Transmission of Hepatitis C

Hepatitis C is a disease with a significant global impact. According to the World Health Organization there are 170 million people infected with hepatitis C virus (HCV). There are considerable regional differences. In Europe and the United States chronic hepatitis C is the most common chronic liver disease. The majority of liver transplants performed in these regions are for chronic HCV. It is difficult to determine the number of new HCV infections, as most acute cases are not noticed clinically.

Parenteral exposure to the hepatitis C virus is the most efficient means of transmission. The majority of patients infected with HCV in Europe and the United States acquired the disease through intravenous drug use or blood transfusion, which has become rare since routine testing of the blood supply for HCV began. The following possible routes of infection have been identified in blood donors (in descending order of transmission risk):

• Injection drug use
• Blood transfusion
• Sex with an intravenous drug user
• Having been in jail more than three days
• Religious scarification
• Having been struck or cut with a bloody object
• Pierced ears or body parts
• Immunoglobulin injection

Very often in patients with newly diagnosed HCV infection no clear risk factor can be identified.

Factors that may increase the risk of HCV infection include greater numbers of sex partners, history of sexually transmitted diseases, and failure to use a condom. Whether underlying HIV infection increases the risk of heterosexual HCV transmission to an uninfected partner is unclear. The seroprevalence of HCV in MSM (men who have sex with men) ranges from about 4 to 8%, which is higher than the HCV prevalence reported for general European populations.

The risk of perinatal transmission of HCV in HCV RNA positive mothers is estimated to be 5% or less (Ohto 1994). Caesarean section has not been shown to reduce transmission. There is no evidence that breastfeeding is a risk factor.

Hemodialysis risk factors include blood transfusions, the duration of hemodialysis, the prevalence of HCV infection in the dialysis unit, and the type of dialysis. The risk is higher with in-hospital hemodialysis vs peritoneal dialysis.

Contaminated medical equipment, traditional medicine rites, tattooing, and body piercing are considered rare transmission routes.

There is some risk of HCV transmission for health care workers after unintentional needle-stick injury or exposure to other sharp objects.

Read More

Simple music from John Lennon - Imagine (official video)

Imagine - John Lennon

Imagine - John Lennon, A song about humanism.

Read More

Signs and Symptoms of Hydrocephalus

The signs and symptoms of hydrocephalus in infants and children vary depending on their age, the degree of hydrocephalus at presentation, the primary etiology, and the time over which the hydrocephalus develops. Ventriculomegaly can progress without obvious signs of increased intracranial pressure because of the plasticity of the infant brain and the ability of the cranium to expand.

In full-term infants, signs often include macrocephaly and progressively increasing occipital frontal head circumference, crossing percentile curves. Normal head circumference for a full-term infant is 33–36 cm at birth. A normal head circumference increases by approximately 2 cm/month during the first 3 months, by 1.5 cm/month during the 4th and 5th months, and by about 0.5 cm/month from months 6–12.

Signs and symptoms of hydrocephalus in children:

Premature infants

• Apnea
• Bradycardia
• Hypotonia
• Acidosis
• Seizures
• Rapid head growth
• Tense fontanel
• Splayed cranial sutures
• Vomiting
• Sunsetting eyes

Full-term infants

• Macrocephaly
• Rapid head growth
• Decreased feeding
• Increased drowsiness
• Tense fontanel
• Vomiting
• Distended scalp veins
• Splayed cranial sutures
• Poor head control
• Parinaud’s sign
• Sunsetting eyes
• Frontal bossing

Toddlers and older

• Headache
• Nausea
• Vomiting
• Irritability
• Lethargy
• Delayed development
• Decreased school performance
• Behavioral disturbance
• Papilledema
• Parinaud’s sign
• Sunsetting eyes
• Bradycardia
• Hypertension
• Irregular breathing patterns

 

Read More

Nurse’s Ethical Duty in Wound Care

Performing an evaluation, assessment, or management of any type of wound is an ethical endeavor and may present ethical challenges at times. The specific concepts of paternalism, autonomy, beneficence, nonmaleficence, fidelity, role fidelity, veracity, therapeutic privilege, conflict of interest, confidentiality, and justice will be addressed.

The nurse might wonder why consideration of morals is of any importance when what he or she is doing is providing clinical services for some type of wound. The practice of wound care is fraught with areas in which the morals or society’s determination of right and good conduct of the health-care professional may be seriously tested. Understanding the concepts of morals, moral duty, and moral obligation are critical in providing wound care.

Specific obligations and duties for the privilege of professional access to patients, including the following:

• First, the patient’s interests are placed above the personal interest of the nurse. If this duty is overlooked or forgotten, the contract (standard of practice) among the health-care provider, the health-care organization, and the patient is broken. — Example: The health-care provider conducts a seminar and needs wound photographs to supplement the written and verbal components of the presentation. The provider takes photographs of the patient’s wounds solely for the purpose of using them in the seminar. The only reason for taking these photographs is for the convenience of the health-care provider, and therefore the activity is actually for the nurse’s personal interest and not for the patient’s best interest. The patient would need to grant the nurse informed consent to use the photographs to avoid any consideration that the photographs are for personal interest. The nurse would need to assure the patient that any refusals on the patient’s part would have no effect on the nurse-patient relationship or the patient’s treatment.
• The patient’s privacy is protected from another individual’s or society’s desire to know details of the patient’s treatment. It is the health-care provider’s responsibility to have a complete understanding of the legal rights of all involved. It is ultimately the responsibility of the nurse to know the legal rights of the patient, family, and health-care provider. However, in many areas of the world, the general public does not have any legal right to knowledge concerning the patient’s care, progress, or prognosis. The health-care provider must identify if the health-care organization has a policy or procedure concerning this challenge.
• Does the health-care provider have a duty to treat the patient who has a wound(s)?

