competencies as thinker, doer, and feeler
o Develop the three aspects through health teaching
 Focus on interventions to help perform the health tasks
o Focus on the family’s problems
 Catalyze behavior change through motivation and support

Criteria for Selecting the Type of Nurse-Family Contact

- Effectivity
- Efficiency
- Appropriateness

Home Visit
- Expensive in terms of time, effort and logistics for the nurse
- Accurate appraisal of family relationships, home and environment, family competencies

Clinic or Office Conference

- Less expensive
- Opportunity to use the equipment

Telephone Conference
- Immediate access to data

Written communication
- Less Time-consuming

School visit
- Help children and adolescent on specific health problems

Industrial plant or job site visit

- Assessment of health risks or hazards, health and safety workers

Developing the Evaluation Plan

- Specifies how the nurse will determine achievement of the outcomes of care
- Criteria, standards, evaluation, methods and sources of data

Evaluation phase
- Continuous critiquing of each aspect of the nursing process
- Must take place concurrently with all the other phases of the nursing process
- Formative and Summative evaluation

Formative Evaluation
- Occurs During the course of the nurse-family relationship
- Done and elicited jointly with the family to determine if goals, plans and intervention strategies are
appropriately focused
- Guides both the nurse and the family on decisions about modifications of goals, objectives and
intervention strategies/measures

Summative Evaluation
- Occurs at the end of the nurse-family relationship
- Determines if the goals as specified in the FNCP are achieved
- The nurse can guide the family on making choices about termination or referral

Documentation
- Family Service and Progress Record (FSPR)
- Charting Nursing Care
- Progress Notes and Client Responses/Outcomes

FAMILY HEALTH PROGRAMS

Essential Health Care Programs
1. Family Health Program
2. Prevention and Control of Non Communicable Diseases (NCDs)
3. Prevention and Control of Communicable Diseases
4. Environmental Health and Sanitation
5. Other priority health programs

Family Health Programs

▪ The DOH - Family Health Office is tasked to operationalized health programs geared towards the health
of the family. It is responsible for the creation, implementation and evaluation of health family programs.
▪ The summary of its objective is to improve the survival, health and well-being of each members of the
family as well as the reduction of morbidity and mortality rates in the family and community

Family Health Programs

1. Maternal Health Program
2. Family Planning Program
3. Child Health Program
4. Expanded Program of Immunization
5. Nutrition Program
6. Oral Health Program
7. Others.

MATERNAL HEALTH PROGRAM

Objective: To improve the survival, health and well-being of mothers and unborn child

Components of Pregnancy Care

1. Antenatal registration
2. Tetanus toxoid immunization
3. Macronutrient and micronutrient supplementation
4. Treatment of diseases and other conditions
5. Early detection and management of complications of pregnancy
6. Clean and safe delivery
7. Support to breastfeeding
8. Family planning counseling
9. STD/HIV/AIDS prevention and management
10. Oral care

Antenatal Registration
▪ 4th to 16 weeks of pregnancy
▪ Home Based Maternal Record (HBMR)
– recording and interpretation of comprehensive information on the health status of woman before her
first pregnancy, during the current pregnancy delivery, post-partum and neonatal periods, and during two
subsequent pregnancies.
▪ Compute the AOG and EDD

Schedule of Prenatal Visits

Prenatal Visits Period of Pregnancy
 1st visit During the first trimester or before the fourth month
 2nd visit During 2nd trimester
 3rd visit During 3rd trimester
 4th visit After the 8th month of pregnancy till delivery (weekly)

Tetanus Toxoid Immunization

▪ Tetanus is caused by an anaerobic spore forming bacteria called clostridium tetani
▪ DOH Administrative Order no. 15s 1995, mandates TTshall be given to women on their 5th to 6th
month ofpregnancy.
 Tetanus Toxoid Immunization (0.5ml)

Vaccine dose Timing of Period of

vaccinations protection

TT1 5th-6th month None

of pregnancy
At least 4
TT2 weeks after 3 years
 TT1
TT3 At the 5th-6th 5 years
month of
succeeding
pregnancy
regardless
interval of
previous
pregnancy

TT4 At the 5th-6th 10 years

month of
pregnancy
regardless of
interval
TT5 At the 5th-6th All child-
month of bearing years
pregnancy
regardless of
interval

Iron Supplementation
▪ Vital because of the blood loss in delivery
▪ 60 mg iron and 400 ug folic acid daily for 6 months (WHO)
▪ 60 mg tablet starting on the 5th month of pregnancy up to 2 months postpartum or for a period of 210
days

Vitamin A Supplementation
▪ Important for visual health, immune function and fetal growth and development
▪ 10,000 IU two times a week starting on the 4th month of pregnancy and not before the 4th month to
avoid congenital disorders

Other Conditions.
Iodine deficiency – cause of mental retardation and brain damage
– One capsule of iodized oil
Malaria - 2 tablets of chloroquine phosphate (250mg/tablet) every week for the duration of the pregnancy

Early Detection and Management of Complications

Report:
▪ Vaginal bleeding
▪ Edema of the face and hands
▪ Headache
▪ Dizziness
▪ Blurred vision
▪ Pallor

Assess:
• Fundic height
• Temperature
• Blood pressure
• Weight
• Signs of urinary infection
• Signs of eclampsia

Mean BP classification
Systolic Diastolic
<120 <80 Normal
120-139 80-89 Prehypertension
140-159 90-100 Stage I
hypertension
>160 >100 Stage II
hypertension

Family Planning
▪ Discussed in the first prenatal visit and the subsequent visits
▪ IUD, condom, progesterone only pill, natural family planning, spermicides, and permanent method

STD/HIV/AIDS Prevention and Management

▪ Screening
▪ Health Education
▪ Referrals

Child Health Programs

▪ Infant and Young Child Feeding
▪ Newborn Screening Test (NBST)
▪ Expanded Program on Immunization
▪ Management of Childhood Illnesses
▪ Micronutrient Supplementation
▪ Dental Health
▪ Early Child Development
▪ Child Health Injuries

Infant and Young Child Feeding

Laws that protects infant and young child feeding:

Milk Code (EO 51)

- Products covered by milk code consist of breast milk substitute, e.g. infant formula, other milk products,
bottled
complementary foods
Rooming-In and Breastfeeding Act of 1992 ( RA 7600)
- Requires both public and private institution to promote rooming-in, it encourage and support the
practice of breastfeeding

Food Fortification Law (RA 8976)

- An act Establishing the Philippine Food Fortification Program and for other purposes” mandating
fortification of flour, oil and sugar with Vitamin A and flour and rice with iron

Food Fortification Program

▪ There are 139 processed food products with Sangkap Pinoy Seal with 83% with vitamin A, 29% with
iron and 14% with iodine (2008)
▪ 37% of the products are snack foods
▪ Most of the products FDA analyzed are within the standard
▪ Based on 2003 NNS Households’ awareness of SPS- and FF-products is 11% and 14%, respectively, in
2008 awareness is 11.6%
▪ Although awareness is low, usage of SPS-products is 99.2%

Newborn Screening Act of 2004 (RA 9288)

▪ Policies and Laws
– Republic Act No. 9288 or the Newborn Screening Act of 2004
– Administrative Order No. 2018-0025: National Policy and Strategic Framework on Expanded Newborn
Screening for 2017-2030
– Administrative Order No. 2014-0045 or the Guidelines on the Implementation of the Expanded
Newborn
Screening Program

Newborn Screening Act of 2004 (RA 9288)

▪ NBS is a public health program aimed at the early identification of infants who are affected by certain
genetic/ metabolic/infectious conditions
▪ Early identification and timely intervention can lead to significant reduction of morbidity, mortality, and
associated disabilities in affected infants.
▪ Expanded Newborn Screening – inclusion of more than 20+ disorders in the NBS Panel of Disorders

Newborn Screening Act of 2004 (RA 9288)

▪ Newborn screening is ideally done on the 48th -72nd hour of life. However, it may also be done after 24
hours
from birth.
▪ A few drops of blood are taken from the baby’s heel,blotted on a special absorbent filter card and then
sentto Newborn Screening Center.

Newborn Screening Act of 2004 (RA 9288)

a) CH (Congenital Hypothyroidism)
b) CAH (Congenital Adrenal Hyperplasia)
c) GAL (Galactosemia)
d) PKU (Phenylketonuria)
e) G6PD (Glucose-6-Phosphate Dehydrogenase)
f) Fatty Acid Disorders
g) Organic Acid Disorders
h) Hemoglobinopathies
i) HbH Disease/Alpha
j) Thalassemia
k) Hemoglobin E Disease or Interacting Hb E/Beta Thalassemia
l) Beta Thalassemia
m) Hemoglobin D Disease

Expanded Program for Immunization

The Expanded Program on Immunization (EPI) was established in 1976 to ensure that infants/children
and mothers have access to routinely recommended childhood vaccines.
▪ Six vaccine-preventable diseases were initially included in the EPI: tuberculosis, poliomyelitis,
diphtheria, tetanus, pertussis and measles.
▪ In 1986, 21.3% “fully immunized” children less than fourteen months of age based on the EPI
Comprehensive
Program review

Expanded Program for Immunization

GOAL: To reduce the morbidity and mortality among children against the most common vaccine
preventable diseases.

1. To immunize all infants/children against the most common vaccine-preventable diseases.

2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus
5. To control diphtheria, pertussis, hepatitis b and German measles.
6. To prevent extra pulmonary tuberculosis among children.

Expanded Program for Immunization

▪ Republic Act No. 10152
– “Mandatory Infants and Children Health Immunization Act of 2011 signed by President Benigno
Aquino III in July
26, 2010
▪ The original objective was to reduce the morbidity and mortality among infants and children caused by
childhood diseases.
▪ Every Wednesday is designated as immunization day in all parts of the country.

Immunization
 The program is based on epidemiological situation; schedules are drawn on the basis of the
occurrences and characteristics features of the said diseases.
 The whole community rather than just an individual is to be protected, thus, mass approach is applied.
 Immunization is a basic health service and as such, it is integrated into the health services provided
for by Rural Health Unit.

Immunization – is a process by which vaccines are introduce to the body, before infectious sets in.

Immunization
Target Setting – (0 – 12 mos.)
 Cold Chain Management (for vaccine life span and utilization)
 Information, education and communication
o 3 Reasons:
1. For parents, to be motivated to submit their child to immunization
2. To provide health teachings on benefits and importance of immunization
3. To inform the public about its availability and schedule (RHU q Weds. BHS q once a month,
and remote area q Quarterly)
 Assessment and evaluation of the programs overall performance
 Surveillance, studies and research.

Cold Chain Management

 Temperature monitoring of vaccines is done:
o In all levels of health facilities
o Twice a day (start and end of shift)
 Temperature is plotted every day in monitoring chart to
 monitor break in cold chain

EPI Logistics
- FEFO (First Expiry, First Out)
- Proper arrangement and labeling of vaccines expiry date

A. BCG Vaccine
  Bacille Calmette-Guerin, is a live-attenuated vaccine for tuberculosis (TB) disease
  Dose: at birth
  Route of administration: intradermal
  Dosage: 0.05 ml
  Shelf life: 12-24 months at 2 - 8 °C

BCG Vaccine: Side Effects

1. Koch’s Phenomenon: Acute inflammatory process starting with in 24 hrs. and may last for 2 – 4
days. Wheal must disappear in about 30 mins – 1hr.
2. Abscess formation: 1st week – soreness and inflammation, 2nd week – 11th week healing of
abscess and ulceration. If there is no scar developed, repeat the procedure
3. Indolent Ulceration – wrong technique, exposure of infant to patient with active TB.
4. Glandular Enlargement – unsterile syringe or needle was used, too much vaccine was injected, the
vaccine might be injected under the skin layer and not instead in its superficial layer.
 BCG Vaccine: Health Teachings
1. Do not massage the area of injection
2. A scar will formed 12 weeks after injection
3. Repeat BCG vaccination if the child does not develop a scar after first injection

B. DPT Vaccine
 Diphteria - infectious disease caused by the bacterium Corynebacterium diphtheria, which primarily
infects the throat and upper airways, and produces a toxin affecting other organs.
 Pertussis - highly contagious disease of the respiratory tract caused by Bordetella pertussis, a bacteria
that lives in the mouth, nose, and throat.
 Tetanus - non-communicable disease contracted through exposure to the spores of the bacterium,
Clostridium tetani

DPT Vaccine
 Diphteria and Tetanus are toxoid vaccines
 Pertussis is an inactivated vaccines
 Doses: 3 doses, 4 weeks interval (minimum of 28 days)
 Dosage: 0.5 ml
 Route: Intramuscular
 Site: Vastus lateralis (R-L-R), outer upper arm if older
 Storage: 2 to 8 C (body of refrigerator)
DPT Vaccine: Side Effects
1. Fever within 24 hours
2. Local soreness pain and swelling

DPT Vaccine: Health Teachings

1. Paracetamol for fever, as prescribed.
2. Alternating cold compress for 24 hours to warm compress if there is pain and soreness

C. OPV
 Oral Polio Vaccine, live attenuated
 Doses: Three (3), 4 weeks interval
 Dosage: 2 drops
 Route: Oral
 Site: Mouth

OPV: Side Effects and Health Teachings

Side effects:
 Causes almost no side effects
 Less than 1% of the people who receive the vaccine develop a headache, diarrhea or muscle pain.
Health teachings:
 Nothing per orem for 30 minutes before and after OPV
 Do not touch the tip dropper bottle to the tongue

D. Hepatitis B Vaccine
 Monovalent vaccine
 Dose: 1st dose at birth, 2nd dose after 6 weeks, 3rd dose after 8 weeks
 Dosage: 0.5 ml
 Route: IM
 Site: Vastus lateralis (L-R-L)

Hep B: Side Effects and Health teachings

Side effects:
 Mild fever that lasts 1-2 days after injection
 Soreness, children may have pain, redness or swelling at the site
Health teachings:
 Paracetamol, as prescribed
 Alternating cold compress for 24 hours to warm compress if there is pain and soreness

E. Measles Vaccine
 Attenuated Measles Virus
 Dose: 1 dose only given at the 9th month. If there is an epidemic, given at 6th month.
 Dosage: 0.5 ml
 Route: SQ
 Site: outer port of the upper arm

Measles Vaccine: Side Effects

 Fever that lasts 1-2 days after injection
 Soreness, pain, redness, swelling at the injection site within 24 hours (resolves within 2-3 days)
 About 1 in 20 children develop a mild rash five to 12 days after receiving the vaccine (lasts about
2 days)

Measles Vaccine: Health Teaching

 Paracetamol, as prescribed.
 Alternating cold and warm compress

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

What is IMCI?
- An integrated approach to child health that focuses on the well-being of the whole child.
- Aims to reduce death, illness and disability and to promote improved growth and development among
children under five years of age.
- Includes curative and preventive elements that are implemented by families and communities and by
health facilities.

Objectives of IMCI
1. Reduce death and frequency and severity of illness and disability
2. Contribute to improved growth and development

Why an integrated approach?

▪ 10 million die each year and majority of these deaths are caused by 5 preventable and treatable
conditions namely:
– Pneumonia
– Diarrhea
– Malaria
– Measles and
– Malnutrition.

Benefits of IMCI
1. Addresses major child health problems because it systematically address the most important causes of
children illness and death.
2. Responds to demands.
3. Promotes prevention as well as cure because IMCI emphasizes important preventive interventions such
as immunization and breastfeeding.
4. It is cost-effective- most cost-effective interventions in low and middle income countries (World
Bank).
5. Promotes cost-saving.
6. Improves equity – IMCI improves inequity in global health care.

Focus of IMCI
1. Improving case management skills of health workers
2. Improving over-all health systems
3. Improving family and community health practices

Steps in IMCI Case Management Process

1. ASSESS THE CHILDS ILLNESS
2. CLASSIFY THE ILLNESS BASED ON SIGNS
3. IDENTIFY TREATMENT
4. TREAT THE CHILD
5. COUNSEL THE CARETAKER
6. FOLLOW-UP

Who are covered by the IMCI protocol?

 Sick children birth up to 2 months (Sick Young Infant)
 Sick children 2 months up to 5 years old (Sick child)

Basis for Classifying the Child’s Illness

▪ PINK - indicates urgent hospital referral or admission
▪ YELLOW - indicates initiation of specific outpatient treatment
▪ GREEN – indicates supportive home care

Principles of IMCI
I. All sick children aged up to 5 years are examined for general danger signs and all sick young infants are
examined for very severe disease. These signs indicate immediate referral or admission to hospital.

II. The children and infants are then assessed for main symptoms.
 For older children, the main symptoms include: cough or difficulty breathing, diarrhea, fever and
ear infection.
 For young children, local bacterial infection, diarrhea and jaundice.
 All sick children are routinely assessed for nutritional and immunization and deworming status
and other problems.

III. Only a limited number of clinical signs are used

IV. A combination of individual signs leads to a child’s classification within one or more symptom
groups rather than a diagnosis.

V. IMCI management procedures use limited number of essential drugs and encourage active
participation of caretakers in the treatment of children

VI. Counseling of caretakers on home care, correct feeding and giving of fluids, and when to return to
clinic is an essential component of IMCI

General Danger Signs

 The child is NOT ABLE TO DRINK or BREASTFEED
 The child VOMITS EVERYTHING
 The child has had CONVULSIONS
 The child is ABNORMALLY SLEEPY or DIFFICULT TO AWAKEN

IMCI Implementation
 Implemented in 70% of all health facilities nationwide.
 Integrated in the Nursing, Midwifery and Medical Pre-Service Education.
CONTROL OF COMMUNICABLE DISEASES
Communicable Diseases
- Spread from one person to another through a variety of ways that include:
- Contact with blood and bodily fluids-
 - Breathing in an airborne virus
- Being bitten by an insect

Tuberculosis
- An infectious disease caused by TB bacteria (mycobacterium tuberculosis)
- It is transmitted from a TB patient to another person through coughing, sneezing and spitting.

National TB Control Program (NTP)

- One of the public health programs being managed and coordinated by the Infectious Diseases for
Prevention and Control Division (IDPCD) of the Disease Prevention and Control Bureau (DPCB) of the
DOH

Tuberculosis: Signs and Symptoms

- Cough of at least 2 weeks duration with or without the following symptoms:
- Significant and unintentional weight loss;
- Fever;
- Bloody sputum (hemoptysis);
- Chest/back pains not referable to any musculoskeletal disorders;
- Easy fatigability or malaise;
- Night sweats; and,
- Shortness of breath or difficulty of breathing.

Tuberculosis: Case Finding

- direct sputum smear microscopy (DSSM)
- TB culture and drug susceptibility test
- tuberculin skin test
- rapid molecular diagnostic tests

Tuberculosis: Treatment
Recommended Treatment Regimen for Adults and Children
Leprosy
- Chronic disease of the skin and peripheral nerves caused by mycobacterium leprae
- WHO Classification of Leprosy
- Paucibacillary (tuberculoid and indeterminate)
o Non-infectious
o Duration of Treatment: 6-9 months
- Multibacillary (lepromatous and borderline)
o Infecof treatment: 24-30 months
o Duration of treatment: 6-9 months
- Incubation period: 3-5 years on average
- No vaccine yet

Leprosy: Signs and Symptoms

- Early signs
 Change in skin color (reddish or white)
 Absence of sensation of the skin lesion
 Loss of sweating and hair growth on the lesion
 Muscle weakness or paralysis of extremities
 Thickened and/or painful nerves
 Ulcers that do not heal
 Redness and pain in the eye

- Late signs
 Loss of eyebrows (madarosis)
 Inability to close eyelids (lagophthalmos)
 Clawing
 Contractures
 Chronic ulcers
 Enlargement of male breast (gynecomastia)
 Sinking of the nose bridge

Leprosy: Prevention
- Health education on avoidance of prolonged skin-to-skin contact
- BCG vaccination
- Adequate nutrition
- Good personal hygiene

Leprosy: Leprosy Control Program

- Aims to provide multidrug therapy (MDT)

1. Paucibacillary
1. Supervised dose – once a month in the health center
1. Rifampicin 600mg
2. Dapsone 100mg
 2. Self administered – Dapsone
2. Multibacillary
1. Supervised dose – once a month in the health center
1. Rifampicin 600mg
2. Lamprene 100mg
2. Self administered – Lamprene 50mg OD

Schistosomiasis
- Also known as Snail Fever
- Parasitic disease common among farmers and fishermen
- Schistosoma japonicum, S mansoni, and S haemotabium

Schistosomiasis: Mode of Transmission

- Transmitted thru skin penetration causing diarrhea, ascites, hepatosplenomegaly
- Tiny snail called Oncomelania quadrasi

Schistosomiasis: Manifestations
- Itchiness of the skin
- Bloody, mucoid stools
- Fever and cough
- Diarrhea
- Abdominal pain
- Dysenteric attacks
- Enlarged liver and spleen
- Weight loss
- Severe liver disease
- Aemia
- Jaundice
- Ascites

Schistosomiasis: Prevention and Control

- Case finding
- Health Education
– Encourage use of rubber boots for protection
- Environmental Sanitation
– Proper disposal of feces
- Snail eradication
– Use of moluscides

Filariasis
- Lymphatic Filariasis or elephantiasis
- Chronic parasitic infection caused by parasites that live inside the lymphatics
- Caused by thread-like parasitic filarial worms which
- lodge in the nodes and vessels of the lymphatic system

Filariasis: Mode of Transmission

- Mosquito bites which carry microfilariae

Filariasis: Manifestations
- Fever
- Enlargement of the extremities

Malaria
- A vector-borne disease caused by female Anopheles mosquito causing symptoms such a fever,
sweating, intermittent chills, anemia, and splenomegaly.
- Chemoprophylaxis – Chloroquine 1-2 weeks before entering an area then continuous until 4-6 weeks
after
leaving the area
- The incubation period in most cases varies from 7 to 30 days.
- Signs and Symptoms:
– Fever
– Chills
– Sweats
– Headaches
– Nausea and vomiting
– Body aches
– General malaise

NON-COMMUNICABLE DISEASES
DOH Vision and Mission
Vision
A Philippines free from the avoidable burden of NCDs

Mission
Ensure sustainable health promoting environments and accessible, costeffective, comprehensive,
equitable and quality health care services for the prevention and control of NCDs, and guided by the
principle of “Health in All, Health by All, Health for All” whereas Health in All refers to Health in
All Policies, Health by All involves the whole-of-government and the whole-of- society and the Health
for All captures the KP (Kalusugan Pangkalahatan) or the Universal Health Care (UHC).

DOH Program Components

▪ Cardiovascular diseases
▪ Cancers
▪ Chronic obstructive pulmonary diseases
▪ Diabetes mellitus

Policies and Laws

▪ AO No. 2011-0003 or The National policy on Strengthening the Prevention and Control of Chronic
Lifestyle
Related Non-Communicable Diseases

▪ AO No. 2012-0029 or the Implementing Guidelines on the Institutionalization of Philippine Package of

Essential
NCD Interventions (PhilPEN) on the Integrated Management of Hypertension and Diabetes for Primary
Health
Care Facilities

▪ AO No. 2013 – 0005 or The National Policy on the Unified Registry Systems of the Department of
Health (Chronic
Non-Communicable Diseases, Injury Related Cases, Persons with Disabilities, and Violence Against
Women and
Children Registry Systems)

▪ AO 2015-0052: “National Policy on Palliative & Hospice Care in the Philippines

▪ AO 2016-0001: “Revised Policy on Cancer Prevention and Control Program

▪ AO 2016 – 0014 - Implementing Guidelines on the Organization of Health Clubs for Patients with
Hypertension and Diabetes in Health Facilities

Cardiovascular Diseases
▪ Coronary Artery Disease
▪ Hypertension
▪ Stroke

Coronary Artery Disease

 Heart disease caused by impaired coronary blood flow.
 It is also known as ischemic heart disease

Risk Factors
 Elevated blood cholesterol
 Smoking
 Hypertension
 Obesity
 Physical Inactivity

Prevention:
 Promote regular physical activity and exercise
 Encourage proper nutrition
 Maintain body weight and prevent obesity
 Promote smoking cessation for active smokers and prevent exposure to second hand
 Early diagnosis, prompt treatment and control of diabetes and hypertension

Hypertension
▪ Primary hypertension has no definite cause.
– It is also called essential hypertension or idiopathic hypertension.

▪ Secondary hypertension is usually the result of some other primary diseases leading to hypertension
such as renal disease.

Risk Factors:
▪ Family history
▪ Advancing age
▪ Race
▪ High salt intake
▪ Obesity
▪ Excess alcohol consumption

Prevention:
▪ Proper nutrition – reduce salt and fat intake
▪ Prevent overweight and obesity
▪ Promote smoking cessation
▪ Early diagnosis and prompt treatment

Cerebrovascular Disease (Stroke)

Loss or alteration of bodily function that results from an insufficient supply of blood to some parts of the
brain.

Types
▪ Thrombotic stroke usually occur in atherosclerotic blood vessels.
▪ Embolic stroke is caused by a moving blood clot usually from a thrombus in the left heart that becomes
lodged in a small artery through which it cannot pass.
▪ Hemorrhagic stroke is due to intracerebral hemorrhage or rupture of intracerebral blood vessels.

Risk Factors:
▪ Increasing age
▪ Family health history
▪ Race
▪ Gender
▪ Hypertension
▪ Smoking
▪ Alcohol
▪ Drug abuse

Prevention:
 Prompt treatment and control of hypertension
 Prevent all other risk factors of atherosclerosis
 Promote smoking cessation and smoke-free environment.
 Avoid intravenous drug abuse and cocaine

Cancer
- Cancer develops when cells in a part of the body begin to grow out of control.
- Normal body cells grow, divide, and die in an orderly fashion.
- Cancer cells often travel to other parts of the body where they begin to grow and replace normal tissue.
This process is called metastasis.

Cancer
Benign (non-cancerous) tumors usually grow slowly, do not spread to other parts of the body and, with
very rare exceptions, are not life threatening unless their location interfere with vital functions like a brain
tumor.

Malignant (cancerous) tumors grow more rapidly, tend to metastasize, and usually cause death unless
growthcan be controlled

Risk Factors:
▪ Age
▪ Sex
▪ Family medical history
▪ Smoking
▪ Dietary factors
▪ Alcohol consumption

Prevention:
  Promote smoking cessation
  Promote proper nutrition
o Increase intake of dietary fiber
o Eat more leafy green and yellow vegetables, fruits and unrefined cereals.
o Beta-carotene, vitamins A, C, E and dietary fiber may be potential anti-cancer substances.
o Eat less fat and fatty foods.
o Limit consumption of smoked, charcoal-broiled, salt-cured, and salt-pickled foods.
 Maintain normal weight through proper nutrition and physical activity and exercise.
 Drink alcoholic beverages in moderation.
 Early diagnosis and prompt treatment
 Avoid intravenous drug abuse and cocaine.

Diabetes Mellitus
It is a genetically and clinically heterogeneous group of metabolic disorders characterized by glucose
intolerance with hyperglycemia present at time of diagnosis.

Diabetes Mellitus
Type I diabetes is insulin-dependent diabetes mellitus (IDDM) – characterized by absolute lack of
insulin due todamaged pancreas, prone to develop ketosis, and dependent on insulin injections.
Type II is non- insulin dependent diabetes mellitus (NIDDM) – characterized by fasting
hyperglycemia despite availability of insulin. Possible causes include impaired insulin secretion,
peripheral insulin resistance and increased hepatic glucose production.

Risk Factors:
 Family history of diabetes
 Overweight and obesity
 Lack of physical activity
 Hypertension
 HDL cholesterol < 35 mg/dl (0.90 mmol/L) and/or triglyceride level > 250 mg/dl (2.82 mmol/L)
 History of Gestational Diabetes Mellitus (GDM) or delivery of a baby weighing 9 lbs (4.0 Kgs)

Prevention:
 Maintain normal weight and prevent overweight/obesity
 Promote proper nutrition - - Eat more dietary fiber, reduce salt and fat intake, avoid simple sugars like
cakes and pastries; avoid junk foods.
 Promote regular physical activity and exercise to prevent obesity, hypercholesterolemia and enhance
insulin action in the body
 Promote smoking cessation for active smokers and prevent exposure to second-hand smoke.

Chronic Respiratory Diseases

- COPD is a disease state characterized by airflow limitation that is not fully reversible.
- The lungs undergo permanent structural change.
- Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements
play a role

Preventions
 Promote smoking cessation among individuals with COPD and asthma
 Promote smoke-free environment
 Recognize triggers that exacerbate asthma such as irritant gases and smoke, house dust mite found in
pillows, mattresses, carpets; respiratory infection, inhaled allergens, weather changes, cold air,
exercise, certain foods/drug

ENVIRONMENTAL HEALTH
Environmental Sanitation
- It is defined as the study of all factors in man’s physical environment, which may exercise a deleterious
effect on his health, well-being and survival.
Goal:
To eradicate and control environmental factors in disease transmission through the provision of basic
services and facilities to all households.
Components
• Water Supply Sanitation Program
• Proper Excreta and Sewage Disposal Program
• Insect and Rodent Control
• Food and Sanitation Program
• Hospital Waste Management Program
35 | C o m m u n i t y h e a l t h n u r s i n g
• Strategies on Health Risk Minimization

Environmental and Occupational Health

Office (EOHO)
1. Water quality surveillance
2. Evaluation of food establishments
3. Proper solid and liquid waste management
4. Sanitation of public places
5. Sanitation management of disaster areas
6. Impact assessment of environmentally critical projects
7. Enforcement of sanitation laws, rules, regulations and standards

Laws and Policies

RA 6969 – Toxic Substances and Nuclear Waste Control Act of 1990

RA 8749 – Clean Air Act of 1999

RA 9003 - Ecological Solid Waste Management Act of 2000

RA 9275 – Clean Water Act of 2004

PD 856 – Sanitation Code of the Philippines

Types of Approved Water Supply and Facilities

Water Supply Sanitation Program

Level I
Non-water carriage toilet facility:
1. Pit latrines
2. Reed Odorless
3. Earth Closet
4. Bored-hole
5. Compost
6. Ventilated
7. improved pit
8. Toilets requiring small
9. amount of water to wash
10. waste into receiving space:
11. Pour flush
12. Aqua-privies
Level II
. On site toilet facilities of the water carriage type with water sealed and flushed type with septic
vault/tank disposal facilities.

