Nurse Care Plan

OVERVIEW

• To evacuate the bowel of stool caused by constipation.
• To cleanse the bowel prior to surgery or other procedures for which the bowel, colon, and rectum are visualized.

• Determine patient’s ability to understand procedure.
• Assess patient’s ability to participate in procedure, such as holding contents when administered.

• Patients who have had recent surgery, or who have arthritis, a cast, lower limb amputations, or fractured pelvis may need additional time for the procedure, owing to limited physical mobility.
• Patients with cardiac history or spinal cord injury may be at risk for complications from vagal stimulation.

• May need more time and instruction of the procedure for optimal participation and results.

• Care should be taken in insertion of the enema tube and instillation of the solution to prevent injury to anus and colon during the procedure.
• Parents should be allowed to comfort infants and children and participate in the procedure.

• Constipation related to decreased peristalsis
• Chronic pain related to abdominal discomfort and distention from bowel malfunction
• Potential for injury related to abdominal distention and trauma to the anus and colon during the procedure

• Patient will return to an optimal bowel elimination pattern
• Patient is able to assist/participate
• Patient will be able to evacuate feces from rectum and colon after the enema
• Patient experiences minimal discomfort during procedure and no injury to the colon and/or anus
• Patient experiences relief and comfort after procedure

• Regular bedpan, fracture pan, or bedside commode
• Water-soluble lubricant
• Clean gloves
• Toilet paper
• Disposable, absorbent bed pads
• Skin care items (i.e., soap or skin cleanser,water, towels)
• IV pole
• Enema container with tubing, normal saline, tap water, soap solution, or commercially prepared enema.

• Check prescriber’s order; identify patient; explain purpose, procedure, and how patient can assist. Assess patient’s ability to participate.
• Confirms order; meets patient’s right to be informed; encourages cooperation and participation.
• Gather all equipment and place in an easy to access area in patient’s room; adjust lighting as needed.Promotes organization of equipment; saves time; and adjusted lighting enhances visualization for procedure.

• Explain to the patient the benefits of relaxing and taking periodic deep breaths. Reduces anxiety and promotes comfort.
• Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms, and prevents contact with urine and/or feces.
• After determining patient’s ability to assist, place disposable waterproof pad under patient. Have patient lift hips or roll from side to side.
• Bed pad protects against soiling of linens.
• Place patient in a left side-lying position with knees flexed. To facilitate flow of solution using contour of the bowel.
• Place bedpan next to patient. For easy access in case patient cannot hold enema solution.

• Fill enema container with 750 mL to 1000 mL of warm solution and check temperature by dripping some solution on inner wrist. If too warm, empty container and refill. Add soap solution if ordered. This amount of solution is the standard volume unless a specific amount is ordered by the physician. This amount is normally what is tolerated; solutions that are too hot or too cold can cause cramping, damage to the rectal mucosa, or extreme shock.
• Allow the solution to run through the tubing to clear out the air; clamp tubing and hang on an IV pole approximately 12 to 18 inches above the patient’s buttocks. Aids in removing air from the tubing that could cause abdominal cramping if instilled into the colon during the procedure; 18 inches is considered a high height, and 12 inches is considered a low height. The higher the pole, the faster the solution will enter the colon.
• Lubricate tip of tubing with generous amount of water-soluble lubricant. Facilitates easier insertion of tubing into the rectum.
• Spread the buttocks, and gently insert the tip of the tubing 3 to 4 inches while the patient is instructed to take slow deep breaths. 3 to 4 inches is the correct placement of tubing in the rectum to allow solution to enter the colon without leakage; slow, deep breaths aids in relaxation of the rectal sphincter.
• Open the regulating clamp and allow the solution to flow slowly. When the solution is instilled slowly, less cramping is experienced by the patient, and the patient will be able to tolerate more volume of the solution.
• Hold the tubing in place in the patient’s rectum at all times, and keep the bedpan nearby. The tubing will slip out easily if not held in place; the patient may need to expel contents before expected.
• Lower the solution container or clamp tubing if the patient complains of cramping, then resume after a few minutes. Lowering the container will slow down the flow of solution and aid in decreasing cramps.
• After solution is instill, clamp tubing and gently remove. Prevents siphoning out enema solution as tube is removed.
• Instruct the patient to hold the solution about 10 to 15 minutes or longer as tolerated. The longer the solution is retained, the more effective the results.
• Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces.
• Instruct patients with cardiovascular disease not to strain when expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest.
• Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms.
• Assist patient back to bed as needed and into a comfortable position. Patient comfort.
• Dispose of enema equipment and clean bedpan or bedside commode as needed. Prevents transmission of infectious microorganisms.
• Remove gloves and wash hands. Prevents transmission of infectious microorganisms.

