Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Alzheimer's disease

Description

  • Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 60.
  • Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. Estimates vary, but experts suggest that as many as 5.1 million Americans may have Alzheimer’s.
  • Dementia involves progressive decline in two or more of the following areas of cognition: memory, language, calculation, visual-spatial perception, judgment, abstraction, and behavior.

Causes

The cause of AD is unknown but knowledge about the hereditary links is growing. Patients with Down syndrome eventually develop DAT if they live long enough. There is a higher-than-normal concentration of aluminum in the brain of a person with DAT, but the effect is unknown. A distinct protein, AZ 50, has been identified at autopsy in the brains of DAT patients. This protein has been isolated from neurons that were not yet damaged, suggesting that its presence early in the degenerative process might cause the neuronal damage. The life expectancy of a DAT patient is reduced 30% to 60%.

Characteristics/ Signs and Symptoms

The disease course is divided into four stages, with progressive patterns of cognitive and functional impairments.


Pre-dementia

Stage 1 is characterized by recent memory loss, increased irritability, impaired judgment, loss of interest in life, decline of problem-solving ability, and reduction in abstract thinking. Remote memory and neurological exam remain unchanged from baseline.

Early

Stage 2 lasts 2 to 4 years and reveals a decline in the patient’s ability to manage personal and business affairs, an inability to remember shapes of objects, continued repetition of a meaningless word or phrase (perseveration), wandering or circular speech patterns (circumlocution dysphasia), wandering at night, restlessness, depression, anxiety, and intensification of cognitive and emotional changes of stage 1.

Moderate

Stage 3 is characterized by impaired ability to speak (aphasia), inability to recognize familiar objects (agnosia), inability to use objects properly (apraxia), inattention, distractibility, involuntary emotional outbursts, urinary or fecal incontinence, lint-picking motion, and chewing movements. Progression through stages 2 and 3 varies from 2 to 12 years.

Advanced

Stage 4, which lasts approximately 1 year, reveals a patient with a masklike facial expression, no communication, apathy, withdrawal, eventual immobility, assumed fetal position, no appetite, and emaciation.

Diagnostic Examination

  • Alzheimer's disease is usually diagnosed clinically from the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions. 
  • Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single photon emission computed tomography (SPECT) or positron emission tomography (PET) can be used to help exclude other cerebral pathology or subtypes of dementia.Moreover, it may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer's disease.
  • Assessment of intellectual functioning including memory testing can further characterize the state of the disease.Medical organisations have created diagnostic criteria to ease and standardize the diagnostic process for practicing physicians. The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically.

Primary Nursing Diagnosis

Self-care deficit related to impaired cognitive and motor function
  • Outcomes. Self-care: Activities of daily living—Bathing, Hygiene, Eating, Toileting; Cognitive ability; Comfort level; Role performance; Social interaction skills; Hope
  • Interventions. Self-care assistance: Bathing and Hygiene; Oral health management; Behavior management; Body
    PET scan of the brain of a person with AD showing a loss of function in the temporal lobe
     image enhancement; Emotional support; Mutual goal setting; Exercise therapy; Discharge planning

Other Nursing Diagnosis

Risk for Injury related to:
  • Unable to recognize / identify hazards in the environment.
  • Disorientation, confusion, impaired decision making.
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Medical Management

There is no cure for Alzheimer's disease; available treatments offer relatively small symptomatic benefit but remain palliative in nature.
The initial management of the patient begins with education of the family and caregivers regarding the disease, the prognosis, and changes in lifestyle that are necessary as the disease progresses.
Basic collaborative principles include:
  • Keep requests for the patient simple
  • Avoid confrontation and requests that might lead to frustration
  • Remain calm and supportive if the patient becomes upset
  • Maintain a consistent environment
  • Provide frequent cues and reminders to reorient the patient
  • Adjust expectations for the patient as he or she declines in capacity

Pharmacologic Treatment

  • Generally, therapy is focused on symptoms with an attempt to maintain cognition.
  • Donepezil (cholinesterase inhibitor; elevates acetylcholine concentration in cerebral cortex by slowing degradation of acetylcholine released by intact neurons) which improves cognitive symptoms; improves cognitive function in the early stages of the disease only; drug effects diminish as the disease progresses
  • Antidepressants (selective serotonin reuptake inhibitors; increases activity of serotonin in the brain) which treats depression, anxiety, and irritability
  • Other Tests: Supporting tests include computed tomography (CT) scan; magnetic resonance imaging (MRI); positron emission tomography (PET). During the early stages of dementia, CT and MRI may be normal, but in later stages, an MRI may show a decrease in the size of the cerebral cortex or of the area of the brain responsible for memory, particularly the hippocampus. Genetic testing for the ApoE gene is available and the presence of the gene is a risk factor for AD. Genetic tests may be helpful in diagnosis, but further studies are needed to confirm their reliability. 

Nursing Intervention

  1. Establish an effective communication system with the patient and his family to help them adjust to the patient’s altered cognitive abilities.
  2. Provide emotional support to the patient and his family.
  3. Administer ordered medications and note their effects. If the patient has trouble swallowing, crush tablets and open capsules and mix them with a semi soft food.
  4. Protect the patient from injury by providing a safe, structured environment.
  5. Provide rest periods between activities because the patient tires easily.
  6. Encourage the patient to exercise as ordered to help maintain mobility.
  7. Encourage patient independence and allow ample time for him to perform tasks.
  8. Encourage sufficient fluid intake and adequate nutrition.
  9. Take the patient to the bathroom at least every 2 hours and make sure he knows the location of the bathroom.
  10. Assist the patient with hygiene and dressing as necessary.
  11. Frequently check the the patient’s vital signs.
  12. Monitor the patient’s fluid and food intake to detect imbalances.
  13. Inspect the patient’s skin for evidence of trauma, such as bruises or skin breakdown.
  14. Encourage the family to allow the patient as much independence as possible while ensuring safety to the patient and others.


