Purpose

1. To the comfort of the patient.
2. To remove tangles from the hair.
3. To preserve or keep the hair in good condition during illness.
4. To observe the presence of lice without the patient’s being aware of it.
5. To prevent infection.
6. In preparation for diagnostic procedures involving the head.

Equipment

• Patient’s bath towel
• Hair comb
• Hair Brush
• Vaseline
• Clips
• Rubber bands or tapes

Procedure

1. Move the patient’s head near the edge of the bed, her face turned away from you.
2. Place towel under the head of the patient extending down the chest and shoulders.
3. Loose the hair and part it in the middle.
4. Brush hair thoroughly.
5. In combing or brushing, comb small stands at a time. Hold the strand at a time wrapping around the forefinger. Hold the stand above the part being combed so that the pull comes on your baud, not on the hair roots and comb the tangles from the end first.
6. Comb gently especially when removing tangles. If the hair is badly tangled, apply vaseline or oil or wet hair with alcohol but time, patience and skill are required.
7. If the hair is long, part down and middle and plaid into two braids shirting towards the front so that a patient lying on her back will not be conscious of this coronet across the front of the head or let them freely down holding the ends with ribbon or tape or rubber bands.
8. Gather all used articles. Clean and disinfect brush and comb and return them into their proper places.

Additional Info

1. Never allow an ill patient to comb her hair.
2. If the hair is too tangled, alcohol or vaseline may be use to remove the tangles.
3. The nurse should never cut the patient’s hair without the patient’s permission.

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List of Passers

Topnotchers

Top Schools

Performance of Schools

Oathtaking Schedules

Registration

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Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume overload.
3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy

Whole blood transfusion

Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.

Packed RBCs

Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.

Platelets

Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.

Granulocytes

May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.

Plasma

Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.

Albumin

Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure.

Cryoprecipitate

Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.

Factor IX concentrate

Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.

Factor VIII concentrate

Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.

Prothrombin complex

Indicated in congenital or acquired deficiencies of these factors.

Blood Components

Objectives

1. To increase circulating blood volume after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia
3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

Nursing Interventions

1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the label of the blood transfusion. Check the following:
   • Serial number
   • Blood component
   • Blood type
   • Rh factor
   • Expiration date
   • Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.
6. Warm blood at room temperature before transfusion to prevent chills.
7. Identify client properly. Two Nurses check the client’s identification.
8. Use needle gauge 18 to 19 to allow easy flow of blood.
9. Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)
12. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.
13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose based IV fluids cause hemolysis.
14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
15. Observe for potential complications. Notify physician.

Complications of Blood Transfusion

1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.

Assess for:

• Flushing
• Rash, hives
• Pruritus
• Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion

Assess for:

• Sudden chills and fever
• Flushing
• Headache
• Anxiety

3. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria.

Assess for:

• Rapid onset of chills
• Vomiting
• Marked Hypotension
• High fever

4. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.

Assess for:

• Rise in venous pressure
• Dyspnea
• Crackles or rales
• Distended neck vein
• Cough
• Elevated BP

5. Hemolytic reaction - it is caused by infusion of incompatible blood products.

Assess for:

• Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
• Chills
• Feeling of fullness
• Tachycardia
• Flushing
• Tachypnea
• Hypotension
• Bleeding
• Vascular collapse
• Acute renal failure

Assessment findings

1. Clinical manifestations of transfusions complications vary depending on the precipitating factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
   • Fever
   • Chills
   • low back pain
   • flank pain
   • headache
   • nausea
   • flushing
   • tachycardia
   • tachypnea
   • hypotension
   • hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
   • fever
   • mild jaundice
   • gradual fall of hemoglobin
   • positive Coombs’ test
4. Febrile non-hemolytic reaction is marked by:
   • Temperature rise during or shortly after transfusion
   • Chills
   • headache
   • flushing
   • anxiety
5. Signs and symptoms of septic reaction include;
   • Rapid onset of high fever and chills
   • vomiting
   • diarrhea
   • marked hypotension
6. Allergic reactions may produce:
   • hives
   • generalized pruritus
   • wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
   • Dyspnea
   • cough
   • rales
   • jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
   • skin changes (e.g. erythema, ulcerations, scaling)
   • edema
   • hair loss
   • hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis

1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion

Planning and Implementation

Help prevent transfusion reaction by:

• Meticulously verifying patient identification beginning with type and crossmatch sample collection and labeling to double check blood product and patient identification prior to transfusion.
• Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
• Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
• Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
• Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
• Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
• Preventing hypothermia by warming blood unit to 37 C before transfusion.
• Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.

