Transcript NSE EMERGENCY NURSING Lecture

TOMASITO M. DEMEGILLO JR, RN.
MAN
EMERGENCY NURSING
Is a specialty area of the nursing profession like no
other.
Provide quality patient care for people of all ages,
emergency nurses must possess both general and
specific knowledge about health care.
Emergency nurses must be ready to treat a wide
variety of illnesses or injury situations, ranging
from a sore throat to a heart attack.
II. HISTORICAL DEVELOPMENT
OF EMERGENCY NURSING
The Emergency Nurses Association (ENA)
 Is the specialty nursing association serving the
emergency nursing profession through research,
publications, professional development, and injury
prevention.
 ENA's mission is to provide visionary leadership for
emergency nursing and emergency care.
 ENA is an organization seeking to define the future of
emergency nursing and emergency care through
advocacy, expertise, innovation, and leadership.
Emergency Nurses CARE (EN CARE)
(Virginia, USA)
 Is a not-for-profit organization with more than
6,000 trained emergency health care professionals
who volunteer their time in their local communities
in 50 states.
 EN CARE's mission is to reduce preventable injuries
and deaths by educating the public to increase
awareness and promote healthy lifestyles.
The ENA Foundation (ENAF)
(Illinois, USA)
 Is the philanthropic arm of ENA and its affiliates.
 Provides support for emergency nursing scholarships,
research, and injury prevention.
(Note: Applicants must be members of ENA)
Philippine Society of Emergency Care Nurses, Inc.
(PSECN)
(Emergency Medical Services Department Philippine
General Hospital Taft Avenue, Manila)
 Is a duly-recognized specialty organization of the Philippine
Nurses Association (PNA).
 The current president is VIRGINIA DUCUSIN
III. TRIAGE
[French, from trier, to sort, from Old French.]
Is the process of determining the priority of
patients' treatments based on the severity of
their condition.
A method of quickly identifying victims who
have immediately life-threatening injuries and
who have the best chance of surviving.
Emergent
 Divided into two:
1.Immediate - unstable and requiring attention
within 15 minutes.
Examples:
 Airway obstruction/compromise (actual or potential)
 Uncontrolled bleeding
 Shock
2. Urgent - temporarily stable but requiring care
within a few hours.
Examples:
 Threatened loss of limb or eyesight
 Multiple long-bone fractures.
Nonemergency Situations - would require
intervention, however, could stand significant delay.
Examples:
 Walking wounded.
 Single long-bone fractures.
 Closed fractures.
 Soft tissue injuries without significant bleeding.
 Facial fractures without airway compromise.
IV. Roles of Emergency Nurse
A. Care Provider
Emergency nurses care for patients and families in
hospital emergency departments, ambulances,
helicopters, urgent care centers, cruise ships, sports
arenas, industry, government, and anywhere someone
may have a medical emergency or where medical
advances or injury prevention is a concern.
B. Educator
Emergency nurses provide education to the
public through programs to promote wellness and
prevent injuries, such as alcohol awareness, child
passenger safety, gun safety, and domestic violence
prevention.
C. Manager
Emergency nurses also work as administrators,
managers, and researchers who work to improve
emergency health care.They find time to provide
excellent care for pts.
D. Advocate
Emergency nurses defend or plead a cause or issue on
behalf of another.
A nurse advocate has a legal and ethical obligation to
safeguard the patient’s interests and rights.
 The Patient’s Bill of Rights a.k.a Patient Care
Partnership


Developed by the American Hospital Association in 1972
Goal is to promote the public’s understanding of their
rights and responsibilities as consumers of health care.
V. Qualifications of ER Nurse
A Graduate of Bachelor of Science in Nursing
A Registered Nurse
Knowledgeable and Skillful for technology and
equipments used in emergency care setting
Must have a basic understanding of triage nursing
Must be calm and collected under pressure and must
be sympathetic to patients and their families
They must be detail-oriented, as doctors' orders must
be carried out instantly and correctly in emergency
rooms.
They must also be able to emotionally handle the daily
sight of physical suffering and the reality that some
patients may not be able to be saved, despite
everyone's best efforts.
VI. Legal Issues Affecting the
Provision of Emergency Nursing
CONSENT
NEGLIGENCE
CONFIDENTIALITY
AUTONOMY
GATHER EVIDENCE
TREATMENT
MALPRACTICE
FIDELITY
REPORT
DECISION MAKING
VII. Management of Care
ANTHROPOMETRIC – is the measurement of the human
individual for the purposes of understanding human
physical variation.
1. Weight
 Accurate weight is required for:
 Pregnant patients
 Infants
 Children
 Elderly individuals
 Patients who have been prescribed certain
medications
 Scale


Should be placed in a spot that the patient is
comfortable with
Measured in pounds or kilograms
Types:
 Balance beam scale
 Digital scale
 Dial scale
2. Height
 Can be measured using a
 Movable ruler on the back of most balance beam
scales
 Graph ruler mounted on the wall
 Parallel bar moved down against the top of the
patient’s head
The Three
Types of
Scales Used in
Medical
Offices
Include the
Digital, Dial,
and Balance
Scale
VIII. Safety & Infection Control
Disease can be directly transmitted in two ways:
A. Vertical disease transmission – passing a disease
causing agent vertically from parent to offspring,
such as perinatal transmission.
B. Horizontal disease transmission – from one
individual to another in the same generation (peers
in the same age group).
AIRBORNE TRANSMISSION
 Occurs when bacteria or viruses travel on dust particles
or on small respiratory droplets that may become
aerosolized when people sneeze, cough, laugh, or
exhale.
 They hang in the air much like invisible smoke.
 They can travel on air currents over considerable
distances.
Examples:
- Anthrax (inhalational)
- Smallpox
- Tuberculosis
- Measles
- Pertussis (whooping cough)
- Chickenpox
- Influenza
Airborne Precautions:
Be in a different room from the person who is ill,
with a closed door in between.
2. If you need to be in the same room, wearing a mask
may help for a brief exposure.
3. Covering the mouth or nose when coughing or
sneezing decrease the risk of transmission.
1.
DROPLET TRANSMISSION
 Occurs when bacteria or viruses travel on relatively large
respiratory droplets that people sneeze, cough, drip, or
exhale.
 They travel only short distances before settling, usually
less than 3 feet.
 They can be spread directly if people are close enough to
each other.
 The droplets land on hands, toys, tables, mats, or other
surfaces, where they sometimes remain infectious for
hours.
Examples:
 Common cold
 Diphtheria
 Influenza
 Meningitis
 Mumps
 Pertussis (whooping cough)
 Plague
 Rubella
 Strep (strep throat, scarlet fever, pneumonia)
Droplet Precautions:
1.
Frequent hand washing help prevent transmission.
2. Covering the mouth or nose when coughing or
sneezing decreases droplet transmission.
3. Using disposable towels and cups reduces the risk for
infection.
4. Cleaning or disinfecting commonly touched infected
surfaces (doorknobs, faucet handles, shared toys,
mats in daycare) can also help.
CONTACT TRANSMISSION
 Requires some form of touch to spread an infection.
 It is divided into two:
Direct contact transmission - involves immediate contact
between two people (or with an animal).
b. Indirect contact transmission - involves fomites ; an
object that becomes contaminated by touch then spreads
the infection by touch.
a.
Examples:
 Abscesses
 Diphtheria (cutaneous)
 Lice
 Scabies
 Athlete’s foot
 Conjunctivitis (“pink eye”)
Contact Precautions:
 Avoid direct contact with infected person especially
when there is a break in the skin.
Frequent hand washing
Surface disinfecting can interrupt some disease
transmission.
Avoid sharing hairbrushes, combs, and hats.
REVERSE TRANSMISSION
 The patient is being protected from the nurse and all
the people in contact with the patient.
Examples:
- Immunocompromise patients
- Cancer patients undergoing chemotherapy
IX. Prevention & Early Detection
ASSESSMENT
1. Glasgow Coma Scale

Is a neurological scale that aims to give a reliable,
objective way of recording the conscious state of a
person for initial as well as subsequent assessment.
Generally, brain injury is classified as:
o Severe GCS ≤ 8
o Moderate GCS 9 – 12
o Minor GCS ≥ 13 and above
The GCS has limited applicability to children,
especially below the age of 36 months (where the
verbal performance of even a healthy child would be
expected to be poor).
Pediatric Glasgow Coma Scale - a separate yet
closely related scale, was developed for assessing
younger children.
2. Palpatory
 The sensory skills developed by trained physicians and
used in diagnosis and manipulative techniques.
3. Pulse Pressure
 Is the difference between the systolic and diastolic
pressure.
 It represents the force that your heart generates each
time it contracts.
In a person with a systolic blood pressure of 120 mmHg and a
diastolic pressure of 80 mmHg,
the pulse pressure would be 40 mmHg.
When the Pulse Pressure is greater than 60 mm Hg
there is an increased incidence of adverse
cardiovascular events especially in the older
population.
Several studies have identified that high pulse
pressure:
Causes more artery damage compared to high blood
pressure with normal pulse pressure
ii. Indicates elevated stress on a part of the heart called
the left ventricle
iii. Is affected differently by different high blood pressure
medicines
i.
4. Level of Consciousness (LOC)
 Is a measurement of a person's arousability and
responsiveness to stimuli from the environment.
Levels:
 Conscious
- Oriented to time, place, name and date.
 Somnolent
- Shows excessive drowsiness and responds to
stimuli only with incoherent mumbles or
disorganized movements.
 Obtunded
- Has decreased interest in their surroundings, slowed
responses, and sleepiness.
 Stuporous
- People with an even lower level of consciousness,
stupor, only respond by grimacing or drawing away
from painful stimuli.
 Comatose
- Do not even make this response to stimuli, have no
corneal or gag reflex, and they may have no pupillary
response to light.
5. Reflexes
1.
Stretch or Deep Tendon Reflexes (DTRs)

Measurement of the DTRs reflects the integrity of the reflex at
specific spinal levels as well as the cerebral cortex function.
For valid responses, the limbs should be relaxed and the
muscles partially stretched.
Elicit the reflex by applying a short, quick blow of the reflex
hammer onto the muscle’s insertion tendon.
Use a relaxed hold on the reflex hammer.
Use the pointed end of the reflex hammer when testing a
smaller target such as thumb on the tendon site.
Use the flat end of the reflex hammer when the target is wider
or to diffuse the impact and prevent pain.
Compare the right and the left sides – the response should be
equal.