Alpha-fetoprotein (AFP)

Definition

Alpha-fetoprotein (AFP)
is a glycoprotein produced by fetal tissue and tumors that differentiate from midline embryonic structures. During fetal development, AFP levels in serum and amniotic fluid rise; because this problem crosses the placenta, it appears in maternal serum. In late stages of pregnancy, AFP levels in fetal and maternal serum and in amniotic fluid begin to diminish. During the first year of life, serum AFP levels continue to decline and usually remain how low thereafter.
High maternal serum AFP levels may suggest fetal tube defects, such as spina bifida and anencephaly; but positive confirmation requires amniocentesis and ultrasongraphy. Other congenital anomalies, such as Down syndrome and other chromosomal disorders, may be associated with low maternal serum AFP concentrations.
Elevated serum AFP levels in 70% of nonpregnant persons may indicate hepatocellular carcinoma (although low AFP levels don’t rule it out) or germ cell tumor of gonadal, retroperitoneal, or mediastinal origin.
Serum AFP level rises in patients with ataxiatelangiectasia and in patients with cancer of the pancreas, stomach, or biliary system. Transient modest elevations can occur in nonneoplastic hepatocellular disease, such as alcoholic cirrhosis and acute or chronic hepatitis. Elevation of AFP levels after remission suggests tumor recurrence.

Purpose
  • To monitor the effectiveness of therapy in malignant conditions, such as hepatomas and germ cell tumors, and certain nonmalignant conditions such as ataxiatelengiectasia.
  • To screen those patients needs amniocentesis or high-resolution ultrasonography during pregnancy.

Procedure
Preparation
  1. Explain that the AFP tests helps in monitoring fetal development, screens for a need for further testing, helps detect possible congenital defects in the fetus, and monitors the patient’s response to therapy by measuring a specific blood protein, as appropriate.
  2. Inform the patient that she need not restrict food, fluids, or medications.
  3. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.
  4. Explain to the patient that she may experience slight discomfort from the tourniquet and needle puncture.
Implementation
  1. Perform a venipuncture and collect the sample in a 7 ml clot-activator tube.
  2. Record the patient’s age, race, weight, and week of gestation on the laboratory request.
  3. Handle the sample gently to prevent hemolysis.
Nursing Interventions
  1. Place the patient in comfortable position.
  2. Encourage deep breathing exercise to alleviate fear.
  3. Apply direct pressure to the venipuncture site until bleeding stops.

Interpretation
Normal Results
  • When testing by immunoassay, AFP values are less than 15 ng/ml (SI, <15 mg/l) in male patients and nonpregnant female patients.
  • Values in maternal serum normally are less 25 ng/ml (SI, 25 ug/L). At 15 to 18 weeks gestation, values range from 10 to 150 ng/ml (SI, 10 to 150 ug/L).
Abnormal Results
  • Elevated maternal serum AFP level may suggest neural tube defect or other tube anomalies.
  • Definitive diagnosis requires ultrasonography and amniocentesis.
  • High AFP levels may indicate intrauterine death, or high levels indicate other anomalies, such as duodenal atresia, omphalocele, tetralogy of fallot, and Tuner’s syndrome.
  • Elevated serum AFP levels occur in 70% of nonpregnant patients with hepatocellular carcinoma.
  • Elevated levels are also related to germ cell tumor of gonadal, retroperitoneal, or mediastinal origin.
  • Transient modest elevations can occur in nonneoplastic hepatocellular disease, such as alcoholic cirrhosis and acute or chronic hepatitis.
  • Elevation of AFP levels after remission suggests tumor recurrence.

Precautions
  • Handle the sample gently to prevent hemolysis.

Interfering Factors
  • Hemolysis from rough handling of the sample.
  • Multiple pregnancies that may cause false positive result.

Complications
  • Hematoma at the venipuncture site.

Addison's Disease vs Cushing's Disease


  ADDISON’S DISEASE CUSHING’S DISEASE
Definition
Hyposecretion of adrenocortical hormones leading to:
  • Metabolic disturbances (sugar)
  • Fluid and electrolyte imbalances (salt)
  • Deficiency of neuromuscular function (salt and sex)
 