On detecting any signs or symptoms of reaction:

• Stop the transfusion immediately, and notify the physician.
• Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
• Send the blood bag and tubing to the blood bank for repeat typing and culture.
• Draw another blood sample for plasma hemoglobin, culture, and retyping.
• Collect a urine sample as soon as possible for hemoglobin determination.

Intervene as appropriate to address symptoms of the specific reaction:

• Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
• Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
• In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
• Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
• For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions for Complications

1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.
2. Start IV line (0.9% NaCl)
3. Place the client in fowler’s position if with SOBand administer O2 therapy.
4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician’s order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

Evaluation

1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.

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Purpose

1. To stimulate the circulation and give general relief.
2. To prevent bedsore
3. To give comfort to the patient.

Equipment Needed

• Alcohol 25%
• Talcum powder
• Bath towel

Procedure

1. Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. If the supine position is used and the patient is a woman, pillow under the abdomen removes pressure from the breasts and favor relaxation.
2. Raise the gown.
3. Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long strokes and kneading motions (see below). The amount of pressure to exert depends upon the patient’s condition. Begin from neck and shoulders then proceed over the entire back.
4. Massage with both hands working with a strong stroke. In upward then in downward motions. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be used.
5. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes.
6. Turn patient on his back and put on the gown.
7. Fix and make patient comfortable.

Movements Used

Effleurage Techniques

1. Effleurage (stroking) —is a long sweeping movement with palm of hand conforming to the contour of the surface treated, over small surface (on the neck) the thumb and fingers are used. Strokes should be slow, rhythmical and gentle with pressure constant and in the direction of venous stream.
2. Kneading—performed with the ulnar side palm resting on the surface and the fingers, and thumb grasping the skin and subcutaneous tissues which move with the hand of the operator.
3. Friction—is performed with the whole palmar surface of the hand or fingers and thumbs over limited areas. This movement is a circular form of kneading with pressure against the underlying part of tissue which cannot be grasped.

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Purpose

1. To refresh the patient and prepare him for sleep
2. To promote muscular relaxation
3. To prevent bedsore

Preparation of Patient and Environment

A tray containing:

• Basin of warm water
• Alcohol 70%
• Soap in soap dish
• Talcum powder
• Hair comb or brush
• Bath towel & wash cloth
• Pitcher of warm water
• Mouth wash tray with
• Mouth wash solution
• Tooth brush
• Kidney basin
• Linen required

Procedure

1. Allow patient to brush his teeth, wash his face, hands and forearms. If patient is unable to help himself, do it for him.
2. Turn patient to his side, unfasten his camisa or hospital gown and bathe her back.
3. Massage back with alcohol 70% or skin lotion paying particular attention to the bony prominences and other reddish spots on the back.
4. Dust with powder
5. If the patient is wearing a binder, remove it when giving care to the back. Inspect dressing for bleeding or discharge and changes or reinforce p.r.n. Return the binder in place.
6. Brush and comb hair. Protect back and camisa with towel
7. Fasten patient’s camisa Move patient to one side brush crumbs or dirt from the bed.
8. Tighten beddings.
9. Fluff up pillows and replace
10. Replace ice cap or hot water bag p.r.n
11. Give bedtime medicine if any. Attend to all patient’s request
12. Place signal cord or bell within the reach of the patient.
13. Remove all unnecessary things from the room: trays, dishes, etc. Empty wastebasket.
14. Adjust screen or blinds and light.
15. Document