The reflex response is graded on a 4 – point scale as follows:
4+ Very brisk, hyperactive with clonus, pathologic
3+ Brisker than average, may be pathologic
2+ Average, normal
1+ Diminished, low normal
0
No response
Abnormal Findings:
 Clonus is a set of rapid, rhythmic contractions of the same
muscle.
 Hyperreflexia is the exaggerated reflex seen when the
patient has upper motor neuron lesions (e.g., stroke).
 Hyporeflexia is the absence of a reflex. This is a lower
motor neuron problem (e.g., spinal cord injury).
a.



Biceps Reflex (C5 to C6)
Support the patient’s forearm. Use he patient’s forearm
on yours. To relax and partially flex the patient’s arm.
Place your thumb on the biceps tendon and strike a blow
on your thumb. Use the pointed end of the reflex
hammer.
Normal response is contraction of the biceps muscle and
flexion of the forearm.
b. Triceps Reflex (C7 to C8)
 Instruct the patient to let the arm fully relax as you
suspend it by supporting the upper arm.
 Strike the triceps tendon directly just above the elbow.
Use the pointed end of the reflex hammer.
 Normal response is extension of the forearm.
c. Brachioradialis Reflex (C5 to C6)
 Hold the patient’s thumb to suspend the forearm in
relaxation.
 Strike the forearm directly about 2 to 3 cm. above the
radial styloid process. Use the pointed end of the
reflex hammer.
 Normal response is flexion and supination of the
forearm.
d. Quadriceps Reflex (“Knee Jerk”) (L2 to L4)
 Let the lower legs dangle freely to flex the knee and
stretch the tendons. The popliteal area (back of the
knee) should be few inches away from the edge of the
bed.
 Place your hand above the patient’s knee.
 Strike the tendon directly just below the patella. Use
the flat end of the reflex hammer.
 Normal response is extension of the lower leg.
Contraction of the quadriceps (muscle of the thighs)
may also be palpated.
Note: if the patient is unable to sit, place him/her in
supine position. Use your own arm as a lever to
support the weight of one leg against the other leg.
(Place your arm under the patient’s knee near you, and
your hand above the knee of the other leg).
. Achilles Reflex (“Ankle Jerk”) (L5 to S2)
 Position the patient with the knee flexed and the hip
externally rotated.
 Hold the foot in dorsiflexion, and strike the Achilles
tendon directly.
 Normal response is plantar flexion against your hand.
Note: For the patient in supine position, flex one knee
and support that leg. (Place the leg to be tested on top
of the other leg, and externally rotated to have easy
access on the Tendon of Achilles). Dorsiflex the foot
and tap the tendon.
f. Clonus. Test for clonus when the reflexes are hyperactive.
 Support the lower leg (under the knee) with one hand.
 With the other hand, move the foot up and down a few
times to relax the muscle.
 Then, stretch the muscle by briskly dorsiflexing the foot.
 Hold the stretch.
 Normal response is no further movement is felt.
 Abnormal Finding:
 When clonus is present, you feel and see rapid, rhythmic
contractions of the calf muscle and movement on the foot.
 A hyperactive reflex with sustained clonus (lasting as long as the
stretch is held) occurs with upper motor neuron disease.
2. Superficial (Cutaneous) Reflexes
 These reflexes test the sensory receptors in the skin.
The motor response is localized muscle contraction.
a. Abdominal Reflexes – Upper (T8 to T10),
Lower (T10 to T12)
 Place the patient is supine position with the knees
slightly bent.
 Use the handle end of the reflex hammer, or a wood
applicator tip, or the end of a split tongue blade to
stroke the skin of the abdomen.
 Move from the side of the abdomen to the midline at
both the upper and lower abdominal levels.
 Normal response is ipsilateral (same side)
contraction of the abdominal muscle, with an
observed deviation of the umbilicus toward the
stroke.
 Abnormal Finding:
 Superficial reflexes are absent in diseases of the pyramidal
tracts (e.g., stroke).
b. Cremasteric Reflex (L1 to L2)
 This is not routinely done.
 It is done only on an unconscious male patient.
 Lightly stroke the inner aspect of the thigh with handle of
reflex hammer or tongue blade.
 Normal response is elevation of the ipsilateral testis.
 Abnormal Finding:
 Absent in both upper motor neuron (UMN) and lower
motor neuron (LMN) lesions.
c. Plantar Reflex (Babinski Reflex) (L4 to S2)
 Position the thigh in slight external rotation.
 Use the handle of the reflex hammer to lightly stroke
the lateral side of the foot from the hee, upward and
inward across the ball of the foot (“inverted J fashion”).
 Normal response is plantar flexion of the toes and
inversion and flexion of the forefoot (Negative
Babinski Reflex).
 Abnormal Finding:
 Dorsiflexion of the big toe and fanning of all toes
(positive Babinski). This indicates UMN disease of the
corticospinal (or pyramidal) tract.
 Note: Positive Babinski is normal only among infants,
which disappears by age 1 year.
SUMMARY OF PATHOLOGIC (ABNORMAL REFLEXES)
Reflex
Method of Testing
Abnormal Response and
Indications
1. Babinski
Stroke lateral aspect and across ball
of foot.
Extension of great toe,
fanning of toes
- Corticospinal
(pyramidal) tract disease,
e.g., stroke and trauma
2. Oppenheim
Using heavy pressure with your
thumb and index finger, stroke
anterior medial tibial muscle.
Same as above
3. Gordon
Firmly squeeze calf muscles
Same as above
4. Hoffman
With patient’s hand relaxed, wrist
dorsiflexed, fingers slightly flexed,
sharply flick nail of distal phalanx of
middle or index finger.
Clawing of fingers and
thumb.
- Corticospinal
(pyramidal) tract disease,
e.g., stroke and trauma
5. Kernig
In supine position, raise leg
straight or flex thigh on
abdomen, then extend knee.
Resistance to
straightening (because
of hamstring spasm),
pain down posterior
thigh
- Meningeal irritation,
e.g., meningitis
infections
6. Brudzinski
With one hand under the neck and
other hand on patient’s chest,
sharply flex chin on chest. Watch
hips and knees.
Resistance and pain in
neck, with flexion of hips
and knees.
OBTAINING SPECIMEN
1. Stool
→ A stool analysis is a series of tests done on a stool
(feces) sample to help diagnose certain conditions
affecting the digestive tract .
→ These conditions can include infection (such as from
parasites, viruses, or bacteria), poor nutrient
absorption, or cancer.
2. Urine
→ Urine test checks different components of urine, a waste product
made by the kidneys.
→ The test can give information about your health and problems
you may have.
3. Sputum
→ A sputum culture is a test to detect and identify bacteria or fungi
(plural of fungus) that are infecting the lungs or breathing
passages.
→ A sample of sputum is placed in a container with substances that
promote the growth of bacteria or fungi.
→ If no bacteria or fungi grow, the culture is negative.
→ If organisms can cause infection grow, the culture is positive.
COMPLETE BLOOD COUNT


One of the most commonly ordered blood tests.
The complete blood count is the calculation of the
cellular (formed elements) of blood.
CAPILLARY BLOOD GAS


Capillary Blood is an attractive substitute sample that
is routinely used in some clinical settings.
The gold-standard sample for blood-gas analysis is
arterial blood obtained via an indwelling arterial
catheter or by arterial puncture.
 Blood-gas analyzers measure blood pH, and the
oxygen and carbon-dioxide tensions of blood.
 Blood-gas analysis is helpful for assessment and
monitoring of patients suffering a range of
metabolic disturbances and respiratory diseases.
ELECTROCARDIOGRAPH




