Bacterias In our Body

10 Trillions Microorganism In and Out of

our Body
3% - harmful bacteria
HYGIENE 87% - not harmful
10% - opportunistic
· the science of health and
its maintenance Factors Influencing hygienic practices

· a highly personal matter · Culture

· involves care of the whole · Religion

body
· Environment
· skin, hair, teeth, nails, oral,
& nasal cavities. · Developmental Level

· Give a feeling of · Health and Energy

comfortness and
personal hygiene is very · Personal Preferences
important
Personal Hygiene - is the self care by
which people attend to such functions as Care of the Skin
bathing, toileting, general body hygiene, Skin
and grooming - the largest organ of the body
Hygiene Care Type: - the body’s first line of defense
- Has transient and resident
1. Early Morning Care - provides to microorganism that are not usually
clients as they awaken in the harmful
morning Intact Skin - refers to the presence of
normal skin and skin layers uninterrupted
· consist of providing urinal or by wounds
bedpan to the client confined 5 Major Functions of the Skin
for bed / washing the face
1. It protects underlying
2. Morning Care - provides after tissues from injury by
the client have breakfast preventing the passage
of microorganisms
· perineal care
2. It regulates body
3. Hour of sleep or PM Care - temperature
provided to the clients before
they retire for the night 3. It secretes sebum (an
oily substance)
4. As Needed (PRN) Care -
provided as required by the 4. It transmit sensations
client (diaphoretic (sweating through nerve receptors
profusely), with incontinence
(no more control of urine and 5. It produces and absorbs
stool) Vitamin D in
conjunction with
ultraviolet rays from the
Deficient Knowledge – lack of knowledge sun, which activate
vitamin D precursor
Self Care Deficit – unable to perform self present in the skin.
care Regulation of Body Temperature By:
 · cooling of the body occurs the body thru
through… evaporation
Skin Function:

· Body temperature General Guidelines for Skin Care:

· Cooling the body Nursing Implication:

Bathing - removed accumulated oil,
· Evaporation of perspiration, dead skin cells, and bacteria.
perspiration Excessive bathing can interfere with the
lubricating effect of the sebum causing
· By radiation and dryness to the skin.
conduction of Purpose of Bathing:
heat from the
body 1. Bathing stimulates
Sebum circulation (from distal
to proximal)
1. Lubricates the hair and
skin 2. Bathing produce a sense
of well being
2. prevents hair from
becoming brittle 3. Bathing offers an
excellent opportunity
3. decrease water loss from for the nurse to assess
skin all clients

4. Lessens the amount of

heat lost from the skin
Common Skin Problem:
5. Has a bactericidal
(bacteria-killing) action 1. Abrasion - scraped or
Sudoriferous (sweat) Glands - glands of rubbed away
the dermis that secretes sweat
2. Excessive Dryness - flaky
· 2-5 million sweat glands and rough
which are present at
birth 3. Ammonia Dermatitis -
diaper rash caused by
· mainly water but also skin bacteria reacting
consist; salt, potassium, with urea in the urine.
chloride, glucose, The skin becomes
urea,& lactate reddened.
Sweat - main function is to control body
temperature 4. Acne - inflammatory
2 Classification of Sweat Glands condition with papules
(elevated lesions) and
1. Apocrine Glands pustules (small lesions)
-produces sweat but of
little use in 5. Erythema - redness
thermoregulation. It is associated with variety
due to emotional stress of condition such as
and anxiety. rashes, exposure to the
sun, elevated body
2. Eccrine Glands - most temperature
common and more
numerous than the 6. Hirsutism - excessive
apocrine glands / cools hair on a person’s body
 and face, particularly in CHECK UP
women

ORAL CARE
PURPOSES OF BRUSHING AND FLOSSING
Crown- exposed part
-TO PREVENT DECAY
Dentin- ivory colored internal
45 DEGREE BRUSH
Root- tooth imbedded