It is important to remember that this information concerns the ethical decision making only and is not to be construed as presenting a legal argument for or against treatment. Failure to treat may have potential legal consequences.

Read More

Overview of Respiratory Function

The major function of lungs and pulmonary circulation as the pulmonary system is to deliver oxygen (O₂) to cells and remove carbon dioxide (CO₂) from the cells (gas exchange). The adequacy of oxygenation and ventilation is measured by partial pressure of arterial oxygen (PaO₂) and partial pressure of arterial carbon dioxide (PaCO₂). The pulmonary system also functions as a blood reservoir for the left ventricle when it is needed to boost cardiac output; as a protector for the systemic circulation by filtering debris/particles; as a fluid regulator so water can be kept away from alveoli; and as a provider of metabolic functions such as surfactant production and endocrine functions.

Terminology in Respiratory

• Alveolus—air sac where gas exchange takes place
• Apex—top portion of the upper lobes of lungs
• Base—bottom portion of lower lobes of lungs, located just above the diaphragm
• Bronchoconstriction—constriction of smooth muscle surrounding bronchioles
• Bronchus—large airways; lung divides into right and left bronchi
• Carina—location of division of the right and left main stem bronchi
• Cilia—hairlike projections on the tracheobronchial epithelium, which aid in the movement of secretions and removal of debris
• Compliance—ability of the lungs to distend and change in volume relative to an applied change in pressure (eg, emphysema—lungs very compliant; fibrosis—lungs noncompliant or stiff)
• Dead space—ventilation that does not participate in gas exchange; also known as wasted ventilation when there is adequate ventilation but no perfusion, as in pulmonary embolus or pulmonary vascular bed occlusion. Normal dead space is 150 mL.
• Diaphragm—primary muscle used for respiration; located just below the lung bases, it separates the chest and abdominal cavities
• Diffusion (of gas)—movement of gas from area of higher to lower concentration
• Dyspnea—subjective sensation of breathlessness associated with discomfort, often caused by a dissociation between motor command and mechanical response of the respiratory system as in:
  • Respiratory muscle abnormalities (hyperinflation and airflow limitation from chronic obstructive pulmonary disease [COPD]).
  • Abnormal ventilatory impedance (narrowing airways and respiratory impedance from COPD or asthma).
  • Abnormal breathing patterns (severe exercise, pulmonary congestion or edema, recurrent pulmonary emboli).
  • Arterial blood gas (ABG) abnormalities (hypoxemia, hypercarbia).
• Hemoptysis—coughing up of blood
• Hypoxemia—PaO₂ less than normal, which may or may not cause symptoms (Normal PaO₂ is 80 to 100 mm Hg on room air.)
• Hypoxia—insufficient oxygenation at the cellular level due to an imbalance in oxygen delivery and oxygen consumption (Usually causes symptoms reflecting decreased oxygen reaching the brain and heart.)
• Mediastinum—compartment between lungs containing lymph and vascular tissue that separates left from right lung
• Orthopnea—shortness of breath when in reclining position
• Paroxysmal nocturnal dyspnea—sudden shortness of breath associated with sleeping in recumbent position
• Perfusion—blood flow, carrying oxygen and CO₂ that passes by alveoli
• Pleura—serous membrane enclosing the lung; comprised of visceral pleura, covering all lung surfaces, and parietal pleura, covering chest wall and mediastinal structures, between which exists a potential space
• Pulmonary circulation—network of vessels that supply oxygenated blood to and remove CO₂-laden blood from the lungs
• Respiration—inhalation and exhalation; at the cellular level, a process involving uptake of oxygen and removal of CO₂ and other products of oxidation
• Shunt—adequate perfusion without ventilation, with deoxygenated blood conducted into the systemic circulation, as in pulmonary edema, atelectasis, pneumonia, COPD
• Surfactant—fluid secreted by alveolar cells that reduces surface tension of pulmonary fluids and aids in elasticity of pulmonary tissue
• Ventilation—movement of air (gases) in and out of the lungs
• Ventilation-perfusion (V/Q) imbalance or mismatch—imbalance of ventilation and perfusion; a cause for hypoxemia. V/Q mismatch can be due to:
  • Blood perfusing an area of the lung where ventilation is reduced or absent.
  • Ventilation of parts of lung that are not perfused.

Read More

Biologic and Genetic Principles on Nursing

The impact of genetics on nursing is significant. The American Nurses Association (ANA) officially recognized genetics as a nursing specialty. This effort was spearheaded by the International Society of Nurses in Genetics (ISONG), which also initiated credentialing for the Advanced Practice Nurse in Genetics and the Genetics Clinical Nurse. ANA and ISONG have collaborated in the establishment of a scope and standards of practice for nurses in genetics practice. Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics were finalized in 2006. They reflect the minimal genetic and genomic competencies for every nurse regardless of academic preparation, practice setting, role, or specialty.

Cell as The Basic Unit of Biology

• Cytoplasm—contains functional structures important to cellular functioning, including mitochondria, which contain extranuclear deoxyribonucleic acid (DNA) important to mitochondrial functioning.
• Nucleus—contains 46 chromosomes in each somatic (body) cell, or 23 chromosomes in each germ cell (egg or sperm).

Chromosomes

Each somatic cell with a nucleus has 22 pairs of autosomes (the same in both sexes) and 1 pair of sex chromosomes. Females have two X sex chromosomes; males have one Y sex chromosome and one X sex chromosome. Normally, at conception, each individual receives one copy of each chromosome from the maternal egg cell (1 genome) and one copy of each chromosome from the paternal sperm cell (1 genome), for a total of 46 chromosomes (2 genomes). Karyotype is the term used to define the chromosomal complement of an individual, for example, 46, XY, as is determined by laboratory chromosome analysis. Each chromosome contains 800 to 3,000 genes.

