Five Fold Fundamental Goals of Nursing

• To promote health
• To prevent illness
• To restore health
• To alleviate suffering
• To promote spiritual environment

Functions of a Nurse

Dependent function works with the doctor. The doctor provides the legal order for the nurse to perform. Example of a dependent function is medication administration. Independent function the primary basis is the nurses’ assessment. An example of an independent function of the nurse is sponge bath. Interdependent or collaborative function is where the nurse works together with other members of the health care team.

Seven Known Functions of a Nurse

• Application and execution of the doctor’s legal orders.
• Observation of symptoms and reactions.
• Supervision of the patient.
• Supervision of those participating in care (except the doctor). Includes the nursing aide, nursing orderlies, nursing assistants, families, student nurses.
• Application and execution of nursing procedures and techniques.
• Reporting and recording.
• Promotion of physical and emotional health by direction and teaching.

Roles of a Nurse

• Communicator
• Decision maker
• Comforter
• Researcher
• Manager
• Teacher
• Counselor
• Care giver
• Protector and client advocate
• Rehabilitator

Temperature

This provides a numeric value of the core body temperature. Thermoregulation is done by the anterior hypothalamus in humans and an increase or decrease in temperature may hold a significant meaning.

Normal human body temperature is other wise known as Normothermia or Euthermia, is a concept that depends upon the place in the body at which the measurement is made.

Equipments used in Temperature Taking

Two Types:
• Mercury Glass Thermometer – A Calibration is present in the body of thermometer to provide the temperature reading as the mercury rises.
• Alcohol Glass Thermometer – Is less toxic and evaporates quickly.
Cleaning of Glass Thermometers

Before use : Bulb to other end. After use : End to bulb.

Disadvantages of Glass Thermometers:

There is a risk of injury from cracking the thermometer if too much force is applied by the teeth to hold them in place and the alcohol or mercury contents are poisonous.

Electronic thermometers are made of plastic and use a solid metal (thermocouple) sensor.

Plastic thermometer strips are placed on a local area and gives an approximate local reading, that depends to a great extent on ambient air temperature and local circulation effects. Using a thermometer to record the temperature under the armpit is less affected by surrounding air temperature, but is still prone to diverge from true core temperature if there are alterations in blood circulation.

Has become readily available. It is thought that the eardrum closely mirrors core temperature values. The tympanic thermometer work by detecting the infrared heat emission from the tympanic membrane and a measurement is quickly taken within one second making them popular for use with children.

Heart Rate or Pulse Rate

Is the measure of the number of heart beats per minute. It is obtained by placing two fingers (forefinger and middle finger) on one of the common pulse sites. (Apical, Brachial, Carotid, Dorsalis Pedis, Femoral, Popliteal, Posterior Tibialis, Radial, Temporal, and Ulnar).

Respiration

It is the measure of the number of respiration or breaths per minute. Can be obtained with the fingers used to palpate on the pulse still on place, counting the rise and fall cycle of the chest as one and so on.

Blood Pressure

Is the pressure (force per unit area) exerted by circulating blood on the walls of blood vessels. It is obtained by the use of a Sphygmomanometer by listening for the Korotkoff sound. The first sound heard is the Systolic and the cessation of sound is the Diastolic.

Nursing Considerations:

Never perform a BP on an arm with a dialysis shunt, injury or same side mastectomy or axilla surgery. Avoid arms with IV(Intravenous)/VAD (Vascular Access Device) if possible.

Normal Range for an Adult

• Heart Rate: 60-100 bpm
• Respiratory Rate: 12-20 cpm
• Systolic Blood Pressure: 95-130 mmHg
• Diastolic Blood PRessure: 60-90 mmHg
• Temperature:
  • Tympanic: 37°C – 38.1°C
  • Oral: 36.4°C – 37.6°C. Oral temperatures are influenced by drinking, eating and breathing.
  • Rectal: 37°C – 38.1°C. Rectal temperatures lag behind changes in core body temperature and there is a risk of cross-contamination.
  • Axillary: 35.9°C – 37°C. Is not always reliable indicators of core body temperature, especially during those critical times when core body temperature is increasing or decreasing.

Acute Pain is a pain that stops without treatment, rest, or with the use of analgesia. If the occurrence of pain is less than 6 months then it could be classified as an acute pain. This type of pain is identifiable, reversible, and controllable.

Chronic Pain is a type of pain that persists longer than the course of natural healing and is usually associated with a type of disease or injury. If the occurrence of pain is more than 6 months and/or is recurrent then one can classify it as chronic pain. This is type of pain usually vague. The classifications of chronic pain are:

1. Chronic Non-Malignant
2. Chronic Intermittent
3. Chronic Malignant

Negative Effects of Pain

1. Prevents Ambulation. Without ambulation, Deep Vein Thrombosis (DVT) may develop.
2. Prevents Coughing and Deep Breathing. The secretions become stagnant and proliferation of bacteria is eminent.
3. Increase in Cathecholamines. This increases Blood Pressure.
4. Decreases Gastrointestinal motility. This decrease leads to constipation.
5. Decreases Urinary bladder motility. This causes urinary retention, which may lead to UTI or the development of kidney stones.
6. Abdominal muscle spasm and tension
7. Increased myocardial oxygen demand. It cause ischemia that can lead to myocardial infarction
8. Decreased immune system. Can cause the development of infections.