Level III
1. Water carriage types of toilet facilities connected to septic tanks and/or to sewerage system to
treatment plant.

Environmental Sanitation
Unapproved type of water facility:
o Open dug wells
o Unimproved springs
o Wells that need priming

Disinfection of water supply sources is required on the following:

o Newly constructed water supply facilities
o Water supply facility that has been repaired or improved
o Found to be positive bacteriologically by lab analysis
o Open dug wells
o Unimproved springs
o Surface water
Proper Excreta and Sewage Disposal System
Level 1
Non-water carriage toilet facility:
o Pit latrines
o Reed Odorless
o Earth Closet
o Bored-hole
o Compost
o Ventilated
o improved pit

Toilets requiring small amount of water to wash waste into receiving space:
o Pour flush
o Aqua-privies

Level 2
1. On site toilet facilities of the water carriage type with water sealed and flushed type with septic
vault/tank disposal facilities.

Level 3
1. Water carriage types of toilet facilities connected to septic tanks and/or to sewerage system to
treatment plant.

Environmental Sanitation
Proper Solid Waste Management
- refers to satisfactory methods of storage collection and final disposal of solid wastes.

Household Community
A. Burial
- Deposited in 1m x 1m deep pits covered with soil, located 25m away from water supply.
 Open Burning
 Animal feeding
 Composting
 Grinding and disposal sewer

Community
A. Sanitary landfill or controlled tipping
- Excavation of soil deposition of refuse and compacting with a solid cover of 2 feet.
 Incineration

ENVIRONMENTAL SANITATION

Food Sanitation Program

Policies:
o Food establishment are subject to inspection (approved of all food sources containers and transport
vehicles).
o Comply with sanitary permit requirement
o Comply with updated health certificates for food handlers, helpers, cooks
o All ambulant vendors must submit a health certificate to determine present of intestinal parasite and
bacterial infection.
DOH AO #1
 Requires all laboratories to use Formalin Ether Concentration Technique ( FECT ) instead of the
direct fecal smear in the analysis of stools of food handlers.
 This will enable laboratories to identify food handlers with parasitic infection and treat them before
they are allowed to work in food establishment.
 All ambulant vendors must submit a health certificate to determine present of intestinal parasite and
bacterial infection.

Environmental Sanitation
Food establishment shall be rated and classified as:
Class A- Excellent
Class B- Very Satisfactory
Class C- Satisfactory

3 Points of Contamination
- Place of production processing and source of supply
- Transportation and storage
- Retail and distribution points

Four Rights in Food Safety

Right Source:
1. Always buy fresh meat, fish, fruits & vegetables.
2. Always look for the expiry dates of processed foods and avoid buying the expired ones.
3. Avoid buying canned foods with dents, bulges, deformation, broken seals and improperly seams.
4. Use water only from clean and safe sources.
5. When in doubt of the water source, boil water for 2 minutes.

Right Preparation:
1. Avoid contact between raw foods and cooked foods.
2. Always buy pasteurized milk and fruit juices.
3. Wash vegetables well if to be eaten raw such as lettuce, cucumber, tomatoes & carrots.
4. Always wash hands and kitchen utensils before and after preparing food.
5. Sweep kitchen floors to remove food droppings and prevent the harbor of rats & insects.

Right Cooking:
1. Cook food thoroughly. Temperature on all parts of the food should reach 70 degrees centigrade.
2. Eat cooked food immediately.
3. Wash hands thoroughly before and after eating.

Right Storage:
1. All cooked foods should be left at room temperature for NOT more than two hours to prevent
multiplication of bacteria.
2. Store cooked foods carefully. Be sure to use tightly sealed containers for storing food.
3. Be sure to store food under hot conditions (at least or above 60 degrees centigrade) or in cold
conditions (below or equal to 10 degrees centigrade). This is vital if you plan to store food for more than
four to five hours.
4. Foods for infants should not be stored at all. It should always be freshly prepared.
5. Do not overburden the refrigerator by filling it with too large quantities of warm food.
6. Reheat stored food before eating. Food should be reheated to at least 70 degrees centigrade.

Rule in Food Safety: “When in doubt, throw it out!”

Hospital Waste Management

Goal:
To prevent the risk of contraction nosocomial infection from type disposal of infectious; pathological and
other wastes from hospital.

Policies:
 All newly constructed/ authorized and existing government and private hospitals shall prepare and
implement a Hospital Waste Management (HMW) as a requirement for registration and renewal of
licenses.
 Use of appropriate technology and indigenous resources
 Training of all hospital personnel
 Public information campaign on health and environmental hazard shall be the responsibility of the
hospital administration.

Health risk minimization

o Anti- smoking Belching Campaign and Air Pollution Campaign
o Zero Solid Waste Management
o Toxic, chemical, and Hazardous Waste Management
o Red Tide Control and Monitoring
o Integrated Post Management and Sustainable Agriculture
o Pasig River Rehabilitation Management

HERBAL MEDICINE

Herbal Medicine

RA 8423: Alternative Traditional Medicine Law

A program where patient may opt to use herbal plants especially for drugs that are not available in dosage
form or patients has no financial means to buy the drug.

10 Advocated Herbal Plants by DOH: LUBBY SANTA

1. Lagundi (Vitex Negundo)

Indication: Asthma, cough, colds & fever (ASCOF)
Pain and inflammation
Plant Part Used: Leaves
Preparation: Decotion, Poultice

2. Ulasimang Bato (Peperonia pellucida)

Indication: Gout, Arthritis, Rheumatism
Plant Part Used: Leaves
Preparation: Decoction, Poultice

3. Bayabas (Psidium quajava)

Indication: Diarrhea, Tootache, Mouth and wound wash
Plant Part Used: Leaves
Preparation: Decoction

4. Bawang (Allium sativum)

Indication: HPN, Toothache
Plant Part Used: Clove/Bulb
Preparation: Poultice

5. Yerba Beuna (Mentha cordifelia)

Indication: Same as Lagundi except asthmas
Plant Part Used: Leaves
Preparation: Decoction, Poultice

6. Sambong (Blumea baldanifera)

Indication: Edema, Diuretic
Plant Part Used: Leaves
Preparation: Decoction
7. Akapulko (Cassi alata)
Indication: All forms of skin disease
Plant Part Used: Leaves
Preparation: Decoction, Poultice, Cream

8. Niyog-niyogan (Quisqualis indica)

Indication: Intestinal Parasitism (Nematodes)
Plant Part Used: Seeds
Preparation: Decoction, Poultice, Juice

9. Tsaang Gubat (Carmona resuta)

Indication: Diarhhea, Infantile colic (Kabag), Dental caries
Plant Part Used: Leaves
Preparation: Decoction, Poultice

10. Ampalaya (Mamordica charantia)

Indication: Type II Diabetes (NIDDM)
Plant Part Used: Leaves
Preparation: Decoction

Decoction
The liquor resulting from concentrating the essence of a substance by heating or boiling

Poultice
A soft, moist mass of material, typically of plant material or flour, applied to the body to relieve soreness
and inflammation and kept in place with a cloth.

Malunggay or horseradish tree (Moringa Oleifera)

1. Malunggay can be mixed with chicken in soups and beans. It’s considered as a superfood that Filipinos
use to increase milk in lactating women.

2. The leaves are source of phosphorus and iron. It has strong antioxidant and anti- inflammatory
compounds. It contains vitamin A, potassium, calcium, and vitamin C.

3. It is best when added in soup but it can also be consumed raw.

Tawa-tawa or asthma Plant (Euphoria Hirta)

1. The DOH recommended this plant as effective treatment for dengue fever. In 2014, it was listed as
beneficial when it comes to maintaining the upper respiratory and increasing the blood platelet count.

2. Tawa-tawa is valuable in the health industry as it boosts the immune system. It was also recorded to
help patients recover from Dengue faster.

Banaba or giant crape myrtle (Lagerstroemia speciosa)

1. This herbal plant can be used to treat diabetes and kidney failure, as well as obesity and high fever.

2. In folklore, banaba is used to prevent constipation, kidney inflammation, and urinary dysfunctions.
 DIGESTIVE SYSTEM

 Function of digestive system is to break down food via hydrolysis into simpler substance nutrients
 Functions: Elimination of undigested food residues, Absorption of digested nutrients,
 Homeostatic regulation of calcium, iron, phosphate.
 Digestion begins at mouth.

Five Basic Activities:

Ingestion - taking of food in the body.
Peristalsis - physical movement or pushing of food along the digestive tract
Digestion - breakdown of food by both mechanical and chemical mechanisms
- allow body's cell convert food energy into the high energy ATP molecules \
run cell's machinery.
Absorption - passage of digested food from the digestive tract into the cardiovascular
& lymphatic systems for distribution to body's cells
- Absorbs the nutrients in the we eat in small intestine and water in large
intestine
Defecation - elimination from the body of those substances that are indigestible &
cannot be absorbed.

The organs of digestion are part of two main groups:

1. Gastrointestinal Tract / Alimentary Canal

- long tube, runs through the ventral cavity of body extends from mouth to anus.
- 30 ft. or 9 meters.
- Organs: Mouth, oropharynx, esophagus, stomach, small & large intestines.

2. Accessory organs
- teeth, tongue, salivary glands, liver, gallbladder and pancreas.

Muscular contractions in the tube break down food physically by churning it; enzymes from cells in the
tube's wall break down food chemically.

Walls of Alimentary canal from the esophagus to anal canal have same arrangement of tissue layer coats/
tunics

Four Tunics of Canal inside to outside : Tunica mucosa, Tunica submucosa, Tunica muscularis , Tunica
Serosa(Adventitia)

1. Tunica Mucosa - innermost, consists of mucous membrane attached to thin layer of visceral muscle.
 Three layers make up the mucous membrane:
 Epithelial tissue layer (endothelium) - direct contact with contents of the canal.
 Lamina Propria - underlying layer of loose connective tissue. Supports the epithelium then binds
to
 Muscularis Mucosa - provides w/ lymph and blood supply.
 Epithelial layer functions: protection, secretion of enzymes, mucus and absorption of nutrients.
 Tunica Mucosa of small intestine --- special layer Muscularis Mucosa made of special fibers that
produce folds tremendously increase digestive and absorptive area of small intestine.
2. Tunica Submucosa - loose connective tissue, binds tunica mucosa to tunica muscularis.

3. Tunica Muscularis - mouth, pharynx & first part of esophagus. Allow voluntary act of swallowing.
- contains major nerve supply to the alimentary canal -- Plexus of Auerbach.

4. Tunica Serosa / Adventitia - serous membrane, made up connective and epithelial tissue --- Visceral
Peritoneum
 Covers organ and its large folds, weave in and between organs, binding organs to each others and
to walls of cavity. Contains blood and lymph vessels, nerves that supply organs.

One extension of the Visceral Peritoneum forms the mesentery.

Mouth or Oral Cavity

 Buccal cavity
 Digestion begins here.
 Mechanical digestion of food with teeth and tongue.
 Functions: taste, chemical digestion of carbohydrate using the salivary enzyme : amylase
Sides - cheeks Roof - hard and soft palates Floor - tongue

Lips - fleshy folds surround the opening or orifice of the mouth.

During chewing of food the lips & cheeks help keep food between the upper and lower teeth. Assist in
speech.

Hard palate forms anterior part of the roof of the mouth. (bony)

Soft palate posterior portion of the roof of mouth (muscular)

Uvula cone shaped; hanged from posterior border.

Function in swallowing process & prevents food from backing up into nasal area.

Tongue form floor of the oral cavity. Consist of skeletal muscle covered w/ mucous membrane.
 Divided into symmetrical halves by a septum --- lingual frenulum
 Attached & supported by hyoid bone.
 2 skeletal muscle found in tongue -- extrinsic & intrinsic

Extrinsic muscle originate outside, insert into it. Moving tongue from side to side. In & out to
manipulate food.

Intrinsic muscle insert within the tongue, altering size and shape of tongue for speech and swallowing.

Papillae covers the upper surface and side of tongue. Produce rough surface of tongue.

Filiform Papillae - important for licking.

Salivary Gland
 Saliva contains 99% water , contains amylase.
 Volume of saliva 1-1.5 liters within 24 hrs.
 Immunoglobulin A - found in saliva.
 Buccal Gland small glands, mucous membrane lining of the mouth. Secretes small amount of saliva.

Three pairs of salivary glands:

 Parotid Gland - large gland
 Submandibular / Submaxillary Gland
 Sublingual Gland - under tongue

Saliva's function: Moistened Food, Ingested food.

Pharynx
Passage of air, food and water.
 Function in digestive system, process of swallowing or deglutition.
 Swallowing begins when the tongue w/ the teeth and saliva forms a soft mass -- food bolus. Food is
forced to the back of the mouth cavity then into the oropharynx.

Epiglottis direct air to trachea, food to esophagus. Cause aspiration.

Three parts:
Nasopharynx, oropharynx, Laryngopharynx

Esophagus
Closes cardia sphincter.
- 10 inches.
- secrete mucus and transport food to the stomach.

LES (Lower Esophageal Sphincter) separate esophagus from stomach prevent esophageal ulcer.
Chyme - Food meet the acid in stomach.
- Semifluid mass of partly digested food expelled by the stomach to the duodenum

Stomach
Temporary storage of food. Storage of ingested food.
- stomach secretes 1500 - 3000 mL
- 3 mL within 24 hrs (acids)
- 1.1 - 2.4 gastric pH normal.
- chief cell, produce pepsin.
- parts: fundus, pylorus or antrum , cardia

Gastrin - stimulate gastric acid.

- Gastrin is produced by G-cells which stimulates the production of HCl from parietal cells and
pepsinogen by chief/zymogenic cells

Gastric pH - Intrinsic Factor

- produced by parietal, needed for absorption.
- Extrinsic Factor
- 1500 to 3000 mL gastric juice per day.

Vit b 12- maturation of RBC

Gastric glands -- Three kinds of secreting cells:

 Zymogenic or chief cells - secrete principal gastric enzyme -- pepsinogen
 Parietal Cell - secrete hydrochloric acid, activates the pepsinogen to become pepsin --
breakdown proteins.
 Mucous cells - secrete mucus that protects the stomach from being digested.
2 Hormones release by duodenum
1. Secretin - secretes enzymes
amylase - breakdown carbohydrates
Lipase - breakdown fats – from pancreas
Pepsin - Protein.
2. CCK Cholecystokinin - emulsify fats. / trigger Gallbladder to release bile & enzyme.

Gastrin - stimulate release HCL & pepsinogen in stomach. Produced by G- cells

Phases of Digestion:
Cephalic Phase
- Vagus Nerve
sight/ smell or thought of food will stimulate the vagus to send signals to the stomach, stomach
will produce gastric juices by gastrin.

Gastric Phase
- presence of food on stomach increases acid
- bolus of food reaches the antrum.

Intestinal Phase
- arrival of food in the duodenum.

Small Intestine
Complete digestion & absorption
 Duodenum - 10 inches (originates from the pyloric sphincter)
 Jejunum - 8 ft.
 Ileum - 14 ft.

Ileocecal Valve opening of small intestine

Villi - hair like structure seen in the small intestine and help absorb digested food nutrients

Peristalsis - involuntary wave like muscle contraction pushing bolus of food in small intestines

Large Intestines
Formation of feces. Reabsorption of water.
- Cecum - Colon - Rectum

13 clotting factors - for us not to bleed.

Good Bacteria should stay in the large intestine.

Colon look like a tube of consecutive pouches -- called haustrae

Ascending colon - Watery

Transverse Colon - Mushy
Descending Colon - Soft
Sigmoid Colon - Well formed

ACCESSORY ORGANS
Good bacteria assists in production of vitamin K - chyme

Liver
 detoxification of poison, drugs and alcohol
 largest gland in the body.
 Produces Bile - digest/ breakdown fats.
 Produces albumin - plasma membrane that holds the water fluid from going out (Osmotic pressure)
 Stores glycogen, vitamins A D E K, copper, iron
 Manufactures heparin, prothrombin, thrombin -- without these you'll bleed.

If liver is broken it can't breakdown fats. It goes directly to feces, wherein it looks greasy and has foul
odor.

When you are sick, you are increasing the activities of the cell, liver is made up of epithelial tissues

Thrombin - anticoagulant that are involved in the blood clotting mechanisms

- gluconeogenesis – fats & proteins -> glucose
- glycogenesis – glucagon -> glucose (formation of glycogen from sugar)
- glycogenolysis – glycogen -> glucose

Gall bladder
 Bile stored
 Gallbladder storage for bile -- 800 - 1000 cc bile within 24 hrs.
 Store and concentrate the bile produced by the liver lobules until it is needed in small intestines.

Hepatic Portal Vein - where the lower extremities, unoxygenated blood enter the liver to be cleansed and
enter the inferior vena cava.

Hepatic sinusoid - unoxygenated blood pass thru. & bile

Pancreas
Has a duct for the passageway of pancreatic juice
Highly bicarbonate pancreatic juice.
- Exocrine Gland - Acinar & duct tissue
- Endocrine Gland - Islets of Langerhans
Islets of Langerhan (pancreatic juice -> Duct of Wirsung -> Ampulla of Vater

ISLETS OF LANGERHANS | PANCREATIC ISLETS

Acini – releases a mixture of digestive enzymes / pancreatic juice
Alpha cells – synthesizes hormone glucagon
Ampulla of Vater – pancreatic duct that unites with common bile duct
Kupffer cells – phagocytes certain bacteria (macrophages in the liver)
Escherichia coli – type of bacteria that normally lives in the intestines of people and animals that feeds
on the undigested animals
 ENDOCRINE SYSTEM

HOMEOSTASIS
- Maintenance of homeostasis, which involves growth, maturation, reproduction, metabolism, and human
behavior

HORMONES
- Control the internal environment of the body from cellular level to the organ level of organization
- Control cellular respiration, cellular growth, and cellular reproduction
- Help regulate metabolism, water and electrolyte concentrations in cells, growth, development, and
reproductive cycles

NEGATIVE FEEDBACK LOOP

- Corrects the stimuli and helps in maintaining homeostasis

ENDOCRINE GLANDS
- Ductless glands that secrete hormones directly into the bloodstream

HYPOTHALAMUS
- Sends directions via chemical signals (neurotransmitters) to the pituitary gland
- Nerve cells in the hypothalamus produce chemical signals called releasing hormones and releasing
inhibitory hormones
- CRH – the hormone that stimulates the other glands to produce/secrete their hormone

Major Endocrine Glands & Their Hormones

 PITUITARY GLAND | HYPOPHYSIS
 - Location: Below the hypothalamus of the brain

LARGER ANTERIOR PITUITARY LOBE | ADENOHYPOPHYSIS

- PRODUCE 7 HORMONES

 GROWTH HORMONES | SOMATOTROPIN (GH)

- Stimulates cell metabolism in most tissues of the body
- Stimulates the growth of bones, muscles, and organs
- Increase protein synthesis and the breakdown of fats and carbohydrates
- Releases SOMATOMEDIS or Insulin-Like Growth Factors (IGF)
- Peak secretion of GH occur during periods of: SLEEPING, EXERCISE, and FASTING
- Growth is also influenced by nutrition, genetics, and sex hormones during puberty
- Increase the cellular uptake of amino acids and protein synthesis in many organs
- Stimulates the breakdown of triglycerides
- Stimulates the breakdown of glycogen

 THYROID-STIMULATING HORMONE (TSH)

- Stimulates the thyroid gland to produce its hormones (T3, T4, Calcitonin)

 ADRENOCORTICOTROPIC HORMONE (ACTH)

- Stimulates adrenal cortex to secrete its hormone; CORTISOL

 MELANOCYTE-STIMULATING HORMONE (MSH)

- Increase the production of melanin in melanocyte of the skin, causing a deepening pigmentation
or darkening of skin

 FOLLICLE-STIMULATING HORMONE (FSH)

- Stimulates the development of follicle in the ovaries – female
- Stimulates the production of sperm cells – male

 LUTEINIZING HORMONE (LH)

- Stimulates the ovulation and production of progesterone, helps maintain pregnancy –female
- Stimulates the synthesis of testosterone and production of sperm cells – male

 LACTOGENIC HORMONE (LTH) | PROLACTIN (PRL)

- Stimulates lactation or production of milk in the mammary gland after pregnancy

SMALLER POSTERIOR PITUITARY LOBE | NEUROHYPOPHYSIS

- PRODUCE 2 HORMONES
- Consists primarily of nerve fibers and neuroglial cells

 ANTIDIURETIC HORMONE (ADH) | VASOPRESSIN

- Maintains the body’s water balance by ordering the renal tubules to reabsorb water
- Causes the kidney to retain water
- Reduces diuresis – less urine / increase urine retention
- Maintains the blood when bleeding, restoring the blood volume
- Compensates the loss of fluid

 OXYTOCIN
- Stimulates contraction of smooth muscle in the lining of the uterus when giving birth or having
sex
- Stimulates milk ejection or lactation (Lactation: LH & Oxytocin)

 THYROID GLAND
- Consists of two lobes connected by isthmus
  T3 TRIIDOTHYRONINE – contains 3 iodine atom
 T4 TETRAIODOTHYRONIN or THYROXINE – contains 4 iodine atom

- Regulates the metabolism of the body (oxygen, carbohydrates, fats, and proteins)
- Necessary for normal growth and development and nervous system maturation
- Increase the rate of carbohydrate and lipid breakdown into energy molecules

 CALCITONIN
- Thyroid gland releases calcitonin when the calcium in the blood is high, because calcitonin
decreases the blood calcium by bone reabsorption
- involved in regulating the calcium and phosphate in the blood

 PARATHYROID GLAND
- Four pea size gland located at the back of the thyroid gland
 PARATHYROID HORMONE | PARATHORMONE (PTH)
- Inhibits the activity of osteoblast and causing osteoclast to breakdown bone matrix
tissue (osteoblast: bone makers, osteoclasts: bone breakers)
- Releases calcium and phosphate ions into the blood
- Causes the kidneys to conserve blood calcium and stimulates intestinal cell to absorb
calcium from digested food in the intestine

 PINEAL GLAND
 MELATONIN
- Helps us relax and sleep

 SEROTONIN
- Happy hormone (found in bananas)
- Body’s natural pain reliever

 ADRENAL GLAND | SUPRARENAL GLAND

- Smalls glands found atop of each kidney

ADRENAL MEDULLA
- Inner part of the adrenal gland
- Produces large amounts of adrenaline hormones (epinephrine: vasodilation/increases heart rate,
norepinephrine: vasoconstrictor/increases blood pressure)

ADRENAL CORTEX
- Have three tissue layes

 ZONA GLOMERULOSA – 15% of the wall

- Produces a mineralocorticoid; ALDOSTERONE

ALDOSTERONE
- a hormone essential for sodium conservation in the kidney, salivary glands, sweat glands, and colon
- for the reabsorption of sodium
- helps maintain blood when bleeding

 ZONA FASCICULATA – 78% of the wall

- Produces a glucocorticoid; CORTISOL

CORTISOL
- Helps control blood sugar levels, regulate metabolism, help reduce inflammation, and assists with
memory retention
 - Has a controlling effect on salt and water balance, and helps control blood pressure
- Makes us eat a lot
- A type of steroid
- Being released when you are under stress
- Increase blood-sugar
- Inhibits the immune and inflammatory reaction
- Needed to make capillary membrane stable

 ZONA RETICULARIS – 7% of the walls

- Innermost of the walls
- Involved in secretion of different sex hormones (ANDROGENS/TESTOSTERONE)

NOTES:
3 HORMONES THAT INCREASES BLOOD SUGAR LEVEL
1. CORTISOL
2. GLUCAGON
3. GROWTH HORMONE

2 HORMONES THAT HELPS IN RETAINING BLOOD WHEN YOU ARE BLEEDING

1. ANTIDIURETIC HORMONE (ADH)
- because it maintains body’s water balance by ordering the renal tubules to reabsorb
water which causes the kidneys and the body to retain the blood and water in the body

2. ALDOSTERONE

GLYCOGENOLYSIS
- The liver converts glycogen into glucose

GLUCONEOGENESIS
- The liver converts fats and lipids into glucose
 FUNDAMENTALS IN NURSING
IMMOBILITY
NATURE OF MOVEMENT
1. ALIGNMENT AND BALANCE
- Scoliosis and Osteoporosis

2. Gravity and Friction

- Body weight oppose movement

3. Skeletal System
- Joints, Tendons, Ligaments

4. Skeletal Muscle
- Provide breakage due to movement

5. Nervous System
- Primary control

PATHOLOGICAL INFLUENCES OF MOBILITY

1. Postural Abnormalities
- Posture
2. Muscular Abnormality
- Stroke patients w/ paralyzed side.
3. Damage to CNS
- Stroke
- Direct trauma to the musculoskeletal system.

FACTORS INFLUENCING MOBILITY

1. Systemic Factors
- SYSTEMS

A) METABOLIC CHANGES
- Endocrine metabolism
- Calcium reabsorption
- Functioning of the GI System (immobility leads to constipation)

B) RESPIRATORY CHANGES
- Lack of movement laces patients at risk for respiratory complications.
(any immobility can cause pneumonia)

C) Cardiovascular Changes
- Orthostatic hypotension
- Increased cardiac workload
- Thrombus formation (deep vein thrombosis)

 Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the
deep veins in your body, usually in your legs

D) Musculoskeletal Changes
- Muscle effect (Patient loose lean body mass)
- Skeletal Effect (impaired calcium metabolism)
 URINARY ELIMINATION CHANGES
1. Immobility alters urine flow
2. Abnormal Gravitational Pull

INTEGUMENTARY CHANGES
1. High risk in sore pressure (Bed Sores)

PSYCHOLOGICAL EFFECTS
1. Patients with immobility have different emotional and behavioral response.
2. Depression

NURSING INTERVENTION FOR IMMOBILITY

1. Range of Motion
- Active Range
- Passive Range
- Do to prevent contractures (Hardening of the joint)

2. Applying Compression
- Stockings or SCD (Sequential Compression Device)
- Provides circulatory support to avoid blood pooling.
- To also avoid DVT.

3. Incentive Spirometry/Deep Breathing Exercise

- Avoid Pneumonia

4. Use of heparin
- To avoid DVT

POSITIONING TECHNIQUE
1. Semi-Fowler
2. Supine Position
3. Prone position
4. Side-lying position

INFECTION
1. Infection
- Invasion of microorganisms resulting to a disease LIVE

2. Colonization
- Invasion of microorganisms in the DEAD

 Communicable Disease
- Can be transmitted

a) Symptomatic
- Presence of symptoms due to infection

b) Asymptotic
- Walang symptoms pero may sakit ka.
 Chain of infection
Infectious agent  Reservoir  Portal of Exit  Mode of transmission  Portal of Entry  Host.
INFECTION PREVENTION CONTROL
 INFECTION
- Invasion of microorganisms to a susceptible host resulting a disease
- Colonization – presence of growth of microorganisms with the host
 - Communicable disease
- Symptomatic
- Asymptomatic
CHAIN OF INFECTION

 Infectious agent
 Reservoir
 Portal of exit
 Mode of transmission
 Portal of entry
 Host

DEFENSE AGAINST INFECTION

 Body System Defense

HEALTH CARE ASSOCIATED INFECTIONS

 HAI – Health Care Associated Infections
 MDRO – Multi Drug Resistant Organisms

NURSING KNOWLEDGE BASE

FACTORS INFLUENCING INFECTION PREVENTION AND CONTROL
 S – STRESS
 A – AGE
 N – NUTRITIONAL STATUS
 D – DISEASE PROCESS

NURSING INTERVENTIONS: A PATIENT WITH HIGH RISK OF INFECTION

CONTROLLING TRANSMISSION
 Hand Washing/Hand Hygiene
 Isolation and Isolation Precautions
  Personal Protective Equipment
 Universal/Standard Precaution
 Transmission Based Precautions
- Contact Precaution
- Droplet Precaution
- Airborne Precaution
 Reverse Isolation

BODY DEFENSE SYSTEM

1. Barrier - Skin
2. Phagocytosis- Wbc/Rbc - Engulfing microorganisms

HAI – Healthcare Associated Infections

MDRO – Multi Drug Resistant Organism

FACTORS INFLUENCING INFECTION

Stress
Age
Nutritional Status
Disease Process

Controlling Transmission
1. Hand Hygiene
2. Isolation Precaution
3. PPE

TYPES OF PRECAUTION
1. Universal Precaution
- Hand Hygiene

2. Transmission Based Precaution

a) Contact Precaution
- Gowns, gloves, hand hygiene
b) Droplet Precaution
- Surgical Mask, Glasses
c) Airborne Precaution
- Viral
- MTC/MTV (Measles, TB, Varicella/C.pox)

3. Reverse Isolation
- Can easily contract disease

INFECTION
1. Infection – growth of microorganism in an are where they should not be growing.
2. Normal Flora – microorganism in a specific body part.