Derived from the Greek electro,(electrical activity),
cardio, (heart), and graph, ("to write“).
Is a transthoracic interpretation of the electrical
activity of the heart over time captured and externally
recorded by skin electrodes.
It is a noninvasive recording produced by an
electrocardiographic device.
ECG works mostly by detecting and amplifying the
tiny electrical changes on the skin that are caused
when the heart muscle "depolarizes" during each heart
beat.
 At rest, each heart muscle cell has a charge across its
outer wall, or cell membrane.
 Reducing this charge towards zero is called
depolarization, which activates the mechanisms in the
cell that cause it to contract.
 Different types of ECGs can be referred to by the number
of leads (3- lead, 5- lead, and 12- lead)
12-lead ECG
 Is one in which 12 different electrical signals are
recorded at approximately the same time and will often
be used as a on-off recording of an ECG, typically
printed out as a paper copy.
3- and 5-lead ECGs
 Tend to be monitored continuously and viewed only on
the screen of an appropriate monitoring device.
Example:
- During an operation or whilst being
transported in an ambulance.
PLACEMENT OF ELECTRODES
Feature
Description
Duration
RR interval
The interval between an R wave and the next R wave .
0.6 to 1.2s
P Wave
During normal atrial depolarization, the main
electrical vector is directed from the SA node towards
the AV node, and spreads from the right atrium to the
left atrium.
This turns into the P wave on the ECG.
80ms
PR Interval
The PR interval is measured from the beginning of
the P wave to the beginning of the QRS complex.
The PR interval reflects the time the electrical
impulse takes to travel from the sinus node through
the AV node and entering the ventricles.
The PR interval is therefore a good estimate of AV
node function.
PR
Segment
The PR segment connects the P wave and the QRS
complex. This coincides with the electrical
conduction from the AV node to the bundle of His to
the bundle branches and then to the Purkinje Fibers.
This electrical activity does not produce a contraction
directly and is merely traveling down towards the
ventricles and this shows up flat on the ECG.
The PR interval is more clinically relevant
120 to 200ms
50 to 120ms
QRS
Complex
The QRS complex reflects the rapid depolarization of
the right and left ventricles. They have a large muscle
mass compared to the atria and so the QRS complex
usually has a much larger amplitude than the P-wave.
80 to
120ms
J-Point
The point at which the QRS complex finishes and the ST
segment begins.
Used to measure the degree of ST elevation or depression
present.
N/A
ST
Segment
The ST segment connects the QRS complex and the T
wave.
The ST segment represents the period when the ventricles
are depolarized. It is isoelectric.
80 to 120ms
T Wave
The T wave represents the repolarization (or recovery) of
the ventricles. The interval from the beginning of the QRS
complex to the apex of the T wave is referred to as the
absolute refractory period. The last half of the T wave is
referred to as the relative refractory period (or
vulnerable period).
160ms
ST Interval The ST interval is measured from the J point to the end of
the T wave.
320ms
QT
Interval
The QT interval is measured from the beginning of
the QRS complex to the end of the T wave.
A prolonged QT interval is a risk factor for
ventricular tachyarrhythmias and sudden death.
U Wave
The U wave is hypothesized to be caused by the
repolarization of the interventricular septum.
They normally have a low amplitude, and even more
often completely absent.
They always follow the T wave and also follow the same
direction in amplitude.
If they are too prominent we suspect hypokalemia,
hypercalcemia or hyperthyroidism usually.
J Wave
The J wave, elevated J-Point or Osborn Wave appears as a
late delta wave following the QRS or as a small secondary
R wave .
It is considered pathognomonic of hypothermia or
hypocalcemia.
300 to
430ms
N/A
X. Coping, Adaptation, and
Psychological Adaptation
DIET THERAPY


Is an effective method of healing, especially when
utilized as a complementary method of care.
Is used for people who are trying to increase or
decrease their body weight, have a sensitive digestion
system that may be prone to allergies, who may not be
able to digest certain foods, or are trying to overcome
vitamin or mineral deficiencies.
Types:
1.Ayurveda Diet
Is an ancient Indian practice that works to prevent
disease and rejuvenate the body.
→ Treat every part of the body, mentally and physically,
through diet and meditation.
→
2. Macrobiotics Diet
→
Is recommended for people suffering from cancer or
other chronic diseases because it emphasizes eating
low-fat, high-fiber food that is wholesome and
minimally processed.
The National Cancer Institute conducted a study
showing that 90 percent of cancer in humans can be
attributed to environmental causes. Food may be one
of these causes.
To prevent illness and boost the immune system
→ Eat a diet containing plenty of fresh fruit, vegetables and
whole grains.
→ Reduce consumption of saturated and unsaturated fats
and ditch caffeine and alcohol as much as possible.
Nutrition
 Also called nourishment or aliment
 Is the provision, to cells and organisms, of the materials
necessary (in the form of food) to support life.
 Many common health problems can be prevented or
alleviated with a healthy diet.
 There are six major classes of nutrients:
1.
2.
3.
4.
5.
6.
Carbohydrates
Fats
Minerals
Protein
Vitamins
Water
These nutrient classes can be categorized as either:
1. Macronutrients (needed in relatively large amounts)
2. Micronutrients (needed in smaller quantities)
MACRONUTRIENTS
 Includes carbohydrates, fats, fiber, protein, and water.
 The macronutrients (excluding fiber and water) provide
structural material (amino acids from which proteins are
built, and lipids from which cell membranes and some
signaling molecules are built) and energy.
Carbohydrates
 May be classified as monosaccharides,
disaccharides, or polysaccharides depending on the
number of monomer (sugar) units they contain.
 They constitute a large part of foods such as rice,
noodles, bread, and other grain-based products.
Complex Carbohydrates
 It take slightly longer to digest and absorb because
their sugar units must be separated from the chain
before absorption.
Simple Carbohydrates
 Are absorbed quickly, and therefore raise blood-sugar
levels more rapidly than other nutrients.
Carbohydrates are not essential to the human diet, as
they are relatively low in vitamins and minerals, and
energy can be provided from excess fats and proteins
in the diet.
FIBER
 Is a carbohydrate (or a polysaccharide) that is
incompletely absorbed in humans and in some
animals.
 When it is metabolized it can produce four Calories
(kilocalories) of energy per gram.
 Dietary fiber consists mainly of cellulose, a large
carbohydrate polymer that is indigestible because
humans do not have the required enzymes to
disassemble it.
 Whole grains, fruits (especially plums, prunes, and
figs), and vegetables are good sources of dietary fiber.
 Dietary fiber helps reduce the chance of
gastrointestinal problems such as constipation and
diarrhea by increasing the weight and size of stool and
softening it.
There are two subcategories:
1. Insoluble fiber
 Found in whole-wheat flour, nuts and vegetables,
especially stimulates peristalsis (the rhythmic
muscular contractions of the intestines which move
digesta along the digestive tract).
2. Soluble fiber
 Found in oats, peas, beans, and many fruits, dissolves
in water in the intestinal tract to produce a gel which
slows the movement of food through the intestines.
 This may help lower blood glucose levels because it
can slow the absorption of sugar.
 Additionally, fiber, perhaps especially that from whole
grains, is thought to possibly help lessen insulin
spikes, and therefore reduce the risk of type 2 diabetes.
FAT
 It is consists of several fatty acids (containing long chains
of carbon and hydrogen atoms), bonded to a glycerol.
 They are typically found as triglycerides (three fatty acids
attached to one glycerol backbone).
 It may be classified as saturated or unsaturated depending
on the detailed structure of the fatty acids involved.
Saturated fats
 It is from animal sources
 It is typically solid at room temperature (such as butter or
lard),
 Have all of the carbon atoms in their fatty acid chains
bonded to hydrogen atoms.
Unsaturated fats
 Example is vegetable oil it is considered healthier
 Typically liquids (such as olive oil or flaxseed oil)
 Have some of these carbon atoms double-bonded, so their
molecules have relatively fewer hydrogen atoms than a
saturated fatty acid of the same length.
 It may be further classified as monounsaturated (one
double-bond) or polyunsaturated (many double-bonds).
Trans fats
 Are a type of unsaturated fat with trans-isomer bonds
 These are rare in nature and in foods from natural sources
 They are typically created in an industrial process called
(partial) hydrogenation.
Protein
 Are the basis of many animal body structures (e.g.
muscles, skin, and hair).
 They also form the enzymes that control chemical
reactions throughout the body.
 Each molecule is composed of amino acids, which are
characterized by inclusion of nitrogen and sometimes
sulphur (these components are responsible for the
distinctive smell of burning protein, such as the
keratin in hair).
 The body requires amino acids to produce new
proteins (protein retention) and to replace damaged
proteins (maintenance).
 Sources of dietary protein include meats, tofu and
other soy-products, eggs, legumes, and dairy products
such as milk and cheese.
 Excess amino acids from protein can be converted into
glucose and used for fuel through a process called
gluconeogenesis.
 The amino acids remaining after such conversion are
discarded in urine.
Water
 Is excreted from the body in multiple forms; including
urine and feces, sweating, and by water vapour in the
exhaled breath.
 Therefore it is necessary to adequately rehydrate to replace
lost fluids.
 Early recommendations for the quantity of water required
for maintenance of good health suggested that 6–8 glasses
of water daily is the minimum to maintain proper
hydration.
 For healthy hydration, the current EFSA (European
Food Safety Authority) guidelines recommend total
water intakes of 2.0 L/day for adult females and 2.5
L/day for adult males.
 These reference values include water from drinking
water, other beverages, and from food.
 About 80% of our daily water requirement comes from
the beverages we drink, with the remaining 20%
coming from food.
MICRONUTRIENTS
 Are minerals and vitamins
Minerals
 Are the chemical elements required by living organisms,
other than the four elements carbon, hydrogen, nitrogen,
and oxygen that are present in nearly all organic molecules.
 The term "mineral" is archaic, since the intent is to describe
simply the less common elements in the diet.
 Are often artificially added to the diet as supplements; the
most famous is likely iodine in iodized salt which prevents
goiter.
Macrominerals
 Many elements are essential in relative quantity
 They are usually called "bulk minerals“
 Some are structural, but many play a role as electrolytes
1.
Calcium

2.
Chlorine as chloride ion

3.
A common electrolyte, but also needed structurally (for
muscle and digestive system health, bone strength, some
forms neutralize acidity, may help clear toxins, provides
signaling ions for nerve and membrane functions)
Very common electrolyte
Magnesium