Pulp cavity- contains blood vessels

GAG REFLEX-PHARYNGEAL REFLEX
DENTAL CARRIES- CAVITIES
-PARANG MASUSUKA GAG
GINGIVA- GUM

GINGIVITIS- INFLAMMATION OF GUMS

PERIODONTAL DISEASE- GUM DISEASE,

LOSS OF TEETH HANDS, FEETS, AND NAILS

PYORRHEA- ADVANCED PERIODONTAL Hand washing

DISEASE
-before and after eating
PLAQUE- INVISIBLE SOFT FILM
-after toileting
XEROSTOMIA- DRY MOUTH
-after hand contact
DENTIFRICE- TOOTHPASTE

TARTAR- HARD DEPOSIT PLAQUE

HANDS CANT BE STERILIZE UNLESS YOU
HALITOSIS- BAD BREATH USE STERILE GLOVES

GLOSSITIS- inflammation of tounge FOOT STRUCTURES

EXCORIATED MUCOSA- ILL FITTING 26 bones, 107 ligaments, 19 muscle each

DENTURES foot

CHEILOSIS- CRACKING OF LIPS -not fully grown until 20

SORDES- ACCUMULATION OF FOUL PROBLEMS AT THE FOOT

MATTER
callus- thickened epidermis
STOMATITIS- INFLAMMATION OF ORAL
MUCOSA corn- bony prominence from friction

PAROTITIS- INFLAMMATION OF PAROTID Unpleasant odor- moistured foot

Fissures- cracking dryness sole of foot

MEASURES TO PREVENT TOOTH DECAY- Athletes foot- ring worm caused by fungus

BRUSH THOROUGLY Plantar warts- papovavirus

FLOSS TEETH Ingrown toenail- inward growth of nail

 of dry, thickened skin that may be scaly or
have a rough texture.
FOOT CARE
Psoriasis: Psoriasis is a chronic
Purpose autoimmune condition that causes the
rapid buildup of skin cells, leading to thick,
-to prevent foot infection silvery scales and itchy, dry, red patches
that may be painful.

Hair Loss: Hair loss, also known as

NAILS alopecia, is the partial or complete loss of
hair from areas where it is normally
-present at birth present. It can occur on the scalp or other
parts of the body.

Ticks: Ticks are small, blood-feeding

Nail care parasites that can transmit diseases to
humans and animals through their bites.
Ingrown- unguis incarnate They are commonly found in wooded and
grassy areas.
Onycholysis- Separation of nail from nail
bed Pediculosis: Pediculosis is an infestation
of lice, which are parasitic insects that live
Paronychia-inflammation of skin fold on the scalp and feed on blood. It
commonly affects children and spreads
Fungal infection- death of nail through close contact.

Nail clubbing- symptoms of cardiac

problem
Scabies: Scabies is a highly contagious
CARE OF HAIR skin infestation caused by the Sarcoptes
scabiei mite. It results in intense itching
-appearance of the hair reflects persons and a pimple-like rash.
feelings
Hirsutism: Hirsutism is a condition
-proper uniform to be a role model characterized by excessive hair growth in
women in areas where hair is typically
-reflects states of health absent or minimal, such as the face, chest,
and back. It is often caused by an excess
Alopecia- hair loss of male hormones (androgens)

Dandruff: Dandruff is a common scalp Brushing and combing hair

condition characterized by small, white
flakes of dead skin that appear in the hair -stimulate circulation of blood in the scalp
and on the shoulders. It often causes
itching. -distribute oil along hair shaft

Seborrheic Dermatitis: Seborrheic -helps to arrange hair

dermatitis is a chronic skin condition that
primarily affects the scalp and causes HYGIENIC ENVIRONMENT
redness, itching, and flaking. It can also
affect other oily areas of the body, such as Florence Nightingale- environmental
the face and upper chest. theory