• Prepare patient and environment as described in first section.
• Lubricate tip of enema container as needed (most are prelubricated). Facilitates easier insertion into the rectum.
• Spread buttocks and insert the tip into the rectum.
• Gently squeeze entire contents of the container. Aids in optimal results if all solution is instilled.
• Remove the tip while continuing to squeeze the container. To prevent the solution from being siphoned back into the container.
• Instruct the patient to hold the solution at least 5 to 7 minutes. To ensure optimal results.
• Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces.
• Instruct patients with cardiovascular disease not to strain when expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest.
• Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms.
• Assist patient back to bed as needed and into a comfortable position. Patient comfort.
• Dispose of enema equipment, and clean bedpan or bedside commode as needed. Prevents transmission of infectious microorganisms.
• Remove gloves and wash hands. Prevents transmission of infectious microorganisms.

• Evaluate patient compliance and ability to tolerate procedure
• Administration of an enema is done correctly, safely, and successfully
• An optimal pattern of elimination is maintained or restored

• Record date, time, type, and results of enema administration, as well as amount and other important characteristics of stool (as required in the designated area on the patient record).
• Record patient’s tolerance of procedure and any complications that occurred.
• Report patient teaching about prevention of constipation.

• To provide a method for evaluating a patient for the presence of risk factors that could lead to the development of a pressure ulcer.
• To determine the presence of risk factors, provide a rationale for implementing preventive measures to avoid pressure ulcers, and maintain skin integrity.
• To perform a skin assessment for the presence of any lesions, ulcers, blisters rashes, warmth, redness, bruising, scaling, moisture, or dryness.

• Screen all patients on admission to determine the presence of risk factors that may result in a pressure ulcer. Note whether there is any history of a pressure ulcer or skin problem.
• Use a risk assessment tool to identify risk factors: immobility, inactivity, incontinence, malnutrition, friction, and shear.
• Perform a head-to-toe skin assessment to determine any abnormal skin findings: lesions, ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture, or dryness.
• Document all findings, be specific in describing any problems, and illustrate findings on the skin assessment form. (Forms vary according to facility.)

• Identify the patient at risk for developing a pressure ulcer, according to the Norton Scale, the Braden Scale, or the preferred risk assessment scale in the facility.
• Institute the protocol for prevention of pressure ulcers based on the risk assessment.
• Obtain specific skin care orders when there is a problem.
• Determine if there are other factors that may place the patient at risk for a pressure ulcer, such as altered mental status, unstable vital signs.
• Reassess every patient at least every 48 hours and perform risk assessment at any time when there has been a significant change in the patient’s condition to prevent skin breakdown.
• Continue to monitor and document the skin condition and report any change in skin integrity promptly to prevent a pressure ulcer.
• Always document any special protocols, including skin or ulcer care or special pressure-reduction mattresses or beds.