Hypersecretion of adrenocortical hormone
Predisposing Factors
  1. Atrophy of the Adrenal gland
  2. Fungal infections
  1. Hyperplasia of Adrenal gland
  2. Tubercular infection (MILIARY – TB to adjacent organs)
Signs and
Symptoms
  1.  hypoglycemia (TIRED)
    • Tremors and tachycardia
    • Irritability
    • Restlessness
    • Extreme fatigue
    • Diaphoresis and depression
  2. Decreased tolerance to stress (d/t decreased cortisol) à Addisonian Crisis
  3. Hyponatremia
    • Hypotension
    • Signs of dehydration
    • Weight loss
  4. Hyperkalemia
    • Irritability and agitation
    • Diarrhea
    • Arrhythmias
  5. Decreased Libido
  6. Loss of pubic and axillary hair
  7. Bronze-like skin pigmentation d/t decreased cortisolà stimulation of MSH from pituitary gland
  1.  Hyperglycemia à can lead to DM
    1. Polyuria
    2. Polydipsia
    3. Polyphagia
    4. Wt. Gain
    5. Glucosuria
  2. Increased susceptibility to infection (Reverse isolation!)
  3. Hypernatremia
    1. HPN
    2. Edema
    3. Wt. gain
  4. Moonface appearance, buffalo hump, obese trunk, pendulous abdomen, thin extremities
  5. Hypokalemia
    1. Weakness and fatigue
    2. Constipation
    3. U wave on ECG tracing
  6. Hirsutism
  7. Easy brusing
  8. Acne and Striae
  9. increased masculinity in females
Diagnostics
  1. FBS decreased (N= 80-120 mg/dl)
  2. Serum Na decreased (N= 135-145)
  3. Serum K elevated (N=3.5-5.5meq/L)
  4. Plasma cortisol decreased
  1. FBS elevated
  2. Elevated Na
  3. Decreased K
  4. Elevated Cortisol
Nursing
Management
  1.  Monitor strictly VS, IO to determine presence of Addisonian crisis which results from acute exacerbation of Addison’s disease characterized by:
    • Hyponatremia
    • Hypovolemia
    • Dehydration
    • Severe Hypotension
    • Weight lossà Which may lead to progressive stupor à coma.
      • Assist in mech vent, steroids as ordered, forced fluids
  2. Administer medications as ordered
    • Corticosteroids
      • Universal rule: administer 2/3 dose in AM and 1/3 dose in PM to mimic the N diurnal rhythm of the body
      • Taper the dose. Withdraw gradually from the drug
      • Monitor SE: Cushingoid Sx
      • HPN, Increased susceptibility to infection, Weight gain, Hirsutism, Moon face appearance
      • Ex: Hydrocortisone, Dexamethasone, Prednisone
    • Mineralocorticoids – fluorocortisone
  3. Forced fluids
  4. Maintain patent IV line
  5. Diet: high CHO/calories, Na and CHON, low K
  6. Meticulous skin care
  7. Provide health teaching and d/c planning
    • Avoidance of precipitating factors leading to addisonian crisis:
      • Stress, Infection, Sudden withdrawal to steroids
    • Prevent Complications – hypovolemic shock
    • Hormonal replacement therapy for life
    • Importance of ffup care
  1. Monitor IO, VS
  2. Restrict Na and Fluids
  3. Weigh pt. daily and assess for pitting edema (ANASARCA – generalized edemaà nephritic syndrome)
  4. Measure abdominal girth daily, notify MD
  5. Diet: low CHO, NA, High CHON and K
  6. Administer medications as ordered
    • K-sparing diuretics - Spironolactone (Aldactone); excretes sodium but retains potassium
  7. Prevent Complications – DM
  8. Provides meticulous skin care
  9. Assist in Surgical Procedure – Bilateral Adrenalectomy
  10. Hormonal replacement for life
  11. Importance of ffup care

Acute Respiratory Distress Syndrome

Description

  1. Acute respiratory distress syndrome is a form of acute respiratory failure that occurs as a complication of some other condition, is caused by a diffuse lung injury, and leads to extravascular lung fluid.
  2. The major site of injury is the alveolar capillary membrane.
  3. The interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance.
  4. The ABG’s identify respiratory acidosis and hypoxemia that does not respond to an increase percentage of oxygen.
  5. The chest X-ray film shows interstitial edema.
  6. Some of the causes includes sepsis, fluid overload, shock, trauma, neurological injuries, burns, disseminated intravascular coagulation, drug ingestion and inhalation of toxic substances.

Causes & Risk Factors

ARDS can be caused by any major swelling (inflammation) or injury to the lung. Some common causes include: 
  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Pneumonia
  • Septic shock
  • Trauma
ARDS leads to a buildup of fluid in the air sacs. This fluid prevents enough oxygen from passing into the bloodstream.

The fluid buildup also makes the lungs heavy and stiff, and decreases the lungs' ability to expand. The level of oxygen in the blood can stay dangerously low, even if the person receives oxygen from a breathing machine (mechanical ventilator) through a breathing tube (endotracheal tube).

ARDS often occurs along with the failure of other organ systems, such as the liver or the kidneys. Cigarette smoking and heavy alcohol use may be risk factors.


Assessment
  1. Tachypnea
  2. Dyspnea
  3. Decrease breath sounds
  4. Deteriorating gas levels
  5. Hypoxemia despite high concentration of delivered oxygen
  6. Decreased pulmonary compliance
  7. Pulmonary infiltrates

Diagnostic Evaluation
  1. Based on clinical criteria history of risk factors acute onset of respiratory distress bilateral pulmonary infiltrates absence of left heart failure and severe refractory hypoxemia.
  2. Chest X-ray shows bilateral infiltrates and pulmonary edema.

Primary Nursing Diagnosis
  • Impaired gas exchange related to increased alveolar-capillary permeability, interstitial edema and decreased lung compliance
Other Diagnoses that may occur in Nursing Care Plans For ARDS
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Activity intolerance
  • Anxiety (specify level: mild, moderate, severe, panic)
  • Risk for aspiration


Medical Management
  • Identify and treat the underlying condition insure early detection; use aggressive supportive treatment; prevent infection ( intubation and mechanical ventilation).
  • As disease progresses, use positive and expiratory pressure PEEP ( neuromuscular blocking agent such as pancuronium (pavulon and vecuronium) (norcuron) maybe used to paralyzed patient for easier ventilation.
  • Monitor arterial blood gas values , pulse symmetry , and pulmonary function testing.
  • Provide circulatory support; treat hypovolemia carefully ; avoid overload
  • Provide adequate fluid management ; administer intravenous solutions
  • Provide nutritional support; (35 to 45 kilocalories per kilogram daily)
  • Pharmacologic therapy may include human recombinant interleukin-1 receptor antagonist, neutrophil inhibitors, pulmonary- specific vasodilators, surfactant replacement therapy, antisepsis agents, antioxidant therapy, and corticosteroids (late in the course of ARDS).