3. Asepsis
a) Medical/Clean technique
b) Surgical/Sterile Technique
4. Sepsis -acute organ dysfunction occurs (Infection in the blood)

2 Kinds of Infection:
a) Nosocomial
- Infection from hospital environment
b) Iatrogenic
- Infection from procedures done
How Infection Happens?
1. Number of organisms present in the area.
2. Severity of microorganism
3. Potency

HAND HYGIENE
Hand Hygiene – most effective infection prevention
  PURPOSE of HAND HYGIENE
1. Reduce number of microorganisms
2. Reduce Risk of transmission
3. Reduce risk of cross contamination among other patients.
4. Reduce transmission to oneself (nurse)
  ASSESSMENT
1. Cut nails
2. Remove jewelry
3. Check skin for breakage
  PREPARATION
1. Assess factors that may contribute to possibility of infection.
2. If the client uses immune suppressive drugs.
3. Nutritional Status
4. Signs and Symptoms
a) Localized
b) Systemic
5. Recent procedure that caused open wound

PATIENT SAFETY AND QUALITY

1. Patient Safety – reduces the risk for illness and injury (maintains patient functional status)

SCIENTIFIC KNOWLEDGE BASE

1. Environmental Safety – physical/psychosocial factor that may affect the patient.
2. Safe Environment – protect the health care worker as well.

BASIC NEEDS
1. Oxygen
2. Nutrition
3. Temperature
a) 18-25c – comfort zone
b) 42c – Heat Stroke

PHYSICAL HAZARDS
1. Safety Vehicle – the usage of seatbelt and airbags
2. Poison
3. Falls – major public health concern
4. Fire – Fire related deaths
5. Disaster – Natural , Manmade, Bioterorrism

TRANSMISSION OF PATHOGENS
1. Pathogen – microoganisms producing illness
2. Hands – most common men of transmission
3. Medical Asepsis and Hand Hygiene – most effective limiting transmission
4. Immunization – reduce/prevent transmission.

POLLUTION
1. Prolonged pollution can lead to disease conditions
NURSING KNOWLEDGE BASED
 RISK AT DEVELOPING CHANGES
1. INFANT, TODDLERS, PRESCHOOLERS.
a) Lead Poisoning
b) Accidental Burning
c) Falling from bike
d) Drowning

2. SCHOOL AGE
a) Head Injuries
b) Bike Accidents

3. ADOLOSCENTS
a) Risk taking behavior (smoking)
b) Drinking and Drugs

4. ADULT
a) Lifestyle Problem
b) Stress Related (GI Ulcer)

Chain of Infection

3Ds
a. Delirium
b. Dementia
c. Depression

RISK IN HEALTH CARE AGENCY

 Patient Safety – one pressing health care challenges.
 Medical Errors - Non payment of the hospital.
1. Patient Inherit Accident
- Patient is the primary reason of the accident.
2. Procedure Related Accident
- Caused by healthcare provider
- Medication errors
 - Dressing errors
3. Equipment Related Errors
- Malfunction or misuse of equipment
 5 Vital Signs
1. BP
2. Pulse
3. Respi
4. Temperature
5. Pain Assessment
 Pain Assessment
- Unpleasant sensory experience which is associated with tissue damage

CLASSIFICATIONS
a. Acute
- Sudden sensation of pain
b. Chronic
- Continuos
c. Cancer Pain
- Tumors

Physiologic Responses to Pain

- Anxiety, Fear (SNS)
- Cries
- Decreased gastric and intestinal motility
- Decreased in urinary retention
Pain = increase vital signs

GENERAL OBESERVATION OF PAIN

1. Posture
2. Facial Expression
3. Joints and Muscles
4. Skin for scars

7 Behavioral Signs of Discomfort

1. Noisy Breathing
2. Negative Vocalization
3. Sad facial expression
4. Frightened F.
5. Frown
6. Tense body language
7. Fidgeting

APPROPRIATE NURSING DIAGNOSIS

1. Wellness Diagnosis
- Patient doesn’t feel pain anymore
2. Risk Diagnosis
- Future complications
- Assumptions
3. Actual Diagnosis
 Oxygen Saturation
Normal – 95-100%
 Oxygen Pressure
- 760 mmHg
- 754 (Inhale)
- 764 (exhale)
 GASSES IN AIR
- 78% - Nitrogen
- 21% - Oxygen
- 1% - Other gases
 80-100 mmHg -normal oxygen in blood
 Oxygen Saturation
- Binding of oxygen and blood
 12-18 g/dl of hemoglobin
- Normal rbc count
 1.34% - 1 g of hemoglobin can carry oxygen
 Below 12g/dl - anemic

MEDICATION ADMINISTRATION
 PHARMACOKINETICS
Drugs Movement
-Movement of the drugs
 ABSORPTION- Absorb thorough the blood
 DISTRIBUTION- Distribute through the body
 METABOLISM
 EXCRETION- Feces

TYPES OF MEDICATION
 THERAPEUTIC EFFECT- Intended effect
 SIDE EFFECT- Kasama sa effect ng drug
-Not detrimental
 ADVERSE EFFECT- Detrimental side effect
 TOXIC EFFECT- High dosage of drugs that can cause toxicity
 INDIOSYNCRATIC EFFECT- Unknown effect
 ALLERGIC REACTION- Stimulates immune system

MEDICATION ADMINISTRATION SCHEDULE

ABBREVIATION MEANING
ac Before meals
pc After meals
OD Once a day
BID Twice a day
TID Trice a day
QID 4 times a day
Q1H Every 1 hour
Q12H Every 12 hours
STAT Emergency (ASAP)
OD Am Once a day AM
OD Pm Once a day afternoon
PRN As needed

STANDARD OF SAFE NURSING PRACTICE

-To prevent medication error
 Right Patient
 Right Medication
 Right dosage
 Right route
 Right time
 Right Documentation
SYSTEM OF MEDICATION MEASUREMENT
 Metric system
 Apothecary
 Household measurement

METRIC APOTHECARY HOUSEHOLD

1 ml 15 minims 15 drops
5 ml 1 dram 1 teaspoon
15 ml 4 dram 1 tablespoon
30 ml 1 fluid ounce 2 tablespoon
240 ml 8 fluid ounce 1 cup
500 ml 1 pint 1 pint
1000 ml 1 quarts 1 quarts

 Medication - a substance used in the diagnosis, treatment, cure, relief, or prevention of health
problems. (Potter, et al., 2013, p. 565)

 The Nurse’s Responsibilities includes the following:

o 1) Evaluating the effects of the medications to the patient.
o 2) Educating the patient about the medications and its side effects.
o 3) Ensuring the adherence to the therapeutic regimen.
o And, 4) Evaluating the ability of the patient and the family to administer the medications.
o (Potter, et al., 2013, p.565)

Route of Administration:
 The route of administration is influenced by the following:
o 1) the properties and the desired effects of the medication
o 2) and, the physical and mental condition of the patient. (Potter, et al., 2013, p.571)

Oral Route of Administration: (Potter, et al., 2013, p.593)

 Food delays stomach emptying which may decrease the therapeutic effects of oral medications. Most
oral medications reach their therapeutic action best if given 30 minutes to 1 hour before meals.
 Nurse need to take precautions for aspirations. Aspiration occurs when food, fluid or medications
intended for the Gastrointestinal inadvertently enters the respiratory tract. Position the client at 90
degrees when administering oral medications if not contraindicated by his or her condition. Slightly
flexing the neck in a chin-down position reduces risks for aspiration.
 When giving medications through gastric or enteric tubes, verify first the placement of the tubes. Use
liquid medications when possible. If liquid medications are not available crush simple tablets or open
gelatin capsules and dilute them in sterile water. Do not use tap water as tap water may contain
contaminants which may interact with the medications. Flush tubes with at least 15 mL of sterile
water before and after giving medications. Determine if the medication should be given on an empty
stomach or is not compatible with the feeding (e.g. phenytoin, carbamazepine [Tegretol], Warfarin
 [Coumadin], Fluoroquinolones, proton pump inhibitors), the feeding can be withheld at least 30
minutes before or 30 minutes after medication administration.
 Types of Oral Routes of Medication Administration:
o Oral, Buccal, Sublingual
 Oral
 Medications are taken in the mouth and swallowed.
 The oral route is the most commonly used route.
 Medications have slow onset action and prolonged effect.
 Easiest and preferred by most patients (Potter, et al., 2013, p.571)

 Buccal
  Medications that are taken in the mouth and are placed in the mucous membranes of the
cheeks to dissolve and be absorbed.
 Medications should not be chewed or swallowed.
 Alternate cheeks to with each subsequent dose to avoid mucosal irritation.
 Drinking liquids is avoided until medication is completely dissolved. (Potter, et al., 2013,
p. 572)

 Sublingual
 Medications that are taken in the mouth and are placed under the tongue to dissolve and
be absorbed.
 Medications should not be swallowed.
 Drinking is avoided until medication is completely dissolved. (Potter, et al., 2013, p. 571)

Medication Forms Commonly Prepared for Administration by Oral Route (Potter, et al., 2013, p.567)

Solid Forms
 Capsule – Medication encased in a gelatin shell.
 Tablet – Powdered medication compressed into a hard disk or cylinder; in addition to primary
medication, contains binders (adhesive to allow powder to stick together), disintegrators (to promote
tablet dissolution), lubricants (for ease of manufacturing), and filters (for convenient tablet size).
 Caplet – Tablet shaped like a capsule coated for ease of swallowing.
 Enteric-coated – Coated tablet that does not dissolve in the stomach; coatings dissolve in the
intestines, where medication is absorbed.

Liquid Forms
 Elixir – Clear fluid containing water and/or alcohol; often sweetened
 Syrup – medication dissolved in a concentrated sugar solution.
 Extract – syrup dried from pharmacologically active medication, usually made by evaporating
solution.
 Aqueous Solution – Substances dissolved in water and syrups.
 Aqueous Suspension – Finely divided drug particles dispersed in liquid medium; when suspension is
left standing, particles settle at the bottom of the container

Other Forms
 Troche (lozenge) – Flat round tablets that dissolve in the mouth; not meant for ingestion.
 Aerosol – Aqueous medication sprayed and absorbed in the mouth and upper airway; not meant for
ingestion.
 Sustained Release – Tablet or Capsule that contains small particles of a medication coated with
material that requires varying amount of time to dissolve.

Advantages and Disadvantages of the Oral Route. (Potter, et al., 2013, p.571)
 Advantages
o Convenient and Comfortable for Patients
o Economical
o Easy to Administer
o Often produce Local or Systemic Effects
o Rarely causes Anxiety for Patients
 Disadvantages
o Oral Route is Avoided when Patient has Alterations in the Gastrointestinal Functions (e.g.
Nausea, Vomiting), Reduced Motility (After General Anesthesia or Bowel Inflammation), and
Surgical Resection of Gastrointestinal Tract.
o Oral Administration is Contra-indicated in Patients Unable to Swallow. (e.g. Patients with
Neuromuscular Disorders, Esophageal Strictures, Mouth Lesions)
 o Oral Administration is Contra-indicated in Unconscious or Confused Patient who is Unable or
Unwilling to Swallow or hold medication under tongue.
o Oral Medication cannot be administered when patients have gastric suction; are contraindicated
before some test or surgery.
o Oral Medications sometimes Irritate lining of the Gastrointestinal Tract, Discolor Teeth, or
have Unpleasant Taste.
o Gastric secretions destroy some medications.

Drug Computation
Formula
Dose Ordered x Amount on Hand = Amount to be Administered
Dose on Hand

Dose Ordered – is the amount of medication prescribed

Dose on Hand – is the dose of medication supplied by the pharmacy
Amt on Hand – is the quantity of the medication that contains the Dose on Hand

Sample: The physician ordered 500mg of amoxicillin to be administered every 8 hours. The bottle
of amoxicillin shows 400mg/5ml

500 mg x 5 mL = 5 x 5mL = 25 mL = 6.25 mL

400 mg 4 4

FOUNDATIONS OF THE NURSING PRACTICE

 Patient Safety and Quality
 Safety
- Freedom from psychological and physical injury
- A basic human need
 Patient Safety
- A safe patient environment reduces the risk for illness and injury
- Helps contain the cost of health care
- Maintains patient’s functional status
- Increases patient’s sense of well being

SCIENTIFIC KNOWLEDGE BASE

 Environmental Safety
- Includes physical and psychosocial factors that influences or affect the life and survival of the
patient
- A safe environment protects the health care worker as well

BASIC NEEDS - SAFETY

 Oxygen
- Not flammable but supports combustion
- Smoking is banned in the hospital premises
- Carbon monoxide affects the oxygen of a person
 Nutrition
- Food and Drug Administration (FDA) regulations
- Food poisoning is the highest in children, pregnant women, and other adults
- Unsanitary preparation leads to risk for infection
 Temperature
- Comfort Zone in temperature (18.3 to 23.9 degrees)
- Extremes in temperature in summer and winter
- Affects comfort, productivity, and safety
- Prolonged exposures can lead to either hypothermia or heat stroke
PHYSICAL HAZARDS - SAFETY
 Motor Vehicle Accidents
- Safety in the vehicle - seat belt, air bags, laminated windshields
- Laws - driving license, safety belt use, child restraint use, use of helmet
- Risk is higher among 16 - 19 years old - lowest seat belt use, intoxication, drug use, not able to
recognize dangerous situation

 Poison
- A substance that impairs health or destroys life when ingested, inhaled or absorbed by the body
- Drugs, medicines, other solid and liquid substances, gases and vapors
- Home accidental poisoning - greatest in toddlers, preschoolers, and young school age children
- Lead poisoning

 Falls
- A major public health concern
- Risk of falling is higher for age 65 and above , history of falling, reduced vision, and orthostatic
hypotension, lower extremity weakness, gait and balance problems, improper use walking aids, and effect
of various medications
- Physical Hazards - inadequate lighting, barriers along normal walking path and stairway, loose rug and
carpeting, and lack of safety devices at home

 Fire
- Fire Related Deaths - careless smoking (in bed at home)
- Improper use of cooking equipment and appliances
- Safety - fire extinguisher , smoke detectors

 Disasters
- Natural Disasters - flood, tsunami, earthquake, hurricanes
- Man Made disasters
- Bio-terrorism - use of anthrax, small pox

 Immobility
 Infection Prevention and Infection Control
 Vital Signs
 Health Assessment and Physical Examination
 Medication Administration
 Complementary and Alternative Therapies

OXYGENATION
 Respiratory system
 Carina- Part of trachea
 Alveoli- functional unit of respiratory system.
 Anatomical dead space- do not have any dunction in exchanging gases.
 Type I cells- cell membrane
 Type II cells- surfactant decreases surface tension and. Decreases friction
 Type III cells- macrophages
 Respiratory System
 Nasal cavity- an anatomical dead space

Alteration in Respiratory Functioning

 Hypoventilation - "respiratory depression" occurs when ventilation is inadequate, gas exchange is
needed.
 Hyperventilation - occurs when rate on tidal volume of breathing eliminates more co2 then body
produce.
 Hypoxia - body or it's region is deprived of an adequate oxygen supply.
 Anoxia - absence of oxygen in region of body.

RESPIRATORY PHYSIOLOGY

CARDIOVASCULAR SYSTEM
 Cerebral and Carotid Artery- Brain artery
 Cardiac output
 Heart= 1%
 Brain= 20%
 Kidneys= 20%
 Intestines= 10%
 SA NODE- pacemaker of the heart 60-100 bpm
 AV NODE- 40-60 bpm
 BUNDLE OF HIS- 20-40 bpm
 Ventilation- movement of gases in and out of the lungs

ARTERIES CARRIES BLOOD TO:

 Mesenteric artery- intestines
 Carotid artery- brain
 Coronary artery- heart
 Lymphatic artery- liver

EXCHANGE OF GASES
 oxygen transport- RBC
 Carbon dioxide problem- RBC in the form of carbonic acid.

CARDIOVASCULAR PHYSIOLOGY
 Starling Law of Heart - “The greater the stretch, the greater the contraction”
 All or None Law of heart - “The heart will function at is best heart to survive or could stop
functioning.
 Conduction system- a group of specialized cardiac muscle cells in the walls of the heart that send
signals to the heart muscle causing it to contract. The main components of the cardiac conduction
system are the SA node, AV node, bundle of His, bundle branches, and Purkinje fibers.
 Cardiac output is affected by the SV preload, intraload, and afterload
 o Afterload- reflects the force that the left ventricle has to overcome to eject blood through
the aortic valve.
 C.O. formula = HR x SV (stroke volume) 80 x 70 = 5600mL / min blood
 Normal blood volume = 4-6 liters
 High blood- high afterload
 Low cardiac output- may lead to organ damage

Disturbance in Electrical Conduction

 Altered Cardiac Output
 Impaired Valvular Function
 Myocardial Ischemia - oxygen deprivation of tissue

ACUTE CARE OF PATIENTS WITH OXYGENATION PROBLEMS

 Hydration- intake of 1,500 to 2,000 ml/day.
 Humidification- process of adding water into the gas.
 Nebulization- adds moisture and medication into the inspired air.
 Coughing and deep breathing exercises- coughing permits patient to remove secretions in the upper
and lower respiratory tract. Dryness of deep breathing can increase volume and airway diameter.
o Incentive spirometry is used for deep breathing exercises
 Chest physiotherapy- mobilizing respiratory secretions. A group of therapies of respiratory secretions
that includes PD- pustular drainage CP- Chest percussion and CV- Chest Vibrations
 Suctioning- Indicated for patients who are unable to clear their secretions from coughing or other less
invasive procedure.
 Oxygen theraphy- The goal is to relieve and prevent tissue hypoxia by delivering oxygen
concentration in the ambient air.
 Nasal Candula- 1-6 liters/min
 Simple face mask- 6-12 liters/min
 Non breathable mask- 13-15 liters/min.

FLUIDS AND ELECTROLYTES

Fluid Distribution- 60% Fluids made in body
 Intracellular- 40% of body weight
 Extracellular- 20% of body weight

Two types
 Interstitial- between
 Intravascular- inside; only this can be measured
 Extracellular- outside the cell
AGE RELATED FLUID CHANGES
 Full term baby- 80% water
 Lean adult male- 60% Female- 50%
 Aged client- 40%

Passive Transport systems

 Diffusion
 Filtration
 Osmosis

Active transport system

 pumping ( sodium potassium pump)
 Requires energy expenditure
 Diffusion- solutes. Molecules move across a biological membrane from an area of higher
concentration to an area of lower concentration
 Osmosis- solvent. Movement of solvent from an area of lower solute concentration to one higher
concentration and it occurs to a semi permeable membrane using big osmotic water pulling pressure.
 Filtration- Movement of solute and solvent across a membrane caused by hydrostatic (water pushing
pressure)
 Occurs at the capillary level
 If normal pressure gradient changes (as occurs with right-sided heart failure edema results from third
spacing.

ACTIVE TRANSPORT SYSTEM

 solutes can be moved against a concentration gradient
 Aka pumping
 Dependent on the presence of ATP

Fluid and Electrolyte Transport

Passive Transport Systems Active Transport System
Diffusion Pumping
Filtration Requires energy expenditure
Osmosis

Fluid types
 Isotonic- no changes
 Hypotonic- swelling cell
 Hypertonic- shrinking cell
 Isotonic solution- No fluid shift because solutions are equally concentrated. Has normal saline
solution at
 0.9% NaCl and it is the safest solution to give to patient.
 Hypotonic solution- Lower solute concentration and they are fluid shifts.
 Hypertonic solution- Higher solute concentration and fluid is drain into the hypertonic solution to
create a balance where cell shrinks. It has 5% dextrose in normal saline.

Electrolytes
 charged particles in a solution
 Ca+ions
 An(-)ions
 Integral part of metabollic and cellular peocesses
Cations
 Sodium
 Potassium
 Calcium
 Magnesium

Anions
 chloride
 Bicarbonate
 Phosphate
 Sulfate

Transmission of impulse
 more cations= more stimulation
 More anion= more depressed

Electrolyte imbalances
 Hypo/Hypernatremia- sodium
 Hypo/hyperkalemia- potassium
 Hypo/hypermagnesimia- magnesium
 Hypo/hypercalcemia- calcium
 Hypo/hyperphospatemia- phosphate
 Hypo/hyperchloremia

NURSING INTERVENTIONS IN CORRECTION FLUIDS

 Oral replacement of fluids
 Parenteral replacement if fluids
 IV therapy
 SAFEST IV FLUID IS NORMAL SALINE

IV SOLUTION BASICS
D- DEXTROSE
NS- NORMAL SALINE
W- WATER

SIMPLIFYING SOLUTIONS OF IV Isotonic solution- normal saline 0.9%

 lactated ringer’s
 Solution
 DSW- because desociate it may be hypotonic

Hypotonic solution
 Half NS- 0.45% NaCl
 Sterile water

Hypotonic solution
 D5NS
 D5LR
 3% sodium chloride
 D5 1/2 NS
 D5 1/4 NS

SLEEP AND PAIN MANAGEMENT

 Sleep- provides healing and restoration and best possible quality of sleep-good health and recovery of
illness.
 Hospital environment and staff patients from getting adequate rest.
 Other patient’s have pre existing sleep problems (every four hours)

Physiology of sleep
 circadian rhythm- The 24 hour night cycle located in the hypothalamus
 Have influence in HR,temp, BP, hormones, secretions, sensory activity and mood.
 Sleep regulation- sleep regulator- Hypothalamus. Process S- Homeostatic process, Process C-
circadian (biological clock)
 Reticular Activating System- may lead to Coma

Move to Stage 2 after

5-15 minutes

5 2
Move into REM sleep After another 15 mins
Approx 90 mins after move into non-REM
first feeling sleepy sleep, the Delta Stage
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STAGES OF SLEEP
 Stage 1- Light sleep, and it lasts for few minutes
 Stage 2- Light sleep, lasts for 10-20 mins, relaxation process
 Stage 3- Deep sleep, lasts for 15-30 mins
 STAGE 4- Deepest sleep, lasts for 15-30 mins, uninterrupted sleep, release of growth hormones (for
restoration of sleep)
 Rapid eye movement sleep (REM)- occurs after 90 minutes of sleep very difficult to arouse, patient is
usually dreaming. Sedatives to psychiatric patients 6-10 times to dream.

SLEEP DISORDERS
 Insomnia- difficulty falling asleep, frequently awaking from sleep, short periods of sleeps or sleeps
that is non restorative.
 Obstructive Sleep Apnea- Lack of airflow through the nose and mouth for a period of 10 seconds or
longer during sleep.
 Narcolepsy- Dysfunction of mechanisms that regulate sleep and wake states. Excessive daytime
sleepiness is the most complaint associated with disorder.
 Sleep deprivation- Insufficient sleep. Sleep of less than 6 hours per day.

NURSING KNOWLEDGE
 Environmental controls- closing the curtains between patients in semi private rooms. Dimming that
lights and reducing the noise.
 Promoting comfort- Keeping the bed clean and dry. Applying dry and moist heat and the use of
pillow in positioning
 Establishing rest periods and sleep- Avoid disrupting the sleep of patients by scheduling.
 Promoting safety and use of side rails- Patient with OSA. Frequent monitoring of and use of CPAP
device.
 Stress reduction- Providing information about procedures and surgeries. Check if sedatives is
indicated.

PAIN MANAGEMENT
 Spinothalamic pathway- Substantia gelatinosa, Anterior Spirothalamic tract, Lateral spinothalamic
tract, Thalamus
 1st order neurons- Peripheral nerves transmit pain sensation
 2nd order neurons- Pain goes to parietal primary sensations
 Local Anesthesia- Blocks nerves
 Spinal Anesthesia- Blocks spinal
 Opiod Analgesics- IV/CNS decreases brain
 Non-opiod- Peripheral nerves

TYPES OF PAIN
 Acute pain- Protective is usually with identifiable cause. Common in acute injury and it eventually
resolves with or without treatment.
 Chronic pain- Protective serves with no purpose. It usually lasts longer than 6 months. It does not
have identifiable cause. (e.g. Arthritis, Low back pain, peripheral neuropathy)
 Cancer pain- Caused by tumor progression and related pathological processes. Under treatment of
cancer pain is still frequent. Needs the use of opioids.
 Chronic episodic pain- Pain that occurs sporadically. over a period of time on and off pain. (e.g.
migraine headache for less than 14 days per month.)
 Idiopathic pain- Chronic pain in the absence of identifiable physical or psychological cause.

GATE CONTROL THEORY

 Non-painful input closes the nerve gates to painful input which prevents pain sensation from traveling
to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.
 Composed of 2 gates- Nociceptive and Non-nociceptive.
 Flooding one gate will override the other.

MANAGEMENT OF PAIN
 Non Pharmalogical pain relief- Cognitive behavioral intervention (e.g. meditation, yoga and guided
imagery)
 Distractions- Person receives excessive sensory inputs, a person ignores the pain stimuli.
 Music therapy- Diverts person’s attention away from the pain.
 Relaxation- A form of cognitive behavioral therapy.
 Guided Imagery- A form of cognitive behavioral therapy.
 Therapeutic touch- Restores harmony is a person’s energy field.
 Cutaneous stimulation- Effective for producing physical and mental relaxation, reducing pain, and
enhancing pain medication.

PHARMALOGICAL INTERVENTIONS
 Analgesics- The moist common and effective method of pain relief.
 Non-opiod effects- It is not entirely clear, thought to decrease the production of prostaglandins.
 Opiod- For mild and moderate pain to control drugs and it is the action on the higher centers of the
brain that can cause numerous side effects. (e.g. morphine, demerol and feutancy.)
 Adjuvants- (Alternatives) Medications are not intended for pain but was discovered to work on
treating pain. (e.g. Tricyclic antidepressants, into convulsants, corticosteroids, sedatives - sleep
medications.) Overdosage- toxicity

OPIOD TOXICITY
 Confusion, hallucination, coma
 pupil constriction
 bradypnea, hypoventilation
 hypotension, bradycardia
 nausea vomiting, constipation
 pruritus (allergy to medications)
 tolerance
 withdrawal syndrome
 Correcting overdosage- morphine overdosage= Naloxone

NUTRITION
 DIGESTIVE TRACT
 Mouth
 Esophagus
 Stomach
 Small intestine
 Large intestine
 Anus
 Cardiac sphincter

Physiology of digestive system

 digestion- Mechanical breakdown
 Metabolism and storage of nutrients
 Metabolism- All chemical reactions in the body
 Storage of nutrients- Glycogen and adipose
 Elimination- Removal of waste products

EATING DISORDERS
 Anorexia nervosa- Restriction of energy intake relative to requirements leading to significant low
body weight.
 Bulimia Nervosa- Recurrent episodes of binge eating with recurrent use compensatory mechanism.
 Dysphagia- Difficulty in swallowing. Signs or symptoms: coughing and choking when eating or
drinking.
 Aspiration- entry of food or digestive contents into the lungs

THERAPEUTIC DIETS IN THE HOSPITAL

 ORAL FEEDINGS
 NPO- Nothing per orem (fasting)
 Clear liquid- coffee,tea, clear fruit juices, popsicles and ice chips
 Full liquid- ice cream, soups, custards, all fruit juices and frozen yogurt
 Mechanical soft/soft diet- flaked fish, rice,potatoes, bananas, pancakes (for dysphagia)
 Low sodium- for preventing hypertension
 Low fat/cholesterol- 300mg/day cholesterol
 Diabetic- balanced intake pf carbs proteins and fats.
 Regular diet and tolerated- no restrictions unless specified.

ENTRAL TUBE FEEDINGS

 provides nutrients into the G.I. Tract. Preferred method of meeting nutritional needs if a patient is
unable to swallow or take in nutrients orally.

TYPES
 Nasogastric tube (for stroke patients)
 PEG tube ( percutaneous endoscopic gastrostomy tube)
 Jejunostomy tube ( forgastric canncee patients)

PARENTERAL NUTRITION
 A form of nutrition provided intravenously.
 Indicated for nonfunctional GI tract extended bowel rest and preparation for GI operations.
 Central lines- connecting big veins that directs to the right atrium.

URINARY ELIMINATION
 basic human function

ROLE OF THE NURSE

 Assess patient’s urinary tract function
 Support bladder emptying
 Urinary catheter
 Monitoring of urine output
 Minimise risk of infection when bladder function is impaired.
 30 ML for moisturization -normal urine
 More than 30 ML- urinary stasis
 Less than 30 ML- urinary failure

URINARY ELIMINATION PROBLEM

 Urinary retention- inability to partially or completely empty the bladder. Causes feeling of
pressure,discomfort or pain.
 UTI- The most common health care acquired infection. Most commonly caused by E.Coli. Signs and
symptoms may include pain and diaphoresis.
 Urinary incontinence- Complaint of any involuntary loss of urine. More common in women.