Required for processing ATP and related reactions (builds
bone, causes strong peristalsis, increases flexibility,
increases alkalinity)
4. Phosphorus
 Required component of bones; essential for energy
processing
5. Potassium
 A very common electrolyte (heart and nerve health)
6. Sodium
 A very common electrolyte; not generally found in dietary
supplements, despite being needed in large quantities,
because the ion is very common in food: typically as
sodium chloride, or common salt.
 Excessive sodium consumption can deplete calcium and
magnesium, leading to high blood pressure and
osteoporosis.
7. Sulfur
 For three essential amino acids and therefore many proteins
(skin, hair, nails, liver, and pancreas).
 Sulfur is not consumed alone, but in the form of sulfurcontaining amino acids.
Trace Minerals
 Many elements are required in trace amounts, usually
because they play a catalytic role in enzymes.
1.
Cobalt
 Required for biosynthesis of vitamin B12 family of coenzymes.
 Animals cannot biosynthesize B12, and must obtain this cobalt-
containing vitamin in the diet.
2.
Copper
 Required component of many redox enzymes, including
cytochrome c oxidase.
3.
Chromium
 Required for sugar metabolism
4. Iodine
 Required not only for the biosynthesis of thyroxine, but probably,
for other important organs as breast, stomach, salivary glands,
thymus.
5.
Iron
 Required for many enzymes, and for hemoglobin and some
other proteins.
6. Manganese (processing of oxygen)
7. Molybdenum
 Required for xanthine oxidase and related oxidases
8. Nickel
 Present in urease
9. Selenium
 Required for peroxidase (antioxidant proteins)
10. Vanadium
 Is required for some lower organisms.
11. Zinc
 Required for several enzymes such as carboxypeptidase, liver
alcohol dehydrogenase, and carbonic anhydrase
Vitamins
 Some vitamins are recognized as essential nutrients,
necessary in the diet for good health.
 Vitamin D is the exception: It can be synthesized in the
skin, in the presence of UVB radiation.
 Certain vitamin-like compounds that are recommended in
the diet, such as carnitine, are thought useful for survival
and health, but these are not "essential" dietary nutrients
because the human body has some capacity to produce
them from other compounds.
 Moreover, thousands of different phytochemicals have
recently been discovered in food (particularly in fresh
vegetables), which may have desirable properties including
antioxidant activity.
 Vitamin deficiencies may result in disease
conditions, including goiter, scurvy, osteoporosis,
impaired immune system, disorders of cell
metabolism, certain forms of cancer, symptoms of
premature aging, and poor psychological health.
 Excess levels of some vitamins are also dangerous to
health (notably vitamin A), and for at least one
vitamin, B6, toxicity begins at levels not far above the
required amount.
 Deficient or excess levels of minerals can also have
serious health consequences.
RANGE OF MOTION EXERCISES (ROM)

Is the movement of joint through its full ROM to
prevent contractures and increase or maintain muscle
tone/ strength.
Types:
1.
2.
3.
4.
Active – carried out by the client
Passive – carried out by the nurse without assisstance
from the client.
Active assistive – client moves body part as far as
possible and nurse completes remainder of movement.
Active resistive – contraction of muscles against an
opposing force
Instructions on ROM Exercises:
 Learn passive ROM exercises from the person's
caregiver. Practice the exercises with the caregiver
first. The caregiver can make sure you are doing the
exercises right. Caregivers can also show you the
easiest way to do the exercises so you do not get hurt or
tired.
 Raise the person's bed to a height that is
comfortable for you. This will help keep you from
hurting your back or other muscles. Make sure the
wheels of the bed or wheelchair are locked before
you start the exercises.
 Do all ROM exercises smoothly and gently. Never
force, jerk, or over-stretch a muscle. This can hurt the
muscle or joint instead of helping.
 Move the joint slowly. This is especially important if
the person has muscle spasms (tightening). Move the
joint only to the point of resistance. This is the point
where you cannot bend the joint any further. Put slow,
steady pressure on the joint until the muscle relaxes.
 Stop ROM exercises if the person feels pain. Ask the
person to tell you right away if he feels any pain. Watch for
signs of pain if the person is unable to talk. The exercises
should never cause pain or go beyond the normal
movement of that joint.
 Make ROM exercises a part of the person's daily
routine. Do ROM exercises at the same time every day. Do
them while bathing the person or while the person watches
TV. This will make the time go faster and help the person
relax more.
 Follow the caregiver's orders. The person's caregiver will
tell you how many times per day you should do ROM
exercises. The caregiver will tell you how many repetitions
(number of times) you should do exercises on each joint.
 THANK YOU & GOD BLESS!

GOODLUCK FOR THE RETURN DEMONSTRATION..c”,)
• TOMASITO M. DEMEGILLO JR., RN. MAN
How to deal with combative/ Psych. Pt.
XI. Basic Care Comfort
ENEMA
 Is the procedure of introducing liquids into the rectum
and colon via the anus.
 The increasing volume of the liquid causes rapid
expansion of the lower intestinal tract, often resulting in
very uncomfortable bloating, cramping, powerful
peristalsis, a feeling of extreme urgency and complete
evacuation of the lower intestinal tract.
 It can be carried out as treatment for medical
conditions, such as constipation, fecal impaction and
surgical procedure such as sigmoidoscopy or
colonoscopy.
Types of Enema Solutions:
Water/Water with mild hand soap
2. Mineral Oil - functions as a lubricant and stool
softener, but which often has the side effect of
sporadic seepage from the patient's anus which can
soil the patient's undergarments for up to 24 hours.
3. Isotonic Saline - least irritating to the rectum and
colon, having a neutral concentration gradient.
1.
1. Fleet Enema/ Clyss-go
 Useful as a laxative in the relief of constipation, and as
a bowel evacuant for a variety of diagnostic, surgical
and therapeutic indications.
 When administered rectally as an enema, they
produce a watery evacuation of the bowel.
 Provides cleansing action and induces complete
emptying of the left colon usually in 2 to 5 minutes.
Contraindications:
Should not be used when the following medical problems
exist:
o Appendicitis (or symptoms of),
o Intestinal blockage
o Ulcerative colitis
o Ileitis
o Heart disease
o Rectal bleeding
o High blood pressure
o Kidney disease
Children: Not recommended for infants
under 6 months of age
BANDAGE

Is a piece of material used either to support a medical
device such as a dressing or splint, or on its own to
provide support to the body.

Is available in a wide range of types, from generic cloth
strips, to specialized shaped bandages designed for a
specific limb or part of the body.
Types:
Gauze bandage
 The most common type of bandage
 It is a simple woven strip of material, or a woven strip of
material with a Telfa absorbent barrier to prevent
adhering to wounds, which can come in any number of
widths and lengths.
 It can be used for almost any bandage application,
including holding a dressing in place.
Compression bandage
 Describes a wide variety of bandages with many
different applications.
a. Short stretch compression bandages