• Impaired Physical Mobility related to trauma, surgery, or neuromuscular deficit
• Impaired Skin Integrity related to prolonged pressure on joints and bony prominences
• Ineffective Communication related to illness

• Factors that place a patient at risk for developing a pressure ulcer will be recognized, reported, and documented
• Patient will be assessed for pressure ulcer risk in a timely manner, and a prevention plan will be instituted
• Patient will maintain optimal skin integrity

• Risk assessment tool (Norton Scale, Braden Scale, or specific risk assessment tool for facility)
• Standard facility admission form for documentation of skin assessment
• Nursing record or flow sheet for ongoing skin assessment
• Adequate lighting to perform thorough skin assessment
• Measuring device to document size of skin lesion, ulcer, or other abnormal finding
• Sheet or appropriate drape for patient comfort during the skin assessment
• Any Personal Protective Equipment (PPE), such as gloves, mask, gown, goggles, as indicated by patient’s diagnosis

• Perform skin assessment on admission, and complete admission assessment form. Explain procedure to patient and/or caregiver. Use clean gloves and/or any other PPE if indicated. Determines whether skin is intact or if there is a pressure ulcer or skin problem at time of admission. Provides baseline documentation of skin condition. Provides explanation to patient and/or caregiver. Reduces transmission of microorganisms.
• Assess risk with risk assessment scale. Determines risk category and potential for skin breakdown.
• Initiate prevention protocol based on risk assessment and risk factors identified. Check on prevention protocol and strategies. Prevention strategies decrease the risk for developing a pressure ulcer. Consistent turning, skin care, and incontinence management increase the potential for maintaining skin integrity.
• Document all preventive care or wound care if there is a skin problem. Documentation ensures that care was provided. Flow sheets provide adequate documentation; record additional description as needed in the narrative and nurse’s notes.
• Communicate all skin care with nursing staff, and promptly notify the patient’s prescriber when there is a change in the skin condition. Prompt notification ensures that any necessary change will be made to reduce risk for further skin damage.
• Continue to assess the patient’s skin for changes: no blanching erythema, swelling, moisture may increase risk for a pressure ulcer. Skin assessment must be included in the head-to-toe assessment; regular skin assessment ensures that any change will be noted and prevention methods will be initiated.
• After completing assessment, remove gloves and PPE, and wash hands. Reduces transmission of infectious organisms.

1. Px w/ R pneumonectomy, post-op position = R side lying
2. Post liver biopsy = placed R side lying
3. Rales at L lower lobe of lungs, px must be positioned for chest PT = on his R side w/ hip slightly higher than the head
4. When inserting TPN to a central line, w/c position shld. the RN place the px to prevent introducing air to the system = Trendelendburg
5. How shld. the RN position in hypovolemic shock = flat w/ legs slightly elevated
6. Pregnant in labor is exhibiting late deceleration in fetal monitor; RN shld change her position to = L lateral recumbent position
7. Pregnant experienced lightheadedness, dizziness,what position to relieve S/sx = L lateral recumbent position
8. Post supratentorial craniotomy, the RN shld. place the px in = low Fowler’s position
9. After hip repair, px makes the ffg. statements, w/c one reflects need for further teaching = “I will make sure to separate my legs when I have to tie my shoe lace.”
10. A px experiences lightheadedness, diaphoresis, diarrhea. History reveals px had gastrectomy in the past = relieve symptoms by lying down
11. After cataract surgery, px shld. be position = unaffected side to prevent edema
12. Px w/ hiatal hernia, w/c is C/I = lying supine immediate after meals
13. Post tonsillectomy position of a child = on the abdomen w/ head turn to side
14. Post R carotid endarterectomy = R position – supine w/ head elevated at 30degree
15. Px w/ abruptio placenta, w/c position appropriate = Supine
16. Px w/ emphysema , what position shld. px assume = Sitting while leaning forward
17. Px to undergo Ba enema, w/c position is appropriate = L side lying
18. Post femoro-popliteal bypass, RN shld. = keep leg of px elevated on a pillow
19. Post spinal anesthesia, to prevent hypotension, RN shld. = place px in supine position
20. Px w/ CVP reading of 3 shld. be placed in what position = lower extremity elevated
Px w/ TOF exhibits cyanosis, RN shld. place in what position = Squatting position
21.Mastectomy=semi fowler's 30 with the affected arm elevated on a pillow,turn only on the unaffected side and back
22.Hypophysectomy=elevate head of the bed
23.Thyroidectomy=semi fowler's- sandbags/pillows support head and neck
24.HEMORRHOIDECTOMY=lateral side lying
25.GERD=reverse trendelenberg
26.LIVER BIOPSY=during procedure:supine right side right arm extended on the left shoulder
after procedure:right lateral(side lying)place small pillow or folded towel under the punctured site
27.NG TUBE-
a)insertion-high fowler's
b)irrigation/feeding-semi fowler's head of bed 30*
28.Rectal enemas=left sim's position
29.COPD=sitting position,leaning forward with clients arms over several pillows
30.Laryngectomy=semi fowler's to fowlers
31.Bronchoscopy=semi fowler's
32.Postural drainage=the lung segment should be in the uppermost position
33.Thoracentesis=during procedure:sitting the edge of the bed
after procedure: fowler's position
34.Abdominal Resection (ANEURISM)
limit to 45*(FOWLER'S)
35.Amputtion of the lower limbs=elevate foot of the bed;prone 20-30 mins
36.Arterial vascular Grafting
a)bedrest 24* with extremities straight
b)limit movement
37.Cardiac catherization
a)bedrest 3-4 hrs,side to side after
b)keep straight ang head of bed elevated no more than 30*
38.Congestive heart failure with pulmonary edema=high fowler's position
39.Perpheral arterial disease=elevate feet at rest but not raise above heart level
40.Deep vein thrombosis=bed rest with leg elevation,out of bed after 24*
41.Varicose veins=leg elevation above heart level
42. Venous leg ulcers=leg elevated
43.Autonomic dysreflexia=elevate head of bed to fowlers
44.Cerebral aneurism=semi fowler's
45.cerebral angiography=bed rest