NURSING INTERVENTIONS.
 promoting normal micturition- routines of patients before voiding, provide privacy, respond to
request for toileting ASAP.
 Maintaining adequate fluid intake- teach the importance of adequate hydration, set schedule for
drinking extra fluids, identify fluid preference, encourage frequent sips of fluid, avoid drinking fluids
2 hours before bed time.
 Promoting complete bladder emptying- Help patient assure normal position while voiding, assess
mobility status of patients, perform perineal hygiene after voiding.
 Stimulate micturition sound of running water, dipping hand of patient in warm water.
 Bladder exercise, Kegel’s exercise
 Crede’s method on manual compression.
 Preventing infection- encourage women to wipe from front to back after voiding defecation, avoid
bubble baths, tight clothings, perfumed perineal washes, have patient void at regular intervals.
 Catheterization- Types of catheter, catheter sizes, catheter drainage system, routine catheter care,
preventing catheter associated infections, removal of in dwelling catheter.

HAZARDS OF CATHETER
 infection
 Trauma

TYPES OF URETHRAL CATHETERS

 Straight I
 Robinson
 Indwelling catheters (lasts up to 30 days)

GUIDELINES FOR PREVENTING CATHETER-ASSOCIATED URINARY INFECTIONS

 Have an established control program
 Catheterize clients only when necessary by using aseptic technique, sterile equipment and trained
personnel.
 Maintain a sterile closed- drainage system
 Do not disconnect the catheter and drainage tube
 Remove the catheter ASAP
 Follow and reinforce good hand washing technique
 Provide routine perineal hygiene, including cleansing with soap and water after defecation.
 Prevent contamination of the catheter with feces of the client.

BOWEL ELIMINATION
• Large intestine
 • Cecum
• Appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Rectum
• Anus

Common bowel elimination patterns

 Constipation- A symptom, not a disease passage of hard, dry stools.
 Impaction- Results when a patient has unrelieved constipation and is unable to express the hardened
feces retained in the rectum.
 Diarrhea- Increase in the number of stools and the passage of liquid, unformed feces. (Must be less
than3 times a day) It is a 1st defense against toxins and it is not a disease.
 Incontinence- Inability to control the passage of feces and gas from the anus. Incontinence harms the
patient’s body image.
 Flatulence- Gas accumulation in the lumen of the intestines. A common cause of abdominal fullness,
pain and cramping.
 Hemorrhoids- Dilated, engorged veins in the lining of the rectum. They are either internal or
external.

Nursing knowledge
 Cathartics and laxatives- medications which initiate and facilitate passage of stools. And Agents
that promote defication.
 Antidiarrheal agents- Decreases the intestinal muscle tone to slow the passage of feces. However,
the cause of diarrhea should be determined before effective treatment can be ordered.
 Enema- Instillation of a solution into the rectum and sigmoid colon, indicated to promote defecation
by stimulating peristalsis. (E.g. Innodium) Given 14 inches abovethe patient. Given 5-10 minutes. It
is a solution introduced into the rectum and large intestine. Distends large intestine and irritates the
intestinal mucosa thereby increasing peristalsis and the excretion of feces and flatus.

Types of Enema
Cleansing
 High Enema
 Low Enema

Retention
 Return Flow Harris
 Flush
 Colonic irrigation

Chief dangers of Enema

 Irritation of the rectal mucosa by too much soap or irritating soap
 Negative effectiveness of Hypertonic or hypotonic solution on the body fluid sand electrolytes.
 Tap water enemas can cause water intoxication.

Commonly used enema solutions for adults

 100 ml
 Commercially prepared- 90-120 ml of a hypertonic solution such as sodium phosphate.
 Saline- 500-1000 ml of normal saline
 Tap water- 500-1000 ml of tap water
 Soap- 3-5 ml of white bland soap to 1000 ml of water
 Oil- 90-120 ml of oil, commercially prepared mineral, olive or cotton seed.
Guidelines for administering enema
 Temperature- Adult (40.5- 43 Celsius) Children (37.7 Celsius)
 Some oil retention enemas are given at 33 Celsius
 Distance of ingestion of an adult- 7-10 cm or 3-4 inches
 Distance of ingestion of children- 5-7.5 cm or 2-3 in
 Distance of ingestion of infants- 2.5-3.5 cm or 1-1.5 in

Guidelines for administering enema

 Length of the solution should be retained
 Oil retention enema- 1-3 hrs
 Other enemas- 15 minutes

Height of the container

 Adult- High cleansing enema- 30-45 cm or 12-18 in
 Children- Other enemas- 30 cm or 12 in
 Infants- 7.5 cm or 3 in

Assuming a lateral position for enema

 Left side lying position because of the rectum

Colostomies
 Patients with temporary or permanent bowel diversions have a unique elimination needs.
 An individual with a colostomy wears a pouch to collect efficient or output from the stoma.
 A healthy stoma should be pink or red.
 Skin protection is important because the effluent land digestive enzyemes.

SKIN INTEGRITY AND WOUND CARE

Chapter 48 Skin Integrity and Wound Care
The skin is the body’s largest organ, comprising 15% of the total body weight. The skin provides:
A protective barrier against disease-causing organisms
A sensory organ for pain, temperature, and touch
Vitamin D synthesis
Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal
healing
pattern will help students recognize alterations that require intervention.

2 Scientific Knowledge Base: Skin

Dermal-epidermal junction
Separates dermis and epidermis
Epidermis
Top layer of skin
Dermis
Inner layer of the skin
The epidermis has several layers. The stratum corneum is the thin, outermost layer that is flattened with
dead
keratinized cells. The basal layer divides, proliferates, and migrates towards the epidermal surface.
The dermis provides tensile strength, mechanical support, and protection to the underlying muscles,
bones, and
organs. The dermis is made of collagen, blood vessels, and nerves.

3 Pressure Ulcers Pressure ulcer Pathogenesis

Pressure sore, decubitus ulcer, or bed sore
 Pressure is the major element in the cause of pressure ulcers.
Pathogenesis
 Pressure intensity- –Tissue ischemia can occur due to capillary occlusion for a prolonged period of
time
–Patient’s with decreased sensation cannot respond to discomfort associated with ischemia hence tissue
death results

Blanching- occurs when normal red tones of the light skinned client is absent (doesn’t occur in darkly
pigmented skin)
 Pressure duration- –Low pressure over a prolonged time period and High-intensity pressure over shot
period
 Tissue tolerance- –Depends on integrity of the tissue and the supporting structures
–Shear, friction and moisture make skin more susceptible to damage from pressure
–Ability of underlying skin structures to assist with redistribution of pressure
 A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony
prominence. It results from pressure in combination with shear and/or friction.
 Pressure is the major contributor to pressure ulcers.
 If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded
for a prolonged period of time, tissue ischemia occurs. If left untreated, tissue death results.
 Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in
darkskinned clients.
 Pressure duration assesses low and extended pressures. Low pressures over a prolonged period of
time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to
cell death.

The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting
structures.

4 Risk Factors for Pressure Ulcer Development

 Impaired sensory perception-Patients are more risk for impaired skin integrity than those with normal
sensation. Patients are unable to feel when a part of their body undergoes increased, prolonged,
pressure or pain.
 Alterations in Level of consciousness- patients who are confused or disoriented, those who have
expressive aphasia or the inability to verbalize. they feel pressure but are not always able to
understand how to relieve it.
 Impaired mobility- Patients unable to independently change positions are at risk for pressure ulcer
development.
 Shear- Shear force is the sliding movement of skin and subcutaneous tissue while the underlying
muscle and bone are stationary.
 Friction- The force of two surfaces moving across one another such in the mechanical force exerted
when skin is dragged across a coarse surface.
 Moisture- The presence and duration of moisture on the skin increases the risk of having ulcer
formation. It reduces The resistance of the skin to other physical factors.
 These six factors contribute to pressure ulcer formation.
 Clients with altered sensory perception for pain and pressure are at risk because they cannot feel their
body sensations.
 Clients who are unable to independently change positions are at risk because they cannot change or
shift off of bony prominences.
 Clients who are confused or disoriented or who have alterations in LOC are unable to protect
themselves.
 Sheer is the force exerted parallel to skin resulting from both gravity pushing down on the body and
resistance (friction) between the client and a surface.
 Friction is the force of two surfaces moving across one another, such as the mechanical force exerted
when the body is dragged across another surface.
 The presence and duration of moisture on the skin reduces the skin’s resistance to other physical
factors.
5 Classification of Pressure Ulcers
Pressure ulcer staging describes the pressure ulcer depth at the point of assessment.
 Stage I
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Discoloration
of the skin may be present.
 Stage II
Partial-thickness skin loss involving epidermis, dermis, or both present as a shallow, open ulcer with a
red-pink wound bed without slough.
 Stage III
Full-thickness tissue loss with visible fat but bone, tendon, and muscles are not present.
 Stage IV
Full-thickness tissue loss with exposed bone, muscle, or tendon or subcutaneous fat.
The National Pressure Ulcer Advisory Panel (NPUP) has defined pressure ulcers.
 Unstageable/Unclassified: Full-thickness skin or tissue loss-depth unknown- Full-thickness tissue loss
in which actual depth of an ulcer is completely obscured by slough (yellow, tan or grey) or eschar
(tan, brown or black in the wound bed is unstageable.
 Suspected, deep-tissue injury- depth unknown- It its a purple or maroon localized area discolored
intact skin or a blood-filled blister caused by the damage of underlying soft tissue from pressure or
shear.

6 Wounds Classification Wound healing Repair Complications

Two methods are currently used to classify skin wounds:
 Describe the status of skin integrity, cause of the wound, severity or extent of the injury or damage
and cleanliness of the wound
 Describe qualities of the wound tissue such as color
 wound healing occurs by primary or secondary intention.
 Primary intention occurs when the edges are closed approximated.nPrimary intention = edges are well
approximated or closed; risk of infection low; heals quickly; minimal scar formation
–Example: surgical wound
 Secondary intention occurs when the wound heals with scar tissue.Secondary intention = wound is
left open until becomes filled with scar tissue; chance of infection is great; longer healing time
–Example: burn, pressure ulcer, severe laceration
 The form wound repair- takes depends on the wound’s thickness. Partial thickness will heal via the
inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal
layers. Full-thickness wounds heal via inflammatory response, proliferation, and remodeling.
 Complications of wound healing
 - Hemorrhage/hematoma- Bleeding from a wound site Occurs within several minutes unless large
blood vessels are involved or poor clotting function of a patient.
 Infection–Second most common health care associated infection. Microorganisms invade the wound
tissues.
 Dehiscence = partial or total separation of wound layers
 Evisceration = protrusion of visceral organs through wound opening
 Fistulas = abnormal passage between two organs or between organs and the outside of the body
 includes hemorrhage, infections, dehiscence, evisceration, and fistulas.
 Process of wound healing- The tissue layers involved and their capacity for regeneration determine
the mechanism for repair for any wound.

7 Nursing Knowledge Base

Prediction and prevention of pressure ulcers
 Norton Scale- to assess the risk for pressure ulcer in adult patients. The five subscale scores of the
Norton Scale are added together for a total score that ranges from 5-20.
Physical and mental condition, activity, mobility, and continence
 Braden Scale- The purpose of the scale is to help health professionals, especially nurses, assess a
patient's risk of developing a pressure ulcer.
 Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
When a client develops a pressure ulcer, the length of stay is extended and the overall cost of care
increases.
 Even though preventive measure are expensive they should be used. Prevention includes special beds
and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.

8 Factors Influencing Pressure Ulcer Formation and Wound Healing

Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
For maintenance of skin and wound healing, clients need 1500 kcal/day. At times enteral or parenteral
nutrition may need to be provided. See Chapters 44: Nutrition, Chapter 50: Care of Surgical Clients.
Clients need vitamins A and C, calories, and proteins to heal. See Table 48-5.
Tissue perfusion occurs when tissue oxygenation fuels cellular function. Clients who are in shock or who
are diagnosed with diabetes mellitus are at risk for poor tissue perfusion.
Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents
epithelialization and tissue destruction. Signs of wound infection include: pus; change in odor, volume, or
redness of tissue; fever; or pain.
Body image changes due to a wound may cause problems with self-concept.

9 Assessment Skin Presence of ulcers Mobility Nutrition and fluid status

Pain
Existing wounds, appearance, character
Wound culture
Baseline assessments as well as continual assessments all provide valuable data that will indicate skin
integrity as well as any risks for pressure ulcer development.

10 Nursing Diagnosis and Planning

The assessment will reveal important information regarding the client’s status.
Use NANDA-I–approved diagnoses.
Write client goals and outcomes specific to the client’s needs.

11 Implementation Health promotion Topical skin care Positioning

Protect bony prominences, skin barriers for incontinence.
Positioning
Turn every 1 to 2 hours as indicated.
Support surfaces
Decrease the amount of pressure exerted over bony prominences.
Support surfaces include mattresses, integrated bed systems, mattress replacement, overlay or set cushion.
Table 48-8 presents support surfaces.

12 Acute Care Wound management Debridement Nutrition Client education

Mechanical, autolytical, chemical, or surgical/sharp
Nutrition
Client education
You will want to take a holistic approach to wound management. You will want to work with the
dietician, wound care nurse, and pharmacist to ensure all client needs are met.
An individualized plan of care must be developed for each client, taking into account age, nutrition,
present medical conditions, and other contributing factors.
Client education is a must. You need to impress on the client and client’s family the importance of
nutrition, fluids, and body positioning.
13 Dressings Dry or moist Hydrocolloid Hydrogel Wound V.A.C. Gauze
Protects the wound from surface contamination
Hydrogel
Maintains a moist surface to support healing
Wound V.A.C.
Uses negative pressure to support healing
The use of dressings requires an understanding of wound healing and factors that influence healing. A
variety of dressing materials are available. You will learn various dressing techniques in the nursing skills
lab.
The choice of dressings and the method of dressing a wound influence healing.
A proper dressing does not allow a full thickness wound to become dry with scab formation.

14 Dressings Changing Securing Comfort measures

Know type of dressing, placement of drains, and equipment needed.
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently cleanse the wound.
Administer analgesics before dressing change.
Follow health care facility for policies and procedures.
Document findings and report to other staff members.
For very complex dressing care, consult with the wound care/enterostomal nurse or carefully develop a
stepby-step procedure to provide consistent wound care.
Make sure to offer pain medications before beginning wound care/dressing changes.

15 Wound Cleansing Cleansing Irrigation Suture Care Drainage Evacuation

Apply noncytotoxic solution.
Irrigation
Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle
Suture Care
Consult health care facility policy.
Drainage Evacuation
Portable units that exert a safe, constant, low-pressure vacuum to remove and collect drainage
Wound cleansing removes surface debris, preventing the invasion of healthy tissue.
Normal saline works best. Betadine, hydrogen peroxide, and acetic acid are toxic to fibroblasts, the key
component in wound healing.
Always refer to health care facility policy and procedures for wound care and wound irrigation.
If available, consult the enterostomal/wound care nurse.

16 Bandages and Binders Bandages Binder application

Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin
Binder application
Breast, abdominal, sling
At times, simple gauze dressings do not supply adequate immobilization or support to a wound. Bandages
and binders are applied over or around dressings to provide extra protection and/or therapeutic benefits by
creating pressure over a body part, immobilizing a body part supporting a wound, reducing or preventing
edema, or securing a splint or dressing.
When binder or bandages are applied, an assessment must be made.
Ask students what they should assess?
Answers may include: inspect skin for abrasions, edema, discoloration, open wounds, circulatory
impairment (coolness, pallor, cyanosis, pulses, swelling, numbness or tingling).

17 Heat and Cold Therapy Assessment for temperature tolerance

Bodily responses to heat and cold
Factors influencing heat and cold tolerance
Education
Before beginning heat or cold therapy, you will need to identify and understand the normal body
responses to localized temperature variations.
Heat and cold applied to an injured body part provides therapeutic benefit.
Ask students to identify when heat and cold are used.
Answers may include:
Heat: arthritis, degenerative joint disease, localized muscle strain, menstrual cramping, hemorrhoid,
perianal inflammation or local abscess.
Cold: direct trauma such as sprain, strain, fracture, muscle spasms, superficial laceration, minor burn,
arthritis, after an injection or joint trauma.
Education will be an important component. Those who suffer from decreased sensations should be very
careful when using these therapies.

18 Evaluation
Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the
client has met the identified outcomes or goals.

PLANNING/ SELECTING NURSING INTERVENTIONS

Nursing Interventions
 Activities the nurse plans and implements to help a patient achieve an identified goal.
 Any treatment based on clinical judgment and knowledge that the nurse performs to enhance patient
outcomes.
When planning nursing interventions
 The nurse must know What is to be done
 When the activities is to be done
 Duration for each intervention
 Any follow-up activity
 Date interventions were selected
 Sequences in which nursing activities are to be performed
 Signature of the nurse writing the plan of care. Types of Nursing Interventions
 Independent/Nurse-initiated interventions- Actions the nurse as licensed to initiate on the basis of the
knowledge and skills.
 Dependent/Physician-initiated interventions- Actions the nurse is involves carrying out physician
prescribed orders.
 Interdependent/Collaborative interventions- Actions that involve the nurse that carries out in
collaboration with other health terms.

Components of nursing interventions

 PDx (Diagnostics)- Weighing, Vas, High monitoring
 PTx (Therapeutic)- Administering of paracetamol 500 mg = 1 tablet
 PEx ( Education for health teaching)- Teaching the patient to have proper care such as drinking
medicines on the right time
 HGT- Hemo Gluco Test (Blood sugar test)

Criteria for selecting Nursing Interventions

 Safe and appropriate for the patient
 Congruent with other therapies
 Develop the behavior in the goal statement
 Realistic
 Necessary to asses and monitor effect of medical treatment

Writing individualized Nursing Interventions on Care Plan

 Nursing interventions in NCP should be Dated when they are written
 Relieved regularly as intervals
IMPLEMENTATION
 Doing a task
 Delegating
 Documenting
 Putting the nursing carte plan into action of the expected outcome.
 Done to resolve/reduce identified nursing problems on the patient, with the patient and for the patient.

Purposes
 Promote health
 Prevent illness
 Restore Health
 Assist patient in achieving desired health
 Facilitating with altered health promotion

Stages of care
 Health promotion
 Preventing Screening Illness
 Curative
 Rehabilitation

Involves:
 Giving nursing care/carrying out the planned nursing activities

Aspects of nurse’s role

 Care aspects
 Curative
 Protective
 Teaching
 Patient advocate

EVALUATION
 Based on plan
 Terminal behavior demonstrated by patient
 Consistency

Evaluation statement
 Conclusion+Supporting data
 Goal Met
 Goal partially met
 Goal Not met

Fundamentals of Nursing RLE

Nursing Diagnosis
Diagnosing
 interpret assessment data.
 Identify client strength & problems
 NANDA diagnostic label + etiology = N. Diagnosis

Nursing Diagnosis
 clinical judgement concerning a human response to health conditions/ life processes or a vulnerability
for that response by an individual, family, group, community.
 Provides basis for nursing intervention selection to achieve outcomes
 Domain includes health states that nurses are educated and licensed to treat
 Judgement made only after thorough, systematic data collection
 Describes continuum of health states: deviations from health, presence of risk factors and areas of
enhanced personal growth.

Kinds of Nursing Diagnoses based STATUS

 Actual Diagnosis
 Health Promotion Diagnosis
 Risk Nursing Diagnosis
 Syndrome Diagnosis

Actual Nursing Diagnosis

 client problem that is present at the time of nursing assessment
 based on the presence of associated s/sx
o (ex) Ineffective airways clearance r/t excessive secretions.
 Disturbed sleep pattern r/t inability to assume usual sleep position.
Health Promotion Diagnosis
 client's preparedness to implement behaviors to improve health condition
o Readiness for enhanced communication
o Readiness for enhanced self care

Risk Nursing Diagnosis

 Clinical judgement that a problem does not exist but the presence of risk factors indicate that a
problem is likely to develop unless nurses intervene
o Risk for deficient fluid volume
o Risk for impaired religiosity related to confinement to bed.

Syndrome Nursing Diagnosis

 Comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a
certain situation or event.

Nursing diagnoses that have similar interventions.

 Disuse Syndrome
 Environmental Interpretation syndrome
 Post trauma Syndrome
 Risk for post trauma syndrome
 Rape trauma syndrome
 Relocation stress
 Risk for relocation stress
 Self- care deficit syndrome

Components of NANDA Nursing Diagnosis

1. Problem (diagnostic label) and definition - problem statement/diagnostic label, describes the client's
health problem/ status or response for which nursing theraphy is given.
Ex. Deficient, impaired, decreased, ineffective, compromised.

2. Etiology (related factors & risk factors) - identifies one or more probable causes of a health problem,
gives direction to the required nursing therapy & enables the nurse to individualize the client's care.
( combine diagnostic label and etiology)

3. Defining Characteristics - clusters of signs & symptoms that indicate the presence of a particular
diagnostic label. ( combine diagnostic label, etiology and defining characteristics.)

Collaborative Problems
- type of potential problem that nurses manage using both independent and physician- prescribed
interventions,
- present when a particular disease or treatment is present

Steps of Diagnostic Process

1. Analyzing Data
2. Identifying health problems, risk & strengths
3. Formulating diagnostic statement

Analyzing Data
a. Comparing data w/ standards
Identify significant cues:
o (+) or (-) change in health status or pattern
o Varies from norm of client's population
o (+) developmental delay

b. Clustering cues
- process of determining the relatedness of facts and determining whether any patterns are present,
whenever the data represents isolated incidents and the data are significant.
- grouping of data/cues that point to the existence of a health problem.

c. Identifying gaps and inconsistence of data

- include final check to ensure that data are complete and correct.
- skillful assessment minimizes gaps and inconsistencies of data.
- possible sources of inconsistencies: measurement error, expectations and inconsistent or unreliable
reports.

Identifying Health Problems, Risks & Strengths

 Identifying problems that support tentative actual and risk diagnoses
 Establish the client's strengths, resources and abilities to cope
 Determine whether the client's problem is a nursing diagnosis or a collaborative problem.

Formulating Diagnostic Statement

a. Basic two- part statement
b. Basic three- part statement
c. One- part statement

Basic two-part nursing diagnosis

Problem (P)
o Statement of the client's health state or response
o Diagnostic label
Etiology (E)
o Factors contributing to or probable causes of the responses
(ex) Constipation r/t prolonged laxative use
Severe anxiety r/t threat to physiologic integrity: possible CA diagnosis.

Basic three-parts nursing diagnosis

Problem (P)
o Statement of the client's health state or response
o Diagnostic label
Etiology ( E)
o Factors contributing to or probable causes of the responses.

Signs & Symptoms (S)

o Defining characteristics manifested by the client.
(ex)
Situational low self- esteem r/t feelings of rejection by husband as manifested by hypersensitivity to
criticism.

Altered dentition related to chronic use of tobacco as manifested by tooth enamel discoloration.
One part Statement
 Consist of a NANDA label only
 Health promotion diagnoses & syndrome diagnoses
(ex) rape- trauma syndrome and readiness for enhanced parenting

Variations Basic Formats

1. Writing unknown etiology when defining characteristics are present but the nurse does not know the
cause or contributing factors.
(ex) Noncompliance (medication regimen) r/t unknown etiology.

2. Using complex factors when there are too many etiologic factors,
(ex) Chronic low self-esteem r/t complex factors
3. Using the word possible, to describe either the problem or the etiology require more data about the
client's problem or etiology.
(ex) Possible low self esteem r/t loss of job and rejection by family.

4. Using secondary to divide the etiology into two parts.

(ex) Risk for impaired skin integrity r/t decreased peripheral circulation secondary to diabetes.

5. Adding a second part to the general response or NANDA label to make it more precise.
(ex) Impaired Skin Integrity (left lateral ankle) r/t decreased peripheral circulation.

Nursing Diagnosis Medical Diagnosis

Statement of nursing judgment Made by physicians

Refers to a condition that nurses by virtue of their refers to a condition that only physician can treat
education, experience and experience are licensed
to treat.
Describe human response, client's psychological & Refers to disease processes.
spiritual responses to an illness or health problem
Nursing actions -independent Nursing actions primarily dependent

Guidelines for writing a Nursing diagnosis

1. State in terms of a problem, not a need
 Deficient fluid volume r/t fever
o Fluid replacement r/t fever

2. Word the statement so that it is legally advisable.

 Impaired skin integrity r/t immobility
o Impaired skin integrity r/t improper positioning

3. Use nonjudgemental statements

 Spiritual distress r/t inability to attend church services secondary to immobility.
o Spiritual distress r/t strict rules necessitating church attendance.

4. Make sure that both elements of the statements do not say the same thing.
 Impaired skin integrity r/t immobility
o Impaired skin integrity r/t ulceration of sacral area.
 5. Be sure that cause & effect are correctly stated.
 Pain: severe headache r/t fear of demands of student life
o Pain r/t severe headache

6. Word the diagnosis specifically and precisely to provide direction for planning nursing
intervention.
 Impaired oral mucous membrane r/t decreased salivaton secondary to radiation of neck.
o Impaired oral mucous membrane r/t noxious agent.

7. Use nursing terminology rather than medical terminology to describe the client's response.
 Risk for ineffective airway clearance r/t accumulation of secretions in lungs
o Risk for pneumonia

8. Use nursing terminology rather than medical terminology to describe the probable cause of the
client's response.
 Risk for ineffective airway clearance r/t accumulation of secretions in lungs.
o Risk for ineffective airway clearance r/t emphysema

Planning
 Developing a plan of care to assist the patient to an optimum or improved level of functioning in the
problem areas identified in the nursing diagnosis
 Nurse works with the client to set goals/ outcomes to prevent, correct or relieve health problems and
determine appropriate nursing interventions

Planning Process
1. Setting Priorities
2. Establishing client goals/ desired outcomes
3. Selecting nursing Interventions
4. Writing individualized nursing interventions on care plan.

Setting Priorities
- Determine which problems identified during the assessment phase are in need of IMMEDIATE
attention and which problems may be dealt with at a later time.

Guide in Setting Priorities

 Maslow's Hierarchy of needs
 ABC's of Life
 Life preservation

Consider:
1. The most important problems to the patient
2. Effect of potential problems
3. Costs, resources available, personnel, time needed

Establishing Goals
• describes a change in the patient’s health status or functioning
• desired outcome of nursing care that which you hope to achieve with your patient
• expected outcome, predicted outcome, outcome criterion, objective

Long term & Short term goals

Situation: Frail elderly man with a pressure ulcer on his sacral area
Long term goal Short term goal

The patient’s sacral area will exhibit no evidence of At the end of the first week, the patient’s pressure
a pressure ulcer. ulcer has decreased in size by a quarter inch.

Guidelines for Writing Goals

o S – Specific
o M – Measurable
o A – Attainable
o R – realistic
o T – Time bounded

SPECIFIC GOAL
Nursing Dx: bathing self-care deficit r/t presence of a heavy cast in the left leg

Goal: The patient will be able to bathe with assistance within the next 24 hours.

MEASURABLE GOALS
• The patient will be able to ambulate by tomorrow.
• The patient will be able to ambulate with assistance from bed to bathroom by tomorrow.

ATTAINABLE AND REALISTIC GOALS

• The patient will be able to drink fluid amounting to 1200 mL within an 8-hour period.
• The patient will be able to drink fluid amounting to 1200 mL within an hour.

TIME BOUNDED
• The patient will be able to bathe with assistance within period of hospitalization.
• The patient will be able to ambulate with assistance from bed to bathroom by tomorrow.
• The patient will be able to drink fluid amounting to 1200 mL within an 8-hour period.

Guideline for writing goals

Write goals in terms of patient outcomes, not nurse activities.

• Whenever possible, the goal is important and valued by the patient, the nurses, and the physician.
• Derive each goal from only one nursing diagnosis.
• Keep the goal short.

Goal Statement= patient’s behavior + criteria of performance + time + conditions (if needed)

Examples of Goal Statements

Nursing Diagnosis
Imbalanced Nutrition: more than body requirements r/t poor eating habits

Goals
Will lose 20 lbs. within 12 wks.
Will reach target wt. of 122 lbs. by June. 20, 2012
Will identify 10 low-calorie snacks he is willing to try within 3 days

Nursing Diagnosis
Impaired physical mobility r/t general muscle weakness

Hyperthermia r/t infectious process

Goal
Before discharge, patient will ambulate the length of hallway independently.

Body temperature will decrease from 38.50C to 37.50C within 2 hours

Nursing Diagnosis
acute pain r/t post-surgical incision

risk for infection r/t presence of open wound on the right forearm

Goal
verbalization of decreased pain from a scale of 2 to 1(where 3=severe, 2=moderate, 1=mild, 0=no pain)
within the shift

will not manifest any sign of infection during hospitalization

Variables that Influence Goal Outcome Achievement

a. patient variables
• patient’s changing ability
• willingness to participate in the plan of care
• previous responses to nursing interventions
• progress towards goal

b. nurse variables
• nurse’s level of expertise and creativity
• willingness to provide care
• available time

c. resources
• adequacy of staff, equipment and supplies
• financial resources of the patient
• adequacy of community-based resources

d. ethical and legal guides to practice

• laws and regulations
• ethical dimensions of clinical practice

Massage
- the manipulation of tissues (by stroking, kneading, or tapping) with the hand or an instrument
for remedial or hygiene purposes

Types of Massage Strokes

Effreuge,Petrissage, Tapotement

Purposes of Massage
 To relieve muscle tension
 To promote physical & mental relaxation
 To relieve insomnia
 To improve muscle & skin functioning
 To provide relief from pain

Duration: 5- 20 min in accordance w/ the client’s tolerance.

