Ward Class

An Online Resource Site For Student Nurses

Welcome

Ward Class is an online resource for student nurses. Created with the aim of helping student nurses cope with the demands of nursing school and clinicals, it offers free downloads, notes, sample NCPs, sample drug studies, study aids, news and updates, and practical tips to its users.

Site Announcement

The December 2012 PRC Nursing Board Exam Result is already available here at Ward Class and at Pinoy R.N.




Good Luck to all June 2008 NLE Candidates!


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Good Luck!
You're cooler and bigger than the Nursing Board Exams!
Hugs and Kisses
!

--CyNurse and Lyle, RN | Ward Class and Pinoy R.N.

Lymphatic Filariasis (Elephantiasis)


  • Lymphatic Filariasis, also known as Elephantiasis, is a disease which affects more than 120 million people in 80 different countries and a leading cause of permanent disability worldwide.
  • It is a parasitic disease caused by microscopic, thread-like worms.
  • Lymphatic Filariasis is prevalent in tropical and subtropical areas esp. in areas where there is rapid and unplanned growth cities that often result in the creation of numerous breeding sites for mosquitoes that transmit the disease.
Cause
  • Filariasis is caused by thread-like, parasitic filarial (slender, parasitic nematode worms) worms Wuchereria bancrofti and Brugia malayi that live almost exclusively in humans
  • Wuchereria bancrofti and Brugia malayi worms live in the human lymphatic system, live for 5-7 years and produce millions of microfilariae or minute larvae that circulate in the blood.
Transmission
  • Lymphatic Filariasis is spread from person to person by mosquito bites. When a mosquito bites a person infected with lymphatic filariasis, microfilariae in the person's blood enters the mosquito. The microscopic worms develop inside the mosquito for 7-21 days and then migrates to the mosquito's mouth parts. When the infected mosquito bites a person, the microscopic worms enters the person's punctured skin where they travel to the lymph vessels where they grow as adults and live for more than 5 years, mate, and release millions of microscopic worms that circulate in the person's blood.
Signs and Symptoms
  • enlargement of the entire leg and/or the entire arms
  • hydrocoele (fluid-filled balloon-like enlargement of the sacs around the testes) and enlargement of the scrotum and penis in men
  • enlargement of the vulva and breasts in women
  • acute bacterial infections in the skin
  • pulmonary symptoms: cough, wheezing, shortness of breath
  • high levels of IgE (Immunoglobulin E) and antifilarial antibodies in the blood
Diagnosis
  • The new development of a very sensitive, very specific simple "card test" to detect circulating parasite antigens without the need for laboratory facilities and using only finger-prick blood droplets taken anytime of the day has completely transformed the approach to diagnosis.
  • The standard method for diagnosing active infection is the identification of microfilariae by microscopic examination. This is difficult as microfilariae are nocturnally periodic, which means that they only circulate in the blood at night. Thus, the blood collection has to be done at night to coincide with the appearance of the microfilariae.
Prevention
  • Mosquito bites should be avoided, especially between dusk and dawn. It is best to sleep under a mosquito net, wear long sleeves and trousers, and use mosquito repellent on exposed skin.
  • Communities may be given medicines that kills microscopic worms through an annual mass treatment program. This reduces the level of microfilariae in the blood and thus, diminishes transmission of infection.
Treatment
  • Diethylcarbamazine (DEC) is the drug of choice for persons currently infected with the parasite-->kills microfilariae and some adult worms in the blood-->prevents transmission of the disease from one person to another
  • For patients with lymphedema, the following is recommended by a lymphedema therapist:
  1. Carefully wash the swollen area with soap and water every day.
  2. Elevate and exercise the swollen arm or leg to move the fluid and improve the lymph flow.
  3. Disinfect any wounds. Use antibacterial or antifungal cream if necessary.
  • The treatment for hydrocoele is surgery.
Related Link:
DOH: National Filariasis Elimination Program

DOH: National Filariasis Elimination Program

Filariasis, more commonly known as elephantiasis, is a major parasitic infection which continues to be a public health problem in the Philippines. It is a painful and profoundly disfiguring disease which has a major economic and social impact on endemic regions.

Filariasis is prevalent in remote rural areas and in economically disadvantaged urban areas. Globally, the number of cases has increased due to worsening poverty. And since Filariasis is incapacitating to patients, it also prevents patients from having a normal working life, adversely affecting economic conditions at different levels.

The Department of Health, in collaboration with the World Health Organization, formulated the National Filariasis Elimination Program. The program's main objective is to eliminate Filariasis through its Mass Annual Treatment strategy and the creation of the National Advisory Group for Filariasis. This drive to eliminate the disease, started in 1963 and revitalized in 2000, is currently ongoing.

To learn more about the National Filariasis Elimination Program, click on the download link provided below.

File Download:
DOH: National Filariasis Control Program


Res Ipsa Loquitur

Res ipsa loquitur is a legal term which means "the thing itself speaks" but is often translated "the thing speaks for itself". It is used in actions for injury by negligence and signifies that no further details are necessary as the happening itself is accepted as proof.

The doctrine of res ipsa loquitur is applied to tort (a civil wrong or injury) claims and is useful to the plaintiff (one who brings an action in a court of law) in certain negligence cases. However, to invoke the doctrine of res ipsa loquitur in the context of negligence, the plaintiff must prove that:
  1. The injury would not ordinarily have occurred without someone's negligence.
  2. The instrumentality which caused the injury was under the exclusive control of the defendant during the time of the likely negligent act.
  3. The plaintiff's voluntary or involuntary actions did not contribute to the injury.

In her book Professional Nursing in the Philippines, Lydia M. Venzon cites the following examples of obvious negligence wherein a defendant's negligence is established under the doctrine of res ipsa loquitur:
  1. A patient came in walking to the out-patient clinic for injection. After injection was administered to his buttocks, the patient experienced extreme pain, leg weakness, and was subsequently paralyzed.
  2. The presence of sponges in the patient's abdomen after an operation.
  3. Fracture on a newly-delivered baby born by breech presentation.