 

Genes

Gene is the basic unit of inherited information. Each copy of the human genome in the nucleus has about 30,000 genes. Cells also have some nonnuclear genes located within the mitochondria within the cytoplasm. Alternate forms of a gene are termed alleles. For each gene, an individual receives one allele from each parent, and thus has two alleles for each gene on the autosomes and also on the X chromosomes in females. Males have only one X chromosome and, therefore, have only one allele for all genes on the X chromosome; they are hemizygous for all X-linked genes. At any autosomal locus, or gene site, an individual can have two identical alleles (homozygous) for that locus or can have two different alleles (heterozygous) at a particular locus. Genotype refers to the constitution of the genetic material of an individual; for practical purposes it is commonly used to address a specific gene pair. For example, the gene for sickle cell disease, the gene for cystic fibrosis, or the gene for familial polyposis. Phenotype refers to the physical or biochemical characteristics an individual manifests regarding expression of the presence of a particular feature, or set of features, associated with a particular gene. Each gene is composed of a unique sequence of DNA bases.

 

DNA: Nuclear and Mitochondrial

• Human DNA is a double-stranded helical structure comprised of four different bases, the sequence of which codes for the assembly of amino acids to make a protein—for example, an enzyme. These proteins are important for the following reasons:
  • For body characteristics such as eye color.
  • For biochemical processes such as the gene for the enzyme that digests phenylalanine.
  • For body structure such as a collagen gene important to bone formation.
  • For cellular functioning such as genes associated with the cell cycle.
• The four DNA bases are adenine, guanine, cytosine, and thymine-A, G, C, and T.
• A change, or mutation, in the coding sequence, such as a duplicated or deleted region, or even a change in only one base, can alter the production or functioning of the gene or gene product, thus affecting cellular processes, growth, and development.
• DNA analysis can be done on almost any body tissue (blood, muscle, skin) using molecular techniques (not visible under a microscope) for mutation analysis of a specific gene with a known sequence or for DNA linkage of genetic markers associated with a particular gene.

Normal Cell Division

Mitosis occurs in all somatic cells, which, under normal circumstances, results in the formation of cells identical to the original cell with the same 46 chromosomes.

Meiosis, or reduction division, occurs in the germ cell line, resulting in gametes (egg and sperm cells) with only 23 chromosomes, one representative of each chromosome pair.

During the process of meiosis, parental homologous chromosomes (from the same pair) pair and undergo exchanges of genetic material, resulting in recombinations of alleles on a chromosome and thus variation in individuals from generation to generation.

Read More

Using Electrocardiography (ECG) to Measures the Heart's Electrical Activity

Prepare the machine by placing the ECG machine close to the patient's bed, and plug the power cord into the wall outlet. To accommodate the precordial leads and minimize electrical interference on the ECG tracing, remove the electrodes if the patient is already connected to a cardiac monitor. Keep the patient away from objects that might cause electrical interference, such as equipment, fixtures, and power cords.

Explain the procedure to the patient as you set up the machine to record a 12-lead ECG. Tell him that the test records the heart's electrical activity and it may be repeated at certain intervals. Also, tell him that the test typically takes about 5 minutes. Emphasize that no electrical current will enter his body.

Have the patient lie in a supine position in the center of the bed with his arms at his sides. You may raise the head of the bed to promote his comfort. Expose his arms and legs, and drape him appropriately. His arms and legs should be relaxed to minimize muscle trembling, which can cause electrical interference.

Place the patient's hands under his buttocks to prevent muscle tension if the bed is too narrow. Also use this technique if the patient is shivering or trembling. Make sure his feet aren't touching the bed board.

Select flat, fleshy areas to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the stump. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin to enhance electrode contact.

Apply the electrode paste or gel or the disposable electrodes to the patient's wrists and to the medial aspects of his ankles. If you're using paste or gel, rub it into the skin. If you're using disposable electrodes, peel off the contact paper and apply them directly to the prepared site, as recommended by the manufacturer's instructions. To guarantee the best connection to the leadwire, position disposable electrodes on the legs with the lead connection pointing superiorly.

If you're using paste or gel, secure electrodes promptly after you apply the conductive medium. This prevents drying of the medium, which could impair ECG quality. Never use alcohol or acetone pads in place of the electrode paste or gel because they impair electrode contact with the skin and diminish the transmission quality of electrical impulses.

Connect the limb leadwires to the electrodes. Make sure the metal parts of the electrodes are clean and bright. Dirty or corroded electrodes prevent a good electrical connection.

You'll see that the tip of each leadwire is lettered and color-coded for easy identification. The white or RA leadwire goes to the right arm; the green or RL leadwire, to the right leg; the red or LL leadwire, to the left leg; the black or LA leadwire, to the left arm; and the brown or V₁ to V₆ leadwires, to the chest.

Now, expose the patient's chest. Put a small amount of electrode gel or paste on a disposable electrode at each electrode position.

If your patient is a woman, be sure to place the chest electrodes below the breast tissue. In a large-breasted woman, you may need to displace the breast tissue laterally.

Check to see that the paper speed selector is set to the standard 25 mm/second and that the machine is set to full voltage. The machine will record a normal standardization mark—a square that's the height of two large squares or 10 small squares on the recording paper. Then, if necessary, enter the appropriate patient identification data.

If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization to half-standardization. Note this adjustment on the ECG strip because this will need to be considered in interpreting the results.

Now you're ready to begin the recording. Ask the patient to relax and breathe normally. Tell him to lie still and not to talk when you record his ECG. Then press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording three consecutive leads simultaneously. Some machines have a display screen so you can preview waveforms before the machine records them on paper.

When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the patient's skin. After disconnecting the leadwires from the electrodes, dispose of or clean the electrodes, as indicated.