Equipment: lotion or oil

Procedure:
 Explain the procedure to the client.
 Perform handwashing.
 Provide privacy.
 Prepare the client (position: prone).
 Pour a small amount of lotion onto the palms of your hands and hold it for a minute .
 Effleurage entire back.
 Optional: Petrissage the back & shoulders of the client.
 Apply moderate pressure movements up to the back.
 Optional: Effleurage & petrissage the upper back & shoulders, using long soothing strokes.
 Apply pressure strokes along the spinal column.
 Using gentle pressure, apply large circular movements to the back.
 Complete the massage by using light effeurage to the entire back. With each massage stroke, lessen
the pressure.
 Pat dry any excess lotion with a towel.
 Assist the client to a position of comfort.
 Document the massage & the client’s response.

Hot and Cold Application

- A therapy applied to body part for local or systemic change in the body’s temperature for various
therapeutic purposes.

Therapeutic
Comfort
Rehabilitation

TRANSFER OF HEAT OR LOSS OF HEAT OCCURS IN ANY WAYS OF THE FOLLOWING:

Conduction – Contact
Convection – movement
Evaporation- through liquid –gas transfer
radiation – electromagnetic waves
Conversion – transfer from one energy to another

Heat Application
Indications of Heat Application
1. Relieves aches and pain
2. Comfort and relief
3. Client with musculoskeletal problem

Cold Application
Cold application is most often used for sport injury
1. Relieves pain
2. Limit inflammation and suppuration
3. Control bleeding

Indications for HEAT Application

1. Promotes wound healing
2. Relieves pain
3. Relieves muscle tension and joint stiffness
4. Warms part of the body
5. Reduces edema / swelling
6. Eliminate toxic products

COLD – SUPPURATION – PUS FORMING PROCESS OF DISCHARGING PUS

Guidelines in Local Applications of heats and cold

1. Determine the client ability to tolerate therapy
2. Identify conditions that might be contraindicate treatment
3. Explain the application to the client
4. Assess the skin area to which the heat and cold to be applied
5. Ask the client to report any discomfort
6. Return to the client 15 mins after stating the heat and cold
7. Remove the equipment
8. Examine the area which heat and cold was applied, record client response.

Factors to Consider in Safe Application of Heat and Co

1. Patient’s Condition
 Age
 Circulatory or neurologic deficiencies
 Level of consciousness
 Amount of body fats
 Condition of the skin in the area being treated
 Patient’s diagnosis
2. Adaptation of thermal receptors
3. Thermal application must be stopped before “rebound phenomenon” begins

SIGNS OF TISSUE DAMAGE

a. bluish & mottled skin appearance
b. numbness
c. stiffness
d. pallor
e. sometimes blister & pain

2. Moisture conducts heat better than air

3. Length of exposure and the area to be exposed
4. Condition of the equipment

Local Effects of Heat

Vasodilatation and increases blood flow to the affected area

 Increase supply of oxygen
 Promote soft tissue healing
 Used for client with (joint stiffness, low back pain)
 Sedative effect
 Improve circulation

Increase supply of oxygen, nutrients, antibodies, and leukocytes

Decreased blood viscosities

Disadvantages of Heat Application

 Increase Capillary Permeability
 Extra cellular fluid & substance as plasma to pass through the capillary walls
 Edema

Systematic effect of heat

 Heat applied on large body area
 Excessive peripheral vasodilation
 Drop in BP
 Fainting attack

Contraindications to the use of Heat Applications

 The first 24 hours after traumatic injury (heat increase bleeding and swelling).
 Active hemorrhage (heat causes vasodilatation and increase bleeding)
 Non inflammatory edema (heat increases capillary permeability and edema).
 Skin disorder (heat can burn or cause further damage to the skin).
 Localized malignant tumor (heat increase cell growth and accelerate metastases).

Local effect of cold

 Lowers the temperature of the skin and underlying tissue
 Vasoconstriction
 Decrease capillary permeability
 Slow bacterial growth
 Decrease inflammation
 Local anesthetic effect

Decrease Blood circulation

Delayed re –absorption of fluid
Increased coagulation of blood

Systematic Effect of Cold

 Excessive cold application
 Vasoconstrictions
 Increased BP
Prolonged cold = shivering

Contraindications to the use of Cold Application

 Open wound (cold can increase tissue damage by decreasing blood flow to an open wound ).
 Impaired circulation (cold can further impair nourishment of the tissue).
 Allergy and hypersensitive to cold application.
 Some people react by decrease Bp.
 Inflammatory response (swelling, joint pain).

Description Temperature Application

Very Cold Below 15 C Ice bag
Cold 15-18 c Cold packs
Cool 18-27 c Cold compresses
Tepid 27-37 c Alcohol sponge bath
Warm 37-40 c Warm bath
Hot 40-46 c Hot soak, hot compresses
Very Hot Above 46 c How water bag for adult

Classification of Hot Applications

Local
Dry Heat Moist Heat
 Hot water bottles  Hot water bottles
 Chemical heating bottles  Chemical heating bottles
 Infrared rays  Infrared rays
LOCAL
 Ultraviolet rays  Ultraviolet rays
 Electric cradles  Electric cradles
 Electric heating pads  Electric heating pads
 Sun Bath  Steam Baths
GENERA
 Electric cradles  Hot packs
L
 Blanket Bed  Whirlpool Bath (Full immersion bath)

Classification of Cold Applications

Local
Dry Cold Moist Cold
 Ice bags
 Ice to suck
 Ice collar
LOCAL  Cold compress
 Ice packs
 Evaporating lotion
 Chemical cold packs
 Cold sponging
GENERAL  Hypothermia  Cold bath
 Cold packs

Methods of Applying heat and cold

 Hot water bag (bottle)
o More common source of dry heat
o Inexpensive
o Improper use leads to burning
 Hot & Cold Packs
o Commercially prepared hot and cold packs provide heat or cold for designated time
 Electrical Pads
o Provide constant heat
o Are light weight
o Some place have water proof covers to placed over a moist dressing
 Ice bags
o Filled either with ice chips
 Compresses
o Can be either warm or cold
o Are moist gauze dressing applied to a wound
 Soak
o Refers to immersing a body part in a solution
o Sterile technique is generally indicated for open wound
 Sitz Bath or hip bath
o Used to soak a client's pelvic area
o The client's sit on the chair nd immersed in the solution
 Cooling Sponge Bath
o Promoting heat loss through conduction
o Companied by antipyretic medication

TRANSFER OF HEAT OR LOSS OF HEAT OCCURS IN ANY WAIST OF THE FOLLOWING:

Conduction – Contact
Convection – movement
Evaporation- through liquid –gas transfer
Radiation – electromagnetic waves
Conversion – transfer from one energy to another

DIATHERMY
a medical and surgical technique involving the production of heat in a part of the body by high-frequency
electric currents, to stimulate the circulation, relieve pain, destroy unhealthy tissue, or cause bleeding
vessels to clot.

Hot Water Bag Application

1. Check the order & specify
2. Identify the patient
3. Assess the general condition of the patient
4. Explain the procedure
 5. Prepare equipment & supplies.
6. Wash hands.
7. Provide privacy & comfort
8. Check temperature of water. Fill the hot water bag half to 2/3 full.
9. Expel remaining air from bag. Fasten up securely. Check for leaks.
10. Cover the bag with towel or other protector & apply to prescribed area.
11. Remove hot water bag after 15- 20 minutes (or as ordered by the physician).
12. Evaluate
13. Document
14. Perform hand hygiene.

Ice Bag Application

1. Check the order & specify
2. Identify the patient
3. Assess the general condition of the patient
4. Explain the procedure
5. Prepare equipment & supplies.
6. Wash hands.
7. Provide privacy & comfort
8. Place towel or absorbent pad under area to be treated.
9. Prepare ice bag or collar:
a) Fill bag with water, secure cap & invert.
b) Empty water & then fill bag 2/3 full with small ice chips.
c) Release excess air from bag by squeezing its sides before securing cap.
d) Wipe bag dry.
e) Apply snugly over area.
10. Check condition of the skin every 5 minutes
11. After 15- 20 minutes (or as ordered by the physician), remove cold application & gently dry
off any moisture.
12. Assist client to comfortable position.
13. Evaluate
14. Document
15. Perform hand hygiene.
Exceeding normal temperature ranges can damage tissues.

Rebound Phenomenon: Heat

 Occurs at the time that maximum therapeutic effect of hot and cold application achieved
 Heat produces maximum vasodilation in 20-30 mins
 Continuation beyond 30-45 minutes causes TISSUE CONGESTION, the blood vessels
CONSTRICTS

Now the opposite effect is occurring because of vascular constriction

Recovery time of 1 hr is advised before reapplication

Rebound Phenomenon: Cold

 Maximum VASOCONSTRICTIONS occurs when the skin temperature reaches 15˚ or in about 30
mins to 1 hour
 VASODILATION begins as a protective device to prevent the body tissue from freezing
 Recovery time of 1 hr is advised before reapplication

Backrubs
Purpose
Stimulate circulation
Prevent skin breakdown
Soothing
 Refreshing
 May be performed after drying off the back during the bath.
 Position of Patient: Prone or side-lying
 Expose only the back, shoulders, upper arms. Cover remainder of body
 Lay towel alongside back
 Warm lotion in your hands—still explain that it may be cool and wet.
 Start in the sacral area, moving up the back.
 Massage in a circular motion over the scapula.
 Move upward to shoulders, massage over the scapula
 Continue in one smooth stroke to upper arms and laterally along side of back down to iliac crests.
 Do NOT allow your hands to leave the patient’s skin
 End by telling your patient that you are finished

NOTE
 Some Patients Are Not Allowed To Have Back Rubs!
 Check With The Nurse And The Care Plan
 If When Applying Lotion You Notice Reddened Areas Of Skin--- Massage Around The Area But
Not Over The Reddened Area

THERAPEUTIC COMMUNICATION
Verbal Communications
 Largely conscious
 Consider the ff:
 Pace and intonation
 Simplicity
 Clarity & brevity
 Timing & Relevance
 Adaptibility
 Credibility
 Humor

Non Verbal Communications

 Body language (gestures, body movements, use of touch, physical appearance including
adornment
 Physical appearance (clothing & adornment)
 Posture & Gait
 Facial Expression
 Gestures
 HEALTH ASSESSMENT
ANATOMY: SPECIAL SENSES | SENSE OF HEARING | EARS

HEARING
- Sense of hearing and equilibrium

MECHANORECEPTORS
- Detect sound waves (touch & hearing)

 OUTER EAR
PINNA | AURICLE
- The only visible part of the ear with its special helical shape

EXTERNAL AUDITORY CANAL | EXTERNAL ACOUSTIC MEATUS

- A tube running from the outer ear to the middle ear

TYMPANIC MEMBRANE
- Thin, cone-shaped membrane that separates the external ear from the middle ear

 MIDDLE EAR
 TYMPANIC CAVITY
- An air chamber
- It contains a chain of movable bones which transmits the vibrations of the tympanic
membrane across the cavity to the middle ear

MASTOID ANTRUM | TYMPANIC ANTRUM

- An airspace in the petrous portion of the temporal bone

AUDITORY TUBE | EUSTACHIAN TUBE

- Equalizes the pressure between the outer and inner ear
- EQUALIZES THE PRESSURE BETWEEEN THE INNER EAR AND THE
ATMOSPHERE
- Methods we use when we feel pressure inside our ear: swallowing yawning, and
chewing (happens here)

AUDITORY OSSICLES
1. MALLEUS | HAMMES
- Transmits sound vibrations from the eardrums to the incus

2. INCUS | ANVIL
- The middle bone; connects to the malleus and to the stapes

3. STAPES | STIRRUP
- Transmits sound vibrations from the incus to the oval window
- It connects middle ear to the inner ear

 INNER EAR
COCHLEA
- Receives sounds in the form of vibrations
- Transforms vibrations of the cochlear liquids and associated structures into a neural
signals
- Organ of hearing

VESTIBULE
- Detect changes in gravity and linear accelerations
- Responsible in balance
- Contains utricle and saccule

1. UTRICLE
- Changes in velocity when traveling (horizontal & vertical)
2. SACCULE
- Acceleration & Deceleration

A. OVAL WINDOW | VESTIBULAR WINDOW

- Transmits the vibrations to the inner ear
B. ROUND WINDOW | COCHLOEAR WINDOW

SEMICIRCULAR CANALS (ANTERIOR, POSTERIOR, LATERAL)

- Helps maintain balance when turning spinning, or tumbling
- Fluid filled tubes in your inner ear that helps you keep your balance

FLUIDS IN THE EAR

- Help in transmission of the sound
- Are separated from each other
- Chemically different
1. PERILYMPH
- Fluid outside
2. ENDOLYMPH
- Fluid inside

NOTES:
FLUID
- The flow of fluid in the ear counter flows the movement of our body to maintain balance
CERUMINOUS GLANDS
- Produces earwax

EARWAX | CERUMEN
- Helps keep the skin in the ear canal soft
- Keeps the bugs out

CUPULA
- Hair-like structure
- It helps the movement of the fluid; Endolymph

VESTIBULOCOCHLEAR NERVE VII

- VESTIBULAR – maintain balance
- COCHLEAR – auditory sense

SENSE OF HEARING
- Last sense that is last to leave the body when you die
- First to return when you wake up

AUDITORY PATHWAY
1. AURICLE
2. EXTERNAL AUDITORY CANAL
3. TYMPANIC MEMBRANE
4. AUDITORY OSSICLE
5. COCHLEAR FLUID is disturbed
6. Ripple disturbs hair cells in the ORGAN OF CONTI/COCHLEA
7. COCHLEAR NERVE
8. BRAIN STEM
9. THALAMUS
10. AUDITORY NERVE OF TEMPORAL LOBE

ASSESING THE EAR/HEARING

Position
- Alignment of pinna with the corner of the eye and within 10 degree angle of vertical position

  INFANTS
Inspection:
- Top of the pinna should match on imaginary line extending from the corner of the eye to the
occiput
- Should be positioned 10 degrees of vertical
- New born: hasn’t yet developed the cartilage that will give shape and firmness of shape of the
external ear
- Folded/misshape ears are normal for infants

Skin Conditions:
- Smooth without nodules
- Colour pink
- Consistent with the patient’s facial colour
- Intact on the skin with no lesions
 To Assess:
- To assess gross hearing, ring a bell from behind the infant or;
- Have the parent call the child’s name to check for a response
- If there is response to the sound the infant may open eyes wider
- 3 -4 months of age, the child will turn head toward the sound
- There are many variations in size and shape of the ear

Palpation:
Palpate the external ear;
- Normal: non tender auricle, tragus
Mastoid process for;
- Normal: no tenderness, warm to touch, mastoid process easily palpated
- Tenderness, temperature, oedema

 Deviations

 Hypoplastic ear
- Can be genetic
 Ear tag
- The infant’s external part of the ear are the first areas to develop inside a pregnant mother
- Associated with loss of hearing in babies
- It may indicate that the internal ear didn’t form correctly inside

 Lop ear
- Can be treated – treatment: ear moulding

 TINITUS
- is the perception of noise or ringing in the ears
- it's a symptom of an underlying condition, such as age-related hearing loss, ear injury or a
circulatory system disorder
At risk:
 - seniors / older adults
- military personnel
- musicians
- construction workers
 TESTS
 Whisper Test
- to assess high-frequency hearing
- have the patient occlude one ear
- go out of the patient’s sight, at distance of 1-2 ft. , whisper
- ask the patient to repeat the phrase
- the patient should be able to repeat the phrases correctly

Conductive Hearing Loss

- is the result of interrupted transmission of sounds through the external and middle structure of the ear
- a tear/obstruction in tympanic membrane

Sensorineural Hearing Loss

- damage to the inner ear, auditory ear, hearing centre in the brain (cochlea)

Mixed Hearing Loss

- combination of conduction and sensorineural hearing loss
- external to inner ear

 OTOSCOPY
- an examination that involves looking into the ear with an instrument called an otoscope (or auriscope)
- performed in order to examine the 'external auditory canal' – the tunnel that leads from the outer ear
(pinna) to the eardrum
 WEBER TEST
- Ernst Heinrich Weber
- Using a tuning fork
- Quick screen test for hearing
- When holding a vibrating tuning fork, always hold the fork by its base preferable as low as possible
- Generally performed first and assess for lateralization of sound or whether sound is heard louder in one
ear
Normal: sound is heard equally in both ears (WEBER NEGATIVE)
Deviation: sound is better in impaired ear, including a bone-conductive hearing loss
sound is heard better in ear without a problem indicating a sensorineural disturbance
(WEBER POSITIVE)
- If the result is WEBER NEGATIVE no need to perform additional test
 RINNE TEST
- In the event of sound lateralization perform Rinne Test
- Helps to determine in what area have deviation
- Sound lateralizes to the ear with a conductive hearing loss
- Masking effect of air conduction has been lost
Expected: sound is heard by both air conduction and bone conduction, air conducted sound can
mask the bone conducted sound
- Bone Conductive Deficit: ossicles respond to the direct stimulation of the vibrations and not any sound
that is transmitted by air conduction
- Ear with Conductive Hearing Loss: does not receive any air conduction sound to ask or dilute bone
conduction and sound is lateralized to that ear
- Compare air conduction to bone conduction
- Normal: air conduction of sound is generally louder and heard twice as long as bone conduction ACBC
2:1
- Thus if the patient heard the sound by bone conduction for 8 seconds, sound should be heard by air
conduction by 16 seconds
- Ask whether the patient now hears the sound, sound conducted by air is heard more readily
- Normal: AC>BC
- Deviation: BC>AC or BC = AC – indicates a conduction hearing loss

GENERALLY:

Weber And Rinne Tests

- Negative Rinne test: The sound is perceived by bone conduction but not by air conduction
(middle ear disease/deafness)
- Positive Rinne test the sound is perceived by air conduction but not bone conduction
(sensorineural deafness cochlea or cochlear nerve damage)

Rinne: Rinne 0.5K Hz A/C > B/C AU: air conduction is louder in the ear versus
the matoid in both ears @ 0.5K Hz.
Rinne 0.5K Hz A/C > B/C AS: air conduction is louder in the bone in the
left ears @ 0.5K Hz.

Rinne 0.5K Hz A/C = B/C Patient could not identify whether the fork
was louder via A/C or B/C

Rinne 1K Hz B/C > A/C AD: Bone conduction is louder than air
conduction in the right ear @ 1K Hz.

Weber: Weber  (Patient hears it at middle)

Weber AD (Patient hears it in the right ear)

Weber AS (Patient hears it in the left ear)

Legend: AD: Auris dextra in the Latin origin of these letters and refers to the right ear
AS: Auris sinistra is the Latin origin of these letters and refers to the left ear
AU: Auris Unitas in the Latin origin of these letters and refers to both ears

Weber & Rinne Tests

- Weber test: determines if hearing loss present in one ear, but does not distinguish conductive and
sensorineural deafness
- Rinne test: Evaluates an individual’s ability to hear sound conducted by air or bone
- Used together, these test can distinguish between the two types of hearing loss
ANATOMY: EYE
 MUSCLES OF THE EYE
SUPERIOR RECTUS Rolls eyeballs upward
INFERIOR RECTUS Rolls eyeballs downward
MEDIAL RECTUS Rolls eyeballs medially
LATERAL RECTUS Rolls eyeballs laterally
SUPERIOR OBLIQUE Rolls eyeballs on axis
INFERIOR OBLIQUE Rolls eyeballs on axis

3 LAYERS OF THE EYE

1. SCLERA 2. CHOROID 3. RETINA
Hardest part Highly pigmented Avascular / no blood
Contains lots of
Serves as an
blood vessels | Photoreceptors and very fragile
attachment
Vascular
Helps maintain
Middle layer Innermost layer
shape
RODs – acts night-time, detects colour (black,
Outermost layer
white, and gray), functions in peripheral vision
CONEs – acts daytime, detects various/all
colours, functions best in bright light
3 types of CONES (BLUE: 16%) (GREEN: 10%)
(RED: 74%)
LACRIMAL GLAND
- Produces tears

FOVEA CONTRALIS
- Small central pit composed of closely packed cones in the eye
- Located in the center of the macula lutea of the eye

MEIBOMIAN GLAND
- Produce and oily substance that keeps the eyes moist

CONJUNCTIVA
- Mucous membrane, lines the inner surface of the eyelids
- Transparent, coral pink, may visible small vessels

CORNEA
- Avascular
- Most exposes and transparent
- Nothing protects cornea
- Protective window for which the light passes

IRIS
- Makes the constriction and dilation of pupils
- Iris muscle
- CIRCULAR MUSCLE – when contracts it constricts the pupil (parasympathetic)
- RADIAL MUSCLE – when contracts it dilate the pupil (sympathetic)

PUPIL
- Protective reflex
- Prevents excessively bright light from damaging the delicate photoreceptor
- ACCOMODATION PUPILLARY EFFECT – pupil constrict to increase depth of focus of the eye by
blocking the light
- PUPILLARY LIGHT REFLEX – the reflex of the eye to the brightness or dimness of the light
CORNEAL LIGHT REFLEX
- asymmetrical placement of the corneal light reflex indicates that the eye are not in the proper alignment
- can be due to strabismus
- generally caused by weakness or paralysis of eye muscle

LENS
- Avascular like the cornea
- 65% water 35% protein
- To focus light rays on the retina by accommodation
- Distant object – the lens flattens
- Near object – the lens gets rounder and thicker

MACULA LUTEA OR FUVEA

- Contains very high concentration of cones

CILLARY BODY
- Controls the shape of the lens (cilliary muscle)
- Cillary epithelium – produces aqueous humor
- Vitreous humor – produced in the non-pigmented portion of the cillary body

AQUEOUS HUMOR
- Help with the movement of the eye
- Anterior
- Nourishing the cornea and the lens by supplying nutrition such as amino acids and glucose, the aqueous
humour will: Maintain intraocular pressure.

VITREOUS HUMOR
- Fillers of the eyeball behind the lens
- Posterior

NORMAL INTRAOCULAR PRESSURE (IOP)

- Ranges from - 12 – 21 mm Hg

CANAL OF SCHLEMM
- Circular canal lying in the substance of the schlerocorneal junction of the eye and;
- Draining the aqueous humor from the anterior chamber
- Aqueous humor circulation.

VISUAL PATHWAY
1. LIGHT
2. CORNEA
3. PUPIL
4. CLEAR LENS
5. RETINA
6. RODS & CONES
7. OPTIC NERVE
8. BRAIN
AQUEOUS HUMOR CIRCULATION

1. CILLIARY BODY
2. POSTERIOR CHAMBER OF THE EYE
3. ANTERIOR CHAMBER OF THE EYE
4. CANAL OF SCHLEMM

ASSESSING THE EYES

PALPEBRAL FISSURES
- Length : Endocanthion to Exocanthion
- the elliptic space between the medial and lateral canthi of the two open lids
- In adults, this measures about 10mm vertically and 30mm horizontally.
EYELIDS
- Overlaps the superior area of / part of the iris and approximate completely with the lower lids when
close.

 INFANTS
- First week after birth and up to 3 months, baby can focus only on objects and people that are
close up, about 10 – 12 inches from her face
- Four to six months when the baby is able to see colour and perceive depth
- Baby is able to develop the ability to focus on objects/people – 6 months
- 8 months – infants can now almost see to the level of an adult with regards to clarity and depth
perception, and able to recognize faces
- Infants do not have tears until – 3 months
- By 6 months, average infant’s vision is already 20/20
*Binocular fixation pattern

 DEVIATIONS
 Infantile Esotropia
- A form of ocular motility disorder where there is an inward turning of one or both eyes, commonly
referred to as crossed eyes.
- It occurs during the first 6 months of life in an otherwise neurologically normal child.
 Periorbital area – Periorbital Oedema
- a term for swelling around the eyes
 Purpura
- discoloration - around the eye
 Ptosis
- Droopy eyelid caused by more serious conditions such as stroke, brain tumour, or cancer of the
nerves or muscle
- Uneven opening of the eyes

 Lid Lag
- static situation in which the upper eyelid is higher than normal with the globe in downgaze
- most often a sign of thyroid eye disease, but may also occur with cicatricial changes to the eyelid or
congenital ptosis

 Hordeolum/Sty
- Most often caused by staphylococcus bacteria
- Usually lived around the surface of the eyelid without causing any harm
- When a gland becomes clogged with dead skin cells or old oil, these can become trapped and cause
infection
- Found on the sides of the eye

 Chalazion
- Found at the middle
- Caused by non-infectious meibomian gland occlusion, whereas a hordeolum usually caused by
infection

 Conjunctivitis
- Aka sore eyes

 Subconjunctival haemorrhage
- bleeding underneath the conjunctiva
- the conjunctiva contains many small, fragile blood vessels that are easily ruptured or broken
- when this happens, blood leaks into the space between the conjunctiva and sclera

 Foreign Object
 - something that enters the eye from outside the body

 Pterygium
- Growth of the conjunctiva that occurs the white part of your eye over the cornea
- Shape : wedge shape
- CAUSE: unknown, too much sun/UV exposure

 Jaundice Sclera
- The conjunctiva of the eye are one of the first tissues to change color as bilirubin levels rise in
jaundice.
- This is sometimes referred to as scleral icterus.
- The sclera themselves are not "icteric" (stained with bile pigment), however, but rather the
conjunctival membranes that overlie them.
- CAUSE: High bilirubin levels

 Red Sclera
- caused by dilation of tiny blood vessels that are located between the sclera and the overlying clear
conjunctiva of the eye
- usually are caused by allergy, eye fatigue, over-wearing contact lenses or common eye infections
such as pink eye (conjunctivitis)

 Strabismus
- one eye looks directly at the object you are viewing, while the other eye is misaligned
- inward (esotropia, "crossed eyes" or "cross-eyed")
- outward (exotropia or "wall-eyed")
- upward (hypertropia)
- downward (hypotropia)

 TESTS

 SNELLEN’S CHART
- Children are tested with snellen letter chart (ages 7 – 8 years old)
- To assess the quality of the eyesight of the patient
- Expected visual activity is 20/20
Numerator – indicating distance from the chart, it is constant
Denominator – representing the distance a person with normal vision could see and interpret symbol
- Its score is recorded L 20/40
- The patient is 20ft from the eye chart and reads with the left eye at 20ft what the “normal” eye
visualizes at 40ft
- The patient visual acuity is determined by what line the patient can read correctly
 FIXATION TEST
- Used to screen vision in children 6 months to 2½ years and for those children up to 3 years cannot
be tested with picture eye *
- Used : Penlight & colourful object (RED)
- Cover one eye and hold the light 1 ½ ft. away from the child
- Move the light/toy from midline, side-to-side
- Normally the child will track the light or toy with both eyes
- It fails when he objects

 TESTING VISUAL FIELDS

- Measure peripheral vision
50 – Upward field
 90 – Temporal field
60 – Nasal Field
70 – Downward field
- Considered a neurological rather than ocular
- It assesses the integrity of the optic nerve and its appropriate pathways
- Deviation: homonymous hemianopia

Measurement of deviation
1. Hirschberg test
- it gives rough objective estimate of the angle of a manifest aquint
- useful in young or uncooperative patients or when fixation in deviating eye is poor.
- Procedure – Here the patient is asked to fixate at point light held at a distance of 33 cm and the deviation
of the corneal light reflex from the centre of pupil is noted in the squinting eye.