Eczema: Eczema, also known as atopic Room temp. 20-23 degree celsius
dermatitis, is a skin condition
characterized by inflammation, itching, Ventilation- remove unpleasant odors
and redness. It often appears as patches
Noise- increase awareness of noise bpm, BPM - beats per minute
BPH - benign prostatic
bed - important element hypertrophy
BRP - bathroom privileges
Place must be clean safe and comfortable BS - bowel or breath sounds
BR - bed rest
Bed making- BSC - bedside commode
BSD - bedside drainage
Types of unoccupied Bed: BW - body weight
Bx, bx - biopsy
1- Open bed: the top covers are folded - with
back so the patient can easily get back in C - Centigrade, Celsius
to bed. C1, C2 (etc.) - 1ST Cervical vertebra,
- 2nd cervical vertebra
2- Closed bed: the top sheet blankets and CA - cancer, carcinoma
bedspreads are drawn up to the head of Cal - calorie
the mattress and under the pillow; this is cap - capsule
prepared in a hospital room before a new Cath - catheter, catheterize
client is admitted to the room.of the c.c., CC - chief complaints
mattress and under the pillow; this is cc - cubic centimeter
prepared in a hospital room before a new CHF - congestive heart failure
client is admitted to the room. CHO - carbohydrate
Cl - chloride
occupied bed- is an available bed where CBC - complete blood count
there is a patient physically in the bed or CBR - complete bed rest
the bed is being retained for a patient CCU - Coronary Care unit
CHON - protein
Nursing Abbreviation CHD - Congenital heart disease
Cl liq - clear liquid
@ - at cm - centimeters
- before CNS - central nervous system
abd - abdomen CO2 - carbon dioxide
ABG - arterial blood gases c/o - complaints of
a.c., ac - before meals (ante COPD - chronic obstructive
cenam, ante pulmonary
cebum) disease
ad lib - as desired (ad libitum ) COLD - Chronic obstructive lung
adm - admission, admitted disease
ADL - activities of daily living CPR - cardiopulmonary
ABO - the main blood group resuscitation
system CS - cesarean section
AMI - acute myocardial C&S - culture and sensitivity
infarction CSF - cerebrospinal fluid
A.M., AM, a.m. - morning (ante meridiem) CVA - cerebrovascular accident,
AMA - against medical advice stroke
amb - ambulate, ambulatory CVD - cardiovascular disease
amt - amount CXR - chest x-ray
ANST - after negative skin test DAT - Diet as tolerated
AP, ap - apical pulse dc, disc, DC, D/C – discontinue
A-P - anterior-posterior dl - deciliter (100 ml)
approx - approximately Disch - discharge
ASAP - as soon as possible DM - diabetes mellitus
B&B - bowel and bladder training DNR - do not resuscitate
BaE, BE - barium enema DOA - dead on arrival
BCG - Bacille Calmette-Guerin DOB - date of birth
bid, b.i.d. - twice a day ( bis in die ) DOE - dyspnea on exertion
bld - blood DR - delivery room
bm, BM - bowel movement Drsg, dsg - dressing
BP - blood pressure DTR - deep tendon reflexes
DVT - deep venous thrombosis Kg - kilogram
Dx, dx - diagnosis Kcal - kilocalorie
DDx - differential diagnosis KUB - kidney, ureter, and bladder
ECG, EKG - electrocardiogram KVO - keep vein open
EEG - electroencephalogram L - liter
EENT - eyes, ears, nose, throat , lt - left
EOMs - extraocular movements Lab - laboratory
ER - emergency room lat. - lateral
F - fahrenheit lb - pound
Fb - foreign body liq - liquid
FBS - fasting blood sugar LLQ - left lower quadrant
FF - force fluid LMP - last menstrual period
FFP - fresh frozen plasma LUQ - left upper quadrant
FHS - fetal heart sound M - male
FHR - fetal heart rate MAR - medication administration
Fld - fluid record
FOB - foot of bed MD - medical doctor
Ft - foot, feet Meds, meds - medications
FUO - fever of undetermined origin mEq - milliequivalent
Fx - fracture MI - myocardial infarction
gal - gallon MICU - Medical Intensive Care Unit