Are good for protecting wounds on one's hands,
especially on one's fingers.
Are applied to a limb (usually for treatment of
lymphedema or venous ulcers).
Is capable of shortening around the limb after
application and is therefore not exerting everincreasing pressure during inactivity. This dynamic is
called resting pressure and is considered safe and
comfortable for long-term treatment.
 The stability of the bandage creates a very high
resistance to stretch when pressure is applied through
internal muscle contraction and joint movement.This
force is called working pressure.
b. Long stretch compression bandages
 Have long stretch properties, meaning their high
compressive power can be easily adjusted.
 They also have a very high resting pressure and must be
removed at night or if the patient is in a resting position.
Triangular bandage
 Also known as a cravat bandage
 Is a piece of cloth cut into a right-angled triangle, and
often provided with safety pins to secure it in place.
 It can be used fully unrolled as a sling, folded as a
normal bandage, or for specialized applications, as on
the head.
 One advantage of this type of Bandage is that it can be
makeshift and made from a fabric scrap or a piece of a
t-shirt.
Tube bandage
 Is applied using an applicator, and is woven in a
continuous circle.
 It is used to hold dressings or splints on to limbs, or to
provide support to sprains and strains, and it stops the
bleeding.
CASTS
DEFINITION
 Is a temporary immobilization device which is made up
of gypsum sulfate, unhydrous by calcination when mixed
with water swells and forms into a hard cement.
FUNCTIONS
1. To immobilize
2. To prevent or correct deformity
3. To support, maintain and protect realigned bone
4. To promote healing and early weight bearing
PRINCIPLES
1. A cast is applied with padding applied first.
-wadding sheet
-roll of cotton
-stockinette
2. Apply it to include the joint above and joint below the
injured part.
3. Apply it in circular motion and mold it as you do the
procedure using the palm of your hands.
4. Support it with the palm.
CONTRAINDICATIONS:
o Pregnancy
o Skin diseases
NURSING CARE
1. Assess neurovascular status.
- pain, swelling, discoloration, cool skin, paresthesia,
slow capillary refill, diminished or absent pulse,
paralysis.
2. Assess skin integrity.
- odor, drainage
3. Handle cast with the palm of hands especially during
drying time.
4. Encourage isometric exercises for the muscles of the
casted extremities.
5. Turn the client every 2 hours. (hip spica)
6. Encourage deep breathing and coughing exercises.
(body cast)
7. Increase fluid intake.
8. Increase CHON and CHO in the diet.
9. No lotions, creams or oils use only alcohol.
10. Check for any complications.
COMPLICATIONS:
1. Neurovascular compromise
2. Incorrect fracture alignment
3. Cast syndrome (body cast)
- Probably results from hyperextension of the spine;
characterized by nausea, abdominal pressure and vague
abdominal pain.
- Compression of superior mesenteric artery
4. Compartment syndrome
- Vascular insufficiency and nerve and muscle
compression due to unrelieved swelling
- Bivalving or windowing
5. Infections
Examples:
LONG LEG CAST
LONG ARM CAST
SHORT LEG HIP SPICA CAST
DOUBLE HIP SPICA CAST
REMOVAL OF CASTS
Instruments Needed:
a. Cast cutter
b. Spreader
c. Knife
d. Bandage scissors
Nursing Care
a. After the cast is removed, support the part and move the
extremities gently.
b. Observe the skin for any abrasions.
c. Clean skin with mild soap and apply oil or lotion.
POSITIONING
 It is a deliberative placement of the patient or a body
part to promote physiologic and/or psychologic wellbeing.
SUPINE POSITION
 Is a position of the body: lying down with the face up.
 When used in surgical procedures, it allows access to
the peritoneal, thoracic and pericardial regions; as well
as the head, neck and extremities.
PRONE POSITION
A position with the patient lying face down with
arms bent comfortably at the elbow and padded
with the arm boards positioned forward.
FOWLER’S POSITION
 Is a standard patient position.
 It is used to relax tension of the abdominal muscles,
allowing for improved breathing in immobile patients,
and to increase comfort during eating and other
activities.
 It is also used in postpartum women to improve
uterine drainage.
 The patient is placed in a semi-upright sitting position
(45-60 degrees) and may have knees either bent or
straight.
There are several types of Fowlers positions:
a. Low Fowler’s
b. Semi- Fowler’s
c. High Fowler's.
Low Fowler's Position
 Is when the patient's head is elevated 30-45 degrees.
Semi- Fowler’s Position
 Is when a patient is lying in bed in a supine position with
the head of the bed at approximately 30 degrees.
 Used for patients who are on tube feedings.
High Fowler's Position
 Is when the patient's head is raised 60-90 degrees.
 Used when feeding a patient (especially one on feeding
precautions), radiology needing to take a specific type of
x-ray at the bedside, (at times) when a breathing
treatment being given to the patient, when the patient is
having difficulty breathing, dependent drainage after
abdominal surgery, grooming, etc.
STANDING POSITION
 Is a human position in which the body is held upright and
supported only by the feet, referred to as an orthostatic state.
SITTING POSITION
 Is a rest position supported by the buttocks or thighs where the
torso is more or less upright.
SQUATTING POSITION
 Is a posture where the weight of the body is on the feet (as with
standing) but the knees are bent either fully (full or deep squat)
or partially (partial, half, semi, parallel or monkey squat)
 It gives a greater increase of pressure in the pelvic cavity with
minimal muscular effort. The birth canal will open 20 to 30%
more in a squat than in any other position.
 It is recommended for the second stage of childbirth.
TRENDELENBURG POSITION
 The body is laid flat on the back (supine position) with the
feet higher than the head.
 Is a standard position used in abdominal, gynecological
surgery, and for hypotensive patients.
KNEE-CHEST POSITION
 A prone position in which the individual rests on the knees
and upper part of the chest, assumed for gynecologic or
rectal examination.
 Also called genupectoral position.
DORSAL RECUMBENT POSITION
 Patient on the back, with lower limbs flexed and
rotated outward.
 Used in vaginal examination, application of obstetrical
forceps, and other procedures.
LITHOTOMY POSITION
 Is a medical term referring to a common position for
surgical procedures and medical examinations
involving the pelvis and lower abdomen, as well as a
common position for childbirth
 The patient is laid on the back with knees bent,
positioned above the hips, and spread apart through
the use of stirrups.
SIM’S POSITION
 It is performed by having a patient lie on their left side,
left leg extended and right leg flexed.
 Is usually used for rectal examination, treatments and
enemas.
ORTHOPNEIC POSITION
 A position assumed to relieve ORTHOPNEA (difficulty
breathing except when in an upright position)
 The patient assumes an upright or semivertical
position by using pillows to support the head and
chest, or sits upright in a chair.
ORTHOPNEIC
TRENDELENBURG
XII. Pharmacological & Parenteral
ECART DRUGS
 Atropine Sulfate




Sodium /luminal
Aminophylline
Buscopan 100mg/ ml
Amoiordarone
Dopamine 200 mg/ 5ml
Epinephrine
(DBL)
Hemostan 500 mg/15cc Dobutamine 200 mg/5ml
 Benadryl 50 mg/ cc







Lanoxin/ Digoxin 0.5/2
Xylocaine
Mg. Sulfate 250 mg/ml
Furosemide/ Lasix
Nifedipine/ Calcibloc 5mg
Diazepam
Verapamil/ Isoptin 5mg/ml
Calcium Gluconate 10mg/ml
Magnesium Sulfate 4mg/ml
Bricanyl 1cc
Dormicum 15mg/2ml
DRUG COMPUTATION
1.
Oral and solid medication doses:
Desired X quantity
Stock
2.
Intravenous Drip Rate:
Total Number of milliliters ordered = number of ml/hr
Number of Hours to run
Total Vol. = cc/hr
# of hours to run
Briefly, #ml ordered = ml/hr
#hr to run
# of milliliter per hour X tubing drip factor = drops/min.
Number of hour
Briefly, ml/hr x TF = drops per minute
#min
INSULIN ADMINISTRATION
ONSET
PEAK
DURATION
1 hr.
4 hrs.
8 hrs.
INTERMEDIATE
2 hrs.
8 hrs.
16 hrs.
LONG-ACTING
4 hrs.
16 hrs.
32 hrs.
REGULAR
VOLUMETRIC PUMP
 A device for administration of intravenous fluids with
great accuracy.
The Soluset Solution Set
 Comes complete with a 100mL calibrated burette,
injection site on the burette with automatic shutoff
valve, and a Y-Site 6" from the needle adapter end. 60
drops per mL drip chamber.
S
O
L
U
S
E
T
BLOOD TRANSFUSION
BLOOD
o A mixture of cells
o A complex TRANSPORT
mechanism
Transport hormones
Removes waste products
Regulates body
temperature
Protects the body
Promotes hemostasis
Supplies oxygen
COMPOSITION OF BLOOD
Temperature
38˚C (100.4˚F)
pH
7.35- 7.45
Specific Gravity
1.048- 1.066
Body Weight
7%
5 times the viscosity of water
Volume
- Male
5-6 Liters
- Female
4-5 Liters
Cellular Components:
 Formed elements of blood:
1. RBC = responsible for oxygen transport
2. WBC = play a major role in defense against
microorganisms
3. Platelets = function in hemostasis
National Blood Services Act of 1994
Also known as the Republic Act 7719
AN ACT PROMOTING VOLUNTARY BLOOD
DONATION PROVIDING FOR AN ADEQUATE
SUPPLY OF SAFE BLOOD, REGUALTING BLOOD
BANKS, AND PROVIDING PENALTIES FOR
VIOLATION THEREOF.
BLOOD TRANSFUSION
Is the process of receiving blood products into one's
circulation intravenously.
A life saving therapy for patients with a variety of
medical and surgical conditions in need of blood.
Early transfusions used whole blood, but modern
medical practice commonly uses only components of
the blood, such as red blood cells, white blood cells,
plasma, clotting factors, and platelets.
Blood Collection Methods:
1. Unrelated Donor ( Allogeneic)
2. Directed Donor
3. Autologous Donor (Self)
Component
Volume
Recommended Hrs. of Transfusion
WB
500ml
4 hours
PRBC
250ml
1 hr. 30 min. – 2 hrs.
Platelets
50ml
10-15 min.
Cryoprecipitate
20ml
5-10 min.
FFP
200-250ml
5-10 min.
Eligible Donor Must Be:





18 years old and above
Weight at least 110 lbs. (50 kgs.)
Free from skin diseases
Not have donated in the past 56 days
Have a hemoglobin level of at least :
12.5 g/dL(women)
13.5 g/dL (men)
Ineligible Donor:
 AIDS
 Hepatitis
 Types of Cancer
 Hemophilia
 Have received clotting factor concentrations
Acute Transfusion Reactions
- Usually appear within the first 5- 15 minutes after the
transfusion is started.
 Bloody Urine
 Chills
 Hypotension
 Severe low back/ flank or chest pain
 Low or absent UO
 Nausea and vomiting
 Dyspnea, wheezing
 Diaphoresis
NURSES MUST BE:
 Assure the informed consent has been obtained before
starting a transfusion
 Appropriate information to include in patient
education includes:
- Benefits
- Risks
- Alternatives to transfusion
 Document all patient education regarding
transfusion therapy and the responses of patients
and family members after teaching.
Safety Precaution
 Make sure that you are protected by:
-Wearing proper PPE
- Always perform disinfection technique
- If using sharps, do not recap needle
- Always observe proper waste disposal according to
your institutions policy
- Make sure the blood bag is secured
- Always double or triple check
- Always perform HAND HYGIENE
Transfusion Precaution
 Don’t add medicines to the blood
 Don’t transfuse the blood product if you discover a
discrepancy in the blood number, blood slip type, or
patient identification number.
BEFORE TRANSFUSION
 When you received the delivery from the blood bank
you should receive both the product and the
transfusion record that corresponds to it.
Inspect the following:
 Labels
 Integrity of unit
 Appearance
DURING TRANSFUSION
 Administer the blood or component at the
recommended rate
 Stay with the patient for the first few minutes of
transfusion
 Review signs and symptoms of what the patient should
report
AFTER TRANSFUSION
 Continue to monitor patient for any signs and
symptoms of reaction for at least one hour after the
transfusion
 Obtain any ordered post- transfusion laboratory
studies
Note: The Registered Nurse shall follow these steps
immediately after detecting signs and symptoms
of an acute transfusion reaction.
1. Stop the transfusion immediately.
2. Change the I.V. tubing to prevent infusing more
blood. Save the blood tubing and bag for analysis.
3. Administer normal saline solution to keep the vein
patent (open).
4. Take and record the patient’s vital signs.
5. Notify the doctor.
6. Prepare for further treatment.
7. Complete transfusion reaction report and an
incident report according to your facility’s policies
and procedures.
CHANGING OF IV LINES/ TUBINGS
When to change IV Lines/ Tubings (trouble shooting)?
1.
1.
Usually according to the hospital policy
(usually 72 hours)
Contamination is suspected and noted
XIII. Reduction of Risk Potential
ASSISTIVE DEVICES
 Is an umbrella term that includes assistive, adaptive, and
rehabilitative devices for people with disabilities and also
includes the process used in selecting, locating, and
using them.
 It promotes greater independence by enabling people to
perform tasks that they were formerly unable to
accomplish, or had great difficulty accomplishing, by
providing enhancements to or changed methods of
interacting with the technology needed to accomplish
such tasks.
Cane - A stick used as an aid in walking or carried as an
accessory.
Types:
a. single
b. tripod cane
c. quad cane
Nursing Care:

Teach client to hold cane in hand opposite affected
extremity, and to advance cane at the same time the
affected leg is moved forward.
Walker
1. Mechanical device with four legs for support
2. Nursing Care
 Teach client to hold upper bars of walker at each side,
then to move the walker forward and step into it.
Crutches
1. Assure proper length.
a. When client assumes erect position the top of
crutch is 2 inches below the axilla, and the tip of
each crutch is 6 inches in front and to the side of
the feet.
b. Client’s elbow should be slightly flexed when hand
is on hand grip.
c. Weight should not be borne by the axilla.
2. Crutch gaits
a. Four point gait – used when weight bearing is
allowed on both extremities.
1. advance right crutch
2. step forward with left foot
3. advance left crutch
4. step forward with right foot
b. Two point gait – typical walking pattern
1. step forward moving both right crutch and left
leg simultaneously.
2. step forward moving both left crutch and right
leg simultaneously.
c. Three point gait – used when weight bearing is
permitted on one extremity only.
1. advance both crutches and affected extremity
several inches, maintaining good balance.
2. advance the unaffected leg to the crutches,
supporting the weight of the body on the hands.
d. Swing – to gait – used for clients with paralysis of
both lower extremities who are unable to lift feet
from floor.
1. both crutches are placed forward
2. client swings forward to the crutches
e. Swing- through gait – same indications as for
swing – to gait
1. both crutches are placed forward
2. client swings body through the crutches
SINGLE CANE
TRIPOD CANE
QUAD CANE
Walker
Crutches
Carry: 1 man, 2 man, 3 man
LOG ROLLING
 Is a maneuver used to turn a reclining patient from one
side to the other or completely over without flexing the
spinal column.
 The arms of the patient are folded across the chest, and
the legs extended.
 A draw sheet under the patient is manipulated by
attending health care team members or nursing
personnel to facilitate the procedure.
BED TRANSFER
 Is performed independently or with caregiver
assistance depending on if the person has a low or
high level of mobility.
 This technique requires some practice, but knowing
the necessary actions for a safe transfer from a bed to a
chair can increase self-reliance and decrease the risk of
an injury.
General Rules for Safe Patient Handling:
Think first before initiating any patient activity
Plan the activity
Maintain the curve in your low back
Get as close to the patient as possible when
providing care
• Get necessary assistance of another person or
assistive equipment whenever possible
• Keep your stomach tight and your head and
shoulders up
•
•
•
•
• Pivot or side step – DO NOT TWIST
• Make sure the path is clear and the floor is dry
• If transferring to a chair, make sure the chair is
properly positioned
• Always transfer the patient to their unaffected
stronger side unless otherwise instructed by a
Physical Therapist
• Use your legs, not your back, when lifting
• Bend your knees – never lift with your legs straight
• Have the patient help you as much as possible,
know their transfer and ADL status
• Provide simple clear directions for the patient and
explain what you are doing each step of the way
• Use a draw sheet if the patient is heavy or can only
minimally assist
• Whenever possible, use your body weight and
momentum to move the patient rather than just
muscle strength
• Place feet shoulder width apart or one foot in front
of the other to provide a wide, solid base of
support
Equipments used in Bed Transfer:
a. Hoyer Lifts
 For patients who are unable to provide their own
assistance in the transfer
b. Transfer boards
 Allow the user to slide slowly into a wheelchair
 For independent transferring
c. Bed rails
 Act as stability bars to lift themselves off the bed and
move at their own rate of transfer.
 For independent transferring
d. Trapeze bar

Act as stability bars to lift themselves off the bed
and move at their own rate of transfer.
 For independent transferring
 You can put a free standing trapeze bar hovering
above the bed or have an attached trapeze bar
hang over the bed for disabled persons to pull
themselves into position for resting, sitting or
transferring without much or any assistance from
caregivers.
HOYER LIFTS
TRANSFER BOARDS
BED RAILS
TRAPEZE BAR
XIV. Physiologic Adaptation
ABG READING
 Is taken to measure the Ph of arterial blood.
 Ph of the arterial blood is normally between 7.35 and
7.45.
 A Ph above or below this range is dangerous to a
patient.
Normal ABG Range
1. Ph - 7.35-7.45
2. PaCO2 - 35-45 mm/hg
3. HCO3 - 22-26 mm/hg
4. PaO2 80-100 mm/hg - The oxygen level in the arterial
blood.
pH
Alkalosis Acidosis
PCO2
Acidosis
HCO3
Alkalosis Acidosis
PCO2
HCO3
- Respiratory (Lungs)
- Metabolic (Kidney)
Alkalosis
OXYGEN THERAPY
1. Nasal Cannula
 It a device used to deliver supplemental oxygen or
airflow to a patient or person in need of respiratory help.
 This device consists of a plastic tube which fits behind
the ears, and a set of two prongs which are placed in the
nostrils. Oxygen flows from these prongs.
 Is connected to an oxygen tank, a portable oxygen
generator, or a wall connection in a hospital via a flow
meter.
 It carries 1–6 liters of oxygen per minute
 The oxygen fraction ranges from 24% to 35%
2. Face Mask
 Are made up of clear, pliable plastic or rubber that can
be molded to fit the face.
 They are designed to cover the nose and mouth
 There are several holes in the sides of the mask
(exhalation ports) to allow the escape of exhaled carbon
dioxide.
 It carries 5-8 Liters per minute
 The oxygen fraction ranges from 40% to 60%
NEBULIZATION
 Drawing into the respiratory tract, a non- volatile drug,
transformed into a fine mist with the use of nebulizer, or
aerosol apparatus.
Purpose: To deliver finer mist at a faster rate
Special Considerations:
1. Administer the inhalation not too close to meal time
2. Give the therapy prior to coughing exercises or
postural drainage.
Reasons to avoid the treatment include:
 Increased blood pressure
 Increased pulse
 History of adverse reaction to the medication
Equipments:
Lined tray with:
Nebulizer
b. Prescribed drug
c. Sterile syringe & needle or medicine glass
d. Normal Saline Solution
e. Spout with medicine container
a.
PROCEDURE:
1. Assemble the equipments
2. Measure the prescribed amount of drug with a syringe
needle and place into the nebulizer’s drug compartment
3. Placed on a lined tray and bring to the client’s bedside
4. Connect the nebulizer directly into the electric outlet
5. Place client in fowler’s or sitting position if tolerated
6. Direct the nebulizer towards the client’s mouth and
instruct to inhale the mist deeply through the mouth,
pause and hold breath for 3-4 seconds. Exhale slowly
through pursed lips.
7. Instruct client to continue until the solution is vaporized.
Often, the effects of the treatment are most apparent
15-20 minutes later, and you may need assisted coughing or
suctioning at that time.
CHEST PHYSIOTHERAPY
 Sequence is usually positioning, percussion, vibration, &
removal of secretions by coughing or suction.
Chest Percussion

Also called clapping or cupping
 It is done by forcefully striking the skin with cupped
hands over specified congested lung area to
mechanically dislodge tenacious secretions from the
bronchial walls.
 It is carried out for only 1 or 2 min. or up to 5 min.
over each area according to M.D.’s order.
Vibration




A series of vigorous quiverings produced through
hand that are placed flat against the chest wall.
It is used after percussion, to increase the turbulence
of the exhaled air and thus loosen thick secretions.
It can replace percussion if client is experiencing
chest pain.
It is often done 4 or 5 times during postural drainage.
Postural Drainage