Pharmacologic Intervention
  • General Comments: Use of genetically engineered surfactant has been studied in ARDS but has not demonstrated the success that has occurred in premature infants with surfactant deficiency. Corticosteroids have been widely used in ARDS, yet studies have not consistently demonstrated any improvement in patient outcomes and remain controversial. Some evidence exists that prolonged treatment with low-dose corticosteroids may benefit patients with unresolving ARDS, particularly by reversing the process of fibroproliferation. If the patient is difficult to ventilate, she or he may receive skeletal muscle relaxants such as vecuronium (Norcuron), which are neuromuscular-blocking agents that paralyze the patient’s skeletal muscles. These medications are used only when the patient’s gas exchange is so poor as to threaten his or her life. Neuromuscular-blocking agents paralyze the patient without affecting mental status, so the patient requires sedation to counteract the accompanying fear and anxiety that occur when the patient is unable to move.
  • Nitric oxide Inhalation route a pulmonary vascular vasodilator to decreases pulmonary vascular resistance with increased perfusion to ventilated areas

Nursing Intervention
  1. Identify and treat cause of the Acute respiratory distress syndrome
  2. Administer oxygen as prescribed.
  3. Position client in high fowler’s position.
  4. Restrict fluid intake as prescribed.
  5. Provide respiratory treatment as prescribed.
  6. Administer diuretics, anticoagulants or corticosteroids as prescribed.
  7. Prepare the client for intubation and mechanical ventilation using PEEP.

Documentation Guidelines
  • Respiratory status of the patient: respiratory rate, breath sounds, and the use of accessory muscles; arterial blood gas (ABG) levels; pulse oximeter and chest x-ray results
  • Response to treatment, mechanical ventilation, immobility, and bedrest
  • Presence of any complications (depends on the precipitating condition leading to ARDS)

Discharge and Home Healthcare Guidelines
  • PREVENTION. Prompt attention for any infections may decrease the incidence of sepsis,which can lead to ARDS.
  • COMPLICATIONS. If patients survive ARDS, few residual effects are seen. Complications are directed to any other conditions the patient may have.

Acute Renal Failure

Description 


  • Is a sudden decline in renal function, usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention.
  • Acute renal failure are classified into following:
    • Prerenal failure – results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy).
    • Postrenal failure – results from obstruction of urine flow.
    • Intrarenal failure – results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders).
  • The disease progresses through three clinically distinct phase which is oliguric-anuric, diuretic, and recovery, distinguished primarily by changes in urine volume and BUN and creatinine levels.
  • Complication of ARF include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, end-stage renal disease, and death from uremia or related causes.

Pathophysiology


Assessment:
  1. Oliguric-anuric phase: urine volume less than 400 ml per 24 hours; increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium; lasts 3 to 5 days in infants and children, 10 to 14 days in adolescents and adults.
  2. Diuretic phase: begins when urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising; length is availabe.
  3. Recovery phase: asymptomatic; last several months to 1 year; some scar tissue may remain.
  4. In prerenal disease: decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia.
  5. In postrenal disease: difficulty in voiding, changes in urine flow.
  6. In Intrarenal disease: presentation varies; usually have edema, may have fever, skin rash.
  7. Nausea, vomiting, diarrhea, and lethargy may also occur.

Diagnostic Evaluation:
  1. Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various forms of ARF(prerenal, postrenal, intrarenal).
  2. Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal.
  3. Renal untrasonography estimates renal size and rules out treatable obstructive uropathy.

Primary Nursing Diagnosis
  • Fluid volume deficit related to excessive urinary output,vomiting,hemorrhage
Other Diagnoses that may occur in Nursing Care Plans For Acute Renal Failure
  • Ineffective tissue perfusion (renal)
  • Excess fluid volume
  • Risk for infection
Therapeutic and Pharmacologic Interventions:
  1. Surgical relief of obstruction may be necessary.
  2. Correction of underlying fluid excesses or deficits.
  3. Correction and control of biochemical imbalances.
  4. Restoration and maintenance of blood pressure through I.V. fluids and vasopressors.
  5. Maintenance of adequate nutrition: Low protein diet with supplemental amino acids and vitamins.
  6. Initiation of hemodialysis, peritoneal dialysis, or continuous renal replacement therapy for patients with progressive azotemia and other life-threatening complications.

Nursing Interventions:
  1. Monitor 24-hour urine volume to follow clinical course of the disease.
  2. Monitor BUN, creatinine, and electrolyte.
  3. Monitor ABG levels as necessary to evaluate acid-base balance.
  4. Weigh the patient to provide an index of fluid balance.
  5. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions.
  6. Adjust fluid intake to avoid volume overload and dehydration.
  7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac arrest.
  8. Watch for urinary tract infection, and remove bladder catheter as soon as possible.
  9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high.
  10. Provide meticulous wound care.
  11. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
  12. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside.
  13. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity.
  14. Explain that the patient may experience residual defects in kidney function for a long time after acute illness.
  15. Encourage the patient to report routine urinalysis and follow-up examinations.
  16. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.

Documentation Guidelines
  • Physical findings:Urinary output and description of urine, fluid balance, vital signs, findings related to original disease process or insult,presence of pain or pruritus,mental status,GI status, and skin integrity
  • Condition of peritoneal or vascular access sites
  • Nutrition: Response to dietary or fluid restrictions, tolerance to food, maintenance of body weight
  • Complications:Cardiovascular,integumentary infection

Discharge and Home Healthcare Guidelines
All patients with ARF need an understanding of renal function,signs and symptoms of renal failure ,and how to monitor their own renal function. Patients who have recovered viable renal function still need to be monitored by a nephrologist for at least a year. Teach the patient that she or he may be more susceptible to infection than previously. Advise daily weight checks. Emphasize rest to prevent overexertion. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions. Explain that the patient should tell the healthcare professional about the medications if the patient needs treatment such as dental work or if a new medication is added. Explain that ongoing medical assessment is required to check renal function. Explain all dietary and fluid restrictions. Note if the restrictions are life-long or temporary.

Patients who have not recovered viable renal function need to understand that their condition may persist and even become chronic. If chronic renal failure is suspected, further outpatient treatment and monitoring are needed. Discuss with significant others the lifestyle changes that may be required with chronic renal failure.

Acute Bronchitis

Description
  • Is an infection of the lower respiratory tract that generally follows an upper respiratory tract infection. As a result of this viral (most common) or bacterial infection, the airways become inflamed and irritated, and mucus production increases.