Furthermore, it is important to note that res ipsa loquitur is not synonymous with prima facie, another legal exression. Prima facie is a term which means "the matter seems obvious and self-explanatory". Res ipsa loquitur, on the other hand, is the legal argument which means "that because it is so obvious, the plaintiff need not explain further to prove the defendant's liability". For example:

There is a prima facie case that the defendant is liable. The patient consented to an appendectomy and the surgeon removed the patient's appendix. After a week, the patient sought medical consultation due to severe stomach pains. Serial radiologic studies reveal that sponges were left inside the patient's abdomen. Res ispsa loquitur.

Indeed, it requires no further explanation to establish that a surgeon who performs appendectomy and leaves sponges inside a patient's abdomen after the operation is negligent as there is no legitimate reason for him to do so.

Sample NCP for Pernicious Anemia

Here is a sample NCP for Pernicious Anemia to supplement the review notes on the disease published last month.

Since there are different types of anemia, nursing care for the patient with the condition may revolve around the same goals even though medical treatments may vary. For instance, the nursing diagnosis Activity Intolerance related to imbalance between oxygen supply and demand is applicable to patients with Pernicious Anemia, Iron Deficiency Anemia, Hemolytic Anemia, or Aplastic Anemia. Still, interventions such as administering Vitamin B12 injections are planned specifically for patients with Pernicious Anemia due to a deficiency in vitamin B12 resulting from a loss of intrinsic factor, a defining characteristic of the disease.

Before preparing an NCP for Pernicious Anemia, nursing students should remember that it is a hematologic disorder that affects tissue perfusion. Hence, the nursing goals when preparing a nursing care plan for a patient diagnosed with this disorder should include prevention of complications and the patient performing ADLs (with or without assistance of others).

NCP Download:
Sample NCP for Pernicious Anemia

Related Link:
Hematologic Disorders: Pernicious Anemia

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DOH: National TB Control Program

According to the World Health Organization in their Global Tuberculosis Control Report for 2008, Tuberculosis is still a major cause of illness and death worldwide. A total of 9.2 million new cases were recorded in 2006 alone as population growth has boosted both prevalence and death rates.

Globally, the Philippines ranks fourth as to the number of recorded TB cases and in Southeast Asia, has the highest number of TB cases per capita. Approximately 5 million cases are reported each year and an estimated 2/3 of the Philippine population is infected with the disease.

In line with the WHO's goal to halt and reverse the incidence of TB by 2015, the Department of Health formulated the National TB Control Program . This program utilizes the Directly Observed Treatment Short Course (DOTS) which was initiated by the WHO in 1996.

Under the National TB Control Program, the Department of Health, in collaboration with LGUs, PhilCAT, and Philhealth, organized the TB Network which is dedicated to help TB patients. The goal of the TB Network is to increase yearly case detection and cure rates in accordance with the benchmarks set by the National TB Control Program.

To learn more about the National TB Control Program, DOTS, and TB Network, click on the download link below.

File Download:
DOH: National TB Control Program


Respiratory Disorders: Cystic Fibrosis

  • a disease in which there is a generalized dysfunction of the exocrine glands
  • mucus secretions of the body, particularly in the lungs and pancreas, have difficulty flowing through gland ducts
  • also characterized by a marked electrolyte change-->sweat and saliva have high levels of sodium chloride
  • an autosomal recessive trait, caused by an abnormality in the long arm of chromosome 7-->results in an inability to transport small molecules across cell membranes-->leads to dehydration of the epithelial cells in the airway and pancreas
  • most common lethal genetic disease among Caucasians in United Sates and Europe
Assessment Findings
  • Extent of Organ Involvement
    • Pancreas-->85% of clients with cystic fibrosis (CF) have pancreatic involvement
      • ducts are obstructed leading to fibrosis and atrophy of pancreas and eventual little or no release of pancreatic enzymes (lipase, amylase, trypsin)
      • malabsorption of fats and proteins due to absence of enzymes
      • steatorrhea-->foul-smelling, greasy stools
      • failure to thrive due to loss of nutrients and inability absorb fat-soluble vitamins (A, D,E,K)
    • Respiratory Tract-->99.9% of clients with CF have respiratory involvement
      • increased production of secretions causes airway obstruction
      • pulmonary congestion leads to cor pulmonale
      • death occurs by drowning in own secretions
    • Reproductive System
      • males are sterile
      • increased mucus in vaginal tract of females make conception difficult
      • pregnancy increases stress on respiratory system of females with CF
    • Liver
      • One-third of clients with CF develop portal hypertension/cirrhosis
  • Signs and Symptoms
    • Pancreas
      1. growth failure
      2. large, foul-smelling, fatty stools (steatorrhea)
      3. meconeum ileus-->blockage of intestines in newborns, usually first sign
      4. rectal prolapse--often caused by stools that are difficult to pass or frequent coughing
      5. voracious appetite
      6. protruding abdomen (caused by bulk of feces in intestines) and thin extremities and buttocks
      7. symptoms of ADEK deficiency (night blindness, dry skin, rickets, he,olysis of RBCs, bleeding tendencies, and fractures)
      8. anemia
      9. diagnostic tests:
        • duodenal contents contain little or no trypsin
        • increased fecal fat in stool specimen
    • Respiratory System
      1. signs of respiratory distress (nasal flaring, open-mouthed breathing, wheezing, use of accessory muscles when breathing)
      2. frequent productive cough
      3. frequent pseudomonas infections
      4. nasal polyps
      5. barrel chest-->due to air trapping
      6. clubbing of fingers
      7. activity intolerance
      8. diagnostic tests
        • chest x-ray-->atelectasis (collapse of lung tissue), infiltration, emphysemic changes
        • abnormal pulmonary function studies
        • ABG reveals respiratory acidosis
    • Electrolytes
      1. hyponatremia in hot weather
      2. salty taste to sweat-->due to high levels of NACL in sweat
      3. diagnostic tests: pilocarpine iontophoresis sweat test reveals elevated NACL (2-5x higher than normal)
Medical Management
  1. bronchodilators-->medications such as albuterol, delivered by an inhaler or a nebulizer, helps keep airway patent.
  2. antibiotics-->given for frequent Pseudoman infections
  3. chest physioterapy.
  4. oral enzymes and better nutrition-->Pancrease, Cotazym, Viokase-->given with meals and snacks
  5. diet modifications-->high-calorie, high-protein, low-fat diet for older children; predigested formula for infants
  6. ibuprofen (Advil, Motrin, others) may slow lung deterioration in some children with cystic fibrosis
Surgical Management

Lung transplantation for severe breathing problems, life-threatening pulmonary complications or increasing resistance to antibiotics used to treat lung infections.