The drainage by gravity, of secretions, from various
lung segments.
A wide variety of positions is necessary to drain all
segment of the lung, but not all positions are
required for every person.
Only those positions that drain specific diseased
areas are used.
Each position is usually assumed for 10-15 min.
Treatment is scheduled 30 min. to 1 hour before
meals so that a client will not vomit the meal.
Before treatments, bronchodilators or moisturizing
nebulization therapy may be ordered.
Things needed:
 Pillows to support the client comfortably in the required
positions
 Tissues for expectorated secretions
 Sputum container for expectorated secretions
 Mouthwash to clean and freshen the mouth following the
treatment
 Bed that can be placed in trendelenburg’s position
 Gown or pajama to prevent undue exposure and to protect
the skin during percussion and vibration
 A towel to place over the area to be percussed to prevent
discomfort
DRAINAGE OF THE UPPER LOBES
Three segments – the apical or uppermost segments
and below them, the anterior and posterior
segments.
A. To drain the apical segments of the upper lobes
 Lie back at a 30 degrees angle
 Percuss and vibrate between the clavicles and above the
scapulae
B. To drain the posterior segments of the upper
lobes
 Have client sit upright in a chair or bed with the head
bent slightly forward.
 Percuss and vibrate the areas between the clavicles and
the scapulae.
C. To drain the anterior segments of the upper lobes
 Have client lie on a flat bed with pillows under the knees
to flex them.
 Percuss and vibrate the upper chest below the clavicles
down to the nipple line, except for women.
DRAINAGE OF THE RIGHT MIDDLE LOBE AND
LOWER DIVISION OF THE LEFT UPPER LOBE
Two segments – lateral and medial. The lower division
of the left upper lobe, called the lingual of that lobe,
has two segments – superior and inferior
To drain the Right Lateral and Medial Segments
 Elevate the foot of the bed about 15 degrees or 40 cm
(15 in.), and have the client lie on the left side.
 Help the client to lean back slightly (about a quarter
turn) against pillow extending at the back from the
shoulder to the hip.
 A pillow may be placed between the knee for comfort.
For male: Percuss and vibrate over the right side of the
chest at the level of the nipple between the 4th and 6th
rib.
For female: Position the heel of your hand toward the
axilla and your cupped finger extending forward
beneath the breast to percuss and vibrate beneath the
breast.
To drain the Left Lingular Segments
 Elevate the foot of the bed about 15 degrees and have the
client lie on the left side.
 Percuss the right side of the chest beneath the breast.
To drain the lateral Basal Segments
 Have the client lie partly on the unaffected side and
partly on the abdomen.
 Elevate the foot of the bed about 30 degrees or 45 cm
(18in) or to the height tolerated by the client.
 An alternative is to elevate the hips with pillows.
 Percuss and vibrate the uppermost side of the lower ribs.
To drain the Posterior Basal Segments
 Have client lie prone.
 Elevate the foot of the bed about 30 degrees or 45 cm (
18in) or to the height tolerated by the client.
 Elevate the hip on two or three pillows to produce a jack
knife position from the knees to the shoulders.
 Percuss and vibrate over the lower ribs on both sides
close to the spine, but not directly over the spine or the
kidneys.
DRAINAGE OF THE LOWER LOBES
Four Segments – superior, anterior basal, lateral
basal, and posterior basal.
To drain the Superior Segments
 Have client lie on the abdomen on a flat bed, and place
two pillow under the hips.
 Percuss and vibrate the middle area of the back on both
sides of the spine.
To drain the Anterior Basal Segments
 Have client lie on the unaffected side, with the upper
arm over the head.
 Elevate the foot of the bed about 30 degree or 45 cm
(18 in), or to the height tolerated by the client.
 Place one pillow between the knee. Another under the
head is optional.
 Percuss and vibrate the affected side of the chest over
the lower ribs, inferior to the axilla.
NASOGASTRIC TUBE
 Levin Tube is commonly used
 Is a common procedure that provides access to the
stomach for diagnostic and therapeutic purposes.
Purpose:
–To provide feeding
–To irrigate stomach ( gastric lavage)
–For decompression
–To administer medications
–To administer supplemental fluids
GASTROSTOMY
 Is a surgically created opening in the stomach.
 Is needed if you are not able to eat enough for adequate
nutrition during treatment.
 Extra food and fluids are given through a gastrostomy
tube, also called a G-tube.
GASTROSTOMY TUBE
 Is placed in the stomach to help with feeding or venting
of stomach gas.
There are 2 main types of G-tubes:
o A G-tube that is placed in the stomach during surgery
and has a tube that stays on the outside. This tube is
held in place by a small fluid-filled balloon inside the
stomach.
o A percutaneous endoscopic gastrostomy (PEG) tube
placed in the stomach using a scope passed through the
mouth into the stomach. A balloon or plastic disc (cap)
in the stomach holds the tube in place.
GASTROSTOMY CARE
Wash your hands with soap and water before and
after touching the area.
2. Use warm water and soap to clean around the
gastrostomy site 2 to 3 times a day or as needed.
3. Make sure that you gently soak or scrub off all
crusted areas on the skin around the tube and on the
tube itself. You may need to use a diluted solution of
hydrogen peroxide (1/2 peroxide and 1/2 water) with
Q-tips to clean around the tube site.
1.
4. After cleaning, rinse around the area with plain water
and pat dry.
5. You may use an antibiotic ointment around the site if
the area looks red or sore
COLOSTOMY
 Is a reversible surgical procedure in which a stoma is
formed by drawing the healthy end of the large
intestine or colon through an incision in the
anterior abdominal wall and suturing it into place.
 This opening, in conjunction with the attached
stoma appliance, provides an alternative channel for
feces to leave the body.
 A temporary colostomy may be needed to allow the
colon to rest and heal for a period of time. It may be
in place for weeks, months, or years. It will
eventually be closed and bowel movements will
return to normal.
 A permanent colostomy is usually needed when a
part of the colon must be removed or cannot be
used again.
Types of Colostomies:
1. Ascending colostomy
 Has a stoma (opening) that is located on the right side of the
abdomen. The output (stool) that drains from this stoma is in
liquid form.
2. Transverse colostomy:
 Has stoma that is located in the upper abdomen towards the
middle or right side. The output that drains from this stoma
may be loose or soft.
3. Descending or sigmoid colostomy:
 Has stoma that is located on the lower left side of the
abdomen. The output that drains from this stoma is firm.
Things used for Colostomies:
1. Pouch

Are lightweight and odor-proof. Pouches have a
special covering that prevents the pouch from sticking
to the body. Some pouches also have charcoal filters
which release gas slowly and help to decrease gas odor.
Types of Pouches:
1. Open-ended pouch
2. Close-ended pouch
3. One-piece
4. Two-piece
5. Pre-cut or cut-to-fit pouches
2. Stoma covers and caps



Can be placed on the stoma when the stoma is not
active (draining).
People with descending or sigmoid colostomies who
irrigate may use stoma covers or caps.
Is attached to the skin in the same way as pouch
3. Skin protection
Film


Can be placed on the skin to protect against damage
from the adhesive material.
Are helpful for people with sensitive, dry, or oily skin.
Pectin-based paste or paste strips/rings



Are helpful for protecting skin against output that
contains digestive enzymes (proteins that break
down foods).
Ascending or transverse colostomies can produce
output that contains digestive enzymes, which can
irritate or damage the skin.
The paste is also used to create a flat pouch
surface by filling in small skin creases.
POUCH
STOMA CAPS
Emptying the pouch:
 Empty the pouch when one-third to one-half full. Do not wait
until the pouch is completely full because this could put pressure
on the seal, causing a leak. The pouch may also detach, causing
all of the pouch contents to spill.
 Place toilet paper into the toilet to reduce splash back and noise.
 Take the end of the pouch and hold it up. Remove the clamp (if
the pouch has a clamp system).
 Take the end of the end of the pouch and make a cuff to keep it
from getting soiled. Some pouches will not require you to cuff
the pouch.
 Drain the pouch by squeezing the pouch contents into the
toilet.
 Clean the cuffed end of the pouch with toilet paper or a
moist paper towel. You may also rinse the pouch but it is
not necessary. Make sure and keep the end of the pouch
clean.
 Undo the cuff at the end of the pouch. Replace the clamp
or close the end of the pouch according to your caregiver's
instructions.
IRRIGATION
 Means putting an enema into the stoma.
 Allows a person to have timed bowel movements.
 Allow a person to be free from stool output for about 24
to 48 hours.
Things Needed:
1.
2.
3.
Plastic irrigating container
Irrigation sleeve
Adjustable belt
Procedure:
Fill the irrigating container with about 16 to 50
ounces of lukewarm water. The water should not be
cold or hot. The amount of water each person needs
to put in the irrigating container varies.
2. Hang the irrigation container at a height in which
the bottom of the container is level with your
shoulder. Sit up straight on the toilet or on a chair
next to the toilet.
3. Take the adjustable belt and attach it to the
irrigation sleeve. Place the belt around your waste
and place the sleeve over your stoma. Place the end
of the irrigation sleeve into the toilet bowel.
1.
4. Release air bubbles from the tubing on the plastic
irrigating container by releasing the clamp. Allow a
small amount of water to be released into the sleeve.
Clamp the tubing again.
5. Moisten the end of the cone with water or lubricate it
with water-soluble lubricant.
6. Place the tip of the cone about three inches deep into
the stoma. Make sure there is a snug fit but do not
place the cone too deeply or forcefully into the
stoma. Release the clamp on the tubing again and
allow the water to flow into the stoma. The water
must go in slowly and takes about five to ten
minutes. Keep the cone in place for another 10
seconds.
7. Remove the cone from the stoma. Allow the output
to drain into the irrigation sleeve for about 10 to 15
minutes.
8. Dry the end of the irrigation sleeve. Clip the bottom
of the sleeve to the top with a clasp or close the end
of the sleeve with the tail closure. You may move
around for about 30 to 45 minutes until all the water
and stool has drained.
9. Drain the output from the sleeve into the toilet.
Clean the area around the stoma with mild soap and
water and pat dry.
IRRIGATION
CONTACT A CAREGIVER IF:
 You have a fever (increased body temperature).
 Unusual odor that lasts longer than a week.
 Your skin around the stoma is red and irritated and