GI - gastrointestinal mg - milligram
GIT - gastrointestinal tract ml - milliliter
Gm, gm, g - gram min - minute
GP - general practitioner mm Hg - millimeters of mercury
G1 - gravida one mod - moderate
GTTS, gtt, gtts - drops (guttae) MVP - mitral valve prolapse
GUT - genitourinary tract NA - nursing assistant
Gyne, GYN - gynecology neg - negative
H2O - water NG - nasogastric
h/o - history of NKA - no known allergy
hr, h - hour NICU - Neonatal Intensive Care
hgb, hct, H&H - hemoglobin and Unit
hematocrit nil - nothing, none
Hx - history noc - night
Hgb or Hb - hemoglobin NPO, npo -nothing per orem, (non per
HCL - hydrochloric acid os)
Hg - mercury - nothing per mouth
H2O2 - hydrogen peroxide NS, N/S - normal saline
hs - hour of sleep ( hora N/V - nausea and vomiting
somni), OB - obstetrics
at bedtime od - daily
ht - height OD - right eye (oculo dexter,
HOB - head of bed oculo dextro )
BP, HTN, HPN - hypertension OOB - out of bed
HPI - history of present illness oint. - ointment
ICU - intensive care unit OPD - out patient department
I&D - incision and drainage - after
IBW - Ideal body weight OR - operating room
ICS - intercostal space OS - left eye ( oculo sinister,
Ig - immunoglobulin oculo sinistro )
IM - intramuscular OU - both eyes, each eye (oculo
in - inch utro)
I&O - intake and output OT - occupational therapy
IV - intravenous oz - ounce
IVP - IV push PACU - Post Anesthesia Care Unit
IVPB - IV piggyback pc, p.c. - after meals (post cebum
IVP - intravenous pyelogram , post
IU - international unit cenam )
PDA - patent ductus arteriosus tab - tablet
PE, PX - physical examination tbsp - tablespoon
PEDS - pediatrics TB - tuberculosis
per - by or through TO - telephone order
pH - potential hydrogen (degree tsp - teaspoon
of tid, t.i.d. - three times a day (ter in
acidity or alkalinity) die)
PID - pelvic inflammatory disease TLC - tender loving care
PICU - Pediatric Intensive Care TPR - temperature, pulse, and
Unit respiration
PM, P.M., p.m. – afternoon TPN - total parenteral nutrition
PMI - point of maximal impulse Tr, tinc -tincture
po - by mouth Tx - treatment
postop - postoperatively UA - urinalysis
preop - preoperatively “u” - unit
prep - preparation UTZ - ultrasound
PRN, p.r.n., prn - whenever necessary ( pro URI - upper respiratory infection
re nata ) UTI - urinary tract infection
pt - patient, pint vol - volume
PTA - prior to admission VO - verbal order
PTB - pulmonary tuberculosis VS, V/S, vs - vital signs
q - every VSS - vital signs are stable
qAM - every morning WB - whole blood
QD, Q.D., qd, q.d. - daily (quaque die) WD - well developed
qh, qlh - every hour WN - well nourished
q2h - every 2 hours WNL - within normal limits
qhs - every night at bedtime WBC - white blood cells
qid, q.i.d. - four times a day wt - weight
QOD, Q.O.D, - every other day - except
qod, q.o.d. # - number
qt - quart , (+) - positive
rt, ® - right , (-) - negative
RBC - red blood cells 20 - secondary to
Rm - room - increase
RN - registered nurse - decrease
R/O - rule out (either confirm or > - greater than
eliminate) < - less than
ROM - range of motion ≥ - greater than or equal to
ROS - review of systems ≤ - less than or equal to
RR - recovery room
RLQ - right lower quadrant Color Coding of Medication Cards
RUQ - right upper quadrant
Rx - take, treatment,
prescription
s,S - without
SICU - Surgical Intensive Care
Unit
SOB - shortness of breath
STD - sexually transmitted
disease
surg - surgery
spec - specimen
stat, STAT - at once now, immediately Common Abbreviations
(statim)
syr - syrup
Sx - symptoms
S /Sx, S/S - signs & symptoms
SC, SQ - subcutaneous
SVI - systemic viral infection
 ● Controlled substances are kept in a
locked drawer
● Controlled substances uses a
special inventory forms for
recording