Thinking through each individual situation and applying the following
simple principles when moving and handling will enable you to maintain
health and safety whilst undertaking the task.

• Assessment of the task
A full and comprehensive assessment should be made of the task before undertaking the move. This assessment of all aspects of the task will enable you to identify risks and hazards and to problem solve to enable the undertaking of safe manoeuvres.

• Maintain a stable base
Position the feet slightly apart, with the lead foot pointing in the direction of movement.
Stability provided by positioning the feet in such a way will prevent loss of balance and falling or twisting during the manoeuvre. When moving and handling a client, for example from one bed to another, it may seem impossible to keep both feet on the floor to provide a stable base without over stretching. It is possible and the situation should be reassessed so as to ensure a stable base whilst undertaking the move. If this is difficult seek guidance from the in-house moving and handling trainer.

• Lower the centre of gravity
By bending or flexing the knees slightly, the centre of gravity will be lowered. This bending of the knees will not only help the posture to be more relaxed and less taut but also provide more stability.

• Keep the spine in line
The spine’s natural curves should be maintained in their normal position, often referred to as ‘in line’, to prevent the occurrence of injury during movement and handling activities. Keeping the spine ‘in line’ also means avoiding top-heavy postures and positions where the spine is twisted or
rotated at any point.

• Keep the load close to your body
Keeping the load close to the body reduces the strain/effort involved in the manoeuvre, by having the load closer to the centre of gravity. It increases efficiency of the movement. It reduces the likelihood of injury.

• Move your head up
Raising the head in an upward direction/movement when undertaking a move leads the body in its movement and helps maintain good posture throughout.

• Holds
Holds used should be relaxed palm-type holds or stroking. Grasping or direct holds should not be used. Using indirect holds allows the hold to be released should the manoeuvre be beyond one’s abilities and reduces the likelihood of injury. Stroking down clients’ limbs to aid in their movement is gentler for the client and they are less likely to respond by suddenly withdrawing the limb, which could result in one being jerked or injured.

• Remember individual capabilities
Remember to consider the individual capabilities of all concerned in the manoeuvre; this includes you and your colleagues as well as the client. Those who have had previous injuries, or pregnant women, may be at greater risk when moving and handling.