Causes
  • Acute bronchitis is usually caused by viruses. Established risk factors include a history of smoking, occupational exposures, air pollution, reduced lung function, and heredity. Children of parents who smoke are at higher risk for pulmonary infections that may lead to bronchitis.

Assessment:
  • Fever, tachypnea, mild dyspnea, pleuritic chest pain (possible).
  • Cough with clear to purulent sputum production.
  • Diffuse rhonchi and crackles(contrast with localized crackles usually heard with pneumonia).

Diagnostic Evaluation:
  • Chest X-ray may rule out pneumonia. In bronchitis, films show no evidence of lung infiltrates or consolidation.

Primary Nursing Diagnosis
  • Impaired gas exchange related to obstructed airways

Medical Management:
  • Chest physiotherapy to mobilize secretions, if indicated.
  • Hydration to liquefy secretions.

Pharmacologic Interventions:
  • Inhaled bronchodilators to reduce bronchospasm and promote sputum expectoration.
  • A course of oral antibiotics such as a macrolide may be instituted, but is controversial.
  • Symptom management for fever and cough.

Nursing Interventions:
  • Encourage mobilization of secretion through ambulation, coughing, and deep breathing.
  • Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused by fever and tachypnea.
  • Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate recovery.
  • Instruct the patient to complete the full course of prescribed antibiotics and explain the effect of meals on drug absorption.
  • Caution the patient on using over-the-counter cough suppressants, antihistamines, and decongestants, which may cause drying and retention of secretions. However, cough preparations containing the mucolytic guaifenesin may be appropriate.
  • Advise the patient that a dry cough may persist after bronchitis because of irritation of airways. Suggest avoiding dry environments and using a humidifier at bedside. Encourage smoking cessation.
  • Teach the patient to recognize and immediately report early signs and symptoms of acute bronchitis.

Documentation Guidelines
  • Respiratory status of the patient: Respiratory rate, breath sounds, use of oxygen, color of nail beds and lips; note any respiratory distress
  • Response to activity: Degree of shortness of breath with any exertion,degree of fatigue
  • Comfort, body temperature
  • Response to medications, oxygen,and breathing treatments
  • Need for assistance with activities of daily living
  • Response to diet and increased caloric intake, daily weights

Discharge and Home Healthcare Guidelines
  1. Medications. Be sure that the patient understands all medications, including the dosage, route, action, and adverse effects. Patients on aminophylline should have blood levels drawn as ordered by the physician. Before being discharged from the hospital, the patient should demon- strate the proper use of metered-dose inhalers.
  2. Complications. Instruct patients to notify their primary healthcare provider of any change in the color or consistency of their secretions. Green-colored secretions may indicate the pres- ence of a respiratory infection. Patients should also report consistent, prolonged periods of dyspnea that are unrelieved by medications.
  3. Follow-up. Consider that patients with severe disease may need assistance with activities of daily living after discharge. Note any referrals to social services. Send patients home with a diet, provided by the dietitian and reinforced by the nurse, which provides a high-caloric intake. Encourage the patient to cover the face with a scarf if he or she goes out-of-doors in the winter. If the patient continues to smoke,provide the name of a smoking cessation program or a support group. Encourage the patient to avoid irritants in the air.

Abruptio Placenta

Description

  • Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage.

Etiology

1. The cause of abruptio placenta is unknown.

2. Risk factors include:
  • Uterine anomalies
  • Multiparity
  • Preeclampsia
  • Previous cesarean delivery
  • Renal or vascular disease
  • Trauma to the abdomen
  • Previous third trimester bleeding
  • Abnormally large placenta
  • Short umbilical cord

Pathophysiology

  • The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas basalis.

Assessment Findings

1. Associated findings. Severe abruption placentae may produce such complications as:

a. Renal failure
b. Disseminated intravascular coagulation
c. Maternal and fetal death

2. Common clinical manifestation include:

a. Intense, localized uterine pain, with or without vaginal bleeding.
b. Concealed or external dark red bleeding
c. Uterus firm to boardlike, with severe continuous pain
d. Uterine contractions
e. Uterine outline possibly enlarged or changing shape
f. FHR present or absent.
g. Fetal presenting part may be engaged.

3. Laboratory and diagnostic study findings.
  • Ultrasound may be able to identify the extent of abruption. However, the absence of an ultrasound finding does not rule out the presence of abruption.

Nursing Management

1. Continuously evaluate maternal and fetal physiologic status, particularly:
  • Vital signs
  • Bleeding
  • Electronic fetal and maternal monitoring tracings
  • Signs of shock-rapid pulse, pallor, cold and most skin, decrease in blood pressure
  • Decreasing urine output
  • Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.

2. Assess the need for immediate delivery. If the client is in active labor and bleeding cannot be             stopped with bed rest, emergency cesarean delivery may be indicated.

3. Provide appropriate management.
  • On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.
  • Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level.
  • Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask.
  • Prepare for cesarean section, which is the method of choice for the birth.
4. Provide client and family teaching.

5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the          extent of the separation, amount of fetal hypoxia, and amount of bleeding.

Acromegaly

Definition

Acromegaly is a rare, chronic, and disabling disorder of body growth and endocrine dysfunction in adults (after closure of the epiphyses) that is caused by excessive levels of growth hormone (GH). It occurs in approximately 40 persons per million. In adults, it is almost always due to a growth hormone–secreting pituitary adenoma. The excess production of GH causes enlargement of tissues and an altered production of glucocorticoids, mineralocorticoids, and gonadotropins. Left untreated, acromegaly causes gross physical deformities, crippling neuromuscular alterations, major organ dysfunctions, and decreased visual acuity. Arthritis or carpal tunnel syndrome may also develop. Acromegaly increases an individual’s risk for heart disease, diabetes mellitus, and gallstones. The resultant cardiac disease reduces life expectancy.
 
Causes

The overproduction of GH is a result of hyperpituitarism. More than 90% of patients have a pituitary adenoma. The etiology of adenomas is unknown. Hyperpituitarism can also occur with lung, gastric, breast, and ovarian cancers and may have a genetic cause.