 

 

Read More

Educational and Competency Requirements for The Administration and Supply of Medications by Nurses in Rural and Remote Areas

Following are the areas of responsibility that rural and remote nurses must accept if medication management is to become part of their legal practice.

Knowledge of Medicines:
Nurses should have contemporary knowledge of pharmacology for safe and appropriate nursing practice in rural and remote communities. The nurse also must have sound knowledge and skills relating to medications in their facility’s approved medication list. Another requirement is that the nurse should have reasonable access to and familiarity with the resources available for collaboration, consultation/reference in regards to the use of medications.
Relevant and appropriate clinical educational preparation and competency assessment will support best practice in the administration and supply of medication by registered nurses in rural and remote settings.

Knowledge of Law:
The nurse must have knowledge of the statutory and common laws, which govern medication use by registered nurses, for practice.

Civil laws, statutory acts and regulations establish the standard of the delivery of appropriate and safe care to patients. Knowledge of the legislative requirements is essential to ensure registered nurses’ practise within the law.

Assessment of Competency:
The practice of initiating, administering and supplying medications in rural or remote areas should be confined to registered nurses who have demonstrated competency in these areas.
An assessment of competency should include:

• Knowledge and skills for patient assessment and diagnosis
• An examination of medication knowledge.
• A test of competency in medication calculations.
• Knowledge of the medication schedules as they impact on clinical practice.
• A clinical/practical assessment of compliance with protocols in the practice context.

Knowledge of clinical assessment and medication use is essential to enable the nurse to make an informed decision about the initiation of safe and appropriate treatment. Competency in medication/IV calculations may reduce the risk of dose/rate errors. It is the nurse’s responsibility to have knowledge of current schedules to practise in accordance with the relevant legislation. Current literature indicates that a significant number of nursing students have serious numeracy skill deficits and that even if these skills are mastered, they can deteriorate if not continually exercised.

Read More

Materials of Bandaging

Bandaging is both a science and an art. The proper bandage, properly applied, can aid materially in the recovery of the patient. A improperly or carelessly applied bandage can cause discomfort to the patient and may imperil his life.

Bandages are employed to hold dressings, to secure splints, to create pressure, to immobilize (make immovable) joints and in correcting deformity. Bandages should never be used directly over a wound. They should only be used over a dressing.

Various materials, such as gauze, flannel, crinoline, muslin, linen, rubber, and elastic webbing are employed in making bandages. Gauze is used most frequently because it is light, soft, thin, porous, readily adjusted, and easily applied. Flannel, being soft and elastic, may be applied smoothly and evenly, and as it absorbs moisture and maintains body heat, is very useful for certain conditions. Crinoline, rather than ordinary gauze, is used in making plaster of paris bandages, the mesh of the crinoline holding the plaster more satisfactorily than gauze. Muslin is employed in making bandages because it is strong, inexpensive, readily obtainable, and can be used more than once. For the latter reason, muslin bandages are usually employed in bandage practice. Muslin should be soaked in water to cause shrinkage, dried, and finally ironed to remove wrinkles. A large piece of this material may be easily torn into strips of the desired width. Rubber and elastic webbing are used to afford firm support to a part. The webbing is preferable to the pure rubber bandage. It permits the evaporation of moisture.

Bandage material is commonly made into either a triangular bandage, a roller bandage, or a manytailed bandage.

 

 

Read More

ECG Waveforms And Components

The electrocardiogram (ECG) is a graphic recording ofelectric potentials generated by the heart.The signals are detected by means of metal electrodes attached to the extremities and chest wall and are then amplified and recorded by the electrocardiograph. ECG leads actually display the instantaneous differences in potential between these electrodes.

The clinical utility of the ECG derives from its immediate availability as a noninvasive, inexpensive, and highly versatile test. In addition to its use in detecting arrhythmias, conduction disturbances, and myocardial ischemia, electrocardiography may reveal other findings related to life-threatening metabolic disturbances (e.g., hyperkalemia) or increased susceptibility to sudden cardiac death (e.g., QT prolongation syndromes). The widespread use of coronary fibrinolysis and acute percutaneous coronary interventions in the early therapy of acute myocardial infarction has refocused attention on the sensitivity and specificity of ECG signs of myocardial ischemia.

An electrocardiogram (ECG) waveform has three basic components: the P wave, QRS complex, and T wave. These elements can be further divided into the PR interval, J point, ST segment, U wave, and QT interval.

P wave and PR interval

The P wave represents atrial depolarization. The PR interval represents the time it takes an impulse to travel from the atria through the atrioventricular nodes and bundle of His. The PR interval measures from the beginning of the P wave to the beginning of the QRS complex.

QRS complex

The QRS complex represents ventricular depolarization (the time it takes for the impulse to travel through the bundle branches to the Purkinje fibers).

The Q wave appears as the first negative deflection in the QRS complex; the R wave, as the first positive deflection. The S wave appears as the second negative deflection or the first negative deflection after the R wave.

J point and ST segment

Marking the end of the QRS complex, the J point also indicates the beginning of the ST segment. The ST segment represents part of ventricular repolarization.

T wave and U wave

Usually following the same deflection pattern as the P wave, the T wave represents ventricular repolarization. The U wave follows the T wave, but isn't always seen.

QT interval

The QT interval represents ventricular depolarization and repolarization. It extends from the beginning of the QRS complex to the end of the T wave.

Read More

What Are Involve at Planning of Care?

Planning involves three subsets: setting priorities, writing expected outcomes, and establishing target dates. Planning sets the stage for writing nursing actions by establishing where we are going with our plan of care. Planning further assists in the final phase of evaluation by defining the standard against which we will measure progress.