 HIRSCHBERG TEST
- Muscle strength and position of the eye can also be determined
- The light reflex should be in the same position bilaterally
- DEVIATION: Strabismus

 PUPILLARY ASSESSMENT
- To assess pupillary size in a darkened room, illuminate the face from below. Slowly move the light
up to the patient's eye level and check the pupillary response

 ACCOMODATION OF PUPIL
- The normal pupillary response is constriction of the pupils and convergence of the eyes

 PUPILLARY ASSESSMENT
Fixed, pinpoint pupils:
- Indicate PONS involvement or the use of opiates/drugs
CN III – Oculomotor – constriction of the eye – Originates from the midbrain

Tumour, Clotted blood, Oedema, Aneurysm

- Compression of the nerve may result in dilation on the side of the lesion or the area affected

Cataract
 - The lens are affected
- Number 1 cause is AGING

Arcus Senilis
- Cause: lipid/cholesterol (those who are fat or obese) deposits in the periphery of the cornea
stromal layer

 ADDITIONAL/S
PERRLA (Pupils Equal Round React to Light and Accommodation)
Normal Pupil size: 3-5 mm
Response to light
- Brisk, sluggish, non-reactive or fixed
- Normally constrict when exposed directly to light
- Consensual response
- Have at least 10 seconds interval between assessment of each eye

 Older adults
- Visual acuity decreases
- the eye ages and become more opaque and loses elasticity
- peripheral vision diminishes
- eyeball may appear sunken
- Less absorption of vitamin B12 in the ileum which may result in PALE CONJUNCTIVA

ASSESSING THE FACE & SKULL AND NECK

FACE
2 Structures of the face that are important in assessing for symmetry
1. Nasolabial Folds
2. Palpebral Fissures

HEAD AND NECK

- Framework of the head is the skull
- Normal size of the skull (infant) ranges from 32-38 with an average of 34 – 55-57 in adult
- All of the facial bones are immovable except for mandible
- The face also consist of many muscles that produce facial movements and expressions

NECK
- Composed of muscles, ligaments, and the cervical vertebrae
- Hyoid bone, several blood vessels, larynx, trachea, thyroid gland

LYMPH NODES OF THE HEAD AND NECK

- Lymph nodes produces lymphocytes and antibodies as defence against invasion by foreign
substances
- Size and shape of lymph nodes vary ; but are buried deep in the connective tissue
- Normally lymph nodes are either not palpable or they may feel like small beads

Order in assessing the lymph nodes

1. Pre-auricular
2. Post auricular
3. Occipital
4. Submental
5. Submandibular
6. Jugulodigastric/tonsilar
7. Superficial cervical
8. Deep cervical
9. Posterior cervical
10. Supraclavicular
  DEVIATIONS
 Acromegaly
- Enlargement of the facial features (nose,eyes) and the hands and feet

 Microcephaly
- Small head
 Anencephaly
- No brain

 Hydrocephalus
- Abnormal enlargement of the head

 Cushing’s Syndrome
- May present with a moon shaped face with reddened cheeks and increased facial hair

 Scleroderma
- Tightened-face with thinning facial skin
- Autoimmune disease
- Unknown cause

 Bell’s Palsy
- Paralysis of the facial nerve (7)
- Symptoms may include twitching, weakness, paralysis, drooping eyelid and corner of the mouth,
drooling

 Hyperthyroidism
- Enlarged thyroid gland (goiter)

 Exopthalmus
- Bulging of the eye

 Jugular Vein Distention

- occurs when the pressure inside the vena cava increases and appears as a bulge running down the
right side of a person's neck

 NVE
- Pressure in the right side of the heart is high
Normal Characteristics of the Thyroid Gland
- Smooth surface
- Firm consistency
- Nontender to gentle pressure

Bruit sound
- An indicator of thyroid hyperplasia
- Best heard with the bell of a stethoscope
- A soft, pulsatile, whooshing, blowing sound
- This bruit is not present normally

PHYSICAL EXAMINATION
Inspection
- It is a visual examination
- This examination must be systematic to assess colour, body shape, wounds, facial expression,
motor behaviours and some area to be examined
Palpation
 - Used to validate your inspection
- It is an examination using the sense of touch. The pads of the fingers are used because the
concentration of nerve endings are highly sensitive to tactile discrimination
o Light Palpation
o Deep Palpation
Percussion
- The examiner places one hand on the patient and then taps a finger on that hand, with the index
finger of the other hand
- It can determine the position, size, and consistency of an internal organ
- Based on the auditory and tactile perception, the notes heard can be categorized as follows:
• Tympanic
• Hyperresonant (pneumothorax)
• Normal resonance/ Resonant
• Impaired resonance (mass, consolidation)
• Dull (consolidation)
• Stony dull (pleural effusion)
Auscultation
- Technical term for listening to the internal sounds of the body, usually using a stethoscope;
based on the Latin verb auscultare "to listen"
- To auscultate heart, lungs, abdomen

Palpation
PRINCIPLES
- Have short nails
- Warm your hands prior to placing them on the patient
- Encourage the patient to breathe normally throughout the palpation
- If pain is experienced during the palpation, discontinue the palpation immediately
- Inform the patient what you are going to do and why it is necessary

TYPES OF PALPATIONS
Light Palpation
- Light pressure is applied by placing the fingers together and depressing the skin and underlying
structures about ½ inch (1cm)
- Used to check the muscle and tenderness

Deep Palpation
- It is used/done with caution because pressure can damage internal organs
- Depresses the skin 2cm or deeper

Hooking Technique
- To know the size of the liver
Fingertips
- used for localized pulsations

Thrills
- is felt from light palpation over the chest wall

Lifts
- is a slight movement – a palpable vibration due to strong heart murmur (like a purring cat)
Heaves
- is more vigorous movement than the lift, a vibratory sensation felt on the skin overlying an area of
turbulence

Percussion
- Used to determine the size and shape of internal organs by establishing their border
- The detect the presence of air, fluid, enlargement of organ
BONE – flat sound

Lungs / PRESENCE OF AIR – resonance

ORGANS / WATER – dull

ABDOMEN – tympanitic

TYPES OF PERCUSSION
Indirect Percussion: Using the finger of the one hand to tap the finger of the other hand.
*plexor strikes the finger of the examiner’s other hand, which in in contact with the body surface being
percussed (pleximeter – the middle finger of the nondominant hand).
Direct Percussion: Using one hand to strike the surface of the body.

Auscultation
- the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a
part of medical diagnosis
- Listening to sounds produced by the body
- Instrument: stethoscope (to skin)
Diaphragm – high pitched sounds (Heart, Lungs, Abdomen)
- Used for analyzing the second heart sound, ejection and midsystolic clicks and for the soft but
high-pitched early diastolic murmur of aortic regurgitation

Bell – low pitched sounds (Blood vessels)

- used for mid-diastolic murmur of mitral stenosis or S3 in heart failure

Diaphragm
- breathe sounds
- bowel sounds
- normal heart sounds

Bell
- murmur
- bruit
# Most used position when auscultating are – sitting position and supine

Instruments used in physical examination

BASIC
- Stethoscope
- Opthalmoscope
- Dermatoscope
- Otoscope
- Tape measure
- Reflex hammer
- Monofilament
- Tuning fork

STANDARD PRECAUSIONS
Nosocomial Infection
- Infection acquired during hospitalization

Hand Washing / Hand Hygiene

- Before and after physical contact with each patient
- After inadvertent contact (blood, body fluids, secretions, excretions)
- After handling any equipment w/ body fluids
- Before and after gloving
Gloves
- Use when you’re going to be in contact with;
- Blood and Body Fluids
- Excretions and Secretions
- And any contaminated things
Gown
- Wear in doing any procedure to protect yourself
Linen / Laundry
- Are placed in a private room and linens from patients with infectious disease/s are separated

SKIN ASSESSMENT
SKIN: FUNCTIONS
 1. Regulates body temperature.
2. Prevents loss of essential body fluids, and penetration of toxic substances.
3. Protection of the body from harmful effects of the sun and radiation.
4. Excretes toxic substances with sweat.
5. Mechanical support.
6. Immunological function mediated by Langerhans cells.
7. Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.
8. Vitamin D synthesis from its precursors under the effect of sunlight and introversion of
steroids.

 Infants and Children

- Have very smooth skin – lack of exposure to environmental variables
- Subcutaneous is poorly developed thus predisposing infants to hypothermia

Vernix Caseosa
- Cheese-like substance (sebum)
- For the skin not to be easily macerated
- Creamy substance on newborn’s skin and has anti-microbial and moisturizing qualities that help protect
them in their new environment
 Lanugo
- The baby’s body (esp. shoulders and back) are covered with fine silky hair
- (if present) it disappear 10 – 15 days

Apocrine Glands
- Do not function at this age resulting in odourless perspiration
- Makes the skin with a less oily texture

Merocrine
- Begins to function about 4 weeks
- Merocrine is a term used to classify exocrine glands and their secretions in the study of
histology. A cell is classified as merocrine if the secretions of that cell are excreted via exocytosis
from secretory cells into an epithelial-walled duct or ducts and thence onto a bodily surface or
into the lumen

Eccrine Glands
- Perspiration – present after 1 hour (after birth)

INSPECTION
Skin Colour Skin Uniformity
Erythema – reddening of the skin - Skin’s generally uniform except in areas exposed
Cyanosis – bluing to the sun and areas prone to friction (armpit,
Pallor – paling of the skin groins, etc.)
Jaundice – yellowing of the skin - Areas with lighter pigmentation (esp. noticeable
in dark skinned people) – palms, lips, nail beds

 Deviations – Abnormal

HYPERPIGMENTATION
- Abnormal distribution of melanin
- Freckles, birthmarks, Mongolian blue spots – etc
 Cutis Marmorata
- Skin has a pinkish blue mottled or marbled appearance when subjected to cold temperature
- It loses when exposed to warm temperature / normal temperature again (Rewarming)

Senile Lentigines
- spots that appears when you get old (hyperpigmentation)
 Freckles
- Indication of sun damage
- When the skin produces more melanin pigmentation (UV RAYS)
- Light brown spots (face, neck, and shoulders)
- More prominent to Caucasians

Addison’s Disease
- Also known as primary adrenal insufficiency, result from the insufficient production of these two
hormones, cortisol and aldosterone. Major symptoms include fatigue, gastrointestinal abnormalities, and
changes in skin colour (pigmentation).

HYPOPIGMENTATION
- Pallor
- Partial or complete absence of melanin
 Vitiligo
- Destruction of melanocytes in the area (most prominent in Africans)

Albinism
- Complete or partial lack of melanin
- A congenital disorder
- (white) skin, hair, and eyes
- Associated with a number of vision defects; photophobia, nystagmus, amblyopia)
- They are more prone to sunburn and skin cancer
Physiological Jaundice
- RBC / Hemoglobin in the blood is divided to HEME and GLOBIN, HEME is divided into
BILIVERDIN and ****** which are then converted to BILURUBIN. BILIRUBIN is collected
by the liver, since the new born or infants (physiological jaundice) have undeveloped/not fully
developed LIVER, since they don’t have fully developed liver they don’t have the capability to
collect the unneeded BILIRUBIN, which then causes the yellowing of the skin of the new born /
infant
(JAUNDICE)
- Yellowing of the skin, sclera and mucous membranes
- Occurs at 3rd – 4th day of life – normal
- Reaches its maximal intensity (3-6 days)
- Subside (10 days – 2 weeks)
- Jaundice occurring in the first 24 hours of life is abnormal –

PALPATION
 Temperature
- The skin should be warm (to touch) and the temperature should be equal bilaterally
Hypothermia
- Generalized or localized coolness
- May cause immobilized extremity
- Happens when limb is in cast

Hyperthermia
- High temperature
- When you have; fever, infection, trauma
 Skin Turgor
- Ability of the skin to change shape and return to normal after pinching (turgor)
- A sign commonly used by health workers to assess fluid loss of dehydration

Edema
- Swelling
- abnormal accumulation of fluid in certain tissues within the body
- Edema happens when your small blood vessels leak fluid into nearby tissues
- Pitting Edema – applying pressure to the swollen area causes and indentation that persists for some time
 INSPECTION | PALPATION
Lesions
- Uses inspection and palpations to describe skin lesions;
- Colour, elevation, size, location

Pedunculated Lesions
- small wound that have its own blood vessels

 Shape or Pattern

Annular Lesions
- The term “annular” stems from the Latin word “annulus,” meaning ringed
- The lesions appear as circular or ovoid macules or patches with an erythematous periphery and central
clearing.
 Confluent Lesions Linear Lesions
 Size
- Size in centimetres : use ruler to measure

 Location and Distribution

- Any exudate – note any color
- Palpate lesions
- Gently scrape a scale to see if it comes off, or if it bleeds when the scale comes off
- Do the lesions blanching

**Tumbler Test
- Used to check if the lesion is pressed a glass and non-blanchable it could be; Erythema, herpes zoster,
etc.

Herpes Zoster or Shingles – highly infectious

Macule
- Flat, cannot be palpated, skin colour may change (brown, white, tan, purple, red)
- Note the colour
- Less than 1cm with circumscribed border
Patches
- Bigger than macule
- More than 1cm and may have an irregular border
- Freckles, flat moles, petechiae, rubella, vitiligo
Papule
- Small, containing solid mass, elevated
- Have circumscribed border and are less than 0.5cm
Plaque
- Small flat (small little deviation)
- Coming together
Petechiae
- Small red spots - are tiny, circular, non-raised patches that appear on the skin or in a mucous or
serous membrane.
- They occur as the result of bleeding under the skin
Purpura
- Ex. Meningitis, snake bites
- Purplish spots
Ecchymosis
- Hemorraghic blotching due to pooling of blood under the skin or mucous membrane
Comedone
- Increased in sebaceous gland activity, creates increase oiliness
- Common skin problem of adolescence (7-8)
- Peak (14-16 in girls, 16-19 in boys)
Pustule
- Puss-filled vesicle or bulla
Wheals/Hives
- Ex. Allergies, urticarial, insect bites
- Elevated mass with transient borders that is often irregular
- Size and color vary
Urticarial
 - Characterized by elevated lesions caused by local edema
Acrochordons
- Skin tags
- Common in areas where there is skin friction
- Neck, axilla cheeks and trunk
Nodule
- They feel like large peas under the surface of the skin.
Tumour
- extremely common as people get older
- Some common benign tumors include: Warts (skin tumor resulting from a virus) Seborrheic
keratoses (growths on the skin ranging from light skin color to dark brown)
Vesicles
- small, fluid-filled sacs that can appear on your skin
- The fluid inside these vesicles may be clear, white, yellow, or mixed with blood
Bulla
- fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin
- It's a type of blister
Cyst
- Cysts are noncancerous, closed pockets of tissue that can be filled with fluid, pus, or other
material.
- can develop as a result of infection, clogging of sebaceous glands (oil glands), or around foreign
bodies, such as earrings
Cherry Angioma
- Red moles
- They're usually found on people aged 30 and older
- The collection of small blood vessels inside a cherry angioma give them a reddish appearance
Hair
- Color – texture (fine, straight, curly, kinky)
- In young, should be shiny
- Oiliness is natural (not excessive)
- Note for any scalp lesions;
- Lice, loss of hair (alopecia)- autoimmune disease

Nails
- Inspect and palpate the nails
- Blanching
- Shape
- Curvature (Convex, 160 c)
ADULT/AGED
- drier skin and less perspiration
- thinning and nuttering epidermis
- risk for injury
- greying of hair
- nail growth slows down
- the toenails; thicker, hard, brittle and yellowing appearance

ASSESSING THE HEART AND NECK VESSELS

- When beginning the examination, the ideal location to stand is on the right side

INSPECTION
 General Appearance
 Skin Colour
- Skin; warm to touch
- Homogenous in colouring
- Without significant moisture

 Capillary Refill
- The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and
the amount of blood flow to tissue.
 Heaves or Lifts
- A parasternal heave (or lift) is a precordial impulse that may be felt (palpated) in patients with cardiac or
respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which
originate on the heart or the great vessels.
 Pulsations (apical) – left ventricle on the 5th ICS, left MCL
- Jugular Venous Pulsation / Distention
< is connected to superior vena cava
**NVE – Neck Vein Engorgement

 Deviations
Skin Pallor & Cyanosis
- May suggest poor tissue perfusion
Skin Diaphoresis
- May result from SNS stimulation as a result of diminished cardiac output

Cyanosis
- Best seen in the lips, earlobes, mucous membranes, or where the skin is thin

 Hands and Fingernails

Schamroth’s Test
- Detects fingers clubbing
- Normal: small diamond-shaped “window” is typically apparent between the nail beds
- Deviation: increased convexity
< loss of normal – 165 degrees between the nail bed and cuticle
< may indicate endocarditis or a classic indicator of Cyanotic Congenital Heart Disease (CCHD)
<< CCHD – cardiac malformations that commonly affect the atrial or ventricular walls, heart valves,
or large blood vessels
<< Endocarditis – inflammation of the heart’s inner lining (endocardium)
< TB, Chronic Hypoxia, Liver Cirrhosis, IBD

 Anterior Chest
- For visible pulsations or movements
- Apical impulse / apex beat / Point of Maximal Impulse (PMI)
< Location: 5th ICS, left MCL
- Generally not observed in healthy individuals (unless the patient is thin)

 Internal Jugular Vein & External Jugular Vein

IJV_bigger_anteriori EJV_posterior
- Normal: pressure on the left side of the heart is always higher than the right
- Deviation: Jugular Vein Distention (JVD)
< occurs when the pressure inside the vena cava increases and appears as a bulge down the right side of a
person’s neck
< sign of increases Central Venous Pressure (CVP)
<< CVP – measurement of the pressure inside the vena cava
Indicates how much blood is flowing back into your heart and how well your heart can move that blood
into your lungs and the rest of your body
- Occurs when CVP increases above a normal/healthy level
- Can be caused by Right-sided heart failure
<often occurs due to left-sided heart failure, when the weakened and/or stiff left ventricle loses power to
efficiently pump blood to the rest of the body. As a result, fluid is forced back through the lungs,
weakening the heart's right side, causing right-sided heart failure
(READ MORE) LINK: https://www.healthline.com/health/jvd

JUGULAR VEIN ASSESSMENT

1. Examine position
- Head of bed elevated at 45 degree angle
- Head turned to right

2. Identify top of venous pulsation in neck (JVP)

- Jugular Venous Pulsations are inward
- Contrast with outward Carotid Artery pulsations

3. Identify the sternal angle (Angle of Louis)

- Located at superior edge or notch of Sternum

4. Measure distance between top of pulsation and Sternum

- Measured in centimetres
PRECORDIUM
- Book – anterior chest area that overlies the heart and great vessels
- The region or the thorax immediately in front of the heart
- Front of the chest wall over the heart

PALPATION
- Patient should be in supine position
- Be on his/her right side to gain easy access to the apex of the precordium
- Pulsation
- Heaves
- Thrills
- Displacement of the apex beat is often associated with ventricular enlargement / cardiomegaly
< abnormal enlargement of the heart

 THRILLS
- Palpable murmurs – vibratory sensations
- Felt from light palpation over the chest wall
- Deviation: loud heart murmur – caused by an incompetent heart valve

 LIFTS
- A slight movement

 HEAVES
- More vigorous movement
- Sustained forceful thrusting of the ventricle during systole
- Palpable lifting sensation under the sternum and anterior chest left sternal border suggest a central
precordial heave associated with RVH
< Right Ventricular Hypertrophy – affecting right ventricle – right side of the heart is enlarged
Caused by either congenital heart conditions or high blood pressure in the lungs / pulmonary hypertension

****MUST TO KNOW****
Left Lateral Decubitus Position (LLDP)
- Patient is lying on his/her left side
- To bring the heart (nearer) to the chest wall to listen/feel for the sounds/vibrations better

Tissue Perfusion
- Flow of blood

**a parasternal heave or lift is a precordial impulse that may be felt (palpated) in patients with cardiac or
respiratory disease
**Precordial impulse are visible or palpable pulsations of the chest wall, which originate on the heart or
the
great vessel

2nd Part Palpations

- Peripheral Pulses – rate, rhythm, quality
- Thrills, Heaves, Lifts
- Apex Beat (PMI) – Point of Maximal Impulse
- Aortic Pulsation
< Deviation: 6th ICS – Posterior Axillary Line
< Runs from the heart, down to the centre of the chest, and into the abdomen

Abdominal Aortic Aneurism (AAA)

< occurs in the part of the abdomen
< Thoracic Aortic Aneurism – occur in the part of the aorta located in the chest area
 Capillary Refill Time (CRT)
- Refers to the amount of time it takes for capillary circulation to return to the fingertips after capillary
circulation is obliterated
- A common indicator of peripheral tissue perfusion
- Normal: less than 3 seconds / position above heart level / pinch/blanch finger nails, in older adults – it
can be longer than 3 seconds, in neonates – pressure is exerted in the sternum for 5 seconds

SIGNIFICANCE
- Prolonged CRT is suggestive of hypoperfusion and/or dehydration
< decreased blood flow through an organ cerebral hypoperfusion (may cause pallor?)

- In adults prolonged CRT is also suggestive to CHF and/or PVD

< CHF Congestive Heart Failure – failure of heart to pump blood with normal efficiency
Heart is unable to provide adequate blood flow to other organs, such as the brain, liver, and kidneys
< PVD Peripheral Vascular Disease – blood circulation disorder that causes the blood vessles outside the
heart to narrow, block, or spasm

< Peripheral Artery Disease (PAD) – common cause ATHEROSCLEROSIS

<< gradual process in which a fatty material builds up inside the arteries
Less common cause: blood clots, injury to the limbs

PERCUSSION
- To estimate heart size

AUSCULTATION
- Blood Pressure
- Carotid Bruit
- Heart Sounds
- Normal: no sound should be heard
- Essential that auscultation of heart sounds be done in a quiet environment as possible
- Avoid a cold stethoscope on an exposed skin

- Auscultate the CAROTID ARTERY for the presence of bruit

< supplies the brain with blood
<< RIGHT COMMON CAROTID ARTERY – originates from brachiocephalic trunk the left from the
aortic arch in the thorax

- Presence of bruit indicates atherosclerosis plaque, build up on the interior lumen

39 | H e a l t h a s s e s s m e n t
< means a clogged/plagued/ presence of clotted blood
<< Thrombus – causes stroke, clogged artery/vein
<< Embolus – the clotted blood travels through the blood vessels
 There would be a presence of a bruit sound when there is/are – fats, blood clot
 PENUMBRA - Occlusion of the MCA with irreversibly affected or dead tissue in black and tissue at
risk or penumbra in red.

CARDIAC OUTPUT
- Amount of blood ejected by the heart in 1 minute
- 5-8 litres per minute
- 20% of the blood goes to the brain

STROKE VOLUME
- Amount of blood ejected by the valves/heart per contraction

FORMULA:
CO = SV x HR/PR
SV – constant: 70cc

CONDUCTION SYSTEM OF THE HEART

Step 1: Pacemaker Impulse Generation

The first step of cardiac conduction is impulse generation. The sinoatrial (SA) node (also referred to as
the pacemaker of the heart) contracts, generating nerve impulses that travel throughout the heart wall.
This causes both atria to contract. The SA node is located in the upper wall of the right atrium. It is
composed of nodal tissue that has characteristics of both muscle and nervous tissue.

Step 2: AV Node Impulse Conduction

The atrioventricular (AV) node lies on the right side of the partition that divides the atria, near the bottom
of the right atrium. When the impulses from the SA node reach the AV node, they are delayed for about a
tenth of a second. This delay allows atria to contract and empty their contents into the ventricles prior to
ventricle contraction.

Step 3: AV Bundle Impulse Conduction

The impulses are then sent down the atrioventricular bundle. This bundle of fibers branches off into two
bundles and the impulses are carried down the center of the heart to the left and right ventricles.

Step 4: Purkinje Fibres Impulse Conduction

At the base of the heart, the atrioventricular bundles start to divide further into Purkinje fibers. When the
impulses reach these fibers they trigger the muscle fibers in the ventricles to contract. The right ventricle
sends blood to the lungs via the pulmonary artery. The left ventricle pumps blood to the aorta.

Cardiac Conduction and the Cardiac Cycle

Cardiac conduction is the driving force behind the cardiac cycle. This cycle is the sequence of events that
occur when the heart beats. During the diastole phase of the cardiac cycle, the atria and ventricles are
relaxed and blood flows into the atria and ventricles. In the systole phase, the ventricles contract sending
blood to the rest of the body.

Cardiac Conduction System Disorders

Disorders of the heart's conduction system can cause problems with the heart's ability to function
effectively. These problems are typically the result of a blockage that diminishes the rate of speed at
which impulses are conducted. Should this blockage occur in one of the two atrioventricular bundle
branches that lead to the ventricles, one ventricle may contract more slowly than the other. Individuals
with bundle branch block typically don't experience any symptoms, but this issue can be detected with an
electrocardiogram (ECG). A more serious condition, known as heart block, involves the impairment or
blockage of electrical signal transmissions between the heart's atria and ventricles. Heart block electrical
disorders range from first to third degree and are accompanied by symptoms ranging from light-
headedness and dizziness to palpitations and irregular heartbeats.

 DIASTOLE s2
- During ventricular diastole, the AV valves are open and the ventricles are relaxed. This causes
higher pressure in the atria than in the ventricles. Therefore, blood rushes through the atria into
the ventricles. This early, rapid, passive filling is called early or protodiastolic filling. This is
followed by a period of slow passive filing. Finally, near the end of ventricular diastole, the atria
contract and complete emptying blood out of the upper chambers by propelling it into the
ventricles. This final active filling phase is called preystole, atrial systole, or sometimes the “atrial
kick”. This action raises left ventricular pressure.

 SYSTOLE s1
 - The filling phases during diastole result in large amount of blood in the ventricles, causing the
pressure in the ventricles to be higher than in the atria. This causes the AV valves (mitral and
tricuspid) to shut. Closure of the AV valves produces the first heart sound (s1), which is the
beginning of systole. This valve closure also prevents blood from flowing backward (a process
known as regurgitation) in the atria during ventricular contraction. At this point in systole, all four
valves are closed and the ventricles contract (isometric contraction). There is now high pressure
inside the ventricles, causing the aortic valve to open on the right side of the heart. Blood is
ejected rapidly through these valves. With ventricular emptying the ventricular pressure falls and
the semilunar valves close. This closure produces the second heart sound (s2), which signals the
end of systole. After closure of the semilunar valves, the ventricles relax. Atrial pressure is now
higher than the ventricular pressure, causing the AV valves to open and diastolic filling to begin
again.

 ABNORMAL HEART SOUND s3

- Normally diastole is silent
- DEVIATION: when ventricular filling creates vibration \
- Resistant to filling during the early rapid filling phase
- Occurs immediately after s2
- Low pitched, quiet sound – difficult to hear
- Cause: Myocardium is RIGID
- When present in adults, s3 is considered pathological indicating decreased ventricular
compliance
- May be produced by either the right or left side of the heart and is often initial of heart failure

ANATOMY OF RESPIRATORY SYSTEM

 LUNGS
- Have a lower and upper compartment
- 3 lobes on the right, 2 lobes in the left
 Diaphragm
- Major muscle for respiration
- Separates the thoracic from the abdominal region
- INHALATION – down
- EXHALATION – up
- Rests on the lobe of the liver
-
 UPPER RESPIRATORY
o Passageway for respiration
o Moistens incoming air
o Receptors for smell
 Nose
 Nasopharynx
 Oropharynx
 Laryngopharynx
 Larynx (voice box)

 NOSTRILS
- Filters the air we breathe and the debris from the air

 NASAL CAVITY
- The nasal cavity is a hollow space within the nose and skull that is lined with hairs and mucus
membrane.
- The function of the nasal cavity is to warm, moisturize, and filter air entering the body before it reaches
the lungs.

 TURBINATE
- These structures are responsible for warming, humidifying, and filtering the air we breathe.
- Normally there are three turbinates including the superior (upper), middle, and inferior (lower)
turbinates.
o Pulmonary Ventilation
o Internal and External Respiration
o Cleanse the airs, warms the air, moisture

 PHARYNX
o Is also called the throat.
o Is the passageway for both air and food and forms a resonating chamber for speech sounds
o It serves as both a connection between the mouth and the digestive tract and as a connection between
the nose and respiratory system.
o It is divided into three portions:
o Nasopharynx – It has 4 openings in its walls: the 2 internal nares and 2 openings that lead to the
auditory or Eustachian tubes.
o Oropharynx – It has only 1 opening called Fauces which connects to the mouth; It is a common
passageway for both food and air.
o Laryngopharynx/Hypopharynx – Connects with the esophagus posteriorly and with the larynx
anteriorly.

 LARYNX
o Is also called the Voice box.
o It connects the pharynx to the trachea.
o Thyroid Cartilage – It is the largest piece in the larynx. It is also known as the Adam’s apple
which is larger in males than in females.
o Epiglottis – Allows food to go down to the oesophagus; It closes the trachea.
o Vestibular Folds/ False Vocal Cords.
o Vocal Folds/ True Vocal Cords.

 EPIGLOTTIS
- SUPRAEPIGLOTTIS – GLOTTIS (VOCAL CHORDS) – SUBGLOTTIS
- Closes the trachea for the food and water to enter the oesophagus
 TRACHEA
o Is also referred to as the windpipe.
o It is the passageway for air.
o Goblet Cells – Produces mucus and the Ciliated Cells provide the same protection against dust
particles.

  ANATOMY OF THE LUNGS

o PLEURAL MEMBRANE – It encloses and protects each lung.
o PARIETAL PLEURA – It is the outer layer that attaches the lung to the wall of the thoracic cavity.
o VISCERAL PLEURA – It is the inner layer which covers the lungs.
o PLEURAL CAVITY – Is the space between the parietal and visceral pleura which contains pleural
cavity.
o PLEURAL CAVITY – It is a pleural fluid that prevents friction between the two membranes and
allows them to slide past each other during breathing, as the lungs and thorax change shape.

THE BRONCHI AND THE BRONCHIAL TREE

BRONCHI
- Passageway of air
- Has goblet cells that produce mucus
- Contains mucus that traps foreign bodies
1. The trachea terminates in the chest by dividing into a:
o Right Primary Bronchus – Goes to the right lung.
o Left Primary Bronchus – Goes to the left lung.

2. On entering the lungs, the primary bronchi divide to form smaller bronchi called the:
o Secondary or Lobar Bronchi – The right lung has 3 lobes and the left lung has 2 lobes.

3. The secondary bronchi continue to branch forming even smaller bronchi called:
o Tertiary or Segmental Bronchi

4. And tertiary bronchi divide into smaller branches called:

o Bronchioles
5. Bronchioles finally branch into smaller tubes called:
o Terminal Bronchioles

 THE ALVEOLI
- The actual exchange of respiratory gases between the lungs and the blood occurs by diffusion across
the ALVEOLI and the walls of the capillary network that surrounds it.

 ALVEOLAR-CAPILLARY MEMBRANE – The membrane through which the respiratory gases

move.
- The blood–air barrier in the gas exchanging region of the lungs. It exists to prevent air bubbles
from forming in the blood, and from blood entering the alveoli.

 SURFACTANT
o Is a fluid that coats the surface of the membrane inside each alveolus.
o It helps reduce surface tension (the force of attraction between water molecules) of the fluid.
o Breaks the bond of water molecules
o Helps prevent alveoli from collapsing or sticking shut as air moves in and out during breathing.
o It is produced by Alveolar Type 2 Cells.
o During inspiration, when alveoli expand, the molecules move apart.
o During expiration when lungs shortened, molecules move together and become concentrated thus
surface tension is reduced.