Nursing Management
  1. administer pancreatic enzymes with meals as ordered-->do not mix until ready to use ; best mixed with applesauce
  2. administer antibiotics, expectorants, and mucolytics as ordered
  3. avoid cough suppressants and antihistamines-->respiratory goal for patients with CF is to cough up secretions
  4. provide diet high in calories, protein, but normal in fat; no empty calories
  5. add salt to meals esp. during summer; give salty snacks such as pretzels
  6. provide vitamins ADEK in water-soluble form; other vitamins may be doubled as ordered
  7. encourage coughing and breathing exercises
  8. provide percussion and drainage at least 4 times a day
  9. provide aerosol treatments as ordered (nebulizers, mist tent)
  10. provide client teachings and discharge planning concerning:
    • counseling
      • for parents of child with CF, focus on CF being genetic disorder so it may be passed on to any future children
      • for older clients: focus on marriage and intimacy issues; provide resources on fertility evaluation, genetic, and financial counseling
    • promotion of client's independence
    • avoidance of environmental triggers-->cigarette smoke, pollution, sources of infections
    • availability of support groups and community agencies
    • education for clients -->focus on home education during hospitalization or home recovery; give appropriate referrals to concerned agencies
Prognosis

Cystic Fibrosis is fatal in early life but with early detection and treatments, 50% of infants with CF live past 28 years of age. With lung transplantation, full life expectancy has increased.

Prevention

Cystic Fibrosis is not preventable.

Note: Although Cystic Fibrosis affects the lungs, pancreas, and liver, most reference books categorize it as a respiratory disorder.

Related Link:
Sample NCP for Cystic Fibrosis


Prayer to St. Joseph of Cupertino for Success in the June 2008 Nurse Licensure Examination

Barely nine days into the June 2008 Nurse Licensure Examination, this blogger thinks we should give the examinees every bit of help we can extend. Considering the number of practicing Roman Catholics in the Philippines, well-wishers and candidates alike are probably searching the internet for prayers for success in the aforementioned nursing licensure examinations.

According to EWTN.com, the largest religious media network in the world, the patron saint for weak students and examinees is St. Joseph of Cupertino. Born in 1603, Joseph of Cupertino was called The Dunce for he was the dullest person in their village. He was so dumb and absent-minded that nobody wanted him. When he was 17, knowing he was incapable of learning anything, Joseph of Cupertino decided to become a begging friar. He was a failure at the Franciscan monastery he applied with as he was deemed unsuitable, the nitwit that he was. With the help of his mother, Joseph gained readmission at the monastery not as a brother but as a servant.

As a servant, Joseph attended to the Franciscans wholeheartedly and his devotion and kindness made them reconsider their previous decision. Despite trying hard in his studies, Joseph only learned one thing, St. Luke's "Beater venter qui te portavit", the only text in the Bible he can expound on eloquently. To be conferred the diaconate, he had to pass an examination in the presence of the bishop. During the examination day, the bishop opened the Bible and asked Joseph to discourse on "Beater venter qui te portavit." Joseph began and to everyone's surprise, he had so much to say. He was also ordained into priesthood this way. He was so lucky to be asked only the things he knew and was never asked those he did not know of.

Hence, it is only fitting that St. Joseph of Cupertino be the Patron Saint of Examinees. And as our gift to our beloved candidates, here is the prayer to St. Joseph of Cupertino:

O St. Joseph of Cupertino who by your prayer obtained from God to be asked at your examination, the only preposition you knew.

Grant that I may like you succeed in the June 2008 Nurse Licensure Examination

In return I promise to make you known and cause you to be invoked.

O St. Joseph of Cupertino pray for me

O Holy Ghost enlighten me

Our Lady of Good Studies pray for me

Sacred Head of Jesus, Seat of divine wisdom, enlighten me.

Candidates may want to offer this prayer before the exam so that the only questions that will be asked are on topics they know by heart. It is also this blogger's fervent hope that they will be enlightened as St. Joseph of Cupertino was during his time.


On Student-related Errors During Clinical Rotations


During clinical rotations, student nurses provide direct patient care and are instrumental in enriching patient's experiences during hospitalization. However, there are instances when student nurses find themselves committing errors, most of them medication-related. In her book Professional Nursing in the Philippines, Lydia M. Venzon discussed measures on how to avoid or minimize student-related errors. Below is an excerpt of what Venzon wrote in her book:

Under the Philippine Nursing act of 2002 R.A. 9173, nursing students do not perform professional nursing duties. They are to be supervised by their Clinical Instructors. In order that the errors committed by nursing students will be avoided and/or minimized, the following measures should be taken:

  1. Nursing students should always be under the supervision of their Clinical Instructors.
  2. They should be given assignments that are at their level of training, experience, and competency.
  3. They should be advised to seek guidance especially if they are performing a procedure for the first time.
  4. They should be oriented to the policies of the nursing unit where they are assigned.
  5. Their performance should be assessed frequently to determine their strengths and weaknesses.
  6. Frequent conferences with the students will reveal their problems which they may want to bring to the attention of their instructors or vice versa. Discussions of these problems will iron out doubts and possible solutions may be provided.
This blogger was once a nursing student and went through a very unsettling FIRST day of clinicals. Imagine being assigned to a patient diagnosed with Liver Cirrhosis who vomits blood due to esophageal varices and whose IV fluids you have to attend to even if you are entirely clueless on regulating intravenous flow rates. Worse, you can't find your clinical instructor and the staff nurse you're assigned to is the most 'student-unfriendly' in that institution.

On a more positive note, that fateful day passed without a major slip-up from this blogger's end. And so, if ever you figure in a similar situation during clinicals, always seek for guidance from your instructor or the staff nurses in the unit. If they get a little cranky, just take a deep breath and think of happy childhood memories. If they are inattentive, be persistent. Never mind if you get chewed out for doing so. Because it is always better to be safe than sorry.