Setting Priorities
With the sicker, quicker problem discussed earlier, you are going to find yourself in the situation of having identified many more problems than can possibly be resolved in a 1- to 3-day hospitalization (today’s average length of stay). In the long-term care facilities, such as home health, rehabilitation, and nursing homes, long-range problem solving is possible, but setting priorities of care is still necessary.

Several methods of assigning priorities are available. Some nurses assign priorities based on the life threat posed by a problem. For example, Ineffective Airway Clearance would pose more of a threat to life than the diagnosis Risk for Impaired Skin Integrity. Some nurses base their prioritization on Maslow’s Hierarchy of Needs. In this instance, physiologic needs would require attention before social needs. One way to establish priorities is to simply ask the patient which problem he or she would like to pay attention to first. Another way to establish priorities is to analyze the relationships between problems. For example, a patient has been admitted with a medical diagnosis of headaches and possible brain tumor. The patient exhibits the defining characteristics of both Pain and Anxiety. In this instance, we might want to implement nursing actions to reduce anxiety, knowing that if the anxiety is not reduced, pain control actions will not be successful. Once priorities have been established, you are ready to establish expected outcomes.

Expected Outcomes
Outcomes, goals, and objectives are terms that are frequently used interchangeably because all indicate the end point we will use to measure the effectiveness of our plan of care.

Several guidelines for writing clinically useful expected outcomes:

1. Expected outcomes are clearly stated in terms of patient behavior or observable assessment factors.
2. Expected outcomes are realistic, achievable, safe, and acceptable from the patient’s viewpoint.
3. Expected outcomes are written in specific, concrete terms depicting patient action.
4. Expected outcomes are directly observable by use of at least one of the five senses.
5. Expected outcomes are patient centered rather than nurse centered.

Establishing Target Dates
Writing a target date at the end of the expected outcome statement facilitates the plan of care in several ways:

1. Assists in “pacing” the care plan. Pacing helps keep the focus on the patient’s progress.
2. Serves to motivate both patients and nurses toward accomplishing the expected outcome.
3. Helps patient and nurse see accomplishments.
4. Alerts nurse when to evaluate care plan.

Target dates can be realistically established by paying attention to the usual progress and prognosis connected with the patient’s medical and nursing diagnoses. Additional review of the data collected during the initial assessment helps indicate individual factors to be considered in establishing the date. For example, one of the previous expected outcomes was stated as “Accurately return-demonstrates self-administration of insulin by 9/11.”

The progress or prognosis according to the patient’s medical and nursing diagnosis will not be highly significant. The primary factor will be whether diabetes mellitus is a new diagnosis for the patient or is a recurring problem for a patient who has had diabetes mellitus for several years.

For the newly diagnosed patient, we would probably want our deadline day to be 5 to 7 days from the date of learning the diagnosis. For the recurring problem, we might establish the target date to be 2 to 3 days from the date of diagnosis. The difference is, of course, the patient’s knowledge base.

Now look at an example related to the progress issue. Mr. X is a 19-year-old college student who was admitted early this morning with a medical diagnosis of acute appendicitis. He has just returned from surgery following an appendectomy. One of the nursing diagnoses for Mr. X would, in all probability, be Pain. The expected outcome could be “Will have decrease in number of requests for analgesics by [date].” In reviewing the general progress of a young patient with this medical and nursing diagnosis, we know that generally analgesic requirements start decreasing within 48 to 72 hours. Therefore, we would want to establish our target date as 2 to 3 days following the day of surgery. This would result in the objective reading (assume date of surgery was 11/1): “Will have decrease in number of requests for analgesics by 11/3.”

To further emphasize the target date, it is suggested that the date be underlined, highlighted by using a different-colored pen, or circled to make it stand out. Pinpointing the date in such a manner emphasizes that evaluation of progress toward achievement of the expected outcome should be made on that date. In assigning the dates, be sure not to schedule all the diagnoses and expected outcomes for evaluation on the same date. Such scheduling would require a total revision of the plan of care, which could contribute to not keeping the plan of care current. Being able to revise single portions of the plan of care facilitates use and updating of the plan. Remember that the target date does not mean the expected outcome must be totally achieved by that time; instead, the target date signifies the evaluation date.

Once expected outcomes have been written, you are then ready to focus on the next phase—implementation. As previously indicated, the title supported by this book for this section is “Nursing Actions.”

Read More

Buying The Right Parts For Your Vehicle

Before you go shopping for some parts to replace those on your vehicle, read the tips in this section carefully. They can help you avoid what’s probably the most annoying part of any automotive job: disabling your vehicle to work on it only to find that you need it to drive back to the store to exchange the stuff they sold you in error!

To buy the proper parts for your vehicle, you must know its specifications (or “specs,” as they’re often called). Most of this information should be in your owner’s manual, and a lot of it is also printed on metal tags or decals located inside your hood. You can usually find these in front of the radiator, inside the fenders, on the inside of the hood — anywhere the auto manufacturer thinks you’ll find them. I know of one car that has its decal inside the lid of the glove compartment. These ID tags also provide a lot of other information about where the vehicle was made, what kind of paint it has, and so on.

The service manual for your vehicle should have the specs for the parts you need, and the parts department at your dealership or a reputable auto supply store can also look them up for you.

It’s a good idea to stick with parts from the same manufacturer as those that your vehicle originally came with. That brand may be listed in a service manual for your vehicle. If you don’t have a service manual, tell the sales clerk at the auto parts store that you want OEM (original equipment manufacturer) parts. Quality aftermarket parts are available as well, but unless you trust your parts seller’s recommendations, or you’ve already used a particular aftermarket brand and had good luck with it, stick with OEM parts.

If you can’t find specs for buying and gapping spark plugs in your owner’s or service manual or on your vehicle, just ask to the expert. 