• Know the equipment
It is important to know not only what equipment is available, but also how to use it correctly and to its fullest potential. One should also be aware of the correct methods for sizing of slings/accessories to ensure these are used correctly. The maximum safe working load of all pieces of equipment used in the area should be known. Equipment should be well maintained and serviced regularly. Do not use if faulty and ensure that faulty equipment is labelled as such and reported immediately. All equipment should be checked at least annually and a record kept.

• Good communication
Good communication is important so that everyone involved in the manoeuvre is aware of what their responsibilities are in relation to the move, and when the manoeuvre is to take place. This will also help to ensure that the move is carried out at the correct time in an organized manner.
Communication with the client is also vital not only to ensure their co-operation but also to maintain their trust and confidence.

• Controlled manoeuvres
Remember that manoeuvres need to be controlled and taken in stages if necessary to avoid over-stretching for those undertaking the move and to avoid discomfort or fear for the client.

• Wear appropriate clothing and footwear
Wearing correctly fitting and appropriate clothing will enable free movement without being restricted. Correct footwear will ensure good stability and grip and thus prevent over-balancing or slipping.

• Avoid manual handling
Manual handling, that is, physically moving objects or persons, should be avoided if at all possible.

Remembering these principles and being able to apply them in the variety of movement and handling tasks undertaken both in the workplace and in everyday life will enable problem solving and the identification of safe solutions in respect of movement and handling.
Adopting these principles will provide a more flexible approach to manual handling than learning a specific move for a specific situation, where in real life other factors involved often make such specific manoeuvres learnt unsuitable or unachievable in the practice setting.

PATIENT'S BILL OF RIGHTS

the patient has the right to considerate and respectful care.

The patient has the right to obtain from his physician complete and current information concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand.

The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and/or treatment.

The patient has the right to refuse treatment and to be informed of the medical consequences of his action.

The patient has the right to every consideration of his privacy concerning his own medical care program.

The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential.

The patient has the right to expect within its capacity, a hospital must take reasonable response to the request of a patient for service.

The patient has the right to obtain information as to any relationships his hospital has to other health care and educational institutions insofar as his care is concerned.

The patient has the right to be advised if the hospital proposes to engage in or perform human experimentation affecting his care or treatment.

The patient has the right to expect reasonable continuity of care.

The patient has the right to examine and receive an explanation of his bill.

The patient has the right to know what hospital rules and regulations apply to his conduct as a patient.

1. to relieve urinary retention.
2. To obtain a sterile urine specimen from a woman.
3. To measure the amount of residual urine in the bladder.
4. To obtain a urine specimen when a specimen cannot be secured satisfactorily by other means.
5. To empty the bladder before and during surgery and before certain diagnostic examinations.

1. Assemble equipments. Be sure to wash your hands thoroughly.
2. Have the patient lie on a firm mattress.
3. Provide for good light.
4. After providing for privacy, position the patient in a dorsal recumbent position, with the knees flexed and feet about 2 feet apart, and drape the patient.
5. If the patient is soiled, wash the area around the meatus well with soap or detergent and water, then rinse and dry.
6. After putting on sterile gloves, arrange the sterile equipment for convenience and to avoid contamination.
7. Place the sterile drapes adjacent to the meatal area. Use the drape corners to wrap around the gloved hands.
8. Lubricate the catheter fro about 3.7 cm being careful not to fill the eyes of the catheter.
9. Place the thumb and one finger between the labia minora, and identify the meatus.
10. Be prepaired to maintain separation of the labia with one hand until urine is flowing well and continously.
11. Cleanse the exposed area at the meatus thoroughly using the solution of the agencys choice. Move the cotton ball held in a forceps fro above the meatus down toward the rectum.
12. With the uncontaminated gloved hand, pick up the catheter and insert it into the meatus 5 cm to 7.5 cm.
13. Do not use force to push the catheter through the urethra into the bladder.
14. Ask the patient to breathe deeply, and rotate the catheter gently if slightly resistance is met as the catheter reaches the external sphincter.
15. Hold the catheter surely while the bladder empties. Do not move the catheter in and out as the bladder drains.
16. When the flow of urine begins to decrease, withdraw the catheter slowly, about 1 cm at a time, until urine barely drips, and then withdraw the catheter.
17. Remove the equipment, and make the patient comfortable in bed. Send the urine specimen to the laboratory promptly or refrigerate it.
18. Record the time of the catheterization, the amount of urine removed, a description of the urine, the patients reaction to the procedure, and your name.