you do not know what to do.
You have nausea, vomiting, pain, cramping, or
bloating.
You have diarrhea.
Your bowel habits change, like having little or no
stool output.
Your stoma size changes or becomes narrow
(stenosis).
Your stools are black or bloody.
SEEK CARE IMMEDIATELY IF:
o Your stoma is bleeding and you cannot stop the
bleeding.
o You are too weak to stand up.
o You have bad abdominal (belly) pain.
DM FOOT CARE
DM FOOT CARE
A person with diabetes should do the following:
Foot Examination
 Examine your feet daily and also after any trauma, no
matter how minor, to your feet.
 Report any abnormalities to your physician. Use a waterbased moisturizer every day (but not between your toes)
to prevent dry skin and cracking.
 Wear cotton or wool socks.
 Avoid elastic socks and hosiery because they may impair
circulation.
Eliminate obstacles
 Move or remove any items you are likely to trip over or
bump your feet on.
 Keep clutter on the floor picked up.
 Light the pathways used at night indoors and outdoors.
Toenail trimming
 Always cut your nails with a safety clipper, never a
scissors.
 Cut them straight across and leave plenty of room out
from the nail bed or quick.
 If you have difficulty with your vision or using your
hands, let your doctor do it for you or train a family
member how to do it safely.
Footwear
 Wear sturdy, comfortable shoes whenever feasible to
protect your feet.
 To be sure your shoes fit properly, see a podiatrist (foot
doctor) for fitting recommendations or shop at shoe
stores specializing in fitting people with diabetes.
 Your endocrinologist (diabetes specialist) can provide
you with a referral to a podiatrist or orthopedist who
may also be an excellent resource for finding local shoe
stores.
 If you have flat feet, bunions, or hammertoes, you may
need prescription shoes or shoe inserts.
Exercise
 Regular exercise will improve bone and joint health in
your feet and legs, improve circulation to your legs, and
will also help to stabilize your blood sugar levels.
 Consult your physician prior to beginning any exercise
program.
Smoking
 If you smoke any form of tobacco, quitting can be one of
the best things you can do to prevent problems with
your feet.
 Smoking accelerates damage to blood vessels, especially
small blood vessels leading to poor circulation, which is
a major risk factor for foot infections and ultimately
amputations.
Diabetes control
 Following a reasonable diet, taking your medications,
checking your blood sugar regularly, exercising regularly,
and maintaining good communication with your
physician are essential in keeping your diabetes under
control.
 Consistent long-term blood sugar control to near
normal levels can greatly lower the risk of damage to
your nerves, kidneys, eyes, and blood vessels.
MANAGEMENT DURING SEIZURES AND EPILEPSY
SUPPOSITORIES FOR HIGH FEVER
Fever
 Is part of the body's normal defense mechanisms for
killing bugs in the blood (viruses).
 When you get a fever, your body heats up to burn out the
viruses that are making you feel unwell.
 While a fever may burn itself out over time, a prolonged
high fever may cause brain damage.
FeverAll Acetaminophen Suppositories
 Are the perfect solution when your child can't or won't
take liquid medicine to get the fever down.
 You can use one suppository every four to six hours as
needed to bring the fever down, but not to exceed six in
24 hour period.
NOSEBLEEDING
NOSEBLEEDING
 Is the relatively common occurrence of hemorrhage
from the nose, usually noticed when the blood drains
out through the nostrils.
There are two types:
1.
2.
Anterior (the most common)
Posterior (less common, more likely to require medical
attention).
 Can generally be divided into two categories:
a. Local
o Blunt trauma (usually a sharp blow to the face such as
a punch, sometimes accompanying a nasal fracture)
o Foreign bodies (such as fingers during nose-picking)
o Inflammatory reaction (e.g. acute respiratory tract
infections, chronic sinusitis, allergic rhinitis or
environmental irritants)
b. Systemic
o Allergies
o Infectious diseases (e.g. common cold)
o Hypertension
HOME CARE MANAGEMENT:
 If the nose starts bleeding after a trauma, seek
medical help immediately, as it could indicate a
skull fracture.
 When dealing with a common nose bleed not
caused by trauma, stand with head tilted forward.
 Using the thumb and forefinger, grab the front of
your nose, squeezing tightly and hold this pressure
for five minutes.
 A cold compress on the bridge of the nose can also
help.
 If you cannot stop the bleeding within 15 minutes,
you need to seek medical care.
PROFESSIONAL CARE:
 If trauma is suspected, your doctor will perform an X-ray
to see if the skull has been damaged.
 If no trauma or damage is present, your physician will
probably pack your nose with gauze.
 If this does not work, a catheter in the nose may be used
to collect the blood and put pressure on the artery.
 If you suffer from chronic nose bleeds, your doctor may
cure your condition by cauterizing the blood vessels in
your nose. This involves heating them so that they are
permanently sealed.
FOLEY CATHETER
 Is a flexible tube that is passed through the urethra and
into the bladder.
 Are commonly made from silicone rubber or natural
rubber
 Size is described using French units
 The tube has two separated channels, or lumens,
running down its length.
a. One lumen is open at both ends, and allows
urine to drain out into a collection bag.
b. The other lumen has a valve on the outside end
and connects to a balloon at the tip.
INDICATIONS:
 On patients who are anesthesized or sedated for
surgery or other medical care
 On comatose patients
 On some incontinent patients
 On patients with acute urinary retention.
 On patients who are unable due to paralysis or physical
injury to use either standard toilet facilities or urinals.
 Following urethral surgeries
 Following ureterectomy
Types:
1.
"Three way" or "triple lumen" catheter
- Which is used to infuse sterile saline or another
irrigating solution.
- These are used primarily after surgery on the bladder
or prostate, to wash away blood and blood clots.
2.
Indwelling catheter
- A urethral catheter designed to be held in place
to drain urine from the bladder.
3.
Straight catheter
- Is a straight tube of pliable plastic or rubber.
- One end is rounded to prevent any trauma to
tissue, with the opening of the lumen
(the opening) down the center of the tube) on the
side.
- The other end of a catheter is enlarged to form a
connection to some type drainage or collection
system, and more importantly prevent theV
catheter from being completely "lost" into the
urethra.
REMOVAL OF URINARY CATHETER
1.
Gather equipment.
2.
Explain procedure to the patient
3.
Assist patient into supine position with legs spread
and feet together
4.
Apply sterile drape
5.
Locate the inflation port on the catheter's side and
attach a small syringe.
Draw out the fluid using your syringe until no more
fluid can be drawn.
7. Remove the catheter slowly by gently pulling it out
completely Cut the balloon port tubing, using surgical
scissors, as a second alternative to remove your
catheter. Wait for all the fluid to drain before slowly
pulling out the catheter.
8. Evaluate catheter function and amount, color, odor,
and quality of urine
9. Remove gloves, dispose of equipment appropriately,
wash hands.
10. Document all pertinent information.
6.
SUCTIONING
 Used to clear the airway of excessive secretions when
the patient is unable to clear the respiratory tract with
coughing.
Nasotracheal Suctioning
 Remove secretions from the pharynx by means of a
suction catheter to maintain a patent airway
 To promote pulmonary gas exchange
 Help prevent infections caused by accumulated
secretions.
Oropharyngeal Suctioning
 Is usually performed using a rigid plastic catheter with
one large and several small eyelets that mucous enters
when suction is applied.
 This type of catheter is called a Yankauer or tonsil
suctioning device.
 Alert patients can be taught to use this device to
control excess secretions in the mouth.
TRACHEOSTOMY TUBE SUCTIONING
General Considerations:
1. Never ever remove outer cannula. It is changed only
by the doctor. If accidentally expelled, keep airway
open with a hemostat.
2. Always keep an extra, complete tracheostomy tube
set at the bedside, and a forcep or tracheal dilator or
obturator.
3. If patient shows signs of cyanosis, difficult breathing,
or the tube become dislocated, call the doctor at
once.
4. Do not use any cotton or cotton applicator around a
tracheostomy.
ENDOTRACHEAL SUCTIONING
 A deep suctioning by the use of catheter which is
inserted farther into the trachea and or trachea;
 Usually, 20cm or 8 in. of the catheter is inserted in an
adult.
PURPOSES:
1.
2.
Maintain patent airway by stimulating cough reflex
To aspirate mucus and other secretions farther down
into the trachea
NOTE: Never apply suction during insertion.
Application of suction pressure while introducing the
catheter into the trachea increases risk of damage to
the mucosa and increases the risk of hypoxia because
the removal of oxygen present in the airway.
Remember that the epiglottis is open during
inspiration and facilitates insertion of the catheter
into the trachea.
Elevated pressure settings increase risk of
trauma to mucosa
SKELETAL TRACTION
Traction
 Is the act of pulling or drawing which is associated with
countertraction.
PURPOSES:
To lessen muscle spasm
b. To reduce fracture
c. To provide immobilization
d. To maintain body alignment
a.
SKELETAL TRACTION
 Traction applied directly upon long bones by means of
pins and wires.
Examples:
1.
2.
3.
4.
5.
6.
Halo- Pelvic – for scoliosis
Halo- Femoral – severe scoliosis
90 – 90- subtrochanteric fracture of femur
BST – femur and hips
Overhead – humerus
Halo Traction – cervical spine
HALO PELVIC
HALO-FEMORAL
90-90 SUBTROCHANTERIC
OVERHEAD
BALANCE SKELETAL
TRACTION
(BST)
HALO TRACTION
THANK YOU!!!