When you go to buy parts, keep in mind that most professional mechanics get discounts at auto parts stores. Ask if you can get a discount given that you’re installing the parts yourself. It can’t hurt to try. Even if you don’t get a price break on parts, you’ll still be ahead of the game because you won’t have to pay labor charges.

 

Read More

How a Stethoscope Works

A stethoscope is a medical device for listening to sounds inside the body. The initial stethoscope was invented in the early 19th century by French physician René Laennec, but was actually trying to achieve a rather different end: doctor-patient distance. The stethoscope can be placed against the patient's chest to listen to her breath or heartbeat, or against the lower abdomen to listen to the intestines. On one end of the stethoscope is a diaphragm, a vibrating membrane designed to pick up sound. The diaphragm is connected to a hollow, air-filled tube. That tube splits in two and leads to earpieces, which the doctor wears.

When the heart beats or the lung fills with air, it produces small sound vibrations through the body. These vibrations are picked up and amplified by the diaphragm. The sound passes into the tube, which transfers it into the doctor's earpieces. There are also electrical stethoscopes, which use a kind of microphone to pick up and amplify the sound.

To understand how a stethoscope conveys, say, the "lub-lub" of a heart beat from a heart to a doctor's ears, we'll start with the core components of the tool.

 

Chestpiece: This is the part that contacts the patient, capturing sound. The chestpiece is constructed of metal and is typically double-sided to work for differently sized patients and different areas of the body. The chestpiece has deep cups that capture sounds from the target area and may be ringed with a "chill ring" to keep the patient from being uncomfortable when touched by the cold metal chestpiece. There are two sides of the chestpiece. On one side is the diaphragm, a flat, metal disc that in turn contains a flat, plastic disc. The diaphragm is the larger component of the chestpiece. On the other side is the bell, a hollow, bell-shaped piece of metal with a tiny hole on top. The bell is better at picking up low-pitch sounds, such as heart murmurs (the aforementioned "whoosh"); the diaphragm excels in the higher-pitch range, which includes normal breath sounds and heartbeats ("lub-lub").

 

Acoustic Tubes and Ear Tubes: A Y-shaped configuration of rubber tubesruns from the chestpiece to the headset. The sounds picked up by the chestpiece initially travel through a single tube, eventually splitting into two channels as they near the headset so the listener can hear it in both ears. Stethoscope tubing typically ranges from about 18 to 27 inches (45 to 68 centimeters) long. The acoustic tube connects the ear tubes to the chestpiece and is a flexible tube made of a rubberized material. The acoustic tubing can be filled with different materials to best transmit sound from the patient to the health-care provider. The ear tubes attach the earpieces to the main body of the stethoscope. They are typically constructed of metal and consist of hollow tubes that are ideally suited to transmitting low-frequency sound.

 

Earpieces/ Headset: The earpieces are fitted into the ears and are typically rubberized for comfort and to isolate from external sounds. They are designed to transmit sounds directly into the ears. The rubber tubing ends at a set of metal tubes that carry the sound to the eartips in the listener's ears. The eartips are made of soft rubber, not only for comfort but also to create a seal that helps block out environmental noise.

 

 

Read More

Essential Skills For Assessment In Nursing Process Steps

Assessment requires the use of the skills needed for interviewing, conducting a physical examination, and observing patients. As with the nursing process itself, these skills are not used one at a time. While you are interviewing the patient, you are also observing and determining physical areas that require a detailed physical assessment. While completing a physical assessment, you are asking questions (interviewing) and observing the patient’s physical appearance as well as the patient’s response to the physical examination.

Interviewing generally starts with gathering data for the nursing history. In this interview, you ask for general demographic information such as name, address, date of last hospitalization, age, allergies, current medications, and the reason the patient was admitted. Depending on the agency’s admission form, you may then progress to other specific questions or a physical assessment.

The physical assessment calls for four skills: inspection, palpation, percussion, and auscultation. Inspection means careful and systematic observation throughout the physical examination, such as observation for and recording of any skin lesions. Palpation is assessment by feeling and touching the patient. Assessing the differences in temperature between a patient’s upper and lower arm would be an example of palpation. Another common example of palpation is breast self-examination. Percussion involves touching, tapping, and listening. Percussion allows determination of the size, density, locations, and boundaries of the organs. Percussion is usually performed by placing the index or middle finger of one hand firmly on the skin and striking with the middle finger of the other hand. The resultant sound is dull if the body is solid under the fingers (such as at the location of the liver) and hollow if there is a body cavity under the finger (such as at the location of the abdominal cavity). Auscultation involves listening with a stethoscope and is used to help assess respiratory, circulatory, and gastrointestinal status.

The physical assessment may be performed using a head-to-toe approach, a body system approach, or a functional health pattern approach. In the head-to-toe approach, you begin with the patient’s general appearance and vital signs. You then progress, as the name indicates, from the head to the extremities.

The body system approach to physical assessment focuses on the major body systems. As the nurse is conducting the nursing history interview, she or he will get a firm idea of which body systems need detailed examination. An example is a cardiovascular examination, where the apical and radial pulses, blood pressure (BP), point of maximum intensity (PMI), heart sounds, and peripheral pulses are examined.

The functional health pattern approach is based on Gordon’s Functional Health Patterns typology and allows the collection of all types of data according to each pattern. This is the approach used by this book and leads to three levels of assessment. First is the overall admission assessment, where each pattern is assessed through the collection of objective and subjective data. This assessment indicates patterns that need further attention, which requires implementation of the second level of pattern assessment. The second level of pattern assessment indicates which nursing diagnoses within the pattern might be pertinent to this patient, which leads to the third level of assessment, the defining characteristics for each individual nursing diagnosis. Having a three-tiered assessment might seem complicated, but each assessment is so closely related that completion of the assessment is easy. A primary advantage in using this type of assessment is the validation it gives to the nurse that the resulting nursing diagnosis is the most correct diagnosis. Another benefit to using this type of assessment is that grouping of data is already accomplished and does not have to be a separate step.