Effects of Drugs:
1. Therapeutic Effect ( Desired
Effect)
Medication and Drugs Order - the primary effect intended (the
Medication - a substance administered for reason the drug is prescribed) ex:
the diagnosis, cure, relief of a symptoms, Sleeping Pills
or for prevention of disease.
2. Side Effect (Secondary Effect)
Drugs - has a connotation of an illicitly - one that is unintended, usually
obtained substance such as heroin, predictable and may either
cocaine, or amphetamines. harmless or partially harmful

Medication Orders 3. Adverse Effect or “Reactions”

- A primary care provider usually - more severe side effects
determines the client’s medication - may justify the discontinuation of a
needs and orders medication. drug.
- Only a licensed nurse can give a
specific medication. 4. Drug Toxicity
- deleterious effect of a drug on an
Legal Aspects of Drug Administration: organism or tissue.
● Nurses need to know how nursing - result from; overdosage,
practice acts in their areas, define indigestion of drugs intended for
and limit their function. external use.
- Building of the drug in the blood
● Be able to recognize the limits of because of impaired metabolism
their own knowledge and skills. or excretion

● To function beyond the limits of 5. Drug Allergy

nursing practice acts or one’s - an immunologic reaction to a drug
ability is to endanger client’s lives - severe allergy reaction
and leave oneself open to
malpractice suits. Action of Drugs on the Body:
● Half-Life - time interval req for the
● Nurses are responsible for their body’s elimination process;
own actions regardless of whether lessens dosages
there is a written order. ○ Ex. 100%
8 hrs - 50%
The use of controlled substances: 16 hrs - 25%
24 hrs - 12.5%
 32 hrs - 6.25%
4. Intravenous 25 deg
- into a vein
Routes of Administration: - injection or infusion by means of a
needle or catheter inserted into the
● The route of administration should body
be indicated when the drug is
ordered

1. Oral Administration (30 minutes 5. Topical Applications

effect) - these applied in the circumscribed
- the drug is swallowed surface of the body that includes:
- the most common a. Dermatologic Preparation - skin
- least expensive b. Instillation and Irrigation
- most convenient and safe method c. Inhalations - administered into the
respiratory tract by a nebulizer
2. Sublingual Administration (15 (air,oxygen, & vapor are used to
minutes effect) carry ..
- drugs is placed under the tongue,
where it is absorbed into the blood
vessels on the underside of the Types of Medication Orders:
tongue
● 4 Common Medication Orders:
3. Buccal Administration
- medical tablet held in the mouth 1. Stat Order
against the mucous membranes of - To be given immediately and only
the cheek until the drug dissolves once
- drug act locally on the mucous
membrane, of the mouth or 2. Single Order
systematically when it is - One time order
swallowed in the saliva - For medication to be given once at
a special time
4. Parenteral Administration
- administering by needle 3. Standing Order
- May or may not have a termination
4 Types of Parenteral Administration: date
- A standing order may be carried
1. Subcutaneous (hypodermic) out indefinitely, until an order is
45deg written to cancel it, or may be
- just below the skin carried out for a specified number
of days
2. Intramuscular 90deg - Automatically cancelled after a
- into a muscle specific number of days and must
be reordered
3. Intradermal 10-15deg
- under the epidermis 4. PRN Order
 - As needed order Process of Administering Medications
- Permits the nurse to give 1. Identify the clients
medication when, in the nurse’s 2. Inform the client
judgement the client requires it. 3. Administer the drug (perform three
- Nurses must use good judgements checks)
about when the medication is - Before Preparing
needed and when it can be safely - After Preparing
administered. - Before Administering
4. Provide adjunctive interventions as
indicated
Prescription 5. Record the drug administered
- the written direction (record it immediately)
6. Evaluate the client's response to
(4) Four Kinds of Name of a Drug the drug
1. Generic Name
- given before a drug becomes 10 Rights of Medication Administration
officially an approved medication,
the generic is generally used 1. Right medication
throughout the drug’s use. 2. Right dosage

2. Official Name 3. Right time

- name under which it is listed in one
4. Right route
of the official publications.
5. Right client

6. Right client education

3. Chemical Name
- name by which a chemist knows it; 7. Right documentation
this name describes the
constituents of the drug precisely. 8. Right to refuse