Genetic Considerations
While most cases of acromegaly are not inherited, mutations in the GNAS1 gene can cause GH secreting pituitary adenomas (somatotrophinomas). These can be transmitted in an autosomal dominant pattern. Familial acromegaly may also be a feature of multiple endocrine neoplasia type I (MEN I), an autosomal dominant disorder that includes peptic ulcer disease and pituitary, parathyroid, and pancreas endocrine abnormalities.


Gender, Ethnic/Racial, and Life Span Considerations
Diagnosis of acromegaly usually occurs after the age of 40 in men and 45 in women, and occurs more frequently in women than in men. Ethnicity and race have no known effects on the risk for acromegaly.


Risk Factors

  • Some rare cases of acromegaly are hereditary.
  • The average age of diagnosis is 40-45 years old.


Symptoms

  • Symptoms usually develop very slowly over time.
  • Acromegaly can cause serious complications and premature death if not treated.
  • In children, excess GH production causes elongation of the bones and associated soft tissue swelling. If not treated, children with this disorder can grow ta height of 7-8 feet.
  • Symptoms and complications in adults may include the following:
    • Abnormally large growth and deformity of the:
      • Hands (rings no longer fit)
      • Feet (need a bigger size shoe)
      • Face (protrusion of brow and lower jaw)
      • Jaw (teeth do not line up correctly when the mouth is closed)
      • Lips
      • Tongue
    • Carpal tunnel syndrome
    • Skin changes, such as:
      • Thickened, oily, and sometimes darkened skin
      • Severe acne
      • Excessive sweating and offensive body order due to enlargement of the sweat glands
    • Deepening voice due to enlarged sinuses, vocal cords, and soft tissues of the throat
    • Fatigue and weakness in legs and arms
    • Sleep apnea
    • Arthritis and other joint problems especially in the jaw
    • Hypothyroidism
    • Enlargement of the liver, kidneys, spleen, heart, and/or other internal organs, which can lead to:
      • Diabetes
      • High blood pressure
      • Cardiovascular disease
  • In women:
    • Irregular menstrual cycles
    • Galactorrhea (abnormal production of breast milk) in 50% of cases
  • In men:
    • In about 50% of cases, impotence

Diagnotic Procedures

  • Blood tests will be done to measure the level of insulin-like growth factor (IGF-I), growth hormone releasing hormone (GHRH) , and other pituitary hormones.
  • A glucose tolerance test may all be given to see if the GH level drops—it will not drop in cases of acromegaly.
  • If these tests confirm acromegaly, the following may be done tlocate the tumor that is causing the disorder:
  • Head CT Scan—a type of x-ray that uses a computer tmake pictures of the inside of the brain and surrounding structures
  • MRI Scan

Primary Nursing Diagnosis
  • Body image disturbance related to anxiety over thickened skin and enlargement of face, hands, and feet
    • OUTCOMES. Self-esteem; Body image; Anxiety control
    • INTERVENTIONS. Body image enhancement; Coping enhancement; Emotional support; Self-esteem enhancement; Support group; Anxiety reduction


Medical Management

  • Reduce production of GH to normal levels
  • Stop and reverse the symptoms caused by over-secretion of GH
  • Correct other endocrine abnormalities (thyroid, adrenal, sex organs)
  • Reduce the tumor size
Treatment may include:

Surgery

  • Surgical removal of the pituitary tumor, or other tumor, that is believed to be causing acromegaly may be done. In most cases, this is the preferred treatment.

Radiosurgery

  • Radiosurgery is the use of highly focused external beams of radiation to shrink the tumor. It is used most often in patients which do not respond to conventional surgery or medications.

Radiation Therapy

  • Radiation therapy is used in combination with either medical and/or surgical treatment.

Medication

Drugs may be given to reduce the level of GH secretion from the pituitary gland. These include:
  • Cabergoline (Dostinex)—given orally
  • Pergolide (Permax)—given orally
  • Bromocriptine (Parlodel)—may be given before surgery to shrink tumor
  • Octreotide (Sandostatin)—given by injections
  • Pegvisomant—given by injections for patients not responding to their forms of treatment
Medications must often be combined with other therapies treat larger tumors affecting surrounding structures.


Nursing Management
PREOPERATIVE. At the time of diagnosis, the patient requires education and emotional support. Focus education on the cause of the disease, the prescribed medical regimen, and preparation for surgery. Encourage the patient to interact with family and significant others. Reassure the patient that treatment reverses some of the physical deformities. If you note disabling behavior, refer the patient to psychiatric resources.
Prepare the patient and family for surgery. Explain the preoperative diagnostic tests and examinations. For a patient who is undergoing a transsphenoidal hypophysectomy or a transfrontal craniotomy, explain the postoperative need for nasal packing and a mustache dressing.
POSTOPERATIVE. Elevate the patient’s head to facilitate breathing and fluid drainage. Do not encourage the patient to cough, as this interferes with the healing of the operative site. Provide frequent mouth care, and keep the skin dry. To promote maximum joint mobility, perform or assist with range-of-motion exercises. Encourage the patient to ambulate within 1 to 2 days of the surgery. To assure healing of the incision site, explain the need to avoid activities that increase intracranial pressure, such as toothbrushing, coughing, sneezing, nose blowing, and bending.

Documentation Guidelines
  • Physical findings: Respiratory rate and pattern; nasal drainage: color, amount, and presence of
  • glucose
  • Neurological status: Level of consciousness, motor strength, sensation, and vision
  • Presence of postoperative complications: Diabetes insipidus, hypopituitarism, meningitis
  • Psychosocial assessment: Self-esteem, coping, interpersonal relationships, and sexual dysfunction

Discharge and Home Healthcare Guidelines Referrals

Refer patients with advanced acromegaly who experience arthritic changes and require assist devices for ambulation and activities of daily living to a physical therapist.