 

Read More

Care Plan Or Planning Of Care?

Revisions of nursing standards created questions regarding the necessity of nursing care plans. Some have predicted the rapid demise of the care plan, according to Brider, but review of the revised nursing standards shows that the standards require not less but more detailed care planning documentation in the patient’s medical record.

Review of the new criteria indicates that the standards require documentation related to the nursing process. For example, the plan of care statement reads:

A plan, based on data gathering during patient assessment, that identifies the patient’s care needs, tests the strategy for providing services to meet those needs, documents treatment goals or objectives, outlines the criteria for terminating specified interventions, and documents the individual’s progress in meeting specified goals and objectives. The format of the “plan” in some organizations may be guided by patient-specific policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. The plan of care may include care, treatment, habilitation and rehabilitation.

Rather than eliminating care plans, the requirements call for a more specific as well as a more permanent documentation of the plan of care. This documentation must be in the medical record. The standard indicates that a separate care plan form is no longer necessary; however, the standard also still allows a separate care plan form. Various institutions are now testing flexible ways of documenting care planning. The care plan is not dead; rather, it is revised to more clearly reflect the important role of nursing in the patient’s care. No longer a separate, often discarded, and irrelevant page, the plan of care must be part of the permanent record. The flow sheets developed for this book offer guidelines for computerizing information regarding nursing care.

Faculty can use the revised standards to assist students in developing expertise beyond writing extensive nursing care plans. This additional expertise requires the new graduate to integrate all phases of the nursing process into the permanent record. Rather than eliminating the need for care planning and nursing diagnosis, the standards have reinforced the importance of nursing care and nursing diagnosis.

 

Read More

Care Plan For Decreased Cardiac Output

Nursing diagnosis for decreased cardiac output may be related to altered myocardial contractility, inotropic changes; alterations in rate, rhythm, electrical conduction; or structural changes, such as valvular defects and ventricular aneurysm.

It is possibly evidenced by increased heart rate (tachycardia), dysrhythmias, ECG changes; changes in BP (hypotension, hypertension); extra heart sounds (S3, S4); decreased urine output; diminished peripheral pulses; cool, ashen skin and diaphoresis; orthopnea, crackles, JVD, liver engorgement, edema; or chest pain

Desired outcomes for this nursing diagnosis are, client will have Cardiac Pump Effectiveness-NOC by evaluation criteria

• Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example, hemodynamic parameters within acceptable limits and urinary output adequate.

• Report decreased episodes of dyspnea and angina.

Client also will have Cardiac Disease Self-Management-NOC by evaluation criteria Participate in activities that reduce cardiac workload.

Possible intervention : Hemodynamic Regulation-NIC by action such as

• Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available. Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm.

• Note the heart sounds. S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant, distended chambers.

• Palpate peripheral pulses. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans may be present.

• Inspect skin for pallor and cyanosis. Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent
  areas are often blue or mottled as venous congestion increases.

• Monitor urine output, noting decreasing output and dark or concentrated urine. Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues, but may be increased at night because fluid returns to circulation when client is recumbent.

• etc.

 

 

Read More

Gorengan Lezat Namun Biang Kolesterol?

Beberapa orang menyebutkan bahwa makanan yang digoreng adalah musuh bagi tubuh... Benarkah? Pada dasarnya tubuh kita juga memerlukan kolesterol dengan kadar tertentu, namun kandungan minyak untuk menggoreng biasanya bisa menyebabkan naiknya kolesterol jahat (LDL). 
Apakah semua minyak goreng pasti mengandung lemak jenuh penyebab kolesterol...? 
Ada cara lho yang dapat kita lakukan agar tubuh tetap sehat meski suka sekali makan goreng-gorengan. Diantaranya adalah menggunakan minyak untuk menggoreng dua kali atau tiga kali saja, tiriskan makanan setelah digoreng dan letakkan pada kertas yang dapat menyerap kadar minyak dalam makanan, jangan terlalu sering mengkonsumsi gorengan di penjual pinggir jalan, gunakan minyak zaitun atau minyak dengan kadar lemak jenuh yang rendah.

Selanjutnya terserah Anda.

Read More

Electrocardiography: Equipment Preparation

One of the most valuable and frequently used diagnostic tools, electrocardiography (ECG) measures the heart's electrical activity as waveforms. Impulses moving through the heart's conduction system create electric currents that can be monitored on the body's surface. Electrodes attached to the skin can detect these electric currents and transmit them to an instrument that produces a record (the electrocardiogram) of cardiac activity.

ECG can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and drug toxicity.
The standard 12-lead ECG uses a series of electrodes placed on the extremities and the chest wall to assess the heart from 12 different views (leads). The 12 leads consist of three standard bipolar limb leads (designated I, II, III), three unipolar augmented leads (aVR, aVL, aVF), and six unipolar precordial leads (V1 to V6). The limb leads and augmented leads show the heart from the frontal plane. The precordial leads show the heart from the horizontal plane.
The ECG device measures and averages the differences between the electrical potential of the electrode sites for each lead and graphs them over time. This creates the standard ECG complex, called PQRST. The P wave represents atrial depolarization; the QRS complex, ventricular depolarization; and the T wave, ventricular repolarization. (See Reviewing ECG waveforms and components.)

Variations of standard ECG include exercise ECG (stress ECG) and ambulatory ECG (Holter monitoring). Exercise ECG monitors heart rate, blood pressure, and ECG waveforms as the patient walks on a treadmill or pedals a stationary bicycle. For ambulatory ECG, the patient wears a portable Holter monitor to record heart activity continually over 24 hours.
Today, ECG is typically accomplished using a multichannel method. All electrodes are attached to the patient at once, and the machine prints a simultaneous view of all leads.