Sources of Pain

1. Cutaneous. Affected part is the skin. There is an abrupt onset of pain. If the pain radiates it may have affected the dermatome which are other skin sites that are also supplied by the same spinal nerve root
2. Deep Somatic. This source is poorly localized because it is diffused. This usually affects the muscles, bone, tendons, and ligaments.
3. Visceral. This source is also poorly localized because it too is diffused. Affectations usually include internal organs.

Bronchial

The sound heard over large airways near the second and third intercostal spaces and has a tubular quality that can be compared to air blowing through a cardboard tube. It is relatively louder in expiration than inspiration and are loud and high in pitch.

Vesicular

Vesicular sounds are heard from a distance to the large airways in the lungs. It is comparable to the sound of air blowing to the leaves of the trees and is louder in inspiration than expiration.

Bronchovesicular

Are heard in the center of the anterior chest, are softer than bronchial sounds but are of tubular quality. It is equal during inspiration and expiration. Normal findings on auscultation include:

• Loud, high-pitched bronchial breath sounds over the trachea
• Medium pitched bronchovesicular sounds over the mainstream bronchi, between the scapulae, and below the clavicles
• Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung fields.

Abnormal Breath Sounds

Rales

Can be simulated by rolling hair near the ear between two fingers and is best heard on inspiration by the lower bases of the lungs. This is associated with bronchitis, pneumonia, and congestive heart failure and is unrelieved by coughing.

Wheezes

High-pitched and squeaky. Is best heard on expiration on all lung fields and is often associated with bronchitis and pneumonia. It is often unrelieved by cough

Ronchi

Is coarse, harsh, and loud gurgling and is best heard on expiration over bronchi and trachea. Associated with bronchitis and pneumonia and is often relieved by coughing

Stridor

Harsh, high-pitched, audible sound. Is easily heard without a stethoscope during inspiration and expiration and can indicate a progressive narrowing of the upper airway and can be life threatening. It is associated with partial airway obstruction, croup (on inspiration), and epiglottitis (when severe and audible).

Unilaterally Absent or Diminished

No equal or bilateral breath sounds. It is associated with pneumothorax, hemothorax, tension pneumothorax, or pneumectomy.

Listed below are several guidelines that could be followed by nurses in the occurrence of fires.

1. Remember the acronym RACE!

   • Rescue First remove all clients that are within the vicinity of the fire.
   • Alarm Activate the fire alarm.
   • Confine Close doors and windows when a fire is detected, but remember to provide an exit door or keep the fire exit open.

   • Extinguish Extinguish the fire, using the appropriate fire extinguisher available.

2. Keep open spaces free of clutter.

   Clutter are flammable materials or obstacles. Reducing the clutter in your area, would mean free space to move about during an emergency and a reduction of the probability of having a fire.

3. Clearly mark fire exits.

   Fire exits not marked clearly may be the cause of several people in your area to be trapped. A fire exit sign or an exit sign usually requires the word “EXIT” in large, well-lit green or red letters. Some signs have arrows and an outline of a man, walking or running out.

4. Know the location of all fire alarms, exits, and extinguishers.

   Knowing the location of all these is necessary to allow safe passage of the clients and to be able to extinguish or confine the fire.

5. Know the telephone numbers for reporting fires.

   Check with the local firestation their nos. and emergency numbers to provide quick assistance in cases of fire.

6. Know the fire drill and evacuation plan of the agency.

   Every hospital has an evacuation plan and provides fire drills to its employees. Knowledge is key to be able to work in these situations.

7. Never use the elevator in the event of a fire.

   Being trapped inside the elevator while a fire is on going is the last thing you’d want to be at.

8. Turn off oxygen and appliances in the vicinity of the fire.

   Oxygen is flammable and may heighten the fire. Appliances may cause the fire to further damage the station.

9. In the event of fire, if a client is on life support, maintain respiratory status manually with an ambu-bag until the client is moved away from the threat of the fire and can be placed back on life support.

10. Bedridden clients generally are moved from the scene of a fire by stretcher, their beds, or wheelchair.

11. If there is a fire, ambulatory clients can be directed to walk by themselves to a safe area and can be instructed to may be assist in moving clients in wheelchairs.

12. If a client must be carried from the area of a fire, appropriate transfer techniques need to be used.

    Always observed transfer technics to avoid bodily harm to your clients. Also, observe proper body mechanics to avoid injury to self.

13. If the fire department personnel are at the scene of the fire, they can help evacuate clients. Inform of the officers of the situation.

14. If a burning victim is approaching, log roll the patient. Do not throw any liquids to the flame because certain liquids may cause the flame to combust and further heighten the flame. If a burning pregnant client is approaching DO NOT LOG ROLL the client. Instead, get a blanket, moisten it with water and wrap it around the client’s body.