ACTIVITY RESTRICTIONS. Instruct the patient to avoid activities that increase intracranial pressure for up to 2 months after surgery. Toothbrushing can be resumed in 2 weeks. Instruct the patient to report increased nasal drainage. Incisional numbness and altered olfaction may occur for 4 months after surgery.

MEDICATIONS. If octreotide is prescribed, the patient will need to be able to demonstrate how to administer a subcutaneous or intramuscular injection.

FOLLOW-UP. Patients need to be monitored for development of cardiac disease, diabetes mellitus, and gallstones and a recurrence of symptoms. Advise the patient to wear a medical identification bracelet.

Acid-Base Imbalances

Acid–base imbalance is an abnormality of the human body’s normal balance of acids and bases that causes the plasmapH to deviate out of the normal range (7.35 to 7.45).


I. Respiratory Alkalosis

Respiratory Alkalosis is an acid-base imbalance characterized by decreased partial pressure of arterial carbon dioxide and increased blood pH

Contributing Factors:
  • hyperventilation due to anxiety
  • hypoxia
  • improper mechanical ventilation
  • fever
  • salicylate poisoning
Signs and Symptoms/ Clinical Manifestations:
  • light headedness
  • inability to concentrate
  • convulsions
  • positive Chvostek’s sign nausea and vomiting
  • muscle twitching
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH above 7.45 and partial pressure of carbon dioxide below 35 mmHg.
Nursing Diagnoses:
  • Impaired gas exchange
  • Ineffective Breathing pattern
  • Ineffective Tissue perfusion
  • Acute confusion
  • Risk for injury
Medical Management / Nursing Interventions:
  • Institute safety measures for the patient with vertigo or the unconscious patient.
  • Encourage the anxious patient to verbalize fears
  • Administer sedation as ordered to relax the patient
  • Keep the patient warm and dry
  • Encourage the patient to take deep, slow breaths or breathe into a brown paper bag (inspire CO2).
  • Monitor vital signs
  • Monitor ABGs, primarily PaCO2; a value less than 35 mmHg indicates too little CO2 (carbonic acid)

II. Respiratory Acidosis


Respiratory Acidos is is an acid-base imbalance characterized by increased partial pressure of arterialcarbon dioxide and decreased blood pH.

Contributing Factors:
  • chronic obstructive respiratory disorders
  • chest wall trauma, pulmonary edema, atelactasis, pneumothorax, drug overdose, pneumonia, Guillain-Barre syndrome
  • any condition that results in hypoventilation
  • Signs and Symptoms/ Clinical Manifestations:
  • increased pulse and respiratory rate
  • Increased blood pressure
  • mental cloudiness and feeling of fullness in head
  • weakness
  • dull headache
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH below 7.35 and partial pressure of carbon dioxide above 45 mmHg.
Nursing Diagnoses:
  • Impaired gas exchange
  • Ineffective Breathing pattern
  • Ineffective Tissue perfusion
  • Acute confusion
  • Risk for injury
Medical Management / Nursing Interventions:
  • Institute safety measures
  • Assist with positioning
  • Monitor I&O and administer fluids as ordered
  • Administer oxygen and medications for order; monitor hourly vital signs and respiratory status (may requires mechanical ventilation)
  • Monitor arterial blood gases (ABGs); pH, PaCO2, HCO3

III. Metabolic Alkalosis

Metabolic Alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate.

Contributing Factors:
  • vomiting
  • gastric suctioning
  • excessive intake of alkali (antacids, baking soda)
Signs and Symptoms/ Clinical Manifestations:
  • tingling of fingers
  • dizziness, confusion
  • tetany
  • slow, shallow respirations, possibly apnea
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH above 7.45 and HCO3 above 26 mEq/L; urine chloride concentrations help to differentiate between vomiting or diuretic ingestion or one of the causes of mineralocorticoid excess.

IV. Metabolic Acidosis


Metabolic Acidosis is an acid-base imbalance resulting from excessive absorption or retention of acid or excessive excretion of bicarbonate.

Contributing Factors:
  • ketoacidosis
  • lactic acidosis
  • prolonged fasting
  • salicylic poisoning
  • oliguric renal disease
  • abnormal bicarbonate losses, which can occur in loss of fluid from the lower GI tract from surgery, drains or severe diarrhea
Signs and Symptoms/ Clinical Manifestations:
  • headache
  • drowsiness and confusion
  • weakness
  • increased respiratory rate and depth
  • nausea and vomiting
  • diminished cardiac output with pH below 7, which results in hypotension, cold clammy skin and cardiac arrhythmias.
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH below 7.35 and HCO3 below 22 mEq/L; serum potassium level reveals hyperkalemia

Breastfeeding or Lactation Management Education Training

Introduction
Breastfeeding practices has been proved to be very beneficial to both mother and baby thus the creation of the following laws support the full implementation of this program:
  • Executive Order 51
  • Republic Act 7600
  • The Rooming-In and Breastfeeding Act of 1992

Program Objectives and Goals
  • Protection and promotion of breastfeeding and lactation management education training

Activities and Strategies

1. Full Implementation of Laws Supporting the Program
a. EO 51 THE MILK CODE – protection and promotion of breastfeeding to ensure the safe and adequate nutrition     of infants through regulation of marketing of infant foods and related products. (e.g. breast milk substitutes,         infant formulas, feeding bottles, teats etc. )

b. RA 7600 THE ROOMING –IN and BREASTFEEDING ACT of 1992
  • An act providing incentives to government and private health institutions promoting and practicing rooming-in and breast-feeding.
  • Provision for human milk bank.
  • Information, education and re-education drive
  • Sanction and Regulation
2. Conduct Orientation/Advocacy Meetings to Hospital/ Community