Note: Image courtesy of Nurstoon.com

Eating to Succeed: Tips for the June 2008 Nurse Licensure Examination

With the June 2008 Nurse Licensure Examination fast approaching, we can just imagine how tired and anxious our beloved test-takers must be right now. We can almost see you depleting your energy reserves with all the formal review classes you attend, the study group sessions you join, the supplemental readings you do at home, and all those fatty and sugar-laden food and snacks you consume hurriedly in trying to make the most out of your study sessions.

We know for certain that reviewing is so taxing and you need to boost your energy levels so we came up with tips to help you eat right as you prepare for the June 2008 NLE.
  • Have a healthy breakfast. Ditch your weight-loss diet plan for a moment and focus on eating foods that will keep you energetic throughout the day. Having cereals with some fruit and protein is a healthy way to start your day. Stay away from oily and sugary foods as they will make you sluggish in a matter of hours.
  • Eat small-sized meals. The idea here is to maintain your energy levels by eating small amounts of food every 3 to 4 hours. Eating small meals spaced out throughout the day is better than consuming 3 large meals as the latter will only make you drowsy and unable to concentrate on your review.
  • Eat healthy amounts of carbohydrates, proteins, and fats. Do not eliminate a certain food group from your diet as all three are essential in boosting your energy levels. Carbohydrates will be your main energy source and proteins and fats act as energy reserves and will help keep you sated throughout the day.
  • Incorporate fiber into your diet. Fruits and vegetables are your ever-important fiber sources. Fiber will help you last the day by maintaining sugar levels in your body . Snacking on fruit will also promote regular elimination patterns. You don't want to be constipated from this day onward, do you?
  • Think Omega-3. Omega-3 fatty acids such as those found in tuna and salmon will improve cognitive function and enhance information processing.
  • Maintain hydration. As examination day draws near, make sure to drink lots of fluids to keep you hydrated. You can also have fruit juices to keep you noursihed and fresh throughout those long hours of studying.
  • Keep caffeine intake in moderation. Two to three cups of coffee per day (approximately 200 to 300 mg of caffeine) will help improve concentration and set the setting, so to speak. Beyond that will adversely affect your sleeping pattern such that you won't be able to stick to your study plan the following day.
The next time you reach for that slice of pizza or that bag of potato chips, think of all those months you spent preparing and reviewing for the exams. You are just a few days away from your goal and in order to get there, you have to be a 'smart eater' and start 'eating to succeed'.


Sample NCP for Cystic Fibrosis

Here is a sample NCP for Cystic Fibrosis, a life-threatening inherited disorder causing severe damage to the lungs and nutritional deficiencies.

Before preparing an NCP for Cystic Fibrosis, you might want to consider the following points:
  • Cystic Fibrosis is most oftenly treated as a pediatric respiratory disorder although patients now have a 50% chance to live past 28 years of age.
  • Cystic Fibrosis is an inherited and long-term illness,considered fatal in early life, affecting various organs and systems so when identifying nursing problems, you NEED to prioritize. Always think ABC and Maslow.
  • When preparing the assessment part of your nursing care plan, make sure to keep your patient in mind. For example, when including tachypnea as part of your assessment for a school-aged child, remember that the normal respiratory rate in children is faster than in adults.
  • When including genetic counseling and fertility evaluation as part of your discharge planning and patient teachings (if writing an NCP for an adolescent or an adult client, that is), make sure you read something on it. Hint: Young adults with cystic fibrosis have to deal with marriage and intimacy issues.
NCP Download:

New BSN Curriculum

Effective June 2008, Philippine Nursing Schools and Colleges will follow the new Bachelor of Science in Nursing Curriculum as promulgated by the Commission on Higher Education (CHED).

This is a laudable effort on the part of CHED and the members of the Technical Committee on Nursing Education as the new BSN Curriculum is undeniably more focused and well-constructed compared to the old one (of which this blogger was a product of).

But the question is, what's in it for nursing students? Since we did a quick comparison of the new curriculum with its predecessor, the following changes were noted:
  • Addition of Theoretical Foundations In Nursing as a new subject. This is a very good preparation for the nurse licensure examination. Students won't have to cram lots of information on the nursing theories and respective proponents when they review for the boards. Fifty-four (54) lecture hours will be spent on discussing the contributions of 22 nursing theorists (some names I don't even recognize) on their first semester. Imagine that!
  • The course name for NCM 100 is no longer Foundations of Nursing but Fundamentals of Nursing Practice. Furthermore, it will no longer be limited to the discussion of Nursing as a Profession, Science, and Art. NCM 100 will cover among others:
    • history of nursing, growth of professionalism
    • overview of professional nursing practice including Benner's level of proficiency, roles and responsibilities of a professional nurse, RA 9173, nursing ethics, and legal concepts in nursing
    • fields of nursing
    • communication skills
    • nursing process
    • health and illness
    • basic nursing interventions
    • meeting needs related to grief and dying
  • Health Assessment. Thirty-six (36) lecture hours and fifty-one (51) laboratory hours will be spent going over topics such as health history taking and functional assessments using APGAR, MDSI, and other indexes. Review of systems, conducting PE, assessment during pregnancy, and patient education will also be covered. This is a very good preparation for Maternal and Child Nursing and Medical-Surgical Nursing.
  • Community Health Nursing as a stand-alone subject. Students will spend the whole semester covering topics such as the DOH Public Health Programs, community development, and theories of health promotion among others.
  • The inclusion of Diet Therapy in Nutrition. Nutrition as a nursing subject will no longer be Basic Nutrition and Dietetics. It will be aptly called Nutrition with Diet Therapy. This is a solid move to better equip students on the essentials of providing appropriate health teachings to their clients. The course outline on NuDiet is very specific, basics of nutrition as well as the dietary management of medical conditions and tube feedings will be covered.
  • Nursing Informatics. We are not sure if this is a replacement for basic computer education subjects but assuming it is, this is one bold move on the part of the Technical Committee on Nursing Education. Basing on the course outline, it will cover theories on nursing informatics, application of informatics in nursing practice and research, and the different international perspectives. Students will also be introduced to the use of PDA and other wireless devices-- true Techie Nurses of the 21st Century!
  • Addition of Competency Appraisal Subjects (CA 1 and 2). These subjects cover the core competencies under the 11 areas of responsibility and different nursing scenarios integrating learnings previously acquired.
  • NCM 106 and NCM 107. You guessed it right. The nursing curriculum doesn't end at NCM 105. The new BSN curriculum gives special attention to specific areas. Psychiatric Nursing and care of clients with exception and coordination problems are covered in NCM 104 and no longer lumped with other topics. NCM 106 covers cellular aberrations, acute biologic crisis, problems in inflammatory and immunologic reactions, and emergency and disaster nursing. Whereas in the old curriculum Nursing Leadership and Management was NCM 105, it will be NCM 107 effective June 2008.
  • Biochem. After General Chemistry, nursing students will have to take Biochem. Do I hear protests?:)
  • Increase in the number of RLE contact hours.
Indeed, CHED Order No. 5, s2008 is so comprehensive and well-constructed that if only nursing schools and colleges strictly adhere to the guidelines, nursing education in the Philippines will improve by leaps and bounds.

