Ward Class

An Online Resource Site For Student Nurses

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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.

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




Triage in Nursing



Triage Defined

Triage is defined as a process of prioritizing patients based on the severity of their condition with the goal of treating as many patients as possible when resources are insufficient for all to be treated immediately. It comes from the French verb
trier, meaning to separate, sort, sift or select. Triage can either be simple or advanced.

Simple Triage


In simple triage, patients are categorized based on the severity of their injuries and are usually labeled using triage tags or colored flagging. An example of simple triage is the S.T.A.R.T (Simple Triage and Rapid Treatment), a method used by first responders during a mass casualty incident. In S.T.A.R.T., the patients are evaluated in 60 seconds or less and are labeled with one of the four triage categories:
  • Minor (Priority 3) - treatment can be delayed up to three hours or when possible (e.g. abrasions, minor lacerations, sprains)
  • Delayed (Priority 2)- needs urgent care and constant observation; tansport when practical (e.g. minor amputations, flesh wounds, fractures, dislocations)
  • Immediate (Priority 1) - condition is life-threatening; needs immediate care and transport ASAP (e.g. arterial lesions, major bleeding, major amputations)
  • Deceased - the victim is dead so no medical care is required; collection, guarding of bodies, and identification when possible
Advanced Triage

Advanced triage is performed to divert scarce resources from patients who are not likely to survive. Doctors may withhold treatment from seriously injured patients because the available resources are not sufficient to treat all of those who need medical help.

During extreme situations, the medical team decides if a patient is hopeless to avoid saving a hopeless case at the expense of several other patients with a higher chance of survival. Triage, then, has to be continuous to ensure that prioritization remains correct and medical help is given to those who are more likely to survive.

Secondary triage is typically performed by skilled nurses in the ER during disasters. In advanced triage, patients are divided in the following categories:
  • Black / Expectant- injuries are so severe that patients are unlikely to survive even with treatment and so the goal is to reduce patients' suffering (e.g. severe trauma, massive burns, septic shock, cardiac arrest) by providing painkillers as necessary
  • Red / Immediate- immediate surgery or medical care is required as these patients are likely to survive with treatment
  • Yellow / Observation- patients under this category are considered stable but requires observation and re-evaluation
  • Green / Wait (walking wounded)- patients under this category will require medical care but not immediately; may be asked to wait or go home and come back the day after (e.g. broken bones without compound fractures, soft tissue injuries)
  • White / Dismiss (walking wounded)- these patients have minor injuries and only requires home care (e.g. cuts, scrapes, minor burns)
Emergency Room Triage vs. Disaster Triage

In a controlled environment such as in an emergency room setting, the sickest patient is prioritized and given medical care first. In uncontrolled environments such as in a disaster setting, the patient who is more likely to survive is given priority.
Still, whatever the environment, nurses need to develop clinical decision-making skills before they can accurately triage patients.

Emergency Wound Care

The skin is the largest and most visible organ of the body. Intact skin is the body's primary defense mechanism. Once the protective skin barrier is disrupted, individuals are at greater risk for injury.

Impaired skin integrity is a common problem often requiring visits to a hospital's emergency department. Examples of skin integrity disruption are cuts from sharp objects, bites resulting in lacerations, scrapes, contusions, avulsions, abrasions, or puncture wounds.

To prevent complications such as infection and hemorrhage, emergency wound care is necessary no matter how minor a wound is. Emergency wound care, by definition, is the immediate and temporary treatment of wounds in order to prevent infection, hemorrhage, and further injury to the patient. For wounds requiring immediate medical attention, proper emergency wound care may be instrumental in saving the patient's life and ensuring a rapid recovery.

Before a health worker or any individual renders emergency wound care to a patient, it is important for him/her to remember the following:
  • Only approach the patient if it is safe for you to do so.
  • Observe universal precautions while rendering first aid measures.
  • Call for medical help immediately if there are embedded objects in the wound, if the wound is at special risk of infection, or if old wounds are showing signs of infection.
Emergency wound care provided by healthcare professionals usually involves cleansing the wound, application of measures to control bleeding, closing the wound, application of a protective dresssing, and prohylactic treatment for tetanus or rabies as indicated. These simple first aid measures will improve the patient's rate of recovery and prevent further medical problems.

To download the basic steps in emergency wound care, click on the link provided below.

Sample NCP for Pneumonia

This week's sample nursing care plan will be on Pneumonia, an inflammatory illness of the lung. Pneumonia is a serious concern among older adults and individuals with chronic illnesses and/or impaired immune systems. It is also the leading cause of death in children worldwide.