1. Position the patient on his back. The procedure is usually easier when the patients legs are together. Drape the patient so that only the area around the penis is exposed.
2. Place the catheter set on or next to the patients legs.
3. Generously lubricate the catheter for about 15 cm to 18 cm, being careful not to plug the eyes in the catheter.
4. Lift the penis with one hand, which is then considered contaminated. Cleanse the area at the meatus well with cotton balls held with a forceps in a circular motion.
5. Pull the penis with gentle traction straight up with the fingers on the sides of the penis. Slightly pinch the end of the penis, and insert the catheter for 15 cm to 20 cm.
6. Do not use force to introduce the catheter. If the catheter resists entry, ask the patient to deep breathly, and rotate the catheter slightly.
7. Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder.
8. Connect the catheter to the drainage tubing and drainage bag if not already connected.
9. Tape the catheter along the anterior aspect of the thigh.
10. Hang the drainage bag on the frame of the bed below the level of the bladder.

Triage Principles:·

Mettag: RED – Priority I – Immediate attention. Identifier is a Mettag torn to the red stripe or Roman numeral I placed on the forehead or back of left hand. First priority casualties are those that have life-threatening injuries that are readily correctable. For purposes of priority for dispatch to the hospital, however, a second sorting or review may be necessary so only those “transportable” cases are taken early. Some will require extensive stabilization at the scene before transport may be safely undertaken. A red tag may be used as an additional means of identification.

Mettag: YELLOW – Priority II –Delayed attention. Identifier is the Mettag torn to the yellow stripe or Roman numeral II placed on the forehead or back of left hand. Delayed category casualties are all those whose therapy may be delayed without significant threat of life or limb and those for whom extensive or highly sophisticated procedures are necessary to sustain life.

Mettag: GREEN – Minor injuries. Casualties with minor injuries will receive minimum first aid treatment. They will not be transported to hospitals until all Priority I and II patients have received care. They will be sent from the triage area to a designated area away from the disaster scene in order to reduce confusion. If they are capable, they may also be used as litter bearers or first aid providers.

Mettag: BLACK – Dead. Identifier is the Mettag torn up to the black stripe or an X on the forehead and covered with a sheet, blanket or other opaque material as soon as possible. Unless absolutely necessary, they should be left in place until released by the coroner. The temporary morgue should be an area away from the scene of the triage area.

Persons who are psychologically disturbed, who interfere with casualty handling, should be isolated from the incident scene as quickly as possible. Campus Police will be requested to escort individuals to a designated area away from the disaster scene.

TRIAGE CATEGORY GUIDELINES

For multiple casualty incidents involving up to 80 victims:

RED: IMMEDIATE (Priority I)

1. Asphyxia

2. Respiratory obstruction from mechanical causes

3. Sucking cheat wounds

4. Tension pneumothorax

5. Maxillofacial wounds in which asphyxia exists or is likely to develop

6. Shock caused by major external hemorrhage

7. Major internal hemorrhage

8. Visceral injuries or evisceration

9. Cardio/pericardial injuries

10. Massive muscle damage

11. Severe burns over 25%

12. Dislocations

13. Major fracture

14. Major medical problems readily correctable

15. Closed cerebral injuries with increasing loss of consciousness

Simple Treatment and Rapid Treatment (START): Quick identifiers for Red

• Ventilation > 30/min
• Perfusion <>
• Mental status: unable to follow simple directions

YELLOW: DELAYED (Priority II)