Oncologic Nursing: Chemotherapy

the oncology nurse administering IV chemotherapy
Definition
  • Chemotherapy involves the use of powerful chemical to kill cancer cells
  • Different chemotherapeutic drugs attack cancer cells and interfere with cell growth in different stages of the cell cycle.
  • Chemotherapy works by killing rapidly dividing cells, meaning, it affects cancer cells and healthy cells of the bone marrow, gastrointestinal tract, reproductive system and hair follicles; healthy cells, however, recover after treatment is complete.
  • In some cases, chemotherapy may be the only treatment needed by cancer patients. More often, it's used in conjunction with surgery, radiation or a bone marrow transplant, to improve results. For instance, patients may receive:

      • neoadjuvant chemotherapy-->chemotherapy before other treatments; reduces the size of a tumor prior to surgery or radiation
      • adjuvant therapy-->given after surgery or radiation; eliminates cancer cells not removed by previous treatments
Purposes of Chemotherapy
  • Chemotherapy can be used to eliminate cancer cells in the body, control the spread of cancer to other parts of the body, and relieve symptoms of cancer.
How Chemotherapy is Administered
  • The most common ways to administer chemotherapy are:
    • oral
    • intravenous (IV)
    • intramuscular (IM)
    • subcutaneous (SC)
  • Chemotherapy may also be administered to using the following techniques:
    • Intrathecal: directly to the CNS-->brain, spinal cord
    • Intra-arterial: arteries are used to deliver chemotherapy directly to the organs
    • Intraperitoneal:directly into the abdomen
    • Intravesical: directly in the bladder
Major Side Effects and Nursing Interventions
  • nausea and vomiting
    • administer antiemetics (e.g. Plasil) routinely every 4-6 hours after as well as before chemotherapy is started
    • withhold food and fluids 4-6 hours before chemotherapy-->a light, dry snack may be allowed
    • improve patient's appetite and minimize food aversion by:
      • providing 5-6 small meals per day
      • provide bland, non-greasy foods-->crackers, toast
      • serving foods at room temperature or slightly cooler-->less odor
  • diarrhea
    • administer antidiarrheals as ordered
    • maintain perineal care-->to prevent infection and minimize discomfort; medicated creams may be prescribed
    • give clear liquids as tolerated-->apple juice, ginger ale, jello, broth
    • instruct patient to avoid milk products, spicy foods, and hard to digest foods temporarily-->to rest the bowel
    • monitor potassium, sodium, and chloride levels
    • measure I&O regularly
  • stomatitis
    • provide and instruct patient on good oral hygiene-->inspect mouth regularly, use non-alcoholic mouthwash (e.g.)diluted hydrogen peroxide),removal of ill-fitting dentures, use of soft-brsitled toothbrush
    • provide health teachings on the importance of:
      • keeping mucous membranes moist-->let patients suck on popsicle
      • avoidance of hot and spicy foods-->pasta and tacos
      • avoidance of acidic and/or carbonated food and drinks-->cola, orange juice, grapefruit juice
      • keeping food at room temperature or slightly cool
    • apply water-soluble lubricant such as KY jelly to dry, cracked lips
    • offer viscous lidocaine before meals to minimize discomfort
  • thrombocytopenia (low platelet count)
    • monitor blood count
    • observe for epistaxis, petechiae, and ecchymosis
    • protect clients from injury-->no flossing, use of razor
    • instruct clients to avoid bumping or bruising the skin
    • avoid giving IM injections
  • leukopenia (decrease in number of circulating WBCs)
    • implement careful handwashing technique
    • maintain reverse isolation as ordered
    • monitor for signs of respiratory and other infections
    • instruct patient to avoid crowds/person with infections
    • provide patient teachings on the early signs of infection:
      • Fever above 100.4°F (37.8°C)
      • Chills
      • New cough or production of sputum
      • Sore throat
      • More than three loose stools in a day
      • Pain or burning upon urination
  • anemia
    • monitor hemoglobin and hematocrit
    • encourage adequate rest and sleep periods
    • administer oxygen as needed
    • provide health teachings on symptoms of anemia:
      • Fatigue, dizziness, lightheadedness
      • Shortness of breath
      • Difficulty staying warm
      • Chest pains
  • alopecia
    • inform patient that hair loss is not permanent
    • encourage the patient to obtain bandana or wig before starting treatment
    • administer scalp tourniquet or scalp hypothermia using ice pack as ordered-->to minimize hair loss
    • offer support and encouragement
    • provide health teachings on the importance of:
      • maintaining skin and scalp moisture-->limit shampooing to 3x a week with a mild shampoo and conditioner
      • preventing damage to hair follicles-->avoid using hair dryers, irons, and dyes
      • avoid tangling hair-->wide-toothed comb; use of silk pillowcase when sleeping
  • kidney damage
    • encourage increased fluid intake and frequent voiding to prevent accumulation of metabolites in the bladder
    • administer Allopurinol (Zyloprim) as ordered-->prevents uric acid formation which is common among patients on chemotherapy
  • reproductive organ damage
    • sperm banking is encouraged for men-->chemotherapy may cause infertility
    • advise clients and partners to use reliable methods of contraception-->chemotherapy can cause mutagenic damage to chromosomes leading to birth defect
  • neurologic damage
    • peripheral neuropathies and hearing losses may occur
    • protect patient from injury