 RESPIRATION PROCESS
Carbon Dioxide
- Product of metabolism
Metabolism – use of carbohydrates, proteins, glucose, etc. of the body
- RBC carries the OXYGEN and CARBON DIOXIDE and brings it to the lungs

Breathing In (Inhalation)
a. When you breathe in, or inhale, your diaphragm contracts (tightens) and moves downward. This
increases the space in your chest cavity, into which your lungs expand. The intercostal muscles between
your ribs also help enlarge the chest cavity. They contract to pull your rib cage both upward and outward
when you inhale.

b. As your lungs expand, air is sucked in through your nose or mouth. The air travels down your windpipe
and into your lungs. After passing through your bronchial tubes, the air finally reaches and enters the
alveoli (air sacs).

c. Through the very thin walls of the alveoli, oxygen from the air passes to the surrounding capillaries
(blood vessels). A red blood cell protein called hemoglobin (HEE-muh-glow-bin) helps move oxygen
from the air sacs to the blood.

d. At the same time, carbon dioxide moves from the capillaries into the air sacs. The gas has traveled in
the bloodstream from the right side of the heart through the pulmonary artery.

e. Oxygen-rich blood from the lungs is carried through a network of capillaries to the pulmonary vein.
This vein delivers the oxygen-rich blood to the left side of the heart. The left side of the heart pumps the
blood to the rest of the body. There, the oxygen in the blood moves from blood vessels into surrounding
tissues.

Breathing Out (Exhalation)

A. When you breathe out, or exhale, your diaphragm relaxes and moves upward into the chest cavity. The
intercostal muscles between the ribs also relax to reduce the space in the chest cavity.
B. As the space in the chest cavity gets smaller, air rich in carbon dioxide is forced out of your lungs and
windpipe, and then out of your nose or mouth.

ASSESSING THE LUNGS AND THORAX

ASSESS
SHAPE AND CONFIGURATION
- Thorax is oval, its AP Diameter is half its transverse diameter

FACIAL EXPRESSION
- Should be relaxed

LEVEL OF CONSCIOUSNESS
- Should be alert and cooperative
- Brain cells are affected by lack of oxygen

SKIN COLOR AND CONDITION

- Lips and nail beds are free from pallor and cyanosis

QUALITY OF RESPIRATION
- Automatic, effortless, regular and even, produces no noise
- Chest expands symmetrically

INSPECT
COLOR
- Lesions (scars, stretch marks), use of accessory muscle, over prominence of the ribs (may indicate
respiratory problems)

SYMMETRY
- Nares
- Bulges
- Asymmetry

AP DIAMETER and TRANSVERSE DIAMETER

- Anterioposterior Diameter – side
- Should be half the size of the transverse diameter
- The anteroposterior diameter should be less than the transverse diameter. The ratio of
anteroposterior to transverse diameter is from 1:2 to 5:7. AP = transverse diameter, or
“barrel chest.” Ribs are horizontal, chest appears as if held in continuous inspiration.

 AGED
- AP Diameter is more than half the transverse

TAKE THE RESPIRATORY RATE

- NORMAL – 12-20 RR ADULT | 30-60 RR INFANT

SPINAL ALIGNMENT
- Impedes the space of the lung/s
Kyphosis - is an abnormally excessive convex curvature of the spine as it occurs in the thoracic
and sacral regions – KUBA
Lordosis - is defined as an excessive inward curve of the spine, It differs from the spine's normal
curves at the cervical, thoracic, and lumbar regions, which are, to a degree, either kyphotic (near
the neck) or lordotic (closer to the low back) – LIYAD
Scoliosis - is a medical condition in which a person's spine has a sideways curve. The curve is
usually "S"- or "C"-shaped
 PALPATE
- Warm your hands before palpating or percussing
- When palpating and percussing ask the patient to cross arms and bow head, to see the spinal column
better
- No tenderness, masses, bulges, pulsation

 LANDMARKS

 Anterior Axillary Line

 Midclavicular Line
 Midsternal Line

Accessory Muscles
 - Trapezius
- Scalene Muscle

Respiratory Excursion
- Thumbs on the xiphoid process and fingers on the 10th ribs
- Exhale and inhale – distance between the thumbs should be (5 – 10 cm)
- If obese – pinch the skin
Fremitus
- vibratory tremors that can be felt through the chest by palpation
- ask the patient to say “99”, “blue moon”, “tres, tres”
- palpated using the balls of hand or the ulnar side of the hand
PLEURAL EFFUSION
- accumulation of water in the pleural cavity between visceral pleura and parietal pleura

Diaphragmatic Excursion
- movement of the thoracic diaphragm during breathing
- 3 – 5 cm distance
- Checking the diaphragm muscle
- Measuring the contraction of the muscle
- Resonance and dullness

 DEVIATIONS
ATELECTASIS
- Collapsed lungs or closure of a lung resulting in reduced or absent gas exchange.
- It may affect part or all of a lung.
- It is usually unilateral. It is a condition where the alveoli are deflated down to little or no
volume, as distinct from pulmonary consolidation, in which they are filled with liquid.
PNEUMONIA
- Swelling (inflammation) of the tissue in one or both lungs. It's usually caused by a bacterial
infection. At the end of the breathing tubes in your lungs
POSTOPERATIVE GUARDING
- shallow breathing due to pain
Nasal Flaring
- Difficulty and noisy breathing
- Increased RR
- Use of accessory muscle
PECTUS CARINATUM
- Pigeon chest
- breastbone protrudes outward abnormally
PECTUS EXCAVATUM
- funnel chest
- sternum and rib cage are shaped abnormally
- these can be familial
- most common in boys than girls
- interferes with the functions of the lungs
Barrel Chest
- is normal with infants
- deviations in adult
- MAIN CAUSE: SMOKING
- Too much accumulation of air
- COPD
- Pneumothorax – not with barrel chest
- EMPHYSEMA – Alveoli is destroyed
Accessory Muscles
- Trapezius
- Scalene
 - Sternocleidomastoid
- Note any tenderness, superficial lumps or masses
- Note skin mobility and turgor, temperature and moisture

PERCUSSION
- intercostal spaces
- liver located at the 5th rib to 10th rib
- intercostal margin
o Resonance – presence of air
o Hyperesonance – too
o Dull – organ (Liver – right, Heart – middle)
o Tympanitic - stomach
o Flat – bones

Common Characteristics of New Born

- Nose breather
- 30-53 or 40-60 breathes per minute
- Irregular breathing
Acceptable Range of Respiratory Rates for Age
Age Rate (Breaths per Minute)
Newborn 30-40
Infant (6 months) 20-40
Toddler (2 years) 25-32
Child 20-30
Adolescent 16-19
Adult 12-20

- THORAX – rounded, diameter from the front is equal, barrel chest

- AP Diameter is equal to the transverse diameter
- 30 – 36 cm is the newborn chest, 2 cm smaller that the head circumference
- Ribs and xiphoid process are prominent
- Chest wall is thin
- 85% water
- 6 years old, AP Diameter has decreased in proportion to the Transverse Diameter 1:2 ratio
Tend to breathe normally as with the adult

BREATH SOUNDS
- BRONCHIAL
- BRONCHOVESICULAR
- VESICULAR

AUSCULTATION

Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds,
and abnormal breath sounds.

Absent or decreased sounds can mean:

 Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)
 Increased thickness of the chest wall
 Over-inflation of a part of the lungs (emphysema can cause this)
 Reduced airflow to part of the lungs

There are several types of abnormal breath sounds. The 4 most common are:
 Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person
breathes in (inhales). They are believed to occur when air opens closed air spaces. Rales can be
further described as moist, dry, fine, and coarse.
 Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air flow becomes rough
through the large airways.
 Stridor. Wheeze-like sound heard when a person breathes. Usually it is due to a blockage of airflow
in the windpipe (trachea) or in the back of the throat.
 Wheezing. High-pitched sounds produced by narrowed airways. Wheezing and other abnormal
sounds can sometimes be heard without a stethoscope.

ALVEOLAR HYPOXIA
- Less oxygen in lungs

Smooth Muscles
- Surround the airways in wheezing

 AGED
- Prone to kyphosis – because of osteoporosis and changes in cartilage
- Respiratory muscle strength declines after age 50 and continues to decrease into the
70s
- Small airways, lose their cartilaginous support and elastic recoil; as a result, they tend to
close, particularly in basal or dependent portions of the lungs
- CILIA in the airways decreases in number and are less effective in removing mucus
- Greater risk for pulmonary infections

ASSESSING THE NOSE AND MOUTH

NOSE
- Centre of the face
- The colour should be consistent with the face
- Has plenty of arteries
- Nasal Septum – should be in the midline
BREATHING
- Infants are nose breathers
- Audible effort to breathe
- Inability to such is an indicator of obstruction

NASAL CAVITY
- Moist
- Dark pink

Turbinate
- Pulmonary ventilation
- Cleanse the air, warms the air, moisture
- Inferior and middle turbinate should be the same colour in the surrounding area

Sinuses
- Produce mucus to moisturize the inside of the nose
- Protects from pollutants, microorganisms
- Allow for voice resonance
- Adds moisture to any air that is inhaled

Mucous
- Traps foreign bodies
- Humidifies the air we breathe

 DEVIATIONS
Nasal Flaring
- indicates difficulty in breathing, commonly seen in children and infants (normal)

Epistaxis
- nose bleed

Dyspnoea
- difficulty in breathing

Dysphagia
- difficulty in swallowing

MOUTH

Tongue
- light pink with light coating, smooth and moist
- rough surface due to presence of papillae
- moves the food
- identify the object in the mouth
- should protrude midline, if not there can be weakness or paralysis
NORMAL – light pink with light coating, no cracks, ulcers, or teeth marks
-surface: rough (presence of papillae), smooth and moist, surrounded by anterior and lateral teeth
- ABNORMAL – pallor, cyanosis, redness
VENTRAL TONGUE – should glisten – and a network of small vessel

Frenulum
- Is midline,
- Should allow tongue to reach the roof of the mouth

Uvula
 - Midline, in between the tonsils
- Cone shaped
- Large amounts of thin saliva produced by the uvula serves to keep the throat well lubricated
- Functions in speech as well
- Should lean towards the area with deviation

Soft Palate
- Soft palate and uvula Move together to close off the nasopharynx and prevent food from
entering the nasal cavity
- NORMAL - Smooth, mobile

Pharynx
- Fluid and food passageway

Epiglottis
- A flap in the throat that keeps food from entering the windpipe and the lungs

Buccal Mucosa
- NORMAL – Pink and moist
- inside lining of the cheeks and floor of the mouth and is part of the lining mucosa

 DEVIATIONS
Exudative Tonsillitis
- accumulation of pus between the tonsil and its capsule

Ankyloglossia
- Tongue-tie
- congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an
unusually short, thick lingual frenulum
- may interfere with breast feeding in infants

Oral Leukoplakia
- HIV positive patient
- Fungus

Pernicious Anaemia
- a condition in which the body can't make enough healthy red blood cells because it doesn't have
enough vitamin B12
- caused by autoimmune destruction of gastric parietal cells
- The appearance of the tongue in vitamin B12 deficiency is described as "beefy" or "fiery red
and sore"
- Macrocytic – vitamin B-12 and folate deficiencies can be treated and cured with diet and
supplements
- Microcytic –

White Coating
- Dehydration or poor hygiene, bad oral care
- Common with patients in the ICU

Yellowing of tongue
- Liver or gallbladder problems
- Digestive system disorder

Vagus Paralysis
- Failure of the soft palate to rise symmetrically
- Uvula will deviate towards the affected side
PARESIS
- Weakness

PLEGIA
- Paralysis of the nerve or muscle

ASSESSMENT
- Elevation of the soft palate
- When you say ‘ah’ the movement of the soft palate upwards

PALPATION
Gums, Teeth, Tongue
- Should feel firm, no soft areas, no tenderness

LIPS

Mentolabial Suculus
- Is a permanent crease between the inner lip and the chin, which plays a significant role in
movement of the lower lip and in facial

NORMAL – vertically and horizontally symmetrical, both are at rest and with movement

Vermillion Border
- Should be well defined without any evidence of cracking, swelling, and lesions

INSPECTION
- Lips should be – PINK to RED
- Vertically and horizontally symmetrical

 DEVIATIONS
Chapped Lips
- Bad oral hygiene
- Dehydration
Pale Lips
- Anemia
- Dehydration
Dry, Craked Lips
- Dehydration
- Overexposure to cold temperature
Cold Sores
- STD
- Herpes simplex
- Syphilis
Cheilosis | Cheilitis
- Scaling, painful fissures
- painful inflammation and cracking of the corners of the mouth
- sometimes occurs on only one side of the mouth, but usually involves both sides
- Vitamin B12 deficiency
Aphthous Stomatitis
- benign and non-contagious mouth ulcers
Oral Cancer
- which includes cancers of the lips, tongue, cheeks, floor of the mouth, hard and soft palate,
sinuses, and pharynx (throat), can be life threatening if not diagnosed and treated early

White Patches – Leukoplakia

Red/White Patches – Erythroleukoplakia

Red Patches – Erthryplakia

Addison’s Disease
- Hormonal Imbalance
Halitosis
- Bad breath
Xerostomia
- dry mouth resulting from reduced or absent saliva flow
- decrease in saliva production occurs with age, the gums may get thinner and begin to recede

TEETH
- good oral care will increase, production of saliva, contains antibodies, kills the bacteria in the
mouth and cleanses the mouth

Front teeth – pointed and sharp, for biting and tearing

Back Teeth – flat, for crushing and grinding

Children - Infant
Deciduous Teeth
- begin to erupt by 6 months
- by 2 years all 20 teeth should be present
- begins to be lost around 6 years of age
- by ages 14-15 they are replaced with 32 permanent teeth (same as with the adults)

TETRACYCLINE and DOXYCYLINE

- should not be administered with children below 8 years old
- cause tooth discoloration in the infant by affecting enamel development

 AGED
- Decrease in saliva production occurs with age, causes (XEROSTOMIA)
Tooth Enamel
- tends to weak away with aging, making the teeth vulnerable to damage and decay

 DEVIATIONS
Cavities
- Poor oral hygiene
- Bottled water does not have fluoride added so the individual may be missing

GUMS
- NORMAL – healthy gums are pink in colour, firm, margins of the gums should be tight and
well defined
- NOT NORAML – red, swollen and have tendency to bleed or even have pus
- most fragile part of the body

Gingival Hyperplasia
- Swollen gums, oedematous
- Sodium Dilantin (medication given to patients with seizure) – may cause this deviation – side
effect

Gingivitis
- Red and puffy gums that bleeds easily
- Common type of periodontal disease
- Often resolves with oral hygiene

Malocclusion
- Affect the chewing efficiency as well as the choice of foods
- This has potential to result in malnutrition and gastric alterations

 OLDER ADULTS
- Nasal hair becomes coarser, stiffer and more visible
Air filtration may not be as effective
- Reduction in the sense of smell, reduction of olfactory nerve fibres
- Loss of sense of taste due to loss of papillae
- Reduction of saliva
- Gradual loss of teeth, drift causing malocclusion, affects the chewing efficiency and choice of foods

ASSESSING THE PERIPHERAL VASCULAR SYSTEM

HEMOGLOBIN in RBC brings oxygen
 Ischemia
- an inadequate blood supply to an organ or part of the body, especially the heart muscles
 Albumin
- Responsible for maintaining the osmotic pressure
- helps keep fluid in your bloodstream so it doesn't leak into other tissues
- also carries various substances throughout your body, including hormones, vitamins, and
enzymes
- MADE BY THE LIVER
 Diffusion
- Movement of solute, or particles from a greater to lower concentrated solution
 Osmosis
- Movement of water molecules from lesser to greater concentrated solution
 Oedema
- There is inflammation
- Increased capillary permeability
 Capillary membrane
 - are very thin blood vessels
- They bring nutrients and oxygen to tissues and remove waste products
- They have thin walls/single layer – so that exchange of substances will be easy (oxygen,
electrolytes, nutrients)

 5 CARDINALS OF MANIFESTATION
1. REDNESS
2. PAIN
3. WARM TO TOUCH
4. LOSS OF FUNCTION
5. OEDEMA/SWELLING

>> If there is a tissue injury caused by an inflammation (cut, fall, trauma, incision, injury) – SNS will be
stimulated
– it will stimulate adrenal glands in the adrenal medulla to release CATECOLOMINES – EPINEPHRINE
(increases
Cardiac Rate – more than 100) and NOREPINEPHRINE (increase Blood Pressure 120/80 – arteries
constrict)
CHEMICAL MEDIATORS will be released due to tissue injury;

CHEMICAL MEDIATORS
- Will be released if there is tissue injury

Increases capillary permeability

- Pores in the capillary membrane becomes bigger;
- Intravascular space decreases, Albumin goes out, there will be swelling/oedema because the
water comes out to the interstitial space/third space from the intravascular space.

 Histamine – (more) When we come into contact with an allergen, such as pollen or animal
dander, histamine is released by the body to the site of contact | vasodilator
- Brings more blood to the injured site which causes the skin to be warm to touch | causes
redness/rubor
- Injured site such as; surgery, appendectomy, incision
 Bradykinin - an inflammatory mediator | a peptide that causes blood vessels to dilate (enlarge),
and therefore causes blood pressure to fall
 Prostaglandin – one of the more potent mediators that cause increased blood flow, chemotaxis
(chemical signals that summon white blood cells), and subsequent dysfunction of tissues and
organs
 Serotonin - increases vascular permeability, dilates capillaries, and causes contraction of
nonvascular smooth muscle

Difference between arteries and veins

Artery Vein
Carries blood away from heart Carries blood toward heart
Blood under high pressure Blood under low pressure
Thick walls Thin walls
Pulse flow Smooth flow
Narrow lumen Large lumen
No valves Valves present
Blood rich in oxygen (except pulmonary artery) Blood poor in oxygen (except pulmonary veins)
 {VEINS: clotted blood – gives redness in colour – warm to touch}
{ARTERY: lipids – gives pallor in colour – cold to touch}

WALLS OF THE BLOOD VESSELS

1. Tunica Adventitia
2. Tunica Media
3. Tunica Intima

ARTERY
- Blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries
- Arterial network is a high-pressure system
- Blood is propelled under pressure from the left ventricle of the heart
- There is high pressure, arterial wall must be thick and strong; the arterial walls also contain elastic fibres
so that they can stretch
COLOUR CHANGE TEST
- Arterial occlusion
- Elevate the leg 12 inches above the client’s <3

- NORMAL: it will return to its normal pinkish colour; 15 seconds – veins | 10 seconds or less – artery
**IF occlusion has been shown in developing, there will likely be;
- muscle atrophy
- skin atrophy
- loss of hair growth

BUERGER TEST
- Arterial insufficiency
 - This test can be carried out to further demonstrate poor lower limb perfusion.
1. Ensure the patient is positioned supine
2. Standing at the bottom of the bed, raise both of the patient’s feet to 45º for 2-3 mins:
- Observe for pallor – emptying of the superficial veins
- If a limb develops pallor, note at what angle this occurs e.g. 20º (known as Buerger’s
angle)
- A healthy leg’s toes should remain pink, even at 90º
- A Buerger’s angle of less than 20º indicates severe limb ischaemia
3. Once the time limit has been reached, ask patient to place their legs over the side of the bed:
- Observe for a reactive hyperaemia – this is where the leg first returns to its normal pink colour,
then becomes red in colour – this is due to arteriolar dilatation (an attempt to remove built up
metabolic waste)

VEINS
- Blood vessels that carry deoxygenated, nutrient-depleted, waste laden blood from the tissues
back to the heart
- The vein contain nearly 70% of the body’s volume
Mechanisms
- 1st - Contains VALVES – permit blood to pass through them on the way to the heart and
prevent blood from returning through them in the opposite direction.
- 2nd – muscular contraction
- 3rd – creation of a pressure gradient through the act of breathing – inspiration decreases
intrathoracic pressure while increasing abdominal pressure, thus producing pressure gradient

 Deep Veins
 Iliac vein
 Femoral vein
 Popliteal vein
 Tibial vein
 Superficial Veins
 Greater Saphenous Vein
 Lesser Saphenous Vein

INSPECTION
SKIN COLOUR
- There should be no localized colour changes
SKIN
- Should be mobile and elastic and able to be pinched
- Extremities should be bilaterally equal in size
- Veins should not be visible on the surface or through the skin
- If any veins are visible, elevate the lower extremities; if veins and valves are not compromised?
LESIONS
- Petechiae – smaller, tiny red spots | dengue
- Ecchymosis – medical term for bruises
- Purpura – bigger, purplish colour | snake bites, venous insufficiency
HAIR DISTRIBUTION
- Should be equally distributed bilaterally
 DEVIATIONS
DEEP VEIN THROMBOSIS
- a blood clot that forms in a vein deep in the body
- Most deep vein clots occur in the lower leg or thigh
- If the vein swells, the condition is called thrombophlebitis
- A deep vein thrombosis can break loose (called EMBOLUS) and cause a serious problem in the lung,
called a pulmonary embolism (patient can die after 1 hour)
 Valves are not closing completely or incompetent
 Veins will be distended
 EARLY SIGNS: accumulation of blood – causes-redness
 UNILATERAL SWELLING

When to think of venous thrombosis

Direct sign of thrombus Dense clot sign

Cord sign
Empty delta
Loss of normal flow void on MR

Venous infarction Bilateral – parasagittal bithalamic

Temporal lobe infarction
Cortical edema or hemorrhage

Clinically Seizures
Headache
Loss of consiousness

VARICOSITY
- Valves incompetent – allowing blood to backflow distending the vein – increasing the pressure –pushing
the blood outside the interstitial space/third space – haemoglobin will be released and become
haemosiderin – which causes discoloration

 TESTS
Brodie – Trendelenburg Test
- Test measures the time required to refill the veins in the dorsum of the foot. The LE is elevated to
allow venous blood to empty. A tourniquet on the thigh prevents backflow. After 1 minute, the
individuals stand. If distention occurs within 5 seconds after the tourniquet is released,
incompetence of superficial veins is suspected.

TRENDELENBURG TEST
- To perform this test, elevate the patient’s leg until all of the congested superficial veins collapse (to
drain blood | elevate 90 degrees) | Elevate the leg, put tourniquet between femoral and popliteal vein (to
temporarily stop blood flow)
- Apply direct pressure to occlude the superficial veins below the point of suspected reflux from the deep
system into the superficial varicosity.
- With the occlusion still in place, have the patient stand. If the distal varicosity remains empty or fills
slowly, quickly remove the occluding hand or tourniquet
- *** Tourniquet is applied to prevent 1. Backflow of blood, 2. To temporarily stop the blood flow

NORMAL: slow filling of blood due to competent valves

ABNORMAL: incompetent valves allows rapid venous filling causing rubor
 Deep Vein – if there is engorgement in the vein before releasing the tourniquet within 5
seconds
 Superficial Vein – rapid filling of blood after removing the tourniquet within 30 seconds
causing rubor

Modified Allen’s Test

- Ask the patient to clench his fist tightly and compress the radial and ulnar arteries at the wrist
with the thumbs. Wait for 10 sec and ask the patient to open hand, Pallor can be seen in the palm.
Now release pressure on the radial artery and watch for blood flow. Repeat the test for ulnar
artery. If there is occlusion of either artery, colour changes occur in the fingers slowly.

CAPILLARY REFILL TEST

 - 2 seconds is normal – prolonged in PVD

ALLEN TEST
Assesses for the;
- COMPETENCY
- PATENCY
- ADEQUATE collateral circulation of blood supply

CHARACTERISTICS
Arterial Insufficiency
- There is a deceased blood flow toward the tissues, producing ischemia
- Pulses are usually diminished or absent
- Sharp, stabbing pain occurs because of the ischemia, particularly with activity
- There is interference with nutrients and 0 2 arriving to the tissues, leading to ischemic ulcers and
changes in the skin.

Venous Insufficiency
- There is deceased return of blood from the tissues to the heart
- Leads to venous congestion and stasis of blood
- Pulses are present
- Lead to oedema, skin changes and stasis ulcers

PALPATION OF PERIPHERAL PULSES

The following arteries are to be examined:
- Dorsalis pedis artery
- Posterior tibial artery
- Popliteal artery
- Femoral artery
- Radial
- Brachial artery
- Subclavian artery
- Common carotid artery
- Superficial temporal artery
- Aortic artery
Grade Quality
0 No Pulse
1+ Weak Pulse, Difficult to palpate
2+ Palpable but diminished
3+ Normal, Easy to palpate
4+ Bounding, Very Strong

 PALPATION
1. RATE
2. RYTHYM
3. QUALITY

RADIAL & DORSALIS PEDIS ARTERY

- Two most distal pulses
- Palpate using the 1st and 2nd fingers or finger pads

 AMPLITUDE
- Quality pulse is the measurement of the force of left ventricular contraction that produces the pulse
wave
- Contraction of the heart is slow
- Integrity of the arterial wall will also have effect on the quality of the pulse wave
 The pulse quality is measured on a +3 scale
+3 = full/bounding pulse
+2 = expected
+1 = diminished/barely
0 = absent pulse

ASSESSING THE BRAIN AND NERVES

INFANTS
- The nervous system begins to form within the first 3 weeks of fetal development
- At birth, the nervous system is quite immature
- There is still no BBB (astrocyte) *develops 5-6 years
- Responses by the newborn are primarily primitive reflexes that are present – should subside
while growing up, if not, it indicates an abnormality

 Reflexes
- The disappearance of these reflexes is a measurement of nervous system maturation
- Persistence of these reflexes – indication of CNS dysfunction
- Observe the child’s gait – the child just beginning to walk will have a wide-based gait
- By 4 years of age the child should be able to balance on one foot for about 5 seconds
and by age 5 should be able to balance for 8-10 seconds

 Tonic Neck Reflex

- Appears at birth
- Disappear – 5-7 mos.
- Fencing Reflex

 Babinski Reflex
- Normal up to 2 years

 Rooting Reflex
- Disappear: 4 mos.
 Landau Reflex
- Horizontal prone position
- Appears 6 mos. and hypotonicity (low tone) indicates motor system deficit
- Appears 3 mos. after birth – last up to 12-24 mos. of age
 Moro Reflex
- Consists of rapid abduction and extension of arms with the opening of hands
- The arms then come together as in embrace
- Any sudden movement of the neck initiates the reflex
- Elicit by pulling the baby half-way to a sitting position
- Disappear: 4-6 mos.
 Grasp Reflex | Palmar Grasp Reflex
- Appear – at birth
- Disappear – 8-10 mos.
 Sucking Reflex
- Probably one of the most important reflex – paired with rooting reflex – secretes for a
food source

INSPECTION
1. LEVEL OF CONSCIOUSNESS (LOC)
- Awareness is determined by the patient’s orientation to a person, place and time
PERSON – who the patient is and recognition of other individuals
PLACE – where located at this time
TIME – day, month, and year
- Early manifestation, agitation, drowsy, confusion – probably caused by a lung problem – lack of blood
supply (oxygenated) to the brain
- ASSESSING:
Observe the patient’s ability to follow commands
Ask the patient to squeeze the examiner’s two fingers

NORMAL FINDINGS
- Awake, alert, and responds appropriately to verbal and environmental stimuli
- Should be able to follow a simple command and grasp the examiner’s finger
- When conducting a neurological exam, cranial nerve assessment is the first component of the exam
- Testing CN III (Oculomotor) is the MOST important – because it is an indicator of brain function
- The remaining 11 CNs are not generally tested unless there is a specific reason to do so
Feature Response Score
Open spontaneously 4
Open to verbal command 3
Best eye response
Open to pain 2
No eye opening 1
Oriented 5
Confused 4
Best verbal response Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Obeys commands 6
Localizing pain 5
Withdrawal from pain 4
Best motor response
Flexion to pain 3
Extension to pain 2
No motor response 1

GLASGOW COMA SCALE (GCS)

- Assesses the LOC

CRANIAL NERVES
- Brainstem – consists of most the cranial nerves
- The 12 pairs of CNS are part of the peripheral nervous system
- Can be sensory and/or motor (function)
  CLASSIFICATIONS
 SENSORY CRANIAL NERVES – contain only afferent (sensory) fibres
CN 1 OLFACTORY
CN 2 OPTIC
CN 8 VESTIBULOCOCHLEAR
 MOTOR CRANIAL NERVES – contain only efferent (motor) fibres
CN 3 OCULOMOTOR
CN 4 TROCHLEAR
CN 6 ABDUCENS
CN 11 ACCESSORY
CN 12 HYPOGLOSSAL
 MIXED CRANIAL NERVES – contain both sensory and motor fibres
CN 5 TRIGEMINAL
CN 7 FACIAL
CN 9 GLOSSOPHARYNGEAL
CN 10 VAGUS

LINK: https://teachmeanatomy.info/head/cranialnerves/summary/?
fbclid=IwAR3PzR4ixfyNnJmkvH7STgBpkG8gx0tJpRwjbKpwQTc-HjuQLzmbAguWgp8
LINK: https://www.kenhub.com/en/library/anatomy/the-12-cranial-nerves

CRANIAL NERVE 1 OLFACTORY NERVE

- SENSORY/AFFERENT - innervates the olfactory mucosa within the nasal cavity
- ORIGIN: CEREBRUM
- FUNCTION: Responsible for the sense of smell
Smell is an important component of the appreciation of tasks
- Loss of sense of smell – as a result of
TRAUMA INFECTION AGING
- Do not test routinely
Test with:
REPORT OF LOSS OF SMELL
HEAD TRAUMA
SUSPECTED INTRACRANIAL PRESSURE (ICP)
First: assess patency by occluding one nostril at a time and asking the person to
sniff – with the person’s eyes closed
Use familiar smells, conveniently obtainable and non-noxious smells; coffee,
toothpaste orange, peppermint.
*Alcohol wipes smell are familiar and are easy to find but are irritating
- Normally, a person can identify an odour on each side of the nose
- Sense of smell normally decreased bilaterally with aging
- Any asymmetry is an indication of an abnormality