9. Right assessment
4. Trade or Brand Name
- name given by manufacturer. 10. Right evaluation
- This name is usually selected to be
short and easy to remember
DOCUMENTATION AND REPORTING
Essential Part:
Discussion- entails an informal verbal
1. Full name of the client exchange among two or more healthcare
2. Date and time the order is written personnel aimed at identifying or resolving
3. Name of the drug to be a problem by establishing strategies.
administered
Report- comprises oral, written, or
4. Dosage of the drug computer-mediated communication
5. Frequency and Route of designed to convey information to others
administration
record- also referred to as a chart or client
6. Signature of the individual writing record, serves as a formal, legal document
the order offering evidence of a client’s care,
whether in written or computer-based 4. Focus Charting
format
Focus Charting is a documentation
The act of recording information in a method designed to prioritize the patient’s
client record is known as charting, concerns, needs, and strengths in the
documenting, or recording healthcare record. This system helps
ensure that patient-centered care is
maintained, providing a clear, organized
approach to documenting care activities
Documentation- is anything written or and patient responses.
printed that is relied on as a record of
proof for authorized persons. 5. Charting by exception

Documentation and reporting- in nursing Charting by Exception (CBE) is a

are needed for continuity of care it is also documentation system that focuses on
a legal requirement showing the nursing recording only abnormal or significant
care performed or not performed by a findings, or exceptions to established
nurse. norms. This method aims to facilitate
documentation, reduce redundancy, and
highlight critical information, making it
easier for healthcare providers to quickly
Documentation System identify and address issues that deviate
from expected outcomes.
1. Source-oriented medical record
(SOMR)- 6. Computerized Documentation

A source-oriented medical record (SOMR) Computerized documentation systems

is a traditional format for maintaining have been developed to manage the vast
patient information, where each amount of information required in modern
department or healthcare provider healthcare. These systems leverage
documents their observations, technology to facilitate the documentation
interventions, and outcomes in designated process, enhance accuracy, and improve
sections of the patient’s chart. access to patient information. Here’s a
closer look at how computerized
2. Problem-oriented medical record documentation functions and its benefits:
(POMR)
7. Case Management
The Problem-Oriented Medical Record
(POMR), established by Dr. Lawrence Case management is a coordinated
Weed in the 1960s, represents a approach to delivering high-quality,
significant shift in medical documentation cost-effective healthcare within an
by organizing patient data around specific established timeframe. This method
problems rather than by the source of the focuses on optimizing patient outcomes
information. This method is structured to and resource utilization, ensuring that care
enhance clarity, continuity, and is both efficient and effective.
comprehensiveness in patient care.
Purposes of Documenting and Reporting
3. The problem, intervention, evaluation
model (PIE) Documenting and reporting in nursing
serve multifaceted purposes crucial for
The PIE documentation system is an effective healthcare delivery and
efficient approach to organizing patient accountability.
information, focusing on Problems,
Interventions, and Evaluation. This method
aims to simplify and integrate care 1. Communication. Through
documentation into a continuous, documentation and reporting, nurses
real-time process. facilitate seamless communication
among healthcare professionals, ensuring
the continuity of care and promoting
patient safety.

2. Planning Client Care. Detailed

documentation aids in the formulation and
execution of individualized care plans,
providing a comprehensive overview of
patient needs, interventions, and
outcomes.

3. Auditing Health Agencies. Accurate

documentation enables health agencies to
assess compliance with regulatory
standards, identify areas for improvement,
and ensure the provision of high-quality
care.

4. Research. Documented data serves as

valuable resources for research
endeavors, contributing to evidence-based
practice and advancements in nursing
knowledge and patient care.

5. Education. Documentation and

reporting provide valuable learning
materials for nursing students and
healthcare professionals, offering real-life
case studies and examples to enhance
understanding and skill development.

6. Reimbursement. Thorough
documentation supports reimbursement
processes by accurately reflecting the
care provided to patients, ensuring proper
billing and reimbursement for healthcare
services.

7. Legal Documentation. Documentation

serves as legal evidence of the care
provided, protecting both patients and
healthcare providers in case of litigation or
disputes.

8. Health Care Analysis. Aggregated data

from documentation and reporting
systems allow for the analysis of
healthcare trends, outcomes, and
performance metrics, facilitating
continuous quality improvement initiatives
and informed decision-making.