Perioperative Nursing

the nurse in the intraoperative phase
  • Perioperative nursing includes those activities performed by the nurse in the preoperative, intraoperative and postoperative phases of surgery.
  • Surgery refers surgical operation or procedure, especially one involving the removal or replacement of a diseased organ or tissue. It is a planned alteration that encompasses three phases collectively called the perioperative period.
  • Perioperative nurses are registered nurses who work in hospital surgical departments and ambulatory surgery units; they work closely with the surgical patient, significant others, and other healthcare professionals throughout the perioperative period.
Phases of the Perioperative Period
  • preoperative phase-->begins when the client decides to have surgery and ends when the client is transferred to the operating room bed
  • intraoperative phase-->begins when the client is transferred to the operating room bed and ends when the client is brought to the postanesthesia area
  • postoperative phase-->begins with the admission of the client to the postanesthesia area and ends with the discharge of the client from the hospital or facility providing the continuing care.
The Desired Outcomes for Surgery
  • The client will be free from injuries related to positioning, retained foreign objects, chemical, physical, or electrical hazards.
  • The client will be free from infection.
  • The client's skin integrity will be maintained.
  • The client's fluid and electrolyte balance will be maintained.
  • The client will demonstrate and understanding of the physiologic and psychologic responses to the planned surgery.
  • The client will participate in a rehabilitation process after the surgery.
Types of Surgery

Surgical procedures are commonly grouped according to:
  • degree of urgency
    • elective surgery-->planned weeks or months ahead and based on the client's choice; performed for client's wellbeing and not absolutely necessary for life
    • emergency surgery-->performed to preserve the client's life, body part, or function
  • degree of risk-->surgery may be minor or major; day surgeries are generally considered minor
  • purpose
Factors Influencing Surgical Risk
  • Age-->very young and very old clients are at an increased risk
  • Nutrition-->Emaciated, malnourished, and obese clients face greater risks
  • Fluid & electrolyte balance-->dehydration, hypovolemia, and electrolyte imbalances put clients at greater surgical risks
  • General health-->infection, diseases of the the cardiovascular and respiratory systems. metabolic disorders, and specific disorders affecting the renal and liver function place clients at greater risks
  • Medications
    • anticoagulants (aspirin and NSAIDS)-->predisposes to hemorrhage; to be discontinued 2 wks. prior to surgery
    • tranquilizers (e.g. phenotiazenes)-->may cause hypotension and eventual shock
    • antibiotics-->aminoglycosides may increase effects of anesthesia and may cause respiratory paralysis
    • diuretics-->may cause electrolyte imbalances
    • antihypertensives-->causes hypotension that may result to shock
    • long-term steroid therapy-->may cause adrenocortical suppression
  • Type of surgery planned-->major surgery poses greater risks
  • Psychologic status-->excessive fear or anxiety can increase surgical risk
Nursing Responsiblilities in the Preoperative Phase
  • Provide psychologic support
    • assess client's fears, anxieties, support systems, and patterns of coping
    • establish trusting relationship with client
    • explain routine procedures and encourage client to ask questions
    • demonstrate confidence in surgeon and staff
    • provide for spiritual care, if appropriate
  • Provide preoperative teaching-->usually done on outpatient basis
    • assess client's level of understanding of procedure and its implications
    • clarify and reinforce teachings given by surgeon
    • explain routine and and pre-op procedures and special equipments to be used
    • teach and explain the importance if the ff: coughing and deep breathing exercises, splinting, turning in bed, leg exercises
    • assure client that pain management will be available after the surgery
  • Physical preparation
    • obtain client's medical history: allergies, medications, surgical procedures, dietary restrictions
    • perform baseline assessment, include VS, height, weight
    • ensure that routine diagnostic procedures are preformed: CBC,PT/PTT, electrolytes,urinalysis, ECG, bloodtyping and crossmatching, CXR
    • skin preparation-->reduces risk for infection
      • let client shower using antibacterial soap if ordered
      • shave or clip hairs and cleanse appropriate areas if ordered
    • administer enema if ordered
    • promote adequate rest and sleep
    • instruct client to remain NPO after midnight as ordered-->prevents vomiting and aspiration during surgery
  • Legal Responsibilities-->Ensure that surgeon obtains informed consent from client before surgery
      • confirm that client understands information given
      • if witnessing consent, specify if witnessing explanation of surgery or just signature of client
        • NOTE: Informed Consent is necessary for each operation performed, including minor ones and should be witnessed by a legally authorized person (another physician, nurse). An adult client (over 18) signs his own consent unless unconscious or mentally incompetent. If unable to sign, relative or next of kin will sign. In emergency cases, telephone or via telegram is acceptable (have a second listener available if securing consent via telephone). For minors undergoing surgery, a parent or legal guardian can sign the consent. An emancipated minor may sign his or her own consent (college student living away from home, married minor, any pregnant female or any who has given birth). For emergency care, consents are not needed provided the following criteria are met:
            • there is an immediate threat to life
            • experts agree that it is an emergency
            • client is unable to consent
            • a legally authorized person cannot be reached
  • Preparation immediately before surgery
    • obtain baseline VS, report deviations from the normal range
    • provide oral hygiene,remove dentures, dress client in clean gown
    • remove nail polish, contact lenses, prostheses, jewelry, hair accessories
    • instruct patient to empty bladder
    • check client's identification band
    • administer pre-op medications as ordered
      • narcotic analgesics-->to relax client, enhance effectiveness of general anesthesia
      • sedatives-->to decrease anxiety and promote sleep
      • anticholinergics--to decrease risk of aspiration, undesirable effects of anesthesia (e.g. bradycardia)
    • elevate side rails and provide quiet environment
    • prepare client's chart, attach operative permit, and complete pre-op checklist
Nursing Responsibilities in the Intraoperative Phase
  • Assess the client's physiologic and psychologic status
  • Review the results of diagnostic tests and lab studies
  • Position the client for surgery
  • Perform the appropriate surgical skin preparation
    • remove soil and transient microbes from the skin using using appropriate antimicrobial agents
    • inspect surgical area for moles, rashes, pustules, irritations, or any broken and ischemic areas, record, and report them to the surgeon.
    • remove hair on surgical area as appropriate-->use clippers or chemical hair-removal agents to lessen risk of disrupting skin integrity
Nursing Responsibilities in the Postoperative Phase
  • Recovery Room Care:
    • assess for and maintain patent airway
      • position on side unless contraindicated or on back with head turned to side and chin extended forward
      • check for gag reflex.
      • maintain artificial airway in place until gag or swallow reflex returns
    • administer oxygen as ordered
    • assess respirations-->rate, depth, quality
    • check VS every 15 mins, until stable and then every 30 mins
    • note level of consciousness
    • assess color and temperature--check capillary refill, and mucous membranes
    • monitor all IV infusions
    • check all drainage tubes and take note of quality of drainage.
    • assess dressings for signs of complications such as hemorrhage
    • provide warmth
    • encourage client to cough and deep breath when artificial airway is removed
    • keep patient flat on bed if spinal anesthesia was usesd->check for sensation and movement in lower extremities
  • Surgical Floor Care:
    • promote and monitor for optimal respiratory functioning
      • coughing unless contraindicated
      • splinting
      • turning in bed every 2 hours
      • early ambulation
      • use of incentive spirometer every 2 hours
    • promote and monitor for optimal cardiovascular status
      • leg exercises every 2 hours
      • early ambulation
      • use of antiembolism stockings as ordered
    • promote adequate fluid and electrolyte balance
      • monitor IV fluids
      • measure I&O
      • irrigate NG tube
      • observe for signs of imbalances
    • promote optimum nutrition
      • assess for return of peristalsis-->bowel sounds, flatus
      • add progressively to diet as ordered, note client's tolerance
    • promote return of urinary function
      • measure I&O
      • report to surgeon if client has not voided 8 hours after surgery
      • assess for bladder distention
      • use measures to promote voiding
    • promote bowel elimination
      • encourage early ambulation
      • provide adequate food intake
      • keep stool record
    • provide pain management
      • analgesics as ordered
      • alternative measures such as guided imagery, relaxaton techniques
    • provide wound care
      • check dressings frequently-->should be clean, dry, and intact
      • observe aseptic technique when changing dressings
      • assess for and report signs of infection: redness, drainage, odor, fever
      • encourage diet high in protein and vitamin C for faster wound healing
      • observe for complications such as wound dehiscence or evisceration
    • provide psychologic support to client and significant others
    • provide health teachings: outpatient consultations, wound care, nutrition, medication regimen, activity restrictions, and possible complications