Equipment
ECG machine ; recording paper ; disposable pregelled electrodes ; 4″ × 4″ gauze pads ; optional: clippers, marking pen.

Preparation of equipment
Place the ECG machine close to the patient's bed, and plug the power cord into the wall outlet. If the patient is already connected to a cardiac monitor, remove the electrodes to accommodate the precordial leads and minimize electrical interference on the ECG tracing. Keep the patient away from objects that might cause electrical interference, such as equipment, fixtures, and power cords.

Read More

Cardiovascular Disorders: The Leading Cause of Death

The responsibility of caring for patients with these disorders pervades nearly every area of nursing practice. As a result, cardiovascular care ranks as one of the most rapidly growing areas of nursing. In addition, it's one of the most rapidly changing fields, with the continuing proliferation of new diagnostic tests, new drugs and other treatments, and sophisticated monitoring equipment. Consequently, nurses face a constant challenge to keep up with the latest developments.

Today, nurses assume much of the responsibility for preparing patients physically and psychologically for their hospitalization and ongoing care. Specifically, they play a pivotal role in teaching patients and their families about test and procedure preparation and follow-up care, drugs and other treatments, disease prevention, and lifestyle modification. Through patient teaching, nurses can help patients reduce stress and comply with prescribed therapy.

Cardiac and hemodynamic monitoring represent critical cardiovascular care responsibilities. Cardiac monitoring involves either hardwire or telemetric systems that continuously record the patient's cardiac activity. This makes monitoring useful not only for assessing cardiac rhythm, but also for gauging a patient's response to drug therapy and for preventing complications associated with diagnostic and therapeutic procedures. Once used only in critical care areas, cardiac monitoring is now performed in high-risk obstetric, general medical, pediatric, and transplantation departments.

Similarly, hemodynamic monitoring has become more widely used since its inception in the 1970s. It uses invasive techniques to measure pressure, flow, and resistance within the cardiovascular system. Made with a pulmonary artery (PA) catheter, these measurements are used to guide therapy. Hemodynamic monitoring includes pulmonary artery pressure monitoring, cardiac output measurement, right ventricular ejection fraction and volume measurement, temporary pacing through the PA catheter, and continuous evaluation of mixed venous oxygen saturation.

In cardiovascular emergencies, nurses may perform or assist with cardiopulmonary resuscitation, defibrillation, cardioversion, and temporary pacing. Carrying out these life-saving procedures calls for in-depth knowledge of cardiovascular anatomy, physiology, and equipment as well as sound assessment and intervention techniques. Only nurses with up-to-date information and sharpened skills can provide safe, effective patient care.

Read More

Focus Charting System As Nursing Documentation Tool

The Focus Charting system has been designed by nurses for documentation of frequent/repetitive care and to encourage viewing the client from a positive rather than a negative (problem only) perspective. Charting is focused on client and nursing concerns, with the focal point of client status and the associated nursing care. A Focus is usually a client problem/concern or nursing diagnosis but is not a medical diagnosis or a nursing task/treatment (e.g., wound care, indwelling catheter insertion, tube feeding).

We track what is happening to the client at any given moment by recording of assessment, interventions, and evaluation using Data, Action, and Response (DAR) categories. Thus, the four components of this charting system are:

1. Focus: Nursing diagnosis, client problem/concern, signs/ symptoms of potential importance (e.g., fever, dysrhythmia, edema), a significant event or change in status or specific standards of care/agency policy.
2. Data: Subjective/objective information describing and/or supporting the Focus.
3. Action: Immediate/future nursing actions based on assessment and consistent with/complementary to the goals and nursing action recorded in the client plan of care.
4. Response: Describes the effects of interventions and whether the goal was met.

You can find charting examples that based on the data within the client situation by using google search.

Read More

Basic Procedures That Must Be Understood By Every Nurse

Patients come to the hospital and other health facilities because they require skilled clinical observation and treatment. Millions of people hospitalized each year, and for the most part, it was a trying experience. Inpatient care dealing with patients' needs for privacy and control of his life. He should release at least part of the normal routine. He had to rely on you and your co-workers to meet basic needs. Depending on the complexity of health problems, he and his family may also require teaching, counseling, coordination of care, development of community support systems, and help in coping with changes related to health in his life.

Some broader aims of your care are helping the patient cope with restricted mobility; giving him a comfortable, stimulating environment; making sure his stay is free from hazards; promoting an uneventful recovery; and helping him return to his normal life.

Each time the patient's condition deter or prevent mobility, then your nursing goals include promoting independence by motivating him, helped him set goals, to prevent injury and complications of immobility, he teaches the skills needed, and encourage a positive body image, especially if he faces a long term or permanent immobility.

Besides weakening the patient, illness and any accompanying treatment may impair his judgment and contribute to accidents. Be alert to hazards in the patient's environment, and teach him and his family to recognize and correct them. When caring for a patient with restricted mobility, you must help him as he's moved, lifted, and transported. By using proper body mechanics and appropriate assistive devices, you can prevent injury, fatigue, and discomfort for the patient and yourself. To prevent complications, be sure to use correct positioning, meticulous skin care, assistive devices, and regular turning and range-of-motion exercises.

The first step toward rehabilitation typically is progressive ambulation, which should begin as soon as possible if necessary, using such assistive devices as a cane, crutches, or a walker. Demonstrating a technique such as transferring from a bed to a wheelchair during hospitalization helps the patient and his family to understand it. Allowing them to practice it under your supervision gives them the confidence to perform it at home. Encourage them to provide positive reinforcement to motivate the patient to work toward his goals.

 

Read More

To Care for Others

To care for others.

Read More