Before viewing or downloading this nursing care plan on Pneumonia , nursing students should take into consideration that:
  • Whe I made this nursing care plan, I had a 3-year old pediatric patient diagnosed with bacterial pneumonia in mind, therefore, some assessments and nursing interventions may be age-specific and/or only applicable to Bacterial Pneumonia.
  • Although Ineffective Airway Clearance is identified by most reference books as the priority nursing diagnosis for clients with Pneumonia, Ineffective Breathing Pattern is also a major concern among clients diagnosed with this medical condition as ventilation problems increase the risk for hypoxemia.
  • Most tertiary hospitals (if not all) have respiratory therapists who perform procedures such as nebulization, chest physiotherapy, and suctioning. They may also provide oxygen supplementation, administer aerosol medications to patients, and give instructions on incentive spirometry. For this reason, do NOT be surprised if interventions such as CPT, incentive spirometry, and monitoring of ABG and/or pulse oximetry readings are listed under collaborative nursing interventions.
  • This nursing care plan on Pneumonia is a SAMPLE nursing care plan so just make the necessary modifications, if you please.
To download the Sample NCP for Pneumonia, just click on the link provided below.

NCP Download:

New Downloads on Maternal and Child Nursing

I have been receiving requests for review notes and downloads on Child Development and Developmental Milestones. I figure a good number of nursing students are taking up Maternal and Child Nursing right now, hence, the requests.

I'm wondering if nursing instructors don't provide their students with lecture hand-outs anymore. If I remember correctly, my Maternal and Child Nursing lecturer provided my class with a compilation on Child Development. It came in those mimeographed sheets of paper stapled together but what it lacked in presentation, it certainly made up for in terms of nursing content. It was so concise and well-organized (complete with tables and nursing bullets) that we didn't have to lug those heavy Maternal and Child Nursing textbooks to school anymore. I should thank that nursing instructor again for being considerate and making life as a nursing student a tad easier for me back then.

And so for today's blog entry, I came up with two downloads on Maternal and Child Nursing. For those who requested for review notes and downloads on the said nursing topics, kindly click on the links provided below.

Child Development

Developmental Milestones


Latest Update on the November 2008 Nurse Licensure Examination

Applicants to the November 2008 Nursing Board Exam should secure a copy of the Nurses Application Form (NAF) from their respective nursing deans.

The accomplished Nurses Application Form (NAF) and complete requirements should be filed by the applicant (no proxies allowed) at the PRC central or regional offices on or before October 17, 2008.

The PRC Board of Nursing reminds all applicants to refrain from entrusting their November 2008 NLE applications to anybody as the PRC will NOT accept applications unless personally filed by the applicant.


The November 2008 Nurse Licensure Examination is scheduled on November 29 & 30, 2008.

Related Link:
PRC-BON Advisory to November 2008 Nurse Licensure Examination Applicants

Sample NCP for Laryngeal Cancer

To supplement Ward Class' previous entry on Laryngeal Cancer, this week's nursing care plan will be on Impaired Verbal Communication.

For nursing students who are about to view this sample nursing care plan for Laryngeal Cancer, I'd like to emphasize the following points:
  • When I drafted this NCP for Laryngeal Cancer, I had a post-total laryngectomy patient in mind. Hence, some interventions are very specific for total laryngectomy cases and are NOT applicable to patients with partial laryngectomy ( e.g. referrals to a speech therapist on the use of artificial larynx and esophageal speech).
  • Although maintaining a patent airway is a general nursing priority when caring for patients who have had a laryngectomy, loss of speech is also a major concern for clients as it poses a serious psychological issue. And believe it or not, there is no risk for aspiration after total laryngectomy because the trachea and esophagus are permanently separated after surgery unless a fistula forms from the trachea to the esophagus.
  • When going over this nursing care plan, you might be surprised to find out that I didn't include dependent nursing interventions. As previously mentioned, the nursing diagnosis is Impaired Verbal Communication and so I deemed it appropriate that the nursing interventions will be based (solely) on the nursing problem identified. Still, your clinical instructor may think otherwise so just modify the NCP as necessary. This, after all, is a SAMPLE nursing care plan.
To download the sample NCP for Laryngeal Cancer, just click on the link provided below.

NCP Download:
Sample NCP for Laryngeal Cancer

Related Link:
Respiratory Disorders: Laryngeal Cancer

Respiratory Disorders: Laryngeal Cancer



  • refers to malignant tumors that develop in the larynx (voice box)
  • may occur on the glottis (true vocal cords), the supraglottic structures, or the subglottic structures
  • most common upper airway malignancy; accounts for 2% to 3% of all malignancies and usually occurs in men during midlife or late adulthood
  • primarily caused by cigarette smoking--> linked directly to the mutation of p53 gene in squamous cell carcinoma (most common malignant tumor of the larynx)
  • other risk factors include excessive alcohol use, chronic laryngitis, vocal abuse, and occupational exposure to asbestos, wood dust, petroleum products, mustard gas, and other noxious fumes
Assessment Findings