The Nursing Gang MV

Ward Class would like to share this delightful Animated Music Video produced by Johnson Healthcare Systems, Inc. as tribute to the nursing profession.

Meet Kiki, Ashleigh, Danny, and DeVaughn-- the cool dudes and dudettes of the Nursing Gang. Watch them care for patients and strut their stuff. Have fun!!!



Sample NCP for Stomach Cancer

As promised, here is Ward Class' first NCP upload. An NCP for stomach cancer was chosen because it covers very important nursing considerations for a medical and surgical patient-- the client diagnosed with gastric cancer. It also included topics such as Dumping Syndrome and vitamin B12 supplementation, which by the way, is a favorite among instructors the moment gastric surgery as surgical management for Stomach Cancer is discussed.

Furthermore, Ward Class would like to emphasize the ff. points:
  • For our NCPs, we will be using a 6-column format. We have added a column for RATIONALE(s) in order to state the basis for each nursing intervention included in a specific care plan.
  • Before submitting an NCP as part of your requirements, you might want to ask your clinical instructor certain things such as whether to write statements made by patients in vernacular or paraphrase them in English. Secondly, you might want to ask your instructor if he/she prefers all NCP care plans to include interventions such as Establishing Rapport and Obtaining Baseline Vital Signs. Also, you might consider asking your instructor if you can use a separate column for RATIONALE (like we did) or just state the rationale immediately under each nursing intervention. Lastly, it will be prudent to ask whether to evaluate the care plan as a whole or make a number of evaluation statements depending on the number of expected outcomes specified.
  • Our Sample NCPs are intended to guide students in making their own and are NOT to be submitted as is. The patients you will encounter during clinical rotations have unique healthcare needs so care plans should be prepared with this in mind.
  • There is no standard format for NCPs but in writing them, you should always be guided by the nursing process (if you are studying nursing in the Philippines, your clinical instructor will most likely stress the importance of following the ADPIE format). You must also prioritize your client's nursing problems (think Maslow and ABC).
NCP Download:


The Nursing Care Plan (NCP)