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Purpose

1. To strengthen the patient gradually.
2. To provide a change in position.

Equipment

• Chair or wheelchair
• Patient’s robe and slippers
• Pillows
• Blanket, sheet or draw sheet

Procedure

1. See that the chair or wheelchair is in good condition.
2. Place the chair conveniently at night angles to the bed—back of chair parallel to the foot of the bed and facing the head of bed.
3. Place pillow on the seat of the chair. If using wheelchair, line it with a blanket or sheet and arrange pillows on the seat and against the back. Put the foot rest up and lock the wheels.
4. Take the patient’s pulse
5. Assist the patient to a sitting position on bed, i.e., put one arm under the head and shoulders and the other arm under her knees and pivot her to a sitting position with the legs hanging over the side of the bed.
6. Watch the patient for a minute to defect any change in his color, pulse and respiratory rate.
7. Put on patient’s robe and slippers. Place the foot stool under the patient’s feet.
8. Stand directly in front of the patient and with a hand under each axilla, assist him to stand, step down and turn around, with his back to the chair. Let patient flex his knees and lower body to seat him to the chair. Anchor chair with foot or have someone hold it on. (Or let patient place his arm over your shoulders while you put your arm around his waist. Turn patient around with his back to the chair and seat him gently). Help him get comfortable in the chair.
9. Adjust the pillows and wrap blanket over patient’s lap. If in a wheelchair adjust the foot rests.
10. Observe frequently for changes in color and pulse rate, dizziness or sign of fatigue.
11. To put him back to bed, assist to stand, help to turn and stand on stool and back to bed. Support patient while he sits on the side of bed. Remove robe and slippers. Pivot to a sitting position in bed, supporting her head and shoulders with one arm and her knees with the other arm, and lower slowly to bed in lying position.
12. Draw up bedding.
13. Take pulse after
14. Document

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In appreciation for Nursing Assistants, the community will host the Great Food Truck Roundup, offering free lunch to any assistant via eight food trucks at the following sites:

• Community Hospice Charles M. Neviaser Educational Institute (Mandarin) 4266 Sunbeam Road, Jacksonville, FL 32257 Food Truck: Gourmet Aviator
• St. Catherine Labouré Manor (St. Vincent’s Riverside) 1750 Stockton Street, Jacksonville, FL 32204 Food Truck: Brucci’s Pizza
• Community Hospice Anne and Donald McGraw Center for Caring (Mayo Clinic campus) 4715 Worrall Way, Jacksonville, FL 32224 Food Truck: Dagwoods
• Lanier Manor (North Side) 12740 Lanier Rd, Jacksonville, FL 32226 Food Truck: The Super Food Truck Orange Park Medical Center 2001 Kingsley Avenue, Orange Park, FL 32073 Food Truck: Driftwood BBQ
• Community Hospice Bailey Family Center for Caring 200 Health Park Boulevard, St. Augustine, FL 32086 Food Truck: Mother Fletcher’s
• Quality Health of Fernandina Beach 1625 Lime Street, Fernandina Beach, FL 32034 Food Truck: Wiki Wiki
• Macclenny Nursing & Rehab Center  755 South 5th Street, Macclenny, FL 32063 Food Truck: Monster Burger

Available 11:30 a.m. to 1 p.m., lunch is free to all nursing assistants who display their employer-issued photo identification. Others are welcome to purchase their own lunch.

For more information, visit www.facebook.com/communityhospicenefl. And also the official flyer for this event.

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Scorchy Barrington began the online petition after she noticed that photographer David Jay’s photos from the SCAR Project — a series of photographs of young breast cancer survivors — were being removed from the social media site.

“As a woman living with Stage IV breast cancer, photos like The Scar Project help me feel a little less alone in what I’m going through,” she wrote on Change.org. “With so many young women facing breast cancer diagnoses, I know these photos give them hope, too. By removing the photos, Facebook is sending us a message that our struggle with this disease should be kept in the dark.”

READ: Social Media Guidelines for Nurses

On Wednesday, Facebook released a statement that said it would allow photos of mastectomy scars.