1. Vascular injuries requiring repair
2. Wounds of the genitourinary tract
3. Thoracic wounds without asphyxia

4. Severe burns under 25%

5. Spinal cord injuries requiring decompression

6. Suspected spinal cord injuries without neurological signs

7. Lesser fractures

8. Injuries of the eye

9. Maxillofacial injuries without asphyxia

10. Minor medical problems

11. Victims with little hope of survival under the best of circumstances of medical care
For multiple casualty incidents with an overwhelming number of survivors or over 80 victims:

RED: IMMEDIATE (Priority I)

1. Asphyxia

2. Respiratory obstruction from mechanical causes

3. Sucking cheat wounds

4. Tension pneumothorax

5. Maxillofacial wounds in which asphyxia exists or is likely to develop

6. Shock caused by major external hemorrhage

7. Dislocations

8. Severe burns under 25%*

9. Lesser fractures*

10. Major medical problems that can be handled readily
YELLOW: DELAYED (Priority II)

1. Major fractures (if able to stabilize)*

2. Visceral injuries or evisceration*

3. Cardio/pericardial injuries*

4. Massive muscle damage*

5. Severe burns over 25%*

6. Vascular injuries requiring repair

7. Wounds of genitourinary tract

8. Thoracic wounds without asphyxia

9. Closed cerebral injuries with increasing loss of consciousness*

10. Spinal cord injuries requiring decompression

11. Suspected spinal cord injuries without neurological signs

12. Injuries of the eye

13. Maxillofacial injuries without asphyxia

14. Complicated major medical problems*

15. Minor medical problems

16. Victims with little hope of survival under the best of circumstances of medical care

*Conditions which have changed categories

1. PRIMARY PREVENTION- Generalized health promotion and specific protection against diseases. It precedes disease or dysfunction and is applied to generally healthy individuals or groups

2. SECONDARY PREVENTION- Emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Includes prevention of complications and disabilities.

3. TERTIARY PREVENTION- Begins after an illness, when a defect or disability is fixed, stabilized or determined to be irreversible. Its focus is to help rehabilitate individuals and restore them to an optimum level of functioning within the constraints of the disability.

1. Any person 18 years of age or older may become an organ donor by written consent.
2. Informed choice to donate an organ can take place with the use of a written document signed by the client prior to death, a will, or a donor card or an advance directive.
3. In the absence of appropriate documentation, a family member or legal guardian may authorize donation on the descendant’s organs.
4. In case of newborns, they must be full term already ( more than 200 grams)

1. Russian Orthodox: permits all donations EXCEPT THE HEART.
2. Jehovah’s Witness: DOES NOT ALLOW organ donation and all organ to be

3. Judaism: They permit organ donation as long as with RABBINICAL CONSULTATION.
4. Islam: will NOT USE ORGAN STORED IN ORGAN BANKS.

METRIC	APOTHECARY	HOUSEHOLD
1 ml	15-16 minims (m)	15 drops (gtt)
4-5 ml	Fluidram	1 teaspoon (tsp)
15 ml	4 fluidrams	1 tablespoon (tbsp)
30 ml	1 fluid ounce	2 tablespoons
240 ml	8 fluid ounces	1 cup (c)
480 ml (approx. 500 ml)	1 pint (pt)	1 pint (pt)
960 ml (approx. 1 L/liter)	1 quart (qt)	1 quart (qt)
3840 ml (approx. 5 L)	1 gallon (gal)	1 gallon (gal)

1. RESTRAINTS SHOULD NOT BE USED PRN!!!
2. Informed consent and a Doctors order is needed to use restraints.
3. Doctors orders for restraints should be renewed within a specific time frame

4. Restraints should not interfere with any treatments or affect the client’s health problems.
5. Document the following:

1. Before restraints offer explanations, ask someone to stay with the client, use clocks, calendars, TV & radio ( to decrease disorientation) or any relaxation techniques.
2. Use LESS restrictive methods first. RESTRAINTS should always be the last.
3. Assign confuse and disoriented clients to rooms near the nurse’s station.
4. Maintain toileting routines & institute exercise and ambulation schedules as the client