a. Glottic tumor
  1. early: voice change, hemoptysis, hoarseness
  2. late: dyspnea, respiratory obstruction, dysphagia, weight loss, pain
b. Supraglottic tumor
  1. early: aspiration on swallowing (esp. liquids), persistent unilateral sore throat, foreign-body sensation, dysphagia, weight loss, neck mass, hemoptysis
  2. late: dyspnea, pain in the throat or referred to the ear
c. Subglottic tumor
  1. early: none
  2. late: dyspnea, airway obstruction, dysphagia, weight loss, hemoptysis
  • diagnostic procedures
  1. direct or indirect laryngoscopy will reveal abnormalities in the vocal cords
  2. panendoscopy will determine the exact location, size, and extent of primary tumor
  3. biopsy (collection of a tissue sample) --> performed if abnormalities are found; sample is then sent to laboratory for testing
  4. imaging studies--> X-ray, MRI, CT scans, and PET scans may be ordered to determine the extent of laryngeal cancer beyond the surface of the voice box.
Medical Management
  1. radiation therapy--> may be effective in cases of localized disease affecting only one vocal cord
  2. chemotherapy--> may be administered preoperatively to reduce tumor size, postoperatively to reduce risk of metastasis, or as palliative treatment
Surgical Management
  • the goal of surgical intervention for laryngeal cancer are to remove the cancer, maintain adequate physiologic function of the airway, and achieve a personally acceptable physical appearance
  1. laser surgery--> indicated for small tumors as it can preserve much of the glottis, leaving the client with a usable voice; sometimes combined with radiation therapy
  2. partial laryngectomy--> useful for early intrinsic lesions; client will be able to talk and has a normal airway after surgery
  3. total laryngectomy--> involves removal of the entire larynx, hyoid bone, pre-epiglottic space, cricoid cartilage, and 3-4 rings of trachea; the client will have a permanent tracheostomy resulting in a loss of normal speech, breathing, and olfaction.
  4. radical neck dissection--> performed when metastasis is suspected; the larynx, lymph nodes, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve are removed (note: may also include removal of the mandible, submaxillary gland, and portions of the thryoid and parathyroid gland)
Nursing Management
  • for the client with a total laryngectomy
  1. promote optimum ventilatory status
  2. assess for signs of respiratory complications such as dyspnea, tachycardia, restlessness, and tachypnea
  3. suction nose frequently because of rhinitis
  4. provide tracheostomy/laryngectomy, and stomal care; observe for signs of infection
  5. elevate head of bed to decrease pressure on suture lines and to promote lymphatic drainage
  6. support client's back of neck with hands during turning and moving
  7. administer analgesics for pain as ordered
  8. promote nutrition through tube feedings as ordered; increase oral fluid intake as tolerated
  9. prevent infection--> monitoring of WBC, frequent oral hygiene, frequent temperature checks, maintaining sterile technique during suctioning and tracheostomy care, and monitoring for changes in sputum and wound drainage.
  10. provide referrals to speech therapist if necessary (client may have to use esophageal speech or an artificial larynx)
  11. provide encouragement and support on nutrition, self-care, and adaptation to altered physical status
  12. provide client teaching and discharge planning on:
  • tracheostomy/laryngectomy and stomal care
  • administration of tube feedings and care of NGT
  • gradual return to normal diet as tolerated
  • mouth care (brushing toungue with soft toothbrush to control crusting and dryness)
  • need for humidified air
  • shielding of stoma with towel while showering; use of stoma guards
  • drowning precautions
  • use of smoke detectors (due to lack of sense of smell)
  • covering stoma when coughing or sneezing and need to lean forward when expectorating secretions
  • use of electric razors if facial numbness is present (esp. for clients with radical neck dissection)
  • use of clothing that do not emphasize chest or neck
  • information on speech therapy and reconstructive surgery
Prognosis

If discovered early enough, laryngeal cancer is potentially curable. If untreated, laryngeal cancer is fatal; 90% of clients with untreated laryngeal cancer die within 3 years.

Prevention

Laryngeal cancer cannot be prevented but the risks of acquiring it may be reduced by smoking cessation, avoidance of hazardous fumes, a healthy diet, and limiting consumption of alcohol.

Related Link:

Sample NCP for Angina Pectoris

It has been quite sometime since I made a sample NCP for Ward Class' readers. And so to make up for it, I did this NCP for Angina Pectoris -- the medical term for chest pain resulting from inadequate blood supply to the mycocardium. Angina Pectoris is also a manifestation of Coronary Artery Disease (CAD).

Considering that there is an increase in the number of CAD cases in the Philippines, nursing students on clinicals will most likely encounter patients who are brought to the ER due to severe chest pain. Hence, this sample NCP for Angina Pectoris will be useful as caring for patients with cardiovascular disorders can be quite demanding.

Before making an NCP for Angina Pectoris, nursing students must remember that nursing management for clients with Angina Pectoris involves relieving acute attack and preventing further attacks through self-care. Therefore, client education on how to control the risk factors for angina pectoris should be incorporated into the nursing care plan.

As a bonus for our avid readers, I have included related drug study downloads to supplement today's blog entry. To download the sample NCP for Angina Pectoris and the related drug studies, just click on the links provided below.

NCP Download:
Sample NCP for Angina Pectoris

Drug Study Downloads:
Amlodipine
Atenolol
Nitroglycerin