“We have long allowed mastectomy photos to be shared on Facebook, as well as educational and scientific photos of the human body and photos of women breastfeeding,” the statement read. “We only review or remove photos after they have been reported to us by people who see the images in their News Feeds or otherwise discover them. On occasion, we may remove a photo showing mastectomy scarring either by mistake, as our teams review millions of pieces of content daily, or because a photo has violated our terms for other reasons.

“As a reminder, our terms stipulate that we generally do not allow nudity, with some exceptions as laid out above and here, consistent with other platforms that have many young users,” the company added.

Source: NewsMax

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Equipment

1. Tray with bedpan brush, bedpan swab
2. Short-sleeved gown
3. Can of disinfectant solution
4. Soap or any cleanser
5. Several pieces of dusting cloth

Procedure for Cleaning Bedpans and Urinals

1. Put on the short-sleeved gown
2. Collect the bedpans
3. Empty the contents one by one into the hoper. Wash with clean cold water. Use brush p.r.n. Follow with hot water.
4. Put the bedpan in the scan of disinfectant
5. Remove after, wash inside and outside with warm soapy water. Remove any stains using the cleanser
6. Rinse with hot water
7. Wipe to dry with the bedpan wiper and hang it at the bedpan rack.

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cyclobenzaprine hydrochloride

(sye kloe ben‘ za preen)

Apo-Cyclobenzaprine (CAN), Flexeril, Novo-Cycloprine (CAN)

Pregnancy Category B

Drug class

Skeletal muscle relaxant (centrally acting)

Therapeutic actions

Precise mechanism not known; does not directly relax tense skeletal muscles but appears to act mainly at brain stem levels or in the spinal cord.

Indications

• Relief of discomfort associated with acute, painful musculoskeletal conditions, as adjunct to rest, physical therapy
• Unlabeled use: Adjunct in the management of fibrositis syndrome

Contraindications and cautions

• Contraindicated with hypersensitivity to cyclobenzaprine, acute recovery phase of MI, arrhythmias, heart block or conduction disturbances, CHF, hyperthyroidism.
• Use cautiously with urinary retention, angle-closure glaucoma, increased IOP, lactation.

Available forms

Tablets—5, 10 mg

Dosages

ADULTS

10 mg PO tid (range 20–40 mg/day in divided doses); do not exceed 60 mg/day; do not use longer than 2 or 3 wk.

PEDIATRIC PATIENTS

Safety and efficacy in children < 15 yr not established.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 1–3 days

Distribution: Crosses placenta; may enter breast milk

Excretion: Urine

Adverse effects

• CNS: Drowsiness, dizziness, fatigue, tiredness, asthenia, blurred vision, headache, nervousness, confusion
• CV: Arrhythmias, MI
• GI: Dry mouth, nausea, constipation, dyspepsia, unpleasant taste, liver toxicity
• GU: Frequency, urinary retention

Interactions

Drug-drug

• Additive CNS effects with alcohol, barbiturates, other CNS depressants, MAOIs, TCAs; avoid concomitant use

Nursing considerations

Assessment

• History: Hypersensitivity to cyclobenzaprine, acute recovery phase of MI, arrhythmias, CHF, hyperthyroidism, urinary retention, angle-closure glaucoma, increased IOP, lactation
• Physical: Orientation, affect, ophthalmic examination (tonometry); bowel sounds, normal GI output; prostate palpation, normal voiding pattern; thyroid function tests

Interventions

• Arrange for analgesics if headache occurs.

Teaching points

• Take this drug exactly as prescribed. Do not take a higher dosage.
• Avoid alcohol, sleep-inducing, or OTC drugs; these may cause dangerous effects.
• You may experience these side effects: Drowsiness, dizziness, blurred vision (avoid driving or engaging in activities that require alertness); dyspepsia (take drug with food; eat frequent small meals); dry mouth (suck sugarless lozenges or ice chips).
• Report urinary retention or difficulty voiding, pale stools, yellow skin or eyes.

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