Advantages of Breastfeeding:
    Mother
  • Oxytocin help the uterus contracts
  • Uterine involution
  • Reduce incidence of Breast Cancer
  • Promote Maternal-Infant Bonding
  • Form of Family planning Method (Lactational Amenorrhea)
    Baby
  • Provides Antibodies
  • Contains Lactoferin (binds with Iron)
  • Leukocytes
  • Contains Bifidus factorpromotes growth of the Lactobacillusinhibits the growth of pathogenic bacilli
Positions in Breastfeeding of the baby:
  1. Cradle Hold = head and neck are supported
  2. Football Hold
  3. Side Lying Position
    BEST FOR BABIES
    REDUCE INCIDENCE OF ALLERGENS
    ECONOMICAL
    ANTIBODIES PRESENT
    STOOL INOFFENSIVE (GOLDEN YELLOW)
    TEMPERATURE ALWAYS IDEAL
    FRESH MILK NEVER GOES OFF
    EMOTIONALLY BONDING
    EASY ONCE ESTABLISHED
    DIGESTED EASILY
    IMMEDIATELY AVAILABLE
    NUTRITIONALLY OPTIMAL
    GASTROENTERITIS GREATLY REDUCED

Bag Technique

Definition
Bag technique-a tool making use of public health bag through which the nurse, during his/her home visit, can perform nursing procedures with ease and deftness, saving time and effort with the end in view of rendering effective nursing care.

Public health bag - is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles which are necessary for giving care.


Rationale
To render effective nursing care to clients and /or members of the family during home visit.


Principles
  1. The use of the bag technique should minimize if not totally prevent the spread of infection from individuals to families, hence, to the community.
  2. Bag technique should save time and effort on the part of the nurse in the performance of nursing procedures.
  3. Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family.
  4. Bag technique can be performed in a variety of ways depending upon agency policies, actual home situation, etc., as long as principles of avoiding transfer of infection is carried out.

Special Considerations in the Use of the Bag
  1. The bag should contain all necessary articles, supplies and equipment which may be used to answer emergency needs.
  2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at any time.
  3. The bag and its contents should be well protected from contact with any article in the home of the patients. Consider the bag and it’s contents clean and /or sterile while any article belonging to the patient as dirty and contaminated.
  4. The arrangement of the contents of the bag should be the one most convenient to the user to facilitate the efficiency and avoid confusion.
  5. Hand washing is done as frequently as the situation calls for, helps in minimizing or avoiding contamination of the bag and its contents.
  6. The bag when used for a communicable case should be thoroughly cleaned and disinfected before keeping and re-using.

Contents of the Bag
  • Paper lining
  • Extra paper for making bag for waste materials (paper bag)
  • Plastic linen/lining
  • Apron
  • Hand towel in plastic bag
  • Soap in soap dish
  • Thermometers in case [one oral and rectal]
  • 2 pairs of scissors [1 surgical and 1 bandage]
  • 2 pairs of forceps [ curved and straight]
  • Syringes [5 ml and 2 ml]
  • Hypodermic needles g. 19, 22, 23, 25
  • Sterile dressings [OS, C.B]
  • Sterile Cord Tie
  • Adhesive Plaster
  • Dressing [OS, cotton ball]
  • Alcohol lamp
  • Tape Measure
  • Baby’s scale
  • 1 pair of rubber gloves
  • 2 test tubes
  • Test tube holder
  • Medicines
    • betadine
    • 70% alcohol
    • ophthalmic ointment (antibiotic)
    • zephiran solution
    • hydrogen peroxide
    • spirit of ammonia
    • acetic acid
    • benedict’s solution
    Note: Blood Pressure Apparatus and Stethoscope are carried separately.
Steps/Procedures
Actions
Rationale
1. Upon arriving at the client’s home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put the bag’s handles or strap beneath the bag.
To protect the bag from contamination.
2. Ask for a basin of water and a glass of water if faucet is not available. Place these outside the work area.
To be used for handwashing.
To protect the work field from being wet.
3. Open the bag, take the linen/plastic lining and spread over work field or area. The paper lining, clean side out (folded part out).
To make a non-contaminated work field or area.
4. Take out hand towel, soap dish and apron and the place them at one corner of the work area (within the confines of the linen/plastic lining).
To prepare for handwashing.
5. Do handwashing. Wipe, dry with towel. Leave the plastic wrappers of the towel in a soap dish in the bag.
Handwashing prevents possible infection from one care provider to the client.
6. Put on apron right side out and wrong side with crease touching the body, sliding the head into the neck strap. Neatly tie the straps at the back.
To protect the nurses’ uniform. Keeping the crease creates aesthetic appearance.
7. Put out things most needed for the specific case (e.g.) thermometer, kidney basin, cotton ball, waste paper bag) and place at one corner of the work area.
To make them readily accessible.
8. Place waste paper bag outside of work area.
To prevent contamination of clean area.
9. Close the bag.
To give comfort and security, maintain personal hygiene and hasten recovery.
10. Proceed to the specific nursing care or treatment.
To prevent contamination of bag and contents.
11. After completing nursing care or treatment, clean and alcoholize the things used.
To protect caregiver and prevent spread of infection to others.
12. Do handwashing again.

13. Open the bag and put back all articles in their proper places.

14. Remove apron folding away from the body, with soiled sidefolded inwards, and the clean side out. Place it in the bag.

15. Fold the linen/plastic lining, clean; place it in the bag and close the bag.

16. Make post-visit conference on matters relevant to health care, taking anecdotal notes preparatory to final reporting.
To be used as reference for future visit.
17. Make appointment for the next visit (either home or clinic), taking note of the date, time and purpose.
For follow-up care.

After Care
  1. Before keeping all articles in the bag, clean and alcoholize them.
  2. Get the bag from the table, fold the paper lining ( and insert), and place in between the flaps and cover the bag.

Evaluation and Documentation
  1. Record all relevant findings about the client and members of the family.
  2. Take note of environmental factors which affect the clients/family health.
  3. Include quality of nurse-patient relationship.
  4. Assess effectiveness of nursing care provided.