CRANIAL NERVE 2 OPTIC NERVE

- SENSORY/AFFERENT - innervates the retina of the eye and brings visual information to the
brain
- ORIGIN: CEREBRUM
- Test Visual Acuity: Snellen’s Chart for distant vision, newspaper/magazine for near vision
- Test Visual Fields: Confrontation
CRANIAL NERVE 3 OCULOMOTOR
- MOTOR/EFFERENT - both a somatic and visceral efferent motor nerve
- ORIGIN: MIDBRAIN-PONTINE JUNCTION
- FUNCTION: Helps in moving eyeballs in different direction
TEST: Six Cardinal Movements of the Eye
TEST: Pupillary Light Reflex
Shine a direct light or the pupil – Pupillary constriction
 **Symptoms of Nerve Damage
Double Vision – diplopia, the affected eye turns outward when the unaffected eye looks straight
ahead
Ptosis – eyelid droop
Pupil may be dilated
Affected eye can move only to the middle when looking inward and cannot look upward and
downward
CRANIAL NERVE 4 TROCHLEAR NERVE
- MOTOR/EFFERENT
- ORIGIN: posterior side of the MIDBRAIN
It has the longest intracranial length of all the cranial nerves.
- Superior oblique muscle – eye
- TEST: Six Cardinal Movements of the Eye

CRANIAL NERVE 5 TRIGEMINAL NERVE

- SENSORY & MOTOR / AFFERENT & EFFERENT
- ORIGIN: PONS
3 Branches/Divisions
OPTHALMIC (CN V1) - leaves through the superior orbital fissure
MAXILLARY (CN V2) - through the foramen rotundum
MANDIBULAR (CN V3) - exits via the foramen ovale
- Temporal and masseter muscles are examined by palpating the muscles and attempts to resist
the jaw by applying pressure
- Testing pain, thermal, and other sensations in the area supplied by the trigeminal nerve
TEST: The Corneal Reflex test – wisp of cotton (Normal: smooth, transparent, involuntary
blinking)
CRANIAL NERVE 6 ABDUCENS
- MOTOR/EFFERENT
- ORIGIN: PONTINE-MEDULLA JUNCTION - originates from the brainstem and exits the
skull via the superior orbital fissure
- FUNCTION: lateral eye movements (lateral rectus muscle) – abducts the eye; thus the name
abducens
Test for Convergence (far and near object)
- DEVIATION: Strabismus
CRANIAL NERVE 7 FACIAL NERVE
- SENSORY & MOTOR / AFFERENT & EFFERENT
- ORIGIN: PONTINE-MEDULLA JUNCTION
- FUNCTION: Once the facial nerve reaches the face it enables many functions,
such as facial expression, secretion of glands and taste sensation.
- Motor – note mobility and facial symmetry as the person responds to these
requests;
FROWNING
SMILING
- Sensory – test only when you suspect facial nerve injury
When indicated, test sense of taste – salt, lemon,
- TEST: Inspect for NASOLABIAL FOLDS AND PALPEBRAL FISSURES
- DEVIATION: Inability to close eyelid, Drooping of mouth
CRANIAL NERVE 8 VESTIBULOCOCHLEAR
- SENSORY/AFFERENT - comprised of two parts: the vestibular nerve and the
cochlear nerve.
- ORIGIN: PONTINE-MEDULLA JUNCTION
- FUNCTION: The cochlear component enables hearing, while the vestibular part
mediates balance and motion.
- TESTS: Whisper test, Rinne Test, Balance and Hearing
CRANIAL NERVE 9 GLOSSOPHARYNGEAL
- SENSORY & MOTOR / AFFERENT & EFFERENT
 - MEDULLA OBLONGATA - It originates from the brainstem and leaves the skull through the
jugular foramen.
- FUNCTION: It enables swallowing, salivation, and taste sensation, as well as visceral and
general sensation in the oral cavity.
- TEST: Perform – Gag Reflex Test (observe: soft palate & uvula)
- DEVIATION: Nerve damage – dysphagia

CRANIAL NERVE 10 VAGUS

- SENSORY & MOTOR / AFFERENT & EFFERENT
- ORIGIN: MEDULLA OBLONGATA - It originates from multiple nuclei in the brainstem, and
exits the skull through the jugular foramen.
It is the longest cranial nerve and the only one to leave the head and neck region.
- The vagus nerve travels into the thoracic and abdominal cavities, providing parasympathetic
supply to visceral organs.
- FUNCTION: The vagus nerve controls a large number of functions, including gland secretion,
peristalsis, phonation, taste, visceral and general sensation of the head, thorax and abdomen.

CRANIAL NERVE 11 ACCESSORY

- MOTOR/EFFERENT
- ORIGIN: MEDULLA OBLONGATA - originating from the brainstem and spinal cord
- FUNCTION: Acting to enable phonation and movements of the head and shoulders.

CRANIAL NERVE 12 HYPOGLOSSAL

- MOTOR/EFFERENT
- ORIGIN: MEDULLA OBLONGATA Anterior to the olive
- FUNCTION: Its function is to enable tongue movements.
- extremely important for smooth daily functioning of every person, as it plays a significant role
in important mouth functions such as speech and swallowing

 PROPRIOCEPTION
- Unconscious perception of movement and spatial orientation arising from stimuli within the
body
- In humans, these stimuli are detected by nerves within the body itself, as well as the
semicircular canals

 TESTS
CEREBELLAR EXAMINATION
- Assess motor activity by the patient’s ability for muscle movement and coordination
- Should run the test in smooth, rapid, accurate, straight line and coordinated movement
 FINGER-TO-NOSE TEST
 HANDFLIP TEST
 THUMB-TO-FINGER TEST
 HEEL-TO-SHIN TEST
ALTERED MOTOR RESPONSE
- Uncoordinated actions, misses touching the nose/body part several times

 DEVIATIONS
 DYSDIADOCHOKINESIS
- Inability to perform rapidly alternation movements (may be an indication of multiple sclerosis)

 DYSMETRIA
- Inability to perform point to point movements by over-or-under projection of the fingers
- Lose of motor strength or proprioception
- May indicate – Cerebellar lesions
SENSORY
SUPERFICIAL POINT
- With the patient’s eyes closed, touch the patient’s skin lightly with sharp and dull points of a; bent paper
clip, pen, broken tongue blade
- Before testing, it is helpful to touch the patient on both sides

LIGHT TOUCH
- Use; cotton ball, cotton tip swab
- Wait 2 seconds between each touch
- Instruct the patient to indicate where the sensation is felt

BALANCE AND EQUILIBRIUM (CN 8 AND CEREBELLUM)

ROMBERG TEST
- Patient should stand with his/her feet together and arms at the side
- Instruct the patient to close eyes (approx. 30 secs.)
- Observe the patient’s ability to maintain upright position
- Patient may demonstrate slight swaying back and forth, without the danger of falling
- Expected: patient is able to maintain balance and equilibrium within 30
seconds
POSITIVE ROMBERG indicates the possibility of;
CEREBELLAR ATAXIA
- Cerebellum becomes inflamed or damaged
- Cerebellum: responsible for controlling gait and muscle coordination
- Ataxia: lack of fine motor or voluntary movements
VESTIBULAR DYSFUNCTION
SENSORY LOSS
CEREBELLAR LESIONS
- In some instances, the patient will lose balance with the eyes closed but be able to regain
balance when the eyes are opened (cerebellar lesions)

TANDEM GAIT
- A gait (method of walking or running) where the toes of the back foot touch the heel of the front
foot each step
- Ask the person to walk a straight line in a heel-to-toe fashion
- This decreases the base of support and will accentuate any problem with coordination
- NORMALLY the person can walk straight and stay balanced
- Methods – STATIC BALANCE

 REFLEXES
- Subconscious actions and reactions that are vital defense mechanisms of the nervous system.
- Initiates immediate response to alert and protect the patient

Touch
- Sensory receptors in the skin receive the touch stimulus
- Mechanoreceptors in human skin are in the form of naked dendrites
- Prostaglandins intensify the pain by sensitizing the receptors

The Sense of Touch

C Slight pressure is detected by the Touch Receptor
U Pain Receptors detect the slightest pain as they lie very close to the
surface of the skin.
O Heat Receptors are sensitive to heat. The cold is detected by Cold
Receptors.
I Pressure Receptors are only sensitive to heavy pressure as they lie deep
within the skin.
REFLEX ARC
- Neural pathway that controls the action reflex
- A reflex, or reflex action, is an involuntary and nearly instantaneous movement in response to a
stimulus.
- A reflex is made possible by neural pathways called reflex arcs which can act on an impulse before that
impulse reaches the brain.

DEEP TENDON REFLEXES

- Monosynaptic spinal segmental reflexes
- Easily assessed by tapping the tendon
 BICEP REFLEX
- Antecubital fossa
 TRICEPS REFLEX
- Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen)
as it extends across the elbow to the body of the muscle, located on the back of the upper arm.
 BRACHIORADIALIS REFLEX
- Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen)
as it extends across the elbow to the body of the muscle, located on the back of the upper arm.
 PATELLAR REFLEX
- LOCATION: Just below the kneecap
- Striking – will/should cause
- contraction of the quadriceps muscle – extension of the lower leg
 ACHILLES REFLEX
- LOCATION: Directly behind the ankle
- Striking Achilles tendon causes contraction of gastrocnemius muscle – resulting in plantar
flexion of the foot
- DEVIATION: lack of reflex – indicates – neuropathy (lower motor neuron)

SUPERFICIAL TENDON REFLEXES

- Any withdrawal reflex elicited by noxious or tactile stimulation of the skin, cornea, or mucous
membrane, including the corneal, pharyngeal, and cremasteric reflexes.
 PLANTAR REFLEX
- plantar flexion of the foot when the ankle is grasped firmly and the lateral border of the sole is
stroked or scratched from the heel toward the toes
- The reflex can take one of two forms.
 In healthy adults, the plantar reflex causes a downward response of the hallux (flexion).
- DEVIATION: dorsiflexion of the great toe with or without forming BABINSKI-POSITIVE
(this is normal to children under 2y/o)
 ABDOMINAL REFLEX
- A superficial neurological reflex stimulated by stroking of the abdomen around the umbilicus.
- It can be helpful in determining the level of a CNS lesion.
 CREMASTERIC REFLEX
- A superficial reflex found in human males that is elicited when the inner part of the thigh is
stroked.
- Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle
toward the inguinal canal.
- DEVIATION: TESTICULAR TORSION - It happens when the spermatic cord, which provides
blood flow to the testicle, rotates and becomes twisted.
The twisting cuts off the testicle's blood supply and causes sudden pain and swelling.

OLDER ADULTS
- Have less blood supply (20% - ages 60^)
- Gradual atrophy of the brain occurs due to the loss of neurons in the brain and spinal cord
- By 80 years of age, brain has lost 15% of its weight
- Speed of nerve conduction decreases – causing the reaction time of the elderly to decrease
- Decreased in the speed of learning and processing information
- There is an increased delay at the synapses, resulting in a slower traveling time for an impulse
This may result in a diminished sense of smell and taste as well as decreased sensation of pain
and touch
- These,, therefore are the probable reason why older adults/aged are prone to Alzheimer’s
- There is an overall loss of muscle bulk that reduces muscle strength

GATE CONTROL THEORY

- Open Gate -> T-cell -> brings the stimulus to the brain -> the brain (hypothalamus) will interpret it to
pain

SG – Substantia Gelatinosa
- a collection of cells in the gray area (dorsal horns) of the spinal cord
- found at all levels of the cord
 - it receives direct input from the dorsal (sensory) nerve roots, especially those fibers from pain
and thermoreceptors

WHAT OPENS THE GATE

- Lack of sleep
- Stressful lifestyle
- Fear and anxiety about pain
- Depression
- Physical activity / tired
- Mentally focusing on pain
- Hypoglycemia (Normal: 80/100 mg/dl of blood)
- Serotonin and Endorphin deficit
- Consumption of nutrients that increase inflammation (such as fried and oily foods)

WHAT CLOSES THE GATE

- Relaxation
- Exercise
- Medications (Pain relievers, Opioids – Morphin, Demerol)
- Distractions from pain
- Positive Thoughts
- Endorphin
- Avoiding nutrients that increases inflammation (such as fried and oily foods)
- Acupuncture
- Serotonin (consumption of food rich in serotonin such as banana)
- Adequate sleep

PAIN
Transmission
- Impulses from afferent – CNS – Neurons – Spinal Cord –
- Thalamus – relay station for sensory input –
- Midbrain – signals cortex to raise awareness of the stimuli
PAIN TOLERANCE
- Amount and duration of pain a person can stand before seeking relief
- Can vary between different individuals in the same situations
TOLERANCE
- A state of adaptation in which exposure to a drug induces charges that result in a decrease in one
or more of the drug’s effects over time
PAIN THRESHOLD
- Point at which each person recognizes pain
- Tends to be the same among healthy persons
INCREASE TOLERANCE
- Alcohol
- Drugs
- Hypnosis
- Strong beliefs
- Distractions
- Rubbing
DECREASE TOLERANCE
- Fatigue
- Anger
- Boredom
- Anxiety
- Stress
- Depression
** Anxiety and Stress can stimulate or inhibit urination and may provoke urgency and
frequency
 ** Schwann Cells = PNS Oligodendrocytes = CNS = MYELIN SHEATH
 Specific Types of Pain
 REFFERED PAIN
- Discomfort
- Perceived in a general area of the body but not in the exact site where an organ is anatomically
located
 VISCERAL PAIN
- Arises from internal organs that are diseased or injured
- Usually accompanied by ANS symptoms
- Sharp or dull, aching cramping pain
 SOMATIC PAIN
- (e. g a hot stove) Pain may originate in the skin tissues
SUPERFICIAL PAIN
- Sharp, pricking, burning
DEEP SOMATIC PAIN
- Muscles or bones, sharp, dull and aching
 NEUROPATHIC PAIN
- Caused by damage to the CNS or Peripheral nerves
- Damage: vertebrae – causes pressure to the root nerve causing pain
- Damage; to myelin sheath – damaged by our own antibody / autoimmune
- PHANTON PAIN

ENDORPHINS
- Endogenous chemicals that act like opioids to inhibit pain impulses in the spinal cord and brain
- They degrade too quickly
 TYPES OF PAIN
ACUTE
- Tachy – increased bp
- Associated with SNS
CHRONIC
- No changes in Vital Signs
- Assessment of chronic pain should focus on impact of the pain and on patients’ function and
daily activities
**DANGERS OF UNRELIEVED PAIN
- Pain causes shallow breathing and cough suppression -> prevention of pulmonary secretions ->
pneumonia
PAIN
- may delay the return of normal gastric and bowel function
- Peristalsis – inhibited
- Suppress the immune system and heighten susceptibility to illness
CHRONIC PAIN
- Lowers the pain threshold as a result of the depletion of SEROTONIN and ENDORPHIN
 DRUG THERAPHY
Non-Opioid Analgesics
- First line therapy for mild to moderate pain
- Do not produce tolerance or physical or psychological dependence
- Works primarily at the site of injury rather than the CNS
- They do not have antipyretic effect
Opioid Analgesics
- Given when pain is moderate in intensity (PS: 7-10)
- Also for mild but persistent pain
Non-Pharmacologic Methods of Pain Management
- Massage. A lot of people find relief from gentle massage, and some hospice agencies have
volunteers who are trained in massage therapy. Several studies have found that massage is
effective in relieving pain and other symptoms for people with serious illness.
 - Relaxation techniques. Guided imagery, hypnosis, biofeedback, breathing techniques, and
gentle movement such as tai chi. Relaxation techniques are often very effective, particularly when
a patient -- or a caregiver -- is feeling anxious.
- Acupuncture. Several studies have found that acupuncture can be helpful in relieving pain for
people with serious illnesses such as cancer.
- Physical therapy. If a person has been active before and is now confined to bed, even just
moving the hands and feet a little bit can help.
- Pet therapy. If you have bouts of pain that last 5, 10, or 15 minutes, trying to find something
pleasant
-- like petting an animal's soft fur -- to distract and relax yourself can be helpful.
- Gel packs. These are simple packs that can be warmed or chilled and used to ease localized
pain.
PAIN DICRIMINATION – eyes closed

THE HUMAN ORGANISM

ANATOMY
- the study of the structure/shape of the body and the body parts and their relationship to one another
(Snell, 2007)
-the scientific discipline that investigates the structure of the body (Seeley, 2010)
-“ana” means to dissect or to separate; “tomy” means to cut apart (Tortora, 2009)

TWO BASIC APPROACHES TO ANATOMY:

1. SYSTEMIC ANATOMY – study of the body systems (ex: skeletal, muscular, nervous…)
2. REGIONAL ANATOMY – study of organization of the body by areas or region (ex: head, abdomen,
thorax…)

TWO GENERAL WAYS TO EXAMINE INTERNAL STRUCTURES OF A LIVING PERSON:

1. SURFACE ANATOMY – study of external features (ex: bony prominences which serve as landmarks
for locating deeper structures)
2. ANATOMIC IMAGING – involves the use of equipments (ex: X-ray, CT Scan, MRI, Ultrasound)

PHYSIOLOGY
- the science of body functions (Tortora, 2009)
- the scientific discipline that deals with the processes/functions of living things (Seeley, 2010)
-“physio” means nature; “ology” means the study of (Tortora, )

HUMAN PHYSIOLOGY – the study of a specific organism, the human

-has subdivisions: cellular physiology and systemic physiology

MAJOR GOALS OF PHYSIOLOGY:

1. To understand and predict the body’s responses to stimuli (ex: “candy bar”)
2. To understand how the body maintains conditions within the narrow range of values in the presence of
a continually changing environment. (ex: infection » fever » sweating)

LEVELS OF STRUCTURAL ORGANIZATION:

1. CHEMICAL LEVEL – how atoms interact and combine to form molecules (ex: collagen molecules)
2. CELL LEVEL – entails the association of molecules to form cells
3. TISSUE LEVEL – group of similar cells with the same function (ex: epithelial – skin/lungs;
connective –tendons; muscular – cardiac, skeletal, smooth; nervous – brain, spinal cord)
4. ORGAN LEVEL – composed of two or more type of tissues that perform specific function for the
body (ex: heart, skin, urinary bladder…)
5. ORGAN SYSTEM LEVEL – group of organs that cooperate to accomplish a common purpose (The
11 major organ systems are: integumentary, skeletal, muscular, lymphatic, respiratory, digestive, nervous,
endocrine, cardiovascular, urinary and reproductive)
6. ORGANISM LEVEL – any living thing that is considered as a whole (ex: bacterium, plants…)
-the highest level of structural organization

CHARACTERISTICS OF LIFE:
1. ORGANIZATION – specific interrelationship among the parts of an organism and how those parts
interact to perform specific functions. (ex: cells composed of highly specialized organelles » disruption »
loss of function and death)
2. METABOLISM – ability to use energy to perform vital functions (ex: energy from food)
3. RESPONSIVENESS – ability to sense changes in the environment and make adjustments to help
maintain life. (ex: if the body temperature increases, sweat glands produces sweat which can lower body
temperature back towards the normal level)
4. GROWTH – increase in size or part of an organism (ex: bone growth)
5. DEVELOPMENT – includes the changes that an organism undergoes through time, from fertilization
until death. It involves DIFFERENTIATION, the change in cell structure and function from generalized
to specialized.
6. REPRODUCTION – the formation of new cells/organisms

HOMEOSTASIS
-is the body’s ability to maintain relatively stable internal conditions even though the outside world is
continuously changing. (It literally means “unchanging”)
-“homeo” means the same; “stasis” means standing still
-it is the existence and maintenance of a relatively constant environment within the body despite
fluctuations in the environment, either internal or external.

VARIABLES – body conditions that may change their value (ex: temperature, volume, chemical
content…)

HOMEOSTATIC MECHANISMS – maintain the body temperature near an ideal normal value (ex:
sweating and shivering)

SET POINT – the ideal normal value on which the variables are to be maintained

NORMAL VALUES – acceptable range of values on which homeostasis can still be met.

HOMEOSTATIC CONTROL MECHANISMS:

1. NEGATIVE FEEDBACK MECHANISM – regulates most of the body systems to maintain
homeostasis (“negative” means any deviation from the set point is resisted or made smaller)

THREE COMPONENTS TO MAINTAIN HOMEOSTASIS:

a. RECEPTOR – monitors the value of a variable (ex: large blood vessels near the heart » BP)
b. CONTROL CENTER – establishes the set point around which the variable is maintained and
analyzes the information it receives from the receptor to determine the appropriate response or
course of action. (ex: the brain is a control center)
c. EFFECTOR – provides the means to control or change the value of the variable. (ex: heart)

2. POSITIVE FEEDBACK MECHANISM – the deviation from the set point becomes greater
- it is not homeostatic and it is rare among healthy individuals. (“positive” implies that when a
value
deviates from normal, the system’s response is to make it greater)
- example: massive blood loss » decrease heart rate » decrease blood pressure and volume
- example: child birth or normal vaginal delivery – uterine contraction » expulsion of fetus

THE LANGUAGE OF ANATOMY

I. BODY POSITIONS
 - The normal anatomical position refers to a person standing erect with the face directed forward,
the upper limbs hanging to the sides and the palms of the hands facing forward.
- Supine – when a person is lying face upward
- Prone – when a person is lying face downward

II. DIRECTIONAL TERMS

RIGHT Toward the body’s right side
LEFT Toward to body’s left side
INFERIOR Below
SUPERIOR Above
ANTERIOR Toward the front
POSTERIOR (Posterus – following) Toward the back
DORSAL (Dorsum – back) Toward the back (posterior)
VENTRAL (Venter – belly) Toward the front (anterior)
PROXIMAL (Proximus – nearest) Closer to a point of attachment
DISTAL (di + sto = to be distant) Farther from a point of attachment
LATERAL (Latus – side) Away from the body’s midline
MEDIAL (Medialis – middle) Toward the body’s midline
SUPERFICIAL (Superficialis – surface) Toward or on the surface
DEEP (deop – deep) Away from the surface

III. BODY PARTS AND REGIONS

Head
CEPHALIC
Forehead
FRONTAL
Eye
ORBITAL
Nose
NASAL
Mouth
ORAL
Neck
CERVICAL
Thorax
THORACIC
Chest
PECTORAL
Breastbone
STERNAL
Breast
MAMMARY
Abdomen
ABDOMINAL
Navel
UMBILICAL
Pelvis
PELVIC
Groin
INGUINAL
Genital
PUBIC
OTIC Ear
BUCCAL Cheek
MENTAL Chin
CLAVICULAR Collarbone
AXILLARY Armpit
BRACHIAL Arm
ANTECUBITAL Front of Elbow
ANTEBRACHIAL Forearm
CARPAL Wrist
MANUAL Hand
PALMAR Palm
DIGITAL Fingers
COXAL Hip
FEMORAL Thigh
PATELLAR Kneecap
CRURAL Leg
PEDAL Foot
TALUS Ankle
DORSUM Top of Foot
DIGITAL Toes
DORSAL Back
OCCIPITAL Base of Skull
NUCHAL Back of Neck
SCAPULAR Shoulder Blade
VERTEBRAL Spinal Column
LUMBAR Loin
SACRAL Between Hips
GLUTEAL Buttock
PERINEAL Perineum
CRANIAL Skull
ACROMIAL Point of Shoulder
OLECRANON Point of Elbow
DORSUM Back of Hand
POPLITEAL Hollow behind Knee
SURAL Calf
PLANTAR Sole
CALCANEAL Heel
Nine Regions of the Abdomen:
1. UMBILICAL REGION – the area around the umbilicus
» sections of the small & large intestines, inferior vena cava and abdominal aorta
2. EPIGASTRIC REGION – it is superior to the umbilical region
» most of the pancreas, portions of the stomach, liver, inferior vena cava, abdominal aorta and
duodenum
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3. HYPOGASTRIC REGION – it is inferior to the umbilical region; it is the pubic area
» portions of the sigmoid colon, urinary bladder & ureters, and portions of the small intestines
4. RIGHT AND LEFT ILIAC REGIONS – either side of the hypogastric region; inguinal regions
» portions of the small and large intestine
5. RIGHT AND LEFT LUMBAR REGIONS – either side of the umbilical region; the loin regions
» portions of small & large intestines and portions of the kidneys
6. RIGHT AND LEFT HYPOCHONDRIAC REGIONS – either side of the epigastric region
» includes the diaphragm, portions of the kidneys, right side of the liver, spleen and part of the pancreas
NOTE: The “right” and “left” regions are counted separately
IV. PLANES
a. SAGITTAL PLANE – runs vertically through the body; separates it into left and right
-“sagittal” literally means the flight of an arrow
b. MEDIAN PLANE – a sagittal plane that divides the body into equal parts
c. TRANSVERSE OR HORIZONTAL PLANE – runs parallel to the surface of the ground
- separates the body into superior and inferior parts
d. FRONTAL OR CORONAL PLANE – runs vertically from right to left; divides the body into anterior
and posterior parts
LONGITUDINAL SECTION – a cut through the long axis of an organ
TRANSVERSE OR CROSS SECTION – a cut at a right angle to the long axis of an organ
TERMS RELATED TO MOVEMENT:
a. FLEXION – takes place in a coronal or frontal plane
b. EXTENSION – straightening a joint; occurs in a posterior direction
c. LATERAL FLEXION – movement of trunk in a coronal plane
d. ABDUCTION – the limb is moving away from the midline
e. ADDUCTION – movement toward the body in the coronal plane
f. ROTATION – movement of a body part around its long axis
MEDIAL ROTATION – results in the anterior surface of the body part facing medially
LATERAL ROTATION – results in the anterior surface of the body part facing laterally
g. PRONATION OF THE FOREARM – medial rotation of the forearm in such a manner that the palm of
the
hand faces posteriorly
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h. SUPINATION OF THE FOREARM – lateral rotation of the forearm, from the pronated position, so
that the
palm of the hand faces anteriorly
i. CIRCUMDUCTION – combination in sequence of flexion, extension, abduction and adduction
-only ball-and-socket joints are capable of this movement
j. PROTRACTION – move forward
k. RETRACTION – move backward
l. INVERSION – movement of the foot so that the soles face medially
m. EVERSION – opposite movement of the foot so that the soles face in a lateral direction
V. BODY CAVITIES
Three Large Cavities of the Trunk:
a. THORACIC CAVITY –surrounded by the rib cage; separated from the abdominal cavity by the
muscular diaphragm.
MEDIASTINUM – a median structure that divides this cavity into right and left parts; it contains the
heart, thymus, trachea, esophagus, etc. Lungs are found on its sides.
b. ABDOMINAL CAVITY – bounded primarily by the abdominal muscles and contains the stomach,
intestines, liver, spleen, pancreas and kidneys.
c. PELVIC CAVITY – a small space enclosed by the bones of the pelvis and contains the urinary
bladder, part of the large intestine and the internal reproductive organs.
d. ABDOMINOPELVIC CAVITY – the abdominal cavity + the pelvic cavity
VI. SEROUS MEMBRANES
- line the trunk cavities and cover the organs of these cavities.
TWO TYPES OF SEROUS MEMBRANES:
a. PARIETAL SEROUS MEMBRANE – the outer part
b. VISCERAL SEROUS MEMBRANE – the inner part
 As an organ rubs against another organ or against the body wall, the serous fluid and smooth serous
membranes reduce FRICTION.
THORACIC CAVITY – contains three serous membrane-lined cavities: a pericardial cavity and two
pleural
cavities.
PERICARDIAL CAVITY – surrounds the heart; contains pericardial fluid; located between the visceral
pericardium
and the parietal pericardium
VISCERAL PERICARDIUM – covers the heart, which is contained within a connective tissue sac lined
with the
parietal pericardium.
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PLEURAL CAVITY – surrounds each lung, which is covered by the VISCERAL PLEURA; located
between the
visceral pleura and the parietal pleura; contains pleural fluid
PARIETAL PLEURA – lines the inner surface of the thoracic wall, the lateral surfaces of the
mediastinum, and the
superior surface of the diaphragm.
PERITONEAL CAVITY – a serous membrane-lined cavity contained in the abdominopelvic cavity;
located
between the visceral and parietal peritoneum; contains peritoneal fluid
VISCERAL PERITONEUM – covers many organs of the abdominopelvic cavity.
PARIETAL PERITONEUM – lines the wall of the abdominopelvic cavity and the inferior surface of the
diaphragm.
PERICARDITIS – inflammation of the pericardium
PLEURISY – inflammation of the pleura
PERITONITIS – inflammation of the peritoneum
MESENTERIES – anchor the organs to the body wall and provide a pathway for nerves and blood vessels
to
reach the organs; consists of two layers of peritoneum fused together
-connect the visceral peritoneum of some abdominopelvic organs to the parietal peritoneum on the body
wall
or to the parietal peritoneum of other abdominopelvic organs
PARIETAL PERITONEUM – covers organs (without mesenteries and are closer to the body wall)
RETROPERITONEAL – the organs stated above. (ex: kidneys, adrenal glands, pancreas…)