Definition
  • the nursing care plan (or client care plan) is a written guide that organizes information about a client's care
  • the nursing care plan starts as soon as the client is admitted to the healthcare agency or hospital and is continually updated throughout the client's stay, in response to the changes in the client's condition and the client's responses to the nursing interventions rendered
  • types of nursing care plans:
    • preplanned/preprinted--> standardized guides for providing essential care to a specific group of clients with common needs
    • handwritten care plans
    • computerized care plans--> may also be adapted to client's specific needs
    • case management plans-- collaborative care plans; multidisciplinary care plans
Purposes of the Nursing Care Plan
  • Nursing Care Plans are written for the following purposes:
  1. To provide direction for individualized client care--> a nursing care plan is organized according to each client's unique needs; standardized care plans are also adapted to the client's needs and are used in combination with handwritten care plans as needed
  2. To provide for continuity of care--> the nursing care plan is a means of communicating and organizing the actions of the nursing staff; it is constantly updated and changes are communicated to all nursing staff during change-of-shift reporting (or during endorsement, if you are from the Philippines), nursing rounds, and client care conferences.
  3. To provide direction about what needs to be documented in the client's progress notes--> the nursing care plan specifies which observations to make, what actions to carry out, and what instructions the client or family members require; facilitates recording
  4. To serve as a guide for assigning staff to care for the client--> the nursing care plan facilitates delegation among nursing personnel
  5. To serve as a guide for reimbursement from medical insurance companies--> nursing care plans are often accessed by insurance companies for them to determine what they will pay in relation to what services the hospital rendered to the client; a nursing care plan is a documented proof of all nursing care rendered and simply put, "Nursing Care Not Documented is Nursing Care Not Rendered"
General Guidelines for Writing NCPs
  1. Date and sign the plan--> the planning or expected outcome portion is usually dated and signed as basis for evaluation of goal achievement (note: most clinical instructors require end-of-shift NCPs from students and may not require this)
  2. Use appropriate headings such as Assessment, Nursing Diagnosis, Planning, Nursing Interventions, and Evaluation (note: headings may vary per institution but the nursing process is always kept in mind)
  3. Use standardized medical or English key words to communicate your ideas-->e.g. turn and reposition client q2h (not turn and reposition client every two hours)
  4. Keep the care plan clear and concise
  5. Tailor the plan to the unique needs and characteristics of the client
  6. Ensure that the nursing care plan includes preventive, promotive, and restorative aspects of client's health
  7. Ensure that the plan provides for ongoing assessment of the client--> e.g. orders such as measure I&O q shift
  8. Include collaborative activities in the plan
  9. Include discharge planning and health teachings necessary for self-care--> shorter acute hospitalizations necessitate meticulous discharge planning
Note: Ward Class is currently in the process of making SAMPLE NCPs (using a 6-column format) for student nurses. Uploads will be done regularly. To receive automatic updates, please remember to subscribe to the mailing list located at the upper right corner of this site.

Nursing Trivia: The Lady With The Lamp

Florence Nightingale is remembered as 'The Lady With The Lamp,' for bringing hope and comfort to thousands of British soldiers during the Crimean War.

Named after the City of Florence in which she was born in 1820, Florence Nightingale was the second daughter of a wealthy British couple. As a young woman, Florence developed a very strong interest in Nursing. And since Nursing was not considered a suitable occupation for a wealthy and educated young woman, her parents, probably intending to divert her attention, sent her on a tour around Europe with some family friends. In Germany, Florence visited Pastor Theodor Fliedner's hospital and school for deaconesses at Kaiserswerth. When she went home to Britain, Florence succeeded in persuading her parents to let her attend the training school and so she went back to Kaiserswerth to study and train for two years.

In 1853, Nightingale became the Superintendent for the Establishment For Gentlewomen During Illness in the city of London. The year after that, she, along with other nurses, left for Turkey to serve in military hospitals during the Crimean War. The 'Lady With The Lamp', as she was called because of her nightly rounds of the wards, earned the undying respect of countless British soldiers whose lives she touched.


When she returned to England in 1856, Florence became so popular that the public raised funds to help her found a nurses' training institute at St. Thomas' Hospital and King's College Hospital. Florence Nightingale devoted her life to improving public health making nursing a skilled and honorable profession. Her Notes on Nursing, published in 1860, which focused on careful observation and sensitivity to client's needs has been translated in many other languages and still in print today.

In 1883, Queen Victoria awarded Florence Nightingale the Royal Red Cross. In 1907, she became the first woman to receive the Order of Merit. Florence Nightingale died at the age of 90 on August 13, 1910.


The Nursing Process: An Overview


Definition
  • a systematic, rational method of planning and providing nursing care
  • a process that seeks to identify a client's healthcare status, actual or potential health problems, to establish plans to meet the client's identified needs, and to deliver specific nursing interventions to address those needs
Characteristics of the Nursing Process
  • cyclical and dynamic--> components follow a logical sequence but more than once component may be involved at one time; responds to the changing health status of the client so there is no absolute beginning or end
  • open and flexible--> meets the unique needs of the client, family, group, or community
  • client-centered--> the plan of care is organized according to the client’s health problems rather than nursing goals
  • interpersonal and collaborative--> to ensure delivery of quality nursing care, the nurse shares concerns and problems regarding the client’s health status; rapport is developed and an open communication is established between the client and the nurse to carry out the nursing process effectively
  • planned
  • goal directed
  • allows client and nurse to devise ways to solve identified health problems--> decision-making is involved in every step of the nursing process and nurses are not bound by standard responses; nurses can use their skills and knowledge to assist the client attend to health-related goals
  • emphasizes feedback--> determines if there is a need to revise the nursing care plan
  • universally applicable--> it can be used with clients at any age and at any point in the wellness-illness continuum and can be used in a variety of settings.
  • utilizes problem-solving techniques and the systems theory--> decision-making is involved in every component of the nursing process
Components of the Nursing Process

Components

Purpose

Activities

ASSESSING

-Collecting, organizing, validating, and recording data

To establish a database of client’s response to health condition and the ability to manage healthcare needs

-obtain health history

-conduct physical assessment

-review records

-review lit.

-consult support persons/significant others

-consult health professionals

-update data

-organize data

-communicate/document data

DIAGNOSING

-Analyzing and synthesizing data

To identify strengths and health problems to be addressed by collaborative and independent nursing interventions

To develop a list of nursing diagnoses and collaborative problems

-interpret and analyze data (compare against standards, cluster data, identify gaps and inconsistencies)

-determine client’s strengths, risks, and problems

-formulate nursing diagnoses and

collaborative problem statements

PLANNING

-Determining how to prevent, resolve, reduce identified health problems; how to support client’s strengths and how to effectively implement nursing interventions

To develop an individualized care plan (based on your client needs) that specifies goals and related nursing interventions

-collaborate with client regarding

priorities and goals

-write goals/outcome criteria

-select nursing interventions

-consult other members of the healthcare team

-write nursing orders and care plan

-communicate care plan to relevant members of the healthcare team

IMPLEMENTING

-Carrying out planned nursing interventions

To assist the client meet desired goals/outcomes

-Reassess client to update database

-Determine need for assistance

-Perform interventions

-Document care and clients responses; give verbal reports as needed

EVALUATING

-Measuring the degree to which outcomes have been achieved and identifying factors that influenced goal achievement

To determine whether to continue, modify, or terminate plan of care

-collaborate with client and collect data related to outcomes

-determine whether goals have been met

-relate nursing interventions to client outcomes

-make decisions about problem status

-review and modify care plan as indicated